[A case of resected squamous cell carcinoma of the lung complicated with sarcoidosis].

A 64-year-old man with uveitis was admitted to our hospital for detailed investigation of an abnormal shadow on his chest X-ray. Chest radiography and computed tomography of the chest showed mediastinal lymphadenopathy and a tumor shadow in the left hilum. Transbronchial tumor biopsy revealed squamous cell carcinoma. Left upper lobectomy and drainage of bilateral hilar and mediastinal lymph nodes were performed. Histopathological examination revealed the coexistence of squamous cell carcinoma with many non-caseating epithelioid cell granulomas in all hilar and mediastinal drainage lymph nodes, but no metastasis. Non-caseating epithelioid cell granulomas were also seen in the interstitium and alveolar spaces. Coexistence of sarcoidosis and lung cancer in the same patient is not common, and only 29 cases, including ours, have been reported. This case also provides the concept that surgical tumor resection should be considered even if bilateral mediastinal lymphadenopathy is found in a case of lung cancer complicated with sarcoidosis.

[A 36-year-old woman with acute onset left hemiplegia and anosognosia].

We report a 36-year-old woman with right hemiplegia, anosognosia, and rapidly deteriorating course. She was well until the end of January, 1995 when she had an onset of fever, sputum, and cough. A 5 x 5 tumor was found in her left lower lobe. She was admitted to the Pulmonary Medicine on May 24, 1995 when she was 36-year-old. General physical examination was unremarkable. Bone scintigraphy revealed increased uptake in the skull, sternum, right scapula, vertebrae, right femur, and in ribs. Cranial CT scan revealed a large mass lesion in the right frontal subcortical region with central low density and peripheral high density areas, and small low density lesions in the right thalamic area and in the right posterior frontal region; ring enhancement was observed in the latter two lesions. On the second day of admission, she noted left-sided weakness which improved by corticosteroid treatment. On June 17, there was a sudden onset of left hemiparesis and a neurologic consultation was asked. Upon neurologic examination, she appeared somnolent but could understand verbal commands. She showed constructional apraxia, neglect of the left hemisphere, and anosognosia. Cranial nerves were unremarkable. Motor-wise, she showed flaccid left hemiplegia. Deep tendon reflexes were exaggerated on the left and the plantar response was extensor bilaterally. Nuchal stiffness was noted. Her cranial CT scan on June 17 revealed enlargement of the right frontal mass lesion. The subsequent course was complicated by DIC and progressive worsening of her consciousness. On June 18, she was comatose and pupillary light reflex was lost. She developed Cheyne-Stokes respiration and expired on that evening. The patient was discussed in a neurological CPC, and the chief discussant arrived at the conclusion that the patient had a primary adenocarcinoma in the lung with multiple metastases including the brain. The fulminant terminal course was ascribed to hemorrhage within the tumor and subsequent central type of transtentorial herniation. Opinions were divided regarding the cause of hemorrhage; some participants thought hemorrhage was caused by DIC. Post-mortem examination revealed an adenocarcinoma arising at the S6 segment of the left lung with multiple organ metastases. In the brain, a huge hemorrhagic metastasis was found in the right frontal lobe and a non-hemorrhagic metastasis in the right thalamic region. Probably, the size of the metastases influenced the occurrence of hemorrhage. The direct cause of the death was transtentorial herniation.

[A case report of pericardial diverticulum in the upper mediastinum: surgical treatment of two cases].

Pericardial cyst and diverticulum are commonly found in areas of cardiophrenic angles. In this article, we reported on two operated cases (54-year-old female, 43-year-old male) with pericardial diverticula in upper mediastinum. On their chest CT films, well circumscribed cystic lesions were seen in the right (case 1) and left (case 2) upper mediastinum. Based on findings of imaging modalities such as CT, MRI and transesophageal ultrasonography, the lesions were suspected of benign cystic tumors such as bronchogenic cyst, lymphatic cyst, esophageal cyst and pericardial cyst. However, definite diagnoses were made by thoracotomy. Even though the cystic lesion is recognized in the upper mediastinum, pericardial diverticulum should be considered as its diagnosis as well as bronchogenic cyst, lymphatic cyst, esophageal cyst.

