Analysis of continuous first-line treatment with docetaxel and carboplatin for advanced non-small cell lung cancer.

The present study aimed to analyze the efficacy and safety of multiple cycles of docetaxel and carboplatin (CBDCA) as a first-line treatment in patients with advanced non-small cell lung cancer (NSCLC). Patients with stage III or IV NSCLC, whose treatment began between July 1999 and February 2003, were retrospectively evaluated. Relatively low doses of docetaxel and CBDCA were administered for as many cycles as possible. The primary outcome assessed was the overall survival (OS) time, and the secondary outcomes included progression-free survival (PFS) time, response rate (RR) and adverse events. The median cycle number was four (range, 2-12). The median OS time was 400 days, and for adenocarcinoma and non-adenocarcinoma, the OS time was 490 and 192 days, respectively. The median PFS time was 176 days and the RR was 66.7%. The main toxicity of the treatment was neutropenia, with grade 3 or 4 neutropenia occurring in 81.0% of patients. Continuous first-line treatment with this regimen may have encouraging effects within a certain group of advanced NSCLC patients, thereby warranting further investigations.

Recurrent thymoma with stiff-person syndrome and pure red blood cell aplasia.

Stiff-person syndrome (formerly known as stiff-man syndrome) is a very rare autoimmune and neurogenic disorder, thought to present as a paraneoplastic variant in association with thymoma. Pure red blood cell aplasia is also a paraneoplastic disorder associated with thymoma. Although separate cases of stiff-person syndrome and pure red blood cell aplasia have been reported, we describe here what is to our knowledge the first case of recurrent thymoma with both stiff-person syndrome and pure red blood cell aplasia. We describe the successful treatment of the neurogenic symptoms of stiff-person syndrome and the progressive anemia associated with pure red blood cell aplasia by tumor excision.

[Strategy for marginally resectable lung cancer].

Lung cancer accounts for the largest number of new cases of cancer deaths annually. The treatment of locally advanced non-small-cell lung cancer(NSCLC)will continue to be a problem for many years. In particular, the border-zone subset of stage III A(N2)patients, which lies between the generally resectable stage I and II tumors and the unresectable stage III B patients, has been the subject of a wide variety of clinical trials incorporating various combinations of chemotherapy, radiotherapy, and surgery.What is the ideal therapy for stage III A(N2)patients ? is a controversial question, and the role of surgery is not clearly defined because of its heterogeneous nature. Most importantly, treatment decisions for these patients should be dictated by the stage of the patients' disease and the patients' performance status, medical comorbidities, and preferences. At our hospital, therefore, all of these patients' data are discussed at our cancer-board conference, incorporating the options of thoracic surgeons, medical oncologists, and radiation oncologists to determine the optimal prospective treatment strategies for the patients. We focused on a treatment strategy for the patients with the so called marginally resectable' lung cancer in this article.

Ectopic hamartomatous thymoma--a truly rare neoplasm: report of a case.

An ectopic hamartomatous thymoma is an extremely rare benign neoplasm that commonly occurs in the lower neck region. It has distinctive pathological features that include haphazardly arranged spindle cells, epithelial cells, and mature fat tissue. Its histogenesis is still controversial. This report presents a case of a 26-year-old man with ectopic hamartomatous thymoma in the left supraclavicular region, and discusses the current knowledge regarding this type of lesion. Clinicians as well as pathologists should be aware of the existence of this disease so that it can be identified correctly.

Thymoma of the middle mediastinum: 11C-acetate positron emission tomography imaging.

Thymomas arising outside the anterior mediastinum are very rare. Their occurrence is likely to be related to ectopic thymus tissue. We report a case of thymoma in the middle mediastinum, right paratracheal region. There have been few reports of middle mediastinal thymoma. In the present case, (11)C-acetate positron emission tomography (PET) was useful for a preoperative suggestive diagnosis. Recently, (11)C-acetate has been reported to be a more sensitive PET tracer than (18)F-fluorodeoxyglucose and may be a promising tracer for complementing the deficiency of (18)F-fluorodeoxyglucose in PET imaging.

