Assessment of pleural air leakage using digital chest drainage system after surgical pulmonary resection: Comparison of visible alveolar air leakage with the digital value measured by a digital chest drainage system

Background

The sensitivity of postoperative pleural air leakage (PAL) after pulmonary resection is evaluated by a simple subjective grading method in clinical practice. A new electronic digital chest drainage evaluation system (DCS) recently became clinically available. This study was designed to evaluate the clinical application of the DCS in monitoring the airflow volume and managing postoperative PAL.

Methods

We prospectively enrolled 25 patients who underwent pulmonary resection. Postoperative PAL was evaluated using both conventional PAL grading based on the physician’s visual judgment (analog chest drainage evaluation system [ACS]: Level 0 = no leakage to 4 = continuous leakage) and the DCS. The DCS digital measurement was recorded as the flow volume (ml/min), which was taken once daily from postoperative day 1 to the day of chest drainage tube removal.

Results

In total, 45 measurements were performed on 25 patients during the evaluation period. Postoperative PAL was observed in five patients (20.0%) and judged as ACS Level >1. The mean DCS values corresponding to ACS Levels 0, 1, 2, and 3 were 2.42 (0.0–11.3), 48.6 (35.4–67.9), 95.6 (79.7–111.5), and 405.3 (150.3–715.6), respectively. The Spearman correlation test showed a significant positive correlation between the ACS PAL level and DCS flow volume (R = 0.8477, p < 0.001).

Conclusions

A relationship between the visual PAL level by the ACS and the digital value by the DCS was identified in this study. The numeric volume obtained by the DCS has been successful in information-sharing with all staff. The digital PAL value evaluated by the DCS is appropriate, and the use of the DCS is promising in the treatment of postoperative PAL after pulmonary resection.

Primary intrapulmonary thymoma

Primary intrapulmonary thymoma (PIT), which is an intrapulmonary tumor without an associated mediastinal component, is rare. We herein report a resected case of PIT in a 55-year-old female who presented with a 2.5 × 2.4 cm mass in the left upper lobe. We also summarize the clinicopathological features and discuss the diagnosis, pathogenesis, and treatment of PIT.

[A case of long-term survival following combined modality therapy for peritoneal disseminated recurrence of duodenal cancer]

A 65-year-old man was diagnosed with primary duodenal cancer and he underwent pancreaticoduodenectomy in June 2006. S-1 was administered as the postoperative adjuvant chemotherapy. A peritoneal disseminated recurrence was diagnosed together with a right reniportal node and right hydronephrosis in February 2007. A ureteral stent was inserted. DOC +S-1 combination therapy was administered from March 2007. Following progression of the recurrence, CDDP+S-1 combination therapy was administered from August 2007. Temporal diminution of the recurrence was achieved with radiotherapy from May to June 2009. Following re-progression of the recurrence, biweekly CPT-11 therapy was administered from February 2010. Weekly PTX therapy was administered from January 2011. The patient died due to progression of the recurrence in June 2011, 5 years after the operation. Our patient maintained a good quality of life and achieved long-term survival by combined modality therapy for peritoneal disseminated recurrence of duodenal cancer.

[A case successfully treated with abdominoperineal resection after preoperative chemoradiation therapy for anal cancer]

A 46-year-old female was diagnosed with anal squamous cell carcinoma. Chemoradiation therapy was administered for a first-line therapy. Two courses of enforced 5-FU/MMC combination therapy were administered along with radiotherapy (60 Gy). This chemoradiation therapy had complete response. However, three months after, anal cancer had a local recurrence. Since there was no distant metastasis, abdoninoperineal resection was performed. No complications were observed after the operation. We conclude that abdominoperineal resection may be effective in the treatment of anal cancer in cases which the local recurrence was observed after chemoradiation therapy.

