Objective. To evaluate the outcomes after treating patients with stage III non-small-cell lung cancer (NSCLC) using involved-field radiation therapy (IFRT) without elective nodal irradiation and to evaluate the effects of hypofractionated IFRT. Methods. From December 2004 to November 2015, 51 patients with advanced NSCLC underwent IFRT. Of these, 45 patients were enrolled and evaluated. The median age was 69 years (range, 50-89 years), and 42 patients were men and 3 women. Eleven patients (24.4%) presented with adenocarcinoma, 30 (66.7%) with squamous cell carcinoma, and 4 (8.9%) with other types. Twenty-four (53.3%) had stage IIIA and 21 (46.7%) had stage IIIB. In patients treated by conventional IFRT, normal fractionation was used (2 Gy/fraction), and the total prescribed dose ranged from 60 to 66 Gy. In patients treated by hypofractionated IFRT, 2.5 Gy/fraction was used, and the total prescribed dose ranged from 65 to 70 Gy. Results. The 1- and 2-year overall survival rates were 78.4% and 53.7%, respectively. The 1- and 2-year local control rates were 72.2% and 57.7%, respectively. The patients in the conventional IFRT group had a 1-year local control rate of 61.2% and a 2-year local control rate of 47.6%, while the patients in the hypofractionated IFRT group achieved higher local control rates of 87.1% and 72.5%, respectively (P=0.0465). Conclusions. IFRT for patients with stage III NSCLC is feasible, and the incidence of elective nodal failure was low. Hypofractionated IFRT may therefore contribute to improvements in local control and overall survival.
Objectives. We reviewed the outcomes of surgical treatment in lung cancer patients aged 80 years or older. Methods. We introduced comprehensive rehabilitation for lung and airway disorders and performed surgery for 31 lung cancer patients aged 80 years or older from January 2007 to December 2014. We reviewed the outcomes of the surgical treatment. Results. The surgical procedures included partial resection in 18 cases, lobectomy in 12 cases and segmentectomy in 1 case. Complications occurred in 6 cases (19.4%), but there were no surgery-related deaths. The 5-year survival rate was 55.5%, and the median survival period was 30 months. There was no significant difference in the surgical outcomes between the passive limited resection group (17 cases: 16 partial resections and 1 segmental resection) and the lobar resection group (12 cases). Conclusions. If the surgical indication and type of surgery are appropriately selected, favorable surgical outcomes can be expected even in lung cancer patients aged 80 years or older.
Background. Mucoepidermoid carcinoma of the thymus is an extremely rare malignant mediastinal neoplasm. Case. We herein report the case of an asymptomatic 29-year-old man with mucoepidermoid carcinoma of the thymus. Chest radiography revealed an anterior mediastinal mass. Computed tomography of the chest demonstrated multiple 62×38×74 mm cystic masses with a focally-enhanced solid portion. Tumor resection was performed, and the pathological diagnosis was mucoepidermoid carcinoma of the thymus with a thymic cyst. Conclusion. We experienced a case of mucoepidermoid carcinoma of the thymus with a thymic cyst. At the time of writing, the patient remains alive without recurrence at 16 months after surgery.
Background. Malignant pleural mesothelioma often spreads locally into the adjacent tissues. However, it rarely invades the spinal canal. Case. In May 2007, a 69-year-old man presented with an abnormal shadow on a chest X-ray, and was diagnosed with malignant pleural mesothelioma of the right lung (epithelioid-type). He underwent various treatments, including chemotherapy and thermotherapy. However, he developed chest and back pain on the right-hand side and weakness of both lower extremities. He was therefore admitted to our hospital in September 2014. After admission, he developed paraplegia of the lower extremities and bladder and rectal disturbance. Spinal magnetic resonance imaging (MRI) showed that the tumor had invaded the cervical, thoracic, and lumbar epidural space through the Th8/9 intervertebral foramen. His neurological symptoms were temporarily improved by the administration of a corticosteroid. However, he died of respiratory failure due to tumor progression approximately 2 months after admission. On pathological autopsy the malignant pleural mesothelioma was observed to have extensively invaded the epidural space and the spinal dura mater. Conclusion. Malignant pleural mesothelioma can invade the spinal canal through the intervertebral foramen. When a patient with malignant pleural mesothelioma develops radicular symptoms, such as radiating pain, paralysis, and numbness, physicians should consider the possibility that the tumor has invaded the spinal canal.
