[A pulmonary tumorlet with caseous granuloma associated with atypical mycobacterium].

We encountered a case of pulmonary tumorlet with caseous granuloma associated with atypical mycobacterium. A 73-year-old woman was admitted to the hospital because a chest x-ray film showed enlargement of an abnormal shadow in the middle lobe of the right lung. Primary lung cancer was suspected and right middle lobectomy was performed. Acid-fast bacilli (Gaffky 1) were found in a caseous lesion and examination of intraoperatively obtained frozen specimens showed caseous granulomas. The bacilli were later identified as Mycobacterium avium complex. The permanent specimen showed a minute lesion consisting of small clusters of epithelial cells resembling carcinoid tumor in contact with granulomatous tissue. Histopathological examination revealed argyrophilia on Grimelius stain and immunoreactivity to chromogranin-A in the clusters of epithelial cells. Although these results are consistent with small cell carcinoma or peripheral carcinoid tumor, pulmonary tumorlet was diagnosed because of the lesion's small and minimal cytologic atypia, and because of chronic pulmonary damage around the lesion. Pulmonary tumorlets are minute, usually microscopic, tumor-like lesions mostly found in damaged lung tissue obtained at autopsy or during surgery. Morphological diagnosis is sometimes very difficult, but recently these lesions have been regarded as hyperplastic lesions arising in pulmonary neuroendocrine cells (Kultschitzky cells) and caused by chronic pulmonary damage, such as hypoxia and inflammation. Pulmonary tumorlets must be considered in the differential diagnosis of minute lesions suspected to be small cell carcinoma or peripheral carcinoid tumor.

[Limited operation for stage I lung cancer: a retrospective study].

Although lobectomy is standard therapy for Stage I non-small cell lung cancer, it often cannot be performed in poor-risk patients. In this report, we describe the results of a retrospective study to assess the usefulness of limited operation for stage I lung cancer. Over a 21-year period, 1,286 lung cancers were resected at our center. Among the 497 patients with stage I lung cancer, 36 sublobar resections were performed. There was only one surgery-related death, and the 5-year survival rate was 46% for all patients. At 5 years, survival was 69.2% for patients with squamous cell carcinoma and 33.7% for patients with adenocarcinoma. Survival rates were higher in patients who underwent mediastinoscopy than those who did not, and depended on histological findings and accurate pathological staging.

[Flow cytometric analysis of the DNA content of resected non-small cell lung cancer with reference to long-term follow-up].

We measured the cellular DNA content of paraffin-embedded tumor specimens by flow cytometry from 340 cases of resected non-small cell lung cancer, and investigated the correlation of DNA content and prognosis of these cases with long-term follow-up. These 340 cases were divided into some populations according to pathological stage, histologic type, surgical curativity and N factor, and we compared the prognosis of DNA diploidy cases and DNA aneuploidy cases in each population. DNA aneuploidy cases had a significantly less favorable prognosis than DNA diploidy cases in population of stage I adenocarcinoma, stage IIIA non-small cell lung cancer and N2 cases among stage IIIA non-small cell lung cancer, all after curative operation. But in other populations, there was no significant difference in prognosis between DNA diploidy cases and DNA aneuploidy cases. In conclusion, DNA ploidy pattern is a prognostic factor for survival in patients with stage I adenocarcinoma and N2 cases of stage IIIA non-small cell lung cancer.

[T cell lymphoma presenting as recurrent bilateral pulmonary infiltrates over five years].

A 52-year-old man presented with BOOP-like recurrent bilateral pulmonary infiltrates. In 1989 a chest X-ray film showed an infiltrative shadow in the right S6 region which disappeared after administration of prednisolone. Thereafter, bilateral patchy infiltrates recurred many times, and each time they resolved rapidly with steroid therapy. Skin eruptions on the face recurred. In October 1994 the patient underwent an open-lung biopsy of the infiltrate in the left S6 region. The pathological findings were consistent with BOOP, except for the moderate-to marked infiltration of lymphocytes. A lymphoproliferative disorder was suspected, and Southern blot analysis of the specimen revealed a rearrangement of the TCR-beta gene, which led to the diagnosis of T cell lymphoma. Ten months after the diagnosis, no recurrence of the lymphoma had been detected. In this case a gene analysis of the biopsy specimen was very useful for the diagnosis of T cell lymphoma.

