A pulmonary sclerosing hemagioma with an increasing uptake on PET

Pulmonary sclerosing hemangioma is a relatively rare neoplasm of the lung. Although there have been five previous case reports that address the 18-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) findings in a sclerosing hemangioma of the lung, no report has demonstrated an interval change in the FDG-PET findings. This report describes a case of pulmonary sclerosing hemangioma which presented with an increase of uptake of FDG-PET after about one years' follow-up.

Surgical resection of a giant pericardial cyst showing a rapidly growing feature

This report presents an extremely rare case of a rapidly growing giant pericardial cyst which was surgically removed 20 years after the first detection. A 38-year-old asymptomatic male was referred because of rapidly growing mass on the right diaphragm. This lesion was detected about 20 years earlier and checked by a chest roentgenogram once a year. However, this lesion showed rapid growth over the last year, therefore surgical removal was performed. A pathological examination revealed this lesion as a giant pericardial cyst without inflammatory, hemorrhage or malignant cells. Therefore, there was no pathological explanation for the rapid growth of this cyst. In conclusion, general thoracic surgeons should be aware of the possibility of rapid growth, even if the diagnosis is a pericardial cyst.

Prognostic significance of intratumoral blood vessel invasion in pathologic stage IA non-small cell lung cancer

BACKGROUND

The 5-year survival rate of pathologic stage IA non-small cell lung cancer (NSCLC) is excellent; however, up to 10% of patients with pathologic stage IA NSCLC still relapse postoperatively and die. This study retrospectively analyzed the clinicopathologic features of patients with pathologic stage IA NSCLC to identify the prognostic factors and investigate the effect of a combination of intratumoral vessel invasion and tumor size.

METHODS

From December 1991 to December 2003, 217 consecutive patients with stage IA NSCLC were selected, and disease-free survival (DFS) was analyzed.

RESULTS

Intratumoral blood vessel invasion (BVI) was identified as an independent poor prognostic factor (p = 0.0006). The relative risk for patients with BVI was 4.599 times higher than that for patients without BVI (95% confidence interval, 1.913 to 11.056). According to the new T N M system, the difference in DFS between the patients with and without BVI was statistically significant, not only in tumors exceeding 2 cm (T1b with BVI vs T1b without BVI, p = 0.0020) but also in tumors smaller than 2 cm (T1a with BVI vs T1a without BVI, p < 0.0001). The survival curve of T1b patients without BVI was similar to that of T1a patients without BVI (p = 0.0892). Distant recurrence was frequently observed in both T1a and T1b patients with BVI.

CONCLUSIONS

BVI is an independent poor prognostic factor in patients with pathologic stage IA NSCLC. These T1a and T1b patients with BVI both might benefit from adjuvant chemotherapy.

Synovial sarcoma of the chest wall

We here report a rare case of synovial sarcoma of the chest wall. A 71-year-old Japanese woman noticed a left anterior chest wall mass after twice having had surgery for lung cancer. An aspiration biopsy diagnosed synovial sarcoma. She then underwent a surgical resection. Pathology examination revealed a biphasic-type synovial sarcoma. When the prepared RNA from the tumor was subjected to a polymerase chain reaction, SYT-SSX1 fusion gene transcripts were demonstrated. Patients with the SYT-SSX1 fusion gene have a worse clinical outcome than patients with SYT-SSX2-positive tumors. After a second surgery, performed in 1 year later, there was no evidence of recurrence for 30 months; however, careful observation may be required.

Results of a surgical resection of pulmonary metastasis from malignant head and neck tumor

There have been only a few reports about a surgical resection of pulmonary metastasis from malignant head and neck tumor. Here we investigate the survival after a pulmonary metastasectomy, and discuss the prognostic factors. We retrospectively reviewed 25 patients who underwent a pulmonary metastasectomy from malignant head and neck tumor at Kyushu University Hospital from 1981 through 2008. We assessed the five year overall survival by the Kaplan-Meier method and the log-rank (Mantel-Cox) test using the Stat View software program. The three- or five-year overall survival after a metastasectomy was 53.3% and 50.0%, respectively. We investigated the clinico-pathological prognostic factors including gender, age, histology, disease free interval, number or size of pulmonary metastatic tumors, and the operative procedure. Both age (older than 60 years) (P=0.0189) and pulmonary metastases from squamous cell carcinomas in either oral cavity or pharyngeal region (P=0.0002) were identified to be adverse prognostic factors. To obtain a long survival, a positive surgical resection is considered to be an effective and standard treatment for pulmonary metastasis from malignant head and neck tumor. It is also necessary, however, to elucidate fully the primary site and histology of such pulmonary metastasis.