Intrapulmonary localized fibrous tumor of the lung: a very unusual presentation.

Most localized fibrous tumors arise from the visceral pleura on a stalk and project into the pleural cavity in a pedunculated manner. The origin of the tumors is now believed not to be mesothelial but rather submesothelial, based on studies using conventional histology, immunohistochemistry, and ultrastructural analysis. While inward tumor growth into the lung parenchyma with attachment to the pleura is uncommon, the tumor with an entirely pulmonary location is extremely rare. We present here a rare case of entirely intrapulmonary localized fibrous tumor (ie, localized fibrous tumor of the lung), and we review the pertinent literature.

Intrathoracic lipomas: their clinicopathological behaviors are not as straightforward as expected.

BACKGROUND: Lipomas are a common type of benign tumor, and may involve numerous sites. They are common in the subcutaneous region of the upper back, neck, and shoulder, but are rarely seen in the thoracic cavity. Intrathoracic lipomas are a type of deep-seated lipoma, unlike subcutaneous lipomas. Due to the rarity of intrathoracic lipomas, little is known about their clinicopathological features. METHODS: We conducted a retrospective review of the clinicopathological records of 10 patients who had undergone surgical resection for intrathoracic lipomas during a 16-year period (1991 to 2006). RESULTS: There were 9 men and 1 woman with a mean age of 57.9 years. The number of lesions was one in 9 patients and two in 1 patient. Symptoms caused by the tumor were seen in only one patient. Radiographically, the tumors showed well-defined, homogeneous, and fatty density masses/nodules. Intrathoracic lipomas were most frequently seen in the parietal pleura. The resected tumor size ranged from 1.0 to 6.0 cm. Pathologically, three lesions showed an infiltrating type in which mature fat cells were seen between and within muscle or nerve fascicles. One of these three ended in an incomplete resection because the tumor infiltrated the brachial plexus. One patient had a recurrent tumor arising from a resected margin. CONCLUSIONS: Intrathoracic lipomas should be surgically resected if they are detected, because the possibility of liposarcoma or infiltrating development of the tumor cannot be excluded preoperatively. We think that surgical resection of the tumor, rather than conservative management by close observation alone, is a safer treatment.

11C-acetate and 18F-fluorodeoxyglucose positron emission tomography of pulmonary adenocarcinoma.

Positron emission tomography (PET) with 11C-acetate has been recently reported in detection of slow-growing tumors, such as well-differentiated adenocarcinomas of the lung, which are often negative with 18F-fluorodeoxyglucose (FDG) PET. Here we present findings of acetate-PET and FDG-PET in a case of adenocarcinoma that was comprised of peripheral ground glass opacity and solid central components, and was histologically comprised of both a well-differentiated and a moderately-differentiated adenocarcinoma, respectively. Acetate-PET was positive in both components, whereas FDG-PET was only positive in the solid central component. The present case demonstrates the figurative findings of acetate-PET and FDG-PET in lung adenocarcinoma.

Attitudes toward disease and prognosis disclosure and decision making for terminally ill patients in Japan, based on a nationwide random sampling survey of the general population and medical practitioners.

OBJECTIVE: Employing a nationwide cross-sectional survey, we investigated the Japanese general population's attitudes toward disease and prognosis disclosure and related factors. Furthermore, we investigated Japanese medical practitioners' attitudes toward disease and prognosis disclosure for patients and decision making. METHODS: A nationwide anonymous questionnaire survey was conducted. A total of 5000 individuals were randomly sampled from the general population and 3104 physicians and 6059 nurses were randomly sampled in Japan. RESULTS: Finally, 2422 people from the general population (response rate, 48%), 1577 physicians (51%), and 3361 nurses (56%) returned questionnaires. Among the general population, 73% of participants answered that they "want to know" about their disease and prognosis when in an incurable disease state. Ninety percent desired direct disclosure and 8% disclosure through their family. However, few medical practitioners answered "patient himself" (physician 3%, nurses 4%) as the person whom they would primarily notify about the disease and prognosis when in charge of a patient with an incurable disease. On the other hand, physicians answered "family" most frequently (59%), whereas nurses most commonly responded, "depends on patient's condition" (63%). SIGNIFICANCE OF RESEARCH: Several detailed analyses of factors associated with prognosis disclosure were conducted. Japanese physicians need to carefully communicate with the patients individually about whether direct disclosure or disclosure primarily to the family is preferred.

