Successful surgical removal of an intrapulmonary aberrant needle under fluoroscopic guidance: report of a case.

We describe herein the successful surgical removal of an intrapulmonary aberrant needle. An asymptomatic 47-year-old woman underwent a routine chest X-ray which revealed a needle located in the right S8 area. We first tried to extract the needle; however, fluoroscopic examination confirmed that it had broken into two pieces and therefore, partial resection of the right S8 was performed. To avoid rethoracotomy, the operation was done under fluoroscopic guidance. An intrathoracic aberrant needle should always be removed surgically as soon as possible, even if the patient is asymptomatic, due to the possibility of its migration into the vessels and the development of lung abscess or pyothorax.

Invasion beyond interlobar pleura in non-small cell lung cancer.

STUDY OBJECTIVE: To assess the outcome of lung cancer with invasion beyond interlobar pleura and to clarify whether it should be treated in the same way as invasion to the parietal pleura or to other visceral pleura. DESIGN: Retrospective analysis. SETTING: Tokyo Medical College Hospital. PATIENTS: Eighteen resected non-small cell lung cancers with invasion beyond interlobar pleura were studied. The outcomes of those patients, those with parietal pleural invasion, and those with other visceral pleural invasion were compared. Patients with rib invasion, mediastinal organ invasion, or distant metastasis were excluded. RESULTS: The 5-year survival rate for patients with invasion beyond interlobar pleura was 34.2% and the median survival time was 56.5 months. The outcome was significantly better than that of patients with parietal pleural invasion. There was no significant difference between the outcome of invasion beyond interlobar pleura and that of other visceral pleural invasion. In patients without lymph node metastasis, similar results were obtained. There was no difference between the outcome of patients with invasion beyond interlobar pleura, who undergo lobectomy with a parietal resection of the invaded lobe, and that of patients with visceral pleural invasion, who undergo lobectomy. CONCLUSIONS: The behavior of patients with invasion beyond interlobar pleura is different from that of patients with parietal pleural invasion and should be categorized as T2. The optimum operative method was lobectomy with only parietal resection of the invaded lobe to preserve the pulmonary function.

[Intratumoral heterogeneity of DNA content in lung adenocarcinoma].

Quantitative microspectrophotometry was performed in 10 resected lung adenocarcinomas for the purpose of studying intratumoral heterogeneity of DNA content. Histologically, there were 3 stage I, 2 stage IIIA, 2 stage IIIB, and 3 stage IV cases, consisting of 3 well, 4 moderately and 3 poorly differentiated cases. The tumors were cut at the greatest dimension and fine needle aspirations were performed from 5 separate areas (central, cranial, caudal, inward, and outward). One of the imprint smears was submitted for cytology and the other for microspectrophotometry using Feulgen staining. Although G0G1 and G2M phase cell populations varied in each specimen, all 5 specimens showed the same DNA histogram in 9 cases. These were 4 aneuploid, 4 polyploid (euploid but not diploid) and only one diploid tumor. Two stem lines were observed in the remaining single case. One of 5 specimens showed aneuploid, the other 4 specimens showed polyploid. Namely, intratumoral heterogeneity was observed in one case. Ther was no relationship between intratumoral heterogeneity tumor size or differentiation. Most lung adenocarcinomas showed DNA stability. Fine needle aspiration specimens obtained from one area of lung adenocarcinoma represent the DNA contents of the entire tumor.

Outcome of patients with early stage lung cancer.

A study was conducted to evaluate the outcomes of 79 patients with early stage lung cancer diagnosed according to the following criteria. Central tumors were located in the segmental bronchi, or more proximally, and tumor invasion was limited to the bronchial wall without lymph node or distant metastases. Peripheral tumors were located distal to the subsegmental bronchi and were less than 2 cm in greatest dimension, and invasion was limited to the visceral pleura, with no lymph node or distant metastases. The 5-year survival rate was 100% for patients with peripheral type early squamous cell carcinoma, 94.6% for those with central-type early squamous cell carcinoma, and 79.3% for those with early adenocarcinoma. The 5-year survival rate for patients with central-type squamous cell carcinoma without pericartilage layer invasion was 97.0%, and that for those with T1N0M0 peripheral squamous cell carcinoma was 100.0%. To define early stage lung cancer as curable, it should be defined as T1N0M0, peripheral squamous cell carcinoma, or central squamous cell carcinoma without pericartilage layer invasion. For other histologic types, some added parameters are needed. The rate of multiple lung cancers was 10.1% and that of multiple primary malignant disease was 13.9%. Thus, careful followup of patients with early stage lung cancer should be carried out, as second malignancies in the lung and elsewhere are commonly detected.

[Blunt thoracic injury].

