Background. Recently, much attention has been paid to patient-reported outcomes (PRO) as self-administered assessment instruments in the quality of life evaluation of cancer patients. Objective and Methods. In the present study, we reviewed a total of 24 published articles (1999 through 2007) which reported phase III clinical trials for non-small-cell lung cancer, all of which set PRO assessment as one of the study endpoints. We evaluated the questionnaires used for PRO assessment, assessment intervals and patient compliance with PRO assessment in each trial. Several kinds of questionnaires were used in most PRO assessment trials. Results. The European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) was used in 17 out of 24 trials. PRO was commonly assessed before each course of chemotherapy, at the end of chemotherapy and 1-3 months after treatment cessation. Patient compliance at the final assessment had significantly deteriorated compared with baseline PRO assessment, presumably due to the increment of missing data. Conclusion. Further studies which evaluate the problems of PRO assessment as a surrogate marker of therapeutic efficacy in lung cancer patients are warranted.

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Objectives. There are many studies and case reports of pulmonary pleomorphic carcinoma (PC), but few published autopsy studies. The purpose of this study was to determine the clinicopathological characteristics of PC through an investigation of autopsy cases. Methods. We collected and investigated the clinicopathologic features of 5 cases, in which PC was diagnosed at autopsy in our institution between January 2005 and December 2006. Results. All cases were men, with a median age of 69 years (range, 60-91), and a median smoking index of 45 pack-years (range, 21-112.5). In 3 diagnosis was obtained by transbronchial biopsy and the remaining 2 by pleurocentesis, while initial histological examination reported either adenocarcinoma or large cell carcinoma, not PC. One patient was clinical stage IIB, 2 were stage IIIB, and 2 were stage IV. Three received either chemotherapy or chemoradiotherapy, but with no benefit, and their median survival time was 72 days (range, 8-180). Autopsies revealed metastases in the small intestine in 2 cases, in the spleen in 1, and in the kidney in 1 case. These are considered rare metastatic sites of lung cancer. In all cases, ratio of carcinomatous and sarcomatous component and morphologic features of the metastatic lesion were similar to those of the primary lesion. Conclusions. To diagnose PC accurately by biopsy and cytology alone is very difficult, and therefore frequency of PC may be higher than previously reported. More findings from autopsy cases should be collected to determine the clinicopathological characteristics of PC.

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Background. Local therapy for metastatic or recurrent lung cancer lesions is usually available only as palliative therapy. In particular, the surgical resection of metastatic foci is contraindicated in cases with unresectable lung cancer unless the primary site is well-controlled. Case. A 68-year-old man with adenocarcinoma in the right pulmonary hilum (stage cT2bN1M0), was treated with chemoradiotherapy because of poor pulmonary function in October, 2000. Combined treatment resulted in partial response, therefore, low dose cisplatin, tegafur and uracil were administered as consolidative therapy. In May, 2001, however, serial CT examinations revealed a rapidly growing tumor in his spleen. Splenectomy was performed to prevent rupture of the spleen, and pathological examination showed metastasis from lung cancer. Two months later, metastasis in the right inguinal lymph node was found and resected. The right inguinal metastasis occurred again in August, 2002, but the lesion disappeared quickly after 30 Gy irradiation therapy. After the detection of metastases at the inguinal lymph nodes, gefitinib was given as an adjuvant therapy, but a new metastatic lesion was found in the paratracheal region of the mediastinum in August, 2003. The metastatic tumor was surgically removed because of no apparent invasion to the neighboring organs including the great vessels or the trachea. The patient is alive and disease-free as of September, 2009. Conclusion. In a case of locally advanced non-small cell lung cancer which was well-controlled by chemoradiotherapy, local therapeutic strategies, including irradiation and surgical resection for multiple but metachronous metastatic foci, resulted in a significant prolongation of survival. Local treatment may be selected for curative purposes when the primary site is well-controlled. Surgical resection need not be avoided if the lesion is resectable and the patient can tolerate the surgical intervention.

