A laceration of left internal mammary artery caused by an amateur golfer's swing.

We report the rare case of a patient presenting with a spontaneous laceration of left internal mammary artery (LIMA) after playing golf. The patient had no specific history except for cardiac surgery, and there were no results that caused bleeding on preoperative examination. A computed tomography (CT) scan of the chest demonstrated an anterior mediastinal hematoma and a left hemothorax with active extravasation close to LIMA. Through thoracotomy, hematoma evacuation and clipping for lacerated artery were performed. The patient was discharged in stable condition on the sixteenth postoperative day. This is the first reported case of a spontaneous laceration of internal mammary artery (IMA) after playing golf.

Thoracoscopic Bilateral Bullectomy for Simultaneously Developed Bilateral Primary Spontaneous Pneumothorax: Ipsilateral Transmediastinal versus Bilateral Sequential Approach.

Background Simultaneously developed bilateral primary spontaneous pneumothorax (BPSP) is an indication for thoracic surgery of both sides. Recently, we have reported a new technique for BPSP, which is ipsilateral apicoposterior transmediastinal (TM) bullectomy of both sides using video-assisted thoracoscopic surgery (VATS), and we compared this TM VATS with bilateral sequential (BS) VATS for BPSP. Materials and Methods From June 2003 to May 2014, 11 and 14 patients were performed VATS TM and BS bullectomy for BPSP, respectively. We reviewed the medical records and compared the clinical data between the two groups. For TM group, we first performed the right VATS bullectomy and approached through the apicoposterior mediastinal region for contralateral VATS. In the other group, conventional BS VATS bullectomy was performed in the lateral decubitus position change. Results The mean follow-up was 62.0 ± 32.6 months. No mortality and major complications were observed. The operative time (68.18 ± 24.93 vs. 96.07 ± 37.73, p = 0.046), duration of left pleural drainage (1.00 ± 0.45 vs. 3.21 ± 1.37, p = 0.000), and length of hospital stay (3.82 ± 1.54 vs. 4.93 ± 1.07, p = 0.044) were significantly shorter in the TM group than in the BS group. No significant differences were seen in duration of general anesthesia, total number of wedge resections and endostaplers used in both lungs, duration of right drainage, and postoperative recurrence. Conclusion The TM VATS approach may be a safe and feasible modality for BPSP. It may decrease the operative time, patients inconvenience such as bilateral multiple wounds and longstanding placement of chest tubes, and decrease the hospital stay compared with the BS VATS approach.

Collaborative treatment of huge intrathoracic meningoceles associated with neurofibromatosis type 1: a case report.

BACKGROUND: An intrathoracic meningocele is a relatively rare disease, and it commonly accompanies neurofibromatosis type 1. Patients tend to have no symptom but if its size is too large and compresses a lung and neighboring organs, it needs shunt drainage or surgical resection. CASE PRESENTATION: Herein, we present the case of a 52 year-old female patient with huge intrathoracic meningoceles associated with neurofibromatosis type 1, who has complained about chest discomfort and dyspnea at rest. As for a preliminary treatment, a neurosurgeon had performed a cystoperitoneal shunt, but the symptoms continued and the size of mass and the amount of pleural effusion did not change significantly. Therefore, the huge thoracic meningoceles were successfully treated through the thoracotomic approach in combination with lumbar puncture and cerebrospinal fluid drainage. CONCLUSIONS: It is reported that double huge intrathoracic meningoceles associated with neurofibromatosis type 1 was successfully treated by a shunting procedure followed by thoracotomic resection with collaboration of a neurosurgeon.

Factors predictive of the failure of medical treatment in patients with pleural infection.

BACKGROUND/AIMS: The clinical outcomes of some patients with pleural infection may be favorable with medical treatment alone, but in others, the disease progresses and requires additional surgical treatment. However, little is known about the factors affecting this difference. The aim of this study was to investigate the factors predictive of failure of medical treatment in patients with pleural infection. METHODS: A cohort of 127 consecutive patients who were admitted to the hospital with pleural infection was studied. Clinical manifestations and laboratory findings in patients in whom medical treatment succeeded or failed were reviewed. RESULTS: In univariate analysis, the significant factors associated with medical treatment outcome were age, smoking history, duration of chief complaint, serum albumin level, and pleural fluid glucose and lactate dehydrogenase levels (p < 0.05). Multivariate logistic regression analysis identified age and duration of chief complaint as independent predictive factors for failure of medical treatment, with odds ratios of 0.871 (p = 0.013) and 0.797 (p = 0.026), respectively. Receiver operating characteristic curve analysis determined cutoff values of 50.5 years for age and 4.5 days for duration of chief complaint. CONCLUSIONS: We demonstrated that a younger age < 50.5 years and shorter duration of chief complaint < 4.5 days were independent predictive factors for the failure of medical treatment in patients with pleural infection. This suggests their role as evaluative criteria in setting indications for the optimal treatment in patients with pleural infection. A larger, prospective study is required to confirm these findings.

