The diagnosis of pleural mesothelioma should be based on a histological specimen obtained by needle or thoracoscopical biopsy. The tumor tissues are examined by pathologists using not only HE staining but also immunohistochemical staining such as positivity of calretinin and negativity of CEA for epithelioid mesothelioma. It is very important and difficult to make a differential diagnosis from pleomorphic lung cancer, pseudomesotheliomatous adenocarcinoma of the lung and fibrotic pleuritis (benign asbestos pleurisy). The therapeutic options for this disease are extremely limited, because radiotherapy by itself is not effective. Cases from the early stage up to stage III by the classification of IMIG have be indications for extrapleural pneumonectomy (EPP). However, cases of stage III with lymph node metastasis have poor prognosis. In cases of stage III or IV, it would be better to employ chemotherapy using cisplatin (CDDP) +pemetrexed. Treatment of EPP, chemotherapy and radiotherapy (trimodality) has been reported as obtaining best survival, but this therapy is limited to young cases with good performance status. No other reliable therapies have been reported.

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Objective. We investigated the unevenness of screening intervals in annual repeated lung cancer screening. Methods. We performed lung cancer screening with chest X-ray and sputum cytology on behalf of 10 municipalities in 2006. Among 5,304 people aged 40 to 79 years, there were 2,307 receiving annual repeated examinations, and these participants were studied. We checked the annual schedules of lung cancer screening in the 10 municipalities, and classified municipalities into several types by the annual frequency of lung cancer screening. Then we calculated the screening intervals of all annual repeated participants, and surveyed the unevenness of screening intervals in each frequency type. Results. There were 2 high frequency type municipalities, 2 in the 12 times a year type, 2 in the 4 times a year type, 3 in the twice a year type and 1 in the once a year type. As a result of total count, the shortest screening interval was 130 days, the longest screening interval was 665 days and those with an interval of 351-380 days accounted for 46.8%. The unevenness of screening intervals was remarkable. In municipality A, classified as a high frequency type, the shortest screening interval was 295 days, the longest screening interval was 606 days and the 351-380 days interval accounted for 49.1%. In municipality B, also classified as a high frequency type, the shortest screening interval was 130 days, the longest screening interval was 528 days and the 351-380 days interval accounted for 28.0%. The unevenness of screening intervals in municipalities A and B was remarkable. In municipality C, classified as a 12 times a year type, the shortest screening interval was 182 days, the longest screening interval was 665 days and the 351-380 days group was 31.2%. The unevenness of screening intervals in municipality C was also remarkable. In municipality E, classified as a 4 times a year type, the shortest screening interval was 229 days, the longest screening interval was 524 days and 68.5% of subjects had an interval of 351-380 days. In municipality G, classified as a twice a year type, the shortest screening interval was 235 days, the longest screening interval was 494 days and the 351-380 days group accounted for 66.4%. Unevenness with several small peaks was seen in E and G municipalities. In municipality J, classified as a once a year type, all subjects fitted in the 351-380 days interval. Conclusion. The unevenness of screening intervals in annual repeated lung cancer screening was remarkable. Municipalities must take into account that screening intervals in annual repeated lung cancer screening should be about 365 days, when planning a screening schedule or encouraging annual repeated screening.

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Objective. To comprehend the physical relationship between individual basic structures in the mediastinal space and discuss the physical relationship of regional mediastinal lymph node stations from CT images. Materials and Methods. We observed the physical relationship between basic structures in the mediastinal space in 201 patients who underwent total lung CT scan because of suspicion of nodal cell or diffuse pneumonia in Osaka University Hospital, from the beginning of April 2005 to the middle of September 2005, and 7 patients who underwent a preoperative total lung CT scan in the National Cancer Center Hospital, from the middle of May 2005 to the middle of August 2005. We used the "General Rules for Clinical and Pathological Records of Lung Cancer (6th Edition)" for classifying regional lymph node stations. Results. Comparing 2 adjoining basal axial slices, it was clear that there were differences among individuals in the hierarchical relation of basal axial slices and there fell into 4 types as follows: the upper rim of the brachiocephalic (left innominate) vein where it ascends to the left, crossing anterior to the trachea at its middle (79%) and the upper margin of the aortic arch (21%), the upper margin of the azygos vein (61%) and the lower margin of the aortic arch (39%), the upper margin of the azygos vein (96%) and the upper margin of the left pulmonary artery (4%), and the upper margin of the right pulmonary artery (70%) and the tracheal bifurcation (30%). The frequency of the structure of appearing on the upper playing was shown in parentheses. From these differences, it became clear that borders on axial slices which were used to divide stations #2-#4 and #6 were different from the depiction in the General Rules, and the images of each lymph node station also different. Conclusion. The result revealed that the physical relationships between anatomic landmarks in the mediastinal space for classifying regional mediastinal lymph node stations differ considerably in individuals, and the border lines of stations #2-#4, #6 different from the depiction in the General Rules. We should take those relationships into account for accurate diagnosis, treatment and three-dimensional display of regional mediastinal lymph node stations.

