Phase I/II study of nedaplatin and nab-paclitaxel for patients with previously untreated advanced squamous cell lung cancer: Kanto Respiratory Disease Study Group (KRSG) 1302

BACKGROUND

Nedaplatin and nab-paclitaxel are each efficacious in the treatment of squamous cell lung cancer.

PATIENTS AND METHODS

Eligibility criteria were: no prior chemotherapy, advanced squamous cell lung cancer; performance status 0-1, age > 20 years but < 75 years, and adequate hematologic, hepatic and renal function. Patients received escalating doses of nab-paclitaxel under a fixed dose of nedaplatin (100 mg/m², day 1) every 3 weeks in phase I. The initial nab-paclitaxel dose was 100 mg/m² on days 1 and 8 (level 1), and the next dose was 100 mg/m² on days 1, 8, and 15 (level 2). In phase II, patients received the recommended doses. The primary endpoint was tumor response rate.

RESULTS

In phase I, three patients at level 1 experienced no dose-limiting toxicities (DLTs) and two patients at level 2 experienced DLTs. Level 1 was thus determined as the recommended dose. Twenty-three patients were enrolled in phase II. The 3 patients in level 1 and 23 patients in phase II were included together for analyses. Three of these 26 patients were excluded from response analysis due to pneumonia and patient refusal. Response rate was 91.3% (95% confidence interval, 72.0-98.9%). Toxicities observed during all cycles were tolerable.

CONCLUSIONS

The recommended dose for this combination was nedaplatin at 100 mg/m² on day 1 and nab-paclitaxel at 100 mg/m² on days 1 and 8 every 3 weeks. The combination of nedaplatin and nab-paclitaxel appears safe and efficacious in patients with untreated advanced squamous cell lung cancer.

Loop-Mediated Isothermal Amplification as Point-of-Care Testing for EGFR-Mutated Lung Adenocarcinoma

Liquid biopsy has been adapted as a diagnostic test for EGFR mutations in patients with advanced or metastatic non-small cell lung cancer (NSCLC). Loop-mediated isothermal amplification (LAMP) has been widely used for the rapid detection of pathogens through DNA amplification. This study investigated the efficacy of an EGFR-LAMP assay using plasma samples of patients with resected NSCLC tumors. The EGFR status was investigated using both LAMP and next-generation sequencing (NGS) assays in cases that met the following criteria: (1) pulmonary adenocarcinoma with EGFR mutation detected by the Therascreen EGFR PCR Kit and (2) preoperative plasma samples contained enough DNA for the LAMP and NGS experiments. Among 51 specimens from patients with EGFR-mutated tumors or metastatic lymph nodes, the LAMP assay detected 1 EGFR mutation that was also detected in the NGS assay. However, a plasma sample that demonstrated EGFR wild type in the LAMP assay showed an EGFR mutant status in NGS. The detection rates (1.9% in LAMP and 3.9% in NGS) were very low in both assays, demonstrating a similar performance in detecting EGFR mutations in NSCLC tumors; therefore, it could be a more suitable test for the advanced stage, not the early stage. Notably, the LAMP assay was more time-saving, cost-effective, and straightforward. However, further investigation is required to develop a more sensitive assay.

Comparative study of the loop-mediated isothermal amplification method and the QIAGEN therascreen PCR kit for the detection of EGFR mutations in non-small cell lung cancer

Background

Epidermal growth factor receptor (EGFR) mutations are important biomarkers in the treatment of patients with advanced or metastatic diseases. The therascreen EGFR Rotor-Gene Q (RGQ) PCR Kit^® (Qiagen, Inc.) is an approved diagnostic test for EGFR mutations in non-small cell lung cancer (NSCLC). This study aims to investigate the diagnostic capability of a loop-mediated isothermal amplification (LAMP) assay as an accurate, efficient, and cost-effective alternative to the therascreen assay.

Methods

EGFR mutations were investigated by LAMP and therascreen assays using tissue samples that were surgically resected or biopsied from 117 consecutive patients with NSCLC tumors. The EGFR status from the LAMP assay was compared with that of the therascreen assay. Next-generation sequencing (NGS) was performed to confirm EGFR status of tumors that did not match in both assays. To establish an optimal LAMP AUC value, receiver operating characteristics (ROC) curve analysis was performed within tumors with exon 19 deletion or L858R point mutation.

Results

Of the 117 tumors assayed, 45 tumors with EGFR mutations and 68 tumors with EGFR wild type were matched in both assays, four tumors having mismatched EGFR statuses. NGS further confirmed that two of the four discordant tumors had the same EGFR status that was determined by the LAMP assay. The AUC values were 0.973 (95% CI: 0.929–1.00) in exon 19 deletion, and 0.952 (95% CI: 0.885–1.00) in L858R point mutation. In exon 19 deletion, sensitivity, specificity, and accuracy were 89.3%, 98.9%, and 96.6%, respectively, and 94.7%, 95.9%, and 95.7%, respectively, in L858R using AUC value of 0.222.

