A phase II trial evaluating the efficacy and safety of perioperative pirfenidone for prevention of acute exacerbation of idiopathic pulmonary fibrosis in lung cancer patients undergoing pulmonary resection: West Japan Oncology Group 6711 L (PEOPLE Study).

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) often accompanies lung cancer, and life-threatening acute exacerbation (AE) of IPF (AE-IPF) is reported to occur in 20 % of IPF patients who undergo lung cancer surgery. Pirfenidone is an anti-fibrotic agent known to reduce disease progression in IPF patients. A phase II study was conducted to evaluate whether perioperative pirfenidone treatment could reduce the incidence of postoperative AE-IPF patients with lung cancer. METHODS: Pirfenidone was orally administered to IPF patients who were candidates for lung cancer surgery; pirfenidone was dosed at 600 mg/day for the first 2 weeks, followed by 1200 mg/day. Surgery was performed after at least 2 weeks of 1200-mg/day administration. The primary endpoint was non-AE-IPF rate during postoperative days 0-30, compared to the null value of 80 %, and the secondary endpoint was safety. Radiologic and pathologic diagnoses of IPF and AE-IPF were confirmed by an independent review committee. RESULTS: From June 2012 to January 2014, 43 cases were enrolled, and 39 were eligible (full analysis set [FAS]). Both pirfenidone treatment and surgery were performed in 36 patients (per protocol set [PPS]). AE-IPF did not occur in 37/39 patients (94.9 % [95 % confidential interval: 82.7-99.4 %, p = 0.01]) in the FAS, and in 38/39 patients (97.2 % [95 % confidential interval: 85.5-99.9 %, p = 0.004] in the PPS. A grade 5 adverse event (death) occurred in 1 patient, after AE-IPF; no other grade 3-5 adverse events were observed. CONCLUSIONS: Perioperative pirfenidone treatment is safe, and is promising for reducing AE-IPF after lung cancer surgery in IPF patients. TRIAL REGISTRATION: This clinical trial was registered with the University Hospital Medical Information Network (UMIN) on April 16th, 2012 (REGISTRATION NUMBER: UMIN000007774 ).

Epithelioid hemangioendothelioma originating from the chest wall with rib metastases.

An asymptomatic 39-year-old woman was referred to us for an abnormal nodular opacity detected on the chest X-ray. Histopathological and further examinations revealed findings consistent with epithelioid hemangioendothelioma (EHE) originating from the chest wall with metastases to the ribs. Complete excision was performed; however, adjuvant chemotherapy was not administered because of the patient's mental disorder. There are very few reports of EHE arising from the chest wall; therefore, we present this case report with the clinicopathological features of EHE and discuss the therapeutic aspects.

Long-term outcomes after surgical resection of pulmonary metastases from colorectal cancer.

BACKGROUND: Surgical resection has been widely performed on patients with pulmonary metastases from colorectal cancer with favorable outcomes. However, there are currently no standard surgical indications for pulmonary metastases. METHODS: We reviewed 94 patients who underwent complete resection of pulmonary metastases from colorectal cancer between November 1991 and April 2013. The cumulative survival rate after pulmonary metastasectomy was calculated, and prognostic factors for long-term survival were analyzed. RESULTS: There were 60 men and 34 women, and their median age was 66 years. The 5-year survival rate was 45.5% after pulmonary metastasectomy. The 5-year survival of patients with colon and rectal cancers was 62.4% and 33.8%, respectively (p = 0.030), and the 5-year survival of those with normal and high carcinoembryonic antigen (CEA) levels before pulmonary resection was 57.0% and 30.9%, respectively (p = 0.038). Multivariate analysis revealed the preoperative CEA level was an independent prognostic factor. Recurrence was identified in 65 of the 94 patients (69.1%) after pulmonary metastasectomy, and the patients who underwent surgical resection for recurrent lesions in the liver or lungs, or both, had better survival than those who received other treatments or palliative care. CONCLUSIONS: Surgical resection offers a chance to prolong survival in colorectal cancer patients with resectable pulmonary metastases. Owing to the high recurrence rate, careful postoperative follow-up for early detection is recommended, and even for recurrence, surgical resection should be considered for better survival if the lesions are limited to the liver or lungs, or both.

