Objective. Pneumocystis pneumonia (PCP) is known to be a potentially fatal opportunistic infection. PCP is sometimes encountered by lung cancer patients during cancer treatment. In this study, we retrospectively examined the frequency of PCP in lung cancer patients in terms of the clinical characteristics and the treatment method. Study Design. We studied 297 patients with lung cancer treated in our department between January, 2004 and December, 2005. PCP was diagnosed when the clinical conditions and clinical findings agreed with PCP, and Pneumocystis jiroveci was detected by microscopic inspection or polymerase chain reaction method of airway biopsy specimen from patient. Results. PCP was diagnosed in 13 patients (4.4%) out of 297 lung cancer patients. Of the 13 patients with PCP, 4 patients had received chemo-radiotherapy, and 7 patients received chemotherapy with palliative radiotherapy in 4 cases. One patient received radiotherapy only. Surgical excision had been done in one patient. Ten of 13 patients with PCP had received glucocorticoid therapy until PCP was diagnosed. PCP was more frequent in lung cancer patients who had received chemotherapy or radiotherapy, or both. Glucocorticoid therapy with chemotherapy, or radiotherapy, or both was also a risk factor for PCP. Conclusion. It is thought that great caution is necessary in PCP when glucocorticoid is used additionally in lung cancer patients who have received either chemotherapy, or radiotherapy.

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Objective. The aim of this study was to determine the significance of extrapleural pneumonectomy for malignant pleural mesothelioma. A retrospective study was performed on its surgical outcomes and prognostic factors. Subjects. The subjects were 32 patients in whom our research group performed extrapleural pneumonectomy. Results. The patients were 31 men and 1 woman. Their mean age was 55.4 years old. The incidence of postoperative complications was 56.3% which included empyema and detachment of a reconstruction patch for the diaphragm. There were 2 operative deaths (6.3%). Combination therapy was performed in 13 patients (40.6%) including intrathoracic perfusion chemohyperthermia and systemic chemotherapy. The postoperative 2- and 3-year cumulative survival rates among all patients were 40.1% and 16.0%, respectively. The median survival time was 16.2 months. The multivariate analysis on prognostic factors indicated that the following were 3 significant independent factors for good prognosis: an Eastern Cooperative Oncology Group Performance Status of 0, N0, and operative time <600 minutes. The 2- and 3-year survival rates of patients satisfying all 3 factors were 64.8% and 51.9%, respectively. Conclusion. Extrapleural pneumonectomy for malignant pleural mesothelioma can be expected to have a relatively good prognosis by appropriate patient selection.

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Background. Gefitinib, a selective inhibitor of tyrosine kinase of the epidermal growth factor receptor (EGFR), can be effective in patients with non-small-cell lung cancer (NSCLC) harboring somatic mutations of EGFR. However, the clinical resistance to gefitinib is an unsolved problem. Methods. We analyzed patients with advanced NSCLC with EGFR mutations treated with gefitinib between June 2004 and June 2007 in our institution. The effectiveness of gefitinib, the pattern of relapse, progression-free survival (PFS), and overall survival were assessed retrospectively. EGFR mutations were all examined by DNA direct sequence or peptide nucleic acid-locked nucleic acid (PNA-LNA) polymerase chain reaction (PCR) clamp method by using the tumor specimen before treatment, and re-examination of EGFR mutations by using relapsed tumor sample was performed for some patients. Results. From June 2004 to June 2007, 51 patients with advanced NSCLC harboring EGFR mutations started treatment with gefitinib, and 36 had partial response and 8 had stable disease. The overall response rate and disease control rate were 71% and 86%, respectively. Among 44 responders to gefitinib, disease progression was observed in 33 patients by April 2008. The initial sites of relapse were thoracic (primary lung tumor, pleural effusion, etc) in 21 patients, and distant (brain, bone, etc) in 12 patients. There was no statistical difference in PFS among the initial sites of recurrence. T790M, a resistant mutation of EGFR, was detected in 3 specimens obtained after relapse. Interestingly, most of patients with initial relapse in the thorax had to change the treatment from gefitinib within 3 months, however, more than half of the patients with brain relapse could be managed by radiation therapy with gefitinib for over 3 months. The median survival time of patients with initial relapse in the brain was 28.2 months, which is quite better than that of general NSCLC patients with brain metastasis. Conclusion. Different patterns of relapse were observed in NSCLC patients treated with gefitinib. The new therapeutic strategy according to the mechanism of resistance to EGFR-TKI is warranted.