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Background. Calcification in a primary lung carcinoma or its metastases is considered to be uncommon. In general, calcification findings at targeted sites suggest that the disease is benign. Case. A 71-year-old woman underwent right lower lobectomy in 1987, resulting in a pathological diagnosis of pIIIA (T1N2M0) lung adenocarcinoma. She received adjuvant chemotherapy and radiotherapy. In November 2005, chest computed tomography (CT) revealed a bilateral ground glass pattern, and cryptogenic organizing pneumonia was suspected. The CT image also showed slight swelling of the mediastinal and abdominal lymph nodes with massive calcification. Subsequently, old tuberculous lymphadenitis was suspected, and the patient underwent regular follow-up. By October 2007, mediastinal and abdominal lymph nodes were clearly enlarged with calcification. Biopsy of the abdominal lymph nodes was performed, and histopathological examination showed adenocarcinoma with psammoma bodies. Immunohistochemical staining for several specific markers, including thyroid transcription factor-1 (TTF-1) demonstrated that the lymph node lesions were metastases from the lung adenocarcinoma. From December 2007, the patient received chemotherapy with carboplatin and paclitaxel, and the size of the lymph nodes decreased significantly. However, the calcification remained. Conclusion. When enlarged lymph nodes are found, even with massive calcification, regular follow-up or pathological diagnosis is needed, especially for a patient with a past history of malignant disease such as lung cancer.

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Background. The mechanism underlying cavitation in primary lung cancer has not yet been determined. We describe the mechanism of cavitation and treatment for cases complicated by inflammation with some reference to the literature. Case 1. The patient was a 70-year-old man whose chest X-ray film showed an abnormal shadow in the left hilum. Squamous cell carcinoma was diagnosed by transbronchial lung biopsy (TBLB). Cavitation occurred in the tumor and aspiration pneumonia developed. Left lower lobectomy with wedge resection of S¹⁺² was performed 7 days after TBLB. Case 2. The patient was a 60-year-old man who complained of productive cough and whose chest X-ray film showed an abnormal shadow with cavity formation in the right hilum. Squamous cell carcinoma was diagnosed by TBLB. Subsequently, blood was observed in the sputum and his fever became exacerbated. Right lower lobectomy was performed 15 days after TBLB. Case 3. The patient was a 64-year-old man whose chest X-ray film showed an abnormal shadow with cavity formation on a medical examination. Squamous cell carcinoma was diagnosed by transbronchial biopsy (TBB). Subsequently, his sputum become mucopurulent and his fever worsened. Left pneumonectomy was performed 26 days after TBB. Conclusion. In these 3 cases, cavitation occurred after bronchoscopy. Therefore, we hypothesize that the pulmonary cavities in these patients were mainly caused by ischemic necrosis and a check-valve mechanism. In addition, we consider it important to prescribe appropriate antibiotics and perform prompt surgery in cases complicated by inflammation.

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Background. Pulmonary pleomorphic carcinoma is an aggressive tumor with a poor prognosis. The preoperative diagnosis of this carcinoma is difficult, and thus far, no optimal treatment modality has been established. Case. A 43-year old woman visited a local hospital with unbearable pain extending from the right axillary region to the back in July, 2007. Chest radiography showed an abnormal shadow in the right upper lung field. She was referred to our hospital for further evaluation. Computed tomography of the chest showed an ill-defined 6-cm mass with surrounding ground-glass opacity, accompanied by thickening of the interlobular septa in the right upper lobe of the lung, which invaded the right posterior chest wall. Transbronchial biopsy revealed the possibility of sarcomatoid carcinoma composed of carcinoma cells including giant cells. Systemic examination of the patient did not reveal distant metastasis. The mass was diagnosed as pulmonary pleomorphic carcinoma and the cancer stage was identified as IIB (cT3N0M0) preoperatively. Subsequently, the patient was given preoperative concurrent chemoradiotherapy [radiation therapy (RT), 40 Gy/20 Fr and 3 cycles of chemotherapy with cisplatin (80 mg/m² on day 1) and vinorelbine (20 mg/m² on days 1, 8)]. CT revealed that the thickening of the pleura of the right posterior chest wall remained but the solid tumor with surrounding ground-glass opacity in the right upper lobe of the lung had almost completely disappeared. Therefore, preoperative concurrent chemoradiotherapy was considered to have obtained a partial response. We performed right upper lobectomy of the lung, chest wall resection from the 3rd to the 6th rib, and lymph node dissection (ND2a); reconstruction of the chest wall was performed using a Composix Mesh. Postoperative pathological examination revealed residual tumor in the bone, muscle, thickened pleura and lung in the region between the 4th rib and 4th intercostal muscle of the right side. Since there were no complications, the patient was discharged on the 10th postoperative day. The patient is currently alive at 27 months after the operation without signs of recurrence. Conclusion. We report a case of pulmonary pleomorphic carcinoma treated with concurrent chemoradiotherapy followed by successful resection of the tumor. Combined therapy including surgery and chemoradiotherapy for pulmonary pleomorphic carcinoma is important to obtain good outcome, however, further study of similar cases is required.