Prognostic significance of [(18)F]fluorodeoxyglucose uptake on positron emission tomography in patients with pathologic stage I lung adenocarcinoma.

BACKGROUND: [(18)F]Fluoro-2-deoxyglucose uptake on positron emission tomography (FDG-PET) has been frequently used for diagnosis and staging of lung cancer. The prognostic significance of FDG uptake on PET was evaluated in patients with pathologic Stage I lung adenocarcinoma (tumor stages were based on the TNM classification of the International Union Against Cancer). METHODS: Disease-free survival of 98 patients with pathologic Stage I lung adenocarcinoma who were treated by curative resection was examined in relation to sex, age, histologic grade of differentiation, surgical procedure, tumor stage, and FDG uptake measured as the maximum standardized uptake value (SUV). RESULTS: Sixty-three patients were had Stage IA disease and 35 patients had Stage IB disease. Six patients each with Stage IA and Stage IB disease developed disease recurrence after a mean postsurgical follow-up period of 31 months. Ten (23%) of the 43 patients with SUV > or = 3.3 developed a recurrence compared with 2 (4%) of the 55 patients with SUV < 3.3 (P = .020). Ten (20%) of the 51 patients with moderately or poorly differentiated adenocarcinoma developed disease recurrence, compared with 2 (4%) of the 47 patients with well-differentiated adenocarcinoma (P = .056). Multivariate analysis demonstrated that histologic grade of differentiation was not correlated with the frequency of tumor recurrence (P = .286), whereas SUV was found to be marginally correlated (P = .079). CONCLUSIONS: FDG uptake appears to be predictive of disease-free survival in patients with Stage I lung adenocarcinoma. FDG uptake could yield important information for determining the likely value of postoperative adjuvant chemotherapy in such patients.

Obstructive subglottic granuloma after removal of a minitracheostomy tube.

We report herein a patient with subglottic granuloma after removal of a minitracheostomy tube (Minitrach II, SIMS Portex Inc., Hythe, Kent, UK). The patient underwent pulmonary resection for lung cancer followed by insertion of the minitracheostomy tube for prevention of sputum retention. The tube was removed 4 days after insertion. Twelve weeks later, the patient developed severe dyspnea and stridor. Bronchoscopy showed an obstructive subglottic granuloma arising from the anterior wall. The granuloma was removed by coring out using a conventional tracheal tube, followed by local injection of methylprednisolone acetate. The patient is now asymptomatic without regrowth of the granulation tissue 12 weeks after the treatment. With complication in mind, attention should be paid to patients suffering dyspnea or stridor after removal of a minitracheostomy tube.

Usefulness and complications of computed tomography-guided lipiodol marking for fluoroscopy-assisted thoracoscopic resection of small pulmonary nodules: experience with 174 nodules.

