We studied clinicopathological characteristics in 6 patients with coexistence of pulmonary hamartoma and primary lung cancer. Furthermore, we present a patient with pulmonary hamartoma in whom the development of primary lung cancer could be observed. Primary lung cancer was found in 6 (25.0%) of 24 patients with resected pulmonary hamartoma. All of the 6 lung cancer patients with pulmonary hamartoma were resected simultaneously. In 4 of these 6 patients (66.7%), both lesions existed in the same lobe of the lung. Six pulmonary hamartomas were composed of cartilagenous tissue without malignant findings, while four patients had adenocarcinomas and 2 patients had squamous cell carcinoma simultaneously. Several authors have argued the increased risk of lung cancer in patients with pulmonary hamartoma. Our finding also showed a similar tendency. Although little is known about a clear mechanism for the higher risk of lung cancer in patients with pulmonary hamartoma, patients with pulmonary hamartoma should undergo a sufficient evaluations and regular follow-up.
Pulmonary high-grade neuroendocrine tumors (NET) include large-cell neuroendocrine carcinomas (LCNEC) and small-cell lung carcinomas (SCLC), which are difficult to differentiate histologically. We investigated the postoperative outcome and histopathological characteristics of 17 patients with stage I high-grade NET. Seven of the 17 patients died within 15 months after surgery, while the other 10 patients survived for 25-145 months without recurrence. The patients were thus divided into an early death group and a long-term survivor group, and their histopathological differences were investigated. The tumors in the early death group patients comprised mainly undifferentiated tumor components lacking any special structure, whereas many of the long-term survivor group patients had tumors that showed neuroendocrine differentiation or other carcinomatous differentiation such as adenocarcinoma and squamous cell carcinoma. In addition, the early death group patients' tumor specimens showed significantly higher numbers of mitotic figures and higher MIB-1 labeling indexes compared with the long-term survivor group patients' tumor specimens. These results indicate that, even if LCNEC and SCLC are handled together as high-grade NET, the prognosis of the disease in individual patients can be predicted on the basis of the morphological findings.
Fifty-two thymoma patients treated in Osaka City University Hospital from 1986 to 2005 were classified according to World Health Organization (WHO) classification and Masaoka's classification, and analyzed for surgical procedures, postoperative treatment and prognosis retrospectively. There were 25 patients with stage I, 13 with stage II, 9 with stage III, 2 with stage IVa, and 3 with stage IVb according to Masaoka's classification. The 5-year survival rate was 100% for stage I, II, and III, 50% for stage IVa, and 0% for stage IVb. Masaoka's classification reflects the oncological behavior. In this study, there were 15 patients with type A, 17 with type AB, 13 with type B1, and 7 with type B2 tumors according to the World Health Organization (WHO) classification. The 5-year survival rate was 73% for type A, 94% for type AB, 100% for type B1, and 100% for type B2 patients. Since WHO classification does not reflect oncological behavior, we treat thymoma patients based on Masaoka's classification. Further investigation for the relation between WHO classification and prognosis were required. The 5-year survival rate was 97% for patients treated with complete resection and 33% for incomplete resection. Incomplete resection is a poor prognostic factor. No recurrence was observed in patients with stageI or II thymoma. No local recurrence was observed in patients with stage III thymoma who were treated with complete resection and postoperative radiotherapy. Postoperative radiotherapy is effective for preventing local recurrence. Postoperative radiotherapy should be performed for stage III and IV patients. As the necessity of postoperative radiotherapy for stage II thymoma is controversial, further investigation is needed. As patients with advanced stage III and IV disease have a poor prognosis, multimodality treatments should be performed.
Six cases of granulocyte colony-stimulating factor (G-CSF)-producing primary lung cancer were reviewed clinicopathologically. All presented cases were male, who ranged in age from 48 to 71 years old (mean age: 56.0 years old) and were referred to our hospital complaining of fever. Their laboratory data on admission showed marked leukocytosis (14000˜39000/μl), thrombocytosis (37.1˜64.0×104/μl), elevation of CRP (6.9˜21.2mg/dl), and a high serum G-CSF concentration (78.0˜2150.0pg/ml). All cases underwent almost complete resection. Histopathologically, resected tumors were diagnosed as pleomorphic carcinoma, large cell carcinoma and poorly differentiated squamous cell carcinoma in each 2 cases respectively. Immunohistochemical staining with anti-G-CSF monoclonal antibody showed positive results in the tumors of all cases. We diagnosed all cases as G-CSF-producing lung cancer. One case was in stage IB, three were in stage IIB, and two were in stage IIIA. We could perform postoperative adjuvant chemotherapy in only three patients because of the rapid progression of G-CSF-producing lung cancer. So, 3-year survival was achieved in only two patients with stage IB and stage IIB. One of them has survived without recurrence for 36 months, but the other case had pulmonary and bone metastasis and died as a result of the tumors 36 months after surgery. The other four patients died due to recurrence within 10 months post-operatively. As G-CSF-producing lung cancer has a poor prognosis despite complete resection, it is important that a more effective adjuvant therapy be established.
