[Pancoast tumor receiving preoperative concurrent chemoradiotherapy followed by radical resection via transmanubrial approach and posterior thoracotomy].

A 59-year old man complaining of right shoulder pain was diagnosed with Pancoast tumor. Chest computed tomography (CT) scan showed a right superior sulcus tumor, 5.8 cm in diameter, invading the middle-posterior compartment of thoracic inlet. Chest magnetic resonance imaging (MRI) sagittal section showed the possibility of infiltration to subclavian artery. The patient received preoperative concurrent chemoradiotyrapy (CCRT) [radiotherapy : 60 Gy/30 Fr, cisplatin and docetaxel], resulting in tumor regression (PR). The patient underwent right upper lobectomy and resection of the 1st- 2nd ribs and Th1 nerve via transmanubrial approach and high posterior thoracotomy. Pathological examination demonstrated a little live cancer cells and organization of necrotic tissue in the lung and inter costal region (Ef2). Transmanubrial osteomuscular sparing technique maintains an excellent exposure of thoracic inlet and cervical structures safely.

[Mucinous bronchiolo-alveolar cell carcinoma with marked serum elevation of CA19-9: report of a case].

An 83-year-old woman was referred to our hospital to examine for an infiltration shadow in the right lower lobe with progressive bronchorea Computed tomography showed an infiltration lesion with the longest diameter of 10 cm in the right lower lobe and a tumor with the longest diameter of 3 cm in the middle lobe. Serum level of carbohydrate antigen (CA) 19-9 markedly increased to 37,670 U/ml over a period of 3 months. The pathologic study obtained by a transbronchial tumor biopsy revealed a mucinous adenocarcinoma The patient underwent video-assisted thoracoscopic right middle and lower bi-lobectomies with nodal sampling. Postoperative course was uneventful Pathologic study revealed an adenocarcinoma with mixed subtypes, predominantly composed of mucinous bronchiolo-alveolar cell carcinoma (BAC). Immunohistochemical study showed CA19-9 positivity in the apical surface of some tumor cells and diffuse patterns of other tumor cells. Postoperative course was uneventful and serum CA19-9 levels decreased within the normal range. Clinico-pathologic features of the lung cancer patients with serum elevation of CA19-9 and CA19-9 positivity in the cancer cells was discussed. CA19-9 can be an useful tumor marker in the selected patients with mucinous BAC.

[Video-assisted thoracoscopic removal for mediastinal mature teratoma following extraction of cystic components].

Video-assisted thoracoscopic resection for mediastinal mature teratoma is sometimes converted to open thoracotomy. Because it has rich components including pancreatic tissue and dense adhesion, even when it is asymptomatic. Prior to thoracoscopic resection, extraction of the cystic components with the aid of a 20 Fr tube can provide a wide thoracoscopic view leading to easier complete removal. Between October 1998 and June 2008, 6 patients (1 man and 5 women) with benign mediastinal mature teratoma underwent the thoracoscopic operations. The average age was 36.3 (range, 24-54). The mean diameter was 9.0 cm (range, 5-11 cm). The mean operation time was 143 minutes and the mean blood loss was 103 ml. Neither complications nor tumor recurrences developed during the mean follow-up period of 3.4 years. The presented thoracoscopic surgery for benign mature teratoma is a feasible procedure.

[Surgical outcome of tracheobronchial reconstruction for lung cancer].

We retrospectively evaluated the surgical outcome after sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction for lung cancer. From 1993 to 2008, 46 patients with primary lung cancer underwent these surgical procedures. Seventeen patients (37%) received induction therapy, 15 received chemotherapy, while chemoradiotherapy or radiotherapy alone were received by one patient each. Sleeve lobectomy without carinal resection was performed in 41 patients. Carinal resection with 2 sleeve pneumonectomies was performed in 5 patients. There were no operative deaths. Bronchopleural fistula occurred in one patient, who required completion pneumonectomy. One patient presented local mucosal necrosis in the anastomotic site and was managed conservatively. Two patients had bronchial strictures as late complications and successfully dilated by a balloon using bronchoscopy. Overall 5-year and 10-year survival rates were 54% and 48%, respectively. No recurrence developed at any anastomotic site. The results showed that sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction can be performed with low mortality and bronchial anastomotic complication rates. As well, local control of the tumor was satisfactory.

[Complete thoracoscopic lobectomy with systematic nodal dissection via 5 ports for lung cancer].