Changes of cardiac troponin I and operative mortality of coronary artery bypass.

BACKGROUND: Recently, cardiac troponin I has been used to detect myocardial injury because of its superior cardiac specificity. However, there has been debate about the appropriate timing and cutoff level of cardiac troponin I to detect perioperative myocardial injury after coronary artery bypass grafting. The objective of this study was to define the relationship between operative mortality and changes in cardiac troponin I after isolated coronary artery bypass. PATIENTS AND METHODS: A retrospective analysis was carried out on data of 218 isolated coronary artery bypass patients who were operated on between June 2009 and February 2012. All patients followed an institutional perioperative management protocol that included 6 cardiac troponin I measurements (preoperatively and 0, 12, 24, 36, and 48 h after coronary artery bypass). According to the patterns of cardiac troponin I, the patient cohort was divided into 2 groups. Group 1 was patients in whom cardiac troponin I levels decreased 24 h after the operation, and group 2 comprised the patients with cardiac troponin I levels that did not decrease or even increased after 24 h. RESULTS: The operative mortality was 4.1% (9/218). Group 2 showed significantly higher mortality (5/25, 20%) than group 1 (4/193, 2.1%). CONCLUSION: An elevated cardiac troponin I level is common after coronary artery bypass. A persistently high level of cardiac troponin I after 24 h is an important predictor of operative mortality after coronary artery bypass surgery.

Fluoroscopy-assisted thoracoscopic resection for small intrapulmonary lesions after preoperative computed tomography-guided localization using fragmented platinum microcoils.

BACKGROUND: Preoperative localization is frequently necessary to perform thoracoscopic resection of a small and/or deeply located intrapulmonary lesion. We developed a new method that uses a fragmented platinum microcoil, and retrospectively evaluated the efficacy of our technique. METHODS: Between January 2006 and May 2010, self-made microcoils (Easimarker) were used to localize total 32 lesions (21 solid nodules, and 11 ground glass opacities) in 30 patients. Computed tomography-guided localization was performed into, or just around the lesions. Localized lesions were resected using fluoroscopy-assisted thoracoscopic surgery (FATS), and the histopathologic diagnosis was confirmed. The accuracy and complications of the localization procedure, and operative results of FATS were observed. RESULTS: Mean size and depth of all lesions were 11.8 ± 5.1 mm (range: 3 to 22) and 12.2 ± 7.1 mm (range: 2 to 30). CT-guided localizations were successfully performed in all lesions. Four minimal pneumothorax and one parenchymal hematoma related with localization procedure occurred. There were three repeated procedures, which resulted from pleural rebounding of the microcoils. There were two microcoil detecting failures due to intrathoracic displacement during FATS. All 32 resected lesions were histopathologically diagnosed. CONCLUSION: CT-guided localization using the fragmented microcoil combined with FATS of small intrapulmonary lesions is a safe, effective, and a diagnostically accurate procedure.

