Objective. To evaluate the efficacy and safety of carboplatin (CBDCA) and weekly paclitaxel (PTX) combination chemotherapy in patients with advanced non-small cell lung cancer (NSCLC) . Methods. Retrospective analysis was performed of 191 patients with advanced NSCLC, who had received chemotherapy with CBDCA of area under the curve (AUC) 5-6 (day 1) and 60-100 mg/m² PTX (days 1, 8, 15) every 4 weeks. Results. Chemotherapy was administered in 1-6 courses (median, 3 courses) . The overall response rate was 50%. The median time to progression was 160 days, and the median survival time (MST) was 379 days. Grade 3/4 neutropenia occurred in 77 patients (41%) , and hypersensitivity to the anticancer drugs, pneumonitis and febrile neutropenia were observed in 2 (1%), 3 (2%) and 3 (2%) patients, respectively. We divided subjects into a good-physical condition (PC) group (129) and a poor-PC group (62), and evaluated the efficacy and safety of this chemotherapy. The good PC patients were able to participate in the clinical trial, however, the poor PC patients were not. The MST was 486 days in the good-PC group, and 271 days in the poor-PC group. Overall toxicities were generally equivalent in both groups. However, grade 2 or more fatigue was frequently observed in the poor PC patient group. Conclusion. This regimen can yield a good response, and is safe for patients with advanced NSCLC, especially for patients in good PC. Moreover, it was also useful even for patients in poor PC to prolong their survival.

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Objective. The aim of the present study was to define the clinicopathological features and operative prognosis of patients with primary lung cancer with idiopathic pulmonary fibrosis (IPF). Materials and Methods. Of the patients who underwent surgery for non-small cell lung cancer from January 2006 to January 2008 in our hospital, 94 patients who had been preoperatively evaluated with high resolution computed tomography (HRCT) were enrolled in this study. We retrospectively analyzed 9 patients (9.6%) who were given a diagnosis of IPF based on HRCT findings. Results. The patients with IPF consisted of 8 men and 1 woman with an average age of 74.7 years. All 9 patients had a smoking history. Patients with IPF had tumors located adjacent to the pleura significantly more frequently than in 85 patients without IPF (77.8% vs 36.5%; P=0.02). Pathologically, squamous cell carcinoma, and moderately or poorly differentiated tumors were detected significantly more frequently in patients with IPF than without IPF (55.6% vs 20.0%; P=0.05, 88.9% vs 42.4%; P=0.01). The standardized uptake value (SUV) of F-18fluorodeoxyglucose (FDG) on positron emission tomography (PET) of patients with IPF showed a high average value of 11.1 (range, 3.4-31.6). The Ki-67 labeling index also showed a high average value of 46.1%. Up-staging migration from the clinical stage to the pathological stage was noticed in 4 cases due to underestimation of the tumor diameter in 3 cases and intrapulmonary metastasis in 1 case. Recurrences were observed in 4 of 9 cases. Local recurrence was observed in 2 cases (hilar lymph nodes and mediastinal lymph nodes), and distant recurrence was in 2 cases. Conclusion. As primary lung cancer with IPF seems to have a high potential for malignancy and the preoperative T factor can be often underestimated, we should be cautious selecting limited resection as a curative procedure.

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Background. It is well known that mucoepidermoid carcinoma is an extremely rare subtype of thymic cancer. Mucoepidermoid carcinoma of the thymus complicated by myasthenia gravis has not been reported. Case. The patient was a 62-year-old woman who presented with dysphagia, which was diagnosed as myasthenia gravis. Chest CT showed a tumor 4.5×6 cm in size in the anterior mediastinum. The patient was prescribed prednisolone and pyridostigmine bromide for myasthenia gravis. The myasthenia gravis improved, and chest CT showed a reduction in tumor size. It was suspected the tumor was thymoma. The thymoma and an enlarged thymus were surgically removed by median sternotomy. The pathological diagnosis of the specimen was mucoepidermoid carcinoma of the thymus. Conclusion. Mucoepidermoid carcinoma of the thymus complicated by myasthenia gravis is extremely rare.