[A case of long-term survival by combined modality therapy for liver and pulmonary metastasis of rectal cancer]

We report a case of rectal cancer diagnosed in 2001, which enforced a rectal low anterior resection. Then, metastatic liver cancer and metastatic lung cancer recurred and we enforced an operation for both. Furthermore, metastatic lung cancer recurred again and enforced chemotherapy with radiation and systemic chemotherapy for approximately seven years. The metastatic lung cancer was reduced now in 2011, so that the chemotherapy has not been used since then. In our case, we mainly performed a surgical and radiation therapy for a local recurrent site therapy in the first half because we did not have much choice for a systemic chemotherapy like we have now. In the later half, we mainly performed a systemic chemotherapy to control the local recurrent site. A treatment policy for colon cancer recommends a surgical treatment by the guidelines, or even though chemotherapy has been developed at present, if a local therapy is practical. There were many cases where metastases had occurred right after surgery so a local site therapy by excision was good at all unconditionally. However, as a result of our case in a local site therapy combined with whole body chemotherapy, we report here that a long- term survival was obtainable. We also include a brief literature review.

[A case of elderly advanced gastric cancer patient with multiple liver metastases effectively treated by hepatic arterial infusion chemotherapy]

An 85 years old man was performed systemic chemotherapy after the palliative gastrectomy for unresectable gastric cancer with multiple liver metastases. The response evaluation revealed a progressive disease after 4 courses of first-line S-1 therapy and 3 courses of second-line paclitaxel therapy. At this point, metastatic lesions were still localized in the liver, so hepatic arterial infusion chemotherapy (HAI) was introduced as third-line therapy. Despite the marked reduction of all target lesions and reduced tumor marker level after 25 weeks of HAI without any adverse event, novel multiple metastatic lesions had appeared in the lung and celiac LNs, resulted in the cessation of HAI. Then he had suffered grade 3 mucositis oral and anorexia throughout 2 courses of fourth-line S-1 + CDDP therapy and fifth-line docetaxel therapy. Considering that the goal of treatment for unresectable gastric cancer patients is to delay developing symptoms and to prolong their life with the least adverse event, HAI could be an effective therapy.

[A long-term survival after hepatectomy combined with hepatic arterial infusion chemotherapy for hepatic metastasis of colon cancer]

We report on a patient who presented in 2000 with multiple hepatic metastasis of sigmoid colon cancer. We chose the hepatic arterial infusion chemotherapy for this case since there was no effective chemotherapy at that time. After the intermittent chemotherapy for one and half years, we recognized that the tumor became smaller, though it couldn't cure completely. Therefore, two years after the first medical examination, we underwent a hepatic left lobectomy and S8 hepatectomy. No recurrence has been observed until now. As a recent treatment of the hepatic metastasis of colon cancer, there is a tendency to choose chemotherapy before operation. However, there are some cases in which chemotherapy isn't acceptable because of its side effect. Besides chemotherapy, we report another treatment (the hepatic arterial infusion chemotherapy) which has a similar effectiveness with fewer side effects for the hepatic metastasis of colon cancer.

[A case successfully treated with subtotal esophagectomy after preoperative second-line chemotherapy for cT4 esophageal cancer]

A 69-year-old male was diagnosed with type 2 advanced esophageal cancer in the upper and middle thoracic esophagus which invaded the left main bronchus and the aorta. Radio-chemotherapy was administered since a radical resection could not be performed due to the invasion. Two courses of enforced FP combination therapy (5-FU and CDDP) were administered along with radiotherapy. Although this radio-chemotherapy was effective to some degree in tumor reduction, a radical resection still could not be performed due to the invasion of the left main bronchus and the aorta. Thus, we administered four more courses of DCF combination therapy (docetaxel, CDDP and 5-FU). This chemotherapy reduced the esophageal cancer mass significantly, and subtotal esophagectomy was performed. No complications were observed after the operation. We conclude that DCF combination therapy may be effective in the treatment of esophageal cancer in cases which the desired effect cannot be achieved by FP combination therapy alone.