Conclusions

The LAMP assay compared favorably with the therascreen assay and has potential as an effective, simple, rapid, and low-cost diagnostic alternative. Based on these results, a liquid biopsy LAMP system should be developed for point-of-care testing of oncogenes in the near future.

Left upper lobectomy for cancer of the left lung with a rare mediastinal left basal pulmonary artery

We report a rare case wherein a mediastinal left basal pulmonary artery was detected during surgery. Intraoperative findings revealed mediastinal left lingular and basal segments of the pulmonary artery (A⁴⁺⁵ + A^8-10) just dorsal to the superior pulmonary vein. The mediastinal left basal pulmonary artery is classified by its branching type, (1) complete type-wherein the entire that all basal pulmonary artery flow lies between the superior pulmonary vein and the left upper bronchus, as in like this case, (2) incomplete type-wherein that a part of the left basal pulmonary artery segment is on the flow mediastinal side. It is important to understand this rare aberration for undergoing safe surgery.

A novel loop‑mediated isothermal amplification method for efficient and robust detection of EGFR mutations

The activation of somatic mutations conferring sensitivity to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors has been widely used in the development of advanced or metastatic primary lung cancer therapy. Therefore, identification of EGFR mutations is essential. In the present study, a loop-mediated isothermal amplification (LAMP) method was used to identify EGFR mutations, and its efficiency was compared with the Therascreen quantitative PCR assay. Using LAMP and Therascreen to analyze surgically resected tissue samples from patients with pulmonary adenocarcinoma, EGFR mutations were observed in 32/59 tumor samples (LAMP) and 33/59 tumor samples (Therascreen). Notably, the LAMP assay identified one tumor as wild-type, which had previously been identified as a deletion mutation in exon 19 via the Therascreen assay (Case X). However, the direct sequencing to confirm the EGFR status of the Case X adhered to the results of the LAMP assay. Further experiments using Case X DNA identified this exon 19 deletion mutation using both methods. In addition, a novel deletion mutation in exon 19 of the EGFR was identified. Overall, the present study shows that the LAMP method may serve as a valuable alternative for the identification oncogene mutations.

Inter-tumor heterogeneity of PD-L1 expression in non-small cell lung cancer

Background

The Dako PD-L1 immunohistochemistry (IHC) 22C3 pharmDx and the Dako 28-8 IHC pharmDx assays were approved by the US Food and Drug Administration, as a companion diagnostic test for pembrolizumab (Keytruda, Merk, Kenilworth, NJ, USA) and a complementary diagnostic test for nivolumab (Opdivo, Bristol Meyer Squibb, New York, NY, USA) in non-small cell lung cancer (NSCLC), respectively. Increased PD-L1 expression levels can be associated with greater therapeutic efficacy of pembrolizumab relative to other anti-PD-1 agents. However, in treatment decision making, little is known about which tissue (primary or metastatic lesion) should be stained by 22C3 antibody. We investigated the relationship between PD-L1 expression in primary tumors and paired metastatic lymph nodes using the 22C3 assay, and evaluated the concordance between the 22C3 and 28-8 assays.

Methods

PD-L1 expression was evaluated in cells from primary tumors and paired metastatic lymph nodes using the 22C3 and 28-8 IHC assays. Total 35 patients with primary tumor and paired metastatic lymph node were enrolled into this study, and all samples were surgically resected, formalin-fixed, and paraffin-embedded NSCLC tissues. Tumor cells exhibiting complete or partial membrane staining, were considered as PD-L1 positive. On the basis of tumor proportion score (TPS), all samples were classified as no expression (TPS: <1%), low expression (TPS: 1-49%), or high expression (TPS: ≥50%).

Results

TPS distribution was markedly different between primary tumors and paired metastatic lymph nodes. In 22C3 IHC assay, TPS similar to that of metastatic lymph nodes was demonstrated in 10 primary tumors, and concordance rate between them was 28.6%. Concurrently, in 28-8 IHC assay, 11 primary tumors had TPS similar to that of metastatic lymph nodes, with a concordance rate of 31.4%.

Conclusions

TPS concordance rates (for both 22C3 and 28-8 antibodies) between primary tumors and paired lymph nodes were low. Inter-tumor heterogeneity of PD-L1 expression is an important issue for clinical oncologists during treatment planning.

