Objective. To analyse the usefulness of high resolution CT (HRCT) for the diagnosis and localizationof roentgenographically occult lung cancer. Methods. HRCT was performed prospectively on chest X-ray negative patients with bloody sputum or suspicious or positive cells on sputum cytology between 1998 and 2000. After the HRCT scan, white light bronchoscopy and autofluorescence bronchoscopy were perfomed. Result. HRCT depicted 19 hilar bronchial lesions in 13 cases out of 19 patients, of which 9 lesions were confirmed by white light bronchoscope. Of 8 hilar squamous cell carcinomas diagnosed in this study, 7 lesions (87.5%) were depicted by HRCT. One CT-negative case (12.5%) was an in situ carcinoma in left B¹⁺². Four out of 20 lesions which showed bronchoscopic abnormality, could not be depicted by HRCT. Conclusion. HRCT could prospectively detect 80% of the bronchoscopic abnormalities and 87.5% of the hilar squamous cell carcinomas of the tracheobronchial lesions of the lung. Therefore, HRCT can be an effective supplemental means for screening for hilar squamous cell carcinoma. (JJLC. 2002; 42: 1-6) KEY WORDS-Early hilar lung carcinoma, High resolution CT, Diagnosis of localization, Roentgenographically occult lung cancer

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Objective. With respect to the classification of papillary adenocarcinoma, there is a slight difference in the handling of bronchioloalveolar carcinoma (BAC) between the WHO (IASLC) and the Japanese Lung Cancer Society. We therefore evaluated cases diagnosed as papillary adenocarcinoma and BAC clinicopathologically to determine which classification is appropriate. Subjects and Methods. Among all the lung cancers resected from 1987 to 1995, the 183 cases diagnosed as papillary adenocarcinoma or BAC were included in this study. These cases were classifiedby histological findings into 3 groups, namely, specimens showing only a BAC pattern (BAC group), specimens showing a BAC pattern in the marginal region of the tumor and papillary adenocarcinoma pattern in the center of the tumor (PB group) and specimens showing only a pattern of papillary adenocarcinoma without any BAC pattern in the marginal region of the tumor (PA group). Among these 3 groups, clinical findings (age, sex, smoking history), pathological findings (p-TN factor, p-stage, vascular invasion, lymphatic invasion, cancer cell subtype) as well as ki67 antigen expression, VEGF expression, p53 abnormal protein expression by immunohistochemistry and k-ras codon 12 mutation by RFLPPCR were examined and compared. Results. The proportion of females was significantly higher in the BAC group than in the PB+PA group (p=0.008), and significant differences in pT factor, pN factor and p-stage were found between the two groups. Pathologically, a significant difference in vascular invasion, lymphatic invasion and degree of differentiation were found. Significant differences in ki67 expression (p=0.002) and VEGF expression (p=0.029) and k-ras mutation (p=0.022) were also recognized. When the findings were compared between the PB group and PA group, a significant difference was found only in p-stage, and no significant difference in other factors was found clinically or pathologically. In comparison of the 5-year survival rate and freedom from recurrence, prognosis was significantly better in the BAC group than in the PB+PA group, but there was no difference between the PB group and PA group. Conclusion. When we investigate cancer cell subtypes, there may be a difference between the PB group and PA group embryologically. Based on the present results, patients in the PB group and the PA group appears equivalent clinically and pathologically. The above differences, including resulted surgery, were found clinically and pathologically between the BAC group and the PB+PA group. At present, it seems reasonable from a clinical view point that a carcinoma that proliferates and replaces alveolar epithelium, but does not infiltrate interstitially, should be defined as BAC and all others as papillary adenocarcinoma.