We herein report a procedure for thoracoscopic lobectomy with mediastinal dissection for primary lung cancer using 5 access ports. A thoracoscope is inserted through an access port on the mid-axillary line in the 6th intercostal space. The availability of 4 instruments through 4 ports makes it easy to divide bronchus and pulmonary vessels and to dissect mediastinal lymph nodes. Between April 2005 and March 2007, 88 patients with clinical stage I/II primary lung cancer underwent this thoracoscopic procedure. Mean (+/- SD) operation time was 148 +/- 42 minutes and mean (+/- SD) blood loss was 166 +/- 148 ml. No local recurrence was found in patients with pathologic stage I/II diseases, whereas ipsilateral mediastinal lymphadenopathy occurred in 2 with pathologic stage III A disease during the mean post-opetrative period of 518 +/- 200 days. The thoracoscopic surgery for lung cancer presented here was seen to be a feasible procedure and has the advantage of reducing operative time.

[Combined thoracoscopic and open chest approach of lobectomy with inferior chest wall resection for advanced lung cancer].

Patients with advanced non-small cell lung cancer invading a chest wall are surgical candidates if complete resection is possible. When a primary tumor locating the lower lobe invades an inferior chest wall, either a wide skin incision or double skin incisions to secure surgical views both for dissection of hilum and mediastinum and for inferior chest wall resection is necessary. Wider incision causes higher rate of wound necrosis and infection. We describe a combined approach of thoracoscopic and open chest surgery for lobectomy and inferior chest wall resection, respectively. Patient was a 68-year-old man with an advanced non-small cell lung cancer. Video-assisted thoracoscopic middle and lower lobectomies and mediastinal nodal dissection was completed via 5 ports. Chest wall resection including the posterior portion of the 9th and 10th ribs and the transverse process followed inferior postero-lateral thoracotomy. Postoperative course was uneventful. The present surgical approach can avoid a wide thoracotomy for an advanced lung cancer invading an inferior chest wall.

[Hemoptysis one year after video-assisted thoracoscopic bullectomy for spontaneous pneumothorax: report of a case].

A 63-year-old man who had underwent video-assisted thoracoscopic bullectomy for left spontaneous pneumothorax 1 year before developed recurrent hemoptysis. Chest computed tomography showed previous stapling of the subsegmental bronchus in the left apico-posterior segment Bronchial arteriography showed hypervascularization of bronchial artery in the left upper segment and pooling of contrast medium along the staple-suture line. Video-assisted thoracoscopic apico-posterior segmentectomy was performed successfully. Pathological examination revieled hemosiderin lining along the surgical stump of B(1+2)cii, neither with infection nor infarction. These findings suggest that mechanical stapling of B(1+2)cii induced ischemia in the peripheral lung parenchyma causing bronchial hypervascularization. Late onset hemoptysis should be kept in mind as a complication after bullectomy with a mechanical stapler.

[Massive hemoptysis due to traction bronchiectasis caused by thoracic radiotherapy 23 years earlier].

We reported a 72-year-old woman who had a massive hemoptysis due to traction bronchiectasis in the left upper lobe. The patient underwent left radical mastectomy followed by thoracic radiotherapy for left breast cancer. The chest computed tomography showed traction bronchiectasis in the atrophic left upper lobe and the bronchial angiography showed hypervascularization of bronchial and internal thoracic arteries to the left upper lobe. Left upper lobectomy was performed after bronchial embolization for recurrent massive hemoptysis. Postoperative course was uneventful. Pathologic findings showed non-anatomical but clearly-bordered traction bronchiectasis with hypervascularized bronchial artery in the left upper lobe. These lesions were consistent with the field of the previous radiotherapy. Traction bronchiectasis causing massive hemoptysis should be considered as one of pulmonary sequelae after thoracic radiotherapy.

[Video-assisted thoracoscopic left upper lobectomy for lung cancer patients: bronchial dissection technique prior to pulmonary artery dissection].

BACKGROUND: Dissection of anterior segmental artery anatomically crossing over apico-posterior segmental bronchus during left upper lobectomy may sometime cause life-threatening vascular injury. PATIENTS AND TECHNIQUE: Between August 2006 and July 2007, 12 patients with clinical stage IA-lung cancer underwent the video-assisted thoracoscopic left upper lobectomy with bronchial dissection prior to anterior and apico-posterior pulmonary artery dissections following dissection of lingular segmental artery. RESULTS: Operation time ranged from 75 minutes to 190 minutes (average 132 +/- 39 minutes). Operative blood loss ranged from 10 ml to 400 ml (124 +/- 112 ml). Postoperative course was uneventful except 1 patient who had left recurrent nerve palsy. CONCLUSIONS: Bronchial dissection prior to the upper segmental pulmonary artery dissections can produce better surgical field around left main pulmonary artery, leading to safe pulmonary arterial dissection during video-assisted thoracoscopic left upper lobectomy.

