Objective. To verify the role of general practitioner (GP) in notifying the patient that he/she has cancer, from the viewpoint of stepwise notification. Methods. To investigate the characteristic anxiety and conditional anxiety, We performed the State-Trait Anxiety Inventory (STAI) in 82 patients who visited Osaka Medical College Hospital between February 1999 and October 2001, for detailed examination of abnormal shadow in the chest. Furthermore, anxiety increase index (state anxiety-trait anxiety) was compared among subgroups by gender, age of patient, presence or absence of an attendant, final diagnosis (whether or not the patient had lung cancer) and the source of referral (those who had been advised by a general practitioner to undergo detailed examination; “GP group” and those who had undergone a health check and had come without any advice before visiting; “HC group”). Results. As to the comparison of anxiety increase index, there was no significant difference between the two groups in the gender, age of patient, pres-ence or absence of attendant and final diagnosis. However, the values differed significantly between the HC group and GP group (7.6 ± 8.8 and 3.5 ± 8.6, respectively), indicating a significantly lower figure in the GP group (p=0.0358). In other words, the anxiety was less in the subjects of GP group who had already received some explanation from the attending physician (general practitioner) in comparison with those of HC group who came to consultation without any previous explanation on the chest X-rays abnormality. Conclusion. As a part of stepwise notification the explanation of the general practitioner is considered to be effective in the cancer notification and helps alleviate the anxiety of patients. In this regard, the attending physician (general practitioner) is expected to play an important part in notifying the patient of the presence of cancer.

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Objective. Recently, lobectomy by video-assisted thoracic surgery (VATS lobectomy) has been adopted by many institutions because of its less invasive approach for small peripheral lung cancer. The purpose of this retrospective study was to evaluate the practical applicability of the auscultatory triangle approach in VATS lobectomy. Methods. From February 1998 to March 2002, a total of 59 patients with clinical T1NOMO or T2NOMO lung cancer underwent lobectomy with lymphadenectomy in our hospital. Of these, 31 underwent VATS lobectomy (VL group), and 28 underwent standard thoracotomy (ST group). In the VL group, a small incision measuring 6 cm was made for minithoracotomy in the chest above the auscultatory triangle by a muscle-sparing procedure. Next, the fourth or fifth intercostal space (ICS) was entered without rib resection. After starting with dissection of the lymph nodes of the upper mediastinal space, hilar dissection was performed with conventional thoracotomy instruments. Pulmonary arteries and veins were then divided prior to endoscopic stapling. After stapling of the vessels and bronchus, the resected pulmonary lobe was finally removed from the thorax through the mini-thoracotomy using a plastic retrieval bag. In the ST group, patients had a posterolateral thoracotomy with a skin incision 12 to 13 cm in length, and were entered through the fourth or fifth ICS with rib spreading to obtain a sufficient working space. Hilar and mediastinal lymph nodes were dissected, followed by resection of the designated pulmonary lobe in a conventional manner. Results. Although a statistically significant increase in operating time was seen in the VL group compared to the ST group, no significant differences were found between the two groups with respect to the total number of mediastinal lymph nodes dissected or the mean value of surgical blood loss. Statistically significant decreases in duration of postoperative pain and hospitalization were seen in the VL group compared to the ST group (p<0.0001). In addition, the CRP level in serum was significantly lower in the VL group on both the second and seventh postoperative days compared to the ST group (p<0.0001, p=0.013 respectively). Conclusion. The present study showed the technical feasibility of this unique thoracoscopic approach in appropriately selected patients with clinical stage I lung cancer. Due to its low degree of invasiveness, we suggest that VATS lobectomy with an auscultatory triangle approach contributes to improvement of the quality of life following surgery for lung cancer. Longer follow-up will be necessary to determine the long-term survival of patients who underwent VATS lobectomy.

