Fibromyxoma of the rib: report of a case

We present herein the case of a 36-year-old man with fibromyxoma of the rib. At the age of 33 years, an abnormal shadow of the chest was found on a radiographic examination, subsequent to which the mass grew slowly into the intrathorax, and he was referred to our hospital. An X-ray film and computed tomography scan on admission showed an extrapleural mass, 7 x 5 cm in diameter, in the left sixth rib with no evidence of destruction, cortical expansion, or rupture. The patient underwent peripheral osteotomy of the sixth rib, which was resected with a 3-cm margin around the mass. Microscopically, a diagnosis of fibromyxoma was confirmed. To the best of our knowledge, this is the first reported case of fibromyxoma originating in a rib.

Pulmonary small cell carcinoma associated with sarcoid reactions: report of a case

A 45-year-old male was admitted to our hospital for investigation of a nodular shadow in segment 5 of the right lung on a chest computed tomogram. A right middle lobectomy with mediastinal lymph node dissection was performed under a diagnosis of lung cancer, and histologic examination confirmed small cell carcinoma. There were sarcoid reactions in the resected lymph nodes and the lung parenchyma, but no signs of systemic sarcoidosis were evident. Sarcoid reactions are rarely observed in the regional lymph nodes draining malignant tumors. Moreover, while they are most common in squamous cell carcinoma of the lung, they extremely rare in small cell carcinoma. To our knowledge, this is only the third report of this unusual entity in the English and Japanese literature.

[Intrapulmonary lymph node detected as a small coin lesion: a case report and a review of the Japanese literature]

Intrapulmonary lymph node (IPLN) is commonly identified to the level of fourth-order bronchi and is seldom recognized on a plain chest roentgenogram. We experienced a case of intrapulmonary lymph node, and presented a review of the Japanese literature. A 52-year-old female without a smoking history was discovered to have a coin lesion in a mass screening chest roentgenogram. A Chest CT scan showed a small peripheral nodule in segment 9 of the left lung. Malignancy could not be ruled out and an exploratory thoracotomy was performed, and the definite diagnosis was IPLN. We have encountered more frequent detection of small peripheral pulmonary nodules because of increasing availability of chest CT scans. Although reports of IPLN are rare, it should be considered as one of differential diagnoses for benign or malignant pulmonary nodules.

Results of tracheobronchoplasty for bronchogenic carcinoma

Tracheobronchial reconstruction is a safe and effective procedure for patients with the neoplasms of low grade malignancy and bronchogenic carcinoma. We present herein a series of 18 cases that had tracheobronchial reconstruction, and discuss a postoperative complication and prognosis. From 1981 to 1997, 18 patients (2.8%) of 647 cases had tracheobronchial reconstruction with mediastinal lymph node dissection. The average age of the 13 males and 5 females, was 61 (range 51-72) years. We analyzed clinical features, postoperative complication and prognosis. Seventeen patients underwent sleeve lobectomy and one lobectomy with carinal reconstruction (Barkley's montage type). There were 13 squamous cell carcinomas, and one each of adenocarcinoma, typical carcinoid, adenoid cystic carcinoma, mucoepidermoid carcinoma and undifferentiated carcinoma. Stage was IA in 3, stage IB in 6, stage IIB in 3, stage IIIA in 5, and stage IIIB in 1 patient. Curative resection was achieved in 11 patients and non-curative resection in 7 patient who had radiotherapy. Six patients (33.3%) had postoperative complications. Five-year survival and mean survival time were 92.3% and 126 months, respectively. Tracheoplasty group had significantly better prognosis than pneumonectomy group or lobectomy group (p<0.01). This study suggests that tracheobronchoplasty is a more useful procedure than pneumonectomy for lung cancer.

Primary pulmonary collision tumor including squamous cell carcinoma and T-cell lymphoma

We report a very rare occurrence of a primary collision tumor in the lung consisting of squamous cell carcinoma and T-cell lymphoma. A squamous cell carcinoma was diagnosed histologically following a transbronchial lung biopsy in a 71-year-old woman, but the other component was diagnosed histologically and immunohistochemically only on examination of the resection specimen. The malignant lymphoma was stained by the monoclonal antibody UCHL-1 (anti-D45RO) against T-lymphocytes but was not stained by the L26 (anti-CD20) antibody against B-lymphocytes. Immunostaining for CD3 was positive, confirming a T-cell lineage. Despite systemic chemotherapy, the patient died 7 months after operation, from progression of the lymphoma. Our case, which illustrates interesting attributes of collision tumors, consisted of an ordinary squamous cell carcinoma and a rare T-cell lymphoma arising in the lung, with the latter part of the combination dictating subsequent treatment and outcome.

