Objective. In the current TNM staging system for lung cancer, there is no significant difference in survival rate between stage IB and IIA. Furthermore, the number of patients with stage IIA is very small. In this study, we re-evaluated the T factor based on tumor size and visceral pleural invasion to try to solve these problems. Methods. We studied 1245 consecutive patients with non-small cell lung cancer who underwent pulmonary resection. For analysis in order to stratify T2 category into subcategories, pathological T2 category was divided according to the tumor size and the degree of visceral pleural invasion, classified according to the Japan Lung Cancer Society criteria (P factor). Of the patients with current IB disease, those with worse prognostic T2 tumor were classified as IIA disease. Results. The 5-year survival rates and number of patients by pathological stages according to the current TNM classification were as follows: 82.2% for IA (n=354), 64.6% for IB (n=311), 69.2% for IIA (n=39), and 45.5% for IIB (n=145). T2 category was divided according to the tumor size (≤3, >3 to ≤5, >5 cm) and the degree of visceral pleural invasion (P0-1 or P2). Patients with T2 tumor of >3 to ≤5 cm and P0-1 had better outcome than those with T2 tumor of >5 cm or P2, and the 5-year survival rates were 59.5% and 37.5-47.3%, respectively. Therefore, the better prognostic T2 groups were defined as subcategory T2a, and the worse ones as T2b. With regard to stage grouping of TNM subsets, T2aN0M0 was classified as the new IB, and T2bN0M0 was classified into the new IIA together with the current T1N1M0. The 5-year survival rates and number of patients in our modified classification were 70.6% for our proposed IB (n=163) and 60.4% for our proposed IIA (n=145). Conclusions. Of the patients with current IB disease, those with tumor greater than 5 cm or those with P2 tumor have poor prognosis. When these groups of patients are re-classified as new IIA disease, survival rates are stratified in the order of stages IA, IB, IIA, and IIB, and more uniform distribution in the number of patients is achieved.

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Objective. To perform a retrospective investigation of alternate-day administration of gefitinib for reduction of side effects and to determine the efficacy of this approach for maintenance therapy. Methods. We gave gefitinib to 50 patients from July 2002 to May 2004. All patients were initially treated with 250 mg gefitinib daily, and with long-term administration 12 patients developed mild side effects. Administration of gefitinib was reduced to alternate days in these patients, and here we report the effects of this dosage in the 12 patients. Results. All patients showed a reduction of adverse events and long-term gefitinib administration became possible again. The average time to treatment failure (TTF) was 18.4 months for daily administration and 10.9 months for alternate-day administration. However, efficacy of the drug has been maintained for over 600 days in 4 women. Conclusion. Alternate-day administration of gefitinib is useful for reduction of adverse reactions and can serve as an effective maintenance therapy; however, a further prospective study is needed for comparison with other administration schedules.

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Objectives. We evaluated the usefulness of magnetic resonance imaging (MRI) by comparison of MRI studies and pathological findings in lung cancer patients. Materials and Methods. From May 2005 to May 2006, 52 lung cancer patients underwent surgical operation in our division. Forty-five patients, each with a preoperatively recognized peripheral lung lesion underwent the MRI study. Short TI inversion recovery (STIR), high b-value diffusion-weighted imaging (DWI) with free breathing scanning and dynamic MRI studies were performed. Results. There was no statistically significant difference between adenocarcinoma (n=35) and other carcinomas (n=10) on MRI findings. Twenty-seven adenocarcinomas (less than 30 mm in diameter) were histologically diagnosed as follows: 9 patients with bronchioloalveolar carcinoma (BAC), 12 patients with advanced BAC, and 6 non-BAC cases (adenocarcinoma without a BAC component) group. When the lesions demonstrated a strong enhancement (steep type) on dynamic studies or showed a strong signal (score 4) intensity on DWI, we judged them to be positive (indicating invasion). Sensitivity, specificity and accuracy were 94.4%, 66.6%, and 85.2%, respectively. Conclusion. The MRI studies permitted the acquisition of more detailed information on peripheral lung adenocarcinomas, and high b-value DWI is valuable as a supporting tool in evaluating the grade of malignancy.