Thoracoscopic simultaneous bilateral bullectomy through apicoposterior transmediastinal access for bilateral spontaneous pneumothorax: a challenging approach.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) through transmediastinal access (TMA) for contralateral thoracic cavity is an operative alternative for bilateral pulmonary lesions. Recently, we introduced a novel method of apicoposterior TMA to perform simultaneous VATS bilateral bullectomy (BB) for bilateral spontaneous pneumothorax (BPTX). We retrospectively analyzed ten patients on whom this procedure was performed and evaluated the effectiveness of this approach. METHODS: From April 2006 to May 2010, ten patients underwent simultaneous BB through this approach. Mean postoperative follow-up was 33.2 months. All patients were young males (age range = 15-20 years) and eight patients had BPTX that developed simultaneously. Apical blebs or bullae were carefully identified using multidirectional high-resonance computed tomography (HRCT). VATS right bullectomy was done first. The left thorax was reached by going through the apicoposterior mediastinum between the esophagus and vertebral bodies, and then left procedure was performed through this access. RESULTS: All ten patients successfully underwent VATS BB through TMA without intraoperative complications. One patient developed prolonged air leakage for 6 days on the right side. During the follow-up period, two patients developed left PTX recurrence; one was treated with a chest tube at 13 months, and another underwent a left VATS reoperation at 20 months postoperatively because of new bulla formation around the previous stapling line. CONCLUSIONS: A VATS apicoposterior transmediastinal approach is relatively safe and technically reliable for highly selective BPTX patients who have localized blebs or bullae on the left apical lung. Pleural reinforcement procedures may also be required for the prevention of postoperative recurrence.

Thoracic air-leak syndromes in hematopoietic stem cell transplant recipients with graft-versus-host disease: a possible sign for poor response to treatment and poor prognosis.

Bronchiolitis obliterans (BO) or bronchiolitis obliterans organizing pneumonia (BOOP) is one of manifestations of graft-versus-host disease (GVHD), a complication of hematopoietic stem cell transplantation (HSCT). Recently there are reports about thoracic air-leakage syndrome (TALS), but real incidence, clinical course, and implications of TALS remain unclear. Retrospective review of 18 TALS patients among 2,177 patients who received allogeneic HSCT between January 2000 to July 2007 was done. Clinical manifestations, treatments, and outcomes of TALS were reviewed. The incidence of TALS was 0.83% (18/2,177). The onset of TALS was mean 425.9+/-417.8 days (60-1,825 days) after HSCT, and the duration was mean 16.3+/-21 days (2-90 days). The most common types of TALS were spontaneous pneumothroax (n=14), followed by subcutaneous emphysema (n=6), pneumomediastinum (n=5), interstitial emphysema (n=2), and pneumopericardium (n=1). TALS persisted in six patients, who died during the same hospitalization. The 12 patients recovered from TALS, but only 2 survived, while others died due to aggravation of GVHD. TALS may complicate BO/BOOP and be an initial manifestation of BO/BOOP. TALS is hard to be resolved, and even after the recovery, patients die because of aggravation of GVHD. We suggest specifically in HSCT patients, when once developed, TALS seems hard to be cured, and as a result, be related to high fatality.

[A case of carcinosarcoma in a patient with corrosive esophagitis].

Carcinosarcoma of the esophagus is a rare malignancy accounting for approximately 1-2% of all esophageal neoplasms. It presents as a bulky intraluminal polypoid lesion mainly in the mid to lower esophagus, which harbors both carcinomatous and sarcomatous components histologically. It often presents relatively early because of its rapid intraluminal growth. We report the case of a 69-year-old man who had suffered from dysphagia for 1 month. He was previously admitted to the hospital due to corrosive esophagitis caused by ingestion of acetic acid. Endoscopy and radiological studies revealed a bulky polypoid mass with superficial ulcerations and mucosal friability, measuring 10 cm in length approximately, in the mid-esophagus. Subtotal esophagectomy with esophagogastrostomy was done. Microscopically it was composed of sarcomatous component intermingled with squamous cell carcinoma. Immunohistochemical stains reveal cytokeratin, 34betaE12, and p63 positivity in the nests of carcinoma, and desmin and vimentin positivity in the spindle cells of sarcomatous stoma.

Thoracoscopic stapled resection of multiple esophageal duplication cysts with different pathological findings.

Esophageal duplication cyst is a rare congenital esophageal anomaly of the foregut. This cyst usually occurs in isolation, and thus far, was treated by enucleation through thoracoscopic or thoracotomic surgery. Here we report a case of multiple esophageal duplication cysts that showed different pathological findings, i.e., the cysts were lined with pseudostratified ciliated columnar and stratified squamous epithelium. Esophageal cysts were incidentally detected in a 53-year-old man during the treatment of pneumonia. In chest-computed tomography, the cysts showed a thin wall and homogeneous inner density, while in endoscopy, no communication with esophageal mucosa was observed. We resected the esophageal cysts with endo-staplers under thoracoscopic surgery. No postoperative complications, including esophageal mucosal injury, occurred. A follow-up chest computed tomography revealed the complete resection of the cysts.

