[Aneurysmal Bone Cyst of the Rib:Report of a Case].

We report a case of an aneurysmal bone cyst (ABC) originating in a rib. A 34-year-old woman was admitted to our medical department for evaluation of left rib pain and an abnormal shadow in the left 7th rib observed on chest radiography. Computed tomography (CT) revealed an osteolytic lesion involving the left 7th rib. Positron emission tomography/CT showed slight fluorodeoxyglucose uptake in the lesion. We performed 7th rib resection with a 4 cm margin from the tumor, including the intercostal muscles in the 6th and 7th interspaces. Histopathological examination of the resected specimen showed multiple blood-filled spaces and fibrous trabeculae, which confirmed the diagnosis of an ABC. The patient's postoperative course was uneventful. Although rare, clinicians should consider ABCs in the differential diagnosis of rib tumors.

[Xiphoidectomy in a Patient with Severe Xiphodynia Induced by Asthma Attack:Report of a Case].

Xiphodynia is a rare condition, and only a few reports of xiphoidectomy have been published. A 48-year-old male patient was admitted to our medical department because of xiphodynia induced by a severe asthma attack. Computed tomography showed that his xiphoid process protruded forward, with a xiphisternal angle of 160 degrees. It was suggested that the pain induced at severe asthma attack was caused by the prominent xiphoid process and we performed xiphoidectomy, The postoperative course was uneventful, and xiphodynia was dramatically improved.

[Salvage Surgery after Radical Chemotherapy for N3 Non-small Cell Lung Cancer].

A 49-year-old man was admitted to our hospital for an abnormal chest shadow. Computed tomography showed a pulmonary nodular shadow in the right upper lobe and swelling of the right hilar, mediastinal and supraclavicular lymph nodes. A positron emission tomography(PET) scan showed fluorodeoxyglucose accumulation in the tumor and swollen lymph nodes. He was diagnosed with stage cT1aN3M0 (ⅢB) pulmonary adenocarcinoma and was treated with a combination of cisplatin and paclitaxel. After 6 cycles of chemotherapy, serum carcinoembryonic antigen (CEA) level was markedly decreased. A PET scan showed fluorodeoxyglucose accumulation only in the primary site. He was diagnosed with stage ycT1aN0M0(ⅠA) disease, and the salvage surgery was scheduled. As chemotherapy had resulted in severe fibrosis of the lung hilum, he underwent a partial resection. After partial resection of the right upper lobe, he has been alive without recurrence for 8 years.

[Hourglass Transmural Lipoma;Report of a Case].

This case report describes a 73-year-old male with an hourglass-type transmural lipoma who was referred because of an abnormal chest shadow. Computed tomography showed a well-defined fatty mass within the intra-and extra-thorax at the right 3rd intercostal portion. Magnetic resonance imaging showed a high-intensity mass that had the same signal level as fat tissue. Therefore, the tumor was diagnosed as an hourglass transmural lipoma. Tumor resection was performed with video-assisted thoracic surgery, and 3rd intercostal muscle tissue approximately 1cm from the tumor border was also resected. The tumor was 6.5×4.5×3.0 cm in size, and histologically diagnosed as an intramuscular lipoma-infiltrating type, without malignancy. Since infiltrating types of intramuscular lipoma often cause recurrence without malignant appearance, tumor specimens require careful examination. Thoracoscopic surgery was useful to determine the excision line from the intra-thorax, for complete resection of the hourglass tumor.

[Complete Transection of the Cervical Trachea due to Blunt Trauma: Report of a Case].

We herein report a case of complete transection of the cervical trachea due to blunt trauma. A 50-year-old man was transported to our hospital because of blunt neck trauma. His body surface showed only slight bruising on the neck. However, he exhibited see-saw breathing, so we suspected upper airway injury. The patient was carefully intubated using a bronchofiberscope, revealing complete transection of the cervical trachea. Chest computed tomography demonstrated destruction of the cervical tracheal structure. The patient also had a cervical spinal cord injury;thus, we performed tracheoplasty after 3 days of hospitalization. A tracheostomy was necessary because of the cervical cord injury and paralysis of the bilateral recurrent nerve. The patient's postoperative course was uneventful.

[Mediastinal bronchogenic cyst causing severe tracheal stenosis].

