Object. This study evaluated the results of chemoradiotherapy and the effectiveness of accelerated hyperfractionated prophylactic cranial irradiation (AHF-PCI) of 24 Gy/16 fractions/1.6 weeks for limited-stage small cell lung cancer (SCLC).Methods and Materials. Of 149 patients with SCLC who underwent thoracic irradiation between 1985 and 2000, 29 patients were excluded from this analysis because of extended disease (25), surgery (3) and synchronous double cancer (1), and the reminding 120 cases were analyzed retrospectively. Chemotherapy was performed for all patients. Thoracic radiation therapy (TRT) dose ranged from 10.5 Gy to 70 Gy. Survival differences were evaluated using the log-rank test and comparisons were made between the case and control populations using χ² analysis. Results. Patient ages ranged from 38 to 88 years, with a mean of 65 years. The female-to-male ratio was 106: 14. There were no significant differences in outcome by patient characteristics or chemotherapy regimens. The overall survival rates at 2, 3, 5 years were 33%, 21%, 18%, respectively. AHF-TRT with Cisplatin+Etoposide (PE) yielded better survival than any other chemotherapy regimen. Of 47 patients showing complete response after completion of AHF-TRT (45 Gy/30 fractions) combined with 4 courses of PE, 23 patients received AHF-PCI of 24 Gy/ 16 fractions. Initial failure in the brain was 8.7%(2/23) in patients with the PCI, but 41.6%(10/24) in those without PCI, which was significantly different (p=0.0096). Conclusions.In limited-stage SCLC, AHF-TRT with PE was considered to be an effective chemoradiotherapy regimen. Relatively low dose (24 Gy) AHF-PCI seemed to be effective in preventing brain metasatses.

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Objective. To investigate the usefulness of serum KL-6 and SP-D in the diagnosis of radiation pneumonitis. Methods. We measured serum KL-6 and SP-D in patients undergoing radiation therapy of the chest, primarily for lung cancer, in the Department of Radiology, Osaka Medical College and compared the results with the findings on plain chest X-ray films and thoracic computed tomography conducted at the same time. Results. The sensitivity of serum KL-6 and SP-D for diagnosing radiation pneumonitis were 68.2% and 70.0%, respectively, the specificity were 86.6 % and 80.0%, and the accuracy were 82.0% and 77.8%. Examination of the relationship between lesion extent and activity and serum KL-6 showed that serum KL-6 values were higher when the lesion extended beyond the irradiation field than when the lesion was confined to within the irradiation field and that the value tended to be lower for old lesions than for active lesions. In patients with radiation pneumonitis in whom serum KL-6 and SP-D could be measured over time, KL-6 tended to increase after the lesion was discovered by imaging, whereas SP-D increased prior to this in many cases. Examination of the comparison between before radiotherapy and just after radiotherapy in the patients with radiation pneumonitis showed that SP-D had a consistent tendency to increase. Conclusion. Both serum KL-6 and SP-D had a satisfactory degree of sensitivity and specificity for diagnosing radiation pneumonitis. Serum KL-6 correlated with the extent and activity of the lesions. The results suggested that serum SP-D may be helpful for the early detection of radiation pneumonitis.

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Background. Cardiac metastasis from primary lung cancer is often found at autopsy, whereas clinical detection during life is difficult. Case. A 77-year-old man was admitted with a chief complaint of right anterior chest pain. Subsequent chest X-ray and CT scan revealed a tumor in the left hilum, extending into the mediastinum. Atelectasis of the left upper lobe was also found. Biopsy of a mass in the anterior chest wall and cytology of the sputum yielded a diagnosis of squamous cell carcinoma of the lung (T4N3M1, Stage IV). Echocardiography on admission demonstrated a nodular lesion in the left ventricle, which closely mimicked the shadow of myxoma. However, additional echocardiography showed that the nodular tumor changed its morphology and invaded into the ventricular wall. In addition, further tumor was detected in the left atrium. Thus, the cardiac tumors were considered to be metastases, which confirmed on autopsy. Conclusion. In this case, cardiac metastasis of lung cancer showed a unique in its echography pattern, which was difficult to distinguish from myxoma. In addition, myocardial metastasis is relatively rare, and in this case was proved by autopsy. In the presence of any malignancy, diagnosis of cardiac tumors requires careful consideration.