Surgical resection of solitary cardiophrenic lymph node metastasis by video-assisted thoracic surgery after complete resection of hepatocellular carcinoma

This report presents the case of a patient that developed a postoperative metastatic tumor in the cardiophrenic lymph node as a rare pattern of distant lymph node metastases of hepatocellular carcinoma (HCC) after a complete resection. This is the case of surgically and pathologically proved cardiophrenic lymph node metastasis of HCC using video-assisted thoracic surgery. General thoracic surgeons should therefore be aware of the possibility of this rare form of extrahepatic recurrence when a growing nodule is found in the pericardial fat pad during the follow-up of a malignancy in the liver.

Long-term survival of a patient with type A thymoma and Masaoka's stage IV b: case report

Thymoma is the most common neoplasm in the anterior mediastinum. This report presents an extremely rare case of a type A thymoma with Masaoka's stage IV b due to lymph node metastasis. In 1997, a 59-year-old man underwent complete resection of a stage IV b type A thymoma with postoperative radiotherapy to the mediastinum. In 2006, small nodules were detected in the anterior mediastinum and above the right diaphragm and tumor resection was performed. The two lesions were both histologically diagnosed as recurrences of the type A thymoma. There has been no evidence of recurrence 15 months after the second surgery.

Clinicopathological significance of Sip1-associated epithelial mesenchymal transition in non-small cell lung cancer progression

BACKGROUND

Epithelial-mesenchymal transition (EMT) is a key event in cancer progression. The expression of EMT-related factors in non-small cell lung cancer (NSCLC) and their impact on clinicopathological variables was examined.

PATIENTS AND METHODS

A total of 137 NSCLC patients who underwent surgical resections were investigated. The expression of Twist, Snail, smad-interacting protein 1 (Sip1), E-cadherin, N-cadherin, vimentin and beta-catenin was detected by immunohistochemical analyses.

RESULTS

The expression of Sip1 was associated with the reduced expression of E-cadherin (p=0.04) and the positive expression of N-cadherin (p=0.04). There was no association between the expression of Twist nor Snail and the epithelial or mesenchymal markers. The expression of Sip1 correlated with advanced T status (p=0.01), tumor diameter (p=0.01) and advanced stage (p=0.01). Furthermore, the expression of Sip1 was associated with poor postoperative overall survival (p=0.02).

CONCLUSION

The expression of Sip1 is significantly associated with tumor growth and poor prognoses in NSCLC and EMT might be activated via Sip1 expression and result in accelerated tumor growth and poor survival in NSCLC.

[Primary nodular pulmonary amyloidosis]

A 58-year-old woman presented with nodule in the upper lung field on chest roentgenography. Computed tomography (CT) showed irregular nodule in the right upper lobe. The nodule was no accumulation on fluorodeoxyglucose positron emission tomography (FDG-PET). Video-assisted thoracic surgery (VATS) was done to be distinguished from primary lung cancer. Histologic examination showed that pulmonary nodule was consisted of amyloid protein.

Surgical resection of pulmonary malignant tumors after living donor liver transplantation

BACKGROUND

The aim of this study is to report on patients who developed tumor recurrence of the lung or de novo pulmonary malignancies after living donor liver transplantation (LDLT) and to show the benefit of a surgical resection for these pulmonary malignant tumors.

METHODS

A total 246 patients who underwent LDLT were investigated.

RESULTS

Pulmonary malignant tumors after LDLT were observed in 12 (4.9%) of 246 patients studied. These patients included 9 tumor recurrences and 3 de novo malignancies. The frequency of pulmonary recurrence was 9.4% (9 of 96 patients) and that of pulmonary de novo malignancies including 2 primary lung cancer and 1 mucosa-associated lymphoid tissue (MALT) lymphoma, was 1.2% (3 of 246 patients). Four of 9 recurrent patients could undergo surgical resections and the survival range in patients who received surgery was 17 to 56 months with a mean of 36 months after LDLT; on the other hand, the survival range in patients that could not undergo a surgical resection was 4 to 26 months with a mean of 18 months. Among the de novo malignancies, only the MALT lymphoma patient could undergo a surgical resection. Repeated surgical resections of pulmonary malignant tumors could be performed in 3 patients and all these patients have been long-term survivors.

CONCLUSIONS

These results suggest a surgical resection of pulmonary malignancies including tumor recurrences or de novo malignancies after LDLT is a feasible procedure and may prolong survival in selected patients, even under immunosuppressive conditions.

Endotracheal surgery for leiomyoma of the trachea

A 61-year-old male was found to have a tracheal tumor, which was noted at the time of screening by a chest X-ray study. The tumor arose from the membranous portion 4 cm above the carina and was proven by biopsy to be a leiomyoma. Because the disease is a benign tumor, all methods for resection, including bronchoscopic techniques, were thus considered. We performed an endotracheal operation via a window made by an incision of the cartilagenous portion, and removed the tumor through an anterior approach. This type of endotracheal operation is one of the surgical procedures for the removal of benign tracheal tumors.