Background. Epithelioid hemangioendothelioma is an extremely rare non-epithelial tumor originating from the vascular endothelial cells that arises in organs such as the lungs and liver. We report two cases of epithelioid hemangioendothelioma in which it was difficult to make a preoperative diagnosis. Case 1. A 67-year-old male patient was found to have an abnormal shadow on a chest X-ray during a health-checkup, was referred to our department. Chest computed tomography (CT) showed a nodule of 1.5 cm in diameter at segment 1+2 of the left lung. The patient underwent left upper lobectomy and partial resection of segment 6 of the left lung with ND2a-1 lymph node dissection for suspected left lung cancer. The frozen section diagnosis was papillary adenocarcinoma. Following a postoperative pathological examination, the patient was diagnosed with epithelioid hemangioendothelioma. Case 2. A 64-year-old woman presented with coughing symptoms. A chest X-ray and CT showed multiple nodules, and the patient was referred to our department for diagnostic purposes. Abdominal magnetic resonance imaging (MRI) also showed multiple hepatic nodules. The patient underwent partial resection of the right middle and lower lobe of the lung to allow for the definite diagnosis of the abnormal shadow. Epithelioid hemangioendothelioma was diagnosed based on the pathological findings. Conclusions. We encountered two cases of epithelioid hemangioendothelioma in which it was difficult to make a preoperative diagnosis. A surgical biopsy and immunohistochemistry are useful for making a definitive diagnosis in cases of epithelioid hemangioendothelioma.
Background. Reports of multiple ground-glass nodules (GGNs) have been increasing due to the recent spread of high resolution CT (HRCT). We herein report a case of synchronous double cancers: colon and multiple primary lung coexisting with sclerosing pneumocytoma. Case. A 69-year-old woman was diagnosed colon cancer in July 2015 and transverse colectomy D3 dissection was performed. The pathological diagnosis was tubular adenocarcinoma (tub1), pT3(ss)N0M0 stage IIA. She was introduced to our division, because chest HRCT showed bilateral multiple GGNs, a part-solid GGN and a solid nodule. We therefore suspected multiple primary lung cancers and a metastatic lung tumor. At first, we performed right upper lobectomy and wedge resection of the right lower lobe in September 2015. The pathological diagnosis was as follows, four pure GGNs of right upper lobe were all non-invasive adenocarcinomas and a solid nodule of the right lower lobe was sclerosing pneumocytoma. We then performed left superior segmentectomy in November 2015. The pathological diagnosis was minimally invasive adenocarcinoma. She underwent bilateral lung resection; however, her post-operative condition was very good and she comes to our hospital regularly. Conclusion. We reported a case of synchronous double cancer: transverse colon and multiple primary lung cancer coexisting with sclerosing pneumocytoma. We could resect the colon tumor and all of the lung tumors.
Background. Localized malignant pleural mesothelioma has been reported as a rare tumor that exhibits histological and immunohistological findings, but not biological findings, which are similar to diffuse malignant pleural mesothelioma. Case. A 59-year-old female patient with no history of asbestos exposure presented to our hospital to undergo an investigation for an abnormal chest shadow that had been detected during regular visits for articular rheumatism treatment. Computed tomography revealed a mass of approximately 5.5 cm in diameter in the left apex; a superior sulcus tumor was therefore suspected. Computed tomography-guided biopsy revealed non-small cell lung cancer, which was identified as stage IIIA (cT3N2M0). After chemoradiotherapy, left upper lobectomy with partial chest wall resection was performed. Immunohistologically, poorly differentiated epithelium-like atypical cells were found to have proliferated with a high degree of cellularity. The tumor was located between the visceral pleura and parietal pleura. No invasion was observed in the lung parenchyma. Immunostaining was positive for a mesothelioma marker and negative for lung cancer markers. Since there were no signs of the diffuse development of the tumor into the pleura, the case was diagnosed as localized malignant pleural mesothelioma. The patient remains well with no relapse at 8 months after surgery. Conclusion. Localized malignant pleural mesothelioma may have a different pathogenesis to diffuse malignant pleural mesothelioma. Further studies of the biological behavior are essential to evaluate the effectiveness of this treatment approach.