Immunohistochemical analysis of non-small cell lung cancer: correlation with clinical parameters and prognosis.

Non-small cell lung cancers (NSCLC) vary in their biologic behavior. Recurrence and tumor-related mortality may be attributable to molecular abnormalities in primary tumors. This study evaluated such immunophenotypes with regard to cell cycle regulation and proliferation, apoptosis, and angiogenesis, to determine their significance for patient outcome. Core biopsies from 219 patients with NSCLC were assembled on tissue microarrays, and the expressions of p16, p21, p27, cyclin B1, cyclin E, Ki-67, caspase-3, survivin, bcl-2, VEGF, and endostatin were evaluated by immunohistochemistry. Despite previously described prognostic relevance of some of the investigated molecules, many of those markers were not directly associated with recurrence or survival. However, there was a trend for p16 immunoreactivity to be associated with a good prognosis (57% vs. 42% in 5-yr survival) (p=0.071). bcl-2 expression was strongly correlated with a better outcome (65% vs. 45% in 5-yr survival) (p=0.029), and the hazard of death for bcl-2 positive patients was 0.42 times of that for bcl-2 negative patients (p=0.047). A multivariate analysis with Cox proportional hazards model confirmed that the lymph node status (p=0.043) and stage (p=0.003) were other independent prognostic factors. Our results suggest that p16 and bcl-2 provide prognostic information independent of the TNM stage in NSCLC.

Primary polymorphous low-grade adenocarcinoma of lung treated by sleeve bronchial resection: a case report.

We report a surgical case of primary polymorphous low-grade adenocarcinoma (PLGA) of the minor salivary gland-type of the lung. A PLGA originating from the right upper lobar bronchial inlet was successfully treated by sleeve right upper lobectomy. PLGAs are thought to be indolent tumors that are preferentially localized to the palate, and they affect the minor salivary glands almost exclusively. Until now, two cases of distant metastases to the lung have been reported in the English literature. To the best of our knowledge, only one case of PLGA of minor salivary gland-type of the lung without evidence of a previous oropharyngeal primary tumor has been reported in the English literature. But the case was not a single lesion; it was bilateral tumors accompanied by tumors of the cervical lymph nodes. We report here the first case of a single primary PLGA of the minor salivary gland-type of the lung, which was successfully treated by sleeve bronchial resection of right upper lobe.

Thoracoscopic direct suture repair of thoracic duct injury after thoracoscopic mediastinal surgery.

Iatrogenic chylothorax is an uncommon thoracic duct injury, but well-known and serious complication after thoracic surgeries. Recently, video-assisted thoracoscopic surgery has been applied in the management of postoperative chylothorax and could be indicated earlier. We report herein a case of postoperative chylothorax managed successfully by early thoracoscopic direct suture repair of the site of chylous leak that developed after the thoracoscopic resection of mediastinal mass and surrounding fat with ectopic thymus in a patient with persistent myasthenia gravis with non-Hodgkin lymphoma.

Modification of thoracoscopic surgery for spontaneous pneumothorax.

Morbidity, use of analgesics, postoperative drainage, and hospital stay are reduced after video-assisted thoracoscopic surgery for pneumothorax. However, some surgeons prefer a minithoracotomy because the rate of recurrence after thoracoscopic surgery is 5%-10%. A modified thoracoscopic bullectomy is described, which has the advantages of both conventional video-assisted thoracoscopic surgery and a minithoracotomy. Of 69 patients who underwent surgery for pneumothorax from January 2002 to February 2003, 13 were treated by conventional video-assisted thoracoscopic surgery and 21 by the modified thoracoscopic bullectomy. The mean ages were 20.6 years in the conventional group and 23.0 years in the modified group, with follow-up of 25.8 +/- 1.8 months in the conventional group and 20.6 +/- 1.3 months in the modified group. The duration of operation was similar in both groups (49.3 +/- 16.0 vs. 44.2 +/- 19.2 min). Significantly fewer staples were used in the modified group (1.62 +/- 0.74 vs. 2.92 +/- 1.19). The duration of chest tube drainage and postoperative hospital stay were significantly reduced in the modified group. The modified thoracoscopic bullectomy is an effective procedure for the treatment of primary spontaneous pneumothorax.

Current surgical therapy for patients with tuberculous abscess of the chest wall.