OBJECTIVE: Several techniques have been reported for the localization of small pulmonary nodules in thoracoscopic resection. In the present study we examined the usefulness and complications of computed tomography-guided lipiodol marking for thoracoscopic resection in our experience of 174 nodules. METHODS: Computed tomography-guided lipiodol marking was performed on 174 nodules less than 30 mm in size. Of these nodules, 45 showed ground-glass opacity images and 129 showed solid images on computed tomography. The mean size of the nodules was 10 +/- 6 mm (range, 2-30 mm), and their mean depth from the pleural surface was 10 +/- 7 mm (range, 0-30 mm). One to 7 days before thoracoscopy, all of the nodules were marked with 0.4 to 0.5 mL of lipiodol by using computed tomography. The marked nodules were grasped with a ring-shaped forceps during fluoroscopy and resected by means of thoracoscopy. RESULTS: All the nodules could be marked and localized by means of fluoroscopy as a clear spot during thoracoscopic surgery. Complications of the marking were chest pain requiring analgesia in 16 (11%) patients, hemosputum in 11 (6%) patients, pneumothorax in 30 (17%) patients, and hemopneumothorax in 1 (0.6%) patient. Eleven (6%) patients with pneumothorax required drainage, and the patient with hemopneumothorax required an emergency operation. No other complications were observed. CONCLUSION: Lipiodol marking is a useful, safe, and inexpensive procedure for localizing ground-glass opacity lesions, small pulmonary nodules, or both for thoracoscopic resection.

FDG-PET imaging for lymph node staging and pathologic tumor response after neoadjuvant treatment of non-small cell lung cancer.

PURPOSE: A number of studies have demonstrated that 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is effective for staging of lung cancer. However, the efficacy of FDG-PET for staging lung cancer after neoadjuvant treatment is still controversial. This study compared FDG-PET and computed tomography (CT) for lung cancer staging, and evaluated the ability of the two methods to predict the pathologic response of the primary tumor to neoadjuvant treatment. PATIENTS AND METHODS: Twenty-two patients who underwent neoadjuvant treatment followed by surgery were investigated. Eighteen patients received chemoradiotherapy and four patients received chemotherapy only. One hundred and three lymph node stations in the 22 patients were evaluated by FDG-PET and CT. The pathologic responses of the tumors were compared by FDG-uptake and tumor size on CT for the 15 patients who underwent FDG-PET and CT both before and after neoadjuvant treatment. RESULTS: There was no significant difference in the ability of FDG-PET or CT to predict residual viable tumor. Although positive predictive value by FDG-PET (0.29) was lower than that by CT (0.64) (p=0.04) in the mediastinal lymph nodes, there were no statistically significant differences in the other results of lymph nodes by FDG-PET and CT. Both decrease in FDG-uptake and decrease in tumor size by CT after neoadjuvant treatment correlated significantly with pathologic response in the 15 patients (p=0.003 and 0.009, respectively). CONCLUSION: FDG-PET did not appear to offer any advantages over CT for lymph node staging or for predicting the pathologic response after neoadjuvant treatment of non-small cell lung cancer.

A clinicopathological study of resected pulmonary nodules with focal pure ground-glass opacity.

OBJECTIVE: Pulmonary lesions with focal ground-glass opacity (GGO) have been detected increasingly by low-dose helical computed tomography (CT). However, the strategy of treatment for focal pure GGO lesions is still undecided. This study evaluates clinicopathological characteristics of resected pulmonary nodules with focal pure ground-glass opacity. METHODS: Between January 1997 and December 2005, 26 patients (35 lesions) with pure GGO lesions underwent pulmonary resection. The data on patient age, lesion size, pathology, carcinoembryonic antigen (CEA) level and palpability of the tumor in the resected specimen were evaluated. RESULTS: The histological diagnosis was bronchioloalveolar carcinoma (BAC) in 10 patients (12 lesions), atypical adenomatous hyperplasia (AAH) in 15 patients (22 lesions), and focal scar in 1 patient (1 lesion). There were no significant differences in age, sex, tumor size, and CEA level between the patients with BAC, AAH, and focal scar. However, the lesions >10mm in size were all BAC. Palpability of the tumor in the resected specimen was significantly more frequent in BAC cases than in AAH cases (p<0.01). For BAC, lobectomy was performed for four lesions, and limited resection for eight. None of the BACs showed lymphatic or vascular invasion upon pathological examination. At the median follow-up point of 44 months (range: 4-84 months), no recurrences were observed. CONCLUSIONS: BAC and AAH cannot be discriminated by their size. In the resected specimen, BAC lesions are more frequently palpable than AAH lesions. Thoracoscopic surgery is recommended for focal pure GGO after repeated CT even if the GGO lesion is small. Partial resection is a sufficient treatment for pure GGO.