Resection of an azygos vein aneurysm that formed a thrombus during a 6-year follow-up period.

We report a resection of an azygos vein aneurysm that formed a thrombus during a 6-year follow-up period. An azygos vein aneurysm is commonly detected as an asymptomatic mediastinal mass. A thrombus could suddenly form without enlarging the aneurysm. Therefore we suggest that even asymptomatic azygos vein aneurysms causing blood stagnation should be resected before they can form a thrombus and cause a pulmonary embolism.

Usefulness of FDG-PET/CT in the detection of pancreatic metastases from lung cancer.

OBJECTIVE: The objective of this study was to assess the ability to detect pancreatic metastasis of lung cancer and to clarify the degree of fluorodeoxyglucose (FDG) accumulation and computed tomography (CT) characteristics of pancreatic metastasis from lung cancer. METHODS: A total of 573 patients (415 men and 158 women) with lung cancer were retrospectively evaluated. All patients underwent FDG-positron emission tomography (PET)/CT with contrast-enhanced CT for first=stage (313 patients; initial study group) or follow-up study (260 patients; follow-up study group). A lesion was regarded as positive for metastasis on the basis of visual judgment of the degree of increased metabolism by two experienced and independent interpreters, supported by semiquantitative evaluation on the basis of calculation of the maximum standardized uptake value (SUV(max)). RESULTS: Abnormal accumulations in the pancreas were detected in 5 of 313 patients (1.60%) in the initial study group, and 6 of 260 patients (2.31%) in the follow-up study group. Seven of these patients had adenocarcinoma, three had small cell carcinoma, and the rest had large cell endocrine carcinoma. Tumor sizes (longitudinal diameter), measured by CT, of these 11 patients ranged from 6 mm to 52 mm (mean +/- SD 8.3 mm +/- 11.9 mm), and SUV(max) for 1 h ranged from 3.37 to 11.1 (mean +/- SD 6.12 +/- 2.43). Three of these pancreatic lesions were difficult to determine by routine transaxial images, and detection was obvious only by thin-slice images or multiplanar reconstruction images. Contrast-enhanced CT showed gradual fill-in from the peripheral portion to the center. In addition, 10 of 11 cases did not show main pancreatic duct dilatation even if the tumor size was large. CONCLUSIONS: Metastases to the pancreas in lung cancer patients are not so rare and radiologists first have an important role to detect the pancreatic mass and then suggest to metastasis as the likely diagnosis. For this purpose, FDG-PET/CT has an advantage in depicting unsuspected pancreatic metastasis from lung cancer, particularly that which is not detected by CT alone.

A logistic regression predictive model and the outcome of patients with resected lung adenocarcinoma of 2 cm or less in size.

Diagnostic criteria to identify small lung adenocarcinomas that relapse after resection have yet to be established. For this purpose, we developed a mathematical logistic model in the present study. We collected data for patients with lung adenocarcinoma of 2 cm or less in size: the original cohort comprised 28 men and 25 women and the validation cohort comprised 11 men. By entering five clinicopathological factors (vascular invasion, lymphatic permeation, histological subtype, papillary carcinoma component, and smoking status) into the logistic model, we calculated a predictive function for relapse after surgery. The obtained predictive function accurately classified the patients into a recurrence or non-recurrence group: the overall accuracy of the predictive model for recurrence established from the male patients in the original cohort was 86%. Our predictive model is, however, currently limited to male patients only, because the original cohort included only one female patient with relapse. By applying the logistic model to the validation cohort, six patients were classified into a recurrence group and the other five into a non-recurrence group: four of the six patients in a recurrence group had relapsed, while all five patients in the non-recurrence group were well during their follow-up periods. Although the predictive ability of the logistic model did not reach a statistical significance (P=0.0606), nine of the 11 (82%) patients in the validation cohort were correctly classified. Consequently, using a logistic predictive model consisting of the five clinicopathological factors might enable us to predict the recurrence of resected small-sized lung adenocarcinomas in male patients.

F-18 fluorodeoxyglucose accumulation in an inflammatory pseudotumor of the spleen.