[A resected case of esophageal leiomyoma with 15 cm in long diameter, diagnosed by transesophageal ultrasonic endoscopy].

A 28-year-old man whose chest X-ray film showed a mass on the right upper mediastinum was admitted. Preoperative examination, including CT, MRI, esophagogram, did not make it possible to determine clinically from which organ the tumor originated. On diagnosing with transesophageal ultrasonic endoscopy (TUE) the tumor was found to originate in the esophageal submucosa, with no involvement of the mediastinal organ apparent. Esophageal sub-mucosal tumor enucleation was performed. The resected tumor was 15 cm in long diameter and weighed 125 g. We therefore believe that TUE is clinically useful in diagnosing the tumor originating in the esophageal wall or adjoining esophageal wall.

Detection of the mediastinal lymph nodes metastasis in lung cancer by endoscopic ultrasonography.

Mediastinal lymph nodes metastasis of lung cancer was analysed by endoscopic ultrasonography in 96 patients in whom histological diagnosis of the lymph nodes could be proven by thoracotomy. A Receiver Operating Characteristic (ROC) curve was drawn up for determining the criteria for metastatic lymph nodes by endoscopic ultrasonography. The ROC curve was evaluated by using four parameters: The long diameter, the short diameter, the long diameter plus the short diameter, and the product of the long diameter times the short diameter. The long plus short diameter and the long-times-short diameter showed the highest detectability of the metastasis of all histological types on the ROC curve. The reasonable criteria levels were found to be 18 mm and 75 mm2 by means of a moderate threshold. In this level, sensitivity were 77%, 76%; specificity 84%, 84%; and accuracy 82%, 82%, respectively. When examinations were done by histological types, the criteria level for the epidermoid carcinoma should be increased to more than that for the adenocarcinoma. And, sensitivity and specificity were better in the epidermoid carcinoma. Thus, these results suggest that endoscopic ultrasonography is clinically useful for the detection of lymph nodes metastasis in lung cancer.

Observation of lymph nodes and great vessels in the mediastinum by endoscopic ultrasonography.

The mediastinum was studied by endoscopic ultrasonography in 121 lung cancer patients. This method facilitates the observation of the lymph nodes, the large vessels and heart in the mediastinum in real time and dynamically. In this paper, the orientation of mediastinal lymph nodes was ultrasonographically studied. This method can detect lymph nodes as small as 3 mm in diameter, and very highly those in bracheobronchial, subaortic, subcarinal, and hilar regions. The mediastinal vascular structures were also easily detected. This method can provide full clinical applicability for analysis of mediastinal involvements in lung cancer patients.

Carcinoembryonic antigen in bronchoalveolar lavage fluid in patients with idiopathic pulmonary fibrosis.

An increased incidence of lung cancer and epithelial metaplasia or hyperplasia which is felt to be as a precursor of cancer, has been reported in patients with idiopathic pulmonary fibrosis (IPF). In this study, carcinoembryonic antigen (CEA) in bronchoalveolar lavage (BAL) fluid was measured in 53 control patients, 31 patients with sarcoidosis, 10 patients with hypersensitivity pneumonitis, 16 patients with primary lung cancer and 26 patients with histologically confirmed IPF. High ratio of CEA to albumin (Alb), exceeding mean + 2SD of nonsmoking control patients, were found in 8 (25%) out of 32 smoking control patients, 4 (44%) out of 9 nonsmoking patients with IPF, 8 (62%) out of 13 smoking patients with IPF, 3 (75%) out of 4 smoking patients with IPF and lung cancer and 13 (81%) out of 16 patients with primary lung cancer, although BAL was performed at the noncancerous parts of the lung in the cases of lung cancer. Furthermore, it was confirmed that CEA increased in BAL fluid in these subjects were different from nonspecific cross-reacting antigen (NCA) which was detectable in the normal lung. Thus we consider that the increase of CEA/Alb ratio in BAL fluid is a possible marker of these early histological disorders in the lung, and also suggests a greater risk of malignant change in the clinical course of IPF.