[Two cases, of pulmonary sclerosing hemangioma, and peripheral lung carcinoid, in which the diagnoses were difficult by intraoperative frozen section examinations]

Case 1: A 38-year-old man was referred to our hospital because of a chest nodular shadow found on a medical check-up. Chest CT showed a mass about 2 cm in diameter with a sharp margin in the right S6 segment. Right lower lobectomy was performed by video-assisted thoracoscopic surgery, because the mass was thought to be a peripheral lung carcinoid by intraoperative frozen section examination. However, the postoperative histopathological diagnosis was pulmonary sclerosing hemangioma with lymph node metastasis. Case 2: An 81-year-old woman was referred to our hospital because of a chest nodular shadow found on a medical check-up. Chest CT showed a mass about 1.5 cm in diameter with a sharp margin in the right S. Partial lung resection was performed by video-assisted thoracoscopic surgery, because the mass was thought to be an inflammatory lymph node on intraoperative frozen section examination. However, the postoperative histopathological diagnosis was peripheral lung carcinoid. Then, a right middle lobectomy was performed. These cases suggest that it may be difficult to diagnose peripheral lung carcinoid or pulmonary sclerosing hemangioma by intraoperative frozen section examination because of their pathological diversity.

[A case of duodenal penetration by indwelling catheter during hepatic arterial infusion chemotherapy]

We report a patient with hepatic metastasis of descending colon cancer who underwent hepatic arterial infusion chemotherapy using 5-fluorouracil (5-FU) and CDDP, with an indwelling catheter and port system by GDA coil method. Since the tumor became smaller after five months, we decided to follow her up as an outpatient. Considering the possibility of its recurrence, the catheter-port system remained in her. Two and half years later, the recurrent hepatic metastasis was recognised and the hepatic arterial infusion chemotherapy was fulfilled again. The tumor obviously reduced and the same treatment was continued. However, he was hospitalized with a complaint of hematemesis. Upper gastrointestinal endoscopy revealed a projection around the splitting catheter in the duodenal bulb. Therefore, we embolized with coil under angiographic guidance in order not to bleed from the artery and removed the port. With this experience, special attention for the catheter port system must be taken if one considers a long-term treatment. Thereby, we report on the complications of the catheter-port system.

The use of a water seal to manage air leaks after a pulmonary lobectomy: a retrospective study

BACKGROUND

The methods for managing chest drainage tubes during the postoperative period differ among thoracic surgeons and, as a result, the optimal method remains controversial.

PATIENTS AND METHODS

We reviewed 170 consecutive patients undergoing a pulmonary lobectomy for either primary lung cancer or metastatic lung cancer from January 1998 to December 2002. After the operation, the chest drainage tube was placed on a suction pump with a negative pressure of -10 cmH(2)O in 120 patients before 2001, while such drainage tubes were kept on water seal in 47 cases mainly since 2001.

RESULTS

Regarding the preoperative and postoperative variables, postoperative air leak as well as the video-assisted thoracic surgery (VATS) procedure were more frequently observed in the water seal group than in the suction group (p=0.01580, p<0.001, respectively). In comparing these different populations, each Kaplan-Meier curve, which presented the duration of the postoperative air leak seemed to be similar between the two methods.

CONCLUSION

These observations suggest that applying chest tubes on water seal seems to be an effective method for preventing postoperative air leak in clinical practice. However, a prospective randomized trial using a larger series of patients is warranted for this subject.

Multimodal treatment for resectable epithelial type malignant pleural mesothelioma

Background

Malignant pleural mesothelioma is a rare malignancy. The outcome remains poor despite complete surgical resection.

Patients and methods

Eleven patients with histologicaly proven epithelial type malignant pleural mesothelioma undergoing extrapleural pneumonectomy with systemic chemotherapy and/or radiotherapy before and after surgical resection were retrospectively reviewed.