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Background. Pulmonary small cell carcinoma sometimes contains other histological tumor elements. In most cases, the other elements are squamous cell carcinoma or adenocarcinoma. It is known, however, that in very rare cases small cell carcinoma can be accompanied by sarcomatous elements. Case. A 54-year-old man presented with cough and dyspnea on exertion, and lung cancer was suspected after chest X-rays. His dyspnea worsened, starting the day prior to admission, and he required artificial respiration management by the day of hospitalization. We conducted bronchofiberscopy by intubation, resulting in a diagnosis of small cell carcinoma. Although chemotherapy was administered, the patient died 14 days after admission. Based on the autopsy results, pulmonary small cell carcinoma combined with limited osteosarcoma and squamous cell carcinoma was diagnosed. Only extremely rarely is pulmonary small cell carcinoma accompanied by sarcomatous elements. Conclusion. We report a case of combined pulmonary small cell carcinoma, osteosarcoma and squamous cell carcinoma.

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Background. Small bowel metastases from primary lung cancer are rare. Case 1. A 61-year-old man was given a diagnosis of lung cancer recurrence (non-small cell lung cancer) 3 months after a lobectomy. He complained of acute abdomen during the chemotherapy. Radiographic examination revealed free air below the right diaphragm. Gastrointestinal perforation was diagnosed. Despite ileum resection, he died of sepsis 3 days postoperatively. Pathological examination of the resected ileum demonstrated a metastatic type 2 tumor with perforation. Case 2. A 72-year-old man was given a diagnosis of lung cancer (non-small cell lung cancer) in stage IV. He complained of acute abdomen with massive gastrointestinal bleeding during chemotherapy. He underwent ileum resection for refractory melena. Pathology of the resected ileum showed a metastatic type 2 tumor with a large ulcer. He died of disease progression of lung cancer 1 month after the operation. Conclusion. To achieve an early diagnosis and treatment of acute abdomen in patients with primary lung cancer, FDG-PET, PET-CT and/or endoscopic examination should be performed for the screening of gastrointestinal metastasis.

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Background. Pulmonary or bronchial mucoepidermoid carcinoma is a rare subtype of lung cancer, and effective treatment has not yet been established for advanced stage cases. Case. A 41-year-old man with headache and back pain was referred to our hospital because biopsy of a right lower jaw tumor had revealed metastatic carcinoma, and computed tomography revealed a right hilar tumor. In our hospital, fiberoptic bronchoscopy showed stricture of the right middle lobe bronchus and sessile polypoid tumor, and a biopsy specimen revealed high-grade mucoepidermoid carcinoma. ¹⁸F-fluorodeoxyglucose positron-emission tomography (FDG-PET) showed abnormal accumulations in the mediastinal lymph node, and liver, bone, skin and muscular lesions. Multiple metastasis was suspected, and it was classified stage IV (cT1N2M1). After receiving chemotherapy with carboplatin and paclitaxel, the metastatic liver and bone lesions worsened. Gefitinib was administered as a second-line therapy, resulting in a partial response. Molecular screening of the tumor identified an EGFR exon 19 deletion mutation. Conclusion. There is sometimes an EGFR mutation among cases of mucoepidermoid carcinoma. This case suggests that EGFR tyrosine kinase inhibitors could be effective for the treatment of mucoepidermoid carcinoma with EGFR mutation.

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Background. Only 2 cases of lung cancer with epipharyngeal metastasis have been reported in Japan. Lung cancer metastasizes to the epipharynx extremely rarely. Case. An 81-year-old woman with a past history of large cell carcinoma of the lung presented with nasal obstruction. Magnetic resonance imaging (MRI) revealed a mass in the epipharynx and a bulky tumor covered with necrotic tissue was found by nasopharyngoscopy. The histology of the epipharyngeal tumor was the same as that of the primary lung cancer. A diagnosis of lung cancer with epipharyngeal metastasis was given. Local radiation therapy dramatically improved symptoms. Conclusion. We reported an extremely rare case of epipharyngeal metastasis from lung cancer 22 months after diagnosis of the primary lesion. Systemic chemotherapy with local control is preferable unless the patient's condition deteriorates.