Verification of the newly proposed T category (7th edition of the TNM classification) from a clinicopathologic viewpoint in non-small cell lung cancer

7533

Background: The proposed revision of the TNM classification by the International Association for the Study of Lung Cancer (IASLC) has been determined and validated based on the overall survival data. In the present study, we verified the T classification, which was the major point of revision regarding the newly proposed TNM classification, from a viewpoint of the clinico-pathologic findings at the primary tumor site. Methods: The medical records of 621 patients with primary non-small cell lung cancer (NSCLC) who underwent a complete resection at our institution from 1990 through 2003 were reviewed for the clinico-pathologic variables. The patients ranged in age from 31 to 87 years old with a mean of 66.4. The male:female ratio was 382:239. The adenocarcinoma:non-adenocarcinoma ratio was 449:220. Results: According to greatest dimension of the primary tumors, the 5-year postoperative survival was 77.8% for T1a (2cm>; n=168), 63.3% for T1b (3cm>; n=169), 46.4% for T2a (5cm>; n=205), 38.8% for T2b (7cm>; n=48), and 21.4% for T3 (7cm<; n=31) (p<0.001). The incidence of lymphatic permeation within the primary tumor was 12.5% for T1a, 17.2% for T1b, 29.8% for T2a, 35.4% for T2b, and 32.3% for T3 (T1b vs. T2a p<0.05). The incidence of vascular invasion within the primary tumor was 17.8% for T1a, 24.9% for T1b, 35.3% for T2a, 54.2% for T2b, and 64.5% for T3 (T1b vs. T2a, T2a vs. T2b, p<0.05). On the other hand, the incidence of pleural invasion of the primary tumor was 18.1 % for T1a, 29.4% for T1b, 49.3% for T2a, 47.3% for T2b, and 87.5% for T3 (T1a vs. T1b, T1b vs. T2a, T2b vs.T3, p<0.05). Significant differences were observed among the newly revised T subsets in at least one incidence of lymphatic permeation, vascular invasion or pleural invasion. Conclusions: The newly revised T classification, which is based mainly on the tumor dimension, is therefore considered both effective and appropriate for the pathological findings of the primary tumor.

No significant financial relationships to disclose.

[Case of solitary fibrous tumor of the pleura completely resected eleven years after detection]

A 65-year-old woman was referred to our hospital for investigation of increased opacity in the right lower lung field of the chest X-ray. Chest CT demonstrated a large tumor in the right thoracic cavity. A preoperative needle biopsy was performed. The microscopic appearance revealed many spindle cells. An immunohistochemical study was positive for CD34 and vimentin. Solitary fibrous tumor of the pleura was strongly suspected and the operation was performed. The tumor arose from the visceral pleura and was pedunculated. The resected specimen was positive for CD34 and vimentin. The tumor was diagnosed as solitary fibrous tumor of the pleura. Although this case was diagnosed 11 years after detection, the tumor was completely resected. Solitary fibrous tumors are usually cured with complete resection, but long-term clinical follow up is needed because of the possibility of recurrence and metastasis.

Current status of pulmonary metastasectomy from primary epithelial tumors

The resection of pulmonary metastases can prolong the survival of selected patients and its therapeutic value is now accepted. The criteria for eligibility have also evolved. We reviewed the recent literature on pulmonary metastasectomy for various epithelial primary tumors and tried to establish better prognostic indicators for its surgical application. In addition to the welldefined requisites for pulmonary metastasectomy, other requirements include the absence of mediastinal lymph node involvement, a limited number of pulmonary metastatic lesions, a long disease-free interval, small metastasis, and no elevation of tumor markers, although the clinical importance of each factor varies among the primary tumors. On the other hand, with the development of video-assisted thoracoscopic surgery (VATS) and advances in thoracic imaging technology, VATS metastasectomy might become an accepted treatment for metastatic nodules located in the periphery of the lung, which can be easily removed by a wedge resection. Repeat surgery is also possible during follow-up after VATS.

[Pulmonary granuloma possibly caused by a fish bone material]

We herein describe an extremely rare case of pulmonary granuloma possibly caused by a fish bone material. A 60-year-old woman with hemosputum was found to have a right pulmonary nodule. Chest computed tomography showed a nodule with pleural retraction, vascular convergence and ground glass opacity, measuring 23 mm in diameter, located at the S2 Of right upper lobe. Based on these findings, this nodule was considered to be a primary lung cancer, and pulmonary resection was performed. Macroscopically, a foreign material was found in the lesion and the pathologic diagnosis of the nodule was foreign body granuloma possibly due to a fish bone material.

