Video-assisted thoracoscopic surgery of bullous and bleb disorders of the lung using endoscopic stapling device.

The video-assisted thoracic surgical (VATS) approach appears to be a viable alternative to thoracotomy when surgical management of bullous and bleb disorders of the lung is required. Fifty patients with giant bullae (n = 6) and spontaneous pneumothoraces (n = 44) were recently treated by our group using the VATS approach and endoscopic stapling devices. Of the 50 patients, 47 were managed completely by the VATS approach, including six giant bullae that were asymptomatic in five and infectious in one and 41 pneumothoraces, of which 16 were first episode and 25 with recurrent pneumothorax. Median operating times for the bullous and bleb excisions were 147.8 and 45.9 min, respectively (p < 0.01), and median chest tube durations were 5.2 and 1.2 days, respectively (p < 0.05). There was no mortality, and significant morbidity was limited to prolonged air leak in more than 5 days in three patients and postoperative atelectasis in two patients. Median hospital stays of patients with bullous excision was 11.3 days compared with 4.7 days of those with bleb excision. We conclude that the VATS treatment is a safe, effective procedure in patients with bullous and bleb disorders of the lung even in asymptomatic giant bullae or spontaneous pneumothoraces with the first episode. The advantages of the VATS approach for these diseases are ease of operation, less pain, early mobility, and superior cosmetic results.

Characteristics of non-small cell lung cancer 3 cm or less in diameter.

We retrospectively investigated 308 cases of non-small cell lung cancer of < or = 3 cm diameter. There were 204 adenocarcinomas, 78 squamous cell carcinomas, 15 large cell carcinomas, and 11 other carcinomas. According to TNM staging, there were one case stage 0, 208 stage I, 22 stage II, 49 stage IIIA, 15 stage IIIB, and 13 cases stage IV. T1 disease was seen in 262 cases, T2 in 19, T3 in 10, T4 in 16, and Tis in 1. N0 disease was seen in 217 cases, N1 in 30, N2 in 60, and N3 in 1. The 5-year survival rate of all cases was 63%. There were statistically significant differences among T status (T1 vs. T3, T4), N status (N0 vs. N1, N2), and M status (M0 vs. M1) (P < 0.01). The 5-year survival rates of cases with adenocarcinoma and squamous cell carcinoma were 60% and 64%, respectively. In 204 cases of adenocarcinoma, T3 disease was found in one case, T4 disease in 15 (7%), and nodal involvement (N1 + N2) was present in 69 (34%). In 78 cases of squamous cell carcinoma T3 was seen in 6 (8%), T4 in 1, and nodal involvement in 14 (18%). The incidence of T3 disease, T4, and N(+) varied significantly according to histology (P < 0.05). Our investigation suggested that cases of small-sized lung cancer were often at an advanced stage at detection, and that the spread of disease differed according to histology. The patient with small-sized lung cancer should be offered a standard operation regardless of histology.

The close relationship between growth factors and the nucleolar organizer regions in adenocarcinoma of the lung.

We examined immunohistochemically 111 cases of primary adenocarcinoma of the lung, for transforming growth factor alpha (TGF alpha) or epidermal growth factor (EGF), and argyrophilic nucleolar organizer regions (AgNORs). The presence of more than 75% positive cells for both growth factors was designated as a high-GF, while all others were considered to be a low-GF. If AgNORs counts were more than 5.00, it was considered to be a high-AgNORs group, while less than 5.00 was designated as a low-AgNORs group. In our 111 examined specimens, there were 51 (46%) cases of high-GF, and 64 (58%) with high AgNORs. The 5-year survival rates of the patients with a high-GF and low-GF were 34% and 57% (P < 0.05) respectively, while those with high-AgNORs and low-AgNORs were 21% and 81% (P < 0.001), respectively. In the cases of high-AgNORs, the 5-year survival rates of the patients with high-GF and low-GF were 0% and 36% (P < 0.05), respectively. However, in the cases of low-AgNORs, the 5-year survival rates of the patients with high-GF and low-GF were 83% and 79%, respectively. These data suggest that growth factors might be related to the biological malignancy of tumours with a high cell proliferation.

Lymph node cancer of the mediastinal or hilar region with an unknown primary site.

We herein report three cases of lymph node cancer of the mediastinal or hilar region, in which the primary sites could not be determined in spite of performing various systemic examinations. Two cases revealed a large cell anaplastic carcinoma in the mediastinal lymph node, while the other demonstrated a small cell carcinoma in the hilar lymph node. However, based on radiographic and pathological examinations, the primary sites could not be found in either the head and neck, lung, or abdominal organs. All cases underwent surgical resections for lymph node cancer, while two patients also received adjuvant therapy. Two patients experienced recurrence soon after treatment. Despite the rarity of this disease, lymph node cancer must always be kept in mind when an enlargement of either the mediastinal or hilar lymph node is detected in patients with an unknown primary site, and a poor prognosis is generally expected.

Malignant pleurisy and intrathoracic dissemination in carcinoma of the lung: diagnostic, therapeutic and prognostic implications.

Of T4 disease of lung cancer, malignant pleurisy and intrathoracic dissemination are the greatest factor preventing a cure, despite the best efforts of surgery and various adjuvant therapy modalities. Preoperative evaluation of this disease is of first importance using conventional radiology and computed tomography. Of the 43 patients who were intraoperatively diagnosed to be the disease, 8 (18%) appeared on the conventional radiology as small amounts of pleural effusion, and 9 (21%) with a interlobar pleural thickening. Based on CT findings, 16 (67%) had one or more of some disseminated nodules, interlobar pleural thickening and broad pleural indentation. In patients with T4 disease, the 5-year survival rate was 14% in patients with malignant pleurisy and/or intrathoracic dissemination, compared with the 18% in those with direct invasion to great vessels, with no significant difference. According to intrapleural instillation as postoperative adjuvant therapy, the 5-year survival rate was 25% in the patients given interleukin-2, compared with 38 months of survival time for patients prescribed doxorubicin and 33 months for those underwent exploratory thoracotomy. A more favorable prognosis of patients whose malignant pleurisy and/or intrathoracic dissemination are first found at thoracotomy can be expected when postoperative intrapleural instillation of interleukin-2 is prescribed following the resection of the intrathoracic tumors.