Of 161 patients with blunt thoracic injury, 135 were male (83.9%) and 26 were female. The most common cause of injury was traffic accidents (130 patients, 80.7%), followed by falls (22 patients), and crushing (7 patients). There were 46 third decade and 36 second decade patients. Thirty-two patients had single thoracic injury and the other had multiple organ injury. The most common associated injury was head injury (65 patients). Most traffic accidents involved motor cycle accident. Forty-four patients died, 32 within 24 hours, and 4 died to thoracic injury. These 4 patients were shock on arrival and died within 24 hours. The injury severity score, which was under 30 in 78.3% of patients, correlated to the mortality rate. Rib fracture was the most common thoracic injury in 96 patients followed by hemothorax in 91, pulmonary contusion in 79, and pneumothorax in 64. Most of the thoracic injuries were treated conservatively. Thoracotomy was performed in 6 patients. Other than one patient with rupture of the left pulmonary vein, 5 patients recovered. Continued bleeding at a rate of more than 200 ml/h from the chest drainage tube or no recovery from shock and large air leakage preventing re-expansion of the lung are indications for emergency thoracotomy. Thoracotomy should also be considered after conservative treatment in patients with continued air leakage or intrabronchial bleeding negatively affecting respiration. Indications for thoracotomy should be determined individually based on evaluating of vital sign.

Cavitating adenocarcinoma of the lung.

The characteristics and outcomes of resected adenocarcinoma with cavity formation were studied in 7 cases, which were 14.9% of all 47 resected adenocarcinomas in the past three years. Tumor size was less than 3 cm in diameter in 3 cases, 3 to 5 cm in 2 and more than 5 cm in 2. Cavities were multiple in 4 cases and single in 3. Cavities were divided into 4 types pathologically. 1. Central necrosis type: central ischemia was suspected. This type was observed in 2 cases that died due to cancer. 2. Cancer cell lining type: the inner wall of the cavity was lined by viable cancer cells without necrosis. The cause of this type may be detachment of the central portion of a papillary growth tumor without necrosis. One of three patients died from cancer. The others are alive without recurrence. 3. Bronchial expansion type: the inner wall was composed of cancer cells and bronchus. This may be caused by ectatic change of peripheral bronchi following tumor invasion to more central bronchi. One of this type of case died due to myocardial infarction. 4. Alveolar expansion type: the inner wall was composed of cancer cells and alveoli. Detachment of destroyed alveoli or invasion along the wall of cavities of a honeycomb lung was suspected as a possible cause. One of this type of case is alive. Cavity formation can occur in adenocarcinoma even when the tumor is small. However there were few inflammatory related findings in adenocarcinoma with cavity formation. The outcome of the central necrosis type was especially poor, suggesting rapid tumor growth.

[Current trends and problems in disclosure to lung cancer patients].

To assess current trends in the disclosure of cancer, we studied patients with primary lung cancer. Ninety-nine of 101 surgical patients (98.0%) and 96 of 128 non-surgical patients (75.0%) had been informed of their illness. Family members of 2 surgical patients refused to allow disclosure due to concerns about mental intolerance. Reasons for non-disclosure to non-surgical patients ranged from rejection by family members (29 patients) to a lack of ability to understand (3 patients). No mental problems were observed after disclosure. All but 11 patients were informed of their cancers by their physicians. Decisions regarding disclosure were not related to the pathological type or clinical stage of the cancer. For example, small cell carcinoma did not influence methods of or decisions concerning disclosure. Among non-surgical patients, the frequency of disclosure decreased with aging. However, no clear-cut factor appeared to influence the disclosure of metastatic sites. Views about informed consent are still at a transitional stage in Japan. The doctrine that patients have the right to be informed of their cancers and to choose their treatment has not always been the best policy in practice. Nevertheless, it seems desirable that approaches to disclosure adequately reflect the special needs of each patient and provide as much information as possible to allow each patient to make an accurately informed decision about treatment options. Such approaches would foster better relationships between physicians and their patients and relieve physicians from pressure to tell a medical lie.

Spontaneous haemothorax associated with von Recklinghausen's disease: review of occurrence in Japan.

The case history is presented of a 61 year old man with von Recklinghausen's disease who developed a spontaneous haemothorax. In spite of being asymptomatic for five days after drainage, he died as a result of fatal sudden re-bleeding. The post mortem examination showed dissection and rupture of the left subclavian artery. Microscopically, disarrangement of smooth muscle and decrease of elastic fibre was observed in the ruptured artery. Haemothorax in patients with von Recklinghausen's disease may require thoracotomy, even if the condition of the patient appears to be stable.

Primary lung cancer of the middle lobe. Is its prognosis poor?