Expression of mismatch repair proteins, hMLH1/hMSH2, in non-small cell lung cancer tissues and its clinical significance

BACKGROUND

hMLH1 and hMSH2 have been implicated to be involved in the DNA mismatch repair (MMR) system. The purpose of this study is to investigate the expression of hMLH1 and hMSH2 DNA MMR proteins in non-small cell lung cancer (NSCLC) tissue and to elucidate their clinical significance.

METHODS

The hMLH1 and hMSH2 protein expression was evaluated by immunohistochemistry for a consecutive series of 113 NSCLC patients. The expressions of each protein were examined for an association with the clinicopathological variables, including genetic alterations analyzed by high resolution fluorescent microsatellite analysis.

RESULTS

Regarding the hMLH1 expression, the MSI-positive patients showed significantly lower scores than the MSI-negative patients. For hMSH2 expression, the patients with a 20 or higher pack-year index (PYI) showed significantly higher scores than the patients with a PYI less than 20. The expression status of proteins did not affect both the disease free and overall survival of the patients. No significant correlation was observed among the scores for the proteins.

CONCLUSIONS

The expressions of hMLH1 and hMSH2 are independently regulated and play different roles in NSCLC. The genetic instability is possibly due to the reduced expression of hMLH1 protein, and hMSH2 expression is associated with smoking status.

Significance of the urinary 8-OHdG level as an oxidative stress marker in lung cancer patients

OBJECTIVE

In the present study, we investigated the relationship between the urinary excretion rate of the oxidized nucleoside 8-hydroxydeoxyguanosine (8-OHdG) and clinical factors in lung cancer patients.

METHODS

The present study included 100 patients, who underwent a lung surgery. The patients included 62 men and 38 women with a mean age of 65.5 years ranging from 35 to 82. The diagnosis included 81 primary lung cancers, 9 metastatic lung cancers and 10 benign lung diseases. Urine samples collected for 24h were analyzed for the content of 8-OHdG using an ELISA assay.

RESULTS

The urinary excretion rate of 8-OHdG in smokers was significantly higher than that in never-smokers. Specifically, the 8-OHdG excretion rate of current smokers was higher than that of patients who had quit smoking for longer than 1 month. Excluding current smokers, the urinary excretion rate of 8-OHdG did not relate to age or gender, but to the malignant potential of the disease. The urinary 8-OHdG level increased in the order of metastatic lung cancer, primary lung cancer and benign disease. In lung cancer patients, furthermore, the mean urinary 8-OHdG level of patients with stages II-IV disease was significantly lower than that of patients with stage I disease.

CONCLUSIONS

Smoking significantly increased the urinary excretion rate of 8-OHdG, suggesting that smoking causes an increased rate of oxidative DNA modifications. On the other hand, the capacity to repair oxidative DNA modifications might be impaired to some extent in cancer patients.

Serum carcinoembryonic antigen level is associated with epidermal growth factor receptor mutations in recurrent lung adenocarcinomas

BACKGROUND

The presence of epidermal growth factor receptor (EGFR) gene mutations is a good indicator of the clinical efficacy of gefitinib in patients with nonsmall cell lung cancer. It was recently reported that the serum carcinoembryonic antigen (CEA) level could be a predictive factor for the efficacy of gefitinib treatment; therefore, it is suggested that the EGFR gene mutation is associated with the serum CEA level. The current study analyzed the association between EGFR gene mutations and clinical features, including the serum CEA level, in patients with recurrent lung adenocarcinomas.

METHODS

A total of 48 lung adenocarcinoma patients with postoperative disease recurrence who underwent chemotherapy were investigated. EGFR gene mutations at exons 18, 19, and 21 were measured using surgical specimens taken from the primary tumor.

RESULTS

Mutations of the EGFR gene were detected in 25 of the 48 patients and the abnormal serum CEA concentration at the time of disease recurrence was found to be significantly associated with the incidence of EGFR gene mutations (P = .045). The rate of EGFR gene mutations significantly increased as the serum CEA level increased (serum CEA level; <5 vs > or =5 <20 vs > or =20 = 35% vs 55% vs 87.5%, respectively, P = .040). A multivariate analysis revealed that a higher serum CEA level at the time of disease recurrence is independently associated with EGFR gene mutations (P = .036) with an odds ratio of 4.70 (95% confidence interval, 1.1-21.1).

CONCLUSIONS

The serum CEA level appears to be closely associated with the presence of EGFR gene mutations in patients with pulmonary adenocarcinomas.

Pulmonary leiomyosarcoma presenting as a pancoast tumor

A patient presenting with Pancoast syndrome was definitely diagnosed to have pulmonary leiomyosarcoma. The patient underwent a right upper lobectomy combined with resection of the chest wall, including the 1st to 3rd ribs. The disease recurred rapidly at the local and distant sites. No previous reports about pulmonary sarcoma presenting as a Pancoast tumor were found in the literature. The possibility of primary pulmonary leiomyosarcoma should be considered, and early detection and surgical resection are necessary when a round or oval tumor with necrosis is observed in the apex of the lung.

