[Castleman lymphoma originated from the posterior mediastinum resected thoracoscopically: report of a case].

We report thoracoscopic resection of Castleman lymphoma originated from the posterior mediastinum. The patient was a 19-year-old woman, who was pointed out to show an abnormal shadow in the left upper lung in the chest X-ray photograph. It was diagnosed as a blood-rich posterior mediastinal tumor by dynamic MRI, and thoracoscopic surgery was performed. The tumor was adjacent to the vertebral body of the fourth thoracic vertebra. Although operation involved 2 hours and 40 minutes and 670 ml of bleeding due to a strong adhesion between the tumor and the intercostal muscle and considerable bleeding from the tumor itself, it was successfully removed under thoracoscopy. The tumor was elastic and hard, and 50 x 45 x 25 mm in size. The histopathological diagnosis was a Castleman lymphoma, hyaline vascular type. The postoperative course was satisfactory, and the patient was discharged from the hospital on the 7th postoperative day. Castleman lymphoma originated from the posterior mediastinum tends to bleed considerably during its resection. If a blood-rich posterior mediastinal tumor was found preoperatively, thoracoscopic operation must be advanced carefully keeping this disease in mind.

[Cases of death after surgery for pathologic stage I non-small cell lung cancer].

We clinically examined cases of death from pathologic stage I non-small cell lung cancer with the aim of improving the 5-year survival rate after surgery for this condition. The subjects were 70 patients with p-stage IA (20 cases of death) and 59 patients with p-stage IB (26 cases of death) from among those who underwent surgery for p-stage I non-small cell lung cancer between 1986 and 2000. 1) Of 30 patients who died from p-stage I lung cancer, 20 had distant metastases and 10 had recurrence in the thoracic cavity. Of 16 patients who died from other diseases, 5 had respiratory organ disease, 5 had cancers of other organs and 6 had circulatory organ disease. 2) Of 30 patients who died from p-stage I lung cancer, 20 (66.7%) had distant metastases, with lung metastasis occurring most frequently, in 10 of them (33.3%). The most common cause of death of patients with p-stage IB lung cancer was recurrence in the thoracic cavity. 3) The mean durations of survival (mean +/- standard deviation) after surgery for lung cancer of the patients who died from p-stage I lung cancer (30 patients) were 36.3 +/- 22.2 months for the 20 patients with distant metastases and 26.2 +/- 14.3 months for the 10 patients with recurrence in the thoracic cavity, the difference between groups was 10 months, but was not significant. 4) The 5-year survival rate in 45 patients who underwent p-stage IA mediastinal lymph node dissection was 83.1% whereas that in 25 patients without p-stage IB mediastinal lymph node dissection was 50.9% showing a significant difference of 32.2% (p < 0.01). 5) The patients in p-stage IA who died from other diseases were all men (10 patients). The mean durations of survival after surgery for lung cancer in the patients who died from other diseases were 35.2 +/- 19.0 months in the patients with respiratory organ disease, 37.0 +/- 23.9 months in those with cancers of other organs and 60 +/- 19.1 months in those with circulatory organ disease. 6) The 5-year survival rate after surgery in all cases of death was 76% in the patients in p-stage IA and 61.4% in those in p-stage IB. The 5-year survival rates in the patients excluding those who died from other diseases were 85% in the patients in p-stage IA (60 patients) and 60.3% in those in p-stage IB (53 patients) (p < 0.01). 7) To improve the 5-year survival rate in the patients with p-stage IA lung cancer, it is necessary to prevent death from other diseases in men. It is still possible to improve the 5-year survival rate in the patients with p-stage IB lung cancer by raising the accuracy of mediastinal lymph node dissection during surgery.

[A case with lung metastasis of osteosarcoma occurred 21 years after the operation of osteosarcoma on left tibia].

The patient was a 38-years-old woman. A chest X-ray film demonstrated the presence of an abnormal lesion. Her past history included osteosarcoma on the left tibia for which she received amputation of the left inferior limb at 17 years of age without any relapse thereafter. Considering that the patient might have lung metastasis of osteosarcoma on the basis of lung biopsy performed under CT guide, and then a tumor was removed under the thoracoscope. The tumor, 2.8 x 2.2 x 2.1 cm in size, was located right under the pleura at left S10 with its inside being filled up with fragile necrotic tissues. When compared pathohistologically with the primary lesion of osteosarcoma which had occurred 21 years before, the lung tumor was almost identical in terms of the tumor cell morphology but had a higher cell density without evidence of osteoid formation. The diagnosis of lung metastasis of osteosarcoma was established on the basis of the clinical course and the immunohistochemical staining. It is extremely rare case that osteosarcoma recurs in the form of lung metastasis 21 years after the operation of primary lesion. We report this case as a valuable one to identify the prognosis of osteosarcoma and the development mechanism of lung metastasis.

[Lobectomy of two or more lobes in patients with lung cancer].

