[Clinical analysis of surgically resected multiple primary lung cancer]

Synchronous and metachronous lung cancer is occasionally encountered. Frequency of the occurrence is increasing because of recent progress of imaging technique such as high resolution CT and CT based annual lung survey. We analyzed clinical characteristics of both synchronous and metachronous lung cancer treated surgically in our facility. There were 20 cases of multiple lung cancer cases, which is consisted of 12 synchronous multiple lung cancer cases and 8 metachronous lung cancer cases. Mean age was 62 years old and there were 14 male and 6 female cases. Among synchronous group, 8 cases have multiple shadow in ipsilateral hemithorax and 4 cases in both side. Surgery was carried out according to the extent of the disease and lung reserve. Associated cancer was diagnosed stage IA or IB in all cases. Five-year survival was 58.9%. Meanwhile, as regards to metachronous group, mean interval between first cancer and second cancer was 73 months. Seven cases have contralateral second primary lung cancer and one case has ipsilateral second primary lung cancer. In 3 cases, histology of the first and the second disease were different and in 5 cases that were the same. The first procedures were complete resection with systemic mediastinal LN dissection. The second procedures were determined based on the lung reserve. Pathological stage of the second disease were either stage IA or IB. There were no operative mortality and 5 years survival was 75%. Since there is no operative mortality and the outcome seems satisfactory when the patient has enough lung reserve, aggressive surgical resection should be considered in the case of multiple primary lung cancer. There is an increasing chance of synchronous multiple primary lung cancer because of improvement of imaging system. We have to prepare new therapeutic strategy for those patients.

Staple-line reinforcement with a new type of polyglycolic acid felt

Although various materials have been used for reinforcement in lung-volume-reduction surgery to buttress pulmonary staple-line, absorbable materials are not available for use in thoracoscopic surgery. Moreover, even nonabsorbable types of reinforcements have been used only for lung volume reduction surgery. However, elderly patients with spontaneous pneumothorax secondary to emphysematous lung are well treated with staple-line reinforcement. The authors developed a new type of polyglycolic acid felt to buttress staple-line. This felt is absorbable, easier to cut with a stapler knife than is the conventional polyglycolic acid felt, and inexpensive enough to use for various types of thoracic surgeries for emphysematous lungs in Japan, and it can be attached to staplers with a small amount of fibrin glue. These strips were used to reinforce pulmonary staple lines for resection of emphysematous lungs in 14 patients: pulmonary emphysema (n = 1), bilateral giant bullae (n = 1), ipsilateral giant bullae (n = 6), spontaneous pneumothorax with multiple bullae in an emphysematous lung (n = 5), and lung cancer in a patient with pulmonary emphysema (n = 1). There were no air leaks during surgery. Air leaks were noted in three patients after surgery. In two patients, the air leaks stopped within 2 weeks. In one patient, the air leak was found to originate from an untouched lobe during reoperation. No infection or allergic reaction developed in a patient during a mean follow-up of 12 months (range, 1 to 24 months).

Experimental lung transplantation using non-penetrating vascular clips for anastomosis of the pulmonary artery

BACKGROUND

Reliable and rapid anastomosis is critical in lung transplantation. The purpose of this study is to show the appropriateness of sutureless anastomosis of the pulmonary artery using a nonpenetrating vascular clipping device.

METHODS

The left lung was excised and the cranial lobe was transplanted autologously in 9 dogs. The anastomosis of the left main pulmonary artery (PA) (1 cm) was performed using a vascular clipping system.

RESULTS

PA anastomosis was performed in 7 dogs in 8 to 13 minutes. The endovascular surface of the anastomotic site was smooth, and passage of silicone rubber through the anastomosis was good 14 or 28 days after surgery. Microscopic examination of the anastomotic sites showed excellent healing without evidence of intimal hyperplasia.

CONCLUSIONS

The vascular clipping system facilitates anastomosis of the PA in lung transplant surgery.

