Myelolipoma of the posterior mediastinum: report of a case.

Myelolipoma is an uncommon tumor composed of adipose tissue and normal hematopoietic elements, and is most often found in the adrenal glands. We report a patient with a posterior mediastinal myelolipoma. The 68-year-old male patient showed a right lower mediastinal shadow in a chest X-ray. A computed tomographic scan demonstrated a right posterior mediastinal mass. Magnetic resonance imaging provided additional useful information. The patient underwent a successful resection under video-assisted thoracoscopic surgery.

[Assessing the usefulness of erlotinib in patients with unknown or negative epidermal growth factor receptor mutation status].

The patient involved in case 1 was an approximately 50-year-old woman with left lung adenocarcinoma (cT4N0M1), pleural dissemination, and carcinomatous pleural effusion. Chemotherapy with cisplatin and S-1 was administered as first-line therapy, and after the second course of chemotherapy, the thoracic drainage tube could be removed. Thereafter, the patient's performance status (PS) improved to 0. However, brain metastasis was detected, with symptoms of dizziness and headache, and activities of daily living (ADL) decreased, resulting in deterioration of the PS to 4. Although epidermal growth factor receptor (EGFR) mutation status was unknown, erlotinib (150 mg/day) was administered, which was evidently effective in reducing brain metastasis and resulted in recovery of the PS to 0. The patient involved in case 2 was an approximately 50- year-old man with a complaint of coughing. Chemotherapy with 4 courses of cisplatin and pemetrexed was administered as first-line therapy, and local radiation therapy (66 Gy) followed by 4 courses of docetaxel was administered as second-line therapy. However, the patient showed progressive disease (PD) and emergence of brain metastasis. Although the patient was negative for EGFR mutation, erlotinib (150 mg/day) was initiated as third-line therapy. Chemotherapy was successful and the local lesions were under control. We performed left pneumonectomy to improve quality of life (QOL), which had decreased because of repeated obstructive pneumonia caused by the tumor. Owing to the surgery, the patient was able to maintain a PS of 0 and a favorable QOL, while the administration of erlotinib was continued. In conclusion, erlotinib functions effectively in 3 ways. First, it can be used for emergency administration in cases of unknown EGFR mutation status. Second, its use facilitates the performance of salvage surgery in patients who are EGFR mutation negative. Finally, erlotinib is expected to be effective in the treatment of brain metastasis.

Angiomyolipoma in the lung detected 15 years after a nephrectomy for renal angiomyolipoma.

Angiomyolipoma is generally found in the kidney, but is especially rare in the lung. Nine cases of angiomyolipoma in the lung have been reported previously, and in 3 of these patients it was involved with nephrectomy for renal angiomyolipoma. The origination of the tumor was not completely recognized, but lymphangioleiomyomatosis and angiomyolipoma are known to have a common feature. The pathogenesis of angiomyolipoma in the lung has recently been researched in relation with lymphangioleiomyomatosis. We review these case reports of angiomyolipoma in the lung and discuss the clinical features and the generation of these tumors.

Mucinous adenocarcinoma of the thymus: a distinct variant of thymic carcinoma.

BACKGROUND: Primary thymic mucinous adenocarcinoma is a recently described subtype of thymic carcinoma, which behaves aggressively. METHODS: The authors analyzed the clinical and pathological findings of three cases of thymic mucinous adenocarcinoma, and reviewed five cases previously reported in the English literature. RESULTS: The patients were two males and one female between the ages of 38 and 55 years. Macroscopically, the tumors were mostly solid and white to yellowish-white. Areas with a gelatinous appearance were present. Histologically, all of the tumors were adenocarcinomas with abundant mucin production, which resembled the mucinous adenocarcinomas of other organs. Malignant tumor cells in nests, tubules and cribriform structures floated in pools of extracellular mucin. In one case, associated thymic cysts were found at the periphery of the tumor. The cyst wall was partially lined by malignant mucinous epithelium, which showed transition from benign thymic epithelium. Immunohistochemically, all of the tumors showed positive immunoreactivity for cytokeratin (CK) 20 and carcinoembryonic antigen (CEA). CD5 was diffusely positive in one case, and focally positive in the other two cases. The prognoses of these cases were extremely poor, and two of the patients died within 24 months. CONCLUSION: Growing evidence suggests that mucinous adenocarcinoma is a distinct morphological variant of primary thymic carcinoma. We believe that clinicians and surgical pathologists should include thymic mucinous adenocarcinoma in the differential diagnosis of mediastinal adenocarcinoma.

Langerhans cell histiocytosis: coexistence of bronchogenic and thymic cysts in the thymus.

Langerhans cell histiocytosis (LCH) is a disease caused by the proliferation of Langerhans cells in various tissues or organs. A 43-year-old male patient presented with an anterior mediastinal mass in the thymus. Histological examination after a thymectomy revealed a bronchogenic cyst in the thymus, and multiple LCH and small thymic cysts were also incidentally observed in the thymus. Unifocal LCH in an adult occurring in the thymus is extremely rare. Furthermore, no cases of LCH with the coexistence of bronchogenic and thymic cysts in the thymus have been previously reported.

