[Case of overlapping cancers complicated with sarcoidosis]

A 74-year-old man presented with left chest pain. He had been given a diagnosis of sarcoidosis at age 65. Chest CT films on admission revealed a mass shadow in the left lower lung field and a small nodule in the left upper lung field. Because the specimens of transbronchial biopsy were not diagnostic, video-assisted thoracoscopic surgery was performed. The pathologic diagnosis of the resected lung was overlapping cancers (large cell neuroendocrine carcinoma and mucosa-associated lymphoid tissue lymphoma) complicated with sarcoidosis. Adjuvant chemotherapy was not performed. One year after surgery he continues to do well and has no evidence of recurrence.

Correlation of angiogenesis with 18F-FMT and 18F-FDG uptake in non-small cell lung cancer

L-[3-18F]-alpha-methyltyrosine (18F-FMT) is an amino-acid tracer for positron-emission tomography (PET). We have conducted a clinicopathologic study to elucidate the correlation of angiogenesis with 18F-FMT and 2-[18F]-fluoro-2-deoxy-D-glucose (18F-FDG) uptake in patients with non-small cell lung cancer (NSCLC). Thirty-seven NSCLC patients were enrolled in this study, and two PET studies with 18F-FMT and 18F-FDG were performed. Uptake of PET tracers was evaluated with standardized uptake value. Vascular endothelial growth factor (VEGF), CD31, CD34, L-type amino acid transporter 1 (LAT1) and Ki-67 labeling index of the resected tumors were analyzed by immunohistochemical staining, and correlated with the clinicopathologic variables and the uptake of PET tracers. The median VEGF rate was 45% (range, 10-78%). High expression was seen in 30 patients (81%, 30/37). VEGF expression was statistically associated with progressively growing microvessel count. VEGF showed a correlation with LAT1 expression (P = 0.04) and Ki-67 labeling index (P = 0.01). However, it showed no correlation with age, gender, disease stage, tumor size, and histology. Microvessel density (MVD) showed no correlation with any parameters. 18F-FMT and 18F-FDG uptake correlated significantly with VEGF (P < 0.0001, P = 0.026, respectively), whereas the correlation of 18F-FMT and VEGF was more meaningful. The present study demonstrated that the metabolic activity of primary tumors as evaluated by PET study with 18F-FMT and 18F-FDG is related to tumor angiogenesis and the proliferative activity in NSCLC.

Immunocytochemical evaluation of large cell neuroendocrine carcinoma of the lung

OBJECTIVE

To examine whether immunocytochemistry can distinguish pulmonary large cell neuroendocrine carcinoma (LCNEC) among non-small cell lung cancers (NSCLCs).

STUDY DESIGN

Tumor touch imprint cytologic specimens of 109 lung cancers were studied. Immunocytochemistry was done using a total of 8 primary antibodies: chromogranin A, synaptophysin, neural cell adhesion molecule, neuron specific enolase, CK34betaE12, thyroid transcription factor-1, cytokeratin 18 and E-cadherin.

RESULTS

If 2 or 3 antibodies of chromogranin A, synaptophysin and neural cell adhesion molecule were stained positive and CK34betaE12 was not stained, pulmonary LCNEC can be selected accurately among other NSCLCs with 100% sensitivity and 100% specificity.

CONCLUSION

This study reveals that immunocytochemistry can help distinguish LCNEC of the lung from other NSCLCs.

Small large-cell neuroendocrine carcinoma in a patient with pulmonary emphysema

Large-cell neuroendocrine carcinomas (LCNECs) are relatively rare, and most reported occurrences tend to involve relatively large tumors. We report a small LCNEC in a 63-year-old male patient with pulmonary emphysema. The peripheral pulmonary nodule did not have lobulation and spiculation, and it was difficult to establish correct diagnosis before surgery because of its small size and effect of surrounding emphysematous change.

