Of 733 surgical cases of lung cancer recorded over the last 17 years, younger patients less than 40 years of age numbered 24 (3.3%). The youngest patient was a seventeenyear-old female, and all patients under the age of 30 had adenocystic carcinomas. Females accounted for 7 of the 24 cases (29.2%), a proportion higher than the female: male ratio for the entire group (25.2%). There were 9 (37.5%) asymptomatic cases and 15 (62.5%) symptomatic cases. The most common symptom was a cough. Among younger cases 33.3% were non-smokers, compared to 17.1% of the entire group. Histologically there were 10 cases of adenocarcinoma, but fewer cases of squamous cell carcinoma. The histological types were as follows: 11 stage I, 1 stage II, 6 stage III A, 5 stage III B, and 1 stage N. For the younger cases 50.0% had cancers in the advanced stage, compared to 59.6% in the entire group. The surgical outcomes were as follows: 12 cases of completely curative resection, 6 cases of relatively curative resection, 2 cases of relatively noncurative resection, 2 cases of completely noncurative resection, and 2 unresectable cases. Surgical results were considered excellent since the 5 year survival rate was 74.1%. For stage I cancer patients, the 5 year survival rate was 100%, but for stage IIIA cancer patients, the 5 year survival rate was 0%. There were comparatively few asymptomatic advanced cancer cases in which convalescence was satisfactory.

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MRI was performed in 78 primary lung cancer cases to evaluate the optimal diagnostic criteria for regional lymph node metastases. Receiver operating characteristic (ROC) curve analysis for 262 lymph nodes of the hilar and mediastinal regions showed that the optimal size criterion is 10mm in the mean axis of nodal diameter. Employing this criterion, the diagnostic rates for hilar and mediastinal lymph nodes had a sensitivity of 75%, a specificity of 82% and an overall accuracy of 79%. However, the diagnostic rates for subaortic, paraaortic and hilar lymph nodes using the same criterion showed lower specificities than those for other nodes. It was suggested that evaluation by coronal section made the diagnosis for subaortic lymph nodes more precise. In the ROC curve analysis for each histologic type, it was thought that the optimal criterion for adenocarcinoma was 10mm in the mean axis, and that the criteria for squamous cell carcinoma were llmm in the mean axis and 10mm in the short axis.

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Image analysis on the elastic fibers (EF) in the tumor stroma of the peripheral pulmonary adenocarcinoma especially of type 1 was studied. In Weigert's resorcinfuchsin stain, EF selectively stained blackish, and was classified into two types, fine and thick fibers. The fine fibers (FiEF) were characteristic in this type of adenocarcinomaand the thick fibers (ThEF), which run in waves along the tumor margin, showed similar histologic characters as EF in the peripheral alveolar walls.
Using a microscopic image analyzer, it was found that in tumors the total EF increased 3-7 fold and the skeletonized EF increased 1.5-3.3 fold compared to the peripheral alveolar walls in the same division. These ratios increased when calculating in terms of a per unit wall length. In particular, the skeleton ratio may show a contraction rate of pre-existing alveoli in the tumor.
From these findings, the tumor stroma in the early stage might be formed by the thickening and contraction of the alveolar wall while maintaining an air space due to proliferation of the new FiEF.

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Serum BFP levels were determined in 213 primary lung cancer patients by enzyme immunoassay (EIA). CEA, SLX, NCC-ST-439, NSE and SCC were also determined and compared with BFP in the same samples. The positive rate of BFP in all lungcancer patients was 32%. In small cell lung cancer patients, the positive rate was 47%, but even in non small cell lung cancer patients, the positive rate was comparatively high. The change of serum BFP level was related to chemotherapeutic response. In correlation with other tumor markers, BFP weakly correlated with NSE (r = 0.477) but did not correlate with other tumor markers. BFP is a broad spectrum and independent marker. It is concluded that BFP is a useful tumor marker for monitoring in lung cancer patients and in combination assay for lung cancer.

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Twenty-one patients with advanced non-small cell lung cancer were entered into a pilot phase II study of high-dose cisplatin (CDDP) + vindesine (VDS). The response rate among the 19 evaluable patients was 63.2%. Median survival was 12.7 months. Renal toxicity was avoided by administration of hypertonic saline and a divided day-1 and day-8 schedule. Neutropenia was severe (Grade 4, 47.6%), but considered tolerable. In conclusion, combination of high-dose CDDP+VDS seemed to be an effective regimen.