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Background. There have recently been several reports of paraneoplastic cerebellar degeneration (PCD) coexisting with small cell lung cancer (SCLC). However, there are few reports which describe surgical resection of the primary tumor and changes in regard to neurological symptoms after surgery. Case. A 56-year-old Japanese man suffering from the chief complaints of dizziness, walking disturbance, nausea and dysarthria was referred to the Neurology Department of our hospital, and cerebellar dysfunction was diagnosed. Further examination revealed a tumor nodule in the middle lobe of the right lung. Transbronchial lung biopsy showed the presence of a nodule consisting of small cell carcinoma. There were no metastases in the lymph nodes or other organs. PCD and SCLC (cT1N0M0 stage IA) was diagnosed because the anti-Hu antibody tested positive in his serum and cerebrospinal fluid. A right middle lobectomy with mediastinal lymph node dissection was performed with a complete cancer resection (pT1N2M0 stage IIIA). However, he showed no neurological improvements at one month after the operation. Therefore, intravenous immunoglobulin therapy (IVIG) and adjuvant chemotherapy (CDDP+VP-16) were administered. His neurological symptoms, including the walking disturbance and dysarthria, gradually started improving soon after the administration of IVIG, and his symptoms improved further after chemotherapy, but the patient did not achieve complete improvement. Conclusion. We report a case of SCLC with anti-Hu (+) PCD, which was completely resected. The neurological symptoms did not improve after the operation, but a gradual improvement was observed following IVIG and adjuvant chemotherapy. However, complete neurological improvement was not obtained.

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Background. Although germ cell tumors have a high sensitivity to anticancer drugs, it is not always easy to complete chemotherapy without some delay. We report a case of germ cell tumor (embryonal carcinoma) accompanied by an abscess caused by bacterial infection in a metastatic lung tumor. Chemotherapy was completed and complete remission obtained through long-term administration of antibiotics and drainage of the lung abscess. Case. A 37-year-old man was referred to our hospital with pyrexia and dyspnea, and lung cancer was suspected at the referring hospital. A chest X-ray film showed a 10-cm mass with a cavity and an air-fluid level in the left lower lung field and multiple nodular shadows in the bilateral lungs. Immunohistologically, the tumor was demonstrated to be embryonal carcinoma, positive for CD30 and placental alkaline phosphatase (pALP). At the same time, bacterial infection of the cavitary lesion was demonstrated. Continuous drainage and administration of antibiotics was performed and 4 courses of BEP therapy (bleomycin+etoposide+cisplatin) were started. Finally, complete remission was obtained. Conclusion. Chemotherapy for a germ cell tumor can be effective, using adequate management for infection, even if it is accompanied by severe bacterial infection like a lung abscess.

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Background. Stereotactic body radiotherapy (SBRT) is a therapeutic option for stage I lung cancer, but local recurrence after SBRT can occur. This report presents a resected case of local recurrence after SBRT. Case. A 62-year-old woman with left back pain was found to have a huge mass in the left retroperitoneal space adjacent to the adrenal gland and was referred to our hospital. The mass was diagnosed as diffuse large B-cell lymphoma by needle biopsy. Chest CT revealed a tumor (2.5 cm in diameter) in the right lower lung field, which was diagnosed as pulmonary adenocarcinoma by transbronchial biopsy. Because the left retroperitoneal lymphoma was very large (8 cm in diameter) and she had severe systemic symptoms of lymphoma (high fever, fatigue and appetite loss), chemotherapy for lymphoma [8 courses of rituximab plus CHOP (R-CHOP)] preceded lung cancer therapy. During lymphoma therapy, another systemic review was performed and the lung cancer was same size and then diagnosed as T1N0M0 stage IA. Because of her residual lymphoma and continuance of chemotherapy, general weakness (ECOG performance status 2) and pancytopenia due to the chemotherapy, surgical resection was avoided and SBRT (48 Gy) was performed for the lung cancer after R-CHOP was completed. Thereafter, 3 courses of CHOP were administered, and complete response (CR) was obtained, and also there was no recurrence of lung cancer. About 3 years later, multiple small nodules were detected around fibrosis in the right lower lobe on chest CT; needle biopsy revealed local recurrences of lung cancer. A right lower lobectomy was performed (pT4N0M0 stage IIIB), as the lymphoma remained in CR and her preoperative examination results were normal. Her postoperative course was uneventful and she had no recurrence for 10 months after the operation. Conclusion. Although SBRT is a powerful therapeutic option for stage I lung cancer, especially for patients who are not indicated for surgical therapy, local recurrence after SBRT can occur in some cases; therefore, thorough follow-up is necessary.