We report on a case with an inflammatory pseudotumor of the spleen, which showed a moderate accumulation of F-18 fluorodeoxyglucose (FDG) in the tumor. F-18 FDG accumulated mainly in the peripheral portion of this tumor that showed abundant hypercellular inflammatory cells histopathologically. Splenic inflammatory pseudotumors should be recognized as F-18 FDG-avid benign tumors of the spleen.

Amyloid deposition in primary pulmonary marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue.

A rare association between primary pulmonary marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), and pulmonary immunoglobulin light chain (AL) amyloidosis is described in a 65-year-old woman suffering from rheumatoid arthritis (RA). All four nodules in the resected upper lobe of the lung had a similar histological appearance. They were composed of small-medium-sized atypical lymphocytes. Centrocyte-like cells had lymphoepithelial lesions. Immunohistochemically, the tumor cells clonally expressed B-cell markers, and demonstrated clonal rearrangement of the immunoglobulin heavy chain gene on polymerase chain reaction. Based on these findings the diagnosis of primary pulmonary MALT lymphoma was made. In addition, uniform eosinophilic material deposition was identified randomly within the tumor. It was Congophilic and exhibited apple-green birefringence on polarizing microscopy, and remained unaffected by potassium permanganate digestion. Deposited material was immunoreactive to lambda light chain. It was concluded that this material was AL amyloid in primary pulmonary MALT lymphoma. Plasma cells with mRNA of lambda chain was found infiltrated along the border of amyloid deposition. Finally, it is speculated that primary pulmonary MALT lymphoma developing in an autoimmune setting, RA in the present case, is associated with overproduction and abnormal clearance of immunoglobulin by the tumor cells, resulting in AL amyloidosis within the tumor.

Long-term survival after repeat resections of metastases in liver, lung, and stomach from sigmoid colon cancer: report of a case.

A 74-year-old female patient underwent a simultaneous colectomy and hepatectomy for sigmoid colon cancer and its hepatic metastases. Six months later she underwent a hepatectomy for recurrent hepatic metastases; then 10 months later, a pulmonary resection for pulmonary metastasis; and 24 months later, a partial gastrectomy for gastric metastasis. As of December 2005, at 7 years 6 months after the first surgery and at 4 years after the last surgery, the patient is still alive with a good quality of life and no sign of recurrence.

High F-18 fluorodeoxyglucose accumulation in solid pseudo-papillary tumors of the pancreas.

We report two cases of young women with a solid pseudo-papillary tumor of the pancreas which having cystic and hemorrhagic components with marked calcification on computed tomography and magnetic resonance imaging. F-18 fluorodeoxyglucose positron emission tomography revealed abnormally increased accumulation of F- 18 fluorodeoxyglucose in the pancreas tail tumors, especially in the non-calcified solid portion of the tumors. These patients underwent elective resection of the masses and distal pancreatectomy and were diagnosed with solid pseudo-papillary tumors by histopathological analysis. There was no evidence of distant metastasis on follow-up after surgery and they showed no histopathological findings suggesting malignancy. These cases suggest that solid pseudo-papillary tumor may show high uptake of F-18 fluorodeoxyglucose.

Using the supercharge technique to additionally revascularize the gastric tube after a subtotal esophagectomy for esophageal cancer.

BACKGROUND: Maintaining sufficient blood flow to the gastric tube after a subtotal esophagectomy for esophageal cancer is crucial for decreasing esophagogastric anastomotic leakage. METHODS: After subtotal esophagectomy for esophageal cancer, the supercharge technique was performed in 21 esophageal reconstruction patients to additionally revascularize the gastric tube using the splenic artery and vein, external carotid artery, and internal jugular vein. Operative results of the supercharge group were retrospectively compared with those of the control group (patients not receiving the technique). RESULTS: Both operation time and operative blood loss in the supercharge group were significantly longer and larger than those of the control group. However, the incidence of anastomotic leakage was significantly lower in the supercharge group than in the control group. CONCLUSION: This practical supercharge technique reduces leakage during esophageal anastomosis.

Reconstruction of the portal vein and the splenic vein in pancreaticoduodenectomy for pancreatic cancer.