[Present Status and Future Issues of Multidisciplinary Treatment of Lung Cancer from the Viewpoint of a Respiratory Surgeon]

With the advent of molecular targeted therapeutic agents and immunity checkpoint inhibitors, lung cancer drug therapy has advanced. We cannot expect to improve the performance of surgical treatment without drug therapy. The problem of improving the performance of surgical treatment for lung cancer is:① the role of surgery in multidisciplinary treatment for c-stageⅢ N2 lung cancer, ② post-operative adjuvant therapy, ③ multidisciplinary treatment of post-operative recurrence, ④ salvage surgery, and ⑤ sublobar resection in high risk cases. We will describe each of these with reference to our own experiences and literature considerations.

Multicenter prospective study of sublobar resection for c-stage I non-small cell lung cancer patients unable to undergo lobectomy (KLSG-0801): complete republication

BACKGROUND

Local therapy for stage I non-small cell lung cancer (NSCLC) is divided into surgical and radiation treatment, and given to patients unable to tolerate a lobectomy. A prospective phase II study of cases that received stereotactic body radio therapy (SBRT) (JCOG0403) revealed an overall 3-year survival rate (3-YSR) of 76.0 %, 3-year relapse free survival rate (3-YRFS) of 69.0 %, and rate of morbidity of grade 3 or greater of 9 %. However, few prospective multicenter studies have reported regarding surgery for high-risk stage I NSCLC patients.

METHODS

We investigated this issue in the setting of a prospective multicenter observational study. Thirty-two high-risk NSCLC patients (30 males, 2 females; median age 74 years, 61-85 years) were analyzed.

RESULTS

Two (6.3 %) showed morbidity of grade 3 or greater, though there were no postoperative deaths. The margin local control rate was 97.0 % (surgical margin recurrence, 1) and local recurrence control rate was 75.0 % (ipsilateral thorax recurrence, 8), while the 3-YSR and 3-YRFS was 79.0 and 75.9 %, respectively.

CONCLUSION

A sublobar pulmonary resection for patients unable to tolerate a lobectomy with stage I NSCLC was shown to be safe and provided results comparable with those of SBRT.

Acute ischaemic lung injury due to pulmonary vascular obstruction

AIMS

We have encountered cases of a distinctive myxomatous alveolar wall thickening around pulmonary infarctions, and have termed it 'acute ischaemic lung injury' (AILI). In this study we determined if pulmonary infarction is the only cause of AILI and have elucidated its histological features.

METHODS AND RESULTS

We examined 2941 cases that underwent lobectomy, surgical lung biopsies for nodular lesions or autopsies between 1994 and 2014. Cases were divided into pulmonary infarction and non-infarction groups. The histological features of AILI sought were lobule-based alveolar wall thickening (myxomatous or fibrous) with epithelial metaplasia and negligible inflammation. In order to characterize AILI further, we performed immunohistochemical staining using several antibodies. Thirty-four of 69 cases in the infarction group (mean age 57.1 years, 30 males) had AILI, whereas only one (but with vascular obstruction) of the remaining 2872 in the non-infraction group had AILI. AILI was located around infarctions. Separation of the epithelial and endothelial basement membranes of the alveolar wall was observed in 75% of cases.

CONCLUSIONS

AILI is associated almost exclusively with lung infarction, caused presumably by vascular obstruction. We consider AILI to represent a distinct lung lesion other than pulmonary haemorrhage and infarction.

Airspace enlargement with fibrosis shows characteristic histology and immunohistology different from usual interstitial pneumonia, nonspecific interstitial pneumonia and centrilobular emphysema

The histologic characteristics of air space enlargement with fibrosis (AEF) are compared with usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP) and centrilobular emphysema (CLE) to determine similarities and differences. Lung specimens from 39 patients were studied; 9 with AEF, 13 with UIP and 5 with CLE identified in lobectomy specimens for cancer and 12 NSIP cases identified on surgical lung biopsies. We determined the characteristics of cystic structures (i.e. abnormal airspace), degree of inflammation and severity of pneumocyte injury semi-quantitatively. In AEF, the wall thickness of the cystic lesions (0.8 mm) was thinner than in UIP (2.1 mm) and thicker than in CLE (0.07 mm). The degree of inflammation and granulation tissue were milder in AEF than in UIP and NSIP and CLE showed milder inflammatory cells than AEF. As for pneumocyte injury, AEF had fewer erosions (0.1/case) and fewer ubiquitin-positive pneumocytes than UIP (4.8 cells/slide) and NSIP (9.8 cells/slide). Our data suggested that the histological characteristics of AEF differed significantly from UIP, NSIP and CLE.

[Clinical analysis of mycobacteriosis patients with pneumothorax]

BACKGROUND

Secondary pneumothorax caused by mycobacteriosis is rare. The frequency of incidence of pneumothorax in tuberculosis patients is reported to be only 1.5%, and that in nontuberculous mycobacteriosis patients may be very low. It is important to detect mycobacteriosis at an earlier stage in patients hospitalized for pneumothorax, in general wards so that nosocomial infections such as tuberculosis can be prevented.

