[Three cases of pulmonary aspergilloma treated by cavernostomy and simultaneous removal of fungus balls].

We report 3 cases of pulmonary aspergilloma treated by cavernostomy and simultaneous removal of fungus balls to eliminate their symptoms. They presented with hemoptysis and prolonged fever with cavitary lesions in their lungs. It was difficult to perform pulmonary resection for them, because of their high age, low respiratory function, and poornutrition. Treatment with anti-fungal agents, obtained no marked effects and thier symptoms were unchanged. Therefore we carried out cavernostomy and simultaneous removal of fungus balls for symptom management. After the surgical treatment, not only did their symptoms improve, but also we were able to maintain good symptom control for a long time. The burden of the surgery on the patients was light and no complications ensued. We strongly believe that cavernostomy and removal of the fungus ball is one of the useful treatment strategies for the patients with pulmonary aspergilloma who are high risks for pulmonary resection and/or who are poorly controlled with anti-fungal chemotherapy.

(18)F-FDG-PET/CT findings of granulocyte colony stimulating factor (G-CSF)-producing lung tumors.

Tumors producing granulocyte colony stimulating factor (G-CSF), malignant lung tumors in most cases, are rare, and patients present with abnormal elevations of the white blood cell (WBC) count in the absence of any infectious disease. We present the (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) imaging findings of two cases of G-CSF-producing tumor. PET-CT showed abnormally high uptake of (18)F-FDG not only by the tumor itself but also diffusely throughout the bone marrow. Following resection of the tumor, the blood G-CSF level as well as the WBC count dropped down to normal range in both cases. Histopathological examination of the resected tumor specimens revealed the presence of an enormous number of inflammatory cells within the tumors and positive immunostaining of the tumor cells for G-CSF. The (18)F-FDG-PET/CT findings could be explained by the elevated bone marrow metabolism associated with the excessively active production of granulocytes under G-CSF stimulation, and the (18)F-FDG uptake by the inflammatory cells also contributing to the total tumor uptake of (18)F-FDG. These characteristic imaging findings are expected to be useful for the diagnosis of G-CSF-producing tumors.

Tuberous sclerosis complex complicated by pulmonary multinodular shadows.

A 41-year-old woman with a history of epilepsy was referred for multiple nodular ground-glass opacities on a chest computed tomography (CT) scan. They were initially suspected of representing atypical adenomatous hyperplasia or well-differentiated adenocarcinoma. However, the subsequent brain CT and magnetic resonance imaging (MRI) scans revealed a coarse nodular calcification and cortical tubers. A subungual fibroma was also noted. Histological examination of a video-assisted thoracoscopic lung biopsy specimen disclosed multiple nodules of type II pneumocyte hyperplasia with septal thickening. Based on all of these findings taken together, a diagnosis of tuberous sclerosis complex with multifocal micronodular pneumocyte hyperplasia (MMPH) was made.

[A case of pulmonary aspergillosis presenting the pulmonary arterial supply suggested with dynamic MRI].

A 67-year-old man with a past history of pulmonary tuberculosis had been referred to our department complaining of bloody sputum. The chest radiograph on admission showed a cavity in the left upper lung field. Chest CT showed a mass-like fungus ball in the cavity. Pulmonary aspergillosis was diagnosed from the sputum mycology, serum Aspergillus antigen and antibody. Even though 150 mg per day Funguard (micafungin sodium) was given intravenously for 4 weeks, the pulmonary aspergillosis did not improve. Dynamic MRI obtained 20 seconds after intravenous injection of contrast material revealed penetrating vessels in the wall of the cavity, and dilated and proliferative vessels surrounding the cavitary lesion. On the basis of the MRI findings which suggested the risk of massive hemoptysis, we performed left upper lobectomy. The histological specimen revealed dilated pulmonary arteries in the wall of the cavity, corresponding to the penetrating vessels on MRI. This is the first report of radiologic-pathologic correlation using dynamic MRI for pulmonary aspergillosis, to the best of our knowledge.

[Combined effect of micafangin and itraconazole on severe aspergillosis of the bilateral pleural cavities in a patient with Wegener's granulomatosis].