We clinically examined patients who had undergone resection of two or more lobes for lung cancer. The subjects were 50 patients (25 who underwent pneumonectomy and 25 bilobectomy) who underwent lobectomy of two or more lobes from among those with primary non-small cell lung cancers in our hospital between 1975 and 1999; these individuals were assigned to Group A, and compared with 166 patients with lobectomy in Group B. The five-year survival rate was 27.7% in Group A, which differed significantly from the rate of 55.6% in Group B (p < 0.01, Kaplan-Meier method with log-rank test). The percentage of Stage I patients was 34% (17 patients) in Group A and 60.2% (100 patients) in Group B: this difference was significant (chi 2 test, p < 0.01). There were more patients with advanced cancer in Group A than in Group B. However, the five-year survival rates of Stage I patients were 52.4% in Group A and 77.6% in Group B, and significantly different (p < 0.05). In a comparison with respect to histological type, the five-year survival rates also differed significantly between Group A and B (p < 0.01 for adenocarcinoma, p < 0.05 for squamous cell carcinoma, with higher values in Group B for both). Resection of two or more lobes was indicated based on infiltration of the main tumor into adjacent lobes in 19 patients (38%), infiltration of lymph node metastasis into a bronchus or pulmonary artery in 14 (28%), direct infiltration of the main tumor into a bronchus in 10 (20%), and for other reasons in 7 (14%). The five-year survival rates for these groups were 15.8, 22.1, 54 and 42.9%, respectively. There was a significant difference between the patients with infiltration of cancer into adjacent lobes and those with direct infiltration into a bronchus (p < 0.05). The prognosis of patients with resection of two or more lobes was poorer than that of patients with lobectomy even in Stage I. In particular, infiltration of cancer into adjacent lobes accompanied lymph node metastasis in more than 50% in cases, and appeared to suggest a poor prognosis.

A case of primary squamous cell carcinoma of the breast with rapid progression.

Primary squamous cell carcinoma of the breast is a rare disease for which no definite treatment or prognosis has been established. This report describes our experience with one case of primary squamous cell carcinoma of the breast that ended in death after rapid progression. The patient was a 58 year old woman who visited our hospital complaining of a growing tumor and pain in the right breast. Ultrasonographically the tumor consisted of solid tumor and a large cyst. Squamous cell carcinoma was diagnosed by fine-needle aspiration cytology. Neoadjuvant CEF was given, but the tumor continued to grow, so CEF was discontinued after one course and modified radical mastectomy was performed subsequently. There was no evidence of metastasis to lymph nodes. About 5 months post operatively CT of the head and chest X-ray demonstrated metastatic lesions in the brain and lungs. Resection of the cerebral tumor was performed. About 1 month after the operation, however, a new metastatic brain tumor was found and the patient later died.

[A case of G-CSF-producing large cell carcinoma of the lung with gastric metastasis].

We report a rare surgically-treated case of G-CSF-producing large cell carcinoma of the lung with gastric metastasis. A 65-year-old male was admitted to our hospital because of fever, anemia and epigastralgia. Chest X-ray examination and CT scanning revealed a round mass shadow (8 cm) in contact with the chest wall in the right upper lung field and metastasis to the mediastinal lymph nodes. Laboratory examination showed a WBC of 16,800/mm3, CRP of 11.6 mg/dl, and a serum G-CSF of 90 pg/ml. Upper gastrointestinal series and gastroscopy showed an ulcerating submucosal tumorous lesion in the pyloric antrum. The lung carcinoma was treated by right upper lobectomy with chest wall resection. After 1 month, gastrectomy was performed. After the operation, the WBC normalized, and the CRP and serum G-CSF levels decreased. Histopathological examination demonstrated a poorly differentiated large cell carcinoma in the lung and a metastatic lesion in the stomach. Immunohistochemical staining with anti-G-CSF mono-clonal antibody showed negative results in the lung but positive results in the stomach. He was discharged 3 weeks after gastrectomy but died of aggravation of the general condition associated with local recurrence in the chest wall 2 months after discharge.

[Primary clear cell carcinoma of the lung: report of an operative case].

The patient was a 75-year-old man complaining of cough in July 1996. Chest X-ray demonstrated a tumor in the left S6. Percutaneous lung biopsy specimen revealed lung cancer. On September 4, 1996, left lobectomy (R 2 a) was performed. The tumor was 3.8 x 3.2 x 2.1 cm in size and showed a white yellow solid mass (pT2N0M0, pStage I, p1d0e0pm0). The pathological examination was confirmed no differentiation in adenocarcinoma and squamous cell carcinoma. More than 90% of the tumor cells were characterized as having large clear cytoplasm. On immunohistochemical study, the tumor cells expressed positive with EMA, CEA, cytokeratin and negative with vimentin. The postoperative findings showed no presence of renal cell carcinoma. As the result, a diagnosis of primary clear cell carcinoma of the lung was made. The postoperative course is uneventful.

[Giant localized fibrous pleural mesothelioma accompanying lung metastasis--a case report].