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Objective. This study investigated the usefulness of surgical treatment for primary lung cancer in the elderly, mainly based on the long-term results. Methods. A total of 1374 patients underwent surgery for primary lung cancer in our unit between 1979 and 2000 and this group was retrospectively investigated. We mainly investigated long-term survival in three groups of patients: those 65 or younger (group Y, n=578), those between 66 and 75 (group M, n=629), and those 76 or older (group E, n=167). The survival rate was statistically analyzed using the Kaplan-Meier method and the significance of differences was analyzed by the log-rank test. Results. The proportion of limited procedures in group E (16%) was higher than that in groups Y (4%) and M (6%). The ratio of squamous cell carcinomas in group Y (25%) was lower than that in groups M (38%) and E (40%). The ratio of pathological stage I disease in group E (73%) was higher than that in groups Y (54%) and M (57%). The early postoperative (operative + hospital) mortality rate in group E (3.5%) was higher than those in groups Y (1.0%) and M (1.1%), while there were no early postoperative deaths between 1997 and 2000. The overall 5-and 10-year survival rates were 66% and 53% in group Y, 60% and 45% in group M, and 47% and 27% in group E, respectively. There was a significant difference (p<0.001) between these three groups, but there was no difference after the survival rates of these three groups were adjusted based on the Japanese life table. The 5-and 10-year survival rates in stage I disease of non-small cell lung cancer were 82% and 71% in group Y, 70% and 54% in group M, and 52% and 33% in group E, respectively. There was a significant difference (p<0.001) between these three groups, but there was no difference after the adjustment of the survival rates. The 5-and 10-year survival rates in stages II and III were 44% and 39% in group Y, 44% and 39% in group M, and 40% and none in group E, respectively. There was no difference between these three groups prior to the adjustment of the survival rates. Conclusion. The 5-and 10-year survival rates seemed poor in the elderly, but there was no difference between the three age groups after the survival rates of these three groups were adjusted based on the Japanese life table. Therefore, it was thought that elderly patients as well as younger patients were good candidates for lung resection.

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Background. Recently, screening CT has been increasingly used for the detection of lung cancer. We occasionally encounter atypical adenomatous hyperplasia (AAH) which demonstrated CT features similar to small bronchioloalveolar carcinoma (BAC) of the lung. Purpose. To analyze the radiographic characteristics of the lesions of AAH of the lung that can be detected by thin-section CT (TS-CT). Material and Methods. A retrospective study was carried out on patients with AAH who were surgically resected at Kanagawa Cancer Center. Through TS-CT, 26 AAH lesions were identified in 23 patients. The lesions were classified into two types according to attenuation of on TS-CT images as the “air-containing type” or the “solid-density type”. Several parameters were evaluated on TS-CT to characterize these lesions, including their location, size, shape, border and internal density, convergence of the surrounding pulmonary vessels toward the nodules, and presence of pleural indentation detected on TS-CT. Results. All 26 AAHs were found to be the air-containing type. The air-containing type lesions were further divided into two different growth patterns: a complete air-containing type (n=23) and an incomplete air-containing type (n=3). Characteristics observed on TS-CT images consisted of a homogeneous ground-glass attenuation in 77%, pleural indentations in 35%, vascular involvement in 85%, and air bronchogram in 38%. Conclusion. Some cases with lesions of AAH showed the same findings a localized BAC on TS-CT. To obtain more precise differential diagnosis of AAH of the lung, it is necessary to accumulate more information concerning radiologic-pathologic correlation.

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Objective. There are no economical advantages to a clinical pathway system for either patients or hospitals in Japan because of the compulsory public medical case insurance piece rate system. The purpose of this study was to assess the effect of a clinical pathway on rationalization of postoperative management and outcome for pulmonary resections with conventional thoracotomies. Methods. All anatomic (segmentectomy, lobectomy, and pneumonectomy with or without tracheo/bronchoplasty) and partial pulmonary resections with conventional thoracotomies performed from January 1999 to December 2000 were retrospectively analyzed for postoperative pharmaceuticals, laboratory, radiologic, and physiologic tests, oxygen supply, and outcome. The clinical pathway for postoperative management was introduced in January 2000. Comparisons were made between the procedures performed before (control group) and after (path group) pathway implementation. Results. Intravenous drip (control vs. path: 5.2 days vs. 4.5), antibiotic use (5.6 times vs. 2.5), venous blood examination (5.1 times vs. 3.2), and arterial blood gas analysis (2.2 times vs. 0.1), chest X-ray (9.3 sheets vs. 6.5), electrocardiogram monitoring (139 hours vs. 101), and oxygen therapy (101 hours vs. 74), all were significantly greater in the control group than in the path group (all p<0.0002). There were no significant differences between two groups in postoperative complications, readmissions, or overall deaths for one year. Neither 30 day operative deaths nor hospital deaths occurred in either groups. Conclusions. Implementation of the clinical pathway system has resulted in a remarkable rationalization of postoperative management for conventional pulmonary resections with continued quality of outcome.