BACKGROUND/AIMS: We reconstructed the splenic vein besides the portal vein and/or the superior mesenteric vein after resection of the superior mesenteric-portal vein confluence during pancreaticoduodenectomy for carcinoma of the pancreas and the outcome was retrospectively assessed. METHODOLOGY: Twenty-five patients were classified into three groups. Group O, the splenic vein was left intact (n = 11), Group I, the splenic vein was anastomosed to another vein (n = 6), and Group II, the splenic vein was reconstructed to another vein through autovein graft interposition (n = 8). RESULTS: The patency rate of the superior mesenteric-portal vein anastomosis was 100% in 24 patients evaluated. The blood flow from the splenic vein to the portal vein or another vein was witnessed in 10 patients in Group O, in 3 patients in Group I, and in 7 patients in Group II. CONCLUSIONS: The splenic vein could be reconstructed with high postoperative patency rate, especially in those patients, whose splenic vein was reconstructed using autovein interposition graft.

Reconstruction of small bile ducts using a parachute technique.

Benign or malignant stricture of extrahepatic bile ducts may result when small intrahepatic bile ducts are anastomosed to the jejunal loop after resection of extrahepatic bile ducts, hepatic parenchyma, and intrahepatic bile ducts. We applied a parachute technique, which has been used for fine vascular anastomosis, to hepaticojejunostomy in eight patients with either extrahepatic bile duct carcinoma or intrahepatic cholangiocellular carcinoma. One to four small bile ducts were anastomosed to the jejunal loop. No patient experienced a complication due to this anastomosis. Postoperative elevation of the serum bilirubin was transient, and all patients were discharged within 36 days after surgery. Although the follow-up period in this series is not yet long enough to evaluate the long-term outcome of this technique, the ease of the hepaticojejunostomy and good short-term results warrant farther clinical investigation of this technique.

Pulmonary artery stenting for recurrent lung cancer after left pneumonectomy.

We present a case of a patient with stenosis of the pulmonary artery which was successfully treated by implantation of a vascular endoprosthesis. A 50-year-old man underwent left pneumonectomy for lung cancer. Eleven months later, a computed tomographic scan revealed a soft tissue mass in the mediastinum and there was severe stenosis of the remaining right main pulmonary artery. A self-expandable vascular endoprosthesis was implanted in the stenotic portion. We used percutaneous cardiopulmonary support (PCPS) during the procedure. We recommend the technique of pulmonary artery stenting using PCPS as efficacious and safe.

Fibrolamellar hepatocellular carcinoma in a Japanese man: report of a case.

Fibrolamellar hepatocellular carcinoma (FHCC), a rare variant of hepatocellular carcinoma, is becoming more prevalent; however, up until 1999, only 18 cases had been reported in Japan. We recently diagnosed a case of FHCC in a 46-year-old Japanese man who had visited four hospitals before being finally admitted to our department. On admission, he was diagnosed as having multiple liver tumors, with lymph node metastasis and peritoneal dissemination. Both hepatitis B antigen and hepatitis C antibody were negative, and the levels of serum alpha-fetoprotein and PIVKA-II were within normal limits. Under a provisional diagnosis of atypical hepatocellular carcinoma (HCC), a right hepatic lobectomy with resection of the metastatic lymph nodes and peritoneal dissemination was performed. The histopathological diagnosis made by our pathologist was atypical HCC. He underwent another operation for a recurrence in the left external iliac lymph node. It has been 29 months since his first surgery in this hospital and he is progressing well, which led us to establish the diagnosis of FHCC. Moreover, his serum carbohydrate antigen 125 levels have been well correlated with this condition.

Right aortic arch with left lung cancer: focusing on left recurrent laryngeal nerve.

We report a case of a 64-year-old Japanese man with an anomalous right aortic arch who had left lung cancer. We performed lobectomy and mediastinal lymphadenectomy, paying attention to the pathway of left recurrent laryngeal nerve. The left recurrent laryngeal nerve hooked around from the left dorsal to the right ventral part of the left ductus arteriosus, which connected the left pulmonary artery with the aortic diverticulum.