Importance of interleukin-8 in the development of reexpansion lung injury in rabbits

Reexpansion of a collapsed lung induces increased microvascular permeability leading to reexpansion pulmonary edema (REPE). This study was designed to prove the hypothesis that local overproduction of interleukin-8 (IL-8) induces inflammatory cell accumulation which leads to the induction of REPE. Initially, we examined the detailed characteristics of a rabbit model of REPE in association with IL-8 production and its mRNA expression. The lung tissue to plasma ratio of radiolabeled albumin (T/P ratio), the lung wet to dry ratio, and bronchoalveolar lavage (BAL) neutrophil counts were significantly increased in the reexpanded lung. IL-8 concentrations and mRNA expression were significantly increased in the reexpanded lung homogenate. Immunohistochemically, alveolar macrophages (AMs) and epithelial cells in the reexpanded lung and AMs in the collapsed lung were positive for IL-8. Second, we examined the effect of pretreatment with a specific monoclonal anti-IL-8 antibody (Ab) or control IgG on the development of REPE. The T/P ratio and BAL neutrophil counts were conspicuously decreased by pretreatment with anti-IL-8 Ab, but not with control IgG. On a histopathological study, lung injury and leukocyte infiltration were attenuated by the pretreatment with anti-IL-8 Ab. In conclusion, IL-8 production is enhanced in the reexpanded lung, and contributes to the development of REPE. The pretreatment with anti-IL-8 antibody may be useful as a novel protective therapy for this disease.

Radiation therapy for roentogenographically occult lung cancer by external beam irradiation and endobronchial high dose rate brachytherapy

PURPOSE

We investigated the clinical usefulness of radiation therapy by external beam irradiation and endobronchial brachytherapy for the treatment of roentogenographically occult lung cancer.

PATIENTS AND METHODS

From 1995 to 1996, five patients were treated with radiation therapy. We analyzed their treatment outcomes. The follow-up period varied from 3.0 to 3.8 years or until death. External beam radiation (40 Gy/20 fractions/4 weeks) was delivered to the tumor site alone, and not prophylactically given to the mediastinum. Endobronchial brachytherapy using high dose rate iridium (Ir)-192 was concurrently administered principally to a total dose of 18 Gy on the bronchial mucosa in three weekly fractions of 6 Gy each.

RESULTS

Complete remission was obtained in all patients. Two patients died of intercurrent diseases at 12 and 21 months without any evidence of recurrence. The disease has been also controlled in the other three cases. With the above doses, three small tumors < 1 cm were controlled without adverse effect. In two tumors, the dose reference points were set 2-7 mm beneath the mucosa, and larger doses were administered by brachytherapy. An applicator acting as a spacer was not used in these cases. The tumors were controlled, although the irradiated bronchi showed severe stenosis in 6 months following the treatment. However, the patients were asymptomatic and did not need further intervention.

CONCLUSION

External beam irradiation combined with endobronchial brachytherapy was useful for the treatment of roentogenographically occult lung cancer as an alternative to surgery. Further investigation is needed to determine the optimal doses of radiation therapy.

Endobronchial brachytherapy for recurrent thymoma showing endobronchial polypoid growth

The authors report a case of recurrent thymoma displaying endobronchial polypoid growth. Initially, the patient had invasive thymoma with intracaval growth into the right atrium. He was treated with multimodality therapy consisting of chemotherapy, surgical resection, and radiotherapy (50.4 Gy). Both 3 years and 6 years after the initial treatment, the tumor recurred outside the reconstructed superior vena cava. The patient was treated with repeated radiotherapy (50.4 Gy and 40 Gy), and remission was achieved. Eight years after the first therapy, an endobronchial polypoid lesion was detected in the right upper lobe bronchus and was histologically found to be thymoma. Endobronchial high-dose rate brachytherapy (20 Gy at 3 mm/5 fractions) was carried out for palliation because the recurrent tumor occurred outside of the superior vena cava area, which had been reirradiated. After the treatment, the endobronchial tumor shrunk remarkably in size without adverse effects. No tumor regrowth has been noted after a follow-up of 10 months.

