We reviewed 59 cases of lung cancer patients with the tentative diagnosis of c-N2 under preoperative computed tomography, later negated by mediastinoscopic examination. Furthermore, we reviewed the results of mediastinoscopic examinations of all c-N2 cases in our hospital.
The numbers of p-n0, 1, and 2 patients with c-N2, mediastinoscopically negative lung cancer were 31, 18, and 10 respectively. Of 59 lung cancer patients with c-N2 by CT, 49 cases (83.1%) were negated p-n2 by mediastinoscopic evaluation.
In p-n0 and 1 cases, silicotic change, sarcoid reaction, and tuberculous change were found histopathologicaly in nodal specimen in 6, 3, and 1 cases, respectively. Nine cases were complicated by obstructive pneumonia and each one case was complicated by pulmonary tuberculosis, atypical mycobacterial disease, silicosis, and interstitial pneumonitis. However, 26 cases were not complicated by any specific diseases other than lung cancer, which might have been the cause of lymph node swelling.
Among p-n2 cases, 2 of them were failed to confirm metastasis to mediastinoscope accessible level.
Sensitivity, specificity, accuracy, negative predictive value, and positive predictive value of mediastinoscopic evaluation in c-N2 lung cancer patients was 97.7%, 100%, 98.4%, 94.9%, and 100%, respectively.
To avoid unnecessary treatment, the selection of operation or induction therapy should be carefully decided. In this point, mediastinoscopic examination is useful for histopathological diagnosis of mediastinal lymph node metastasis, especially in c-N2 cases, in spite of disadvantages such as the limitation of accessible area.

View full abstract

Application of SNNS to peripheral type primary lung cancer was investigated by fluorescent beads, which are fluorescent polystyrene latex microspheres (Polyscience Inc., USA), as a new tracer in a pig . After the injection of 0.2-1.0μm fluorescent beads into subpleural lung tissue of the right upper lobe, right lower lobe and left upper lobe, drainage to regional lymph nodes was observed for 30 minutes under ultraviolet radiation of 365 nm . Fluorescence was detected around the peribronchial lymph nodes in six of the seven trials (86%). Characteristically, afferent lymph channels facing the sentinel lymph nodes were also clearly seen before the beads reached them . The fluorescent beads could be identified, allowing quantitative analysis, even in the lymph nodes with severe anthracosis. Evaluation was somewhat obscure through the thick capsule of the lymph nodes, however it became possible upon observation of the cut surface. As for the adverse effects, fluorescent beads were extracted from neither the blood nor the urine until three hours after the injection, suggesting that almost all beads remained in the resected specimen .Additionally, injection of fluorescent beads in the tail vein of rats produced neither the acute toxicity nor pathological alteration on microscopy of the lung, liver, and kidney after three weeks.

View full abstract

Objective: If an air leakage from a resected lung surface persists, patients sometimes have to undergo a reoperation. We evaluated the effectiveness of a methods we developed for intrapleural administration of diluted fibrin glue. Methods: Fibrin glue was diluted 4-fold with saline and/or contrast media. Pleurodesis with a large amount of the diluted fibrin glue was performed in 25 patients with intractable pulmonary fistula after thoracic surgery. Results: The air leaks were stopped by the administration of the glue in all except 2 patients, and recurrence was not seen. Pyrexia (7.4%) and chest discomfort (11.1%) were observed as side effects, but there was no occurrence of severe chest pain or thoracic empyema. Conclusions: These results suggested that intrapleural administration of a large amount of diluted fibrin glue for intractable pulmonary fistula after thoracic surgery is an effective treatment for post-surgical intractable pulmonary fistula.

