Composite resection of the left upper lobe and superior segment (S6) of the lower lobe for lung cancer with a mediastinal lingular and basal pulmonary artery.

BACKGROUND: Preoperative evaluation and awareness of anatomical variations in the pulmonary vessel is essential for a secure pulmonary resection. We herein present a patient who underwent complex pulmonary resection for lung cancer with a mediastinal lingular and basal pulmonary artery that had been detected by preoperative three-dimensional computed tomography. CASE PRESENTATION: The patient was an asymptomatic 66-year-old woman who had a 39-pack-year smoking habit. Chest computed tomography (CT) revealed the tumor invading the left upper bronchus and pulmonary artery branches in the left upper lung lobe. Enhanced CT and three-dimensional (3D) images of the pulmonary artery revealed that pulmonary artery branches (A4 + 5, A8, and A9 + 10) were extending into the lingular and basal segment in ventral side of the left upper bronchus. We completed the resection by means of a composite resection of the left upper lobe and the superior segment of the lower lobe, avoiding pulmonary angioplasty to preserve the left lower lobe or pneumonectomy. CONCLUSIONS: 3D-CT is useful for detecting this rare variation of the left pulmonary artery before operation, allowing for proper resection.

Lung Adenocarcinoma in Never Smokers: Problems of Primary Prevention from Aspects of Susceptible Genes and Carcinogens.

Global statistics estimate that approximately 25% of patients with lung cancer are never smokers. We suggest that genes related to susceptibility to metabolic syndrome were present among those related to susceptibility to lung adenocarcinoma (AC) in never smokers. There are many questions concerning lung AC in never smokers, which is increasing in incidence, with female predominance, good prognosis, unique genes related to susceptibility and good response to treatment with specific agents. The purpose of this review was to investigate the carcinogenesis of lung AC in never smokers focusing on genes related to susceptibility to lung AC and carcinogens, including environmental factors. In order to clarify the carcinogenesis of lung AC in never smokers, the definition of never smokers, survey of environmental tobacco smoke, the presence of the physical characteristics of metabolic syndrome, and other carcinogens should be investigated for primary prevention of lung AC.

Genes associated with succeptibility to lung adenocarcinoma among never smokers suggest the mechanism of disease.

Global statistics estimate that 15% of all cases of lung cancer in men and 53% in women are not attributable to smoking, and these data indicate that worldwide, approximately 25% of patients with lung cancer are never smokers. The etiology of lung cancer is disputed. The present study reviews the genes associated with susceptibility to lung cancer among never smokers and suggests possibilities for the involvement of metabolic syndrome. The environment appears to have changed the genes susceptible to lung cancer. Classical genes associated with lung cancer are decreasing and novel emerging genes may reflect changes in lifestyle. We provide evidence that the genes associated with susceptibility to lung cancer in never smokers are very similar to those reported in patients with metabolic syndrome, and that simply quitting smoking is not sufficient as the primary means of preventing lung cancer.

Improvements in surgical results for lung cancer from 1989 to 1999 in Japan.

BACKGROUND: In 1986, Japanese Association for Thoracic Surgery started a nationwide survey of the number of primary lung cancer undergoing resection and this survey was continued annually. Thereafter, investigations of lung cancer surgical results have been conducted three times. The postoperative overall 5-year survival rate was 47.8% in resected cases in 1989, 52.3% in 1994, and 62.0% in 1999, showing improvement over the decade (p < 0.01). OBJECTIVE: To clarify the factors influencing survival improvements retrospectively. PATIENTS AND METHODS: The subjects of the investigation are the patients who underwent resection for primary lung cancers in 1989, 1994, and 1999. Postoperatively, after 5 years, surveys of surgical results were sent to institutes where lung cancer resection had been performed. The subjects undergoing resection who provided 10 items (age, sex, pathologic T factor, pathologic N factor, pathologic M factor, date of resection, histology, curability, prognosis, and survival time) numbered 3004 in 1989, 6895 in 1994, and 12,235 in 1999. They were classified according to the Union International Contre le Cancer 1997 revised tumor, node, and metastasis classification. Differences in age, gender, histology, pathologic stage, curability, and operative death rates were analyzed for each survey year. RESULTS: According to the changes in proportions, the cases over 70 years of age, women, and pathologic stage I increased significantly (p < 0.001), whereas in cases with small cell lung cancer, incomplete resection and operative death decreased significantly over time (p < 0.001). CONCLUSION: The postoperative 5-year survival rate in Japan improved between 1989 and 1999. The main cause of this improvement was the increase in early stage lung cancer, especially cases with tumors 2 cm or less in size.

