[Localized fibrous mesothelioma with bloody pleural effusion; report of a case].

Diffuse malignant mesothelioma with bloody pleural effusion is not rare, but a localized fibrous mesothelioma with bloody pleural effusion is relatively rare. A 45-year-old woman presented with a localized fibrous mesothelioma causing a bloody pleural effusion. Her chief complaint was right-sided lateral chest pain. A chest roentgenogram demonstrated a right-sided pleural effusion, so a chest tube was inserted, and the bloody fluid drained. A preoperative diagnosis of localized fibrous mesothelioma was made based on chest computed tomography and examination of computed tomographic guided percutaneous needle biopsy specimen. At operation, the tumor seemed to have originated from the right lung parenchyma or had invade the right lower lobe because tumor had penetrated deeply in the lung. Tumor and part of the parietal pleura were resected by right lower lobectomy. Final pathology established that the tumor was adherent to the right lung and was only encapsulated by the lung.

[A rational approach of limited resection for small peripheral lung adenocarcinoma with curative intent; analyses of multiple primary adenocarcinomas].

Hundred and forty-one small peripheral adenocarcinomas 2 cm or less in diameter were retrospectively studied to determine the rationale of limited resection with curative intent. We used a conventional computed tomography (CT) which used 2.5 mm thick sections to examine only the main tumor during from March 1985 to May 1999 and a spiral CT which produced 2.5 mm thick sections of the entire lung field during from June 1999 to July 2003. The incidence of small peripheral adenocarcinoma significantly increased from 12.6% to 29.1%, suggesting an increase in the rate of detection with spiral CTs. During the spiral CT era, the percentage of females, pathological stage I a tumors, predominant ground-glass opacity (GGO) tumors and limited resection were significantly higher. The incidence of multiple adenocarcinomas 2 cm or less in diameter significantly increased 2.6% to 14.1%. It increases to 21.9% in small adenocarcinomas and 63.6% in predominant GGO type, when minute GGO lesion which have been followed in 5 patients by a watch and wait policy would be bronchioloalveolar carcinoma (BAC). In conclusion, a paradigm shift of the treatment for small peripheral adenocarcinoma should be warrant, because localized BAC as noninvasive cancer is not rare and often found as multiple BACs.

[Analyses of multiple primary lung cancers; recent trend].

We studied multiple primary lung cancers (MPLCs) in 921 patients who had undergone operation for primary lung cancer since March 1979 in Mie University Hospital. There were 14 synchronous and 5 metachronous MPLCs. Combination of synchronous MPLCs were adenocarcinoma (ADC)/ADC in 7, squamous cell carcinoma (SCC)/SCC in 3, and ADC/adenosquamous cell carcinoma, ADC/small cell carcinoma, ADC/large cell carcinoma and multiple AAH in one. The incidence of synchronous MPLCs was 0.7% (6/815 pts) before May 1999 and 7.5% (8/106 pts) after June 1999 when HRCT was introduced for preoperative evaluation and postoperative follow-up. Six cases with multiple bronchioloalveolar carcinomas (BACs) have undergone operation for last 5 years. Most of them were roentgenographically occult and the operative outcome was good in spite of limited resection. In summary, we need new strategy of diagnosis and operative procedure for peripheral small adenocarcinoma, because multiple MPLCs of BAC are not rare.

[A case of thymoma with pure red cell aplasia].

A 71-year-old man was admitted to the hospital because of general fatigue. There were few reticulocytes in the peripheral blood and no erythroblasts in the bone marrow. Chest CT revealed an anterior mediastinal tumor. Under a diagnosis of thymoma with PRCA, extended thymothymectomy was performed. Histological diagnosis was mixed type thymoma with no invasive growth beyond the capsule. Administration of predonisolone following surgery was not effective for PRCA. Otherwise, peripheral blood counts were significantly improved following occasional onset of acute bronchitis.

[Completion pneumonectomy combined with graft replacement of thoracic aortic aneurysm by simple clamping].