OBJECTIVE

Chart review of mycobacteriosis patients with secondary pneumothorax admitted to the isolation ward, and that of the mycobacteriosis patients with pneumothorax admitted in the general wards of our hospital.

METHODS

We reviewed records of 555 mycobacteriosis patients admitted to the isolation ward of our hospital from January 2006 to December 2008. We analyzed the reasons for admission and cause, treatment, and outcome of pneumothorax.

RESULTS

Of the 555 mycobacteriosis patients, 11 (2.0%) had complications of pneumothorax. Among these 11 patients, 9 had tuberculosis, and 2 had nontuberculous mycobacteriosis. Of the 11, 5 were discharged, but 6 (54.5%) died during hospitalization, while among the remaining 544 mycobacteriosis patients without pneumothorax, 49 (9%) died during hospitalization. The hospital death rate of mycobacteriosis patients with pneumothorax was significantly higher than that of mycobacteriosis patients without pneumothorax (p < 0.0001). Among the 9 tuberculosis patients, 4 in whom pneumothorax was caused by rupturing of bullae showed improvement except one patient, but 5 in whom pneumothorax was caused by tuberculosis died. Excluding the 555 patients admitted to the isolation ward, 388 pneumothorax patients were admitted to the general ward during the same period, among which 3 (0.8%) had mycobacteriosis.

CONCLUSION

Tuberculosis-induced pneumothorax has a poor prognosis because the occurrence of tuberculosis impairs the mechanism of recovery from pneumothorax.

Multicenter, phase II, placebo-controlled, double-blind, randomized study of aprepitant in Japanese patients receiving high-dose cisplatin

Aprepitant is a new neurokinin-1 (NK(1) ) receptor antagonist developed as a treatment for chemotherapy-induced nausea and vomiting (CINV). To evaluate the efficacy and safety of aprepitant used in combination with standard therapy (granisetron and dexamethasone), we conducted a multicenter, phase II, placebo-controlled, double-blind, randomized study in Japanese cancer patients who received cancer chemotherapy including cisplatin (≥70mg/m(2) ). Aprepitant was administered for 5days. A total of 453 patients were enrolled. In the three study groups, (i) standard therapy, (ii) aprepitant 40/25mg (40mg on day 1 and 25mg on days 2-5) and (iii) aprepitant 125/80mg (125mg on day 1 and 80mg on days 2-5), the percentage of patients with complete response (no emesis and no rescue therapy) was 50.3% (75/149 subjects), 66.4% (95/143 subjects) and 70.5% (103/146 subjects), respectively. This shows that efficacy was significantly higher in the aprepitant 40/25mg and 125/80mg groups than in the standard therapy group (χ(2) test [closed testing procedure]: P=0.0053 and P=0.0004, respectively) and highest in the aprepitant 125/80mg group. The delayed phase efficacy (days 2-5) was similar to the overall phase efficacy (days 1-5), indicating that aprepitant is effective in the delayed phase when standard therapy is not very effective. In terms of safety, aprepitant was generally well tolerated in Japanese cancer patients. (ClinicalTrials.gov number, NCT00212602.)

Isolation of Candida species is an important clue for suspecting gastrointestinal tract perforation as a cause of empyema

BACKGROUND

Empyema due to Candida species is a rare entity, and the significance of isolation of Candida species from the pleural effusion is not fully understood.

OBJECTIVE

To elucidate the clinical features of Candida empyema.

METHODS

We retrospectively reviewed the cases of 128 patients with culture-positive empyema.

RESULTS

These 128 patients included 7 whose cause of empyema was esophago- or gastropleural fistula. Empyema was due to Candida species in 5 of the 7 patients. Primary diseases of these 5 patients were spontaneous esophageal rupture in 3 patients, esophageal rupture due to lung cancer invasion in 1 patient, and gastric ulcer perforation in 1 patient. None of these 5 patients had esophageal candidiasis. Among the 121 other patients with empyema not due to esophago- or gastropleural fistula, no patient had empyema due to Candida.

CONCLUSION

We believe that the empyema in these 5 patients was caused by normal commensal Candida species entering the pleural cavity when the fistula between the gastrointestinal tract and pleural cavity was formed. Isolation of Candida species can be an important clue for suspecting gastrointestinal tract perforation as a cause of empyema.

[A surgical case of extramedullary plasmacytoma in the left main bronchus]

A 69-year-old woman complaining of cough and wheezing of 2-months duration was admitted for diagnosis and treatment. She had been treated for bronchial asthma. Chest computed tomography showed an endobronchial tumor in the left main bronchus. Bronchoscopic biopsy yielded a diagnosis of plasmacytoma. We confirmed the absence of M-protein in the serum and urine, bone lesions in bone scintigraphy, and other organ dysfunction. In addition bone marrow biopsy and revealed normal findings. We diagnosed extramedullary plasmacytoma in the left main bronchus. We performed a sleeve resection of the left main bronchus including the tumor and reconstructed the bronchus with primary end-to-end anastomoses. We achieved complete excision and were able to maintain lung function. One year after the operation, the patient remains well, with no evidence of recurrence, or conversion to multiple myeloma. When a patient complains of wheezing, a bronchial tumor should always be considered.