Pulmonary resection in patients aged 80 years or over with clinical stage I non-small cell lung cancer: prognostic factors for overall survival and risk factors for postoperative complications.

INTRODUCTION: This retrospective study was designed to identify the predictors of long-term survival and the risk factors for complications after surgery in patients aged 80 years or older with clinical (c)-stage I non-small cell lung cancer. METHODS: The Japanese Joint Committee of Lung Cancer Registry collated the clinicopathological profiles and outcomes of 13,344 patients who underwent pulmonary resection for primary lung cancer in 1999. The data of 367 patients aged 80 years or older with c-stage I non-small cell lung cancer were analyzed for prognostic factors and risk factors for postoperative complications. RESULTS: The median age was 82 years (range, 80-90 years). Of the total patient number, 102 (27.8%) had some form of comorbidity diagnosed preoperatively. Thirty-one (8.4%) patients presented with postoperative complications, and the operative mortality was 1.4%. The 5-year survival rates were 55.7% for c-stage I patients, 62.0% for c-stage IA, and 47.2% for c-stage IB. Advanced pathologic stage and comorbidity were significant independent predictors of shortened survival (p < 0.0001 and p = 0.032, respectively). Comorbidity and mediastinal lymph node dissection were identified as factors that increased the risk of postoperative complications (p < 0.0001 and p = 0.036, respectively). Survival rates were independent of the extent of pulmonary resection (lobectomy or limited resection). CONCLUSIONS: Octogenarian patients with c-stage I lung cancer in this study had a satisfactory long-term outcome and low-mortality rate. Comorbidity is a factor associated with both prognosis and operative risks. A selection of the patients who would be curable without mediastinal lymph node dissection after an accurate preoperative staging is beneficial to decrease the postoperative complications because this procedure is a risk factor.

Visceral pleura invasion impact on non-small cell lung cancer patient survival: its implications for the forthcoming TNM staging based on a large-scale nation-wide database.

INTRODUCTION: No analyses have been reported on the impact of visceral pleura invasion (VPI) on staging, in relation with the International Association for the Study of Lung Cancer proposals for the 7th edition of the tumor, node, metastasis (TNM) classification of the International Union Against Cancer staging system. The purpose of this study was to evaluate the impact of VPI on survival and propose a method of incorporating VPI status into the TNM classification. METHODS: We reviewed the data on 9758 non-small cell lung cancer patients, who underwent anatomic surgical resection in 1999, accumulated by the Japanese Joint Committee for Lung Cancer Registration, to gain insight into their clinicopathologic characteristics and outcomes. VPI was defined as tumor extension beyond the elastic layer of the visceral pleura. Patients were divided into nine groups according to VPI status and tumor diameter, in accordance with the International Association for the Study of Lung Cancer proposals. RESULTS: On the basis of survival, the nine groups were divided into the following five levels: tumors < or =2 cm without VPI; tumors < or =2 cm with VPI and tumors 2.1 to 3 cm without VPI; tumors 2.1 to 3 cm with VPI and tumors 3.1 to 5 cm without VPI; tumors 3.1 to 5 cm with VPI and tumors 5.1 to 7 cm without VPI; and tumors 5.1 to 7 cm with VPI and tumors >7 cm without VPI or T3 tumors. CONCLUSIONS: The T status of tumors, 7 cm or less, with VPI should be upgraded to the next T level in the future edition of the TNM classification of International Union Against Cancer staging system.

A dangerous venous variation in thoracoscopic right lower lobectomy.

Anatomical variations of the pulmonary vessels present a potential risk of intraoperative bleeding and damage to pulmonary circulation during pulmonary resection. We present details of a dangerous variation of the superior pulmonary vein associated with thoracoscopic right lower lobectomy that could potentially be divided if there was no preoperative foreknowledge of individual vessel configurations.

Risk of Acute Exacerbation After Video-assisted Thoracoscopic Lung Biopsy for Interstitial Lung Disease.