Background. Postoperative infections are a major issue in chest surgery. We changed our perioperative prophylactic antibiotic policy to a single dose of cefazolin before and after surgery in July, 2002. Objective. To identify the risk factors of postoperative infections in patients undergoing chest surgery. Methods. From July, 2002, through December, 2003, 550 patients underwent chest surgery at our division. We reviewed 282 eligible patients for possible risk factors of postoperative infections and the results of sputum culture. Results. Postoperative infections developed in 15 (5.3%) patients. There were 5 (1.8%) wound infections, 4 (1.4%) cases of empyema, 3 (1.1%) of pneumonia, and 3 (1.1%) of urinary tract infection patients. The infection incidence rate did not change significantly after we modified our prophylactic antibiotic policy to a single dose of cefazolin before and after surgery. Multivariate analysis showed diabetes mellitus to be an independent risk factor of postoperative infection. Conclusions. The patients undergoing chest surgery with diabetes mellitus had an increased risk of postoperative infection. The modification of our prophylactic antibiotic policy did not affect the postoperative infection rate.
A 76-year-old man with primary lung cancer was admitted to our hospital complaining of fever and bilateral knee joint pain. Chest X-ray and chest CT demonstrated a giant mass in the right upper lung field. Pulmonary Hypertrophic Osteoarthropathy (PHO), associated with primary lung cancer, was diagnosed, based on the findings of clubbed fingers, periosteal formations in the lower limbs, and abnormal uptake on bone scintigraphy. Right upper lobectomy was performed, and diagnosis of adenocarcinoma was obtained. Postoperatively, symptoms rapidly improved, and the high level of serum Vascular Endothelial Growth Factor (VEGF) observed preoperatively decreased to the normal level. Bone scintigraphic findings became almost normal 1 month postoperatively. Immunohistochemical study of the tumor cells was positive for VEGF. VEGF might play a role in the pathogenesis of PHO with lung cancer.
An 80-year-old male who underwent left upper lobectomy for adenosquamous lung cancer was shown to have recurrent lesions in the right S2 and S6 on chest CT at 1 year after surgery. FDG-PET scans just revealed abnormal accumulations corresponding to the recurrent pulmonary lesions. Because of his advanced age and pulmonary dysfunction, we performed radiofrequency ablation therapy for the lesions. Postoperative chest CT showed a residual mass with a cavity in the tumor lesion, so we could not evaluate the efficacy of the therapy. FDG-PET revealed the disappearance of the accumulation, which would indicate the loss of tumor viability. RFA is so safe and minimally invasive that it promises to be a new local therapy for patients with inoperable lung cancer including recurrent cases. The FDG-PET scan may also be a useful modality for the early evaluation of RFA therapy.
A 56-year-old man was referred to us for the control of refractory pleural effusion. He had a 6-year history of bronchiolitis obliterans with organizing pneumonia (BOOP) and had been under steroid therapy for 4 years. Left pleural effusion together with a yellowish discoloration and thickening of the finger and toe nails had been noticed three years ago. Furthermore, bilateral pleural effusion had been seen one year later. Finally, he was diagnosed as "yellow-nail syndrome" one year ago. Despite the fact that pleural tap had occasionally been performed, dyspnea on exertion gradually worsened because of the rapid increase of pleural effusion. In January, 2006, a right pleuroperitoneal shunt assisted with thoracoscopy was placed under local anesthesia. Thoracoscopic assisted pleuro-peritoneal shunt placement procedure was useful for confirmation of the best region for insertion of the catheter, prospect of the drainage and diagnosis by exclusion of other diseases.
