Objective. We examined the usefulness of ¹⁸F-fluorodexyglucose positron emission tomography (¹⁸FDG-PET) in comparison with ^99mTc bone scintigraphy concerning imaging diagnostic ability for bone metastases. Methods. Lung cancer patients who underwent both bone scintigraphy and ¹⁸FDG-PET within one month from April, 2003 to October, 2004 were entered into this study. The final diagnosis of bone metastases was determined by bone radiography, CT, MRI and also clinical course in addition to both the above examinations. The 29 cases (20 males and 9 females) with an average age of 66.7 years old histologically consisted of 9 squamous cell carcinomas, 13 adenocarcinomas, 1 adenosquamous carcinoma, 3 small cell carcinomas, 2 bronchioalveolar carcinomas and 1 anaplastic carcinoma. The clinical stages of the disease were: stage IA in 6 patients, stage IB in 1 patient, stage IIB in 1 patient, stage IIIA in 5 patients, stage IIIB in 6 patients and stage IV in 10 patients. There were 7 stage IV patients with bone metastases. Results. ¹⁸FDG-PET was found to have a sensitivity of 100%, specificity of 86.3% and 3 false positive cases. Meanwhile, ^99mTc bone scintigraphy had a sensitivity of 100%, a specificity of 81.8% and 4 false positive findings. The causes of the false positivity and false negativity were as follows: (1) distinction between bone periphery metastases and bone metastases was difficult in PET. (2) uptake by bone fracture in PET became negative earlier than in bone scintigraphy. Conclusion. ¹⁸FDG-PET showed almost the same diagnostic ability of bone metastases as bone scintigraphy. If the additional merit of diagnosis for metastases to other organs is considered, ¹⁸FDG-PET is thought to be superior to bone scan.

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Objective. Most small lung cancers less than 15 mm in diameter can be detected by CT. As CT screening for lung cancer becomes more common, more lung cancers less than 15 mm in size will be detected. This study was conducted to evaluate the correlation between clinical characteristics and pathological findings, and the correlation between radiological findings, pathological findings, and outcomes in patients with a peripheral lung adenocarcinoma less than 15 mm in diameter. Methods. A retrospective analysis was conducted including 160 patients with a peripheral lung adenocarcinoma less than 15 mm in diameter resected between 1992 and 2003. The correlation between clinical parameters such as gender or smoking state and Noguchi's subtypes of adenocarcinoma was investigated. We classified lung adenocarcinomas by thin-section CT (TS-CT) in two types: air-containing type and solid type. Differences in pathological findings and prognosis between the two groups were also analyzed. Results. Noguchi's type A and B adenocarcinomas were more frequent in females than males. Noguchi's type D, E and F adenocarcinomas were more frequent in smokers than nonsmokers. Air-containing types had fewer invasive pathological findings and a more excellent prognosis than solid types. Multivariate analysis of prognostic factors including p-stage showed an insignificant correlation between survival and TS-CT findings (p=0.059). Conclusion. Differences in gender and smoking status might lead to the differences in pathological subtype of lung adenocarcinomas. Although a TS-CT finding has not shown to be an independent prognostic factor, it is suggested that we may be able to differentiate early lung cancer by TS-CT.

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Objective. With the support of the Japan Ministry of Health, Labor and Welfare, Clinical Guidelines for the Management of Lung Cancer were published in 2003. The objectives of this study are to assess how the guidelines have been used by surgeons and physicians and to survey their opinions on it. Methods. A questionnaire was designed and sent to 530 hospitals which were certified as training sites for chest surgeons by the Japanese Association for Chest Surgery or which have members of the Japan Lung Cancer Society on their staff. Results. A total of 785 doctors in 260 hospitals answered the questionnaire. More than 80% of the participants had used the guidelines. In more than half, the purpose for using them was for choosing the treatment or for informed consent. Approximately 70% of the participants answered that the guidelines had an influence on their practice, most of which was making their clinical decisions and explanation to their patients easier. The participants gave us many useful opinions including requests for revision. Conclusion. This study revealed that the guidelines were utilized by many surgeons and physicians. It also indicated that the publication of the guidelines contributed to their management of lung cancer. There were many suggestions for the guidelines which should be helpful for its revision currently conducted by the Japan Lung Cancer Society.