Biopsy by video-assisted thoracoscopic surgery (VATS) for interstitial pneumonia allows collection of samples sufficient for accurate histologic diagnosis. Although VATS is relatively safe, several reports have suggested that surgical lung biopsy may be a risk factor for acute exacerbation of idiopathic pulmonary fibrosis (IPF). We retrospectively reviewed data on the 113 cases that underwent biopsy by VATS to diagnose diffuse parenchymal lung disease in our department between 1994 and 2006, and analyzed its complications, in particular, risk of acute exacerbation of IPF. As the final diagnosis, idiopathic interstitial pneumonia was most frequent, involving 52 cases, of which IPF was most frequently found followed by nonspecific interstitial pneumonia and cryptogenic organizing pneumonia, in that order. Among our cases, there were 2 deaths after VATS (mortality rate, 1.8%), and both were IPF cases with acute exacerbation. When examining clinical markers in the 2 fatal IPF cases with acute exacerbation, we found that the percentage of predicted forced vital capacity was 55 or lower, percentage of predicted carbon monoxide diffusing capacity was 40 or lower, serum interstitial pneumonia markers KL-6 and SP-D were elevated, intraoperative inhalation of 100% O2 was 80 minutes or longer, and postoperative thoracic drainage was required for 10 days or longer. Although acute exacerbations of IPF seem to occur at any time during the course of disease, it is important to be aware of the possibility of acute exacerbation of IPF after VATS.

Large-cell neuroendocrine carcinoma without immunohistological positivity or serum elevation of CEA until relapse.

We herein report a case of large cell neuroendocrine carcinoma (LCNEC) originating in the right lung upper lobe and showing unique features at relapse in the right middle lobe. The relapsed tumor pathology included a carcinoembryonic antigen (CEA)-positive mantle component and a CEA-negative core area. The latter showed the same pathological picture as the original tumor, both histologically and immunohistochemically. The serum CEA concentration did not increase until the tumor relapsed, and it fell to within the normal range after resection of the relapsed tumor. Rarely, a newly elevated tumor marker suggests relapse, even in resected cases with a negative immunohistochemical study for the marker.

Reexpansion pulmonary edema.

When a rapidly reexpanding lung has been in a state of collapse for more than several days, pulmonary edema sometimes occurs in it. This is called reexpansion pulmonary edema (RPE). In this article, I present my views on the history, clinical features, morphophysiological features, pathogenesis, and treatment of RPE. Histological abnormalities of the pulmonary microvessels in a chronically collapsed lung will cause RPE, as well as mechanical stress exerted during reexpansion. Although the most effective treatment method is to treat the histological abnormalities of the pulmonary microvessels formed in a chronically collapsed lung, the cause of these abnormalities is not clear, making it difficult to put forward a precise treatment method. However, reasonably good effects can be expected from a symptomatic therapy that reduces the level of mechanical stress during reexpansion. In the future, it is expected that the cause of histological changes of the pulmonary microvessels in a chronically collapsed lung will be revealed, and appropriate therapies will therefore be developed according to this cause.

Spontaneous regression of symptomatic thymoma caused by infarction.

We herein report a 38-year-old man who had spontaneous regression of a thymoma with repeating episodes of chest pain that initially occurred 2 years earlier when the tumor was 35 mm in the long axis. Left video-assisted thoracoscopic thymothymectomy was performed. Pathology examination showed a thymoma 15 mm in the long axis, classified B2 in the World Health Organization classification and stage II by Masaoka staging. The feeding arteriole of the tumor, occluded by organized thrombi, was suggested to be the cause of coagulation necrosis. The patient recovered well from surgery without complication and with no episodes of chest pain at the 9-month outpatient follow-up.

Novel retractor for lymph node dissection by video-assisted thoracic surgery.

In nonrandomized studies, the video-assisted thoracic surgical (VATS) lobectomy seems to be a safe and effective procedure for treatment of lung cancer. However, there are some difficulties in VATS complete mediastinal lymph node dissection. The presence of the lymph node deep in the mediastinal space necessitates retraction of the surrounding organs. Therefore, we developed a retractor to create enough working space during the VATS procedure. To dissect lymph nodes, we use endoscopic bipolar forceps. These instruments are connected to a special electrosurgical generator to apply bipolar soft coagulation, which enables simultaneous dissection and sealing. Thus, "en bloc" lymph node dissection can be performed during the VATS procedure.

[Case of pneumothorax due to pulmonary metastases from uterine leiomyosarcoma].