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Background. Pulmonary carcinosarcoma is an extremely rare malignant tumor of the lung. Recently, we encountered an elderly man with rapidly progressive pulmonary carcinosarcoma appearing as a consolidation with an air bronchogram during follow-up as an outpatient in our hospital. Case. The patient was an 85-year-old man. During outpatient follow-up, periodic X-rays showed an abnormal shadow in the right lower lung field. Chest CT revealed a consolidation with an air bronchogram in the periphery of the right lower lobe and a homogeneous shadow in the lateral segment of the right middle lobe. Although the lesion had a pneumonia-like appearance, the possibility of a tumor could not be excluded, because the patient was relatively asymptomatic. Therefore, CT-guided biopsy was performed. Histopathological examination showed high density, invasive growth of atypical cells. Fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT revealed intense FDG uptake in the right lower lobe and the lateral segment of the right middle lobe, but no FDG uptake suggestive of metastasis. Surgery was performed, and the lesion was diagnosed as a malignant mesenchymal tumor by frozen sectioning; therefore, right lower lobectomy with tumorectomy of the right middle lobe was performed. Histopathological examination showed the dense proliferation of sarcoma-like spindle cells as well as areas of a mixture of osteosarcoma, chondrosarcoma, and rhabdomyosarcoma and an area of squamous cell carcinoma, leading to the diagnosis of pulmonary carcinosarcoma. The tumor recurred early after surgery, and the patient died about 3 months postoperatively. Conclusion. Pulmonary carcinosarcoma is difficult to definitively diagnose by biopsy, and has a poor prognosis. Although he was followed-up by chest X-rays every 6 months, it was difficult to detect and treat the tumor early.

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Background. The incidence of true pulmonary carcinosarcoma is about 0.1% of all lung tumors, and it has a tendency to occur in heavy smokers and elderly men. The tumor sizes of true pulmonary carcinosarcoma are generally large and the prognosis is bad. Case. An abnormal shadow was pointed out on the chest X-ray film of a 74-year-old man in a clinic. The chest X-ray film and CT showed honeycomb lung, lung fibrosis, and pulmonary emphysema predominantly in the bilateral lower lung field and a mass 7.5 cm in diameter in the right lower lobe. The mass was diagnosed as adenocarcinoma accompanied by sarcomatous change by a CT-guided lung biopsy. A right lower lobectomy with ND2a lymph node dissection was performed. The post-operative diagnosis was T4N2M0, p-Stage IIIB, and the tumor sizes were 8.5×8.0×5.3 cm in the primary lesion and 4.0×2.6 cm in the metastatic lesion (right S⁶). The patient passed away 6 months after the operation due to renal failure and cardiopulmonary failure despite chemoradiotherapy. Conclusion. We treated and report a case of true pulmonary carcinosarcoma.

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Background. Various cystic masses can be seen within the mediastinum and can be diagnosed definitively by histological examination of lining cells and tissue components. Case. A 59-year-old man was admitted to our hospital because of an abnormal shadow on the chest X-ray. CT demonstrated a cystic lesion located among the brachiocephalic veins. The cystic lesion was incompletely resected through right thoracotomy. The histological examination revealed that the unilocular cyst was lined by ciliated columnar epithelium. Thymic tissue with aging involution was discovered outside the cystic wall. The immature T-lymphocytes and the epithelial cells of the thymus were clearly demonstrated in the cystic wall by immunohistochemical studies. Conclusion. Atrophic thymic components in the thymic cyst were recognized as a thin band-like layer of vasculo-adipo-lympho-epithelial (VALE) structure. Immunohistochemistry was shown to be a useful method for detecting thin atrophic thymic tissue in the cystic wall.

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Background. Paraneoplastic limbic encephalitis (PLE), one of the paraneoplastic neurological syndromes (PNS), is a rare complication of cancer. However, its diagnosis is difficult because neurological symptoms usually precede the detection of the underlying cancer. Case. A 64-year-old man was admitted to our hospital because of progressive memory loss. T2-weighted and fluid attenuated inversion recovery (FLAIR) MR images revealed bilateral hippocampal abnormalities, and were compatible with limbic encephalitis. Further examinations revealed a mass in the right S⁸ on chest CT, and bronchoscopic examination led to a diagnosis of small cell lung cancer (cT2N2M0 stage IIIA, limited disease) with PLE without evidence of anti-Hu antibody. He was treated with concurrent chemoradiotherapy, leading to a partial response of the tumor, and his memory loss was alleviated. He is doing well without exacerbation for 23 months after the onset of the symptoms. Conclusion. We suppose the early diagnosis and treatment, as well as absence of the anti-Hu antibody contributed to the improvement of neurological symptoms. Therefore, when we see a case with some neurological symptoms of unknown origin, we should take PNS into account.

