[Screening for lung cancer: present and future]

A certified method for lung cancer screening in Japan is the combination of chest X-ray and sputum cytology. The chest Xray examination is intended primarily for the detection of peripheral-type lung cancer. Interpretation of the films should be performed by two different physicians, and the films of screenees suspected to have abnormal shadow should be compared to the same screenee's films from previous screening visits. Sputum cytology is conducted for heavy smokers, and is useful for early detection of central lung cancer. The efficacy of this lung cancer screening method has been shown in several case control studies. There are some problems to solve i. e., a low rate of attendance and inadequate quality control. Low-dose thoracic CT screening is performed with an exposure within a single breath hold, and its interpretation can be conducted with films, CRT, or a LCD monitor. Even when taken at low doses, the radiation exposure dose is large compared to a chest X-ray, being about 3-10 times greater than the absorbed dose and 20-40 times greater than the effective dose. Since the radiation dose in a usual clinical condition is much higher, the clinical condition is not recommended for screening. Concerning the efficacy of low-dose CT screening for heavy-smokers, a positive result was reported in June 2011, and further detailed analyses are required. There are still some problems to solve i. e., the management of undiagnosed shadows, harm caused by the screening, quality control, and efficacy in non-smokers.

Solitary fibrous tumor of the pleura suddenly induced hypoglycemia before surgical treatment

We present a case of a solitary fibrous tumor of the pleura with sudden onset, recurrent hypoglycemia. A 76-year-old smoking male with type-II diabetes mellitus admitted to our hospital for dyspnea and general malaise. Radiological findings revealed a large tumor occupying the right hemithorax. After bronchoscopic examination, the patient developed a fever and began to wheeze. Treatment with antibiotics and several other drugs improved his symptoms. Percutaneous needle biopsy confirmed the diagnosis. After these medical interventions, the patient suddenly developed recurrent hypoglycemia. After the right pneumonectomy, the patient never experienced hypoglycemia again. We should consider the possible relation between hypoglycemia and solitary fibrous tumor of the pleura, even when the patient is not hypoglycemic during the initial examination.

[Descending necrotizing mediastinitis]

We treated of 3 patients with descending necrotizing mediastinitis that is often to be fatal. There are 3 important issues regarding the treatment of this disease. First, the precise sites of abscess should be determined by computed tomography (CT) scans from the neck to diaphragm. Second, effective drainage of the neck and mediastinal abscess should be carried out immediately when the sites of abscess are determined. Third, drainage under video-assisted thoracic surgery (VATS) is an appropriate treatment because VATS is less invasive and provides an easier placement of the drainage tubes at abscess sites.

Lung cancer screening and its efficacy

The efficacy of lung cancer screening should not be evaluated by the survival rate of lung cancer patients but by lung cancer mortality in a certain population because the survival rate can be greatly affected by several types of bias. Randomized controlled trials that were conducted during the 1970s and 1980s in Europe and the United States failed to prove the efficacy of lung cancer screening in decreasing the mortality rate; but recently the results of case-control studies in Japan have revealed that undergoing currently available screening decreases the risk of lung cancer deaths by 30%-60%. A system is now being created in Japan whereby the guidelines regarding cancer screening will continue to be updated. The preliminary reports concerning lung cancer screening using thoracic computed tomography revealed that not only the detection rate of lung cancer but also the survival rate of detected lung cancer patients were surprisingly high. However, the presence of some potential bias in these studies cannot be ignored; therefore, it is still unknown whether there is actual efficacy. Several randomized controlled trials are presently in progress overseas, but the interim results were not favorable. A randomized controlled trial should therefore immediately be started in Japan as well.

Organizing pneumonia with an enlarging tumor-like lesion: immunohistochemical study

An 86-year-old woman was transferred to our department for investigation of an abnormal enlarging pulmonary shadow with vascular convergence. She had no respiratory symptoms or laboratory data suggesting inflammatory disease. A pulmonary wedge resection was performed under video-assisted thoracic surgery. Pathology examination revealed that the tumor was organizing pneumonia and was composed of fibroblast-like spindle cells, macrophages, lymphoplasma cells, and collagen fibers. Immunohistochemical study revealed that the lesion was in the proliferative state with the relatively more Ki-67-positive fibroblast-like spindle cells. When a surgical resection is necessary for an enlarging abnormal pulmonary mass without any systemic inflammatory reaction or respiratory symptoms, a less invasive approach should be selected.