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Objective. Antitumor efficacy and safety of amrubicin were assessed in patients with small-cell lung cancer unfit for combination chemotherapy. Patients and Methods. The study population consisted of patients with small-cell lung cancer for whom platinum-based chemotherapy was difficult due to old age, poor performance status or complications, plus patients who had undergone 2 or more regimens of chemotherapy. Amrubicin was intravenously administered at 40 mg/m² (or 35 mg/m²) for 3 consecutive days. After a 3-week course was repeated 2 or more times, antitumor effect and toxicity were evaluated. Results. Between February 2003 and July 2004, 21 patients were treated with amrubicin. In 6 out of 21 patients, the initial dose was reduced to 35 mg/m². Median age was 71 (range: 51-80) years. Prior chemotherapy had not been performed in 7 patients but had been performed in 14 patients. Response rate was 71% in those without prior chemotherapy and 14% in those with prior chemotherapy. Median survival time was 9.4 months and 6.0 months, respectively. Hematological toxicity was common and relatively severe, whereas non-hematological toxicity was relatively mild. Conclusion. Due to its potential high response rate and better prognosis, amrubicin monotherapy is considered useful for patients with small-cell lung cancer unfit for combination chemotherapy. Further investigation of this agent is warranted.

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Objective. We conducted this study to determine the operative indication for multiple primary lung cancer, including the selection of the type of pulmonary resection, by analyzing the outcome, operative mortality and morbidity. Patients and Methods. We studied 64 patients with multiple primary lung cancer who underwent surgical treatment. Results. The average age at initial treatment was 64.3 years old. There were 49 men and 15 women. We operated on 64 patients for multiple primary lung cancer, which appeared to be synchronous in 27 cases and metachronous in 37 cases. There were two adenocarcinomas in different locations in 27 patients, two squamous cell carcinomas in 14, and the combination of an adenocarcinoma and a squamous cell carcinoma in 11. Thirty-five patients had two lesions diagnosed as p-stage I. Fourteen patients had a p-stage I lesion and a p-stage II lesion. In synchronous lung cancer, 14 patients underwent operation simultaneously, 11 patients underwent operation in two stages. Of 43 patients who underwent operations twice or more, 27 patients underwent lobectomies on the first operation. On the other hand, 28 patients underwent limited surgery on the second operation. Four patients underwent a lobectomy twice for metachronous bilateral lesions and three patients underwent completion pneumonectomy at the second operation. We encountered no operative death and no severe complications after surgery. The 5-year survival rate of the patients with synchronous and metachronous disease from the final treatment was 63.9% and 74.9%, respectively. The 5-year survival rate of the patients with p-stage IA disease in the second lesion of metachronous lung cancer was 85.1%, and that for patients with p-stage IB disease was 66.7%. The survival rate of the patients with p-stage II or more advanced second lesion was significantly less than that with p-stage I disease. The outcome of patients with two primary adenocarcinomas was the best (5-year survival: 81.5%) after analysis of patients by histological types. Conclusions. Surgical treatment for patients with multiple primary lung cancer was generally safe without any severe complications. We performed bilateral lobectomies in two stages or completion pneumonectomy after considering their predicted post-operative pulmonary function and performance status. We conclude that an aggressive surgical approach is recommended for the treatment for multiple primary lung cancer, especially for stage I disease, as it yield good survival.

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Objective. To evaluate the actual situation of medical care for elderly patients with lung cancer (elderly patients). Methods. We reviewed 537 lung cancer patients (our cases) who were treated in our department and lived in the Hokusetsu region between 1985 and 2000. We calculated the expected incidence of lung cancer patients in the Hokusetsu region (expected cases in the Hokusetsu region). We compared the rate of lung cancer patients over 75 years old among our cases and expected cases in the Hokusetsu region. In addition, we calculated the rate of lung cancer patients among Hokusetsu cases who were over 75 years of age and not receiving standard management for lung cancer. We calculated the predicted number of lung cancer patients between 2000 and 2020 in the Hokusetsu region and predicted the number of lung cancer patients over 75 years old without standard management. Results. The rate of lung cancer patients over 75 years old in our cases was 19.2%, which was significantly smaller than that (35.8%) in the expected cases in the Hokusetsu region (p<0.0001). The rate of lung cancer patients over 75 years old without standard management was calculated to be 57.4%. We predicted that the rate of lung cancer patients over 75 years old would increase from 32.0% in 1985 to 57.2% in 2000. It was predicted that lung cancer patients over 75 years old without standard management in 2020 would account for 32.9% of all lung cancer patients. Conclusion. The explosion of the number elderly patients with lung cancer in the future will cause a marked increase of elderly patients without standard management in the Hokusetsu region. It is necessary to start a new research project as soon as possible to seek standard management for elderly patients.