[Pathological study of the natural history of pulmonary infarction mainly seen in lung tumors--pulmonary infarction begins with alveolar wall bleeding]

This study investigated the histological features of pulmonary infarction (PI). We examined lung tissue samples from 25 patients with PI treated in our hospital. The mean patient age was 59 years, 21 were men, and 4 were women. In 22 cases, the PI was located at the periphery of lung cancers. The mean number of slides examined was 2.7 including ordinary and immunohistochemical examinations. There were 3.6 PI per case. Eight cases of alveolar wall bleeding suspected of being at the beginning stage of infarction were characterized by partial alveolar epithelial and capillary endothelial disruption from the alveolar wall and separation of epithelial and endothelial basement membranes (BM). Eleven cases showed acute PI characterized by marked dilatation of the alveolar wall and separation of epithelial and endothelial BM in necrosis. Fourteen were organizing PI. Seven were organized PI with fibrotic encapsulation and partial organization of the infarction. The beginning stage of pulmonary infarction shows separation between epithelial and endothelial BMs and bleeding into the alveolar wall. The organized stage of PI shows gradual organization of infarction.

Placental transmogrification of the lung presenting as a small solitary nodule

Placental transmogrification of the lung is a rare cystic lesion of the lung, which has some histologic resembling to placental tissue. Placental transmogrification of the lung has been considered a variant of unilateral bullous emphysema, but in our case, the patient was a 47-year-old man who had no coexisting emphysema of the lung. Histologically our case showed an interstitial proliferation of clear cells with cystic change interpreted as secondary; we also agree with our colleagues that this proliferation may be the primary event pathogenetically. Surgical resection of this lesion seems to be curative.

Smoking-related changes in the background lung of specimens resected for lung cancer: a semiquantitative study with correlation to postoperative course

AIMS

To assess the pathological findings in lobectomy specimens, to correlate them with smoking history and postoperative course and to compare the findings with those in smoking-related interstitial lung disease.

METHODS AND RESULTS

Patients who had undergone lobectomy for lung cancer were reviewed. Subjects included 230 non-smokers and 587 smokers, of whom 572 had a known smoking index (SI). They were classified into mild, moderate and heavy smokers. Centrilobular emphysema (CLE), respiratory bronchiolitis, airspace enlargement with fibrosis (AEF), the presence of foci resembling usual interstitial pneumonia pattern (UIP/P) and the rate of postoperative respiratory failure were assessed. The incidence of AEF was 6.5% in mild smokers, and 17.7% in moderate smokers (P < 0.01) with lower lobe predominance. There were significant correlations (P < 0.01) between AEF and CLE and AEF and UIP/P. The rate of respiratory failure after lobectomy was 6%, and 10% in patients having UIP/P with or without AEF, but was not seen in patients with AEF alone (P < 0.01).

CONCLUSIONS

AEF is an important smoking-related change in the lung that appears to correlate with the smoking history, and its distinction from UIP/P may be important.

[Lung cancer associated with rheumatoid arthritis and usual interstitial pneumonia]

To assess the effects of usual interstitial pneumonia (UIP) and smoking in rheumatoid arthritis (RA) patients regarding lung cancer risk, we studied 86 RA patients (14 patients with lung cancer, 58 patients with UIP (RA/ UIP), and 14 patients with both). Among the 28 RA patients with lung cancer, 14 patients (50%) had UIP. Compared to the lung cancer patients without UIP, the proportion of smokers (92.6 vs 50%, p = 0.0328) and total pack-years of smoking (57.1 +/- 37.1 vs 19.5 +/- 21.9, p = 0.003) were significantly higher in lung cancer patients with UIP. There was no significant difference in age, sex, and histological type and location of lung cancer between these two groups. Among the 72 RA/UIP patients, 14 patients (19.4%) had lung cancer. Compared to RA/UIP-only patients, the proportion of smokers (92.6 vs 46.6%, p = 0.002) and total pack-years of smoking (57.1 +/- 37.1 vs 25.4 37.4, p = 0.006) were significantly higher in RA/UIP patients with lung cancer. There was no significant difference in age, sex, and the duration of RA between these two groups. The odds ratio of smoking and total pack-years of smoking over 20 for the development of lung cancer in RA/UIP patients were 14.93 and 21.27, and the differences were statistically significant (p = 0.002 and p < 0.001, respectively).