Combined evaluation of Rad51 and ERCC1 expressions for sensitivity to platinum agents in non-small cell lung cancer

DNA repair enzyme expression in tumor cells possibly affects sensitivity to anti-cancer agents. The aim of this study was to determine the relationship between expression status of DNA repair enzymes and chemosensitivity in patients with non-small cell lung cancer (NSCLC). NSCLC tissues prepared from the surgical specimens of 41 patients were subjected to immunohistochemical analysis for Rad51 and ERCC1 proteins and to a chemosensitivity test using the MTT assay. The relationships between the expression status of the DNA repair enzymes and ex vivo chemosensitivity to various agents were evaluated. A positive expression for Rad51 and ERCC1 was observed in 17 cases (41%) and 20 cases (49%), respectively. The positivity of Rad51 was closely related to a certain histologic type of squamous cell carcinoma and poor differentiation, and the positivity of ERCC1 tended to be related to squamous cell carcinoma. In chemosensitivity tests, sensitivities to CDDP and CBDCA were significantly lower when both 2 enzymes were positive (p = 0.012 and 0.04 in CDDP, 0.014 and 0.03 in CBDCA). Both Rad51 and ERCC1 expressions showed no significant relationship with sensitivities to paclitaxel, etoposide, vinorelbine, gemcitabine, 5-FU, or irinotecan. In conclusion, combined expression of Rad51 and ERCC1 expression is associated with resistance to platinum agents in the ex vivo study of clinical NSCLC, and evaluation of expression status of both DNA repair enzymes would be a predictor for clinical response to platinum-based chemotherapies.

Induction of epithelial-mesenchymal transition-related genes by benzo[a]pyrene in lung cancer cells

BACKGROUND

It is believed that epithelial-mesenchymal transition (EMT) occurs during the development and progression of cancer; however, the correlation between tobacco smoking and EMT remains to be elucidated.

METHODS

Cells from the bronchioloalveolar carcinoma cell line A549 were exposed to benzo(a)pyrene (B[a]P) for 24 weeks, and morphology, proliferative activity, and gene expression profiles were analyzed.

RESULTS

Although no apparent morphologic changes were observed, the B[a]P-exposed A549 cells exhibited enhanced proliferative activity in 1% bovine serum that contained medium, and dramatic changes in expression levels were observed in a large number of genes. Of those, the expression of EMT-related genes, such as migration-stimulating factor, plasminogen activator inhibitor-1, fibronectin, twist, transforming growth factor-beta2, basic fibroblast growth factor, and electron transport system, were up-regulated; whereas gene expression of E-cadherin was decreased. Most enhanced expression levels remained 8 weeks after the retrieval of B[a]P in culture.

CONCLUSIONS

The current results indicated that B[a]P seems to induce EMT in lung cancer cells, and it also may drive disease progression in patients with lung cancer.

Hepatic lesion of invasive thymoma: possibility of direct invasion

Thymomas grow slowly but tend to invade the surrounding tissue. We herein report four patients with hepatic lesions of thymomas, which were thought to have directly invaded the liver. These patients had received combined modality treatments throughout the clinical course, and the hepatic lesions appeared a long time after the initial treatment - 11.8 years on average. In these patients, the prognoses after the appearance of hepatic invasion were poor. Appropriate local control in the early stages of the clinical course may therefore be essential for preventing the extrathoracic spread of invasive thymoma.

Toxic Shock Syndrome Following Thoracic Surgery for Lung Cancer: Report of a Case

Postoperative toxic shock syndrome (PTSS) caused by toxin-producing Staphylococcus aureus has incidentally been reported to be experienced following various surgical procedures or wounds. This syndrome includes sudden high fever, headache, muscle ache, a sunburn-like rash, hypotension, and tachycardia, while also often showing a rapid progression and a fatal outcome. To date, no such cases have ever been reported after thoracic surgery. We herein describe a highly probable case of PTSS in a 61-year-old man who underwent a pulmonary resection for lung cancer. The patient recovered after immediate and intensive antibiotic and steroid therapies. PTSS can occur incidentally even in the field of thoracic surgery; therefore, thoracic surgeons should be aware of this possible onset in order to recognize and treat this disease in a timely manner.