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Background. Mucosa-associated lymphoid tissue (MALT) lymphoma of the thymus is a very rare extranodal malignant lymphoma. MALT lymphoma of the thymus shows a large irregular mass in the anterior mediastinum on chest roentgenograms or CT scans. Therefore, differentiating MALT lymphoma from other anterior mediastinal tumors, such as thymoma, or germ cell tumor, is difficult. Case. An 82-year-old man was admitted to the Internal Medicine Department of our hospital for treatment of acute bronchitis, whereupon chest X-ray film and CT showed a large, well-defined mass in the anterior mediastinum. Suspected of having thymoma, he was referred to our department for surgery. An anterior mediastinal tumor was removed through a standard midline sternotomy incision. As a result, the case was diagnosed as having MALT lymphoma of the thymus. Conclusion. We described a case of MALT lymphoma of the thymus. Immunostaining of lymphocytes was useful in making an accurate diagnosis.

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Background. Hyponatremia in patients with lung cancer during treatment may be caused by syndrome of inappropriate secretion of antidiuretic hormone (SIADH), which is rarely produced by anticancer drugs. Case. A 71-year-old man was referred to our hospital for detected examinations of an abnormal shadow on chest X-ray films and edema of the face and the upper extremities. The tumor in the upper lobe of the right lung with mediastinal lymphadenopathy on chest CT was diagnosed as poorly differentiated adenocarcinoma based on the transbronchial lung biopsy findings. Furthermore, this tumor was thought to be a granulocyte colony-stimulating factor (G-CSF) producing lung cancer because of the remarkable leukocytosis and the high levels of plasma G-CSF shown by laboratory data on admission. Two weeks after initiation of radiation therapy, the patient received combination chemotherapy with nedaplatin and docetaxel, resulting in delirium at 9 days after the start of chemotherapy. The diagnosis of SIADH was confirmed based on laboratory findings such as hyponatremia with decreased plasma osmolality and elevation of plasma ADH levels. After treatment by sodium supplement together with intravenous diuretics, fluid restriction improved the patient's clinical condition and hyponatremia did not appear again. Conclusion. Although emergency treatments may be required for patients with symptomatic hyponatremia, it is important to differentiate the cause of the SIADH by considering the possibility of drug-induced SIADH.

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Background. Pulmonary spindle cell carcinoma which consists of only spindle cells, has a poor prognosis. We report a patient who died after rapid progress of the disease, following lung and chest wall resection. Case. A 68-year-old man was admitted because of lung cancer which invaded his chest wall. Chest computed tomography revealed a 7 cm tumor, located in S⁶ of the left lung, and contained a cavity. Distant metastases could not be detected. Left lower lobectomy and chest wall resection were performed about 6 weeks after symptom appeared. Histological findings revealed only spindle cells, and immunohistochemical stain showed it was cytokeratin positive. We diagnosed pulmonary spindle cell carcinoma. The patient was admitted to another hospital about 5 weeks after the operation because of bowel obstruction. Emergency operation was performed. Resected intestinal tumors were diagnosed as metastases of spindle cell carcinoma. Subsequently, local recurrence, lung and bone metastases were detected. The patient died 6 months after the lung operation. Conclusion. Pulmonary spindle cell carcinoma is commonly regarded as having a poor prognosis. We should perform aggressive adjuvant therapy after surgery for this disease.