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Background. There has been no case report regarding severe pyothorax and lung abscess caused by Aspergillus fumigatus that co-occurs with pulmonary pleomorphic carcinoma. We believe that the recording of these rare cases is crucial. Case. The patient, a 75-year-old man, consulted a doctor because of severe pyrexia at 39 degrees centigrade, who was found to have a lung abscess in right S⁹ one month before the admission to our hospital. At the hospital, several combinations of antibiotics were administered, however, which resulted in severe pyothorax. Because of the life-threatening infection, the patient was referred to our department to receive intensive treatment. Because a chest drainage with a large tube (20 Fr) and antibiotics could not control the infection, in order to bail out the patient's life, we performed fenestration surgery. He recovered gradually, but the lung abscess remained. Therefore, we incised the abscess from the window, and a biopsy specimen revealed pulmonary pleomorphic carcinoma and also Aspergillus fumigatus. We controlled the infection by drainage from the window. Since a radical surgery for both the infection and carcinoma was too invasive, radiotherapy through the window was chosen as an alternative, resulted in a good local control. The patient required outpatient treatment to change his gauze (dry dressing) three times a week. However he could be discharged and maintained a good quality of life (ECOG PS: 1) for about 15 months. Notwithstanding adjuvant chemotherapy (DOC only→GEM only), the patient died due to the recurrence and lymphogenous metastasis of the carcinoma 19 months after the first admission. Conclusion. We report a very rare case of severe pyothorax and lung abscess caused by Aspergillus fumigatus that was accompanied with pulmonary pleomorphic carcinoma.

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Background. We report a rare case of combined small cell carcinoma of the lung (CSCLC), what has been histologically classified as the only variant of small cell carcinoma of the lung (SCLC). Case. A 64-year-old man had a tumor 22 mm in diameter, located in the right lower lobe. The tumor was suspected to be poorly differentiated adenocarcinoma on intraoperative diagnosis. Because of firm adhesion around the pulmonary artery, we performed right middle and lower lobectomy and mediastinal lymph node dissection. This case was finally diagnosed as CSCLC. It contained an adenocarcinoma component that was positive for neuroendocrine markers. Conclusion. Since patients with CSCLC are considered to have poor outcome, and careful follow-up is necessary.

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Background. Cases of lung cancer with myasthenia gravis (MG) have rarely been reported. Case. A 76-year-old woman had been complaining of ptosis and muscle weakness of the lower limbs. She received an injection of edrophonium chloride which resulted in improvement of muscle strength. We diagnosed sero-negative MG. Chest X-ray demonstrated an abnormal shadow in the right upper lung field. Chest computed tomography showed 3 lesions, a 3-cm mixed ground glass opacity (GGO) in the right S¹ segment, a 1-cm GGO in the right S³ segment and a 5-mm GGO in the left S¹⁰ segment. She simultaneously underwent extended thymectomy and radical right upper lobectomy with regional lymph node dissection through a median sternotomy without intercostal incision. Histological examination revealed that the lesions of the S¹ and S³ segment were mixed adenocarcinoma and bronchioloalveolar carcinoma respectively. The postoperative course was uneventful, and the patient was transferred to the Department of Neurological Medicine for medication of MG on the tenth day after operation. The patient is alive without any signs of recurrence 50 months later, GGO of the left S¹⁰ segment has not changed, and her strength has remained almost normal with pyridostigmine bromide. Conclusion. We report a case of simultaneously operated primary multiple lung cancers with non-thymomatous myasthenia gravis. It is important to keep the rare possibility of lung cancer associated with MG in mind.

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Background. Mediastinal lymph node metastases from extrathoracic malignancies are reported to be rare. Case. A 56-year-old woman was admitted to our hospital for the purpose of the evaluation of lung nodule in January 2003. She had undergone left mastectomy for the breast carcinoma at age 40. Supraclavicular lymph node metastases in the left side occurred at age 45 and 50, however, both lesions disappeared completely after the chemotherapy. Operation for the lung nodule was performed in April 2003. Because the pathological finding of the resected lung tumor revealed adenocarcinoma, right upper lobectomy and lymph node dissection were done. The pathological findings of a dissected tracheobronchial lymph node revealed a small atypical focus which was positive for estrogen receptor and progesterone receptor immunohistochemically. We diagnosed a metastatic mediastinal lymph node from breast carcinoma. Conclusion. Mediastinal lymph node metastases from extrathoracic malignancies should be considered in double primary cancers involving the lung.