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Objective. We examined the characteristics of lung cancer cases according to the detection method. Methods. A total of 53,427 persons underwent lung cancer screening with chest X-ray and sputum cytology from 1998 to 2005. Forty-two lung cancer cases were detected by lung cancer screening. We classified them into 3 groups according to the detection method; the chest X-ray group, the sputum cytology group, and the chest X-ray plus sputum cytology group, in order to compare the clinical characteristics of these groups. Results. There were 28 lung cancer cases in the chest X-ray group, 5 in the sputum cytology group, and 9 in the chest X-ray plus sputum cytology group. Although the average age did not show a statistically significant difference, the ratio of gender showed a statistically significant difference among 3 groups. The smoking index was high in the sputum cytology group. The mean diameter of the detected tumors was 2.8±1.3 cm in the chest X-ray group, 0.7±0.3 cm in the sputum cytology group, and 4.5±2.2 cm in the chest X-ray plus sputum cytology group, showing a statistically significant difference for all groups. The rate of clinical stage IA lung cancer cases was 53.6% in the chest X-ray group, 100.0% in the sputum cytology group, and 22.2% in the chest X-ray plus sputum cytology group, showing a statistically significant difference for all groups. The surgical resection rate and the complete resection rate were high in the sputum cytology group. Conclusion. This study revealed that sputum cytology was effective in detecting early lung cancer.

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Objective. Pure ground glass opacity (GGO) confirmed by thin section CT scan (TSCT) is considered to be an early state of lung adenocarcinoma. We reviewed the clinical records and TSCT images of cases with pure GGOs of 10 mm or less to assess the appropriate follow-up interval of TSCT scan. Methods. Between 1999 and 2004, pure GGOs (10 mm or less) unchanged for the first 3 months were followed by chest TSCT every 6 months in 62 cases (including 28 cases with a past history of lung cancer operation) at the Cancer Institute Hospital. The accumulated change rate curves by the Kaplan-Meier method was studied with particular attention to such factors as gender, age, smoking, location (above or below the major fissure), number of pure GGOs (solitary or multiple), history of any cancers excluding lung cancer and history of lung cancer alone. Results. The observation periods were 7-79 months and the median was 32 months. Pure GGOs deteriorated in 10 of 62 cases. Nine of these 10 cases had a past history of lung cancer and the pure GGO accumulated change rate was significantly associated only with this background (p=0.0018). Solid part formation was a finding seen only in 2 cases with a lung cancer history. Most of the changes in the cases with a past history of lung cancer were detected between 7 and 24 months after the initial detection of the lesions, while in the case without lung cancer history, a GGO did not change until 48 months after the detection. Conclusion. Pure GGOs of patients with lung cancer history are more likely to change during the first 24 months than cases without a lung cancer history. Therefore follow-up TSCT for these pure GGOs of patients with lung cancer history should be performed every 6 months during the first 2 years.

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Background. The majority of pulmonary hamartomas are recognized as solitary tumors. It is difficult to differentiate multiple pulmonary hamartomas from pulmonary malignant nodules in a patient who has undergone previous surgery for metastatic lung tumor. We report an extremely rare surgical case of multiple pulmonary hamartomas. Case. A 57-year-old woman with an abnormal chest radiograph was referred to our hospital in August 2004 for further evaluation. Chest radiography and computed tomography showed multiple nodular lesions in the posterior basal segment of the right lung. She had undergone surgery for rectal cancer in September 2002 and had undiagnosed bilateral pulmonary nodules identified at that time. Because the pulmonary nodules in the left lung increased in size, partial resection of the left upper lobe was performed in February 2003. Postoperative histopathologic diagnosis of the lung tumor was metastatic adenocarcinoma originating from the rectal cancer. She underwent chemotherapy starting in March 2003, but an increase in number and size of the pulmonary nodules in the right lower lobe was demonstrated on chest films. She underwent partial resection of the posterior basal segment of the right lung by video-assisted thoracoscopic surgery in September 2004 to remove all nodules. Postoperative histopathologic examination of the resected specimens revealed multiple pulmonary hamartomas consisting of various-sized bronchioles without a cartilageous component. She recovered uneventfully and there have been no signs of recurrence for 40 months since the pulmonary resection in February 2003. Conclusion. We encountered an extremely rare surgical case of multiple pulmonary hamartomas. If it is difficult to differentiate it from metastatic lung tumors in this case, minimally invasive surgery such as video-assisted thoracoscopic surgery should be performed to establish a definitive diagnosis.