We report a case of giant posterior mediastinal schwannoma, successfully resected. A 54-year-old man was found to have an abnormal shadow on a routine health check chest X-ray. He was recommended to undergo a thorough examination, but refused because of being free of any symptoms. Five years later, he started to feel dysphagia and came to our hospital. Chest CT revealed a huge mass, 15×8×7cm in size, located in the posterior mediastinum. The mass widely and strongly compressed the left atrium and right pulmonary artery from behind, and also penetrated the esophageal wall, surrounding each bronchus. Biopsy under video-assisted thoracoscopic surgery showed a schwannoma, a benign tumor. We considered excision of the mass, but several physicians expressed reservations because of the risk of mortality caused by intra-operative injuries to the heart or pulmonary artery. After obtaining informed consent, we carried out the operation. The tumor widely adhered to the lung, pulmonary artery, and vein, but was successfully dissected without major difficulty. Partial resection of the esophagus was needed, but it was closed uneventfully. The post-operative course was also uneventful. Radiographic findings indicated that total resection would be difficult, but actually, it was not. Even if there is a huge mass in the mediastinum contacting surrounding organs, if a diagnosis of schwannoma is confirmed, total resection should be considered as the initial treatment.
A 74-year-old male was admitted to our hospital due to hemosputum. He possessed some risk factors for surgery, such as pulmonary emphysema, old myocardiac infarction, and hypertension. Chest computed tomography and flexible bronchoscopy procedures revealed a tumor originating from the bronchial cartilage wall at the left second carina of the upper bronchus that obstructed the airway, and the case was diagnosed as atypical carcinoid histology. A bronchoplasty was performed to preserve the pulmonary function as much as possible, using a posterolateral thoracotomy at the 5th intercostal space. The tumor was extirpated by resection of the bronchial wall, including the second carina bronchus with a malignant negative margin, and the bronchus defect was closed using direct sutures. The postoperative course was uneventful and there was no stenosis at the anastomotic site. The patient was discharged without complications and showed no recurrence after 4 years 8 months. The present method is considered to be an effective option for lung.
Eosinophilic granuloma is defined as being mainly composed of a granulomatous lesion including Langerhans' cells. These cases have emphysematous and cystic lesions and sometimes have a refractory pneumothorax. A 36-year-old man was diagnosed with a right pneumothorax. His chest CT scan revealed emphysematous and nodular lesions and he was diagnosed with eosinophilic granulomas after lung biopsies, concurrent with bulla plication under VATS. After surgery, he quit smoking. Eleven months after the operation, he was well without progression of lung lesions and recurrence of the pneumothorax.
We encountered a case of pleuritis carcinomatosa in which PET CT showed enhanced FDG uptake in the pleura, although CT scan showed neither pleural effusion nor nodule presence. A woman had undergone right middle pulmonary lobectomy with ND2a due to pStage IA well differentiated adenocarcinoma at 56 years old. Three years and nine months after this first operation, she underwent a second thoracotomy because CT scanning revealed the recurrent lesion of the interlobar pulmonary stump in the right upper lobe and a metachronous multiple cancer in the right lower lobe. Preoperative PET CT showed enhanced FDG uptake both in the recurrent lesion of the pulmonary stump and in the pleura adjacent to Th8. Intra-operative macroscopic and microscopic findings revealed this enhanced FDG uptake as pleuritis carcinomatosa. Even if CT scan shows neither pleural effusion nor pleural nodule presence in a lung cancer patient, we should carefully decide the operative procedure and expect pleuritis carcinomatosa if PET shows an enhanced FDG uptake lesion in the pleura.
This is a case of a 60-year-old man who was referred to a previous hospital due to a chest X-ray showing an abnormal shadow in the left hilum. Computed tomography scan revealed a round mass of 2.0cm in diameter. He was compliant to follow-up because of the low possibility of malignant disease. Two years later, the size of the hilar mass had increased to 2.5cm in diameter, and the patient began to suffer from recurrent obstructive pneumonia. At four years since the discovery of the hilar mass, its size had grown to 3.5cm in diameter. Obstructive pneumonia worsened; therefore, surgery was conducted. Left pneumonectomy was performed due to severe invasion to the left main pulmonary artery. Histopathological diagnosis was lymphoepithelioma-like carcinoma, T2N1M0 (stage IIB). The association of Epstein-Barr virus could not be clarified by EBER in-situ hybridization. We reconsidered the procedure of examination and therapy for this case. As a result, we could ascertain valuable information about the long-term clinical course of lymphoepithelioma-like carcinoma.
A 53-year-old man was refered to our hospital under the diagnosis of lung cancer. Right pneumonectomy was performed after a preoperative induction chemoradiotherapy. The pathological TNM stage was pT2N0M0. After a postoperative adjuvant chemotherapy including cisplatin, he was admitted to our hospital because of a high fever with severe neutrocytopenia. He was diagnosed as postpneumonectomy empyema without bronchopleural fistula which occurred under neutrocytopenia after chemotherapy. The culture of pleural effusion revealed empyema caused by penicillin-resistant Streptococcus pneumoniae. Chest tube drainage and irrigation were performed immediately. Antibiotics sensitive to the penicillin-resistant Streptococcus pneumoniae and G-CSF were administered. The general condition of the patient gradually improved. Thoracoscopic debridement of the empyema space was performed without insertion of drainage tube. A muscle flap closure of the pneumonectomy space was not performed. He is currently doing well after a four-month follow-up. Care must be taken concerning neutrocytopenia-associated complications when patients have undergone postoperative adjuvant chemotherapy. Thoracoscopic debridement might be a valuable approach for patients with postpneumonectomy empyema without a bronchopleural fistula.