Results

Ten out of 11 patients underwent complete surgical resection, of these 7 patients had stage I disease. Of these 7 patients, 5 are alive without any recurrence, a 2-year survival rate of 80% was observed in this group. There was no operative mortality or morbidity.

Conclusion

Extrapleural pneumonectomy with perioperative adjuvant treatment is safe and effective procedure for epithelial type malignant pleural mesothelioma.

Induction chemoradiotherapy and surgical resection for selected stage IIIB non–small-cell lung cancer

BACKGROUND

Combination chemotherapy using an oral combination of uracil and tegafur (UFT) plus cisplatin and concurrent thoracic radiotherapy is reported to have a high response rate and less toxicity for locally advanced non-small-cell lung cancer (NSCLC) patients. We performed a phase II trial using this chemoradiotherapy as an induction treatment.

METHODS

Patients with marginally resectable stage IIIB NSCLC, an age younger than 70 years, a performance status of 0 or 1, and good organ function were eligible. The UFT (400 mg/m(2)) was administered orally on days 1 through 14 and 22 through 35 and cisplatin (80 mg/m(2)) was injected intravenously on days 8 and 29. Radiotherapy with a total dose of 40 Gy was delivered in 20 fractions from day 1. A surgical resection was performed from 3 to 6 weeks after completing the induction treatment.

RESULTS

Twenty-seven patients, 18 male and 9 female with a median age of 56 years and ranging from 36 to 69 years, were entered into the phase II trial. Clinical T4 and N3 cancers were observed in 22 and 7 patients, respectively. Twenty-five (93%) achieved a partial response. The most frequently observed adverse event was grade 3 leukopenia in 26%. Of 25 patients who underwent a thoracotomy, 22 had a tumor resection. In all 22 patients a complex resection including a resection of the superior vena cava, carina, and vertebrae was required. Operative morbidity and mortality rates were 36% and 4% respectively. The calculated 1-year and 3-year survival rates of all 27 patients were 73% and 56% respectively.

CONCLUSIONS

Chemotherapy using UFT plus cisplatin and concurrent radiotherapy as induction treatment and a surgical resection for patients with marginally resectable stage IIIB NSCLC is feasible and promising. However it is difficult to conduct multi-institutional trials even for selected stage IIIB disease as a complex resection in almost all patients is necessary.

[A case of preoperative concurrent chemoradiotherapy and curative resection for locally advanced non-small-cell lung cancer]

We report the case of a 58-year-old man who underwent complete resection for locally advanced non-small-cell lung cancer (cT4N2M0). The patient received UFT (400 mg/m2 orally on days 1-14 and 22-35) and cisplatin (80 mg/m2 intravenously on days 8, 29) with a total 40 Gy, delivered in 20 fractions on days 1-26. The tumor reduction rate was 76%, and no remarkable toxicities were observed. The patient underwent complete resection and a pathologic complete response was observed. This induction concurrent chemoradiotherapy (followed by surgery) is considered to be effective and safe.

Treatment outcome of resected and nonresected primary adenoid cystic carcinoma of the lung

BACKGROUND AND OBJECTIVE

The incidence of primary adenoid cystic carcinoma of the lung is relatively rare and the optimal treatment strategy is still unclear.

METHODS

Sixteen adenoid cystic carcinoma patients were treated at our institute from 1972 to 1998 and their clinical features, treatments and survivals were reviewed.

RESULTS

Half of all patients were female and the median age was 46 ranging from 30 to 64. All primary lesions were located in the central bronchial tree and 80% of the patients had some symptoms. Eleven patients underwent a resection of the tumor with/without plasty of the trachea or bronchus. Although 6 (55%) of 11 patients had a microscopic residual tumor after resection, 5 patients who received postoperative radiotherapy survived without recurrence from 3 to 17 years. Five patients received radiotherapy as their initial treatment and all tumors responded well to the treatment. The 5-year and 10-year survival rates were 91 and 76% without local recurrence in the resected group and 40 and 0% in the nonresected group, respectively.