View full abstract

We retrospectively studied the usefulness of pedicled omentum in the management of thoracic problems.
From 1998 to 2001, 23 patients (19 male and 4 female, mean age 65.1 years) underwent omentoplasty for the management of thoracic problems in our hospital. They consisted of 19 patients with empyema and/or bronchopleural fistula (chronic empyema 10, postoperative empyema 6, late bronchopleural fistula 3), 2 patients with non-infective fistula (lung 1, esophagus 1), and 2 patients with preventive reinforcement of bronchial stump/ anastomosis. Of 19 patients with empyema 16 had airleak. Eleven patients underwent omentoplasty after staged thoracostomy, 5 underwent omentoplasty after infection control with tube drainage, and 3 underwent omentoplasty with active infection.
Fifteen of 19 patients with empyema and/or bronchopleural fistula achieved closure of the thorax with infection control. The patients with non-infective lung parenchimal fistula and preventive reinforcement of the bronchial stump/anastomosis obtained freedom from airleak, while the patient with non-infective esophageal fistula was unsuccessful. The main causes of failure in the 4 patients with empyema who required thoracostomy were ischemia of the pedicled omentum and residual infection. Abdominal complication occurred in 2 patients (8.7%); one was perforating peritonitis and the other was strangulating intestinal obstruction, both of which required enterectomy.
Omentoplasty is effective in the management of thoracic problems, however, it remains ineffective in some patients with empyema and contains some complications. Attention should be paid to the transposition of pedicled omentum. It is preferable to use omentum for empyema after infection control.

View full abstract

The malignancy status of 37 stapled-resected peripheral non-small cell lung cancers were compared between those resected using a stapler with an aggressive clamp (AC) and a stapler with less traumatic jaw closure (LTJC). The margin was diagnosed by cytology (run-across method) and histology. Type of stapling method, maximum tumor diameter (MTD), distance from the surgical margin to the tumor (MD), invasion of malignant cells to the lymph duct and location of the tumor were chosen as variables. There were no statistical differences in MTD, MD or location of the tumor. However, the ratio of positive malignancy in the surgical margin was 10/19 (53%) in the AC group and 2/18 (11%) in the LTJC group (p=0.013). A logistic regression test revealed that both the type of stapling method and invasion of malignant cells to the lymph duct were statistically significant using a multivariate analysis. The LTJC type stapling method showed less potential for positive malignancy in the surgical margin than the AC method, which might present a greater risk of surgical margin relapse.

View full abstract

A 46-year-old female was admitted because of chest pain. Chest X-ray and thoracic computed tomography showed masses located in the anterior mediastinum and the sternum. A needle biopsy of the anterior mediastinal mass revealed undifferentiated carcinoma. On June 5, 1997, the sternal tumor including marginal tissue was resected and the anterior mediastinal tumor was removed with the combined resection of the thymic tissue, the upper lobe of left lung and the left brachiocephalic vein. A chest wall defect was reconstructed by means of a pedicled rectal abdominal muscle flap.rThe pathological diagnosis was an undifferentiated thymic carcinoma. After the surgery, she was treated by systemic chemotherapy and mediastinal irradiation. Two years after the operation, a solitary metastasis of the right tibia was pointed out. She was treated by radiation therapy, then had gotten complete remission. Thymic carcinoma has a poor prognosis, but this patient has survived without another recurrence since that metastasis was found.

View full abstract

Case Report: Case 1 was a 44-year-old female. After antileukemic chemotherapy, antibiotic and antifungal therapy, because pulmonary aspergillosis was suspected due to characteristic CT image, had continued toward lung tumor with fever, but the size of the lung tumor was unchanged. Thus, right lower lobectomy and chest wall resection were performed. Case 2 was a 73-year-old female. Though antibiotic and antifungal therapy toward pneumonia and pleuritis following antileukemic chemotherapy was done, she suffered intrathoracic infection with peumothorax. Therefore, decortication and right S⁸ wedge resection were performed. In both cases, after operations, pulmonary aspergillosis was diagnosed pathologically and the infection could be controlled without major complications. Therefore, surgical resection can be an effective therapy for pulmonary aspergillosis after antileukemic chemotherapy.