Combined evaluation of Rad51 and ERCC1 expressions for sensitivity to platinum agents in non-small cell lung cancer (NSCLC)

18085

Background: DNA repair enzyme expression in tumor cells possibly affects sensitivity to anti-cancer agents. The aim of this study was to determine the relationship between expression status of DNA repair proteins and chemosensitivity in patients with NSCLC. Rad51 and ERCC1 play important roles in repair of double and single strand breaks of DNA, respectively, and may protect cells from cytotoxic effect of platinum agents. Methods: NSCLC tissues prepared from the surgical specimens of 41 patients were subjected to an immunohistochemical analysis for Rad51 and ERCC1 proteins and to a chemosensitivity test using the MTT assay. The relationships between the expression status of the DNA repair enzymes and ex vivo chemosensitivity to various agents were evaluated. Results: A positive expression for Rad51 and ERCC1 was observed in 17 cases (41%) and 20 cases (49%), respectively. The positivity of Rad51 was closely related to a certain histologic type of squamous cell carcinoma and poor differentiation, and the positivity of ERCC1 tended to be related to squamous cell carcinoma. In chemosensitivity tests, sensitivities to CDDP and CBDCA were significantly lower when both two enzymes were positive (p = 0.012 and 0.04 in CDDP, 0.014 and 0.03 in CBDCA), but not when either or neither of them was positive. Both Rad51 and ERCC1 expressions showed no significant relationship with sensitivities to paclitaxel, etoposide, vinorelbine, gemcitabine, 5-FU, or irinotecan. Conclusions: Combined expression of Rad51 and ERCC1 is associated with resistance to platinum agents in the ex vivo study of clinical NSCLC, and evaluation of expression status of both DNA repair enzymes would be a predictor for clinical response to platinum-based chemotherapies.

No significant financial relationships to disclose.

The characteristics and failure pattern of gefitinib responders with postoperative recurrence of pulmonary adenocarcinoma

AIMS

Gefitinib shows prominent anti-tumor activity against advanced or recurrent non-small cell lung cancer (NSCLC). However, most gefitinib-responsive patients ultimately relapse. We reviewed postoperatively recurrent NSCLC patients who received gefitinib treatment, and analyzed both the clinical features and manifestations of treatment failure in patients who initially responded to gefitinib.

METHODS

From 2002 to 2006, gefitinib was administered to in 34 postoperative recurrent lung adenocarcinoma patients. There were 13 men and 21 women with a mean age of 65 years. Twenty patients had never smoked while 14 were former smokers. Epidermal growth factor receptor (EGFR) gene mutation was measured using surgical specimens of the primary tumor.

RESULTS

The study group showed 1 complete response, 16 partial responses, 7 stable diseases and 8 progressive diseases. Mutations of EGFR gene were detected in 20 of 34 patients. Only the presence of EGFR gene mutations was significantly associated with the clinical response of gefitinib in our limited study (p=0.036). In 9 of 12 responders, gefitinib treatment failed due to the appearance of new lesions.

CONCLUSIONS

Gefitinib was significantly effective for patients with mutations of the EGFR gene and most responders failed due to the appearance of new lesions without progression of the pre-existent target lesions.

Is oxygen supplementation needed after standard pulmonary resection for primary lung cancer?

OBJECTIVE

Theoretically, anatomical pulmonary resection does not cause any shunt effect, and thus it is thought that oxygen (O(2)) supplementation is not necessary after a pulmonary lobectomy or pneumonectomy. Without O(2) supplementation, we have streamlined our postoperative management for pulmonary resection. In the present study, we prospectively assessed our perioperative management for both requirement of O(2) supplementation and postoperative complications.

PATIENTS AND METHODS

From April 2003 to March 2005, 89 consecutive patients underwent a pulmonary lobectomy or pneumonectomy for primary lung cancer. Our protocol for perioperative care is as follows: [Preoperative] Smoking cessation longer than 2 weeks before surgery. [Intraoperative] Postero-lateral thoracotomy through the 5th or 6th rib bed. Cutting of the 5th or 6th intercostal nerve before closure of the wound. [Postoperative day (POD) 1] O(2) administration was discontinued in the morning. Ambulation without O(2) supplementation. [POD 2] Removal of an epidural catheter. During the postoperative period, percutaneous monitoring of O(2) saturation was continued.

RESULTS

The mean postoperative O(2) saturation of those 89 patients was 97.0% on the POD 1, 96.4% on the POD 2, 96.6% on the POD 3, and 97.5% on the POD 7. Only 3 patients required O(2) therapy after discontinuation of O(2) administration due to non-lethal pulmonary embolism. Depending on the duration of smoking cessation prior to operation, the patients were divided into 4 groups (2 weeks >, 1 month >, 1 month </=, and nonsmokers). Neither the incidence of postoperative complications nor the length of postoperative hospital stay was different among those 4 groups.

CONCLUSION

It is suggested that the postoperative O(2) supplementation is not routinely necessary.

Initial experience with video-assisted thoracoscopic surgery for pulmonary metastasis in the prone position

We performed video-assisted thoracoscopic surgery for pulmonary metastasis with the patient in the prone position because the use of the full lateral decubitus position was not possible owing to a deformity of the upper extremity, which existed because of a previous operation for osteosarcoma. In cases where the lateral decubitus position cannot be used, the prone position is both safe and effective for treating dorsal lesions of the lung by means of video-assisted thoracoscopic surgery.