The right middle lobe is unique because it is surrounded by two other lobes and the pericardium, and it is the smallest lobe. The proper surgical treatment and prognosis for cancer of the right middle lobe has not been definitively established. In order to clarify its prognosis and the best operative technique, 31 surgically treated patients with lung cancer of the right middle lobe were studied clinically and pathologically. The outcome of surgical treatment of the right middle lobe cancer was compared with other locations in the lung. The 5-year survival rate of this group was 51.5%, with a median survival time of 82.3 months. For resectable cases, the outcome for carcinomas of the middle lobe was no worse than for other locations. However the rate of exploratory thoracotomy was highest for the right middle lobe. All five patients with lobectomies are alive and disease free at 26.4-151.4 months. The 5-year survival rate of 23 bilobectomies was 40.0%, with a median survival time of 48.4 months. The difference between lobectomy and bilobectomy cases was statistically significant (P < 0.025). When the tumor was limited to the completely separated middle lobe without dissemination, pulmonary or mediastinal lymph node metastasis, lobectomy was sufficient for curative treatment.

Primary pulmonary lymphoma diagnosed by gene rearrangement: report of a case.

We report herein the case of a 59-year-old asymptomatic man who was referred to our department for investigation of an abnormal shadow detected on a routine chest roentogenogram. Computed tomography (CT) showed an infiltrative shadow and air bronchogram in the right middle lobe without mediastinal lymphadenopathy, and a right middle lobectomy was performed with hilar and interlobar lymph node excision. Microscopically, the tumor consisted of small lymphoid cells without atypia, admixed with neutrophils and other mononuclear cells, but there was no invasion of the bronchial cartilage or visceral pleura, or any lymph node involvement. Most of the tumor cells were positive for L26 and some for UCHL-1. Although a germinal center was not seen, pseudolymphoma could not be ruled out. Southern blot analysis of the frozen tissues revealed clonal rearrangements of the immunoglobulin heavy-chain JH and light-chain J kappa, whereby the tumor was diagnosed as malignant lymphoma of the small lymphocytic B-cell type. Thus, when such lymphoproliferative diseases which are difficult to diagnose are encountered, frozen tissue should be preserved for genetic analysis.

[Staged bilateral upper lobectomy of pathologically different synchronous double primary cancer].

A case of double primary lung cancer was reported, one of which was peripheral type of adenocarcinoma of the right lung and the other was central type of squamous cell carcinoma of the left. A 66-year-old male was referred to our hospital on Nov. 2 1991, because a coin lesion at the right S1 was pointed out on chest X-ray. On bronchoscopy, a nodular tumor at the orifice of the left B3 was unexpectedly found. Biopsy of the left B3 tumor and washing cytology of the right B1 led to a diagnosis of left moderately differentiated squamous cell carcinoma (clinical T1N0 M0) and right adenocarcinoma (clinical T1N0M0). A right upper lobectomy was first performed with R2 lymph node dissection on Nov. 25 1991. Post-operatively, it was confirmed that the lesion was histologically poorly differentiated adenocarcinoma of the right S1, and the pathological stage was T2N0M0. Two weeks after the operation, chemotherapy of CDDP, VDS and MMC was given because of suspicion of rapid metastasis to the left hilar lymph nodes. Left upper lobectomy with R2 dissection was performed 7 weeks after the initial operation. Pathological findings showed squamous cell carcinoma originating from B3 with inflammatory lymphadenopathy and pathological evaluation was T1N0M0. He was discharged after an uneventful course of 3 weeks after the second operation. There are many reports that limited operations are recommended for each lesion in double primary lung cancer to reserve the pulmonary function. However, limited interventions cause frequently local metastasis, especially in peripheral type adenocarcinoma more than 3 cm in diameter and central type squamous cell carcinoma with lymph node metastasis.(ABSTRACT TRUNCATED AT 250 WORDS)

[A comparative study of the effect of granisetron and a combination of granisetron plus steroids on cancer chemotherapy induced emesis].

Effects of 40 micrograms/kg of granisetron monotherapy (K group) and concurrent therapy with a steroid (KS group) on acute and delayed emesis induced by cancer chemotherapy which included CDDP at a dose of 60 mg/m2 or more were compared in random clinical trials under the central registration method. In KS group, either 500 mg of methylprednisolone succinate or 8 mg of dexamethasone phosphate was given prior to granisetron administration. Clinical symptoms such as vomiting, nausea and anorexia were better in KS group than in K group, on any day from day 1 to day 7, and there was a statistically significant difference on day 1 and day 2. The cumulative total control rate throughout the period of seven days was also significantly higher in KS group. KS group was rated higher in the final clinical evaluation based on doctor's impressions, but there was no significant difference between the two groups. Augmented antiemetic effect of granisetron by concurrent therapy with a steroid was most notably demonstrated in male patients under 60 years of age. The antiemetic effect at the acute stage was proven to influence the final clinical effectiveness, thus suggesting the importance of antiemetic therapy of acute emesis. Adverse reactions were seen in two out of 122 patients (1.6%). They were slight headache and moderate diarrhea in 1 case each, both of which disappeared soon, confirming the high safety profile of granisetron.