View full abstract

A 46-year-old male was diagnosed as having right lung cancer and underwent right pneumonectomy and lymph node dissection. Although the histological diagnosis was poorly differentiated adenocarcinoma, large cell carcinoma was also observed. After the surgery, the patient complained of epigastralgia, and gastrofiberscopy showed an elevated lesion whose top was slightly depressed on the greater curvature of the lower body of the stomach. A specimen obtained by endoscopic mucosal resection showed poorly differentiated tumor cells. Two months after pneumonectomy, laparotomy was done on suspicion of stomach metastasis. Surgical findings showed another tumor in the jejunum, so gastrectomy and partial resection of the small intestine were performed. Histological diagnosis was metastases to the stomach and small intestine from lung cancer, because large cell carcinoma was observed mainly deeper than the submucosa. Two months after gastrectomy, brain metastasis was revealed, and then bone and hepatic metastases were detected, and he died at 8 months after pneumonectomy.
Although lung cancer with gastrointestinal tract metastasis is rare, its prognosis is poor, so it is important to determine the treatment strategy carefully.

View full abstract

Gefitinib (IRESSA) is an orally active, selective epidermal growth factor receptor tyrosinekinase inhibitor which has shown tumor regression in patients with advanced non-small cell lung cancer (NSCLC) and has been approved only in Japan. This is a molecular target drug and its adverse events had been reported as “generally mild”, however, severe interstitial lung disease (ILD) has been diagnosed in some patients. In the present case, cough and exertional dyspnea appeared on the 51st day after starting gefitinib. Although this patient was treated with steroid pulse therapy under respiratory control, he died from ILD on the 50th day after initial symptom appeared. The chest X-ray and CT showed bilateral distribution of diffuse ground glass opacities and we diagnosed “interstitial pneumonia”. In the lung autopsy, we detected usual interstitial pneumonia (UIP) with organized diffuse alveolar damage (DAD). A final diagnosis of ILD induced by gefinitib was made on March 26, 2003. Frequent evaluation of the respiratory system is strongly recommended during the first 2 months after starting gefitinib. Investigation into the mechanism of ILD is urgently needed, and the selection of responders/non-responders as well as efficient individual medical treatment is desired.

View full abstract

Neurofibroma originating from the intrathoracic vagal nerve is rare. We present a case of neurofibroma originating from the intrathoracic vagal nerve in a 39-year-old man with von Recklinghausen's disease admitted for an abnormal shadow on chest X-ray. Chest X-ray revealed a mass shadow in contact with aortic arch. Chest MRI revealed a mass shadow along the left vagal nerve. The patient underwent operation under the clinical diagnosis of neurogenic tumor originating from the intrathoracic vagal nerve. The tumor was located lengthways near the origin of recurrent nerve and was resected with a segment of the vagal nerve and recurrent nerve. The tumor measured 8×4×3cm, macroscopic cross section appearance of the tumor was milky-whitish and solid, and histological examination of the specimen revealed nurofibroma. There was no evidence of malignancy.

View full abstract

A 62-year-old man, who was bedridden after cerebral infarction was referred to our hospital because of recurrence of right pneumothorax. After chest tube drainage and two unsuccessful attempts at chemical pleurodesis, we performed pneumoperitoneum under local anesthesia on the 8^th hospital day. Just after the pneumoperitoneum, the rise of the right hemidiaphragm was obtained, and residual intrathoracic air spaces and air leaks ware remarkably improved. Chest drainage tube was removed 14 days after the operation without any complications. We concluded that pneumoperitoneum is an effective and safe method to treat problem of prolonged air leaks with large residual intrathoracic air spaces.

View full abstract

We herein report a resected case of esophageal GIST, in which the preoperative determination of original site was difficult due to its large size and location. The patient was a 58-year-old man. A chest computed tomographic scan revealed a solid tumor, 13 cm in size, in the right posterior mediastinum. The preoperative diagnosis was a posterior mediastinal tumor with rapid growth. During the operation, since the tumor was connected with the esophagus, subtotal resection of the esophagus including complete resection of the tumor and partial resection of lung was performed. Reconstruction was done by stomach tube via an anterosternal route.
Histologically, the tumor was composed of spindle cells forming an irregular pattern with moderate cellularity. Some mitotic figures (2/50HPF) were seen. Immunohistochemically, the tumor cells were positive for CD34 and c-kit. Therefore, the tumor was diagnosed as esophageal GIST, uncommitted type. Karyotypic data identified cytogenetically as follows: 47-48, XY, + mar1×2 [cp6] /47-48, idem, add (5) (p15) [cp4]. Based upon such evidence as the tumor size (over 10cm) and chromosome aberration seen in malignant GISTs, it was considered that the tumor had malignant potential.