CONCLUSION

These observations suggest that surgical resection should be selected first whenever possible, and, in addition, adenoid cystic carcinoma is sensitive to radiotherapy.

Unique minithoracotomy assisted by videothoracoscopy facilitates a maximal view even with a minimal wound for resection of primary lung cancer

Resection for primary lung cancer with an unique minithoracotomy and use of videothoracoscopy is described. Through an incision of approximately 10 cm at an ausculatory triangle, the 5th intercostal thoracotomy is done following dissection of muscles. At the anterior and posterior portion of the 6th rib, the 6th intercostal vessels and nerve were dissected and the rib was resected. This approach makes feasible opening of a thoracic window without injury to the nerve and removal of the rib. Thoracoscopy is introduced through a midaxillary wound of 2 cm. We report nine patients in whom we achieved resection for primary lung cancer by using this approach. This technique facilitates a standard operation for lung cancer and an almost painless postoperative state.

High vascularity in the peripheral region of non-small cell lung cancer tissue is associated with tumor progression

OBJECTIVES

We attempted to determine if the degree of angiogenesis can serve as a prognostic factor in the case of completely resected non-small cell lung cancer patients, with special reference to the center and the periphery of the tumor tissue.

METHOD

For 255 Japanese patients who underwent completely resected non-small cell lung cancer (NSCLC), micro vessel density (MVD) was assessed by visual quantification of microvessels immunostained with anti-CD34 monoclonal antibody in 5 m section. Vascular endothelial growth factor (VEGF) was also immunostained on the same paraffin block specimen.

RESULTS

MVD at the center (MVD-c) and that at the periphery (MVD-p) were frequently different in each individual although a weak positive correlation was observed (r=0.499, P<0.0001). One hundred and one patients with high MVD-p, but not the 107 patients with high MVD-c, showed a significantly higher proportion of advanced stage, larger tumor size and nodal metastasis as compared with MVD. The 5 year survival rate and median survival time for the high MVD-p group were significantly lower than that of low the MVD-p group (43.0%/31 months vs 48.6%/54 months, P=0.0256). As to the relationship among vascular endothelial growth factor (VEGF) and MVD, expression of VEGF was not associated with the degree of MVD. However, patients with high grade MVD-p showed an unfavorable prognosis in cases of high expression of VEGF.

CONCLUSION

High MVD-p is associated with advancement of NSCLC, and it was particularly apparent in conjunction with high VEGF expression.

Reduced expression of cell-cycle regulator p27(Kip1) correlates with a shortened survival in non-small cell lung cancer

BACKGROUND

The cell cycle progression is governed by a family of cyclin-dependent kinases, which are regulated by associated cyclins and by phosphorylation. p27, a cyclin-dependent kinase inhibitor, regulates the progression from G1 into the S phase by binding and inhibiting cyclin/cdks. Although p27 mutations in human tumors are extremely rare, a reduced expression of p27 might to lead to a progression of cancer cells.

METHODS

We examined tissues that had been surgically excised from 161 unselected Japanese patients with non-small cell lung cancer, and investigated the p27 protein expression by immunohistochemistry.

RESULTS

A reduced expression of the p27 protein was found in 63 cases (39.0%). Statistical correlation was found between the reduced p27 expression and advanced stage, although no correlation was found between the level of p27 expression and the gender, T factor, N factor or histological differentiation. The 5-year survival rate in the reduced group was 35.4%, which was statistically poorer than the 63.2% rate in the normal group (P=0.0016), in patients with complete resection. In a multivariate analysis, the level of p27 expression was found to be an independent prognostic indicator.

CONCLUSIONS

We demonstrated the expression of p27 protein to be a biological prognostic indicator which can indicate the subsets of patients with either a good or poor prognosis, in patients who underwent surgical resection.

Survival of non-small cell lung cancer patients with postoperative recurrence at distant organs

BACKGROUND

Recurrence after complete resection of non-small cell lung cancer (NSCLC) is often observed. However, its influence on the prognosis of patients with recurrence is still unclear.