CONCLUSION

50% of RA patients with lung cancer had RA/UIP and 19.4% of RA/UIP patients had lung cancer. These findings suggest that RA/UIP may be associated with increased risk of development of lung cancer in RA patients. In an RA cohort study to assess the development of lung cancer, RA patients should be divided into two groups, one with RA/UIP and another without RA/UIP. Smokers with RA/UIP should be recommended to cease smoking.

Second Primary Digestive Cancer After Resection of Lung Cancer

PURPOSE

We evaluated the clinical findings of patients with second primary digestive cancers (SPDC) after the resection of lung cancer.

METHODS

Among 772 patients who underwent resection of primary lung cancer at Saitama Cardiovascular and Respiratory Center between 1993 and 2002, 10 (1.3%) were diagnosed with SPDC during follow-up. These ten patients were classified into two groups based on whether the SPDC was incidentally (group I) or symptomatically (group S) diagnosed.

RESULTS

The median interval to the detection of SPDC was 17 months in group I and 66 months in group S, and the disease was at an earlier stage in group I than in group S ( P = 0.008). Comparing body weight at the time of lung resection to that at the time of abdominal surgery, significant weight loss was evident in group S ( P = 0.009). The postoperative disease-specific survival rate was 100% in group I. No long-term survivor died of lung cancer.

CONCLUSION

Special attention must be paid to the possibility of SPDC after the resection of lung cancer to improve the prognosis of patients with lung cancer.

[A case of desquamative interstitial pneumonia with bilateral hilar and mediastinal lymphadenopathy]

A 53-year-old man in whom reticulonodular shadows had been noted since 1999 in chest radiographs was admitted to our hospital in January 2003 with a complaint of persistent cough. His thoracic computed tomography (CT) showed diffuse ground-glass opacities in both lung fields and bilateral hilar and mediastinal lymphadenopathy. Histopathological findings from video-assisted thoracoscopic surgical biopsy included diffuse, monotonous interstitial pneumonia with accumulation of macrophages in the alveolar spaces and many lymphoid follicles, which was compatible with desquamative interstitial pneumonia (DIP). There was follicular hyperplasia in the enlarged lymph node without a suggestion of granulomous disease. He responded well to corticosteroid administration, resulting in an improvement of his clinical condition associated with a decrease in the ground-glass opacities. The bilateral hilar and mediastinal lymphadenopathy was slightly reduced. Since we could find no literature reporting DIP with bilateral hilar and mediastinal lymphadenopathy on thoracic CT, we consider the diagnostic problems and therapeutic response of this case to warrant a brief report.

[Imaging diagnosis for intralobar pulmonary sequestration by subclassification of CT findings in bronchoalveolar structures]

We examined the chest CT findings in 12 cases of intralobar pulmonary sequestration. We classified 4 subtypes by evaluating bronchial and alveolar structures, thus: type A (3 cases), mild cylindrical dilatation of the bronchial structure and hyperlucent alveolar structure; type B (3 cases), marked cylindrical dilatation of the bronchial structure and hyperlucent alveolar structure; type C (2 cases), multicystic dilatation of the bronchial structure and alveolar structure without hyperlucency; and type D (4 cases), multicystic dilatation of the bronchial structure and absence of any alveolar structure. All 77 cases (present and previously reported cases) with CT-documented intralobar pulmonary sequestration could be classified into 4 subtypes: type A 9%, type B 34%, type C 19%, and type D 38%. We concluded that these 4 types were useful for the radiological diagnosis of intralobar pulmonary sequestration.

[Churg-Strauss syndrome with alveolar hemorrhage]

A 35 year-old man was admitted to our hospital because of cough, wheezing, and paresthesia of the right upper extremity. He demonstrated marked eosinophilia, bronchial asthma, and mononeuritis multiplex. We diagnosed Churg-Strauss syndrome. Serum MPO-ANCA was elevated to 189 U/ml. Chest high-resolution computed tomography showed panlobular ground-glass attenuation in both lungs. BALF showed bloody fluid, and TBLB revealed findings consistent with eosinophilic pneumonia. Lung biopsy by VATS revealed eosinophilic pneumonia, pulmonary vasculitis, capillaritis, and hemosiderosis. The patient recovered after treatment with prednisolone and cyclophosphamide. We concluded that alveolar hemorrhage due to pulmonary capillaritis could be a complication in cases of Churg-Strauss syndrome.

Behavioral planning in the prefrontal cortex

Recent studies have presented evidence that the prefrontal cortex plays a crucial role in every aspect of the cognitive processes necessary for behavioral planning: processing and integration of perceived or memorized information, associative learning, reward-based behavioral control, behavioral selection/decision-making and behavioral guidance. We propose that the creation of novel information is the means by which the prefrontal cortex operates to achieve executive control over behavioral planning. The prefrontal cortex is the site of operation of nodal points, where neural circuits integrate currently available or memorized information to generate the information that is necessary to perform an action. The prefrontal cortex also regulates the flow of information through multiple nodes to meet behavioral demands.