[The result of reoperation for lung cancer].

Twenty four patients with recurrent or multiple lung cancer were reoperated in our center. Five-year survival rate was 20% for 11 patients with recurrent, while was 25% for 13 patients with multiple after reoperation. The patients with limited operation had well survival and there was no significant difference in procedure. However all four patients with N2 had poor prognosis. Seven patients (29%) had the post reoperative complication in pulmonary system. All of them had the impairment of pulmonary function (FEV1.0% was less than 50%) or more than 75% perfusion ratio, measured with pulmonary perfusion scintigraphy, in the side of the reoperation.

[A case of intractable pulmonary tuberculosis complicated by idiopathic thrombocytopenic purpura (ITP)].

The authors describe a case of pulmonary tuberculosis with multiple drug resistance and complicated by severe idiopathic thrombocytopenic purpura (ITP). The patient was initially treated with high-dose gamma globulin therapy and splenectomy. These procedures resulted in improvement of the patient's condition; the platelet count increased from 7,000/mm3 to 230,000/mm3 and the bleeding time fell from 15 min to 1 min 30 s. Given the significant improvement in the patient's condition, it was considered safe to carry out left pulmonary upper lobectomy and thoracoplasty. There have been no reports describing pulmonary resection performed for inflammatory lung disease in patients with ITP. High-dose gamma globulin therapy rapidly brings about an increase in the platelet count and a reduction of the bleeding time, and it thus extremely useful as preoperative treatment in surgical cases complicated by thrombocytopenia.

[Diagnosis of mediastinal lymph node metastasis in primary lung cancer: comparing CT scan and mediastinoscopy].

In 105 patients with primary lung cancer who were operated on, the rate of diagnosis of mediastinal lymph node metastasis was determined, and the results of CT scanning and mediastinoscopy were compared. The rate of accuracy of mediastinoscopy was 93.8%, considerably higher than that of CT, which was less than 85%. For the lymph nodes other than #7, which indicate contralateral metastasis, the rate of accuracy of mediastinoscopy was even better and reached 96.3%. In the 9 patients who were proved by mediastinoscopy to have contralateral lymph node metastasis, the rate of accuracy of CT was only 44%. Mediastinoscopy was very effective in the diagnosis of mediastinal lymph node metastases from primary lung cancers.

Preoperative mediastinoscopic assessment of N factors and the need for mediastinal lymph node dissection in T1 lung cancer.

The significance of preoperative N factor assessment in T1 lung cancer and the need for mediastinal node dissection in T1 N0 M0 cases were investigated. The results of mediastinoscopy were evaluated in patients with T1 adenocarcinoma or squamous cell carcinoma who underwent preoperative mediastinoscopy and thoracotomy from 1971 to 1991 (n = 164). Mediastinoscopy gave true negative results in 90% of patients, false negative in 1%, and true positive in 9%. The 5-year survival was 90% for patients with T1 N0 M0 disease who underwent nonradical dissection (n = 64) and 70% for those who underwent radical dissection (n = 61), indicating that the prognosis was significantly better (p < 0.05) with nonradical dissection. Distant metastasis was a common cause of death, and no death was related to local recurrence, whether nonradical or radical dissection had been performed. The results strongly suggest that preoperative mediastinoscopy and intraoperative node sampling are sufficient for assessment of N factors in T1 lung cancer. The possible relation between immunologic functional changes associated with mediastinal lymph node dissection and the prognosis in patients without evidence of positive lymph nodes should be clarified by a prospective randomized study.

[A case of solitary plasmacytoma of the chest wall].