[Clinical analysis in patients undergoing extended resection of pT3 non-small cell lung cancer]

Among pT3 cases there contain various subgroups in terms of the organ which is involved in. We analyzed medical records of 85 consecutive patients who underwent extended surgery with diagnosis of pT3 excluding interlober invasion. As regards to the site of invasion, there are not significant differences in survival between pleural invasion, chest wall involvement, pericardial invasion, and diaphragmatic invasion. However, survival of patients who showed involvement of main bronchus seemed better than other groups. Survival of pT3 cases are in part determined by lymph node involvement, N0 group showed 36.0% 5 year survival rate whereas N1 group 20.0%, and there are no patient with N2 disease who survived 5 years. Among pleural and chest wall involvement group, N0 group showed 34.2% 5 year survival and there are no survival in N1 and N2 group. As regards to histologic subgroups, there are not significant differences between each group. Thus we conclude that in pT3 cases, N0 cases are the best candidate for surgical resection, and that adjuvant therapy is necessary for those with N1 or N2 involvement. Cases with bronchial extension should not be argued in the same field of locally invasive lung cancer because of better survival.

[Intralobar pulmonary sequestration with three aberrant arteries: a case report and review of the Japanese literature]

A case of intralobar pulmonary sequestration with three aberrant arteries was reported. The patient was a 26-year-old man. His chest film showed an abnormal shadow suspected of a pulmonary sequestration in the left lower lobe of the lung. Computed tomography of the chest revealed that the aberrant arteries originated from the descending aorta and circulated the emphysematous area of the left lung. Angiography clearly demonstrated three aberrant arteries and three veins draining into the hemiazygos and lower pulmonary veins. Pulmonary sequestration was diagnosed and then resected. Microscopically, the resected lung had emphysematous change, multiple cysts and winded vessels. Aberrant arteries were the elastic type of vessels and accompanied with atherosclerosis. According to the review of 139 Japanese cases of intralobar pulmonary sequestration, 7% of all patients had more than two aberrant arteries. Moreover, only 3% of patients had veins draining into the systemic vessels. In many cases the thin aberrant arteries were clearly demonstrated by angiography and the draining veins were detected. We consider that angiography is necessary to show definitely the aberrant arteries and drainage veins.

[Cystic thymoma without solid mass lesions on diagnostic imaging--a case report]

A 68-year-old man was referred to our hospital because of an abnormal shadow on a chest X-ray film. A chest CT scan and MRI demonstrated a cystic mass without solid lesions on the anterior mediastinum. The CT scan also showed that it was a well-defined and homogenous mass without contrast enhancement effect. 67Ga and 201T1 scintigrams showed no uptake in the mass. Needle aspiration cytology was performed, and there was no evidence of neoplasms. A thymic cyst was diagnosed, and then an operation was performed. At the operation, the cystic tumor was removed along with thymic tissues by a median sternotomy. On the cut section of the resected specimen, the tumor was found to be a cyst with small solid nodules on the wall. Pathologic examination revealed that the tumor was a cystic thymoma. We consider that patients with cystic tumors on the anterior mediastinum should obtain histopathologic diagnosis because of the difficulty in excluding neoplasms such as thymoma.

Epithelioid hemangioendothelioma presenting as a chest wall tumor

We report a case of epithelioid hemangioendothelioma presenting as a chest wall tumor. The patient had invasive bladder carcinoma and a soft-density mass protruding into the left thoracic cavity from the lateral chest wall on a computed tomographic scan. Percutaneous needle biopsy was performed to obtain a definite diagnosis of the chest wall tumor. Because of an intrathoracic hemorrhage after the procedure, the patient underwent an emergency thoracotomy and excision of the mass with adjacent structures. Pathologic examination demonstrated the mass to be a subpleural epithelioid hemangioendothelioma. This rare tumor has never been reported previously as arising from the chest wall.

[Diagnosis of pleural dissemination lung cancer by thin-section CT--a prospective study]

In this prospective study, thin-section CT was used to diagnose pleural dissemination in patients with pulmonary adenocarcinomas in which the primary lesion was found to be adjacent to the pleural surface by conventional CT. The subjects were 32 patients (25) who had undergone resection and 7 who had not with pulmonary adenocarcinoma without pleural effusion from among the 136 patients with pulmonary adenocarcinoma examined at our institution over 3 years. Thin-section CT images of three regions were obtained, and these included the pleural surface adjacent to the lesion, the minor fissure, and the diaphragmatic dome. Histopathological examination revealed pleural dissemination in 12 patients (5 who had undergone resection and who had not), in 2 of whom a diagnosis could not be made preoperatively. Pleural dissemination was diagnosed by CT in 12 patients; there were 2 false positives. In 6 patients who did not undergo resection, cancerous cells were found in fluid obtained by percutaneous pleural lavage, and mediastinal lymph node metastases or distant metastases were also detected. The diagnostic rate of CT was as follows interlobar space. 100% (7/7); mediastinum, 75% (3/4); diaphragm, 71% (5/7); and chest wall, 57% (4/7). In the patients who underwent resection, sensitivity was 100% for the interlobar space, but it was 0% to 33% for other pleural surfaces.