[Complete resection of an advanced mediastinal nonseminomatous germ cell tumor with multiple distant metastases after down-staging by chemotherapy]

A mediastinal nonseminomatous germ cell tumor was completely resected after down-staging by chemotherapy despite the presence of multiple distant metastases. A 22-year-old female was admitted for superior vena cava (SVC) syndrome. Her SVC was obstructed by a large anterior mediastinal tumor; she also exhibited distant metastases on a left rib, in the liver, and multiple in the lung. The blood alpha-fetoprotein (AFP) level was extremely elevated to 57,530 ng/ml. Four courses of BEP therapy [cisplatin (CDDP), bleomycin (BLM), etoposide (VP-16)] and a high dose chemotherapy followed by a peripheral blood stem cell transplantation made the tumor become smaller and effected its down-staging. Residual mediastinal tumor with an intravascular tumor in SVC was completely resected. The SVC was reconstructed by an artificial vessel graft. A mediastinal nonseminomatous germ cell tumor, even though it has multiple distant metastases, can achieve down-staging and complete resection by a chemotherapy based on scientific evidence.

Results of long-term follow-up of photodynamic therapy for roentgenographically occult bronchogenic squamous cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) is considered a useful and minimally invasive modality for treating centrally located early lung cancer. To date, there has been limited information on the long-term outcome of patients treated with PDT, especially those who are medically operable.

METHODS

Beginning in 1994, patients with roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC) who met our criteria underwent PDT at Tohoku University Hospital and were followed up through 2006. Our criteria were as follows: (1) ROSCC without distant metastasis; (2) medically operable by means of lobectomy or further resection; (3) longitudinal tumor length of <or= 10 mm; and (4) superficial bronchoscopic tumor findings.

RESULTS

A total of 48 patients with ROSCC underwent PDT. The complete response (CR) rate was 94% (45 of 48 of patients). Nine patients (20%) had local recurrence after CR. A total of 11 deaths was observed, with 6 resulting from multiple primary lung cancer and only 1 from the original ROSCC. The 5-year and 10-year overall survival rates for all 48 patients were 81% and 71%, respectively. The Cox proportional hazard model showed that only metachronous multiple primary lung cancer was an independent poor prognostic factor.

CONCLUSIONS

PDT is thought to be a first-line modality for patients who have ROSCC with a tumor length of <or= 10 mm, even if the tumor is medically operable. Most local recurrence can be cured by active therapy such as surgery, radiotherapy, or PDT. Multiple primary lung cancer subsequent to PDT is an important issue from the viewpoint of survival.

Increased reabsorption of alveolar edema fluid in the obese Zucker rat

Diabetic patients have a decreased incidence of acute respiratory distress syndrome, but the mechanism responsible for the decreased incidence is uncertain. Reabsorption of alveolar edema fluid (alveolar fluid clearance) has been considered to play an important role in resolution of acute respiratory distress syndrome. However, little is known regarding alveolar fluid clearance in diabetes mellitus. Since the obese Zucker rat has been used as an experimental model for diabetes mellitus, we determined if alveolar fluid clearance increased in the obese Zucker rat. First, we compared alveolar fluid clearance in obese Zucker rats with that in lean Zucker rats and Sprague-Dawley (SD) rats. Then, we determined the role of sodium channel, Na,K-ATPase, and beta(2)-adrenoceptor, which drives alveolar fluid clearance, in obese Zucker rats. Alveolar fluid clearance was estimated by the progressive increase in alveolar albumin concentrations in the isolated lungs. We found that basal alveolar fluid clearance in obese Zucker rats was two-fold greater than that in lean Zucker rats and SD rats. The mRNA expression of alpha(1)-, beta(1)-Na, K-ATPase and beta(2)-adrenoceptor, but not mRNA expression of sodium channel, increased in obese Zucker rats. A selective beta(2)-agrenergic antagonist, but not a Na, K-ATPase inhibitor, specifically inhibited the increase in alveolar fluid clearance in obese Zucker rats. These results indicate that overexpression of beta(2)-adrenoceptor primarily increases basal alveolar fluid clearance in the obese Zucker rat. We speculate that the stimulation of alveolar fluid clearance ameliorates acute respiratory distress syndrome in patients with diabetes mellitus.