[Long-term survival in surgical cases of non-small cell lung cancer with mediastinal nodal involvement]

We studied long-result of the patients with mediastinal lymph node metastasis (N2) in lung cancer. From 1981 to 1991 in National Sanatorium Nishi-Gunma Hospital, we have performed a lobectomy or pneumonectomy with mediastinal lymph node dissection for 306 patients with non-small cell lung cancer. Six operative deaths were excluded (operative death rate: 2.0%). Of these, 53 patients (17%) were diagnosed as adenocarcinoma or squamous cell carcinoma with N2 disease pathologically. The patient consisted of 31 men and 22 woman whose ages ranged from 18 to 73 years, with a mean age of 58.1 years. The results were: Mean survival period was 39 month. Five-and 10-year survival rates were 18.9% and 12.6%, respectively. By motive of detection, the group of following other disease had a better prognosis than the group of having symptom. By pT-factor, T1 had a better prognosis than T3. By the number of nodal involvement level, 1 level had a better prognosis to compared to 3 or more than 4 levels. There were 10 patients of 5-year or over survivors after surgery, none of whom had primary site in left upper lobe. Analysis with a Cox's proportional hazard model demonstrated that the number of nodal involvement level was a useful factor in prognosis.

Occult Boerhaave's syndrome without vomiting prior to presentation. Report of a case

Boerhaave's syndrome (spontaneous esophageal perforation) is an uncommon clinical entity that frequently presents with an antecedent history of marked vomiting followed by chest or abdominal pain. We report a case of spontaneous rupture of the esophagus in 53-year-old male who was referred to our hospital with a chest discomfort. A chest radiogram revealed pleural effusion and pneumomediastinum. Nine hours after onset, the diagnosis of Boerhaave's syndrome become evident. She underwent operative repair and, after a prolonged stay, was discharged in relatively good condition 55 days after admission. The absence of vomiting prior to presentation is the distinguishing feature of this particular case. This is the seventh case in the English literature to our knowledge.

[Enchondroma protuberance with destroying the rib: report of a case]

A 18-year-old female was admitted to our hospital because of a mass shadow in the left upper lung field on chest roentgenogram of a medical check. Computed tomography and magnet resonance imaging of the chest revealed a tumor which located in the left 5th rib, and was unclearly demarcated to the rib. Under the diagnosis of a rib tumor, the patient was treated by radical en bloc excision. The pathologic diagnosis was enchondroma protuberance of the rib. This tumor may be indistinguishable from osteochondroma or chondrosarcoma. Therefore, total resection is recommended for accurate diagnosis and absolute cure.

Low-grade malignant tumors of the lung: is lymph node dissection necessary?

Low-grade malignant tumors (LGMT) of the lung were surgically treated in our institute between 1981 and 1997. Both the characteristics and prognosis were examined. We studied 10 cases with LGMT of the lung, male to female ratio 1:1, age range 15 to 71 years, mean 55 years, 6 central and 4 peripheral. Five patients had lobectomy, 3 had sleeve lobectomy and 2 had bilobectomy. Pathologically, 5 samples were typical carcinoid, 3 were mucoepidermoid carcinoma and 2 were adenoid cystic carcinoma. None of the patients had lymph node metastasis. Nine patients were stage I and one stage IIIA. Seven patients underwent absolutely curative resection; 2, relatively non-curative resection; 1, non-curative resection. In preoperative examination, only 4 patients was diagnosed correctly and the others were misdiagnosed. Mean survival time was 167.5 months. One patient died from causes other than the primary cancer and the others are surviving (range 2-173 months). The LGMT group was significantly younger and had a significantly better prognosis compared with the control group (p=0.02). Mediastinal lymph node dissection is suggested to be omitted. However, further accumulation of cases is necessary regarding to the omission of lymph node dissection.

Resection of pulmonary metastases in six patients with disease-free interval greater than 10 years

BACKGROUND

The relationship between disease-free interval (DFI) and prognosis has been discussed; however, there is little information on long-term DFI. In this study, we surveyed the cases of pulmonary metastases with DFI greater than 10 years.

METHODS

Between January 1980 and December 1995, we saw 6 patients with DFI greater than 10 years. All the patients had a histopathologic diagnosis of pulmonary metastases based on surgical resection, and the patients' characteristics and clinical course were reviewed.