An 86-year-old female patient was transported to our hospital because of progressive dyspnea. Computed tomography revealed a 7-cm-diameter low-density mass located in the upper mediastinum behind the trachea. The mass compressed the trachea and caused severe tracheal stenosis. We diagnosed the tumor as a paratracheal type of bronchogenic cyst. The patient was immediately intubated, and a semiemergent operation was performed. Because of her advanced age, minimally invasive surgery was considered. The cyst was partially resected for fenestration. Just after the operation, the patient was extubated and became asymptomatic. The postoperative course was uneventful, and the patient was discharged from the hospital on the 14th postoperative day. The tumor was histologically diagnosed as a bronchogenic cyst. Six months after the operation, she was still asymptomatic.

[Langerhans cell histiocytosis of the rib in adult male].

A 57-year-old man was admitted to our hospital with an abnormal shadow on chest X-ray film. Computed tomography (CT) scanning demonstrated a low-density, destructive mass on the right 8th rib. The maximum standardized uptake value of the tumor measured by positron emission tomography (PET) was 2.9, indicating malignancy. Wide resection of the tumor, including the right 8th rib and the 7th to 8th intercostal muscle, was performed. Chest wall reconstruction was achieved with Composix Mesh. The histologic findings revealed proliferation of histiocytes and eosinophil infiltration. No malignant cells were detected in the tumor. Histiocytes stained for S-100 protein and CD1a, compatible with a diagnosis of Langerhans cell histiocytosis (LCH). LCH in the ribs is very rare and difficult to diagnose using CT or PET. Tumor biopsy or resection is needed to diagnose LCH.

Long-term survival after removal of a malignant peripheral nerve sheath tumor originating in the anterior mediastinum.

Malignant peripheral nerve sheath tumors (MPNSTs; malignant schwannomas) rarely occur in the anterior mediastinum, and their prognosis is poor. A 75-year-old man was referred to our hospital for examination of an anterior mediastinal tumor. A computed tomography-guided percutaneous needle biopsy revealed only fibrosis. The tumor was completely excised via a median sternotomy with partial resection of the pericardium and right upper lobe of the lung. Thereafter, the tumor was diagnosed as a storiform-pleomorphic type of malignant fibrous histiocytoma. At 1 year after the surgery, a distant metastasis was found in the interlobular space between the right middle and lower lobes. The tumor was completely excised via a right posterolateral thoracotomy. Reexamination of the primary and secondary tumors revealed an MPNST. No recurrence was found up to 5 years after the second surgery without adjuvant chemotherapy or radiation therapy. However, he died from multiple lung metastases after 6 years.

[Endobronchial metastasis from renal cell carcinoma resected 9 years before; report of a case].

A 68-year-old man, who had undergone a left nephrectomy for a clear cell type renal cell carcinoma (RCC) in June 1995 and then received interferon therapy till March 1997, was admitted with dyspnea in June 2004. Chest X-ray showed atelectasis of the left lower lung lobe and chest computed tomography revealed a polypoid mass in the left lower bronchus. He was diagnosed with a pulmonary metastasis of a RCC by transbronchial biopsy. We considered it a slow growing type of RCC because of the long disease free interval (DFI). A left lower lobectomy with bronchoplasty was carried out. However, 6 month after the operation, a new lesion has occurred near the portion of the broncho-anastmosis and multiple metastases have developed in the right lung.

Matrix metalloproteinase inhibitor (ONO-4817) attenuates ischemia-reperfusion injury in rat lung.