A 59-years-old male patient who had left upper lobe partial resection 30 years ago. He was seen at the family physician because of cough. A chest X-ray was showing an abnormal mass shadow measuring 3 x 4 cm in left lower lobe like honey comb. And squamous cell carcinoma (SCC) was detected in his sputum. He was diagnosed as primary lung cancer and introduced to our department to have operation. Chest CT-scan was showing lung tumor suspected SCC measuring 4.3 x 2.6 cm in segment 8 faced chest wall. At the same time, we detected thoracic aortic aneurysm and subcarinal lymph node, but could not see where the boundary is, so it was hard to distinguish between parietal thrombus with thoracic aortic aneurysm and swelling subcarinal lymph node. We decided it swelling subcarinal lymph node by three-dimensional treated CT-scan. Aortic angiography was showing proximal descending aortic aneurysm measuring diameter was 4.5 cm. Abdominal CT-scan was showing infrarenal abdominal aortic aneurysm measuring diameter was 5.5 cm. He was diagnosed as primary lung cancer (It. S8, SCC) (cT2N2M0, Stage IIIB), thoracic aortic aneurysm, abdominal aortic aneurysm, and idiopathic pulmonary fibrosis, and had completion pneumonectomy (R 2 b) for primary lung cancer and graft replacement with aneurysm dissection for thoracic aortic aneurysm without extracorporeal circulation. In this operation, we could find swelling subcarinal lymph node measuring 5 x 3 cm instead of parietal thrombus with thoracic aortic aneurysm. Pathological examination diagnosed middle differential SCC and no metastasis from dissected lymph node (PT2N0M0, Stage I A).

[Results of surgical treatment for pT3 primary lung cancer].

We reviewed pT3 lung cancer for 86 cases (13.1%) out of 659 cases treated surgically for primary lung cancer between 1985 and march 1998. Five-year and ten-year survival rates for all pT3 cases were 48% and 40% respectively and those for pT3N0M0 cases were 67.2%. The operative mortality between 1990 and 1998 (2.4%) was better than that between 1985 and 1989 (6.7%). The extensive resection for pT3 lung cancer was evaluated to be appropriate. However, the prognosis of the patients who underwent combined resection of mediastinal pleura, pericardium or diaphragm was very poor. Five-year survival rate was significantly worse in patients with N2 disease (17.3%) than in patients with N0 disease (65.8%) (p < 0.05). Although the surgical indication for the patients with mediastinal pleura, pericardium or diaphragm disease and N2 disease is still controversial, there is not the extensive surgical indication.

[Selection criterion of limited operation for lung cancer as a radical operation].

We reviewed partial resection and segmentectomy for 75 cases (6.5%) out of 1,212 cases treated surgically for primary lung cancer between 1957 and 1996. The surgical results of limited operation in radicality group and risk group was comparable to that of standard operation for the stage I lung cancer. Five-year survival of clinical stage I non-small cell lung cancer patients that tumor size is 2.0 cm or less was excellent (88.9%). Although risk group may be the best candidates for limited surgery, careful patient selection and theoretical operative procedure could make limited operation a standard procedure in radicality group.

[Surgical treatment for primary lung cancer in octogenarians: the role of limited operations].

34 octogenarians out of 1,214 cases treated surgically for primary lung cancer in our unit between 1957 and 1996. 12 patients underwent limited operation because they had one or more risk factors besides their age actor. We could suppress postoperative complications in octogenarians. 5-year survival rate in octogenarians was comparable to that in younger patients. The octogenarians underwent limited operations were better than those had lobectomies in 5-year survival rate and postoperative quality of life. So our surgical strategy for primary lung cancer in octogenarians was evaluated to be appropriate. However, we should improve the radicality of limited operation furthermore because 5-year survival rate for stage I non-small cell lung cancer was poor in octogenarians than in younger patients.

Expression and degeneration of tenascin-C in human lung cancers.

Tenascin-C is an extracellular matrix glycoprotein produced in response to epithelial-mesenchymal interactions during organogenesis and tissue remodelling. It has therefore been proposed as a stromal marker for epithelial malignancy. To test this hypothesis, 30 human lung cancers, presenting a variety of clinicopathological features, and six specimens of normal tissue were examined by Western and Northern blotting of tenascin-C protein and mRNA. The results obtained were: (1) elevated tenascin-C expression was detected in all 30 cases by Western blotting, with mRNA increase in 22 of them; (2) mRNA for a large isoform of tenascin-C, including an alternatively spliced sequence, was expressed in lung cancer tissues but not in normal lungs; and (3) metastasis to lymph nodes was frequently found in cases whose tenascin-C was degraded into small fragments. These results suggest that tenascin-C degradation can be used as a marker for metastatic potential of a tumour.