Visceral fungal infections are difficult to manage in patients with collagen diseases and immunocompromised hosts. In particular aspergillosis can be a life-threatening complication in these patients. Here we report that combined use of two antifungal agents (micafangin and itraconazole) was effective against severe aspergillosis of the bilateral pleural cavities in a 48-year old male patient diagnosed with Wegener's granulomatosis. Immunosuppressive therapy with corticosteroids and cyclophosphamides improved his nasal and pulmonary symptoms, but inflammation of the bilateral pleural cavities caused bronchial fistulas. Aspergillus fumigatus then infected the bilateral pulmonary cavities through these fistulas. This patient was treated with combined therapy of ITCZ and MCFG was given to this patient because of the risk of renal dysfunction associated with AMPH-B. After 5 weeks of treatment his clinical findings had improved and the fungus was suppressed.

[Two cases of mature mediastinal teratoma complaining of sudden chest pain].

We report two cases of mature mediastinal teratoma complaining of sudden chest pain. Both cases had cystic lesions, multilocular and unilocular, and pleural effusion. One case had fat density by CT and MRI and calcification was not recognized in either case. Surgical resection of the tumor revealed pancreatic tissue in both cases, suggesting that pancreatic enzymes might have led to the rupture of the tumor. The diagnosis of teratoma and its rupture should be considered in the cases of cystic lesion in mediastinal with sudden onset of chest pain.

[Developmental mechanism of the "lung ball"--with reference to the pathological findings of the lung in two resected cases].

The lung ball is a special type of pulmonary aspergillosis (PA) occurring often after chemotherapy for leukemia. Histologically the ball, with air crescent sign on roentgenogram, is compatible with necrotizing lung tissue admixed with Aspergilli. The lung ball differs entirely from the common "fungus ball" in its quality, though they are similar in roentgenological appearances. The present two cases were leukemia which showed pulmonary findings in their therapeutic course, resulting in lung resection. In both cases the lung ball was confirmed histopathologically. Immunostaining of the lung tissue for neutrophil elastase showed elastase in various sites in the bronchial wall, pulmonary blood vessels (artery, vein) and cavitary wall. In our previous studies, much importance was attached to the disturbance of the pulmonary circulation caused by fibrin deposition as a factor in the developmental course of the fungus ball type aspergillosis (semi-invasive type). The circulatory disturbance of the lung was recognized also in the present cases. This two-way destruction of the pulmonary tissue, resulting from both neutrophil elastase activities and pulmonary circulatory disturbances, were regarded as the most important factor for the development of the lung ball. There are few studies on aspergillar lung ball with regard to the above respects.

[The usefulness of 11C-Choline-positron emission tomography in the diagnosis of sclerosing hemangioma of the lung--a case report].

A 64-year-old woman was admitted to our hospital for further examination of an abnormal shadow in the left lung, that had grown slowly for 9 years. Bronchial brushing cytology was performed under bronchoscopy, but was negative for malignancy and for other significant findings. 11C-Choline-positron emission tomography (11C-Choline-PET) showed medium-level uptake in the mass lesion in the S 6 lobe of the left lung, but 18F-fluorodeoxyglucose-positron emission tomography (18FDG-PET) did not yield any such result. These findings suggested the presence of a slowly growing benign tumor, or a neoplastic disease, such as a potentially malignant tumor or a low-grade malignancy. To arrive at a diagnosis, a left partial lobectomy was performed on January 29, 2001. The microscopic findings of this mass lesion showed a solid, hemorrhagic pattern; papillary projections into spaces covered or lined by cuboidal cells, and sheets of round to polygonal cells. The histological diagnosis of this tumor was a sclerosing hemangioma. Recently, 18FDG-PET has been proven to be a clinically useful tool for the detection and staging of malignant tumors, and the follow-up of malignant diseases after treatment; while 11C-choline was recently reported to be a new PET tracer used to visualize various malignancies. The uptake of 11C-choline in tumors represents the rate of tumor cell duplication. It is suggested that 11C-choline-PET may be useful in the diagnosis of sclerosing hemangioma, as in this case.