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Objective. We examined the outcome of patients with surgical treatment for pN2 left non-small cell lung cancer in relation to the difference of methods of mediastinal lymph node dissection. Methods. The pN2 non-small cell lung cancer patients who had undergone curative pulmonary resection were analyzed separately in two groups, high level N2 group: patients with metastasis to the last mediastinal lymph nodes (superior mediastinal, paratracheal, pretracheal, paraaortic lymph nodes) and low level N2 group: patients without metastasis to the last mediastinal lymph nodes. In each group, the outcome was compared among three subgroups: bilateral group in which a bilateral mediastinal lymph node dissection was performed through a median sternotomy for left lung cancer, standard group in which a standard mediastinal lymph node dissection was performed through a lateral thoracotomy for left lung cancer, right group in which a standard lymph node dissection was performed for right lung cancer. Result. There was no difference in survival among the three subgroups in the high level N2 group. In the low level N2 group, the 5-year survival rate of 17.6% for the standard group was significantly lower than that of 60.0% for the bilateral group and that of 55.0% for the right group. Conclusion. The outcome of the standard group was poor in the low level N2 group, but the standard group might have included several high level N2 group or N3 cases because lymph node dissection around the trachea was incomplete. Further examination is necessary to confirm the significance of a bilateral mediastinal lymph node dissection in the treatment of left lung cancer.

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Objective. The evaluation of reduction surgery for small-sized lung adenocarcinoma is still being debated, and the indications for reduction surgery in these patients have not been adequately discussed. Gastrointestinal mucus is not secreted by normal alveolar cells, but some lung adenocarcinomas secrete gastrointestinal mucus, and it is reported that the prognosis of patents with lung adenocarcinomas secreting gastrointestinal mucus is poor. We therefore investigated the relation between lymph node metastasis and the secretion of gastrointestinal mucus in surgically treated cases of small-sized lung adenocarcinoma. Methods. We studied 79 lung adenocarcinoma lesions measuring 2.0 cm or less in patients treated by lobectomy and ND2a dissection between 1989 and 1999. We separated the lesions into two groups according to nodal metastasis: the node-negative group (pN0, 60 lesions) and the node-positive group (pN1, 8 lesions; pN2, 11 lesions). We investigated the incidence of lymph node metastasis in relation to gastrointestinal mucus production, which was determined immunohistologically by staining for HGM, MUC2, MUC5AC, and MUC6, in these two groups. Results. Staining for HGM was negative in all samples. MUC2 was detected in 1 lesion (2%) in the nodenegative group and in 5 lesions (26%) in the node-positive group. MUC6 was detected in 5 lesions (8%) in the nodenegative group and in 6 lesions (32%) in the node-positive group. The difference in the frequency of MUC2 and MUC6 production between lesions with and without lymph node metastasis was statistically significant (p<0.001, p=0.006, re-spectively). MUC5AC was detected in 3 lesions (5%) in the node-negative group and in 3 lesions (16%) in the nodepositive group, a difference that was not statistically significant. Conclusion. The frequency of lymph node metastasis was high in patients with small-sized lung adenocarcinoma with lesions immuno-histochemically positive for MUC2 and MUC6. It is essential that MUC2-or MUC6-positive small-sized lung adenocarcinoma be treated by lobectomy combined with mediastinal dissection.