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Background. In thymic carcinoma, prognosis is generally poor in cases with metastasis or recurrence. However, we encountered a case in which long-term survival was obtained by combined modality therapy suggesting benefit of aggressive treatment. Case. A 51-year-old woman was found to have an abnormal shadow during a check-up in November, 1990, and visited our hospital for the first time. Tumor shadows were observed in the anterior mediastinal space and the liver. Radical thymectomy to remove the thymic tumor and PEIT (percutaneous ethanol injection therapy) for the liver tumor were performed. The pathological diagnosis of the mediastinal tumor was undifferentiated thymic carcinoma, and the liver tumor subjected to intraoperative needle biopsy was undifferentiated metastatic carcinoma. The pathological stage was IV because of mediastinal lymph node and liver metastasis. In October, 1991, the liver tumor re-increased in size, and S8 excision was therefore performed (undifferentiated metastatic carcinoma). In January, 1994, liver S4 partial resection was performed for the liver tumor (undifferentiated metastatic carcinoma). Right chest wall tumor excision was performed in August of the same year, and the pathological diagnosis was small cell carcinoma. In January 1998, she exhibited complete response to treatment with chemotherapy (CDDP+VP-16) and radiation therapy to a tumor in the hilum of the right lung. She also exhibited complete response to treatment with chemotherapy (CBDCA+oral VP-16) for tumor in S¹⁰ of the right lung in August of the same year. Although tumor shadow is now observed in the diaphragm and the right chest wall, her condition is stable and she has been followed without treatment at December, 2005. Conclusion. Some cases of thymic carcinoma with metastasis can obtain long-term survival with combined modality therapy, therefore aggressive treatment can be effective.

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Background. Surgical indications after a previous pneumonectomy are restricted because of limited residual pulmonary function. We report a case of tracheal sleeve resection for endotracheal metastasis following left pneumonectomy for primary lung cancer. Case. A 68-year-old man complained of hemoptysis 2 years after left pneumonectomy for squamous cell carcinoma. Chest CT revealed a tumor in the trachea. Bronchofiberscopic findings showed a tumor arising from the left lateral wall of the sixth ring of the trachea. We concluded that the tracheal tumor was metastatic due to its close histological resemblance to the primary tumor. No distant metastasis, extratracheal invasion, or lymph node enlargement were detected. Under median sternotomy, 3 tracheal rings were resected followed by primary anastomosis of the trachea. The patient was discharged from our hospital without any complications. He is alive 3 years after the operation without any signs of recurrence. Conclusion. Even in patients who have undergone unilateral pneumonectomy, surgical resection of metastatic lesions should be considered based on careful preoperative evaluations, and curative surgical resection can offer good prognoses in selected patients.

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We report a case of malignant melanoma of the lung of unknown origin. Case. A 50-year-old man was admitted to our hospital because of an abnormal shadow on chest roentgenogram and bilateral multiple pulmonary nodules on chest CT. Right upper lobectomy was carried out and the histological diagnosis of the tumor was malignant melanoma. Two nodules of the left lung were resected 1 month after the first operation, and they were also diagnosed as malignant melanoma. Although systemic examination was thoroughly performed, the original lesion was not detected. The color of the right second finger nail had changed to black about 10 years previously, but spontaneously regressed. Therefore the primary lesion might have been the finger nail. Although the patient underwent chemotherapy with DAV-Feron for 5 months after the second operation, metastatic lesions appeared in the lung, liver and vertebrae, and are now recently treatment. Conclusion. Malignant melanoma rarely originates in the lung and spontaneous regression often occurrs. Therefore, we should carefully search for the origin of pulmonary lesions.

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Background. Pleomorphic carcinoma is a histologic subset of lung cancers in the revised classification proposed by WHO in 1999. There maybe many lung cancers that had been previously diagnosed as large cell carcinoma, but are now reclassified as pleomorphic carcinoma. Cases. We reported 52- (patient 1) and 76-year-old men (patient 2), and a 80-year-old woman (patient 3). The former 2 patients were smokers with pleomorphic carcinoma composed of large cell carcinoma with giant cells and spindle cells, presenting as a huge mass invading the pleura. In patient 3, a non-smoker, pleomorphic carcinoma measuring 2.5 cm in diameter consisted of adenocarcinoma and spindle-shaped tumor cells as histologic components. Although patient 2 received anti-cancer chemotherapy, response was poor, he rapidly deteriorated and died 2 months after diagnosis. Patients 1 and 3 underwent surgical resection, and are alive without relapse 11 and 5 months after surgery, respectively. In patient 1, elevated levels of serum G-CSF and CRP in addition to peripheral leukocytosis normalized after surgical resection, suggesting that pleomorphic carcinoma of patient 1 was G-CSF-producing. Conclusion. Pleomorphic carcinoma is a rare lung cancer with many histologic variations. We need to collect more cases of pleomorphic carcinoma in order to clarify the clinical characteristics of each variant of histology.

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