Large cell carcinoma of the lung and squamous cell carcinoma of the oropharynx presenting as uveitis

Ocular manifestations of systemic malignancy may precede the diagnosis of cancer; some intraocular lymphomas can present initially as chronic uveitis. The two cases described were found to have underlying carcinomas of the lung and oropharynx. Both presented with chronic uveitis and decreased visual acuity that were not responding to antiinflammatory therapy.

Primary large cell neuroendocrine carcinoma of the breast: radiologic and pathologic findings

Some breast neoplasms are classified as primary neuroendocrine carcinomas because they are positive for neuroendocrine markers. Although neuroendocrine carcinomas can originate from various organs of the body, primary neuroendocrine carcinomas of the breast are extremely rare. The diagnosis of primary neuroendocrine carcinoma of the breast can only be made if nonmammary sites are confidently excluded or if an in situ component can be found. Here we report a primary large-cell neuroendocrine carcinoma (LCNL) involving the left breast. Breast ultrasonography revealed a lobulated, heterogeneous, low-echoic mass in the left breast, and the lesion appeared as a well-defined, highly-enhancing mass on a chest computed tomography scan. Ultrasound-guided core needle biopsy was performed on the mass, and primary LCNC was confirmed by histopathologic examination.

Incidence and clinical characteristics of symptomatic choroidal metastasis from lung cancer

PURPOSE

To determine the clinical characteristics of symptomatic choroidal metastasis (CM) resulting from metastatic lung cancer.

METHODS

Twenty-two consecutive patients with symptomatic CM resulting from lung cancer were retrospectively reviewed for ocular findings, medical history and systemic disease. All patients underwent a complete screening for further organ metastasis by computed tomography (CT) and bone scintigraphy. Annual frequency of CM was determined and compared with the incidence predicted from ocular screening studies.

RESULTS

In eight of 22 (36%; 95% confidence interval [CI] 17-59) patients, lung cancer had been diagnosed before occurrence of CM, with a median interval of 13 months. In 14 patients lung cancer was detected after diagnosis of CM, with a median interval of 1 month. Choroidal metastasis was unilateral, solitary and located close to or at the posterior pole in the majority of patients. Further organ metastasis with a median number of three affected organ systems was present in 19 (86%; 95% CI 65-97) patients. Median survival after diagnosis of symptomatic CM was 13 months, by contrast with 2 months in lung cancer patients with CM identified in an ocular screening study. The mean number of patients in Berlin diagnosed with symptomatic CM was 1.4 per year, which was two orders of magnitude less than predicted from screening studies.

CONCLUSIONS

Symptomatic choroidal lung cancer metastasis in the majority of patients presents as a solitary tumour before diagnosis of lung cancer in patients with multiple organ systems affected by metastatic disease. Contrary to predictions from ocular screening studies, it is a rare clinical entity.

[Left atrial mass]

A 56-year-old woman presented with a complaint of dyspnea on minimal exertion for the past two months and orthopnea of three-day history. She was first examined at another hospital two years before for nonproductive cough, for which computed tomography was performed that showed a right pulmonary mass. The patient refused further evaluation and treatment at that time. Transthoracic echocardiography revealed a large mass filling the entire left atrium via the inferior pulmonary vein and causing mitral flow obstruction during diastole. Computed tomography of the thorax showed a large mass filling the entire right lower lobe, which occluded the right lateral lobe superior segmental bronchus and obliterated the lower lobe segment bronchi. As the patient was severely symptomatic, she underwent right lower and middle lobectomy and left atrial mass resection, based on the decision of the surgery council. The pathological examination of the specimens from both atrial and pulmonary masses revealed pulmonary large cell carcinoma. The patient died due to cardiopulmonary arrest on the postoperative 20th day.