BACKGROUND: Ischemia-reperfusion injury of the lungs seems to be initiated by the activation of alveolar macrophages, and mediated by matrix metalloproteinases (MMP)s, although their roles have not been fully elucidated. Therefore, we used a novel MMP inhibitor (ONO-4817) with high affinities for MMP-2 and MMP-9 to investigate the roles of MMPs in reperfusion injury of the lungs. MATERIAL/METHODS: After 18 h of cold ischemia, isolated rat lungs were ventilated and reperfused. Lungs without ischemia served as controls. Lungs were reperfused with fresh blood with or without the MMP inhibitor for 120 min at 37 degrees C. RESULTS: The oxygenation capacity of lungs after ischemia deteriorated progressively during 120 min of reperfusion, but was preserved by the MMP inhibitor (p<0.05). The histopathology of the lungs after ischemia-reperfusion showed interstitial edema accompanied by neutrophil migration, and the number of neutrophils, but not macrophages, in the broncho-alveolar lavage increased to more than two-fold the value in control lungs without ischemia (p<0.01). These changes were attenuated by the MMP inhibitor (p<0.01). Similarly, an increase in the tissue malondialdehyde level in lungs after ischemia-reperfusion was ameliorated by the MMP inhibitor (p<0.01). The expressions of CD11c and CD31 adhesion molecules in extracted alveolar macrophages increased in lungs after ischemia-reperfusion compared with control lungs without ischemia, and the MMP inhibitor had no obvious effect. CONCLUSIONS: Our data show that ONO-4817 prevented neutrophil migration into the interstitial space and alveolus in the lungs, and reduced the production of oxygen free radicals, suggesting that this is an important mechanism in reperfusion injury.

MCI-186 (edaravone), a free radical scavenger, attenuates ischemia-reperfusion injury and activation of phospholipase A(2) in an isolated rat lung model after 18 h of cold preservation.

OBJECTIVE: Increased microvascular permeability and extravasation of inflammatory cells are key events in ischemia-reperfusion (IR) injury. We hypothesized that edaravone, a free radical scavenger, is able to attenuate IR lung injury by decreasing oxidative stress and phospholipase A(2) (PLA(2)) activation, which otherwise may lead to lung injury through PAF receptor (PAF-R) activation. METHODS: We used an isolated rat lung model. Five groups were defined (n=7, each): in the sham and vehicle group, lungs were immediately washed after thoracotomy or perfused for 2h without an ischemic period, respectively. In the ischemic groups, 10mg/kg of MCI-186 (edavorane group), 1mg/kg of PAF-R inhibitor (ABT-491 group) or saline (control group) were i.v. administered 20 min before harvest. Lungs were flushed with LPD solution, stored at 4 degrees C for 18 h, and reperfused for 2h. RESULTS: Compared to vehicle group, IR significantly decreased the PO(2) level and increased the wet-to-dry ratio, proteins in bronchoalveolar lavage (BAL), and myeloperoxidase (MPO) activity in the control group, while edaravone treatment maintained the PO(2) similar to the vehicle group and significantly reduced edema formation and neutrophil extravasation. Consistently, IR significantly increased lipid peroxidation, cytosolic-PLA(2) activity mainly via alveolar macrophages, soluble-PLA(2) activity, leukotriene B(4), and PAF-R expression in control lungs, together with a decreased PAF acetylhydrolase (PAF-AH) activity. Edaravone significantly reduced all of these, but increased PAF-AH activity. Furthermore, pharmacological inhibition of the PAF-R attenuated IR injury resembling edaravone action. CONCLUSION: Edaravone attenuates lung IR injury by suppressing oxidative damage and PLA(2) activation, which otherwise partially mediates edema formation and neutrophil extravasation through PAF-R activation.

Aprotinin attenuated ischemia-reperfusion injury in an isolated rat lung model after 18-hours preservation.

OBJECTIVE: Ischemia-reperfusion injury is a major factor in the early phase of lung transplantation. We hypothesized that aprotinin, a nonspecific serine protease inhibitor, attenuates ischemia-reperfusion lung injury by inhibiting the inflammatory response and suppressing NADPH oxidase. METHODS: We used an isolated rat lung model to test the above. A Control group was immediately perfused with fresh heparinized allogeneic blood after lung harvest without an ischemic period. Study lungs were flushed with low-potassium dextran (LPD) solution and stored for 18h at 4 degrees C then divided into two groups: the LPD group was flushed with LPD solution only, and the LPD+A group was flushed with LPD solution +200KIU/ml aprotinin. Lungs in all three groups were then reperfused with fresh heparinized allogeneic blood for 120min at 37 degrees C. RESULTS: Throughout reperfusion, PO(2) levels in the LPD+A group were similar to those in the Control group; although in the LPD group, PO(2) levels were significantly lower (P<0.05). Tissue MDA levels were significantly higher in the LPD group than the Control and LPD+A groups (P<0.05). IL-8 levels were significantly higher in the LPD group than the Control group (P<0.05), while in the LPD+A group they were similar to those in the Control group. Histological evaluation showed interstitial edema accompanied by neutrophil extravasation in the LPD group, whereas this effect was modest in the LPD+A group. An additional study of ischemia-reperfusion in an alveolar macrophage culture showed that the activitvation of NADPH oxidase, and translocation of p47(phox) from the cytosol to the membrane were suppressed in aprotinin group. CONCLUSIONS: Aprotinin attenuates ischemia-reperfusion lung injury by inhibiting the early inflammatory response, neutrophil extravasation and the production of oxygen free radicals through inhibition of the activation of the NADPH oxidase. The inhibition of p47(phox) translocation in alveolar macrophage seemed involved in this mechanism of aprotinin.