Integration of target and body-part information in the premotor cortex when planning action

To plan an action, we must first select an object to act on and the body part (or parts) to use to accomplish our intention. To plan the motor task of reaching, we specify both the target to reach for and the arm to use. In the process of planning and preparing a motor task, information about the motor target and the arm to use must be integrated before a motor program can be formulated to generate the appropriate limb movement. One of the structures in the brain that is probably involved in integrating these two sets of information is the premotor area in the cerebral cortex of primates. The lateral sector of the dorsal premotor cortex is known to receive both visual and somatosensory input, and we show here that neurons in this area gather information about both the target and the body part, while subsequent activity specifies the planned action.

Neuronal activity in the primate prefrontal cortex in the process of motor selection based on two behavioral rules

This study examined neuronal activity in the prefrontal cortex (PF) involved in the process of motor selection in accordance with two behavioral rules. We trained two monkeys to select a target based on the integration of memorized and current sensory information. Initially, a sample cue (triangle or circle) appeared at one of three locations (top, left, or right) for 1 s. After a 3-s delay, one of two types of choice cue appeared. The first type asked the monkeys to reach for a target by matching the location (location-matching task). The second type asked the monkeys to reach for a target by matching the shape (shape-matching task). The choice cue for location matching consisted of either three circles or three triangles, and the choice cue for shape matching consisted of a circle and a triangle. When the color of the choice cue changed from red to green 1.5 s later (GO signal), the monkeys touched the correct object to obtain a reward. We found cue-, delay-, choice-, and movement-related neuronal activity in the lateral prefrontal cortex. During the sample cue presentation and delay periods, we found selective neuronal activity for the location or shape of the sample cue. Shape-selective neurons were located more anteriorly in the ventral bank of the principal sulcus and inferior convexity area, whereas location-selective neurons were more posteriorly. After the choice cue appeared, we found three main types of neuronal activity in the critical period when the subject selected the future target: 1) activity reflecting past sensory information (the location or shape of the sample cue presented 3 s earlier), 2) activity selective for the configuration of the current choice cue, and 3) activity reflecting the properties (location or shape) of the future target. During the motor-response period, we found neuronal activity selective for the location or shape of the reaching target. When muscimol was microinjected into the ventral bank of principal sulcus and inferior convexity area, the performance of both tasks was impaired. Furthermore, we found that the wealth of neuronal activity in the PF that seemed to play a role in motor selection was rarely seen in the primary motor cortex.

Reacquisition deficits in prism adaptation after muscimol microinjection into the ventral premotor cortex of monkeys

A small amount of muscimol (1 microl; concentration, 5 microg/microl) was injected into the ventral and dorsal premotor cortex areas (PMv and PMd, respectively) of monkeys, which then were required to perform a visually guided reaching task. For the task, the monkeys were required to reach for a target soon after it was presented on a screen. While performing the task, the monkeys' eyes were covered with left 10 degrees, right 10 degrees, or no wedge prisms, for a block of 50-100 trials. Without the prisms, the monkeys reached the targets accurately. When the prisms were placed, the monkeys initially misreached the targets because the prisms displaced the visual field. Before the muscimol injection, the monkeys adapted to the prisms in 10-20 trials, judging from the horizontal distance between the target location and the point where the monkey touched the screen. After muscimol injection into the PMv, the monkeys lost the ability to readapt and touched the screen closer to the location of the targets as seen through the prisms. This deficit was observed at selective target locations, only when the targets were shifted contralaterally to the injected hemisphere. When muscimol was injected into the PMd, no such deficits were observed. There were no changes in the reaction and movement times induced by muscimol injections in either area. The results suggest that the PMv plays an important role in motor learning, specifically in recalibrating visual and motor coordinates.

[A case of sleeve resection of the left main bronchus for tuberculous bronchial lesion]

A 31-year-old woman was admitted to our center with left chest pain and dyspnea after treatment of pulmonary tuberculosis. Chest X-ray film showed atelectasis of left lower lobe and left deviation of the mediastium. Bronchofiberscopy revealed obstruction of the left main bronchus. Chest MRI showed intermediate intensity at the left main bronchus and very high intensity at the peripheral bronchus. We performed sleeve resection of the left main bronchus and anastomosed end to end with absorbable monofilament sutures. Postoperative course was uneventful. Bronchoplasty for tuberculous obstructive lesion is a useful procedure.