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Background. It is rare for epidermal growth factor receptor (EGFR) mutation to be examined twice, before therapy and at dissection into lung adenocarcinoma, and one time at dissection into multiple brain metastasis. Here we reveal a case of EGFR mutation in primary lung adenocarcinoma with metastatic lesions treated with gefitinib. Case. A 44-year-old woman visited our hospital with chief complaints of cough and dyspnea. Chest X-ray showed pleural effusion and a tumor in the right lung, and we diagnosed lung adenocarcinoma by CT-guided lung needle biopsy. It was stage IIIB without distant metastasis. First, we gave 2 courses of chemotherapy (carboplatin+gemcitabine) which resulted in progressive disease (PD) with increased pleural effusion. Subsequently, another 4 courses docetaxel (TXT) were added, but the result was PD with multiple brain metastasis. As she refused radiation therapy to whole brain, the third treatment was gefitinib which resulted in partial response (PR). She became well enough as to walk by herself for 6 months until she got worse again and eventually died. Conclusion. We concluded that gefitinib was considerably effective against multiple brain metastasis as exon 19 deletion of EGFR mutation had been perceived on CT-guided lung needle biopsy, yet not worked out either on the lung or the brain without EGFR mutation according to dissection.

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Background. Congenital unilateral absence of a pulmonary artery (UAPA) is a rare anomaly. We report a successfully treated lung cancer in a case of UAPA. Case. A 55-year-old man with persistent cough was found to have an abnormal shadow on chest X-ray film in March, 2004, and was referred to our hospital. Chest CT revealed a nodular shadow with an irregular and unclear margin in the left upper lobe, and absence of the left pulmonary artery was suspected. The nodular lesion was diagnosed as adenocarcinoma by bronchoscopic biopsy, and pulmonary arteriography demonstrated complete absence of the left pulmonary artery. Left pneumonectomy was conducted. Conclusion. We encountered an extremely rare case of surgically treated lung cancer with UAPA.

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Background. Pulmonary adenocarcinoma producing alpha-fetoprotein (AFP) is rare and has a poor prognosis. We report a case of pulmonary adenocarcinoma consisting mainly of clear cells, high-grade adenocarcinoma of the fetal lung type (H-FLAC). Case. An annual check-up revealed an abnormal shadow in the right lower lung field of a 69-year-old man. Chest CT showed a solid, nodular mass with a distinct margin measuring 46×28 mm. A transbronchial lung biopsy revealed non small cell carcinoma. Right lower lobectomy and ND2a dissection was performed. Histologically, the tumor was adenocarcinoma, showing features similar to those of fetal lung. The tumor consisted mainly of tall columnar clear cells, and no morules were found. Immunohistochemically, the tumor was positive for AFP. Accordingly, we made the diagnosis of H-FLAC, pT2N1M0, stage IIB. Two courses of adjuvant chemotherapy (CBDCA+PAC) were administered, but the patient succumbed to recurrence of cancer 9 months after surgery. Conclusion. This was a rare case in which the clinicopathology was not established. Further study is needed to determine a better therapeutic approach.

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Background. Mucoepidermoid carcinoma is a rare malignancy occasionally arising from segmental or subsegmental bronchi. We report a case of mucoepidermoid carcinoma with hemoptysis which was resected after bronchial arterial embolization. Case. A 57-year-old man presented with hemoptysis and was admitted to the Department of Respiratory Medicine. Chest X-ray showed ground glass opacity in the right upper lung field, and CT showed a solid tumor. Right bronchial arteriography demonstrated a hypervascular area in the right upper lobe and embolization was performed. Right upper lobectomy with hilar and mediastinal lymph nodes dissection was performed 11 days after embolization. Examination of the resected specimen revealed a tumor 21 mm in diameter and most of the tumor was necrotic due to embolization. Histologically, the tumor cells were composed of clear cells, intermediate cells and squamous epithelial cells, indicating mucoepidermoid carcinoma (pT1N0M0, stage IA). Conclusion. Bronchial arterial embolization should be considered because mucoepidermoid carcinoma can cause hemoptysis even if it originates in the periphery of the lung.