Criteria for intentional limited pulmonary resection in cT1N0M0 peripheral lung cancer.

OBJECTIVE: The purpose of this study was to establish selection criteria for intentional limited resection in patients with peripheral lung cancer. METHODS: Six hundred eighty-nine cases of cT1N0M0 peripheral non-small cell lung cancer were divided into groups according to maximum tumor diameter. The cases in each group were examined for histopathological invasive factors, and the results of a pilot study of intentional limited resection were assessed. RESULTS: The positive rate of invasive factors was 30.8% among the patients with tumors 2 cm or less in diameter, and significantly lower than the 44.0% noted in those whose tumor diameter was in the 2.1-3.0 cm range. The positive rate was significantly lower in 90 patients with type A or B adenocarcinoma, and none of these patients developed postoperative recurrence. In 24 of these 90 patients, the tumor diameter was in the 2.1-3.0 cm range. The 5-year survival rate in the 74 patients with pT1N0M0 and tumors 2 cm or less in diameter who underwent limited resection was 89.1%. CONCLUSIONS: We attempted to establish selection criteria for limited resection, with the aim of obtaining survival rates that was comparable to those obtained after lobectomy. The selection criteria established in this study are: 1, cT1N0M0 peripheral non-small cell lung cancer; 2, maximum tumor diameter 2 cm or less on diagnostic images, but a tumor diameter in the range of 2-3 cm in adenocarcinoma of Noguchi type A or B cases; 3, limited resection feasible based on tumor location.

Chondrosarcoma of the rib.

A 73-year-old woman evidencing an abnormal shadow on chest X-ray film since 1993 was admitted after a tumor of the left 8th rib was diagnosed in 2001. Computed tomography showed a low-density mass with coarse calcification arising from the left 8th rib and protruding into the abdominal cavity. The tumor was diagnosed as low-grade chondrosarcoma by incision biopsy and was resected together with the left 7th, 8th, and 9th ribs. The chest wall was reconstructed using Marlex mesh. Histological findings were compatible with Grade I chondrosarcoma. The patient had a long clinical course without distant metastasis thanks to the tumor's low malignancy.

Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer.

OBJECTIVE: The present study was undertaken to demonstrate that limited pulmonary resection for peripheral small-sized lung cancer yields outcomes not inferior to those of lobectomy. METHODS: During the 9-year period from 1992 to 2000, patients with cT1 N0 M0 peripheral non-small cell lung cancer whose maximum tumor diameter was 2 cm or less on diagnostic imaging and in whom lobectomy was determined to be feasible were treated with limited resection if the patient consented to the procedure and with lobectomy if consent to limited resection was not obtained. The survival and clinical outcome of the patients whose tumors were postoperatively staged as pT1 N0 M0 were compared between the limited resection group (n = 74) and the lobectomy group (n = 159). RESULTS: The limited resection group consisted of 60 patients treated with segmentectomy and 14 patients treated with wedge resection. Among patients followed up for a mean period of 52 months after the operation, neither the 3-year nor 5-year survivals differed significantly between the limited resection group (3-year survival, 94.0%; 5-year survival, 89.1%) and the lobectomy group (3-year survival, 97.0%; 5-year survival, 90.1%). Postoperative tumor recurrence was noted in 5 patients after limited resection and in 9 patients after lobectomy, and the difference in the incidence of postoperative recurrence between the 2 groups was not significant. CONCLUSIONS: The results of this study indicate that in patients with peripheral T1 N0 M0 non-small cell lung cancer whose maximum tumor diameter was 2 cm or less, the outcome of limited pulmonary resection is comparable with that of pulmonary lobectomy.