Massive hemoptysis successfully treated by modified bronchoscopic balloon tamponade technique

A 60-year-old man with massive hemoptysis was treated successfully by modified bronchoscopic balloon tamponade technique. Compared with previously reported techniques, the modified technique requires no special catheter, no complicated maneuver, and is able to be applied to more massive bleeding.

Experimental tracheal replacement using the esophagus and an expandable metallic stent

An experimental study was conducted to investigate whether a segment of autogenous esophagus with its lumen supported by an expandable metallic stent (EMS) could be successfully used as a tracheal substitute. Seven rings of the cervical trachea were circumferentially removed and reconstructed by interposing a pedicled segment of the esophagus with an EMS in six mongrel dogs. The interposed esophagus was observed endoscopically at various stages after the operation. By 1 month, the EMS was found to be buried under the esophageal mucosa, and the lumen was patent. The dogs died 5, 17, 61, 92, 210, and 478 days after the operation, but the cause of death could not be determined by postmortem examination and no respiratory tract complications were detected. The results of this study indicated that a segment of the esophagus with its lumen supported by an EMS could work as a reliable tracheal substitute, though its practical use is not clinically feasible. Nevertheless, we conclude that some autogenous material other than the esophagus with its lumen supported by an EMS could provide a feasible method for tracheal replacement.

[A case of pulmonary fibroma]

A 42-year-old man without symptoms was admitted to the hospital because of a well-circumscribed mass in his left upper lung field, which was found on a routine chest X-ray film. CT of the chest revealed a well-defined homogeneous mass in the left upper lobe. Bronchial biopsy yielded material unsatisfactory for diagnosis. On thoracotomy a tumor, entirely within the lung parenchyma, was found to occupy S3. Due to its size and location left upper lobectomy was done. Histologically, the tumor contained interlacing bundles of spindle cells compatible with fibroma, with no indicators of malignancy. Intrapulmonary fibromas are rare and only one report could be found in the Japanese literature.

[A case of traumatic diaphragmatic hernia repaired 40 years after the injury]

A 65-year-old male complaining dyspnea on exertion and epigastric discomfort was diagnosed to have left traumatic diaphragmatic hernia elsewhere and referred to Keio university Hospital for treatment. He had thoracicio-abdominal trauma which was conservatively treated, 40 years ago. Because he was symptomatic and the possibility of future strangulation could not be denied, surgical repair of the hernia was performed. The defect in the diaphragm was too large to be directly sutured and it was repaired with GORE-TEX patch. The gastric fundus partially prolapsed in the paraesophageal region, but the diaphragm was repaired quite satisfactorily otherwise. Pulmonary function and dyspnea on exertion improved.

Elevated levels of interleukin-8 and leukotriene B4 in pulmonary edema fluid of a patient with reexpansion pulmonary edema

We experienced a case of reexpansion pulmonary edema (RPE) after surgical treatment of pneumothorax. In this case, protein leakage and polymorphonuclear leukocyte (PMN) accumulation were observed in the reexpanded lung. Interleukin-8 and leukotriene B4 in edema fluid were increased at the onset of RPE. PMN elastase was also increased, though its peak was delayed. The plasma level of P-selectin, which mediates adhesion between PMN and endothelium, was elevated. We speculate that some of these fluid mediators may play important roles in chemotaxis and activation of PMN in the development of RPE.

