Impact of main bronchial lymph node involvement in pathological T1-2N1M0 non-small-cell lung cancer: multi-institutional survey by the Japan National Hospital Study Group for Lung Cancer.

PURPOSE: According to the TNM classification revised in 1997, stage II non-small-cell lung cancer (NSCLC) has an unfavorable prognosis. The purpose of this study was to analyze the prognostic factors for pathological T1-2N1M0 patients with NSCLC and elucidate the significance of main bronchial lymph nodes involvement. METHODS: This retrospective study analyzed patients in a prospective database of cases from an 11-year period (operations from 1992 to 2002, follow-up data until March 2008) obtained from the Japan National Hospital Study Group for Lung Cancer. Among them, a total of 319 patients with pathological T1-2N1M0 disease were identified, and all dissected lymph nodes were classified using the Naruke map. RESULTS: The cumulative overall 5-year survival rate for patients with intralobar or interlobar lymph node involvement (n = 266) was 56.8%, and that for those with main bronchial lymph node involvement (n = 53) was 40.4% (P = 0.002). Among patients with multiple-station N1 nodal involvement including the main bronchial lymph nodes, patients with a lower lobe tumor (n = 12) had a significantly worse prognosis than those with an upper lobe tumor (n = 9) (13.3% vs. 55.6%, P = 0.033). Multivariate analysis demonstrated that age, histology, tumor size, and main bronchial lymph node involvement were independent prognostic factors for patients with pathological T1-2N1M0 disease. CONCLUSION: Involvement of the main bronchial lymph nodes is a significant factor to predict a worse prognosis in pathological T1-2N1M0 patients with NSCLC.

Long-term follow-up study of a population-based 1996-1998 mass screening programme for lung cancer using mobile low-dose spiral computed tomography.

Early diagnosis and treatment are important for improvement of the low survival rate of patients with lung cancer. The objective of this study was to evaluate the long-term survival rate of patients identified to have lung cancer by our population-based baseline and annual repeat low-radiation dose computed tomography (low-dose CT) screenings, conducted in 1996-1998. A total of 13,037 CT scans were obtained from 5480 subjects (2969 men, 2511 women) aged 40-74 years at the initial CT screening. Lung cancer was detected in 63 subjects (57 were detected by CT scans and underwent surgery; 1 was detected by sputum cytology and underwent surgery; 3 rejected treatment; and 2 were interval cases that developed symptoms prior to the next annual repeat CT screening). Follow-up study included review of medical records. Death certificates were examined to check for any deceased interval case among participants. Postoperative follow-up of the 50 survived patients ranged from 70 to 117 (median, 101) months. Eight patients died during follow-up (6 due to lung cancer from 20 to 67 months after surgery and 2 deaths unrelated to lung cancer, each 7 and 60 months following surgery). Three patients who rejected treatment died 14 months to 6 years after positive screening CT scans, and the 2 interval cases died at each 17 and 30 months, respectively, following negative screening CT scans. Survival was analysed in 59 patients with lung cancer detected by low-dose CT screening (excluding two patients; one was detected by sputum cytology and the other had mass lesion already noted on the chest radiograph of the previous year). The 10-year survival calculated by the Kaplan-Meier method was 83.1% (95% CI: 0.735-0.927) for death from all causes and 86.2% (95% CI: 0.773-0.951) for death from lung cancer. The survival rate was excellent for never-smokers, patients with BAC and adenocarcinoma/mixed types with non-solid CT density pattern, associated with Noguchi's type A or B and pathologic stage IA. A poorer prognosis was noted in smokers with adenocarcinomas/mixed types, associated with part-solid or solid CT density pattern and Noguchi's type C or D. All patients with non-solid tumours measuring 6-13.5mm at presentation are alive, patients with part-solid tumours, measuring 17mm or more, or solid tumours, measuring 13mm or more at presentation were associated with increased risk of lung cancer-related morbidity or mortality. The estimated rate of possible over-diagnosis was 13% in total and we failed to cure 17% of patients encountered in the programme. Low-dose CT screening substantially improves the 10-year survival for lung cancer with minimal use of invasive treatment procedures.

CT findings of early-stage small cell lung cancer in a low-dose CT screening programme.