Isolated unilateral absence of a pulmonary artery treated by pneumonectomy in an adult: report of a case.

Congenital unilateral absence of a pulmonary artery (UAPA) is a rare anomaly usually diagnosed in childhood. We report a case of isolated UAPA in an adult without any other cardiovascular anomaly. The patient was admitted for repeated progressive hemoptysis, which we treated with embolization of the bronchial artery three times, despite which the hemoptysis kept recurring. Finally, the patient was treated successfully by right pneumonectomy. Thus, we think that surgical intervention is indicated for recurrent hemoptysis in patients with isolated UAPA.

Positive imaging of thymoma by 11C-acetate positron emission tomography.

Several studies have shown that fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) is not useful for the diagnosis of thymoma. We describe 3 patients with thymoma who underwent both FDG-PET and carbon-11 (11C) acetate (AC)-PET. Although all three thymomas were successfully imaged by AC-PET, one of the thymomas was not imaged by FDG-PET. These results suggest that AC-PET may have a potentially important role in the diagnosis of thymoma. This is the first report of the use of AC-PET for diagnostic imaging of thymoma.

Extended resection of lung cancer invading the left subclavian artery by using cardiopulmonary bypass.

We treated a 54-year-old man with large cell carcinoma of the left upper lobe invading the esophagus and the left subclavian artery (SCA) from its origin. The tumor was completely resected by lobectomy under cardiopulmonary bypass. The left SCA was dissected at the aortic arch and reconstructed with a graft. The muscle layer of the esophagus was resected, followed by patching with an intercostal muscle flap. The pathological tumor stage was T4N0M0. The tumor recurred at two months after surgery in the neck lymph nodes and brain. Both sites were treated with radiation therapy and the patient is now alive without recurrence at 26 months after surgery. Lung cancer invading the great vessels and other mediastinal structures can be cured or long survival can be obtained by extended resection and postoperative adjuvant therapy.

False-positive findings on [18F]FDG-PET caused by non-neoplastic cellular elements after neoadjuvant chemoradiotherapy for non-small cell lung cancer.

We report two patients with non-small cell lung cancer who had a pathologically complete response after neoadjuvant chemoradiotherapy, although they had positive [(18)F]fluoro-deoxyglucose positron emission tomography ([(18)F]FDG-PET) scans. They underwent concurrent chemoradiotherapy, which resulted in a partial response determined by computed tomography (CT). While [(18)F]FDG-PET after chemoradiotherapy was positive, pathological examination showed that the tumors were fibrotic lesions with infiltration of lymphocytes and macrophages, with the appearance of metaplastic epithelial cells. The reasons for the false-positive results on [(18)F]FDG-PET were considered to be the high uptake of FDG in non-neoplastic inflammatory cellular elements, i.e. macrophages, lymphocytes and metaplastic epithelial cells, and squamous metaplasia induced by chemoradiotherapy. Although several studies demonstrated that [(18)F]FDG-PET could predict the response of neoadjuvant treatment of non-small cell lung cancer, one should bear in mind that false-positive results could be observed in pathological complete response of non-small cell lung cancer after neoadjuvant chemoradiotherapy.

Intrapulmonary schwannoma.

A 58-year-old woman was admitted due to an abnormal shadow on chest X-ray, without any symptoms. Chest computed tomography showed a round mass in the anterior segment of the right upper lobe. Segmentectomy was performed and histopathological examination revealed a primary neurogenic tumor of Schwann cell origin. Immunohistochemical staining demonstrated the presence of S-100 protein in the tumor cells. We present a case of intrapulmonary schwannoma and review 62 cases of primary schwannoma of the lung.