Task-dependent selectivity of movement-related neuronal activity in the primate prefrontal cortex

Task-dependent selectivity of movement-related neuronal activity in the primate prefrontal cortex. J. Neurophysiol. 80: 3392-3397, 1998. We studied movement-related neuronal activity in the dorsolateral prefrontal cortex from the perspective of a general role for the prefrontal cortex in controlling motor behavior to achieve a specific goal according to the requirements of a given task. Monkeys were trained to perform two delayed motor tasks. The first task involved reaching for a target that matched the shape of a cue. The second task involved reaching for a target that matched the location of the cue. A majority (54%) of 175 movement-related prefrontal neurons exhibited preference for either the target shape or the type of task requirements. Sixty-four neurons (36%) were selectively active while reaching for a circle or a triangle. On the other hand, the activity of 59 neurons (34%) depended on whether the task required matching the shape or the location. These properties, characterizing the movement-related neuronal activity in the prefrontal cortex, rarely were found in the arm area of the primary motor cortex. Only 1 of 130 movement-related neurons (0.8%) showed task selectivity, and none showed target-shape selectivity.

Neuronal activity in the claustrum of the monkey during performance of multiple movements

1. We studied neuronal activity in the claustrum of monkeys during performance of three different arm movements. We verified recording sites of claustral neurons by histological confirmation of microlesions. For the sake of comparison, we also recorded from the arm area of the precentral motor cortex (MI). Selection of the movements was either visually guided or determined by memorized information. 2. A striking property of claustral neurons is their nonselective relation to the three movements (push, pull, and turn a manipulandum). A vast majority (70%) of movement-related neurons exhibited increase of discharge in relation to all three movements, whereas only 16% were active in relation to one of the three movements. By contrast, about one-half of neurons in the MI were active in relation to a single movement. In both areas, the movement-related activity was similar regardless of whether the movements were selected by visual signals or by memory. 3. The study is the first to reveal involvement of claustral neurons in motor execution, and their activity property suggests that the way they are involved is different from that of MI neurons.

A huge immature cervical teratoma in a newborn: report of a case

A neonate with a large cervical mass was transferred to our hospital at 4 days of age. A computed tomography scan showed a contrast-enhanced solid mass with multiple cystic elements and fine calcification. Ultrasonography also revealed a predominantly solid mass with calcification, containing multiple cysts. These studies suggested a teratoma, but could not rule out a hemangioma. The tumor was removed on the 12th day of life. A pathological study revealed an immature teratoma that demonstrated fetal type cartilage and an immature neural tube. The operative complete removal of a cervical teratoma in neonates is recommended as soon as possible. The management of a pediatric cervical teratoma should also be similar to that of a sacrococcygeal teratoma. The incidence of cervical teratoma in all pediatric teratomas ranges from 2.3%-9.3% in the West, and from 1.6%-8.3% in Japan.

[A case of a synchronous triple primary lung cancer with hamartoma]

We present a case of synchronous triple primary lung cancer. 69-year-old male admitted after mass examination with the tumor shadows on right S3, left S4 and left S8. Further examinations confirmed as squamous cell carcinoma of right S3 and left S8 and as benign tumor of left S4 with right hillar lymph nodal swelling. In addition to these lesion, bronchofiberscopy revealed the squamous cell carcinoma of left basal bronchus. The secondlook operation was planned for bilateral primary lung cancer. At first, patient underwent right S3 segmentectomy with regional lymph nodes dissection. Two month later, left thoractomy was performed, followed by left lower lobectomy. Histopathological examination defined as well differentiated squamous cell carcinoma, moderately differentiated squamous cell carcinoma, squamous cell carcinoma in situ and hamartoma for right S3, left S8, left basal bronchus and left S4, respectively. Lymph node metastasis was found only in #121. Although tumors were resected with good curability, respiratory function was depressed and performance status deteriorated. It is important to attention to the preservation of respiratory function for the surgical treatment to multiple lesions and the combined therapy with radiation, chemotherapy and/or laser may be considered.

Enhancement of the intracranial arterial wall at MR imaging: relationship to cerebral atherosclerosis

PURPOSE

To investigate the relationship between intracranial arterial wall enhancement and atherosclerosis.

MATERIALS AND METHODS

Intracranial vertebral arteries of 30 patients and carotid arteries of 62 patients were studied with spin-echo magnetic resonance imaging with contrast enhancement and spatial presaturation. Arterial wall enhancement was graded as follows: stage 1, no substantial enhancement; stage 2, faint or thin area of enhancement; stage 3, definite and thick area of enhancement.

RESULTS

In vertebral arteries, stage 3 enhancement was seen in 11 patients (mean age, 73.7 years) and stage 1 in eight (mean age, 56.4 years). In carotid arteries, stage 3 enhancement was seen in 13 patients (mean age, 71.0 years) and stage 1 in 21 patients (mean age, 39.0 years). In both arteries, stage was well correlated with age (P < .05).

CONCLUSION

Arterial wall enhancement is related to aging and is probably due to neovascularity in association with atherosclerotic plaques. This finding may permit assessment of intracranial atherosclerosis and other vascular diseases.