View full abstract

A 19-year-old female victim of a traffic accident was admitted to our hospital with fractures of the left ribs and pelvic bone, left hemothorax, left pulmonary contusion and injuries to the left kidney and spleen. The patient showed left chylothorax on the 8th day, hemopericardium 2 months later, and eventually manifested diaphragmatic hernia 4 months after the injury. This case illustrates chylothorax and rupture of the pericardium as rare but possible complications of rupture of the diaphragm after blunt chest trauma.

View full abstract

A 17-year-old male was admitted because of orthopnea and chest CT and MRI revealed a giant tumor mass infiltrating bilateral lungs, SVC and pericardium in the anterior mediastinum. We performed an emergency percuaneous tumor biopsy but could not obtain diagnosis. His condition worsened to cardiac tamponade due to acute growth of the giant mediastinal tumor. We performed emergency operation for reduction of the tumor by clamshell incision. Histological examination comfirmed malignant B cell lymphoma. Clamshell incision is a useful approach for giant mediastinal tumor considering the operative viewing and safety compaired with median or anterolateral incision.

View full abstract

We report a case of tracheal bifurcation injury with destruction of carinal cartilage in association with blunt chest trauma. A 29-year-old male truck driver arrived at the emergency room of a local hospital with subcutaneous emphysema of the neck. His truck crashed into a larger truck from behind after he fell asleep at the wheel. He was unrestrained and hit his mid-chest hard on the wheel. He was diagnosed with a tracheal bifurcation injury and was brought to our university hospital. Chest roentogenogram and CT showed pneumomediastinum. Preoperative flexible bronchoscopy showed a laceration of ∅8 mm at the carinal cartilage of the tracheal bifurcation, through which air bubbles came in and out. This was repaired by complete carinal resection followed by montage-type carinoplasty, since we were afraid that simple repair of the laceration with debridement may have resulted in dehiscence of the suture line or airway stenosis by hypertrophic granulation. The patient was discharged on the 29th postoperative day without any anastomotic problems. There has been no report to our knowledge of carinal resection and reconstruction for a tracheal bifurcation injury. We propose that for a tracheal bifurcation trauma with a widespread destruction of carinal cartilage carinal resection and reconstruction should be selected over simple repair with debridement.

View full abstract

A 70-year-old woman complaining of cough was admitted to our hospital. Chest X-ray and CT demonstrated a tumor, 3.5cm in diameter, on the left S⁶ and swelling of lt. hilar lymph node. A transbronchial biopsy from the S⁶ tumor revealed adenocarcinoma. On October 31, 2001, the patient underwent left lower lobectomy and regional lymph node resection. Pathological examination showed that the pulmonary tumor was moderately differentiated adenocarcinoma (p-T2NOMO stage IB) and the hilar lymph nodes (#10, #11, #12) showed small cell carcinoma (p-TON1M0 stagell A). The patient received adjuvant chemotherapy and is well without recurrence 22 months after surgery.

View full abstract

We report the case of a 43-year-old male with pulmonary nontuberculous mycobacteriosis with bronchial anomaly. He was diagnosed with pulmonary nontuberculous mycobacteriosis and received treatment with mycobacterial chemotherapy in the past, but abnormal shadow was revealed again on chest X-ray. It was observed for a while, but did not improve, so he was admitted to this hospital for treatment. On admission we found a bronchial anomaly on chest CT. Since pulmonary nontuberculous mycobacteriosis with bronchial anomaly is rare, we present the case together with a literature review.

View full abstract