[A patient with very high serum level of human chorionic gonadotrophin; the diagnosis is not always a germ-cell tumour]

A 47-year-old man, who presented with dyspnoea, gynaecomasty, and aphasia due to an extensively metastasized malignancy, was transferred to the hospital for chemotherapy as a matter of urgency. Because of his severe clinical symptoms, the widespread presence of metastases on radiological examination, and a striking increase in serum human chorionic gonadotrophin (HCG), the patient was treated with bleomycin, etoposide, and cisplatin (BEP) for a suspected metastasized germ-cell tumour. Definitive histology, however, revealed not a germ-cell tumour, but instead a large-cell undifferentiated HCG-producing carcinoma of uncertain primary origin. Using this patient's history, ectopic HCG production by malignancies is described in more detail.

ROC graphs for assessing the ability of a diagnostic marker to detect three disease classes with an umbrella ordering

Receiver operating characteristic (ROC) curves and the area under these curves are commonly used to assess the ability of a continuous diagnostic marker (e.g., DNA methylation markers) to correctly classify subjects as having a particular disease or not (e.g., cancer). These approaches, however, are not applicable to settings where the gold standard yields more than two disease states or classes. ROC surfaces and the volume under the surfaces have been proposed for settings with more than two disease classes. These approaches, however, do not allow one to assess the ability of a marker to differentiate two disease classes from a third disease class without requiring a monotone order for the three disease classes under study. That is, existing approaches do not accommodate an umbrella ordering of disease classes. This article proposes the construction of an ROC graph that is applicable for an umbrella ordering. Furthermore, this article proposes that a summary measure for this umbrella ROC graph can be used to summarize the classification accuracy, and corresponding variance estimates can be obtained using U-statistics theory or bootstrap methods. The proposed methods are illustrated using data from a study assessing the ability of a DNA methylation marker to correctly classify lung specimens into three histologic classes: squamous cell carcinoma, large cell carcinoma, and nontumor lung.

Diagnostic yield of flexible bronchoscopic procedures in lung cancer patients according to tumour location

INTRODUCTION

This study aims to determine whether the diagnostic yield of flexible bronchoscopy sampling procedures in patients with lung cancer was dependent on tumour location.

METHODS

A retrospective analysis was conducted on the diagnostic yield of bronchial washing (BW), endobronchial biopsy (EBB), bronchial brushing (BB), bronchoalveolar lavage (BAL), blind brushing (B) and transbronchial biopsy (TBB) specimens obtained at fibre-optic bronchoscopy for patients with lung cancer.

RESULTS

Of 503 patients who underwent fibre-optic bronchoscopy examination, BW, EBB, BB, BAL, B and TBB were performed on 254, 325, 67, 155, 70 and 54 patients, respectively. For patients with bronchoscopically-visible tumours, BW, EBB and BB yielded diagnostic specimens for lung cancer in 28.3 percent, 77.5 percent and 53.7 percent of patients, respectively. For patients whose tumours were not visible bronchoscopically, BAL, B and TBB yielded diagnostic specimens for lung cancer in 35.5 percent, 22.9 percent and 31.5 percent of patients, respectively. EBB was less likely to be diagnostic in patients with tumours in the middle or lingular lobe bronchi. The diagnostic yields of all the other sampling techniques were not influenced by the location of the bronchoscopically-visible or non-visible tumours.

CONCLUSION

The diagnostic yields of bronchoscopic sampling procedures were dependent on tumour visibility during bronchoscopy and location of bronchoscopically-visible tumours.

[Large cell neuroendocrine carcinoma of the lung incidentally found at surgery for pulmonary aspergillosis]

We report a 56-year-old man with pulmonary large cell neuroendocrine carcinoma (LCNEC) incidentally found at the surgery for pulmonary aspergillosis. In 1991, an abnormal chest radiographic shadow was found on a mass screening. A diagnosis of pulmonary aspergillosis was made by bronchoscopic examination. The patient was then followed up without treatment. He had hemoptysis in 2005, and was referred to our hospital. Chest CT scan revealed a cavitary lesion with an air crescent sign and an irregularly shaped nodule in the right apex. Wedge resection of these lesions was performed under video-assisted thoracoscopic surgery. Pathological examination revealed not only aspergilloma, but also an LCNEC 11 x 7 mm in size, which was located close to the aspergilloma. Microscopically, nests of tumor cells were distributed peribronchially. Right upper lobectomy and mediastinal lymph node dissection was performed, and the pathological stage was IIIA (T1N2M0). The patient received four cycles of adjuvant chemotherapy with carboplatin and paclitaxel. No recurrence has been observed since surgery. This is the first report describing co-existence of pulmonary aspergilloma and LCNEC.