RESULTS

The median age was 63 years. Primary sites were breast in 2 patients, and one case each of skin, colon, thyroid, and bladder. The numbers of metastases were one in 4 patients and two in 2 patients. The median DFI was 134 months (range, 127 to 235 months). The median tumor-doubling time was 227 days (range, 80 to 815 days). All the patients underwent a lobectomy. Three patients with metastases from the bladder, colon, and breast died of recurrence. One patient with metastasis from the thyroid died of heart failure. Two patients with metastases from breast and skin cancer survived for more than 3 years.

CONCLUSIONS

Early death occurred regardless of the long DFI, suggesting that intensive follow-up is mandatory for patients with DFI greater than 10 years.

A clinicopathologic study of the resected cases of adenosquamous carcinoma of the lung

Ten cases of surgically resected adenosquamous carcinoma of the lung were studied clinicopathologically, and their outcome was compared with that of adenocarcinomas and squamous cell carcinomas of the lung. The frequency rate of adenosquamous carcinoma was 1.5% of 668 primary lung cancers resected in our hospital. The survival curves of patients with adenosquamous carcinomas, adenocarcinomas, and squamous cell carcinomas indicated that the outcome of adenosquamous carcinoma was statistically poorer than that of adenocarcinoma (p=0. 01), and tended to be poorer than that of squamous cell carcinoma (p=0.051). The amount of adenocarcinoma component did not affect the survival rate. Five-year survival was not obtained in this series. Although our series is small, this study suggests that adenosquamous carcinoma of the lung is an aggressive tumor with poor prognosis.

[Primary large cell carcinoma of the lung in the patients undergoing pulmonary resection: a comparison between pre- and post-operative diagnosis]

Between 1981 and 1995, 591 patients with primary lung cancer underwent operations. Of these, 19 patients (3.2%) was diagnosed as a large cell carcinoma pathologically. Clinicopathologically, we analyzed a discrepancy between pre- and post-operative diagnosis of these patients. This study showed as follows: 1) Accuracy of preoperative diagnosis was 73.7%; 2) No patients with primary site in right upper lobe had a correct diagnosis; 3) Accuracy of preoperation was not depending on tumor size; 4) In retrospective findings of the biopsied specimens, 'incomplete glandular differentation' caused preoperative diagnosis to adenocarcinoma, and modification of the specimens by pneumonia caused it to squamous cell carcinoma; 5) Inadequatespecimens originated from the right upper lobe or pneumonia lobe; 6) The five-survival rate was 27.3%.

The surgical treatment of metastatic tumors in the lung: is lobectomy with mediastinal lymph node dissection suitable treatment?

From January 1981 through October 1995, a total of 28 patients underwent surgery for metastatic lung tumors in our institute. A retrospective review and survival analysis of these patients are reported. There were 12 males and 16 females, with the mean age of 57 years. Of them, 20 patients had solitary lesions. Pulmonary metastasis was from the colon in 8 patients, from the breast in 5, from the stomach and the uterus in each 3, from the bladder, the rectum and the soft tissue in each 2, and from the kidney, the ovarium and the thyroid in each 1. A lobectomy was performed in 22 patients, 17 of whom were accompanied with mediastinal lymph node dissection (R2a). Partial resection without lymph node dissection was performed in 6 patients (R0). Overall 5-year survival was 24.7%. Four-year or over survivor were 4 patients who underwent a lobectomy with R2a. The patients undergoing lobectomy had a significantly better prognosis compared with patients with partial resection (p<0. 05). The patients with R2a had significantly less local recurrence than patients with R1 or R0 (p<0.05). We conclude that lobectomy with R2a is suitable treatment for metastatic lung cancer.

Primary adenoid cystic carcinoma in the lung: report of two cases and therapeutic considerations

Primary adenoid cystic carcinoma in the lung is an uncommon disease, which is regarded as a slow growing low-grade malignancy. However, this disease has a high risk of incomplete resection because of its unique histological invasion patterns. The cases of two patients who recently underwent surgery for adenoid cystic carcinoma in the lung are reported. Both patients received postoperative radiotherapy treatment as a follow-up to a histologically incomplete resection. Both patients have survived for 51 months and 7 months, respectively, with no recurrence. Postoperative radiotherapy is an acceptable treatment of choice to control residual lesions and provides long-term survival even in cases of incomplete resection.

Management of postoperative fever in cardiovascular surgery

BACKGROUND

The causes and management of postoperative fever were studied.

MATERIALS AND METHODS

During a four-year-period beginning in January of 1991, high fever over 38.5 degrees C max occurred in twenty-five (6%) out of 395 patients who underwent cardiovascular surgery.