The survival of patients with small cell lung cancer (SCLC) is related to T, N, M components, and early diagnosis and treatment of limited stage SCLC may improve survival. The objective of this study was to review the initial and annual repeat screening computed tomography (CT) images of all five patients with SCLC, encountered in our 1996-1998 population-based screening for lung cancer, to clarify any subtle, characteristic CT findings of early-stage small cell lung cancer. The medical records of the patients were reviewed to examine demographic and clinical features. We identified characteristic CT features of SCLC in the lung periphery, which were related to gross pathologic findings with longitudinal spread along the bronchial wall: a small spindle-shaped or pyramidal lesion was found as a subtle CT finding of SCLC, and irregularly shaped nodular lesions (vermiform, pine-cone-like or tandem-like nodular lesions) appeared at a more advanced stage. Tumour volume doubling time of the cases ranged from 38 days to 217 days. All five patients were male smokers: four patients underwent surgery and adjuvant chemotherapy; three of them remain alive, while the remaining patient, an interval case, died of lung cancer. One patient refused treatment and died of a cause other than lung cancer. Annual repeat CT screening was useful for detecting SCLC cases mostly at a curable stage, and information about CT features, presented here, should help physicians identify SCLC at an earlier-stage and lead to a more successful treatment of the disease.

Effects of expiratory pressure on nitric oxide in exhaled breath. Is exhaled nitric oxide really unaffected by pressure?

The measurements of exhaled nitric oxide (ENO) concentrations in several previous reports have been quite disparate but the cause of this variability is unclear. In the present study, we have attempted to elucidate the effects of expiratory pressure upon ENO values by taking measurements at pressures ranging from 2 to 10 cmH2O in control subjects and in both smokers and asthmatics. Differences in ENO concentrations (delta pNO) were then estimated and the concentration levels were found to increase with elevated expiratory pressure levels in both the control volunteers and in the asthmatics (under 2 and 3 L/min flow rates). These results indicate that changes in expiratory pressure indeed affect ENO concentrations. The measurement of ENO concentrations in human patients must therefore be undertaken using standard procedures that must incorporate expiratory pressure levels in order to properly interpret ENO values.

Granular cell tumor of the mediastinum.

Mediastinal granular cell tumor is an exceptionally rare tumor; there are only a few previously reported cases. We report a 21-year-old man with a granular cell tumor in the right posterior mediastinum. Chest computed tomography scans and magnetic resonance imaging revealed a 15x20 mm well circumscribed, homogeneous mass, which was closely associated with the vertebral column. The T1-weighted magnetic resonance image showed low intensities, and moderate intensities were found on the T2-weighted magnetic resonance image. Gd-DTPA enhancement was remarkable on the tumor surface. The present case differed from ordinary neurogenic tumors in magnetic resonance imaging findings. Thoracoscopic resection of the tumor was performed. The tumor was associated with the sympathetic nerve. Histologic analysis revealed a benign granular cell tumor.

CT findings and progression of small peripheral lung neoplasms having a replacement growth pattern.

OBJECTIVE: We investigated the imaging findings and progression of replacement lung neoplasms that were revealed on thin-section CT and serial CT. MATERIALS AND METHODS: We evaluated the age of patients and thin-section CT findings (lesion size; percentage of ground-glass opacity areas; and presence or absence of solid portions, lobulation, coarse spiculation, air bronchogram, cavity, multiplicity, and pleural tags) in 73 lesions (11 atypical adenomatous hyperplasias, 17 type A [Noguchi's classification], 18 type B, and 27 type C small peripheral adenocarcinomas). We compared the serial findings of 48 of 73 lesions on low-dose screening CT (n = 21) or thin-section CT (n = 27) obtained at a mean interval of 450 days (range, 85-951 days). Progression from atypical adenomatous hyperplasia through type A to type B and then to type C tumor was studied using trend tests. RESULTS: A significant linear trend was seen for lesion size (r = 0.55; p < 0.001), percentages of ground-glass opacity areas (r = 0.75; p < 0.001), and the prevalence of lobulation (p < 0.001), spiculation (p = 0.001), air bronchogram (p = 0.023), cavity (p = 0.046), pleural tag (p < 0.001), and solid portions (p < 0.001). In general from serial CT assessment, lesions were recognized first as a ground-glass opacity nodule (56% of 48 lesions) with subsequent increase in size (75%), then solid portions appeared in the nodule (17%), and finally solid portions increased (23%) with occasional augmentation of tissue contraction (6%). CONCLUSIONS: CT analysis revealed stepwise progression of replacement-type lung neoplasms.