Endogenous catecholamine stimulates alveolar fluid clearance in rats with acute pancreatitis

BACKGROUND AND OBJECTIVE

Acute pancreatitis causes pulmonary oedema with the accumulation of fluid in the alveolar spaces, possibly due to reduced clearance. This study tested the hypothesis that acute pancreatitis decreases alveolar fluid clearance in a rat model of pulmonary oedema during acute pancreatitis.

METHODS

Acute pancreatitis was induced by a retrograde injection of 5% taurocholate sodium (0.2 mL) into the common bile duct. The lungs were isolated 4, 24 and 48 h after the induction of acute pancreatitis and alveolar fluid clearance was measured in the absence of pulmonary perfusion.

RESULTS

Alveolar fluid clearance increased to 31.0 +/- 3.5% of instilled volume/h in rats with acute pancreatitis for 4 h compared with 17.3 +/- 1.0% of instilled volume/h in sham rats (P < 0.01), then returned to the control level 48 h after acute pancreatitis (16.0 +/- 4.1% of instilled volume/h). In contrast, the lung water to dry lung weight ratio decreased maximally 24 h after acute pancreatitis (P < 0.01), then returned to the control level 48 h after acute pancreatitis. The plasma epinephrine levels increased to 25-fold higher in rats with acute pancreatitis for 4 h than in sham rats without acute pancreatitis. Prazosin (an alpha(1)-adrenergic antagonist, 10(-4) mol/L), yohimbine (an alpha(2)-adrenergic antagonist, 10(-4) mol/L) or a bilateral adrenalectomy inhibited the increase in part, a combination of prazosin (10(-4) mol/L) and yohimbine (10(-4) mol/L) completely inhibited the increase in alveolar fluid clearance in rats after acute pancreatitis for 4 h, whereas propranolol (a beta-adrenergic antagonist, 10(-4) mol/L) had no effect.

CONCLUSIONS

Endogenous catecholamine stimulates alpha-adrenoceptors and increases alveolar fluid clearance in rats with acute pancreatitis.

[Comparison of the images in virtual bronchoscopy under different conditions]

OBJECTIVE

We report herein the comparison of the virtual bronchoscopy (VB) images which were constructed with 2 different computed tomography (CT) scanners combined with 3 different applications in 2 healthy adult volunteers.

METHODS

CT scanners were multi-detector row CT (MDCT) [64 detectors] and MDCT (16 detectors). Applications, by which VB images were made, were Leonardo (Leo), Ziostation (Zio), and Plus XNVZ2 (Plus). The image quality was evaluated by 3 expert bronchoscopists.

RESULTS

The change of the threshold value was necessary in Leo for practical use in subsegmental bronchi and more distal area, but unnecessary in Plus or Zio. When Plus was used, the VB images from the data obtained with MDCT (16 detectors) and MDCT (64 detectors) had almost equal quality.

CONCLUSIONS

Although the process to construct VB images was different in each application, it was regarded that Plus was not inferior to Zio or Leo in VB image quality.

[Multidisciplinary treatment of lung cancer in 21st century]

Lung cancer is the leading cause of cancer deaths in Japan. Recently, big progress in the treatment of lung cancer has been achieved, such as new anti-cancer drugs, molecular targeted therapy, stereotactic radiotherapy, etc. Multidisciplinary approach has been required to the therapy for lung cancer patients. In this paper, we introduce The 21st Century Multidisciplinary Center in Kanazawa Medical University, and the Hokuriku Training Program for Making Specialists in Cancer Treatment.