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Background. Anomalous right upper and middle lobe bronchi originating from a common bronchus is a rare condition. We report a case of lung cancer associated with this anomaly. Case. A 67-year-old woman complained of productive cough and chest pain. A diagnosis of pneumonia was made in the right lung. Despite antibiotics, the shadow in the right lower lung field did not disappear. Therefore she underwent computed tomographic (CT) scan which revealed a mass in the right middle lobe. She was referred to our hospital on the suspicion of lung cancer. Bronchoscopy revealed right upper and middle lobe bronchi originating from a common bronchus. Squamous cell carcinoma was confirmed by curetting cytology of the right middle lobe bronchus. Bilobectomy of the right upper and middle lobes and lymphadenectomy was performed through a thoracotomy. After giving rise anteriorly to a large stem, the truncus superior (TS), the remaining stem of the right pulmonary artery, descended dorsally under the arch of the azygos vein. As the TS was thick, these two stems together presented a double-barreled appearance at surgery. The configuration of the dorsal stem after the branching off of the TS was similar to that seen in the left lung. No minor fissure between the upper and middle lobes was observed, and the posterior part of the major fissure was undeveloped. There was no abnormality in the pulmonary veins. The postoperative course of the patient was uneventful, and she was discharged on the fifth postoperative day. The pathologic diagnosis was stage IA squamous cell carcinoma. Conclusion. The bronchial anomaly was a mirror image of the left upper lobe bronchus. We were able to image the anatomic ramifications of the right pulmonary arteries by CT and 3D-CT scans. Pulmonary arteriography would have been optimal before surgery.

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Background. We report a rare case of typical pulmonary carcinoid with mediastinal lymph node metastasis. Case. A 62-year-old man was admitted to our hospital for further examination of an abnormal shadow on a chest roentgenogram. Chest CT scan showed a 18×18 mm tumor in the middle lobe. With a diagnosis of primary pulmonary small cell carcinoma, a middle lobectomy with mediastinal lymph node dissection was done. The pathological diagnosis of the resected specimen was typical carcinoid. All areas of the tumor was immunohistochemically positive for chromogranin A, NSE, and N-CAM. Subcarinal lymph nodes were metastatic from the carcinoid tumor. Conclusion. A limited operation is thought to be acceptable only in patients with typical carcinoid in a peripheral lesion without lymph node metastasis. Lobectomy with mediastinal lymph node dissection is necessary for possibly metastatic case.

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Background. Lung cancer rarely shows a lymph node metastasis to pulmonary hilar and/or mediastinal regions without the primary site of the lung being unable to be detected. Case. A 68-year-old man demonstrated a right abnormal hilar shadow on a chest X-ray film. A computed tomography (CT) revealed an enlarged mass at the right pulmonary hilar node, and this mass was diagnosed to be poorly differentiated carcinoma by transbronchial aspiration cytology. However, no primary lesion in the lung was apparent, and the extrathoracic findings showed no abnormalities despite a thorough examination. We thus performed a tumorectomy with right upper lobectomy and mediastinal nodal dissection because of the possibility of a lung origin based on the lymphatic routes to the tumor. The microscopical and immunohistochemical findings were consistent with small cell carcinoma in the pulmonary hilar node. Although no primary lesion of the resected lobe and also other lobes of the lung was found despite detailed examinations, positive immunoreactivity against anti-thyroid transcription factor-1 (TTF-1) antibody revealed this tumor to have originated in the lung. Therefore, we consider that this patient is a rare case of primary unknown T0 lung cancer with metastasis in the pulmonary hilar lymph node. Conclusions. In case of T0 lung cancer, since the primary lesion may later be identified, a strict follow-up study after the operation is necessary.

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Background. The accurate evaluation of cancer metastases to hilar or mediastinal lymph nodes or distant organs is very important for the decision of treatment strategy in lung cancer. Recently, positron emission tomography with ¹⁸F-fluoro-2-deoxy-D-glucose (FDG-PET) has become considered useful for the staging of lung cancers. Case. A 55-year-old man with an adenocarcinoma of the right lung was admitted to our hospital for surgical treatment. Enhanced CT scan showed a tumor (measuring 70 mm in diameter) in S⁹ and swollen hilar lymph nodes (#11s and #11i) and left adrenal gland. FDG-PET showed positive accumulation at the primary site, but not in the hilar lymph nodes and the left adrenal gland. Right lower lobectomy was planned based on a pre-operative diagnosis as clinical stage IB (cT2N0M0). Since intraoperative frozen sections of the hilar lymph nodes showed metastases of mucinous adenocarcinoma, right middle and lower lobectomy with lymphadenectomy was performed. Histologically, the right lung tumor was adenocarcinoma with mixed subtypes, consisting of colloid adenocarcinoma and solid adenocarcinoma with mucin. Metastatic lymph nodes showed features of colloid adenocarcinoma with abundant mucin. Conclusion. The analysis of FDG-PET false positive cases and negative cases of lung cancers should improve the accuracy of lung cancer staging.

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