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Background. Multilocular thymic cyst (MTC) is relatively rare. We report a case in which malignant disease and immunological disease coexisted. Case. A 60-year-old woman who had been followed up for mixed connective tissue disease (MCTD) in the Department of Internal Medicine in our hospital, had an anterior mediastinal tumor pointed out on chest CT in 2006. The tumor was suspected to be thymoma because of its tendency to increase in size. Resection was performed via median sternotomy in 2008. She underwent thymectomy because the tumor had multilocular cysts and severe adhesion to mediastinal pleura. This tumor was diagnosed as a case of MTC associated with follicular lymphoid hyperplasia. Conclusion. We report a rare case of MTC with MCTD. There are no clear guidelines regarding the optimal operative procedure for MTC in the present case, because MTC is rare.

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Background. Capillary hemangioma is very rare, particularly in the lung. We report a case that was suspected to be lung cancer, based on chest CT findings, but was pathologically diagnosed as capillary hemangioma of the lung. Case. The patient was a 45-year-old man. A small nodular shadow was incidentally identified in the left lower lung on the left diaphragm on a chest radiograph during a comprehensive medical checkup. A small nodule, 1 cm in diameter was recognized in the left S⁹b on chest computed tomography (CT), and lung cancer was suspected. Positron-emission tomography CT was performed, but did not reveal any marked uptake in the tumor or in any lymph nodes. The preoperative diagnosis was benign tumor, but we were unable to definitively exclude early lung cancer, and partial resection was performed using video-assisted thoracoscopy. On pathological examination, the lesion was a blackish-brown, solid, borderless tumor, measuring 9 × 4 mm. Many dilated capillary vessels were growing densely in the tumor, and as no malignancy was apparent it was diagnosed as capillary hemangioma of the lung. The postoperative course was uneventful. Conclusion. Solitary capillary hemangioma of the lung is very rare, particularly in adults. We report a case with reference to the literature regarding discrimination of early lung cancer and pulmonary capillary hemangiomatosis, which has similar pathological findings.

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One way to understand the typical CT findings of lung cancer is to classify the images into 4 histological types: adenocarcinoma, squamous cell carcinoma, small cell carcinoma and large cell carcinoma. However, lung cancer often consists of various histological components. Therefore, we think that an easier way is to determine the typical findings of lung cancer images, and then determine its usual histological type. Here, we demonstrate typical CT images found at the margin of a peripheral lung cancer nodule showing spiculation, pleural indentation, vessel convergence and notch formation, showing nodule appearance (ground-glass opacity, bubble-like area and cavity formation), and showing central lung cancer (hilar mass with secondary obstructive changes, and a mass adherent to lymph nodes).

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Integrated FDG-PET/CT (¹⁸F-fluorodeoxyglucose positron emission tomography) is routinely used in the diagnosis of primary lung cancer. FDG-PET/CT plays an important role in the diagnosis of pulmonary nodules, mediastinal lymph nodes, distant metastasis, and recurrence. Although FDG-PET has high sensitivity for malignant pulmonary nodules, false-negative PET images can occur for low-metabolism tumors such as well-differentiated adenocarcinoma and bronchioloalveolar carcinoma. The main reason for a false-positive diagnosis of pulmonary nodules is inflammatory conditions. Granulomatous inflammation in benign lymph nodes can cause increased FDG uptake, which can be indistinguishable from malignancy. Because the resolution of PET is limited, distinction of nodal metastasis from small-sized lymph nodes may be overlooked. One of the advantages of PET/CT is its ability to evaluate the whole body and to detect unexpected extrathoracic metastasis. PET/CT is also useful in the diagnosis of recurrence during follow-up. However, though FDG-PET/CT is a highly accurate imaging modality, it has diagnostic limitations. It is essential to interpret and evaluate PET/CT images from both metabolic and morphological aspects.

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Imaging findings of diffuse pleural mesothelioma (DPM) include irregular thick pleural thickening extending to the mediastinal side and multiple pleural masses extending along the chest wall. The major roles of imaging evaluation in the diagnosis and treatment of DPM are the differential diagnosis between neoplastic pleural thickening including DPM and inflammatory thickening, and evaluation of staging and treatment effect. A differential diagnosis between DPM and inflammatory pleural thickening, or DPM and pleural dissemination of other malignant tumors appears impossible based only on imaging findings. Histopathologic investigation is necessary to differentiate DPM from pleural dissemination of other malignant tumors such as bronchogenic carcinoma, unless the primary site is evident. We described current knowledges of imaging findings of DPM, recent advance of imaging diagnosis including the use of ¹⁸F-fluorodeoxyglucose emission CT (FDG-PET), and the usefulness and limitations of imaging diagnosis.

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