Extended sleeve pulmonary resection in a patient with synchronous triple bronchogenic squamous cell carcinoma

A 58-year-old male was admitted to our hospital for evaluation of bloody sputum. He was diagnosed as having synchronous triple bronchogenic squamous cell carcinomas in the right upper lobe, from the right B(6) segmental bronchus to the intermediate trunk and the middle lobar bronchus, and in the spur of the left B(1+2)/B(3) segmental bronchus. He underwent sleeve resection of the right upper lobe, right middle lobe, and right S(6) segment, with an anastomosis between the right main and right basal bronchi. This was followed by YAG-laser treatment and external irradiation for the left tumour and the residual right tumour. Postoperatively, chest X-ray revealed adequate expansion of the right basal segment, and pulmonary function testing showed satisfactory results. Recurrence was not detected during an initial 6-month period, however careful follow-up is required.

Intrapulmonary Solitary Fibrous Tumor Diagnosed by Immunohistochemical and Genetic Approaches: Report of a Case

Although solitary fibrous tumors (SFTs) of the pleura are not uncommon, intrapulmonary SFTs are extremely rare. A 72-year-old woman was admitted to our hospital for an investigation of an enlarging intrapulmonary tumor. Because a definitive diagnosis could not be readily established, a pulmonary wedge resection under video-assisted thoracic surgery was performed. Grossly, the tumor was white, well circumscribed, and separate from the pleural surface. Histologically, it consisted of spindle cells proliferating in a vague fascicular pattern, with many dilated capillaries, and intermingled glandular components. These findings suggested a differential diagnosis that included SFT and nonchondromatous pulmonary hamartoma. On immunohistochemical analysis, the spindle cells showed a strong positive reaction to the CD34 antigen. Interphase fluorescent in situ hybridization revealed an absence of HMGA-1 and -2 translocations. These results supported a diagnosis of SFT. A genetic approach may therefore be useful in the differentiation of SFT from nonchondromatous hamartoma.

Denopamine stimulates alveolar fluid clearance via cystic fibrosis transmembrane conductance regulator in rat lungs

OBJECTIVE

The objective of this study was to test the hypothesis that cystic fibrosis transmembrane conductance regulator (CFTR) plays a role in beta(1)-adrenergic agonist-stimulated alveolar fluid clearance.

METHODS

Isotonic 5% albumin solutions containing different pharmacological agents were instilled into the alveolar spaces of the isolated rat lungs. The lungs were inflated with 100% oxygen at an airway pressure of 7 cm H(2)O and placed in a humidified incubator at 37 degrees C. Alveolar fluid clearance was estimated by the progressive increase in the albumin concentration over 1 h. To test the hypothesis, we determined whether CFTR Cl(-) channel inhibitors (glibenclamide and CFTR(inh)-172) inhibited the effect of denopamine, a beta(1)-adrenergic agonist, on stimulation of alveolar fluid clearance in the isolated rat lungs.

RESULTS

Denopamine increased alveolar fluid clearance in a dose-dependent manner. Atenolol, a beta(1)-adrenergic antagonist, abolished the effects of denopamine on stimulation of alveolar fluid clearance. Although glibenclamide alone or CFTR(inh)-172 alone did not change basal alveolar fluid clearance, these CFTR inhibitors inhibited the effect of denopamine on alveolar fluid clearance.

CONCLUSION

CFTR plays a role in beta(1)-adrenergic agonist-stimulated alveolar fluid clearance in rat lungs.

Fluorodeoxyglucose uptake correlates with the growth pattern of small peripheral pulmonary adenocarcinoma

PURPOSE

Noguchi and colleagues reported that the growth pattern of small-sized adenocarcinoma was related to the vascular involvement and the prognosis of the patient. Noguchi's type A/B tumors had no lymph node metastasis, rare vascular involvement, and an excellent prognosis, which meant that Noguchi's type A/B tumors were preinvasive tumors of the peripheral type. Although Noguchi's classification was usually determined based on resected specimens, it would be useful to make a decision about the therapeutic strategy if the classification could be determined preoperatively based on the fluorodeoxyglucose (FDG) uptake.

METHODS

The FDG uptake in 61 pulmonary adenocarcinomas measuring 3 cm or smaller in diameter was compared with the mediastinal uptake and was classified into five grades. The relationship between the FDG uptake and Noguchi's classification (A to F) was analyzed.