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Objectives. Radiofrequency ablation (RFA) is now recognized as one of the most effective minimally invasive therapeutic options for localized malignant diseases, especially hepatic tumors. We applied this technique for the treatment of malignant tumors in the thoracic cavity. Patients and Methods. Seven patients underwent 14 RFA sessions for 22 intrathoracic tumors from June 2001 through March 2002. Using computed tomographic fluoroscopy guidance, RFA was done with 17-gauge Cool-tip needles inserted into the tumors. Results. The underlying diseases of these patients were 6 cases of metastatic pulmonary tumors and a case of disseminated pleural tumors of diameters ranging from 8 to 55 mm. There were complications including mild pain, pneumothorax, high fever, and pleural effusion, but most of them could be controlled easily. In one patient drainage was necessary for massive pleural effusion following ablation for disseminated pleural tumors of 55 mm in diameter. Following RFA, two of 22 nodules were enhanced on dynamic enhanced CT, and there were some viable tumor cells in seven nodules in specimens of CT-guided needle biopsy. We performed re-ablation for four of these nodules. We lost one patient due to pneumonia seven months after the procedure, while the other six patients are alive but still have tumors. Conclusions. RFA may become a less-invasive, safe, and effective therapeutic option for intrathoracic malignant tumors.

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Background. Although there are some reports of lung cancer complicated by membranous nephropathy, the mechanism of their simultaneous occurrence is not well understood. Case. A 69-year-old man was admitted to our hospital complaining of right back pain. Chest X-ray examination revealed a massive shadow in the right upper lobe. The tumor mass was diagnosed as poorly differentiated squamous cell carcinoma of the lung (T2N3M0 Stage IIIB). Urinary protein excretion was 2.6 g/day. The serum level of cytokeratin 19 fragment (CYFRA21-1) was 39.1 ng/ml. Combination chemotherapy with carboplatin and docetaxel hydrate was started. A partial response was finally obtained after five courses. Serum level of CYFRA21-1 and amount of urinary protein excretion were decreased to 7.1 ng/ml and 0.1 g/day. After discharge, the lung cancer progressed and he finally died of respiratory failure. Adenosquamous carcinoma of the lung and membranous nephropathy were proven by autopsy. Conclusion. This case appears to have exhibited parallel time courses of progression of adenosquamous carcinoma of the lung, membranous nephropathy and changes in serum CYFRA21-1 level. This is of interest in considering the mechanism of the complication of lung cancer by membranous nephropathy.

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Background. Pulmonary epithelioid hemangioendothelioma (PEH) is a rare pulmonary neoplasm, which was formerly known as intravascular bronchioloalveolar tumor, IVBAT. We report a case of PEH, with multiple small nodules throughout both lung fields, and review the published reports. Case. A 63-year-old woman whose chief complaint was back pain was found to have multiple small nodules in both lungs on chest radiograph, and was referred to our hospital. Clinical examination and routine laboratory tests were within normal limits. Tumor markers were not elevated. Diagnostic open lung biopsy was performed. Histologically, the center of the nodule was occupied by a hyalinized matrix and the periphery of the nodules showed intraalveolar or polypoid proliferation of the tumor cells. Immunohistologic staining showed that tumor cells were positive for endothelial markers, CD31, CD34 and Factor VIII-related antigen. These findings were consistent with a diagnosis of PEH. Conclusion. The reported clinical course of PEH was usually relatively slow but sometimes rapid. We have no effective therapeutic regimens for PEH. The patient remains asymptomatic about 1 year 5 months after the diagnosis without treatment. We will carefully follow up this case.

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Background. We report a case of undifferentiated thymic carcinoma that invaded the pericardium and the upper lobe of the right lung. Case. A 61-year-old woman was admitted to our hospital presenting with constriction of the chest and back pain. A CT scan showed an anterior mediastinal tumor and the patient was operated on under a diagnosis of non-invasive thymoma. The tumor was located in the right lobe of the thymus. Since the tumor invaded the pericardium and the upper lobe of the right lung, resection of adjacent structures was necessary. Postoperative pathological examination indicated undifferentiated thymic carcinoma. Protein immunostaining using bcl-2 was positive while p53 protein and ki-67 protein immunostaining were 82% and 38% positive, respectively. The patient was treated postoperatively by adjuvant chemotherapy, mainly with CDDP. Conclusions. Three years and ten months after surgery the patient is well and is free from any signs of recurrence.

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