BACKGROUND: Although anti-tuberculosis medication is essential for the treatment of tuberculous abscess of the chest wall, surgical treatment also plays an important role. We report our surgical experience for patients with tuberculous abscess of the chest wall. METHODS: The series was comprised of 16 patients with tuberculous abscess of the chest wall, and they were treated from May 1996 to June 2003 at St. Vincent's Hospital, Suwon, Korea. The data were retrospectively reviewed. RESULTS: Tuberculous abscesses were managed by combined anti-tuberculosis medication and surgery of either abscess excision with rib resection (11 abscesses) or abscess excision alone (7 abscesses). The overall rate of rib involvement for abscess was 44.4 % (8 abscesses in 7 patients), and the rate of rib involvement was not much different according to the extent of the chest wall involvement. The incidence of performing a second surgical procedure was higher in the following groups: (1) the group with pathologic evidence of bone involvement (3 of 7 patients vs 1 of 9 patients), (2) the group that was not given preoperative anti-tuberculosis medication (4 of 7 patients vs none of 9 patients). CONCLUSIONS: In managing tuberculous abscess of the chest wall, extensive abscess excision with rib resection is considered to be important. Preoperative anti-tuberculosis medication may play an important role in reducing the postoperative complication, including abscess recurrence.

The safety and efficacy of second-line single docetaxel (75 mg/m²) therapy in advanced non-small cell lung cancer patients who were previously treated with platinum-based chemotherapy.

PURPOSE: When used in the second-line setting, single-agent chemotherapy has produced response rates of more than 10% or median survival times greater than 4 months. We studied the safety and efficacy of using second-line single docetaxel (75 mg/m²) for advanced NSCLC patients who were previously treated with platinum-based chemotherapy in Korea. MATERIALS AND METHODS: Thirty-three patients with advanced NSCLC received chemotherapy from May 2002 to January 2005. We retrospectively reviewed the charts of these patients. The patients received 75 mg/m² of doxetaxel on day 1 and this was repeated at 3-week intervals. RESULTS: The median age was 63 years (range: 42~77 years); 16 patients had adenocarcinoma and 8 patients had squamous cell carcinoma. The median number of cycles was 4 (range: 1~7 cycles). Of the 33 patients, 6 patients had partial responses, 13 patients had stable disease and 14 patients had progressive disease. The response rate was 18.2%. The median overall survival was 11 months (range: 7~15 months), and the median progression free survival was 5 months (range: 3~7 months). The median response duration was 5 months (range: 4~9 months). A total of 137 cycles were evaluated for toxicity. We observed grade 3 or 4 neutropenia in 79 cycles (57.6%), grade 3 or 4 leukopenia in 46 cycles (33.6%), and grade 3 febrile neutropenia in 2 cycles (1.5%). The median nadir day was day 9 (range: day 5~19), and the median number of G-CSF injections was 2 (range: 0~6). The most common non-hematologic toxicities were myalgia/arthralgia and neurotoxicity, but any grade 3 or 4 non-hematologic toxicity was not observed. The major toxicity of this therapy was neutropenia. The absolute neutrophil count decreased relatively rapidly, but neutropenic fever or related infection was rare. There were no treatment-related deaths. CONCLUSION: These results revealed a satisfactory response rate (18.2%) with using docetaxel as the second-line chemotherapy for NSCLC. The second-line docetaxel was an active and well-tolerated regimen in patients with advanced NSCLC pretreated with platinum-based chemotherapy.

Expression of caspase-3 and c-myc in non-small cell lung cancer.

PURPOSE: Caspase-3 is a cysteine protease that plays an important role in the process of apoptotic cell death, but little has been studied clinically on caspase-3 in lung cancer. Increased c-myc expression can result in mitosis or apoptosis, and its contribution to the pathogenesis and prognosis of lung cancer has gained interest. In the present study, the expressions of caspase-3 and c-myc, along with their possible correlations with prognostic variables, were analyzed in resected non-small cell lung carcinomas (NSCLC). MATERIALS AND METHODS: Archival tumor tissues from 147 previously untreated NSCLC patients were examined by immunohistochemistry for the expressions of caspase-3 and c-myc proteins. Clinical information was obtained through the computerized retrospective database from the tumor registry. RESULTS: The expressions of caspase-3 and c-myc were detected in 60 (88/147) and 16% (24/147) of tumors, respectively. No association was found between caspase-3 and c-myc expressions. A multivariate analysis demonstrated the N status and pathologic stage to be significantly correlated with poor survival (p-value=.018 and .002, respectively), but positive expression of caspase-3 was associated with a good prognosis (p=.03). CONCLUSION: Our data suggest the involvement of caspase-3 in the tumorigenesis of NSCLC. It is also noteworthy that caspase-3 expression might be a favorable prognostic indicator in these tumors.