[Anti-neutrophil cytoplasmic anti body (ANCA)-negative limited form of Wegener's granulomatosis; report of a case].

A 54-year-old man, who was suspected to suffer from multi-drug resistant lung abcess, was admitted to our hospital. Chest computed tomography (CT) scan showed large cavitary mass in right S6 and nodules in left S1+2 and S10. No abnormal findings were detected without raised immunoglobulin E (IgE) and C-reactive protein (CRP). Anti-neutrophil cytoplasmic antibody (ANCA) was repeatedly negative. We couldn't make a diagnosis by percutaneous biopsy. Finally we performed open lung biopsy of left lung, and Wegener's granulomatosis was diagnosed at last He improved immediately after treatment with prednisolone, cyclophosphamide and sulfamethoxazole-trimethoprim. ANCA-negative Wegener's granulomatosis should be considered when we diagnose multiple pulmonary nodules.

[Localized pleural adenocarcinoma].

We report a 58-year-old male with localized pleural adenocarcinoma, the origin of which was not identified. The disk-shaped pleural tumor was 8 x 6 x 2 cm in size and involved the left upper chest wall including the ribs. A fine needle biopsy showed adenocarcinoma, but whole body survey revealed no neoplasm other than the chest wall tumor. The left chest wall resection was followed by the left pleuropneumonectomy, because a few disseminations were identified in the visceral pleura. Pathological examinations showed no primary tumor in the lung. Immunohistochemical examinations suggested that micro-adenocarcinoma originating the subpleural lung invaded chest wall. It may be possibly a subtype of pseudomesotheliomatous adenocarcinoma. The patient has no recurrent tumor 1 year after the operation.

[Localized nodular pulmonary amyloidosis; report of a case].

A 66-year-old female was admitted to our hospital because of chest abnormal shadow. Chest X-ray and chest computed tomography (CT) on admission showed a nodule in the right middle lobe. The nodule was not diagnosed preoperatively by a bronchoscopy. She underwent partial lung resection including the nodule with video-assisted thoracoscopic surgery. The pathological diagnosis was amyloidosis, and we diagnosed her illness as localized nodular pulmonary amyloidosis, since the amyloid substance was type AL. In addition, electron microscopy showed amyloid as straightly fibrous materials in alveolus. It is difficult to differentiate amyloidosis from lung cancer by radiology, and the lung biopsy with video-assisted thoracoscopic surgery is useful and a safety way to establish diagnosis.

Osteosarcomatous differentiation in lung metastases from a malignant phyllodes tumour of the breast.

Osteosarcomatous differentiation of a phyllodes tumour in the breast is extremely rare. A 54 year old woman presented with a painless lump in her left breast and a mastectomy was performed. Microscopically, the tumour was diagnosed as a malignant phyllodes tumour, where no osteosarcomatous component was found. One year later, two lung tumours were revealed upon chest x ray and were surgically treated. The tumours revealed osteosarcomatous features, and were thought to be metastases from the phyllodes tumour. The present case is very unusual in that osteosarcomatous features are present only in the metastatic lesion of the phyllodes tumour.

[Results of surgical treatment of pulmonary metastatic tumors and analysis of prognostic factors].

We evaluated surgical outcome and prognostic factors in 35 patients who underwent surgery for pulmonary metastatic tumors. Overall 5-year survival rate was 55.3%. Size of lesions and disease free interval were considered as affecting factors for survival, but not statistically significant. Because number of resected tumors, surgical procedure, laterality (unilateral or bilateral) did not significantly affect survival, we considered that partial resection was appropriate for pulmonary metastases if tumors were complete resected. Tumor size and preoperative serum carcinoembryonic antigen (CEA) levels were significant factors influencing survival for patients of colorectal carcinoma, Ki-67 positive cell ratio for patients of colorectal and breast carcinoma.

Modulation of transalveolar fluid absorption by endogenous aldosterone in adult rats.