Background. When a new tumor appears after a long period of remission following surgery for lung cancer, it is difficult to determine whether the tumor is a recurrence or a new tumor. We herein report a case of a chest wall tumor that developed 22 years after pulmonary lobectomy diagnosed by an anaplastic lymphoma kinase (ALK) gene mutation. Case. An 80-year-old man underwent left-lung upper lobectomy for lung adenocarcinoma (pT4N2M0 Stage III) 22 years prior. We treated him with adjuvant chemotherapy after the surgery and did not detect a recurrence for 10 years. However, we noticed a chest wall mass 22 years after the surgery and diagnosed it by a biopsy as adenocarcinoma. The new specimen was stained with anti-thyroid transcription factor-1 (TTF-1) and anti-ALK antibodies, and the pathological specimen from the first surgery was also stained with anti-ALK antibody. We therefore diagnosed the chest wall tumor as a recurrence of the lung adenocarcinoma. We treated him with crizotinib, and the tumor shrank. However, we stopped the treatment because of the development of drug-induced interstitial pneumonia. We switched him to a platinum combination regimen, and follow-up is ongoing. Conclusions. When a lesion is suspected to be a recurrence long after surgery, an examination of gene mutations, such as that of ALK, may be useful.
Background. Advances in diagnostic imaging techniques have increased the opportunities to detect small nodules in peripheral lung fields. Making a differential diagnosis is sometimes difficult. Case. A 65-year-old-man was admitted to hospital to undergo further examination for a reticular shadow in the bilateral lower lung field on a chest radiograph. Chest CT revealed a 12-mm nodule in the right S8, and another 10-mm nodule just beneath the pleura of the same segment. Even though a bronchoscopic examination revealed that it was not malignant, the proximal nodule showed the slight accumulation of FDG-PET. The proximal nodule grew to 23 mm in size, and the nodule beneath the pleura grew to 22 mm in size. We therefore diagnosed the proximal nodule as primary lung cancer, and the nodule beneath the pleura as an inflammatory lesion. The partial resection of both nodules was performed. The intraoperative pathological diagnosis of the nodule on the proximal side was squamous cell carcinoma. We performed right lower lobectomy. The distal nodule was a metastatic intrapulmonary lymph node, and the final diagnosis was invasive squamous cell carcinoma, pT2aN1M0, stage IIA. Conclusion. We should consider intrapulmonary lymph nodes as a differential diagnosis when small nodules are observed in peripheral lung fields. If lung cancer is also suspected, then the possibility of metastasis to the peripheral intrapulmonary lymph nodes should be carefully taken into account, and a partial resection should be considered to enable an early diagnosis.
Background. Although invasive mucinous adenocarcinoma is known as a primary lung cancer, presenting with radiologic findings like pneumonia, it is rare for small cell lung cancer to present with similar findings. It is also rare for systemic sclerosis to be associated with small cell lung cancer in Japan. We herein report a case of small cell lung cancer presenting with air space consolidation during the course of treatment of systemic sclerosis. Case. A 74-year-old man was referred to our hospital with a complaint of dyspnea on exertion. He was diagnosed with systemic sclerosis based on findings of interstitial pneumonia, skin thickening and anti-RNA polymerase III antibody positivity. While the interstitial pulmonary changes on chest radiographs were slightly improved by treatment with prednisolone and cyclophosphamide, non-segmental consolidation in the subpleural area of the right upper lobe appeared after two weeks of treatment. Although it was assumed to be invasive mucinous adenocarcinoma, a trans-bronchial lung biopsy revealed it to be small cell carcinoma. He was treated with chemotherapy. Conclusion. Patients with systemic sclerosis rarely but occasionally develop small cell lung cancer presenting with air space consolidation. We should be alert for concomitant malignancy when anti-RNA polymerase III antibody is associated with systemic sclerosis.