A 58-year-old man with a solitary plasmacytoma of the chest wall is reported. He was admitted because of a painless tumor on the right lateral chest wall. The chest CT scan showed a chest wall tumor surrounding the 7th and 8th ribs without rib destruction. A transcutaneous needle biopsy of the tumor with a Sure-Cut-Needle revealed a plasmacytoma. The bone marrow biopsy findings were normal. Under a diagnosis of solitary plasmacytoma, the chest wall tumor was resected. The tumor was an extramedullary plasmacytoma. Southern blot analysis of the immunoglobulin light chain gene of the tumor cells detected a rearrangement of genes in the lambda chain, while no rearrangements of immunoglobulin genes were detected in the bone marrow specimen. Seven months later another solitary plasmacytoma was found at the left radius, and was resected. Southern blot analysis of the immunoglobulin light chain gene was useful in the differential diagnosis from systemic myeloma and in determining the monoclonality of the tumor.

[DNA content analysis and detection of c-myc and p53 products using flow cytometry in resected lung cancer cases].

We quantitatively analyzed the c-myc and p53 products using flow cytometry in 28 cases of resected lung cancer and one case each of chorio-carcinoma, plasmacytoma, malignant mesothelioma and sclerosing hemangioma. In the lung cancer cases, c-myc and p53 products were detected in 10 cases (35%) and 7 cases (21%), respectively. These rates are higher than the DNA abnormal expression rates of the c-myc and p53 genes (15% and 12%, respectively) in our own data. In the adenocarcinoma of lung cancer cases, c-myc and p53 products were detected in 9 cases (53%) and 5 cases (29%), respectively. Among the squamous cell carcinoma cases, there were one case (11%) of c-myc expression and one case (11%) of p53 expression. DNA content analysis of the lung cancer patients revealed 7 cases of DNA diploidy and 21 cases of DNA aneuploidy. All 10 c-myc-positive cases showed DNA aneuploidy; thus the positive rate for c-myc products in the DNA aneuploidy cases was significantly different compared with the DNA diploidy cases (p < 0.05). In the sclerosing hemangioma case, we detected both c-myc and p53 products. Sclerosing hemangioma has been thought to be a benign tumor, but it may be a malignant tumor.

[Preoperative staging in T1 and T2 lung cancers by mediastinoscopy and mediastinal lymph node dissection].

Between 1975 and 1992, mediastinoscopy and thoracotomy were performed on 184 T1 and 271 T2 lung cancer cases consisting of adenocarcinoma and squamous cell carcinoma. Mediastinoscopy gave true negative findings in 90.8% of the T1 patients, true positive findings in 7.6% and false negative findings in 1.6%. The comparable rates were 76.7%, 17.0% and 6.3% in T2 patients. The 5-year survival rate was 91.3% for T1N0M0 patients (n = 64) who underwent non-radical dissection (= NRD), and 69.4% for those (n = 70) who underwent radical dissection (= RD). The rate with NRD was significantly better (p < 0.006). The 5-year survival rate was 63.2% for T2N0M0 patients (n = 62) undergoing NRD, and 49.8% for those (n = 72) undergoing RD, but the difference was not significantly. Distant metastasis was a common cause of death, whereas there were no deaths due to local recurrence in the T1N0M0 patients, whether NRD or RD was performed. These results support our opinions that preoperative mediastinoscopy and intraoperative node staging are sufficient for assessment of the N factor in T1 and T2 lung cancer, and that mediastinal node dissection should not be performed in T1N0M0 patients.

[Correlation between DNA content and amplification of oncogenes (c-myc, L-myc, c-erbB-2) and correlation with prognosis in 143 cases of resected lung cancer].