RESULTS

Nine of the patients (28%) evidenced bacteriological infections as follows; 3 cases of mediastinitis, 2 cases of respiratory tract infection, 1 case of MRSA colitis and a wound infection in one case. The three patients with mediastinitis died and the two cases of MRSA were detected from the culture of pacemaker leads. Bacteriological infection was not detected in other 18 (72%) patients with fever. However, we speculated that the clinical causes of fever in 9 out of 18 patients were as follows; catheter fever in 3 patients, acalculous cholecystitis in 2, fungus infection in 2, aseptic meningitis in one and viral myelitis in one patient. Two patients with acalculous cholecystitis recovered after percutaneous transhepatic gallbladder drainage. The causes of fever were not apparent in nine patients, however the source might be related to artificial prostheses used intraoperatively in five patients. C-reactive protein (CRP) was elevated beyond 10 mg/dl in 13 (52%) of the 25 patients. CRP increased in all seven bacteriologically positive patients and in six (32%) of the bacteriologically negative patients.

CONCLUSIONS

Precise and prompt bacterial examinations are necessary in patients with CRP elevation because the origins of fever were bacteriological in only 28% of the patients with a high fever. Good prognoses may be obtained by suitable management in bacteriologically negative patients.

[Analyses on the long-term prognosis of surgical treatment for primary lung cancer in the elderly patients of 75 or over years old: how should be treated the non-recurrent death?]

We analyzed the long-term prognosis in 68 elderly (75 years old or over) patients with primary lung cancer. The 5- and 10-year survival rates were 56.5% and 10.2%, respectively. There were 33 deaths due to 16 recurrences (REC) and 17 non-recurrences (NREC). Thirty-three dead patients were divided into two groups; patients with less than 5-year follow-up period (group A) and patients with 5-year or over follow-up period (group B). In group A, the REC/NREC ratio was 15/6, and in group B, the REC/NREC ratio was 1/11. The mortality due to non-recurrence was significantly (p < 0.05) higher in group B. In conclusion, we recommend to include non-recurrent death in the survival rates, because it is impossible to clear the cause of death, strictly.

Early stage primary pulmonary lymphoma

Because of the rarity of its occurrence, there is no established treatment for early stage primary pulmonary lymphoma. We retrospectively examined five patients with early stage primary pulmonary lymphoma to elucidate the optimal treatment for this unusual disease. All patients underwent complete resection with regional lymph node dissection. Lymphatic and blood vessel invasion were pathologically detected in all cases. All four patients with postoperative chemotherapy are alive without recurrence. One patient who did not undergo chemotherapy had an extrapulmonary recurrence 21 months after operation. The combined therapy of complete resection and postoperative chemotherapy may be the treatment of choice for this unusual disease.

Sarcoid reactions in primary pulmonary carcinoma: report of seven cases

In a consecutive series of 326 patients with primary lung cancer, sarcoid reactions were observed in the regional lymph node or resected lung in 7 patients (2.2%). The average age of the 7 patients, 4 males and 3 females, was 54 years, range 45-70. All the patients underwent lobectomy. The sites in which sarcoid reactions were found were the regional lymph node (N) in 3 patients, the lung parenchyma (L) in 2, N and L in 1, and the tumor stroma in 1. The histologic types were adenocarcinoma in 4 patients, squamous cell carcinoma in 2, and small cell carcinoma in 1. Two patients died of recurrence and myocardial infarction, and five patients are alive, range 5-64 months. The patients with lung cancer complicating sarcoid reactions were significantly younger than the control group (p<0.01), and not significant in prognosis. We conclude that the complication of sarcoid reactions do not influence the prognosis, but that the sarcoid reactions may be a local reaction or resistance to cancer cells.

[Limited operation for lung cancer: wedge resection using stapling device]

We employed wedge resection using stapling device for peripheral, clinical stage I lung carcinoma in selected poor-risk patients. Out of 10 patients, four developed local recurrence and one had the second primary in the same lobe resected. Compared with patients having lobectomy with 91% of a recurrence free rate in three years, those who underwent wedge resection had the lower rate of 53%. We conclude that wedge resection using stapling device cannot be an acceptable procedure even for poor-risk patients.

[Primary pulmonary malignant lymphoma of mucosa-associated lymphoid tissue (MALT)--a case report with a review of Japanese literatures]

A case of non-Hodgkin malignant lymphoma of the lung was presented with a review of Japanese literatures. A 53-year-old woman was referred to our hospital because of an abnormal shadow on the roentgenogram of mass screening, with neither subjective symptoms nor abnormalities in physical examinations. Laboratory tests showed normal values. The diagnosis of pulmonary malignant lymphoma was obtained by immunohistochemical examinations. She underwent a upper lobectomy of the left lung with lymph nodes dissection of the mediastinum. The histological immunohistochemical and diagnosis of the resected tumor was primary pulmonary B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) without regional lymph nodes involvement. She has been doing well without any signs of recurrence for 15 months after the operation.