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To evaluate the therapeutic effect of radiation therapy and chemotherapy in lung cancer patients, MR imaging was performed in 59 patients with lung cancer. Tumor size and signal intensity before and after treatment were discussed. MRI patterns of therapeutic effect were divided into 3 types. In 37 cases, mild tumor reduction was recognized, but there was no change in the signal intensity of the tumor after treatment (Type I). In 11 cases, high intensity areas considered to be tumor necrosis were observed inside the tumor on the T2-weighted image, and 9 of these (82%) were squamous cell carcinoma (Type II). In the remaining 11 cases, marked tumor reduction was observed on MRI, thus the signal intensity could not be compared, and 8 of these cases were small cell lung cancer (Type III). It was suggested that there was a certain correlation between these MRI patterns and histologic types. In 11 autopsied cases, comparison images and pathologic findings showed the MRI findings to be consistent with the pathologic findings. MR imaging can evaluate therapeutic effect not only by tumor size, but also by tissue characteristics. Furthermore tumors were clearly delineated from radiation pneumonitis in 5 of 8 cases (63%). Therefore, MRI was useful to evaluate therapeutic effect.

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Two hundred and thirteen cases of female lung cancer diagnosed at Tokyo Medical College Hospital from 1981 through 1987 were studied. The female lung cancer cases composed 21.7% of all lung cancer cases (female to male ratio of 1: 3.6).
Though adenocarcinoma was the most common histological type (69.0%), the ratio of squamous cell carcinoma increased after 1984. This bias was understood to reflect a rise in public concern for preventive medicine and increasing smoking habits.
Approximately one quarter (25.9%) of adenocarcinoma and 70.6% of squamous cell carcinoma cases were smokers, suggesting a relationship between smoking habit and squamous cell carcinoma. The median survival rate was 15.7 months and the 5-year survival rate was 23.6%. The prognosis of female cases was significantly better than that of male cases. However, cases younger than 40 years old are not covered by the Elderly Health Law and as such are not included in health surveys. Therefore in this young age group only a few asymptomatic cases were detected on chest X-ray. Symptomatic cases were too advanced to operate.
Encouragement to stop smoking and education of housewives, especially in high-risk groups and persuading them to undergo regular examinations should help to reduce female lung cancer or to increase early-stage detection.

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Positron emission tomography (PET) using ¹¹C-methionine was performed in 44 patients with chest diseases. In this trial, we introduced a respiration-gated scan which improved the spatial resolution. Positron angiography was simultaneously carried out for the orientation of anatomy. We adopted the expression of differential absorption ratio (DAR), which gave more quantitative information than a mere photographic display.
Malignant tumors were visualized clearly in all patients, and their anatomical location and structures were correctly diagnosed. The mean DAR of all malignant tumors was 4.77±0.95 (n=32) and that of lung cancer was 4.33±0.76 (n=29). It was impossible to identify the cancer cell type or determine malignancy by this method. A few cases diagnosed as inflammatory diseases were positively visualized.
Our method was useful for determining anatomical localization and structure of malignant lesions in the chest.

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Eight cases of adenosquamous carcinoma, surgically treated (5.4% of resected cases of pulmonary carcinoma) during a period of 11 years, were clinicopathologically reviewed. Six were male and 2 female, the average age being 63.1. In 4 cases, cancer was discovered without clinical signs. Five patients were heavy smokers with a smoking index above 600, and in 5 cases out of 7, high blood levels of CEA were observed. Correct diagnosis was not made in any cases preoperatively. Three cases were Stage I, and 5 were Stage III. The carcinoma was of peripheral origin in all cases.
In 5 cases, both components of adenocarcinoma and squamous cell carcinoma were approximately equal, and the latter was predominant in 3. The grade of tumor differentiation was poor in 5 cases.
To compare the carcinomas of this histological type with adenocarcinomas or squamous cell carcinomas experienced in the same period, tumor stage more frequently exceeded Stage III than in cases of adenocarcinomas or squamous cell carcinomas, as determined postoperatively, and although 3-year survival was 28%, being lower than the 51% and 46%, respectively in the latter two, significant difference could not be noted between tumors of this type, and adenocarcinomas and squamous cell carcinomas. There was little difference in prognosis among all 3 types in Stage III or more advanced cases.
Although tumors of this type resemble adenocarcinoma concerning CEA and site of origin, it is extremely difficult to establish diagnosis preoperatively, and tumor frequently advances when discovered, and 5 cases out of 7 that tolerated surgery succumbed within 17 months.