DNA content analysis using flow cytometry and amplification of c-myc, L-myc, and c-erbB-2 oncogenes in 143 cases of resected lung cancer were analyzed using the same specimen, and we examined the correlation with prognosis of DNA content and amplification of oncogenes. There were 54 DNA diploid cases (38%), 81 DNA aneuploid cases (57%) and 8 DNA multiploid cases. Analysis of oncogene amplification revealed 22 cases of c-myc, 4 cases of L-myc, and 22 cases of c-erbB-2. In curatively resected cases, the 5-year survival rate was 65% in 31 DNA diploid cases, and 36% in 40 DNA aneuploid cases. There was a statistically significant difference between the two groups (p < 0.02). However, in non-curatively resected cases, the 5-year survival rate was 11% in 23 DNA diploid cases, and 33% in 49 DNA aneuploid cases. There were no statistically significant differences among these groups. The correlation between DNA content and amplification of oncogenes was as follows. In DNA diploid cases, there were 4 cases of c-myc, and 6 cases of c-erbB-2. In DNA aneuploid cases, there were 15 cases of c-myc, 4 cases of L-myc, and 15 cases of c-erbB-2. In DNA multiploid cases, there were 3 cases of c-myc, and 1 cases of c-erbB-2. Amplification of oncogenes was seen more frequently in DNA aneuploid and multiploid cases than in DNA diploid cases. In 71 curative resected cases, the 5-year survival rate for amplified cases of c-myc (10 cases) was 0%, and that of cases with no amplification was 61% (no statistically significant difference). The 5-year survival rate for amplified cases of c-erbB-2 (10 cases) was 40%, against 52% for cases with no amplification. DNA content analysis using flow cytometry was more convenient than analysis of amplification of oncogenes, and reflects the prognosis of resected lung cancer better than oncogenes. There was no relation between DNA content and gene amplification.

[A resected case of leiomyosarcoma of the esophagus--the diagnosis was supported with DNA content analysis].

A case of leiomyosarcoma of the esophagus was reported. The tumor was located in the lower esophagus. The esophagus was very stenotic, but the mucosa was clear. We thought the tumor had not invaded the mucosa. Enucleation was performed on the tumor. The tumor was encapsulated, so at the time of operation, the microscopic diagnosis was leiomyoma. However, after the operation, the diagnosis was changed to the leiomyosarcoma, because there are many spindle-shaped atypical cells, and many mitoses. We also analyzed the DNA content of the tumor. The DNA index of this tumor was 0.9 and 1.48, therefore, this tumor was DNA aneuploidy. The result of DNA content analysis showed that the tumor is malignant. DNA content analysis is helpful for diagnosis of this kind of sarcoma, because microscopic examination can not readily distinguish benign leiomyoma from malignant leiomyosarcoma. This patient was still alive one year after the operation. Thus, we thought that enucleation of the tumor is a good operational procedure to the leiomyosarcoma of the esophagus, if the tumor is polypoid type and encapsulated.

The role of mediastinoscopic biopsy in preoperative assessment of lung cancer.

Between 1970 and 1989, mediastinoscopy and thoracotomy were performed on 619 patients admitted to our clinic with lung cancer. When mediastinoscopy was analyzed by lymph node location, the highest sensitivity (95.7%) was for the left paratracheal nodes and the lowest (64.0%) was for nodes at the bifurcation (p < 0.01). The 5-year survivals according to the results of mediastinoscopy were 47% for negative results, 14% for false-negative results, and 6% for positive results. The 5-year survival rate however, was significantly higher (28%) in patients (n = 13) with positive mediastinoscopic findings who underwent complete resection of the primary tumor and all involved nodes than in patients (n = 78) who underwent incomplete resection (p < 0.01). These data support our opinion that patients with positive mediastinoscopic results should not always be excluded from treatment by thoracotomy. The role of mediastinoscopy is not to select patients for thoracotomy but to evaluate lung cancer at the pretreatment stage.

[Diagnosis, incidence, clinicopathology and surgical treatment of acquired tracheobronchomalacia].

We report our recent findings on the diagnosis, incidence, appearance of the trachea at autopsy, and surgical treatment of acquired trachobronchomalacia. In the diagnosis of this disease, continuous dynamic CT scanning (1 slice/0.6 second) from inspiration to deep expiration was better than X-ray cine recording. It is difficult to observe the most collapsed airway on coughing using bronchofiberscopic recording, because its duration time was estimated to be 1/10 second by X-ray cine recording, whereas the findings at one instant were easily recorded by video-bronchoscopy on coughing. The degree of severity of this disease was classified into three groups. 1st degree 0-50% narrowing of airway caliber, 2nd degree 50-75%; and 3rd degree 75-100%. Severity of 2nd or 3rd degree was present in 542 (12.7%) of 4283 patients suffering from chest disease who underwent bronchoscopy. Seventy-two percent of patients were aged 50 to 80 years. Third degree tracheomalacia was found in 131 patients with an incidence of 3.1%, which increased from 2.2% at 50 years to 6.2% at 80 years. The autopsy findings of the trachea consisted of fragmentation of the tracheal cartilage and extension of the membranous portion. The pathogenesis may be varied with different types of collapse of the airway, including the saber sheath type and the crescent type. Surgical treatment consists of prevention of the airway collapse by wrapping the airway with Marlex mesh and bonding Lyodura (lyophilized dura mata) with fibrin glue, which is more reliable than the span plasty proposed by Nissen.