A 44-year-old woman who had undergone hystero-oophorectomy for uterine sarcoma presented to our hospital with palindromic pneumothorax and her chest CT revealed multiple cystic lesions. After admission video-assisted thoracoscopic surgery (VATS) showed the pulmonary lesions to be primarily leiomyoma, however, further examination revealed that her uterine sarcoma resected in 2000 exhibited not only mitosis but also venous invasion. We therefore considered her lung tumors as metastases from uterine leiomyosarcoma. Cases of secondary spontaneous pneumothorax (SSP) due to pulmonary metastases are rare and almost half are from mesenchymal tumors. Thin-wall cavities and cysts are formed by a check-valve mechanism in the process of pulmonary metastases formation. When multiple thin-wall cavities and cysts are found in the lung, pulmonary metastases should be considered as one of the causes, and pathological specimens obtained in past illness should be re-examined in detail.

A Japanese Lung Cancer Registry study: prognosis of 13,010 resected lung cancers.

PURPOSE: The validation of tumor, node, metastasis staging system in terms of prognosis is an indispensable part of establishing a better staging system in lung cancer. METHODS: In 2005, 387 Japanese institutions submitted information regarding the prognosis and clinicopathologic profiles of patients who underwent pulmonary resections for primary lung neoplasms in 1999 to the Japanese Joint Committee of Lung Cancer Registry. The data of 13,010 patients with only lung carcinoma histology (97.6%) were analyzed in terms of prognosis and clinicopathologic characteristics. RESULTS: The 5-year survival rate of the entire group was 61.4%. For the small cell histology (n = 390), the 5-year survival rates according to clinical (c) and pathologic (p) stages were as follows: 58.8% (n = 161) and 58.3% (n = 127) for IA, 58.0% (n = 77) and 60.2% (n = 79) for IB, 47.1% (n = 17) and 40.6% (n = 29) for IIA, 25.3% (n = 38) and 41.1% (n = 29) for IIB, 29.0% (n = 61) and 28.3% (n = 60) for IIIA, 36.3% (n = 19) and 34.6% (n = 40) for IIIB, and 27.8% (n = 12) and 30.8% for IV (n = 13). For the non-small cell histology (n = 12,620), the 5-year survival rates according to c-stage and p-stage were as follows: 77.3% (n = 5642) and 83.9% (n = 4772) for IA, 59.8% (n = 3081) and 66.3% (n = 2629) for IB, 54.1% (n = 205) and 61.0% (n = 361) for IIA, 43.9% (n = 1227) and 47.4% (n = 1330) for IIB, 38.3% (n = 1628) and 32.8% (n = 1862) for IIIA, 32.6% (n = 526) and 29.6% (n = 1108) for IIIB, and 26.5% (n = 198) and 23.1% (n = 375) for IV. Adenocarcinoma, female gender, and age less than 50 years were significant favorable prognostic factors. CONCLUSION: This large registry study provides benchmark prognostic statistics for lung cancer. The prognostic difference between stages IB and IIA was small despite different stages. Otherwise, the present tumor, node, metastasis staging system well characterizes the stage-specific prognoses.

Descending necrotizing mediastinitis secondary to retropharyngeal abscess without cervical spread.

Cervical infections can cause neck phlegmonosa and occasionally develop lethal mediastinitis. We report a 52-year-old man with a retropharyngeal abscess causing descending mediastinis without cervical spread. Thoracoscopic drainage without cervicotomy was successful. Deep neck infections causing a descending mediastinitis should be considered in patients even without an abnormal neck appearance.

Chronic diaphragmatic hernia.

Chronic diaphragmatic hernia is a rare entity and requires surgical intervention when it is diagnosed. We report three patients with chronic diaphragmatic hernia that followed a diagnosis of diaphragmatic abnormality with no previous chest injury. Operative findings suggested a diaphragmatic defect in a congenitally weak area. All patients were satisfied with the resolution of their preoperative discomfort and their improved respiratory function after repair using Marlex mesh sheets via thoracotomy and laparotomy. Chronic diaphragmatic hernia should be considered even in patients who had no previous chest injury.

Identification of the transforming EML4-ALK fusion gene in non-small-cell lung cancer.