Ongoing prospective study of segmentectomy for small lung tumors. Study Group of Extended Segmentectomy for Small Lung Tumor.

BACKGROUND: Lesser resection for small lung tumors remains an unresolved problem. This study was conducted to see whether this type of operation is acceptable or not. METHODS: From 1992 to 1994, 55 patients were enrolled in a multicenter trial of limited surgical resection for peripheral tumors of less than 2 cm diameter. The procedure consisted of segmentectomy with exploration of lymph nodes by examining frozen sections. The operation was modified if the report was positive. The intersegmental plane was identified by keeping the resected segments inflated and the preserved segments collapsed. To divide the plane, stapling or electrocauterization on the edge of the collapsed area was used. In this way the resection line was delivered beyond the burdened segment; this was called extended segmentectomy. RESULTS: There were no perioperative deaths, but there were eight postoperative deaths. In 1 patient who died because of local recurrence, it had been known that the margin to the lesion had been narrow (15 mm); 1 had bilateral intrapulmonary nodules, 1 had nodules in the side that was not operated on, and another succumbed to a second neoplasm of small cell lung cancer 4 years after the first operation. The remaining 4 died of nonpulmonary diseases. Almost all other patients are alive and free from recurrence, except for 1 in whom N2 disease was not detected intraoperatively but was confirmed after the operation. CONCLUSIONS: The interim results suggest that extended segmentectomy is applicable in patients with a small peripheral lung cancer. However, a wide margin and aggressive intraoperative pathologic examinations are mandatory.

[Surgical treatment of T4 primary lung cancer].

We investigated 257 T4 primary lung cancer patients who received operation in 30 hospitals of a lung cancer surgical therapy group of Chubu and present the results of questionnaires on the outcomes of surgical treatment for the T4 cases. T4 cases were classified as follows; 147 resections (57.4%); 110 exploratory thoracotomies (42.8%) ; 90 pleural dissemination and pleural effusions; 33 aorta; 30 left atrium and 17 superior vena cava. Survival rate of the T4 lung cancer patients in resection group and exploratory thoracotomy group were respectively 49.1% and 37.8% for one-year survival rate, and 15.1% and 4.7% for three-year survival rate. P of these two groups was 0.06 from Logrank test. Thirty three patients (21 resection and 12 exploratory thoracotomies) survived for two years and more. The number of cases by invasive organ was 17 pleural disseminations and effusion, 4 aorta, 4 left atrium and 3 mediastinum. We questionnaire on surgical operation for T4 cases with poor prognosis and obtained the result that half of the hospitals were positively performing surgery and the other half revealed a policy avoiding surgery.

[Treatments for T4 advanced lung cancer with invasion to the superior vena cava].

We discussed on the treatments for T4 lung cancer with invasion to the superior vena cava, whose prognosis has been poor. However, surgical resection may improve the prognosis compared with radiation therapy. The prosthetic replacement of superior vena cava can be done safely, and its patency is good in cases of ring-enforced ePTFE graft. Although superior vena caval obstruction syndrome had been a hard issue in the advanced cases, stenting in superior vena using the interventional radiological technique is a safe and reliable method. We should consider the stenting as the first choice for superior vena cava obstruction syndrome, because it makes the QOL improve so much.

Fulminant myasthenia gravis manifested after removal of anterior mediastinal tumor.

Myasthenia gravis developed in a 35-year-old man after removal of an encapsulated anterior mediastinal tumor that was preoperatively diagnosed as a teratoma based on a computed tomographic image. Postoperative pathologic diagnosis of the excised tumor was thymoma. The patient was in crisis after the initiation of immunosuppressive treatment. The therapy was changed to immunoadsorbent perfusion therapy because of concurrent severe pneumonia and an extremely high serum concentration of anti-acetylcholine receptor antibodies. Respiratory support was necessary for 2 months after reoperation.