[Surgical treatment of lung cancer with mediastinoscopic positive lymph nodes].

There are no definite criteria for the indication of surgery in lung cancer with mediastinal lymph node involvement. During the past 20 years, 100 patients (76 patients with adenocarcinoma and 24 patients with squamous cell carcinoma) have undergone thoracotomy for lung cancer with mediastinoscopic positive lymph nodes at our hospital. Of these, relatively curative resection was performed on 13 patients. The 5-year survival rate in these 13 patients was 28%, which was significantly higher than the 0% in 42 patients with relatively non-curative resection and the 0% in 26 patients with absolutely non-curative resection. The 5-year survival rate was 9% in both T1 (n = 14) patients and T2 (n = 37) patients. No T3 (n = 21) and T4 (n = 9) patients survived 3 years. The 5 year survival rate in patients with squamous cell carcinoma was 12% and that in patients with adenocarcinoma was 0%, but there was no significant difference. The survival rates of T1 and T2 patients were significantly higher than that of T3 patients (p less than 0.02 and p less than 0.005) respectively. Contralateral mediastinal lymph node metastasis (N3) was observed significantly more frequently in patients with adenocarcinoma (38%) than in those with squamous cell carcinoma (13%), but there was no significant difference in the survival rate. In N2 patients, the survival rate was compared between those with mediastinal nodal involvement of an early stage (N2-1) and those with lymph node metastasis of more advanced stage (N2-2) according to the lobe bearing the primary cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chest wall reconstruction using polyester mesh].

Using polyester, we prepared a new material for chest wall reconstruction. The polyester mesh has the same rigidity and elasticity as Marlex tracheal mesh. From January 1987 through July 1991, we performed chest wall reconstruction using the polyester mesh in 8 patients with lung cancer, 9 with empyema after open drainage, 2 with metastatic chest wall tumors, 1 with a primary osteogenic giant cell tumor originating from the rib and 1 with radiation dermatitis and costal chondritis. Three or more ribs were resected in 17 patients. The defects of the chest wall were reconstructed with the polyester mesh covered with a GORE-TEX soft tissue patch to achieve air tightness. Fifteen cases have passed at least one year with no sign of infection. In conclusion, the polyester mesh prevents flail chest and seems to be a satisfactory material for chest wall reconstruction.

[Surgical indications for thoracotomy in cases of small advanced lung cancer by use of DNA content analysis and mediastinoscopy].

Twenty-seven patients with small advanced lung cancer were treated at Kyoto Katsura Hospital. Of 27 patients, 19 patients underwent thoracotomy. The mean survival time of the 19 resected patients was 49 months, while that of the 8 unresected patients was 36 months. There was no statistically significant difference between these mean survival times. Of the 19 resected patients, 6 patients underwent a relative curative operation (RCO), 4 patients underwent a relative noncurative operation, and 9 patients underwent an absolute noncurative operation. The respective mean survival times were 79 months, 30, and 33. We compared the mean survival time of RCO cases with that of the unresected cases, and there was a significant difference in favor of the RCO cases. So we recommend thoracotomy for patients with small advanced lung cancer if RCO is possible, and that requires of a histological classification of less than N2. We performed mediastinoscopy for 18 of the 27 patients to check for mediastinal lymph node metastasis, and 16 of those patients were confirmed to have metastasis pathologically. Mediastinoscopy is useful and reliable for confirming lymph node metastasis, because it gives us a pathological diagnosis. We also performed DNA content analysis on the 19 resected cases. There were 7 DNA diploidy cases, 11 DNA aneuploidy cases, and 1 case couldn't be determined. There was no significant difference between the mean survival times of DNA diploidy cases and the DNA aneuploidy cases.