Lobe-specific skip nodal metastasis in non-small cell lung cancer patients.

PURPOSE: The purpose of this study is to clarify the lobe-specific nodal metastasis and optimal range of mediastinal nodal dissection in lung cancer patients with skip metastasis. MATERIALS AND METHODS: A total of 136 patients with pN2/3 disease were treated between 1988 and 2002, and these patients were divided into two groups according to whether skip metastasis was identified or not. We drew a comparison of the lobe specificity of mediastinal nodal involvement between skip positive and negative groups. RESULTS: Skip metastasis was identified in 48 (35.3%) of 136 pN2/3 patients. The lymph nodal regions most frequently found (target nodes) were as follows: right upper-#3 and right #4, middle & lower-#3, right #4 and #7, left upper-left #4, #5, and #6, and left lower-#7, #8, and #9. Skip metastasis can be detected at a rate of 82.6% to 91.7% by means of a histological examination of these target nodes. However, the frequency of skip metastasis in other mediastinal nodal regions excluding the target nodes was found to progress to a level of 33.3% to 57.1% insofar as tumor metastasis to these target nodes was identified. CONCLUSIONS: The examination of lobe-specific nodal regions may be helpful for determining patients with skip metastasis. If metastasis is found somewhere in these target nodes, then a systematic nodal dissection may be acceptable for a complete resection even if N1 metastasis is not identified.

[Surgical treatment for clinical stage II and III small cell lung cancer patients].

To evaluate a surgical resection in multidisciplinary treatment for clinical stage (c-stage) II and III small cell lung cancer (SCLC) patients, we examined the postoperative prognosis concerning in 18 patients who underwent complete surgical resection. Five-year survival rate of 8 c-stage II and 10 c-stage III patients showed 62.5% and 46.7%, respectively. Of these, 7 patients underwent preoperative induction chemotherapy resulting in down-staging to c-stage 0-I, and their survival rate at 5 years after sugery was as good as 68.6%. However, in 4 (57.1%) of 7 patients, tumor cells proved to be alive by pathological assessment of lymph nodes. As a consequence, it was suggested that surgery for c-stage II and III SCLC patients is a meaningful treatment considering their prognoses. In particular, even though the patients show a favorable response of preoperative chemotherapy, to completely eliminate remnant tumor cells, a surgical resection may be necessary.

Pulmonary blastoma.

We describe a resected pulmonary blastoma in an 84-year-old male, the oldest of previously reported patients. A chest X-ray showed a 2 cm-sized abnormal shadow in the left lung field. Five months later computed tomography demonstrated a well-demarcated heterogenous mass, measuring 12 cm in diameter, in the left lower lobe of the lung. This mass was diagnosed as a carcinoma using echo-guided percutaneous biopsy. The patient underwent a left lower lobectomy. The resected specimen revealed the tumor to be a pulmonary blastoma arising from lung tissue. Preoperative diagnosis of pulmonary blastoma is extremely difficult because of the histological heterogeneity of tumor. Since it has been noted that pulmonary blastoma rapidly progresses in a short period of time, surgical treatment should be undertaken as quickly as possible when such a tumor is suspected.

Micrometastasis to lymph nodes in stage I left lung cancer patients.

BACKGROUND: To evaluate the frequency and clinicopathological characteristics of lymph node micrometastasis in left lung cancer patients diagnosed to be stage IA and IB based on routine histopathologic examinations, we examined the lymph nodes in patients who had undergone an extended mediastinal lymphadenectomy, using immunohistochemical methods. METHODS: Paraffin-embedded tissue sections from the lymph nodes in 49 patients with stage I left lung cancers were studied. We used AE1/AE3 as the anticytokeratin and Ber-EP4 as the antiepithelial cell antibodies when performing immunohistochemical staining. RESULTS: We identified micrometastasis of the lymph nodes in 13 (26.5%) of 49 patients with stage I left lung cancer. NO disease was reclassified as N1 disease in 5 cases, N2 disease in 6 cases, and N3 disease in 2 cases. The location of the micrometastatic lymph nodes proved to be wide regions including the contralateral and highest mediastinal nodes, and 6 (46.2%) out of the 13 patients with micrometastasis were thus presumed not to be completely eliminated by a standard lymphadenectomy through an ipsilateral thoracotomy. The five year survival rate of patients with reclassified N1 to N3 disease was 74%, and the presence of micrometastasis was found to have no significant effect on the outcomes. CONCLUSIONS: The micrometastatic involvement of the lymph nodes was both more frequent and extensive than expected even in stage I left lung cancer. These results suggest that an extended mediastinal lymphadenectomy may therefore be required for the locoregional control of stage I left lung cancer patients.