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Objective and Methods. To evaluate the prognostic difference in the detection method of lung cancer, the clinicopathologic features of 636 lung cancer patients were analyzed. We classified them into 3 groups according to the discovery method of their lung cancer: mass screening group (n=258), symptomatic group (n=262) and those patients who were discovered during medical examinations for other diseases (other disease group) (n=116). Results. We compared the mass screening group and symptomatic group: both the mean age and smoking index were lower in the mass screening group than in the symptomatic group. Furthermore, lower frequencies of heart-lung complications were observed in the mass screening group than in both the symptomatic group and the other disease group. Serum CEA level, the incidence of advanced cases, the frequency of squamous cell carcinoma cases, and postoperative complications were higher in the symptomatic group than in both mass screening group and the other disease group. That is to say, the features of the other disease group were similar to that of the symptomatic group with regard to patients' back-ground, and to the mass screening group in relation to disease background. The mass screening group showed better outcome than that of the other disease group and symptomatic group. However when death due to unrelated diseases (respiratory failure, cardiac failure etc) was excluded, there was no significant difference in the outcome between the mass screening group and the other disease group. Therefore, it can be considered that the incidence of curable lung cancer in the other disease group is the same as it is in the mass screening group. Conclusion. We must make more efforts to improve the accuracy of mass screening for lung cancer. Furthermore, general medical institutions should have more training in the interpretation of chest x-rays and perform chest CT whenever there are any abnormalities in chest x-rays.

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Objective. Evaluation of the effects of mediastinal lymph node dissection (ND2) on the outcome in octogenarians with primary lung cancer. Methods. The outcome and post-operative complications were retrospectively investigated in 35 octogenarians with lung cancer; 22 underwent standard operation (ND2 group), 13 underwent limited resection (ND 0-1 group). Results. Five-year survival rate was 22.2% and 43.8% in ND2 and ND 0-1 group, respectively (p< 0.05). In cases of pathological stage I, the survival rate was shorter in the ND2 group (30.8%), than in the ND 0-1 group (50.0%). Standard operation with dissection of mediastinal nodes increased the incidence of postoperative cardiac complications (p<0.05). Conclusion. It can be concluded that standard lung operation with mediastinal lymph node dissection leads to higher mortality in octogenarians with lung cancer.

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Backgroud. The biological characteristics of pulmonary carcinoma with sarcomatoid elements are not well known. We report an uncommon case of adenocarcinoma with sarcomatoid findings (classification of the Japan Lung Cancer Society-JLCS) or pleomorphic carcinoma (WHO), with special reference to biological characteristics evaluated by the immunohistochemistry using cytokeratin, epithelial membrane antigen, vimentin and Ki-67 (MIB-1). Case. A 75-year-old man consulted us about an abnormal shadow near the right hilum on chest X-ray. Brushing cytology showed adenocarcinoma cells of the lung. Bilobectomy was performed, because the tumor (25× 22mm) was located in peripheral S⁵ and invaded directly into the upper lobe. The TNM staging of the tumor was pT2N0M0, stage IB. Histopathologically, the main components of the tumor appeared to be sarcomatoid spindle cells (positive for cytokeratin) with mild lymphocytic infiltrates. In any other part, foci of conventional moderately differentiated adenocarcinoma were identified. Additionally, foci of adenocarcinoma and sarcomatoid components were intermingled with each other. Thistumor was diagnosed as adenocarcinoma with sarcomatous findings (JLCS) or pleomorphic carcinoma (WHO). Immunohistochemically, cytokeratin was positive in both components, EMA (epithelial membrane antigen) in adenocarcinoma component, and peculiarly Ki-67 labelled cells in the sarcomatoid component were more numerous than those in the adenocarcinoma. Conclusions. 1. An operated case of pleomorphic carcinoma was reported. 2. Immunohistologically, Ki-67 labelled cells in sarcomatoid components were distinctly more numerous than those in adenocarcinoma. 3. We conclude that the tumor cells located in the sarcomatoid components are cells transforming into more poorly differentiated and highly proliferative cells than those of the adenocarcinoma components.

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Background. There have been very few reports of slow-growing adenocarcinomas, all of which consisted of bronchial gland cell type or goblet cell type with mucin-production. We report a case of well differentiated papillary adenocarcinoma without mucin-production and a long clinical history before operation. Case. A 75-year-old woman was admitted to our hospital because of bloody sputum and an abnormal shadow of the left lung. The shadow had been pointed out 12-years previously, nevertheless, she had not received a detailed examination. Chest CT showed a consolidation, measuring 7× 4× 3cm in size, in the left S⁴. The lesion was diagnosed as adenocarcinoma by transbronchial biopsy and brushing cytology, and left upper lobectomy with nodal dissection was performed. Histologically, most of the tumor showed bronchiolo alveolar growth without fibrous scar formation, but the central part, measuring 1.5cm in diameter, showed papillary growth of cancer cells which resembled bronchial surface epithelial cells and Clara cells without mucin-production. Conclusion. Our case was a rare slow-growing adenocarcinoma with bronchiolo-alveolar growth, non-mucin-production and a long clinical history before operation.