Skip mediastinal lymph node metastasis in non-small cell lung cancer.

We retrospectively investigated 186 non-small cell lung cancer cases with N2 disease in order to clarify the significance of skip metastasis. Of the 186 patients with N2 disease, negative N1 nodes recognized to be skip metastasis were seen in 62 patients (33%). The incidence of skip metastasis was not statistically different regarding histology, T status, or M status. The incidence of the skip metastatic site consisted of 35 cases (56%) at sites 1, 2 and 3, while 8 cases (13%) were found at sites 8 and 9. Among the patients with right lung cancer, the skip metastatic incidence for site 7 (subcarinal) was higher in patients with either middle lobe or lower lobe cancer than in those with upper lobe cancer (P < 0.05). The 5-year survival rates of all N2 patients in comparison to those with skip metastasis were 22% and 24%, respectively. When the sites of mediastinal lymph nodes were classified as superior, aortic, and inferior, the 5-year survival rates of the patients with superior skip metastasis, aortic metastasis, and inferior metastasis were 23%, 36%, and 15%, respectively. No statistical difference was observed. The 5-year survival rate of the skip N2 patients with only aortic region involvement was 50% (n = 7). However, no statistically significant difference was found between the two groups (P = 0.08). Our results thus suggested that mediastinal involvement for the aortic region alone might have a better prognosis than the others. We thus conclude that a dissection of the complete hilar and mediastinal lymph nodes should be the procedure of choice in standard operations for non-small cell lung cancer because of the high frequency of skip metastasis.

Prognostic influence of the co-expression of epidermal growth factor receptor and c-erbB-2 protein in human lung adenocarcinoma.

The epidermal growth factor receptor (EGFR) is structurally similar to the c-erbB-2 oncogene protein. One hundred and nineteen specimens of primary human lung adenocarcinoma were investigated immunohistochemically for the expression of EGFR and the c-erbB-2 protein. Positive staining for EGFR was evident in 55 (46%), and c-erbB-2 protein in 33 (28%) cases. Of the 119 cases, the number staining positively for both the EGFR and c-erbB-2 protein totalled 16 (13%). The incidence of both the expression of EGFR and the c-erbB-2 protein was greater in patients with metastasis1 (M1) than in those with M0 (P < 0.01). The 5-year survival rates of patients with EGFR positivity and those with EGFR negativity were 51% and 42% respectively, however, the results did not show statistical significance. On the other hand, the 5-year survival rates of patients with c-erbB-2 positivity and c-erbB-2 negativity were 30% and 52%, respectively, with statistical significance (P < 0.05). Of the cases with EGFR positivity the 5-year survival rates of patients with c-erbB-2 positivity (n = 16) and negativity (n = 39) were 33% and 59%, respectively, with statistical significance (P < 0.05). In contrast, for the EGFR negative cases, the 5-year survival rates of patients who were positive (n = 17) and negative (n = 47) for c-erbB-2 expression were 27% and 46%, respectively, which were not significantly different. Our data thus suggested that erbB oncogenes may play an important role in both the development of cancer and the prognosis of adenocarcinoma of the lung.

Neoadjuvant chemotherapy in patients with small-cell lung-cancer - radiographic and clinicopathological analysis.

A comparative study on the effect of neoadjuvant chemotherapy was performed for small cell lung cancer, by radiographic and histopathological examinations. Four patients with small cell lung cancer were preoperatively treated with the combination of cyclophosphamide, doxorubicin, vincristine, nimustine, cisplatin and vindesine, for 2 to 3 cycles. The clinical responses to the neoadjuvant chemotherapy included 2 complete, one partial response and one no change. All four patients underwent a planned operation. Based on microscopical evidence, the two complete responders had a residual tumor in the resected specimens. One was tumor-free after 28 months, while the other succumbed to operation-related death at 2 months. The remaining two inadequate responders relapsed and died shortly following operation. We believe a clinically complete responder should be differentiated from a 'true' complete responder by histopathological examination.

[Intraoperative intraperitoneal administration of CDDP against gastric cancer with peritoneal dissemination].

This study was undertaken in order to evaluate the effect of intraoperative intraperitoneal (i.p.) administration of CDDP on patients who underwent gastrectomy for gastric cancer with peritoneal dissemination, compared with MMC or OK-432 i.p. administration group and untreated group. The median survival time was 11 months in CDDP i.p. group (35 patients), 8 months in MMC or OK-432 Ip group (33 patients) and 7 months in untreated group (25 patients). 1- and 2-year survival rates were 30.4% and 12.1% for MMC or OK-432 i.p. group, and 28% and 8% for untreated group, while in CDDP i.p. group, the rates were higher at 46.4% and 14.7%, respectively (CDDP i.p. group vs. untreated group, p less than 0.05). In vitro chemosensitivity test by succinate dehydrogenase inhibition (SDI) test supported the clinical results. CDDP had higher sensitivities than MMC and ADM on poorly differentiated cases as well as peritoneal dissemination cases. Our results suggest that intraoperative i.p. administration of CDDP was useful for the treatment of gastric cancer with peritoneal dissemination.