A thirties-year-old man was admitted with penetrating injuries to the bilateral chest wall by handgun bullets. Chest X-ray showed a left third rib fracture and a massive hemothorax. On chest computed tomography, two bullets were seen in the right thoracic cavity and left thoracodorsal subcutaneous tissue. Left emergency thoracotomy was performed to control hemorrhage because of hemorrhagic shock. Sequentially, right thoracoscopic surgery was performed to explore injuries and remove the bullets. He was discharged uneventfully ten days after surgery.
A 69-year-old female with a huge intrathoracic tumor on chest Xray was referred to our department. We performed a partial resection of the left lower lobe. The pathological findings showed that the tumor consisted of small round cells and was stained positively by the CD99 antibody, resulting in a diagnosis of PNET. PNET is classified according to Ewing's sarcoma family of tumors, so it is important to diagnose it accurately to achieve a better prognosis.
A 26-year-old female with the complaints of chest pain and dyspnea revealed orthopnea, superior vena cava syndrome and heart failure at the outpatient. Echocardiogram and enhanced chest Computed Tomography (CT) showed a mass at the heart in the size of 8cm, compressing left side of the heart and obstructing the right pulmonary artery and superior vena cava. An emergent thoracotomy operation was done and intrapericardial bronchogenic cyst was resected. The postoperative course was uneventful. An intrapericardial bronchogenic cyst is rare disease. In this case, echocardiogram and enhanced chest CT helped the diagnosis and aggressive emergent thoracotomy operation had been important to rescue the patient.
We report a 53-year-old man who suffered from right axillary lymph node swelling. Precise examination revealed a chest wall tumor. The result of needle biopsy of the chest wall tumor was a small cell carcimona of unknown origin. After chemo-radiotherapy with minor response, we performed an operation. In the operation, we resected the three ribs involved with a more than 2cm safety margin and performed reconstruction using composite mesh, covering by a pedicled latissimus dorsi myocutaneous flap. The resected specimen was 17×10cm in size. The pathological diagnosis with immunohistochemistry was plasmacytoma (IgA, lambda type). It is difficult to diagnose solitary plasmacytoma of the chest wall preoperatively, and because of both the shift to multiple myeloma and high recurrent rate after radiation therapy alone, multimodality treatment including surgical resection is needed in its management. In this case, it took about 6 months from biopsy to surgery for chest wall tumor, which made us realize the importance and difficulty of diagnosis of solitary plasmacytoma preoperatively.
A 28-year-old woman presented to our hospital with a 1-month history of dry cough and an abnormal chest radiograph. Chest X-ray and computed tomography showed multiple cysts containing a well-defined air-fluid level in the posteroinferior portion of the right lower lobe. Aortography showed an aberrant artery arising from the right inferior phrenic artery supplying the sequestration. A right lower lobectomy was performed, as the patient is likely to suffer repeated bouts of pneumonia in the future. Intralobar pulmonary sequestration supplied from the inferior phrenic artery is extremely rare, with only 2 cases previously reported.
A 53-year-old man with a complaint of dyspnea on effort was referred to our hospital. Chest x-ray demonstrated a tumor located in the subaortic region. Mediastinal lymph node metastasis was suspected, though no primary lesion was detected. Resection of an enlarged mediastinal lymph node was therefore performed to confirm the diagnosis. Histological examination revealed that the lymph node consisted of poorly differentiated adenocarcinoma with immunoreactivity for keratin and EMA as epithelial markers. No recurrence has been noted for 6 years, without additional treatment. We often treat patients with metastatic cancer from an unknown primary lesion, many of whom suffer relapse and have a poor outcome. We therefore report this rare case of a long-surviving patient with mediastinal lymph node carcinoma from an unknown primary lesion. A review of 31 previously reported cases in Japan revealed that patients with mediastinal lymph node carcinoma from an unknown primary lesion have a better prognosis than those with N2 lung cancer, and exhibit prolonged survival with aggressive medical treatment. We therefore propose that patients with mediastinal lymph node carcinoma from an unknown primary lesion should be treated aggressively.