RESULTS

The FDG uptake was significantly lower in Noguchi's type A/B tumors than in type C or in type D/E/F. Eleven of 12 tumors (92%) with no increased or a weak FDG uptake were classified as type A/B, whereas 32 of 33 tumors (97%) with a strong or very strong FDG uptake were classified as type C-F.

CONCLUSIONS

The FDG uptake is helpful for making an accurate diagnosis of Noguchi's classification preoperatively in patients with pulmonary adenocarcinoma.

Establishment of a new human acute monocytic leukemia cell line TZ-1 with t(1;11)(p32;q23) and fusion gene MLL-EPS15

Human leukemia cell lines are of great value in investigating basic and applied aspects of cell biology and clinical medicine. There have been 37 leukemia cell lines carrying 11q23 translocation and MLL rearrangements; however, cell lines harboring with t(1;11)(p32;q23) have not been established. We report here for the first time a new acute monocytic leukemia (AMoL) cell line with t(1;11)(p32;q23), designated TZ-1, and herein describe its biological characteristics. Mononuclear cells isolated from the ascites from a patient with AMoL (French-American-British classification; acute myeloid leukemia M5a) were isolated and passaged by liquid culture medium for a year. TZ-1 cells revealed typical monocytic features in morphology and had a t(1;11)(p32;q23) translocation. The immunoprofiling as determined by flow cytometry showed that TZ-1 cells are positive for myeloid and monocytic markers with lymphoid-associated markers. Fluorescence in situ hybridization and reverse transcription-polymerase chain reaction analyses revealed MLL-EPS15 fusion transcript and protein. Taken together, these results suggest that TZ-1 is a new monocytic leukemia cell line with t(1;11) translocation and fusion gene MLL-EPS15. The established cell line, TZ-1, could provide a valuable model in the analysis of the pathogenesis of MLL-EPS15-positive leukemia and in the development of new agents for this type of leukemia.

Stimulation of alveolar epithelial fluid clearance in human lungs by exogenous epinephrine

OBJECTIVES

Because several experimental studies have demonstrated that cyclic adenosine monophosphate generation following beta-adrenoceptor activation can markedly stimulate alveolar fluid clearance, we determined whether the endogenous levels of catecholamines that occur in the pulmonary edema fluid and plasma of patients with acute lung injury are high enough to stimulate alveolar fluid clearance in the human lung.

DESIGN

Observational clinical study.

SETTING

Academic university hospital and laboratory.

PATIENTS

Twenty-one patients with acute pulmonary edema plus ex vivo human lungs.

INTERVENTIONS

Measurements of catecholamine levels in patient samples and controlled laboratory studies of the effects of these catecholamine levels on the rates of alveolar fluid clearance in ex vivo human lungs.

MEASUREMENTS AND MAIN RESULTS

The concentrations of both epinephrine and norepinephrine in the pulmonary edema fluid and plasma were approximately 10 M (range of 1-8x10 M) in hydrostatic pulmonary edema (n=6) and acute lung injury patients (n=15). We therefore tested whether 10 M epinephrine or norepinephrine stimulated alveolar fluid clearance in isolated human lungs and found that these epinephrine or norepinephrine concentrations did not stimulate alveolar fluid clearance. However, higher concentrations of epinephrine (10 M), but not norepinephrine (10 M), significantly stimulated alveolar fluid clearance by 84% above control. Glibenclamide (10 M) and CFTRinh-172 (10 M), cystic fibrosis transmembrane conductance regulator inhibitors, completely inhibited the epinephrine-induced stimulation of alveolar fluid clearance.

CONCLUSIONS

These results indicate that endogenous catecholamine concentrations in pulmonary edema fluid are probably not sufficient to stimulate alveolar fluid clearance. In contrast, administration of exogenous catecholamines into the distal airspaces can stimulate alveolar fluid clearance in the human lung, an effect that is mediated in part by cystic fibrosis transmembrane conductance regulator. Therefore, exogenous cyclic adenosine monophosphate-dependent stimulation will probably be required to accelerate the resolution of alveolar edema in the lungs of patients with pulmonary edema.