Expression of c-kit and p53 in non-small cell lung cancers.

PURPOSE: Increasing experimental evidence indicates that abnormal expression of c-kit may be implicated in the pathogenesis of a variety of solid tumors. It has been reported that over 70% of small cell lung cancer (SCLC) contain the c-kit receptor. In the present study, a c-kit analysis has been extended to non-small cell lung cancer (NSCLC). The expressions of p53, vascular endothelial growth factor (VEGF) and cd34, in addition to c-kit, were evaluated to investigate the correlations between these proteins and to determine their potential relationships with the clinicopathological data. MATERIALS AND METHODS: Paraffin-embedded tumor sections, obtained from 147 patients with NSCLC, were immunohistochemically investigated using anti-c-kit, anti-p53, anti-VEGF and anti-cd34 antibodies. RESULTS: c-kit was expressed in 40 (27%) of the tumors examined: 27% of the adenocarcinomas, 27% of the squamous cell carcinomas and 29% of the undifferentiated carcinomas. p53 and VEG F immunoreactivities were present in 107 (73%) and 110 (75%) carcinomas, respectively. Anti-cd34 was negative in all samples. No associations were established among these proteins. The c-kit, however, showed a strong correlation with the T factor: T1 (n=11), 0%; T2 (n=49), 16% and T3 (n=87), 37% (p=.006). CONCLUSION: It is suggested that in NSCLC c-kit is expressed relatively frequently and may become a therapeutic target for the patients with inoperable or recurrent c-kit positive tumors. The alterations in p53 probably constitute an early event, whereas the activated c-kit may contribute to tumor progression.

Effect of Vinorelbine, Ifosfamide and Cisplatin Combination Chemotherapy in Stage III-IV Non-Small-Cell Lung Cancer.

PURPOSE: To evaluate the response rates, toxicitiesy, and survival rates, to vinorelbine (Navelbine(R)), cisplatin and ifosfamide combination chemotherapy, of the patients with inoperable NSCLC (stage III and IV), who received vinorelbine (Navelbine(R)), cisplatin, ifosfamide combinationthe mentioned chemotherapy every 4 weeks. MATERIALS AND METHODS: This study included 26 patients with inoperable NSCLC (stage III and IV), who attended St. Vincent's Hospital Bbetween April 1999 and December 2001, 26 patients were included at St.Vincent's Hospital. The chemotherapy regimen consisted of vinorelbine (25 mg/m2 on days 1 and 8), ifosfamide (1,500 mg/m2 on days 1- and 2 with mesna), and cisplatin (30 mg/m2 on days 1- to 3). The cycles were administered every 4 weeks. A 25% reduction in the doses reduction was applied into subsequent courses if there werewas grade 3~4 neutropenia. RESULTS: The median age was 63 (range, 44~73) years and the male : to female ratio was 19 : 7. One patient had stage IIIa, 6 had stage IIIb and 19 had stage IV. Twenty two patients had an ECOG performance status of 0 or 1, andwith 4 hadhave one of 2. Eighteen of the patients had adenocarcinoma, 7 had squamous cell carcinomas, and 1 had an undifferentiated NSCLC. Two patients were innot able to be evaluatedble due to follow-up loss. Among Of the 24 patients able to be evaluatedble patients, 1 patient had a complete response and 9 patients hada partial responses, and thewith an overall response rate wasof 41.7%. During a total of 104 cycles, grade 3 neutropenia occurred in 29%, grade 4 neutropenia in 12%, grade 3~4 thrombocytopenia in 4%, grade 3 anemia in 11%, and grade 3~4 mucositis in 2%. The mean time to progression was 6.4 months (range 1~13) and the median overall survival was 10 months (range 1.5~32). CONCLUSION: The combination of vinorelbine, ifosfamide and cisplatin, in the dose and schedule employed in this study, shows an response rate of 41.7%, but, because grade 3- or 4 neutropenia occurred in 41%, a careful investigation is needed.