PATIENTS AND METHODS

Of 468 consecutive patients with NSCLC undergoing complete resection during 10 years, 118 experienced recurrence at distant organs. In such patients, the influence of the following variables on post-recurrent survival was analyzed; sex, age at recurrence, disease-free interval, cell type, pathological (p-) stage at operation, adjuvant therapy (thoracic radiation and/or chemotherapy), site of recurrence, and treatment against recurrence. To identify independent factors, multivariate analysis was performed for variables which were considered to be influential in univariate analysis.

RESULTS

Mean post-recurrent survival time was 418 days, and survival rate at 2-years was 15.7%. Multivariate analysis revealed that female, early p-stage, younger age at recurrence, metastasectomy and intra-pulmonary metastasis were the significant favorable factors in patients with distant metastases. Adjuvant therapy and bone metastasis were marginally significant unfavorable factors. Chemotherapy for recurrence tended to prolong survival. Length of disease-free survival and post-recurrent survival exhibited a positive relationship with p-stage. Seven out of 16 patients who underwent metastasectomy survived more than 1000 days after recurrence.

CONCLUSIONS

Patients even with recurrence in distant organs could expect for long survival if they are in the early p-stage of primary cancer or a resectable recurrent disease.

Clinical significance of the Rb expression in adenocarcinoma of the lung

BACKGROUND

Altered retinoblastoma gene expression has been found in various types of cancers including non-small cell lung cancer (NSCLC) and some reports have shown it also to be associated with a poor clinical prognosis in NSCLC.

MATERIALS AND METHODS

We evaluated the expression of Rb protein by immunohistochemistry in 90 patients with lung adenocarcinoma who underwent surgical resection and determined its prognostic significance. Also, the expression of p27 by immunohistochemistry and the mutations of the p53 gene by PCR-SSCP were evaluated.

RESULTS

Fifty-one out of 90 tumors (56.7%) had reduced expression of the Rb gene. There were no statistical differences between the Rb expression level and clinicopathological status. There was no correlation between the Rb expression level and the p53 mutations or the p27 expression level. The 5-year survival rate in the normal group was 55.1%, which was poorer than that of 73.0% in the reduced group, but showed no statistical difference (p=0.0981). In patients with a reduced Rb-expression, the survival rate of the p53 mutation group tended to show a poorer prognosis than that of the p53 normal group (p=0.0880). In addition, the survival rate of the negative p27 expression group tended to show a poorer prognosis than that of the positive p27 expression group (p=0.0537).

CONCLUSIONS

The Rb expression status was not significant as an individual factor for evaluating the prognosis in adenocarcinoma of the lung. Analyses of the accumulation of genetic alteration are necessary to identify the subset of patients with a poor prognosis.

[Anesthetic management of tracheal stent insertion under total intravenous anesthesia--a report of two cases]

Tracheal stent insertion is a useful method for patients with malignant tracheal stenosis. Expandable metal stents were inserted in two patients with severe dyspnea due to tracheal stenosis caused by lung cancer and esophageal cancer. The tracheas were intubated after spraying the pharynx with 4% lidocaine solution. The respiration was assisted. Anesthesia was maintained by intravenous propofol. There were no episodes of coughing during and after the procedure.

Invasive thymoma with long-term survival by extensive reoperation

The recurrence of invasive thymoma is often observed; however, no accepted treatment of recurrent invasive thymoma has yet been established. We herein report a 41-year-old woman with invasive thymoma and pleural dissemination who demonstrated long-term survival after undergoing 4 operations. Based on our findings, reoperation is thus suggested in patients with intrathoracic recurrence and long-term survival can be expected.