Improvement in the clinical outcome of lung cancer is likely to be achieved by identification of the molecular events that underlie its pathogenesis. Here we show that a small inversion within chromosome 2p results in the formation of a fusion gene comprising portions of the echinoderm microtubule-associated protein-like 4 (EML4) gene and the anaplastic lymphoma kinase (ALK) gene in non-small-cell lung cancer (NSCLC) cells. Mouse 3T3 fibroblasts forced to express this human fusion tyrosine kinase generated transformed foci in culture and subcutaneous tumours in nude mice. The EML4-ALK fusion transcript was detected in 6.7% (5 out of 75) of NSCLC patients examined; these individuals were distinct from those harbouring mutations in the epidermal growth factor receptor gene. Our data demonstrate that a subset of NSCLC patients may express a transforming fusion kinase that is a promising candidate for a therapeutic target as well as for a diagnostic molecular marker in NSCLC.

Prognostic factors in 3315 completely resected cases of clinical stage I non-small cell lung cancer in Japan.

BACKGROUND: The objective of this retrospective study was to identify prognostic factors in completely resected clinical (c-) stage I non-small cell lung cancer cases. METHODS: In 2001, the Japanese Joint Committee of Lung Cancer Registry collected data on the outcome and clinicopathological profiles of 7408 patients who had undergone resection for primary lung cancer in 1994. They included 3315 c-stage I patients who underwent complete resection, and in this study attempted to identify prognostic factors in the c-stage IA and c-stage IB cases. RESULTS: The overall 5-year survival rate was 66.5%: 74.7% in the 2085 c-stage IA cases and 52.5% in the 1230 c-stage IB cases. The survival curve of the c-stage IA cases was higher than that of the c-stage IB cases. Multivariate analysis of the c-stage IA cases revealed six factors that predicted a significantly better outcome: age, gender, pathological (p-) T status, p-N status, nodal dissection, and tumor diameter (< or =2 cm), and the same analysis of the c-stage IB cases revealed six factors: age, gender, p-T status, p-N status, operative procedure, and tumor diameter (<5 cm). The c-stage IA patients whose tumor diameter was 2 cm or less had a higher survival rate than the patients whose tumor diameter was more than 2 cm, and the c-stage IB patients whose tumor diameter was less than 5 cm had a higher survival rate than the patients whose tumor diameter was 5 cm or more. CONCLUSION: Tumor size is an independent prognostic factor for postoperative survival in c-stage I patients.

Prognosis of resected non-small cell lung cancer patients with intrapulmonary metastases.

BACKGROUND: In the current TNM staging system revised in 1997 for lung cancer, intrapulmonary metastases (PM) are classified into two categories: PM1 (in the same lobe of the primary tumor), designated as T4; and PM2 (in a different lobe), as M1. There have been no large-scale analyses on PM in non-small cell lung cancer (NSCLC) patients. We collected data nationwide in Japan for 7408 lung cancer patients undergoing surgical resection during a single year, 1994. We analyzed the long-term survival of NSCLC patients to evaluate the prognostic impact of PM in relation to other prognostic factors. METHOD: Medical records of 6525 NSCLC patients undergoing surgical resection during a single year, 1994, were analyzed as a subset work of the Japanese Joint Committee of Lung Cancer Registry. The committee sent a questionnaire on outcome and clinicopathological profiles to 303 institutions. RESULTS: There were 6080 PM0 (no PM), 317 PM1, and 128 PM2 patients. The 5-year survival rates were 55.1% for PM0 patients, 26.8% for PM1, and 22.5% for PM2 patients, respectively. The differences in survival between patients with PM0 and PM1 and between patients with PM0 and PM2 were significant (p < 0.001, respectively); the difference in survival was not significant between patients with PM1 and PM2 (p = 0.298). In R0 and N0 patients, survival differences were similar for PM0, PM1, and PM2 patients. Significant survival difference was detected between T3 and PM1 (p = 0.0317) and between PM1 patients and T4 patients excluding PM1 (p = 0.0083). The 5-year survival rates of PM2 patients and M1 patients excluding PM2 were 22.5% and 20.5%, respectively, and there was no significant difference between the groups (p = 0.434). CONCLUSION: There was no significant survival difference between NSCLC patients with PM1 and PM2. The survival of patients with PM1 was between that of the T3 and T4 patients excluding PM1.

Endobronchial aspergillosis and actinomycosis associated with broncholithiasis.

Endobronchial aspergillosis or actinomycosis associated with broncholithiasis is extremely rare. Here, we describe two cases of endobronchial aspergillosis and actinomycosis associated with broncholithiasis. The patients underwent pulmonary resection due to massive hemoptysis. These cases reveal that a bronchiolith can potentially induce endobronchial fungal or bacterial infection, even in immunocompetent patients.