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Background. Pulmonary infarction associated with lung cancer is very difficult to accurately diagnose. We often need to distinguish pulmonary infarction from intrapulmonary metastasis. Case. A 62 year-old woman was referred to our hospital because of an abnormal shadow on her chest X-ray film. Chest CT revealed two nodules in the lower lobe of the left lung. The cytological result of the transbronchial brushing sample obtained from the proximal lesion was adenocarcinoma. Although the peripheral lesion could not be elucidated bronchofibroscopically, it was considered to be intrapulmonary metastasis and the preoperative clinical stage was categorized as stage IIIB. Left lower lobectomy was performed. The resected specimen demonstrated that the peripheral nodule was a pulmonary infarction lesion and the postoperative stage was stage IA. Conclusion. It is necessary to consider pulmonary infarction in the differential diagnosis when multiple abnormal nodules are detected.

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Background. Brain metastases represent the most serious complication in lung cancer, and synchronous multiple brain metastases from lung cancer have been considered to indicate an unfavorable prognosis. Case. A 60-year-old man was seen for evaluation of a severe headache. A CT scan of the brain demonstrated multiple tumors in the right parietooccipital and frontotemporal regions. A chest X-ray revealed an abnormal shadow in the apex of the right lung, and a CT scan revealed a 1.4×1.2cm mass with spiculation in the right S¹ region. The patient underwent right occipitotemporal and frontal craniotomy, and two masses were completely removed. Then, he received wholebrain radiation therapy. Six weeks later, he underwent right upper lobectomy. Histologically, the lesions of both the brain and the lung were squamous cell carcinomas, and brain tumors proved to be metastatic tumors from the lung cancer. He has been well with no evidence of recurrence for 7 years. Conclusion. Synchronous oneset of multiple brain metastasis from lung cancer does not necessarily represent an unfavorable prognosis, and combined resection with radiation therapy can provide long-term survival in selected patients.

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Background. Cases of lung cancer with bone formation in the cancer lesion are rare. We report a case of adenocarcinoma with stromal ossification. Case. In a 66-year-old man undergoing x-ray examination of the stomach showed an abnormal nodular lesion was found in the right basal area of the lung. Chest high resolution computed tomography revealed a nodular lesion with pleural indentation and a minute high-density area resembling calcification. He underwent a resection of the right lower lobe of the lung with hilar and mediastinal lymphnode dissection. Conclusion. Postoperative pathological examination revealed that there was an ossification island in the center of stroma of the nest of the adenocarcinoma. An immunohistochemical examination revealed that cancer cells around the ossification island showed moderate expression of Bone morphogenetic protein 2.

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Background. Spontaneous regression of primary lung cancer is extremely rare. We report partial regression of tumor in a case with small cell lung cancer. Case. A 65-year-old man was referred to our hospital because of abnormal shadows on a chest radiogram. Chest radiography and CT scanning revealed two nodules in the right middle lung field as well as right hilar lymphadenopathy. The tumor was diagnosed as small cell lung cancer by CT-guided aspiration cytology. After admission, chest radiography and CT scanning showed significant reduction in size of the two nodules and lymphadenopathy, compared to in prior films which were taken 4-6 weeks earlier. His natural killer cells seemed to be highly activated. Video-assisted thoracoscopy was performed to confirm the diagnosis of the tumor because of the unique findings. We concluded that the tumor was small cell lung cancer from the pathological findings. After four courses of chemotherapy (CDDP+VP-16) and concurrent radiotherapy, the size of right hilar lymphadenopathy reduced to 25%. The patient is receiving follow-up without any sign of recurrence. Conclusion. Although its mechanism is not clear, spontaneous regression of cancer has been reported in a variety of malignancies. Elucidation of the mechanism of the spontaneous regression of cancer could lead to the development of more effective treatment and perhaps the prevention of cancer.

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