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Background. Radiofrequency ablation (RFA) for thoracic malignancy is emerging as a minimal invasive treatment, but the pathological effects are not sufficiently understood. We report a resected case of lung metastasis from colon cancer because of local recurrence after RFA. Case. A 65-year-old man underwent sigmoidectomy for sigmoid cancer in March 1999. In November 2004, he underwent systemic chemotherapy for a lung metastasis in the apical segment of left lower lobe. In April 2005, the lung metastasis progressed in the same location. According to the patient's wishes, he underwent the RFA. In May 2006, he underwent RFA again for the local recurrence of the ablated lesion. In December 2006, he underwent a salvage operation, left lower lobectomy with partial resection of the adventitia of descending aorta and soft chest wall tissue, for the local recurrence following the second RFA. The pathological findings confirmed that a large bronchus and pulmonary artery were involved in the recurrence lesion, but firm adhesion between tumor and aorta or chest wall consisted of fibrous tissue without viable cancer cells. The postoperative course was uneventful and he is alive 9 months after operation without any signs of recurrence. Conclusion. Further studies on the possible risk factors and mechanisms related with local recurrence are needed to determine the clinical indication of RFA treatment in lung malignant lesions. We reported a resected case of local recurrence following RFA of a lung metastasis from colon cancer.

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Background. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare preinvasive lesion, sometimes accompanied with peripheral carcinoids or tumorlets. Case. A 52-year-old woman had abnormal shadows on chest radiograph, while chest CT showed small nodules in the left lower lobe and one small nodule in the left upper lobe. Video-assisted wedge resection of the left upper lobe and left S⁸ was performed. On frozen section, the nodule in the left S⁸ was suspected to be adenocarcinoma, and the nodule in the left upper lobe to be fibrosis, therefore video-assisted left lower lobectomy was performed. Postoperatively, the nodule in the left S⁸ was pathologically diagnosed as typical carcinoid. Several carcinoids, tumorlets, and atypical adenomatous hyperplasia in the left lower lobe were noticed. In addition the proliferation of cells with positivity for chromogranin A by immunostaining was observed within the bronchial epithelium, but there was no penetration of the cells to basement membrane, thus we diagnosed as DIPNECH. Conclusion. We encountered a rare case of DIPNECH associated with carcinoid and tumorlet derived from neuroendocrine cells.

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Background. Most outpatients receiving adjuvant chemotherapy for lung cancer show no severe neutropenia, and even though mild respiratory tract infection occurs, antibacterial treatment is usually effective. We report a patient who developed acute respiratory distress syndrome during adjuvant chemotherapy for lung cancer in absence of severe neutropenia. Case. A 68-year-old man who had received postoperative adjuvant chemotherapy with 3 cycles of carboplatin and paclitaxel visited our institution because of fever (38.0°C), progression of productive cough with purulent sputum. Chest computed tomography revealed a mild degree of interstitial changes around emphysematous lesions. Laboratory data showed a slight decrease of WBC (3300/mm³) and elevated C-reactive protein (6.43 mg/dl). On the day of admission, there were no symptoms about half an hour before, but he suddenly developed a fever of 38.9°C, dyspnea and pink frothy sputum. He was immediately treated with oxygen inhalation, but his oxygen saturation remained at 80-90%. He was transferred to the intensive care unit, underwent tracheal intubation, and was subsequently rescued from this crisis. Conclusion. Even if outpatients with chronic obstructive pulmonary disease receiving adjuvant therapy for lung cancer have no severe neutropenia, mild infection may trigger ARDS. Early detection and treatment are required for such patients.

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Background. Malignant pleural mesothelioma (MPM) is associated with a poor prognosis and is often resistant to treatment. Cisplatin+pemetrexed (CP) is a standard regimen for the first-line treatment of MPM. Unfortunately, no data are available on the efficacy of this chemotherapy regimen in patients who have received previous systemic chemotherapy. Case. A 73-year-old man was admitted because of pleural effusion in February 2006, and a mediastinal lymph node biopsy confirmed a diagnosis of malignant mesothelioma. Chemotherapy with cisplatin and gemcitabine, followed by radiotherapy, was then performed. As continuous effects were not obtained, second-line chemotherapy with CP was performed. After 4 cycles of CP, stable disease was observed. The only severe toxicity that occurred was thrombocytopenia (Grade 3). He has been followed up closely as an outpatient without chemotherapy for 10 months. Conclusion. This case suggests that patients with MPM may benefit from CP chemotherapy, which has an acceptable toxicity, even after undergoing systemic chemotherapy.

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[in Japanese]

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[in Japanese]

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