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Background. Meningeal carcinomatosis is a poor prognostic state which sometimes diagnosed in patients with advanced cancer, and shows varied neurological symptoms not limited to those of typical meningitis. It is sometimes hard to establish an accurate diagnosis because an identifiable mass lesion is not always visible on radiological examination. Case. A 56-year-old Japanese man underwent left lower lobectomy and adjuvant chemotherapy for treatment of stage IIIA lung adenocarcinoma. Nine months postoperatively, he experienced right hearing loss, followed by left facial nerve palsy. Eleven months postoperatively, he was admitted to hospital because of progressive left hearing loss, temporary loss of consciousness, amnesia, incontinence, and other symptoms. A tiny metastatic lesion was found on the brain surface of the temporal lobe on cranial MRI. His cerebrospinal fluid was examined, and a diagnosis of meningeal carcinomatosis was established. He deteriorated rapidly and died 13 months postoperatively. Conclusion. This report describes a rare case of meningeal carcinomatosis diagnosed by clinical course, cranial MRI findings, and biochemical examination of the cerebrospinal fluid, showing a variety of neurological symptoms, including hearing loss and facial nerve palsy, without distant metastases to other organs.

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Background. Primary synovial sarcoma of the lung is an extremely rare neoplasm. Case. When a 61-year-old man visited our hospital for follow-up of angina pectoris, a nodule was found in the left middle lung field on the chest X-ray film. Uptake was seen only in the pulmonary nodule on fluoro-deoxyglucose (FDG)-PET CT, with no uptake in other regions. Because this case was considered to be sarcoma with limited lung resection, a left upper lobectomy was performed. Histologically, a dense proliferation of spindle cells was seen. These cells stained positively for bcl-2 protein and CD99 and partially for vimentin and S-100 protein. SYT-SSX-1 fusion gene transcripts were detected by reverse transcription polymerase chain reaction (RT-PCR). There was no evidence of tumor of the limbs on physical examination. As a result, we diagnosed primary synovial sarcoma of the lung. Conclusion. We experienced a case of primary synovial sarcoma of the lung.

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In the pathological diagnosis of lung cancer, macroscopic findings are as important as microscopic findings. The macroscopic view of tumors largely corresponds to their histologic architecture; it is also reflected in radiographic and other tumor images. In this article, the characteristics of various histologic types of lung cancer are reviewed, with emphasis on their histologic architectures. Neoplastic lesions and tumor-forming lesions that may be involved in the differential diagnosis of lung cancer were briefly reviewed.

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Positron-Emission Tomography (PET)/Computed Tomography (CT) is a built-in device in which PET and CT are arranged linearly. Because both PET and CT are performed with the patient in the same position, anatomical misregistration of the image is minimal. This device has two merits. One is the shortening of the examination time with improvement in image quality, achievable by using CT as a transmission scan. The other merit is the ability to obtain precise CT and PET fusion images. Fusion images obtained by PET/CT are more accurate than single modality, because they both has the excellent spatial resolution of CT and the prominent contrast resolution of PET. PET/CT is useful not only for clinical diagnosis, but also for developing the new application for 3-dimensional imaging modalities, such as radiation therapy planning, virtual bronchoscopy, or virtual mediastinoscopy, that are not possible by using PET alone. Various research and developmental progress is ongoing in the field of the hardware and software of the PET/CT, in addition to radiopharmaceutical aspect, and PET may be one of the most promising tools for diagnostic imaging in the future.

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This paper is an overview of chest X-ray, focusing on peripheral lung cancer.

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