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Background. Malignant pleural mesothelioma (MPM) is relatively rare. This disease was diagnosed with difficulty by pleural fluid analysis and radiographic findings. The following is a report on a case of granulocytemacrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF)-producing MPM accompanied by eosinophilic pleural fluid. Case. A 65-year-old man was admitted with right chest and back pain on July 29, 2002. The eosinophil count in the pleural fluid and the findings of computed tomography (CT) suggested eosinophilic pleurisy. Despite steroid therapy, his symptoms rapidly worsened. The white blood cell (WBC) count elevated to 28260/mm³ and the G-CSF level of the serum elevated at 50 pg/dl. A pleural biopsy under video-assisted thoracoscopic surgery (VATS) was performed on September 17, 2002. Histopathologically, the tumor cells consisted of tubular and nest structures from atypical epithelial cells and spindle-shaped cells. The biphasic type of MPM was diagnosed by the pathological findings. The cytoplasms of almost all tumor cells were immunohistochemically stained with anti-GM-CSF monoclonal antibody. The cytoplasms of 5 percent of tumor cells were immunohistochemically stained with anti-G-CSF monoclonal antibody. He had complications with empyema due to prolonged air-leakage. After 17 weeks, he died on November 27, 2002. The autopsy revealed that the tumor had spread to the pleura and pericardium in the thoracic cavity, and penetrated the diaphragm to involve the peritoneum, the small intestine and colon. Conclusion. Even in patients with inflammatory reaction and pleural effusion resistant to treatment, MPM should be considered in the differential diagnosis of tissue biopsy under VATS.

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Background. We encountered a case of adenocarcinoma of hilar type lung cancer detected by sputurn cytology, with a unique tumor growth pattern. Case. A 58-year-old man complaining of a persistent cough had no tumor shadow on chest roentgenogram. However, sputum cytology revealed Class V malignant cells. Bronchoscopic findings showed faded white yellowish mucosa at the spur of the right B¹, B², B³ segmental bronchi. A computed tomograph showed only thickenings of the bronchial walls from the right upper lobe bronchus to the main bronchus. Bronchial biopsy of the dull spur revealed adenocarcinoma. Right sleeve upper lobectomy and lymph node dissection were performed, and the right main bronchus was excised just below the carina due to spread of cancer. The lesion was pathologically diagnosed as a well-differentiated papillary adenocarcinoma, located at the hilar portion of the lung, which had spread mainly in the mucosa from just below the carina and within 2 rings from the bifurcation of middle and lower bronchus and to the subsegmental bronchi of B¹, B ², B³ peripherally. Postoperative irradiation was administered and the patient has been free from cancer for 6 years after surgery. Conclusion. We report a rare case of mucosal spreading hilar adenocarcinoma of the lung. More cases need to be analyzed to elucidate the pathophsyology of this type of lung cancer.

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Background. The most common histology of amylase-producing lung cancer is adenocarcinoma, on the other hand, small cell carcinoma is very rare. We report a case of amylase-producing small cell lung cancer. Case. A 62-year-old man with small cell lung cancer had been treated since February 2001 with concurrent chemoradiotherapy consisting of one course of cisplatin plus etoposide, followed by three courses of cisplatin plus irinotecan. A complete response was obtained after treatment and then prophylactic cerebral irradiation was performed in May 2001. Recurrence appeared in the form of brain and right adrenal metastasis. The resection of brain metastasis, followed by whole brain irradiation, was performed in November 2002. Thereafter, amrubicin hydrochloride was administered as second line chemotherapy. Laboratory data before chemotherapy showed marked elevation of amylase activity both in serum and urine. The amylase isozyme pattern was identified as salivary type amylase. Four courses of chemotherapy successfully led to remarkable reduction of the right adrenal gland metastasis and decrease in both of ProGRP value and serum amylase level. Transbronchial lung biopsy specimen stained positively for and-alpha amylase antibody, which established the diagnosis of amylase-producing cancer immunohistochemically. Conclusion. A rare case of amylase-producing small cell lung cancer was reported, which was confirmed immunohistochemically.