Phase I study of amrubicin hydrochloride and cisplatin in patients previously treated for advanced non-small cell lung cancer

OBJECTIVE

A single-center phase I trial was designed to determine both the dose-limiting toxicities and the maximum tolerated dose (MTD) for amrubicin hydrochloride in combination therapy with cisplatin for advanced non-small cell lung cancer (NSCLC) patients with prior chemotherapy.

METHODS

Eligible patients received amrubicin and cisplatin on days 1 through 3 every 3 or 4 weeks. Cisplatin was administered at a fixed dosage of 20 mg/m(2) while the administered dose of amrubicin was started at 20 mg/m(2). Each group comprised 3 or 6 patients. When dose limiting toxicities were noted in three or more of six patients at a particular level, that level was estimated to be the MTD.

RESULTS

Fifteen patients were enrolled in this study, including 5 males and 10 females, with a median age of 57. The dose limiting toxicities included grade 4 neutropenia which lasted 4 or more days and febrile neutropenia. The non-hematologic toxicities were well managed and rarely severe. The MTD of amrubicin in this combination regimen was estimated to be 30 mg/m(2).A partial response was observed in 4 of 15 patients (27%).

CONCLUSIONS

The recommended dose was thus determined to be 25 mg/m(2) amrubicin with 20 mg/m(2) cisplatin for 3 consecutive days. A phase II study is currently underway.

Intrathoracic omental herniation through the esophageal hiatus in a young patient

We herein present a case of intrathoracic omental herniation through the esophageal hiatus in a young patient. A 21-year-old obese man was asymptomatic, and his chest X-ray demonstrated a large, sharply defined mass. A computed tomography scan of the thorax indicated a large retrocardial mediastinal mass in which the density indicated the presence of fatty tissue judging from the Hounsfield unit range. A thoracotomy was performed under a diagnosis of either mediastinal lipoma or liposarcoma with an encapsulated fatty mass, measuring 17 x 12 x 8 cm in size. The mass, however, proved to be an omental herniation through the esophageal hiatus. It is generally assumed that the major contributing factors leading an individual to develop an omental herniation through the esophageal hiatus include aging and obesity. This is the first report of omental herniation through the esophageal hiatus in a patient still in his twenties.

Malignant schwannoma of the upper mediastinum originating from the vagus nerve

BACKGROUND

Malignant schwannoma of the upper mediastinum originating from the vagus nerve is extremely rare.

CASE PRESENTATION

A 46-year-old female was admitted for a left cervical mass which was associated with both hoarseness and Horner's syndrome. Chest computed tomography showed a mass extending from the left upper mediastinum to the left supraclavicular area. A fine needle aspiration cytological examination suggested primary lung cancer stage IIIB large cell carcinoma. After administering induction chemo-radiotherapy, a complete surgical resection was performed. The tumor was found to involve both the left vagus nerve and the left sympathetic nerve. Histological examination of the resected specimen revealed the tumor to be malignant schwannoma.

CONCLUSION

Despite incorrect preoperative diagnosis, the multimodality treatment administered in this case, including induction chemo-radiotherapy and surgery, proved to be effective.

Serum carcinoembryonic antigen as a predictive marker for sensitivity to gefitinib in advanced non-small cell lung cancer

Gefitinib is an inhibitor of epidermal growth factor receptor tyrosine kinase, which has a tumour reducing effect in non-small cell lung cancer (NSCLC). In this study, we retrospectively reviewed the clinical data from 105 patients with advanced NSCLC treated with gefitinib at our department between May 2002 and April 2004. The overall response rate was 27.8% and the median survival time was 9.3 months. Pretreatment characteristics suggested that those with no history of smoking or an elevated serum carcinoembryonic antigen (CEA) level were more likely to be sensitive to gefitinib (P = 0.009). A multivariate analysis indicated good PS (P < 0.0001) and elevated serum CEA level (P = 0.0027) to be independent prognostic factors. These data show that the serum CEA level can be a predictive factor for the efficacy of gefitinib treatment while it is also a prognostic factor for advanced NSCLC patients undergoing this treatment.

Triplet Chemotherapy with Cisplatin, Gemcitabine and Vinorelbine for Malignant Pleural Mesothelioma

BACKGROUND

The incidence of malignant pleural mesothelioma (MPM) is expected to increase due to delayed control of occupational exposure to asbestos in Japan. We investigated the use of triplet combination chemotherapy with cisplatin (CDDP), gemcitabine (GEM) and vinorelbine (VNR) for the treatment of Japanese patients with MPM.

METHODS

From December 2000 to August 2003, 12 patients received the following regimen: CDDP 40 mg/m(2), GEM 800 mg/m(2) and VNR 20 mg/m(2) on days 1 and 8 every 4 weeks. Among the 12 patients, six selected patients underwent an extrapleural pneumonectomy (EP) after a median of three cycles of triplet chemotherapy.