[Primary solitary neurofibroma of the chest wall: report of a case resected with video-assisted thoracoscopic surgery]

Primary solitary neurofibroma of the chest wall is rare. We present a 38-year-old man with this disease. The patient was admitted to our hospital because of an abnormal shadow of the left lung in chest roentgenograms. Chest CT scanning showed an extrapleural tumor, 4 x 5 cm in size, which was homogenous and sharply demarcated. The tumor was resected with video-assisted thoracoscopic surgery. The pathohistological diagnosis was neurofibroma originating from the 5th intercostal nerve. His postoperative course was uneventful. Neurofibroma commonly occurs in posterior mediastinum but rarely in the chest wall.

[Video-assisted thoracoscopic surgery for a 89-year-old patient with primary lung cancer--report of a case]

A 89-year-old woman was referred to our hospital because of a relatively defined shadow of the right peripheral lung in chest roentgenograms. Although this case couldn't be diagnosed with transbronchial lung biopsy, adenocarcinoma of the lung (c-T1N0M0) was suspected because of radiological findings. We planned video-assisted pulmonary partial resection of the S6 in consideration of age and general status. Her postoperative courses was uneventful with no complications. Video-assisted thoracoscopic surgery is one of the treatments for elderly patients with peripheral early stage lung cancer.

[Pulmonary metastasis from breast cancer: a case report with 19-year disease-free interval]

We report pulmonary metastasis from breast cancer in a 59-year-old female with 19-year disease-free interval. The patient had undergone a radical mastectomy for left breast cancer 19 years ago. Chest X-ray films revealed on abnormal shadow in left upper lung field. Further examinations including bronchoscopic lung biopsy suggested primary adenocarcinoma of the lung. A left upper lobectomy with mediastinal lymph node dissection was performed. The histological diagnosis of resected specimen was mucinous adenocarcinoma, suggesting pulmonary metastasis from breast cancer with 19-year disease-free interval. We reported our patient because of a rare case with distant metastasis after a long-term interval.

[T4 lung cancer: surgical indications based on results of surgical treatment]

During the period of 1981 and 1995, 54 patients with T4 lung cancer underwent pulmonary resection in our institutes. The actuarial survival rate of them was 30% at three years and 12% at five years. The five-year survival rate of 12 patients with complete resection was 33%. On the other hand, the five-year survival rate of 30 patients with incomplete resection was 9%. The five-year survival rates of 17 patients with N0 disease, 9 patients with N1 disease, and 22 patients with N2 disease were 13%, 40%, and 5%, respectively. There was a significant difference in survival between patients with N1 and N2 disease. Four patients survived for more than five years after the operation : two patients had invasion to the left atrium and two had a slight degree of pleural dissemination. Radical pulmonary resection may yield long-term survival in T4 lung cancer patients having invasion to the left atrium.

[Right traumatic diaphragmatic hernia: a case report]

A periodic examination of chest-X-ray films showed abnormal elevation of the right diaphragm in a 39-year-old man, who had a history of right cordal contusion due to fall from a bridge one and a half years ago. The patient had no clinical symptoms after the accident. Chest and abdominal CT scans and barium examinations of gastro-intestinal tract revealed herniation of the omentum, colon and liver into the right thoracic cavity. Under the diagnosis of diaphragmatic hernia, the patient underwent an operation through a thoracoabdominal approach showing prolapse of the omentum, colon, gall bladder and a part of liver into the thoracic cavity. Prolapse of a gallbladder is rare. Further examinations are necessary with this lesion in mind when physicians find an abnormal shadow of the diaphragm.

[So-called carcinosarcoma of the lung: A case report]

A 50-year-old male was admitted to our hospital because of an abnormal shadow in chest X-ray films. The diagnosis of adenocarcinoma was obtained by transbronchial brushing cytology. Right lower lobectomy with hilar and mediastinal lymph node dissection was performed. Histological examinations of the resected specimen showed that the tumor was composed predominantly of spindle-shaped cells containing scattered islands of moderately differentiated adenocarcinoma. Immunohistochemically, the spindle cells were positively stained by vimentin, keratin and epithelial membrane antigen, suggesting sarcomatous transformation of adenocarcinoma cells.