Effects of inhaled nitric oxide in single lung transplantation in rats with monocrotaline-induced pulmonary hypertension.

BACKGROUND: The edema of grafted lungs during the early postoperative period is one of the serious complications of single lung transplantation for primary pulmonary hypertension. METHODS: The effectiveness of inhaled nitric oxide in single lung transplantation for primary pulmonary hypertension during the early postoperative period was evaluated with the use of rats with monocrotaline-induced pulmonary hypertension. In the inhaled nitric oxide group, rats were given 60 parts par million of nitric oxide for 24 hours just after left lung transplantation; in the no inhaled nitric oxide group, rats were kept without nitric oxide inhalation; in the control group, normal rats received left isografts. RESULTS: Three hours after transplantation, the mean pulmonary artery pressure of the no inhaled nitric oxide group (28.0 +/- 4.6) was significantly higher than that of the control group (23.3 +/- 0.9, p < 0.05) and the inhaled nitric oxide group (22.7 +/- 1.7, p < 0.05). On the first postoperative day, the mean left-to-right pulmonary blood flow ratio in the inhaled nitric oxide group was 0.34 +/- 0.03; it showed no significant difference to those of the other two groups, whereas that of the no inhaled nitric oxide group (0.42 +/- 0.14) was significantly elevated compared with that of the control group (0.14 +/- 0.03, p < 0.05). Histopathologically, the edema of the grafted lungs 24 hours after operation in the inhaled nitric oxide group was less severe than that in the no inhaled nitric oxide group. CONCLUSIONS: The postoperative use of inhaled nitric oxide is effective to reduce the pulmonary edema of the grafts in single lung transplantation for pulmonary hypertension by reducing acute pulmonary blood flow shift toward grafts after transplantation.

[Successful treatment of a giant bulla by thoracoscopic excision and laser ablation].

A 39-year-old male complaining of shortness of breath on mild exertion. Radiographs revealed that a giant bulla occupied more than half the area of the right lung field. Thoracoscopic excision of the giant bulla was performed using some autosutures. After the emphysematous lesion was consolidated by laser ablation, it was sutured using PDS thread. The bulla in the left lung was similarly excised 3 weeks after the first procedure. The FEV1.0% improved from 72% to 89% after excision and laser ablation of a giant bulla and bullae. Thoracoscopic excision and laser ablation of a giant bulla appears to be an effective alternative to conventional thoracotomy.

Surgery for T4 lung cancer: the prognoses of T4 lung cancer.

The prognoses of T4 lung cancer patients treated surgically were investigated in 76 patients. Extended resection was performed in 21 patients, palliative resection in 21 and exploratory thoracotomy in 34. Although the five-year survival of the extended resection group did not differ significantly from that obtained in the exploratory thoracotomy group, the mean survival time of the extended resection group was 3.1 months longer than that of the exploratory thoracotomy group. Two patients who had undergone resection for left atrial involvement, survived for two years or more, and a T4N0 patient with squamous cell carcinoma, in whom resection for aortic involvement was carried out, died from an unrelated disease after 15 months. Two patients with pleural dissemination, who underwent panpleuropneumonectomy, survived for two years. Surgical intervention did not improve the prognosis of patients with N2-squamous cell carcinoma, those with malignant effusion or those with multiple organ involvement.

Descending necrotizing mediastinitis secondary to a retropharyngeal abscess.

A rare case of descending necrotizing mediastinitis (DNM) secondary to a nontraumatic retropharyngeal abscess is reported. Even in the era of antibiotics, the mortality of DNM is still around 40%. In spite of drainage of a localized neck abscess, and the administration of systemic antibiotics, the retropharyngeal abscess extended to the pericardial and pleural cavities. Several drainage procedures and thoracotomies were performed to treat the bilateral empyemas and purulent pericarditis. The patient was discharged on hospital day 52. Computed tomography was used to follow the progression of disease, and assess the efficacy of treatment. DNM is a very aggressive form of mediastinitis. The importance of proper mediastinal drainage, as well as the systemic administration of antibiotics, must be emphasized.