We experienced a case of giant localized fibrous pleural mesothelioma accompanying lung metastasis. The patient was a 26-year-old woman, who was pointed out elevation of the left diaphragma by the chest roentgenogram in 1992 but left it as it was. In 1995, a giant tumor occupying 1/2 or more of the left thoracic cavity was detected by chest CT and MRI. A giant localized pleural mesothelioma was suspected since there was no accumulation in Ga scintigram and an operation was performed. The tumor originated without pedicle and with invasion of the lung from the pleura of the left S8 and it was excised by separating the left lower lobe at 7-cm distance from the tumor. The tumor was 20 x 12 x 11 cm in size weighing 1700 g and the histopathological diagnosis was localized fibrous pleural mesothelioma. A lung metastasis of 1.0 cm in size was found in a part of the left lower lobe resected at the same time. The postoperative course has been satisfactory and there is no sign of recurrence at present. There are occasional cases of recurrence associated with a localized fibrous pleural mesothelioma even though it is judged benign. In the present case, a metastatic focus was already present at the time of initial surgery and is considered a valuable case.

[A surgical case of T-cell non-Hodgkin's lymphoma originating in the wall affected by chronic tuberculous empyema following artificial pneumothorax].

A 63-year-old male patient underwent artificial pneumothorax for right pulmonary tuberculosis 39 years ago, and thereafter suffered from chronic empyema, though asymptomatic. In December, 1989, he was found to have a 5 cm tumor in his right chest wall. The tumor grew to 15 cm in 2 weeks and was associated with severe pain. A chest CT revealed that the tumor of the chest wall corresponded to the area of the wall affected by empyema. The patient underwent full thickness resection of the chest wall including the tumor and the empyematous wall (20 x 20 cm) on March 7, 1990. The tumor was 11 x 8 x 7 cm large and had developed from the empyematous wall to the lateral side of chest wall. There was no invasion of the thoracic cavity by the empyema. The lesion was pathologically diagnosed as diffuse, large to intermediate T-cell non-Hodgkin's lymphoma. Postoperatively the patient was treated with radiotherapy and VEPA therapy, but the tumor metastasized to both lungs, and the patient died 161 days after surgery. The majority of cases of malignant lymphoma reported to have originated in empyematous chest walls have been of the B-cell type. The T-cell type is rare, and the present case is only the second case reported. Chest CT was an effective method of diagnostic imaging in this disease.

[A case report of primary malignant fibrous histiocytoma of the lung].

In this paper, a case of a 59-year-old female of primary malignant fibrous histiocytoma (MFH) of the lung is reported. The patient, who had dyspnea as a main complaint, presented with an abnormal shadow in the chest about 20 years ago, and rapid increase of the shadow has been recognized from one year ago. A pulmonary tumor of the left upper lobe was diagnosed by chest CT, bronchography, pulmonary arteriography. A left pneumonectomy was performed and metastases in lymph nodes and pleural dissemination were recognized. The tumor was 11 X 8 X 6 cm, white, multiple nodular, and solid with a clear border. Histologic examination showed the storiform pleomorphic type of MFH mixed with fibroblastoid cells and histiocytoid cells. Ga scintigram, bone scintigram, and CT conducted before and after the surgery did not show metastasis, but the patient died due to respiratory insufficiency caused by metastasis to the right pleura at 9 months after surgery.

[A case of malignant fibrous histiocytoma of the cecum].

A case of primary malignant fibrous histiocytoma (MFH) of the cecum was reported. Patient was a 52-year-old female, and complained of right lower abdominal pain. The barium enema and abdominal computed tomography demonstrated a localized mass involving the entire circumference of the cecum. Right hemicolectomy was performed and the resected specimen revealed a tumor of 8 X 6 X 5 cm in size extending to the entire circumference of the cecum. The histopathological examination revealed a storiform pattern, which was diagnostic of MHF. The tumor proliferated chiefly in the subserous tissue and partially infiltrated the tunica muscularis propria. The postoperative course was uneventful and she showed no sign of recurrence at 15 months after operation. This is the ninth reported case of primary MFH in digestive organs.

[A case of dumbbell neurogenic tumor in the posterior mediastinum].

We have recently experienced a dumbbell tumor that developed in the posterior mediastinum in a 64-year-old male. The patient suffered from dorsalgia one year and a half previously. Chest X-ray examinations revealed a well-defined boundary in the right posterior mediastinum. Myelography followed by computerized tomographic scanning (CT) revealed that the tumor developed in a paravertebral area linked with a vertebral canal through an intervertebral foramen and destructed a rib in growing in the paraspinal muscular layer. Longitudinal incision of about 10 cm was made downward from immediately above the first thoracic spinous process, and the chest was opened by posterolateral incision extending into the muscles of the back in an arc shape. The tumor was entirely excised by additional laminectomy. Since malignant schwannoma was diagnosed histologically, Linac X-ray of 50 Gray was given. The patient is now enjoying his healthy daily life with no postoperative complication 2 years after operation. Myelography followed by CT was proved to be quite useful in evaluating a relationship between the tumor and the spinal cord in the diagnosis of this disease.