We examined whether transalveolar fluid transport is modulated by aldosterone in adult rats. Because colocalization of mineralocorticoid receptors (MR) with 11beta-hydroxysteroid dehydrogenase type 2 (11betaHSD2) is important for aldosterone specific action, we first determined the immunohistochemical distribution of MR and 11betaHSD2 in the lung. We found that alveolar epithelial cells express both MR and 11betaHSD2. Reverse transcriptase polymerase chain reaction (RT-PCR) demonstrated that rat alveolar type II epithelial cells express both MR and 11betaHSD2. We then measured alveolar fluid clearance in rats treated with chronic low-sodium diet. A low-sodium diet (0.1% NaCl for 12 to 14 days) caused hyperaldosteronism accompanied by hypokalemia, whereas serum corticosterone and adrenaline levels remained normal. We found that hyperaldosteronism was associated with significantly higher alveolar fluid clearance and that this increase was related to the amiloride-sensitive component. In addition, the increase in alveolar fluid clearance was inhibited by spironolactone. Our results show that aldosterone is able to stimulate Na+ channels of alveolar epithelial cells. We conclude that alveolar epithelium is a physiological target tissue for aldosterone and transalveolar fluid absorption could in part be modulated by endogenous aldosterone acting via MR.

Effects of EP4 solution and LPD solution vs Euro-Collins solution on Na(+)/K(+)-ATPase activity in rat alveolar type II cells and human alveolar epithelial cell line A549 cells.

BACKGROUND: Intact alveolar epithelial Na(+)/K(+)- adenosinetriphosphatase (ATPase) function is important in preventing alveolar fluid accumulation after lung transplantation. We examined whether the type of preservation solution used influences Na(+)/K(+)-ATPase activity in alveolar epithelial cells. METHODS: Rat alveolar type II cells were preserved with EP4, low-potassium dextran (LPD), or Euro-Collins solution at 7 degrees C for 5 and 20 hours. To assess cell toxicity, we measured cell viability and lactate dehydrogenase release. Na(+)/K(+)-ATPase activity was measured as ouabain-sensitive ATPase hydrolysis. We also examined the effect of terbutaline (10(-3) mol/liter) and dibutyryl cyclic adenosine monophosphate (dbcAMP) (10(-3) mol/liter) on Na(+)/K(+)-ATPase activity in A549 cells preserved for 5 hours. RESULTS: All solutions caused significant damage of rat alveolar type II cells at 20 hours. However, Na(+)/K(+)-ATPase activity was preserved at normal levels with EP4 and LPD over 20 hours. Terbutaline and dbcAMP significantly increased Na(+)/K(+)-ATPase activity in A549 cells preserved with EP4 and LPD solutions for 5 hours. However, we observed no activation in the cells preserved with Euro-Collins solution. We found no significant difference in intracellular cAMP levels after terbutaline challenge among the types of preservation solution. CONCLUSIONS: We conclude that extracellular-type solutions such as EP4 and LPD may be preferable for maintaining not only the basal activity but also the ability to activate Na(+)/K(+)-ATPase in response to beta-adrenergic agonists, in alveolar epithelial cells.

Immunohistochemical study of basaloid squamous cell carcinoma, adenoid cystic and mucoepidermoid carcinoma in the upper aerodigestive tract.

Non-squamous cell carcinoma is a rare but distinct neoplasm of the upper aerodigestive tract. Among these carcinomas, basaloid-squamous cell carcinoma (BSCC) has frequently been confused with adenoid cystic carcinoma (ACC) and mucoepidermoid carcinoma of the upper aerodigestive tract. In this study, we examined immunohistochemically the expression of differentiation-related substances, including cytokeratin (CK) subtypes, p53 and p27, and cell adhesion-related molecules E-cadherin and alpha-catenin to clarify the biological features of these neoplasms. We studied seven cases of BSCC of the oesophagus, five cases of ACC and seven cases of mucoepidermoid carcinoma. Squamous cell carcinoma and adenocarcinoma of the oesophagus and trachea were also studied for comparison. Among the cytokeratin subtypes examined, CK14, CK17 and CK19 immunoreactivity was detected in BSCC. ACC and mucoepidermoid carcinoma were immunopositive for CK8, CK14 and CK17 and for CK8, CK14, CK17 and CK19, respectively. These findings suggest that CK subtypes, especially CK8, CK14 and CK17, are useful in differentiating these malignancies. BSCC was more frequently associated with decreased E-cadherin and alpha-catenin immunoreactivity than ACC and mucoepidermoid carcinoma. Nuclear p53 immunoreactivity was detected more frequently in BSCC (5 out of 7) than in ACC (2 out of 5) and mucoepidermoid carcinoma (4 out of 7). There were no significant differences in p27 immunoreactivity among these carcinomas. Carcinoembryonic antigen (CEA) immunoreactivity was detected in mucoepidermoid carcinoma (2 out of 7), SCC (8 out of 11) and adenocarcinoma (9 out of 9), but it was not detected in BSCC (7) or ACC (5). Carbohydrate antigen 19-9 (CA19-9) immunoreactivity was detected only in mucoepidermoid carcinoma (4 out of 7) and adenocarcinoma, but not in BSCC, ACC, or SCC. These findings indicate that BSCC, ACC and mucoepidermoid carcinoma are distinct neoplasms arising in the upper aerodigestive tract. In addition, decreased expression of E-cadherin and alpha-catenin proteins and increased p53 expression in BSCC may be correlated with aggressive behaviour.