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The authors analyzed the relationship between the location of primary tumor and level of mediastinal lymph node metastases and the prognosis in resected non-small cell lung cancer with mediastinal lymph node metastases. The frequency of mediastinal lymph node metastases in tumors in the upper lobe was higher in the upper mediastinal lymph nodes (mostly the lower paratracheal in the right and the subaortic in the left) and in the lower lobe the frequency was higher in the subcarinal lymph node. The majority of the number of positive levels in mediastinal lymph node was one positive level and there was no significant difference in frequency between tumors in the upper lobe and those in the lower lobe. In patients who had undergone curative operations, the survival rate of tumors in the lower lobe (7.8% at 5 years) was less (P<0.01) than that of tumors in the upper lobe (36.7% at 5 years). The results suggest differences in the mode of mediastinal lymph node metastases according to the location of primary tumor influences the prognosis.

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From January 1979 to December 1989, 54 patients with T4 NSCLC were treated by external radiotherapy (RT). Of those, 26 patients evaluable by CT scan before and after RT were analyzed in terms of individual tumor responses in association with invaded organs, symptom relief, and survival. Local responses were CR 1, PR 10, NC 10, PD 5, showing a response rate of 42%(11/26). RT demonstrated effective tumor response rates in each involved site as follows, SVC (60%), carina (50%), aorta (50%), trachea (50%), and spine (46%), respectively. Symptoms were improved in 73%(19/26), such as hemosputum (100%), cough (86%), chest pain (75%), SVC syndrome (67%). Duration of the effect on symptoms ranged 1.5-41+months. Median survival time was 6.5 months and the 3-Y-actuarial survival rate was 18%. Fourteen patients were irradiated in combination with chemotherapy, but no significant contribution to survival was observed.
RT for T4 NSCLC showed no survival benefit, but was validated by improvement of the patients' quality of life.

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After resection of a wide area of the chest wall for the treatment of advanced lung cancer involving the chest wall, reconstruction of the chest wall with a silastic sheet was performed in 3 cases. All 3 were primary lung cancers and the histologic types were squamous cell carcinoma, adenocarcinoma and large cell carcinoma. All of them widely infiltrated in the chest wall and the numbers of concomitantly resected ribs were 4 in 1 case and 5 in the other 2 cases. Since the extensive chest wall defects were considered to possess the danger of postoperative respiratory failure, reconstruction of the chest wall with a silastic sheet was performed to maintain the structure of the thorax. As a result, in 2 cases, flexed deformities of the covering sheet were observed and in 1 case, at an early postoperative stage, an impairment of expectoration caused by a paradoxical movement of the thoracic wall was observed. However, none of them required any respiratory control and neither exfoliation of the sheet nor any infection was observed. Further, the external deformation of the thorax was slight and the pain on motion of the upper limb of the operated side was also mild. Since the importance of reconstruction of the chest wall after the resection of the chest wall has been advocated, covering of the defect with various materials has been performed. The silastic sheet used in the prevent study is a material suitable for reconstruction of the chest wall.

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The relationship between the staining pattern of type IV collagen, the quantity of silver-binding nucleolar organizer regions (AgNORs), and survival time of 23 patients with pathological stage I or II adenocarcinoma of the lung was studied.
Type IV collagen was stained using immunohistochemical techniques, and AgNORs staining was performed by the one-step silver staining method. There was no significant relationship between AgNORs and survival rate.
The survival rate of patients with the continuous pattern of type IV collagen staining was significantly better than that of patients with the discontinuous pattern (P<0.001).
Metastatic potential indicated by this staining pattern seems to be a far more serious factor for the prognosis of patients with lung adenocarcinoma than proliferative activity indicated by the quantity of AgNORs.