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Background. Cancer-associated retinopathy and metastatic thoracic lymphadenopathy of unknown origin are rare phenomena in lung cancer. A patient with cancer-associated retinopathy (CAR) from small cell lung cancer (SCLC) is described. Case. A 67-year-old woman presented with mediastinal lymphadenopathy and had visual disturbance of sudden onset. The mediastinal nodes, removed under thoracotomy, pathologically showed oat cell type small cell carcinoma. No primary tumor was found despite a thorough workup. Although anti-CAR antigen antibody was not detected, CAR was diagnosed according to multiple clinical examinations. A primary SCLC was detected in the right lower lobe 15 months after resection of the mediastinal nodes. Conclusion. This case demonstrates that undetectably small tumors can produce a large mass by lymph node metastasis and cause CAR.

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Background. Metastasis of lung cancer to the small bowel is uncommon and symptomatic small bowel metastasis requires a surgical approach. However preoperative diagnosis of small bowel metastasis is difficult. Case. A 60-year-old man was given a diagnosis of unresectable lung cancer (adenocarcinoma, stage IIIB) in November 2001, and received chemotherapy until January 2002. In early March, he was readmitted due to severe right lower abdominal pain. His chest roentgenogram showed free air under the diaphragm and an abdominal computed tomographic scan revealed wall thickening of the small bowel and localized intra-abdominal fluid. From the clinical course, laboratory data and CT scan findings, we considered this case to be perforative peritonitis due to a metastatic small bowel tumor from lung cancer. Therefore, an emergency laparotomy was performed, revealing two tumors in the ileum, one accompanied by perforation with peritonitis. They were histologically diagnosed as metastases of lung cancer to the small bowel by immunostaining for thyroid transcription factor-1 (TTF-1). Conclusion. Metastasis of lung cancer to the small bowel is uncommon and previous reports have shown preoperative diagnosis of small bowel metastasis to be difficult. In our experience, abdominal computed tomographic scan was useful to detect the presence of small bowel metastasis and perforative peritonitis preoperatively, and immunohistochemical study for TTF-1 was also useful to confirm intestinal metastatic lesions from lung cancer.

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Background. We report an extremely rare case of multiple localized fibrous tumor of the pleura (LFTP). Case. A 54-year-old woman presented with an abnormal shadow in the right lower lung field on chest X-ray. Chest CT scan showed a mass in the right hemithorax. Preoperative CT-guided percutaneous transthoracic aspiration cytology revealed Class III cells, and she underwent tumor resection because of the possibility of malignancy. Intraoperative findings revealed three extrapulmonary tumors in the right hemithorax. One of them, 5 cm in diameter, was attached by a pedicle to the diaphragm. The others, 10 mm in diameter, arose from the parietal pleura. Postoperative pathological diagnosis, including immunohistochemical study, revealed benign LFTP. Conclusion. Reports of multiple LFTP are rare and the cause of multiple growth is still unknown. Even though such tumors are histologically benign, local recurrence may occur after removal of LFTP. We suggest that lifelong follow-up is required because of the possibility of recurrence.

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Background. Remitting seronegative symmetrical synovitis with pitting edema (RS₃PE) syndrome is characterized as a sudden onset symmetrical polyarthritis together with pitting edema of the hands, feet and legs which mainly affects the elderly. This syndrome responds to low dose steroids, and does not relapse. Recently, some cases of malignancy, although rarely lung cancer, have been reported in association with RS₃PE syndrome. Case. An 83-year-old man had been followed up with RS₃PE syndrome since April 2002. He was referred to our hospital because of an abnormal shadow in the left upper lung field in January 2003. Chest computed tomography (CT) revealed a 2.5 cm nodule in the S¹⁺²segment of the left lobe. He was diagnosed as having squamous cell carcinoma of the lung, T4NOM1, stage IV. He was treated with radiation therapy for brain metastasis and he is now being followed up as an outpatient. Conclusion. We report a rare case of squamous cell carcinoma of the lung in association with RS₃PE syndrome. Considering previous report in the past literature, RS₃PE syndrome may have been a prodrome of lung cancer in this case.

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