Alveolar shrinkage in bronchioloalveolar carcinoma without central fibrosis.

Preservation of alveolar architecture in small bronchioloalveolar carcinoma (BAC) is one of the most important factors for predicting their prognosis, alveolar shrinkage in BAC, however, has not been studied well. In ten cases of pure BAC without collapse or central fibrosis, we measured two two-dimensional (2D) parameters; side-length of the alveoli facing alveolar ducts and circumference of the alveoli forming complete circles. And we also examined three-dimensionally (3D) elastic fibers and myofibroblasts in the thick sections. In BAC, 2D parameters showed alveolar shrinkage. The elastic fibers forming the alveolar framework, including the alveolar orifice, were 3D sinuous and bent in BAC, and suggested that alveolar shrinkage cased by folding of the alveolar wall. Myofibroblasts lay transversely and longitudinally in the interstitium in BAC, intertwined with the elastic fibers. Proliferation of myofibroblasts may be of importance in alveolar wall-folding and alveolar shrinkage in BAC.

Prognostic significance of high-resolution CT findings in small peripheral adenocarcinoma of the lung: a retrospective study on 64 patients.

OBJECTIVE: We studied the prognostic importance of high-resolution CT (HRCT) findings in lung adenocarcinomas. PATIENTS AND METHODS: HRCT findings (lesion size, percentage of ground-glass opacity (GGO) areas of lesion, and presence or absence of lobulation, coarse spiculation, air space, pleural tag, and multiplicity of lesion), clinical data (age and surgical method), and pathologic findings (tumor subtypes and presence or absence of nodal metastasis) in 64 consecutive patients with 64 peripheral adenocarcinomas of 20 mm or less (mean, 13 mm), including 36 women and 28 men with a mean age of 64 years were analyzed and correlated with survival of the patients using Kaplan-Meier method and stepwise Cox proportional hazards modeling. Follow-up periods of the patients ranged from 6 to 45 months (mean, 22 months). Tumors were classified into six subtypes (types A-F) according to tumor growth patterns defined by Noguchi et al. RESULTS: Six (9%) of the 64 patients died of lung cancer. In univariate analyses, a significant difference was noted for lesion size (P=0.043), the percentage of GGO areas (P=0.005), and tumor subtypes (P=0.006). Lesion size of <15 mm (n=35), a lesion with GGO areas of >57% (n=36), and type A (n=16) or type B adenocarcinomas (n=16) indicated a significantly better survival. In multivariate analyses using these three parameters as independent variables, the percentage of GGO areas was the only significant independent factor for survival (P=0.044, relative risk=0.95). CONCLUSION: GGO areas measured on HRCT may have an independent prognostic significance of small adenocarcinomas of the lung.

Chest wall myxoma protruding into the thoracic cavity.

Myxoma protruding from the chest wall into the thoracic cavity is very rare. We report our experience in treating a 42-year-old man admitted for a painless mass on the anterior chest wall. Magnetic resonance imaging showed a sharply defined 5 x 4 x 4 cm mass protruding from the chest wall into the thoracic cavity, which we excised surgically. Histologically, the tumor proved to be a myxoma.

[A case of hemoptysis caused by vegetable foreign body (cryptomeria) and actinomycosis].

A 54-year-old man was admitted to our hospital with hemoptysis. Chest radiography and chest CT scanning demonstrated atelectasis in the right middle lobe. Bronchoscopy showed nothing of abnormal appearance. We performed a middle lobe lobectomy suspecting that the continuing hemoptysis was caused by the lesion in the middle lobe. Histologically, a vegetable foreign body (cryptomeria) was recognized in a bronchiole of the middle lobe, surrounded by inflamed tissues and sulfur granules. It was suggested that all of these were the cause of the hematoptysis. The patient was discharged on the fourteenth postoperative day, and has been asymptomatic since. This was a very rare case of hemoptysis caused by a vegetable foreign body and actinomycosis.