Expression of the isoamylase gene of Flavobacterium odoratum KU in Escherichia coli and identification of essential residues of the enzyme by site-directed mutagenesis

The isoamylase gene from Flavobacterium odoratum KU was cloned into and expressed in Escherichia coli JM109. The promoter of the gene was successful in E. coli, and the enzyme produced was excreted into the culture medium, depending on the amount of the enzyme expressed. The enzyme found in the culture medium showed almost the same M(r), heat-inactivating constant, and N-terminal sequence as those of the enzyme accumulated in the periplasmic space. This result indicated that the enzyme accumulated in an active form at the periplasm was transported out of the cell. The primary sequence of the enzyme, which was deduced from its nucleotide sequence, showed that the mature enzyme consisted of 741 amino acid residues. By changing five possible residues to Ala independently, it was found that Asp-374, Glu-422, and Asp-497 were essential. The sequences around those residues were highly conserved in isoamylases of different origins and the glycogen operon protein X, GlgX. The comparison of the distance between these essential residues with those of various amylases suggested that the bacterial and plant isoamylase but not GlgX had a longer fourth loop than the other amylases. This longer fourth loop had a possible role in accommodating the long branched chains of native glycogens and starches.

UFT plus cisplatin with concurrent radiotherapy for locally advanced non-small-cell lung cancer

A phase II study of combined-modality treatment consisting of uracil and tegafur (in a molar ratio of 4:1 [UFT]) plus cisplatin (Platinol) and concurrent radiotherapy was conducted to evaluate the activity of this regimen in patients with locally advanced non-small-cell lung cancer. Eligible patients with cytologically or histologically confirmed, unresectable stage III non-small-cell lung cancer received UFT (400 mg/m2 orally on days 1 through 52) and cisplatin (80 mg/m2 intravenously on days 8, 29, and 50). Radiotherapy, with a total dose of 60.8 Gy, was delivered in 38 fractions on days 1 through 52. Among the 17 patients entered, 16 experienced partial responses (94%; 95% confidence interval, 83% to 100%). The median time to tumor progression was 30 weeks (range, 8 to 87 weeks), and the 1-year survival rate was 80%. Hematologic toxicity was moderate. Grade 3 leukopenia occurred in 10 patients (59%), but no grade 4 hematologic toxicity was observed. No grades 3 or 4 nonhematologic toxicities were reported. These observations suggest that oral UFT plus cisplatin with concurrent radiotherapy can be safely administered to patients with locally advanced non-small-cell lung cancer. The demonstrated antitumor activity is high, making this combined-modality treatment worthy of further investigation in a multi-institution trial.

Spontaneous pneumothorax complicating lung metastasis from lingual carcinoma

We report a patient with pneumothorax caused by a metastatic tumour from carcinoma of the tongue, which had given rise to a bronchopleural fistula with subsequent induction of pneumothorax. Although rare, pulmonary metastasis should be considered in the aetiology of spontaneous pneumothorax. Despite advanced disease, surgical treatment may be feasible.

Second primary cancers after resection of lung adenocarcinoma with ras gene mutation

BACKGROUND

Ras gene mutations are associated with a poor prognosis in patients with adenocarcinoma of the lung. However, the association between cases with ras gene mutation and an occurrence of second primary cancer is unknown.

MATERIALS AND METHODS

We examined 89 adenocarcinoma of the lung obtained from patients treated by curative resection, and four second primary cancers, for mutation at codons 12, 13, and 61 of three ras oncogenes using polymerase chain reaction and oligonucleotide hybridization techniques.

RESULTS

Ras gene mutations were detected in 13 cases. Six patients died from recurrent disease within 3 years. Of the seven patients who survived over 5 years, three patients demonstrated a metachronous second primary cancer after the operation for lung cancer, and one patient had synchronous laryngeal cancer. Two of the cases with second primary cancer demonstrated the ras gene mutation. One had the same mutation as that of the primary lung cancer, and the other had a different mutation from the first lung cancer.

CONCLUSION

Ras gene mutations play an important role in tumor progression of lung adenocarcinoma and also might have an role in the carcinogenesis in respiratory tract cancer.