[Targeting therapy for lung cancer].

Many approaches have been developed to targeting therapy for lung cancer. The representatives types have included photodynamic therapy (PDT), bronchial arterial infusion of anticancer agent and/or embolization, intensification of the effect of drugs on tumor tissue and drug delivery systems (DDS) using liposomes. In our hospital, 195 lung cancer patients, including those with 56 early stage lesions, have been treated with PDT, and a CR rate of 65.2% was obtained. Bronchial arterial infusion (BAI) for clinical N2, in-operable non-small cell lung cancer patients has prolonged median survival time compared to the patients treated without BAI. Combined modalities of chemotherapy and low power laser (He-Ne Laser) irradiation in the experimental animal model have been shown. This combined therapy may permit enhancement of the antitumor effects of routine chemotherapy by reducing the side effects of the drug. DDS using liposomes may well be a major targeting therapy for lung cancer. In our data, trans-bronchial injection of chemotherapeutic drugs encapsulated with liposomes will be most effective for mediastinal lymph node metastasis of lung cancer.

Recurrence at the bronchial stump after resection of lung cancer.

OBJECTIVE: Recurrence at the bronchial stump frequently is difficult to diagnose before the disease progresses. Patients with recurrence at the bronchial stump after surgical treatment were studied to clarify characteristics. SUMMARY BACKGROUND DATA: Reports on this type of recurrence are few. METHODS: Between January 1979 and December 1988, 625 primary lung cancers were resected. Fourteen patients (2.2%), in whom recurrence occurred at the bronchial stump, were studied pathologically and clinically. RESULTS: Eight tumors (57.1%) were squamous cell carcinomas, five (35.7%) were adenocarcinomas, and one (7.1%) was small cell carcinoma. Pathologically, six tumors (42.9%) were stage I, four (28.6%) were stage II, two (14.3%) were stage IIIA, and two (14.3%) were stage IV. Eight patients had bloody sputum at recurrence; two cases were asymptomatic. Submucosal tumors were observed bronchoscopically at recurrence in 11 patients. Considering lymphadenopathy on chest x-ray, the submucosal type recurrence may have been direct invasion from metastatic lymph nodes. The periods from the operation to the recurrence were 7 to 102 months (mean 28.8 months). In 8 of 14 patients, recurrence was observed within 24 months. All but one patient died within 24 months of recurrence detection. CONCLUSIONS: Long survival could be expected only if there were no metastases in the mediastinal lymph nodes. If the tumors were detected earlier, it was possible to cure the tumors by intensive therapy, even in submucosal type recurrence. Regular bronchoscopic examination is needed to diagnose the recurrence at the bronchial stump as early as possible.

[A case report of mediastinal malignant lymphoma with long survival following combination chemotherapy using adriamycin, vincristine and cyclophosphamide].

Mediastinal B-cell malignant lymphoma of a 22-year-old female was successfully treated by combination chemotherapy including Adriamycin, Vincristine and Cyclophosphamide. She suffered from dyspnea and axillary tumor in September 1984. Roentgenological examination revealed a large anterior mediastinal tumor. Biopsy of the axillary tumor yielded a diagnosis of metastatic undifferentiated carcinoma from thymus by hematoxylin and eosin. Radiotherapy and chemotherapy including CDDP and ACNU resulted in a symptom-free period of only 2 months. Superior vena cava syndrome and massive pleural effusion recurred. Salvage chemotherapy including Adriamycin, Vincristine and Cyclophosphamide resulted in rapid therapeutic effect. Six courses of chemotherapy were administered, and she is alive and well 4 years after the first salvage chemotherapy. A definitive diagnosis of B-cell lymphoma was made after review of biopsy specimens using immunohistochemical procedures. To select adequate treatment for mediastinal malignant lymphoma, reliable diagnostic procedures including immunohistochemistry are needed. Intensive chemotherapy with appropriate drugs may obtain good response even in advanced cases, such as this.

[Surgical indications of small cell carcinoma of the lung].

A statistical analysis of 143 cases of small cell carcinoma treated at the Department of Surgery of Tokyo Medical College in the 15-year period from January 1968 to December 1982 was performed. The results suggest that surgery is not indicated in any oat cell case, with the possible exception of an extremely rare early stage case. However, since here is a significant difference in the survival of stage I and II cases of the intermediate cell type, surgery can be indicated in certain such cases. Even in such cases surgery should be thought of as merely one step of induction therapy. In addition, it is necessary to tailor adjuvant chemotherapy, keeping in mind that the most frequent causes of death in cases of small cell carcinoma of the lung are local failure, metastasis to intraabdominal organs and to the brain.