Bronchoplastic procedures for tuberculous bronchial stenosis

Thirty-six patients underwent tracheobronchoplastic procedures for treatment of tuberculous tracheobronchial stenosis. The modes of operations were left upper sleeve lobectomy in 13 patients, sleeve resection of the left main bronchus in 12 patients (two underwent concomitant left upper lobectomy), right upper sleeve lobectomy in five patients, sleeve resection of the right intermediate bronchus in two patients, right sleeve superior segmentectomy of the lower lobe in one patient, sleeve resection of the trachea with concomitant left pneumonectomy in one patient, carinal resection with right upper sleeve lobectomy and middle lobectomy in one patient, and dilatation of the left main bronchus with a free skin graft reinforced with a steel wire in one patient. One patient died of pulmonary edema of unknown cause on the first postoperative day. Anastomotic stenosis occurred in seven patients. One of these patients underwent reoperation and six underwent endoscopic dilatation. One patient died in the hospital of massive bleeding during endoscopic dilatation 4 months after operation. Slight to moderate stenosis resulted in the remaining patients. Although there are some complications, we believe bronchoplastic operation is worthwhile for restoring pulmonary function in patients with tuberculous tracheobronchial stenosis.

[Multidisciplinary treatment for a patient with recurrent thymoma associated with myasthenia gravis (MG), pure red cell aplasia (PRCA), and hypogammaglobulinemia]

The patient is 62-year-old female. When she was 43 years old, MG occurred. At age of 49 years thymoma was found and complete thymectomy (stage III) and postsurgical irradiation were performed. At age of 57 years pleural dissemination of the thymoma was found. Chemotherapy was effective but did not obtain total tumor cell kill. Though chemotherapy has been repeated for each tumor regrowth, the regimen used at first recurrence became ineffective and the interval between tumor regrowth became shorter. This year, when she is 62 years old, PRCA and hypogammaglobulinemia were accompanied with the forth tumor regrowth.

[A case of cervical teratoma in adult]

Cervical teratomas are rare neoplasms in adults. A 21-year-old male was admitted to our hospital for evaluation of a cervical tumor. CT scan and MRI showed the tumor extended into the mediastinum and not invaded to surrounding tissue. 201T1 scintigram showed increased uptake in the tumor. The tumor was resected with coller incision and median sternotomy. Histological examination revealed mature teratoma. The patient remains free of disease one year and seven months after operation.

[A case of slowly-growing localized malignant mesothelioma]

We report a case of localized malignant mesothelioma. The patient was a 37-year-old male, admitted to our hospital because of a solitary nodular shadow in the right middle lung field noted on chest X-ray. Five years prior to admission, a solitary nodular shadow had been seen in the same area on chest X-ray, and the diameter of the tumor had gradually increased. A transbronchial biopsy specimen revealed proliferation of spindle-shaped tumor cells, suggesting fibrosarcoma. No other lesions were identified as primary foci, so we made the tentative diagnosis of primary pulmonary sarcoma prior performing right upper lobectomy. The resected specimen revealed that the tumor, which partially touched the pleura, contained a number of large and small cystic spaces, and was composed of numerous spindle-shaped tumor cells. Some of the tumor cells were immunohistochemically positive for cytokeratin and epithelial membrane antigen, and many mitotic figures were noted. Thus, we made the histopathological diagnosis of localized malignant mesothelioma.

[Nd-YAG laser therapy of tracheobronchial lesions by malignant tumor]

Thirty-seven patients with tracheobronchial lesions by malignant tumor were treated with Nd-YAG laser. Thirty-seven patients were twenty-three males and fourteen females and ages ranged from 34 to 79 years. Diseases included were primary tracheal tumor in 3 cases, lung cancer in 16 (8 squamous cell carcinoma, 5 adenocarcinoma, 2 large cell carcinoma, 1 small cell carcinoma), cancer of adjacent organs in 9 (5 thyroid cancers, 4 esophageal cancers), and metastatic cancer to the lung or mediastinal lymph nodes in 9 (4 renal cell carcinoma, 2 thyroid cancer, one patient respectively, colon cancer and breast cancer). Intermittent irradiation of YAG laser was done for 0.5 second at 30-40 Watt through flexible bronchoscope under local anesthesia. It was repeated 1 to 41 times (mean 4.1 times) and energy amount was 148 Joules to 18,513 Joules (mean 3,305 J). The result was; stenosis disappeared in 22 cases (59.4%), improved in 14 (37.8%), and in one case YAG laser therapy discontinued due to intractable bleeding. The Nd-YAG laser therapy for tracheobronchial lesions by malignant tumor is very useful to improve dyspnea or atelectasis.