RESULTS

The overall response rate for all patients and the response rate for chemotherapy-naive cases were 58 and 67%, respectively. The median survival time and survival rate at 2 years for all patients were 11 months and 50%, respectively. The 2-year survival rates for the patients with and without EP were 83.3 and 16.7%, respectively.

CONCLUSIONS

Triplet chemotherapy with CDDP, GEM and VNR was thus found to be highly effective for patients with MPM and its toxicity was manageable. A multi-institutional phase II trial is now being planned to establish the effectiveness of this new regimen in chemotherapy-naive patients with MPM.

Long-term survival after an aggressive surgical resection and chemotherapy for stage IV pulmonary giant cell carcinoma

BACKGROUND

Pulmonary giant cell carcinoma is one of the rare histological subtypes with pleomorphic, sarcomatoid or sarcomatous elements. The prognosis of patients with this tumor tends to be poor, because surgery, irradiation and chemotherapy are not usually effective.

CASE PRESENTATION

We herein report a patient with pulmonary giant cell carcinoma with stage IV disease in whom aggressive multi-modality therapy resulted in a long-term survival. A 51-year-old male underwent an emergent operation with a partial resection of small intestinal metastases due to bleeding from the tumor. The patient also underwent a left pneumonectomy due to hemothorax as a result of the rapid growth of the primary tumor. Thereafter, two different regimens of chemotherapy and a partial resection for other site of small intestinal metastases and a splenectomy for splenic metastases were performed. The patient is presently doing well without any evidence of recurrence for 3 years after the initial operation.

CONCLUSION

This is a first report of a rare case with stage IV pulmonary giant cell carcinoma who has survived long-term after undergoing aggressive surgical treatment and chemotherapy.

Long-term survivors in stage IV non-small cell lung cancer

BACKGROUND AND OBJECTIVES

To determine the prognostic factors for long-term survivors (LTS) with stage IV non-small cell lung cancer (NSCLC) who had undergone various treatments.

PATIENTS AND METHODS

From 1990 to 1999, 222 NSCLC patients with stage IV disease, who had been treated in our department, were reviewed. As the initial treatment, 135 patients (48%) were treated with chemotherapy alone, 52 patients with a combination of chemotherapy and radiotherapy, 19 patients underwent an operation with or without any other therapeutic modalities and 16 were received radiotherapy alone.

RESULTS

Seventeen (7.7%) patients survived for more than 2 years, and all but one had adenocarcinoma. Among these LTS, eight patients received surgery as the initial therapy, and 16 (94.1%) received some type of local-control therapy, including surgery or radiotherapy, during the course of their disease. Regarding the clinical characteristics between LTS and others (non-LTS), an early N status, a single metastatic site, a good performance status, and surgery for initial therapy were all found to be significantly important factors for LTS. A multivariate analysis using a logistic regression model also showed an early N status and surgical treatment to be significantly associated with LTS.

CONCLUSIONS

Selected patients with an early N status may be appropriate candidates for aggressive multimodality treatment including surgery, in order to provide a long-term survival for stage IV NSCLC.

The effects of pretreatment with donor antigen and immunosuppressive agents on fully allogenic tracheal graft

BACKGROUND

Obliterative bronchiolitis is a major clinical problem in cases involving a transplanted lung. We examined drug-induced tolerance to a fully allogenic tracheal graft in a murine heterotopic transplantation model.

MATERIALS AND METHODS

Recipient mice (C57BL/6) were primed iv with 1 x 10(8) splenocytes of donor mice (BALB/c). Day 0 was the day of the splenocyte injection. Cyclophosphamide and Busulfan were injected intraperitoneally on day 2. On day 3, 1 x 10(7) donor bone marrow cells were intravenously injected. On day 28, a donor tracheal graft was implanted into a subcutaneous pocket. Grafts were harvested at 3-week intervals, and the degree of obstruction of the inner cavity, the condition of epithelium, and the viability of chondrocytes were examined.

RESULTS

All of the isograft controls (BALB/c) and grafts implanted in the T cell-free recipients (BALB/c-nu) showed patent, lined epithelium and viable chondrocytes. All allografts tested showed total luminal occlusion by granulative tissue and inflammatory cells, and the epithelium was totally absent. Five of 11 drug-treated grafts were completely patent, although the epithelium was almost absent and the chondrocytes were substantially destroyed. However, when the chimerism was analyzed by flow cytometry analysis of the recipient T cells, approximately 90% of the donor cells were recognized.

CONCLUSIONS

Even by this pre-treatment-induced chimerism, a transplanted allogenic trachea was not completely preserved. The present results suggest that a non-allogenic response might have contributed to the rejection.