Role of fine needle aspiration cytology in diagnosis of lung tumours--a study of 100 cases

The aim of this study was to assess the usefulness of fine needle aspiration cytology (FNAC) as a diagnostic method in lung tumour as well as to determine the incidence of lung cancer in various age and sex group and in relation with smoking. Hundred cases of lung tumours were investigated. Out of 100 patients, 88 were male and 12 were female. The age of patients varies from 23-78 years most of the patient were in the age group of 50-70 years. The most common tumour was squamous cell carcinoma (45%) followed by adenocarcinoma (22%), small cell carcinoma (16%) and large cell carcinoma (8%). Eighty out of 100 patient had history of smoking. Diagnostic accuracy of cytology with final histopathological report was established with accuracy rate of 95%.

EU-USA pathology panel for uniform diagnosis in randomised controlled trials for HRCT screening in lung cancer

Randomised controlled trials for lung cancer screening using high-resolution computed tomography are now underway. In order to allow effective future comparison of the different trials, as well as strengthening conclusions based upon the analysis of larger data sets, uniformity and consistency of pathology diagnosis are essential. The aim of the present study was to determine the effectiveness of the learning process in this difficult area of diagnostic pathology. Eight pathologists received two CD-ROMs, each with digital images of 30 cases. After diagnosing the first series, selected background reading was provided. Kappa (kappa) scores were calculated for each pathologist and category, and were compared to the consensus score. The readings of the first series showed a moderate agreement kappa score: mean+/-sd for category numbers 8 (all eight categories) and 2 were 0.53+/-0.05 and 0.65+/-0.04, respectively. The kappa 2 score distinguished between categories denoting benign and malignant lesions. The second series resulted in a good agreement kappa score: 0.65+/-0.06 for category number 8 and 0.81+/-0.02 for category number 2. In conclusion, this study demonstrates that screen-detected cases pose particular problems for pathologists and that a trained pathology panel serving randomised controlled trials is likely to lead to more consistent and accurate tissue diagnosis.

[Lung cancer associated with bulla found during an operation of pneumothorax; report of a case]

A 50-year-old man was admitted to our hospital because of dyspnea. His chest X-ray and computed tomography (CT) showed right pneumothorax and multiple bullae. His pneumothorax was drained with a chest tube, however, because of a persistent air leak, bullectomy was performed 18 days after the occurrence of pneumothorax. Intraoperatively, we found a palpable tumor in the bulla approximately 10 mm in diameter and resected it with the bullae. Histologically, the tumor was diagnosed as a large cell carcinoma.

Analysis of differentially expressed genes in neuroendocrine carcinomas of the lung

INTRODUCTION

Large cell neuroendocrine carcinoma (LCNEC) and small cell lung carcinoma (SCLC) show considerable differences in their histology but share neuroendocrine (NE) characteristics and also genetic and/or expression patterns.

METHODS

We used the subtractive expression method to identify differences in gene expression that would allow discrimination between these two types of NE lung carcinoma.

RESULTS

Eight cDNA fragments were transcribed at a higher level in LCNEC compared with SCLC, and these corresponded to five mitochondrial genes, two ribosomal genes, and one fetal regulation factor, neuronatin (NNAT). Immunohistochemically, NNAT protein was detected in 43% (6/14) of LCNECs but in only 8% (1/13) of SCLCs (p < 0.05). Positive staining for NNAT was observed in areas that did not show the NE morphology, such as palisading and rosettes.

CONCLUSIONS

The present results suggest that NNAT has the potential to be used as a differential maker between LCNEC and SCLC.