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Although the obstruction of the superior vena cava (SVC) is well established as a fatal complication in patients with lung neoplasms, the obstruction of the inferior vena cava (IVC) is less documented. We recently observed 4 cases of IVC obstruction associated with lung cancer. There seemed to be three routes that resulted in IVC obstruction. In 2 cases, both the IVC and the SVC were obstructed simultaneously by external compression of the right atrium due to the mediastinal involvement of lung cancer. In one case, IVC was obstructed in the abdominal space due to metastasis in the right lobe of the liver and the right adrenal gland. Direct invasion to the IVC around the diaphragm was observed in one case from the cancer in the posterior basal segment of the right lower lobe. Major clinical signs such as edema in the lower extremities and ascites are relatively less severe and less specific in comparison with those of SVC syndrome. This might be the reason why these patients are overlooked, resulting in a low reported incidence of IVC obstruction in patients with lung cancer. We must pay attention to the possibility of IVC obstruction in patients with lung cancer showing the above-mentioned clinical signs. Because 3 of 4 cases were at an advanced stage, noninvasive methods such as ultrasonography, CT and magnetic resonance imaging are useful for evaluation of IVC. Since it is able to be performed at the bedside, ultrasonography was the most useful among these noninvasive methods.

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On chest X-ray film, a well defined and lobulated mass shadow was incidentally detected in segment 9 of the left lung in a 73-year-old heavy smoker (BI: 3, 180), who had been treated for another disease. Although the lesion could not be diagnosed by cytological examinations such as TV-brushing and aspiration, lower lobectomy of the left lung was performed, because the size of the tumor shadow increased on chest X-ray film.
The resected tumor was a soft well-demarcated cystic mass 4.5cm in diameter, and was tightly packed with mucus. Histologically, goblet cell type cancer cells were identified only in the peripheral area of the tumor, and the lesion was almost completely occupied with massive mucin. This case was pathologically diagnosed as mucinous carcinoma of the lung (p-T2N0M0). Because of the unusual clinico-pathological features, the tumor was considered to be a cystic variant of mucus-producing adenocarcinoma of the lung.

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A case associated with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) due to an oat cell carcinoma of the lung with high plasma atrial natriuretic peptide (ANP) levels was reported. The patient was admitted with cough and fever. Laboratory data showed serum hyponatremia (114mEq/l) associated with serum hypoosmolality (233mOsm/l) and high plasma levels of ANP (157pg/ml, normal range<10pg/ml). Because of the absence of dehydration and normal renal function a diagnosis of SIADH was made. Findings of the Carter-Robbins test with a Swan-Gantz catheter suggested that ANP was not released from the tumor, but that it might be from cardiac muscles. Treatment with multimodality therapy resulted in improvement of hyponatremia with reduction of the tumor. A high concentration of ADH and very low concentration of ANP was detected in the resected tumor extract. It is suggested from this result that the mechanism of hyponatremia in cases of SIADH is as follows:(1) inappropriate secretion of ADH, (2) increase of circulating blood volume, (3) increase of atrial pressure, (4) ANP secretion, (5) powerful natriuretic effect.

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A 63-year-old man with small cell lung cancer metastatic to the orbit was reported. After 3 courses of chemotherapy he showed a good response on chest roentgenogram, additional radiotherapy 5320 cGy was performed. Ten months after initiation of the treatment, left side blepharoptosis developed, with pain and swelling of the orbit, biopsy of which revealed metastatic small cell carcinoma. Although three courses of chemotherapy with Vindesine 4.5mg (days 1, 8, 15) were effective for the orbital metastasis, he died due to progression of the primary lesion and liver metastasis. Reported cases of lung cancer metastatic to the orbit in Japan were reviewed and the effects of Vindesine on the orbital metastasis in this case were discussed.

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A 22-year-old male complained of fever and cough. Chest X-ray showed obstructive pneumonia in the right lower lobe. Six months later, obstructive pneumonia recurred. Bronchoscopy revealed complete occlusion of the right basal bronchus by an endobronchial tumor, biopsy of which yielded a diagnosis of granular cell tumor. Right lower lobectomy was performed. The polypoid tumor arose from the orifice of right B⁷, measuring 30×30×10mm. An immunohistochemical study was positive for S-100 protein, and NSE.
Granular cell tumor of the lower respiratory is relatively rare. Surgical resection is recommended if the tumor is comparatively large.

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