Expression of 11 beta-hydroxysteroid dehydrogenase type 2 and mineralocorticoid receptor in primary lung carcinomas.

We examined the immunohistochemical distribution of 11 beta-hydroxysteroid dehydrogenase type 2 (11 beta HSD2) and mineralocorticoid receptor (MR) in 63 primary lung carcinomas. Immunoreactivity of 11 beta HSD2 and MR was detected in 37 cases and in 32 cases of 42 adenocarcinomas, respectively. There was a significant correlation between 11 beta HSD2 and MR immunoreactivity. In three adenosquamous carcinomas, both 11 beta HSD2 and MR were detected only in adenocarcinomatous components. Neither 15 squamous cell carcinomas, 2 small cell carcinomas nor 1 large cell carcinoma expressed 11 beta HSD2 or MR. In papillary and acinar adenocarcinomas, both 11 beta HSD2 and MR immunoreactivity was significantly correlated with the grade of histological differentiation. The patterns of 11 beta HSD2 and MR expression in 10 lymph-node metastases were similar to those determined in the primary lesions. These data suggest that the patterns of 11 beta HSD2 and MR expression may reflect cellular origin and differentiation status of primary lung adenocarcinomas and serve as a new useful marker of differentiation.

Intact alveolar epithelial permeability and transalveolar fluid absorption after thoracic irradiation in rats.

We have addressed the question of how the alveolar space stays relatively free of fluid when thoracic irradiation injures the pulmonary capillary endothelium and plasma fluid leaks into the interstitium. A single dose of 15 Gy to the thorax of rats significantly increased the pulmonary capillary filtration coefficient and the lung wet/dry weight ratio 2 h after irradiation. However, there was no significant increase in the release of lactose dehydrogenase or leaking of Evans blue dye into the alveolar space, indicating that alveolar epithelial permeability remained intact. We found no significant difference in the basal alveolar fluid clearance between control and irradiated animals. There was also no significant difference in blockage of alveolar fluid clearance by amiloride. This indicates that the function of the alveolar epithelial Na(+) channels is not impaired and that alveolar epithelium absorbs fluid normally. Examination of lung tissue by light microscopy demonstrated accumulation of fluid in the perivascular region but not in the alveolar space. Our data appear to indicate that the alveolar epithelial barrier function is more resistant to radiation than that of the pulmonary capillary endothelium. We conclude that intact alveolar epithelial permeability and normal transalveolar epithelial fluid absorption ability are of critical importance in keeping the alveolar space relatively free of fluid during acute radiation lung injury.

Difference in the effect of phloridzin on alveolar fluid absorption in anesthetized rats and in ex vivo rat lungs.

We reexamined the effect of phloridizin on alveolar fluid absorption by utilizing ex vivo rat lungs, which are considered to be a useful tool to investigate electrolyte and fluid transport across alveolar epithelium. Alveolar fluid absorption was almost completely reduced by 10(-3) M phloridzin with 10(-4) M amiloride as reported previously. However, we found that phloridzin alone was also able to significantly reduce alveolar fluid absorption. We then examined the effect of phloridzin on lung metabolism and compared the data with those determined in the presence of iodoacetic acid (IAA) and NaCN. Phloridzin reduced alveolar glucose uptake with no decrease in lung ATP content. Both IAA and NaCN decreased lung ATP content significantly. Our data indicate that the effect of phloridzin on alveolar fluid absorption in ex vivo rat lungs is not the secondary effect to the alteration of lung energy metabolism. Therefore our data support the current concept that Na(+)-glucose cotransport is involved with transalveolar active Na+ transport, which is a separated pathway from amiloride-sensitive Na+ channels.