Large-Cell Neuroendocrine Carcinoma of the Lung: An Aggressive Neuroendocrine Lung Cancer

Large cell neuroendocrine carcinoma (LCNEC) is part of the neuroendocrine spectrum of pulmonary tumors. This increasingly recognized tumor has been reported to have 5-year actuarial survival rates following resection that are worse than those described for other variants of non-small cell lung cancer (NSCLC). Therefore, debate has emerged regarding whether the tumors should be classified and treated as NSCLC or small-cell lung cancer. This article reviews the tumor characterization, biology, presentation and diagnosis, surgical therapy, results of therapy, and long term prognosis of patients with LCNEC.

Immunohistochemical differential diagnosis between large cell neuroendocrine carcinoma and small cell carcinoma by tissue microarray analysis with a large antibody panel

To elucidate additional phenotypic differences between large cell neuroendocrine carcinoma (LCNEC) and small cell lung carcinoma (SCLC), we performed tissue microarray (TMA) analysis of surgically resected LCNEC and SCLC specimens. Immunostaining with 48 antibodies was scored based on staining intensity and the percentage of cells that stained positively. Four proteins were identified as significantly expressed in LCNEC as compared with SCLC: cytokeratin (CK)7, 113 vs 49 (P < .0301); CK18, 171 vs 60 (P < .0008); E-cadherin, 77 vs 9 (P < .0073); and beta-catenin, 191 vs 120 (P < .0286). Immunostaining of cross-sections containing LCNEC and SCLC components revealed significant expression of CK7, CK18 and beta-catenin in the LCNEC component compared with the SCLC component in 2 of 3 cases. Our results indicate that significant expression of CK7, CK18, E-cadherin, and beta-catenin is more characteristic of LCNEC than of SCLC, and these findings provide further support that these tumor types are separate entities morphologically and immunophenotypically, if not biologically.

Integrated multislice CT and Tc-99m Sestamibi SPECT-CT evaluation of solitary pulmonary nodules

PURPOSE

The purpose of this study was to evaluate efficacy of multislice computed tomography (MSCT) and single photon emission computed tomography (SPECT)-CT with Tc-99m Sestamibi in the assessment of solitary pulmonary nodules of uncertain significance. Scintigraphy was performed using a 'hybrid' g-camera that allows simultaneous acquisition of SPECT and CT images, with interesting results in diagnostic oncology.

MATERIALS AND METHODS

Between September 2003 and August 2004, 23 patients with a solitary pulmonary nodule detected on CT underwent SPECT-CT using Tc-99m Sestamibi as a radiotracer. Nodules with positive scintigraphy were immediately subjected to biopsy or surgical resection. Nodules with negative scintigraphy were followed up after 3-4 months by MSCT with automatic segmentation software (Advanced Lung Analysis, ALA) and histological characterisation.

RESULTS

Of the 23 nodules (size range 0.8-2 cm) discovered with MSCT, 11 showed intense uptake of Tc-99m Sestamibi. Ten lesions were true positive: seven adenocarcinomas, one squamous cell carcinoma, one large cell carcinoma and one metastasis. The only false positive was histologically classified as a large cell granuloma. Twelve lesions had negative scintigraphy: five fibrous lesions, three hamartomas, three granulomas and one adenocarcinoma (false negative). Benign nodules without tracer uptake underwent another CT scan 3-4 months later, which confirmed stability of the nodule size. Correlation of Sestamibi SPECT with histology showed sensitivity (Se) of 90.9 %, specificity (Sp) of 91.6 %, diagnostic accuracy of 91.3 %, positive predictive value (PPV) of 90.9% and negative predictive value (NPV) of 91.6 %.

CONCLUSIONS

The integrated use of MSCT and Tc-99m Sestamibi SPECT-CT could be very useful in the management of solitary pulmonary nodules (SPNs). In particular, in our preliminary study, scintigraphy provided significant diagnostic information to differentiate benign from suspicious pulmonary nodules. The use of scintigraphy could be helpful to anticipate histological assessment and surgical treatment of SPNs identified at CT.