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Background. Patients with multiple cancer risk factors (especially asbestos exposure) may suffer from multiple cancers. Case. A 75-year-old man had occupational asbestos exposure over a 30-year period. At a medical check up performed by his company, a nodule in the right lower lobe and some nodules in the left lower lobe were discovered in his chest X-ray and computed tomography (CT) scans, so the patient was referred to our hospital for examination. Based on a CT-guided lung biopsy performed after admission, we diagnosed lung squamous carcinoma. Further systemic examinations revealed that he also suffered from gastric cancer and colon cancer, and thus triple cancer was proven. Multiple lung, mediastinal and hilar lymph nodes and liver metastases were also revealed, so we concluded that systemic chemotherapy was indicated for this patient. We chose irinotecan and S-1 as an effective regimen. After 3 courses were performed, his tumors were reduced in size. Conclusion. In cases of asbestos exposure, it is well known that the incidence of lung cancer is high, while some reports indicate that incidences of gastric and colon cancer are also high. Especially in cases with multiple cancer risk factors, clinicians must be aware of the possibility of multiple cancers.

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Background. We report here a case of synchronous primary lung cancer and follicular lymphoma, in which both diseases were treated with curative intent. Case. A 68-year-old man was referred to our hospital with an abnormal shadow on chest roentgenogram taken at an annual checkup, and a diagnosis of lung cancer was suspected at the referring hospital. In a whole-body physical examination, multiple swollen abdominal lymph nodes were shown besides a lung lesion. Biopsy of the swollen abdominal lymph nodes revealed follicular lymphoma. Next, we performed lung biopsy under bronchoscopy although the lung lesion was suspected to be adenocarcinoma based on a biopsy performed at the referring hospital. The pathological diagnosis of the lung lesion was adenocarcinoma. Consequently, the lung cancer was clinical stage IB and the follicular lymphoma was stage II. The patient underwent a radical operation for lung cancer, followed by chemotherapy for follicular lymphoma. Conclusion. We could accurately diagnose synchronous multiple malignancies (primary lung cancer and follicular lymphoma), based on active biopsy of abdominal lymph node under laparotomy which was an invasive approach. Curative treatment was performed for both diseases.

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Background. When treating malignant pleurisy, we often cannot achieve complete reexpansion of lungs and control pleural effusion even after thoracic drainage. We report a successfully treated case with intrapleural urokinase for loculated malignant pleural effusion and trapped lung. Case. A 56-year old woman. She had left pleural effusion after operation for left breast cancer. Subsequently the pleural effusion increased remarkably, so she was admitted because of dyspnea on exertion. Thoracic drainage and pleurodesis were performed, but pleural fluid loculation and trapped lung remained. For fibrinolysis, urokinase was administered into the thoracic cavity via an thoracic tube. Immediately after the urokinase administration, the multilocular pleural effusion was resolved and complete pulmonary reexpansion was achieved. She underwent pleurodesis again and was discharged. She died of breast cancer 7 months later, but was able to survive without deterioration of her respiratory condition due to pleurisy. Conclusion. Intrapleural urokinase might be one therapeutic approach for trapped lung caused by malignant pleurisy.

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Background. Mucoepidermoid carcinoma of the lung is classified with bronchial adenomas which arise from the bronchial glands. Mucoepidermoid carcinoma is rare, about 0.1% of all lung cancer. Case. A 68-year-old man presented with dyspnea. His chest X-ray showed diffuse hypolucency in the left lung. Because of the ventilation-perfusion mismatch and the worsening of his respiratory status, tracheal intubation was performed. Bronchoscopic examination revealed an occlusive tumor in the left main bronchus and biopsy revealed squamous cell carcinoma. Left pneumonectomy was performed after his general condition had improved. The 31×26 mm tumor occluded the left main bronchus. Postoperative histological examination revealed that this tumor was a mucoepidermoid carcinoma. Conclusion. Mucoepidermoid carcinoma of the lung is classified into bronchial adenomas which arise from the bronchial glands. It is difficult to diagnose preoperatively because of its histological character and low frequency. The overwhelming majority are low grade malignant tumors and behave in a benign fashion, however about 20% of them are high grade malignant tumors. So, when high grade malignant tumor is suspected in postoperative histological examination, careful follow-up is needed.

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