[Surgical approach for lung cancer with multiple pulmonary nodules]

A computed tomography (CT) and high-resolution CT (HRCT) have provided us an increasing opportunity to find multiple small pulmonary nodules, which sometimes appear ground glass opacity (GGO). Recently, fluorodeoxyglucose-positron emission tomography (FDG-PET) had a great contribution to our assessment for these small pulmonary nodules. However, since it is yet difficult to establish a diagnosis for these nodules during preoperative workup, a surgical lung biopsy is often required for an accurate diagnosis. We have experienced 9 patients who had undergone lung resection for primary lung cancer accompanied by multiple pulmonary lesions. Since the multiple lesions were consisted of malignant and benign lesions, it is still uncertain whether excessive lung resection should be performed in such patients. In this brief article, we summarized the characteristics of the pulmonary lesions in those patients and discussed difficulty of preoperative diagnosis, viability of pulmonary resection and problems underlining a surgical treatment.

Computed tomographic images reflect the biologic behavior of small lung adenocarcinoma: they correlate with cell proliferation, microvascularization, cell adhesion, degradation of extracellular matrix, and K-ras mutation

BACKGROUND

We previously reported that the computed tomographic M/L ratio (area of the tumor in the mediastinal computed tomographic image/area of the tumor in the lung computed tomographic image) of small peripheral lung adenocarcinoma is correlated with patient prognosis.

METHODS

Immunostaining for p53, bcl-2, Ki-67, vascular endothelial growth factor, CD34, matrix metalloproteinase 2, matrix metalloproteinase 9, tissue inhibitor of matrix metalloproteinase 2, and mutation of K-ras was assessed in 131 surgically resected, primary peripheral lung adenocarcinomas of 30 mm or less in maximum diameter to clarify the relationship between computed tomographic findings and biologic activities.

RESULTS

The numbers of patients with high labeling indexes of Ki-67 and high expression of vascular endothelial growth factor, CD34, matrix metalloproteinase 2, and matrix metalloproteinase 9 in the solid-type group (computed tomographic M/L ratio > or = 50%) were significantly higher than those in the faint density-type group (computed tomographic M/L ratio < 50%; P = .04 for Ki-67, P = .03 for vascular endothelial growth factor, P = .0009 for CD34, P = .001 for matrix metalloproteinase 2, and P = .00001 for matrix metalloproteinase 9). The number of patients with high levels of CD44v6 or tissue inhibitor of matrix metalloproteinase 2 staining in the faint density-type group was significantly higher than that in the solid-type group (P = .02 for CD44v6 and P = .01 for tissue inhibitor of matrix metalloproteinase 2). Independent variables capable of predicting computed tomographic M/L ratio included CD34, matrix metalloproteinase 2, matrix metalloproteinase 9, and tissue inhibitor of matrix metalloproteinase 2 (P = .0093, P = .0003, P = .0027, and P = .01, respectively; binary logistic regression analysis).

CONCLUSIONS

Our results suggest that the computed tomographic image of small lung adenocarcinoma is correlated with biologic activities and thus provides possible prognostic information.

Pulmonary T2N0 adenocarcinoma with metastasis to a lymph node in the thoracic wall

We experienced a rare case of lung cancer without hilar/mediastinal nodal involvement or direct invasion to the thoracic wall, but with metastasis to a lymph node in the thoracic wall. A 72-year-old woman with lung cancer was admitted to our hospital for the surgical therapy. She had suffered from right pleuritis in her childhood. During the dissection of the pleural adhesion around the whole lung, one small black lymph node was found in the thoracic wall and resected. Then, right middle and lower lobectomy and systematic nodal dissection were performed. The postoperative pathological examination revealed that nodal involvement was not observed in all samples except in the lymph node in the thoracic wall. In lung cancer patients with broad pleural adhesion, we should pay attention to lymph nodes in the thoracic wall. If we find them, the nodes should be resected for accurate staging.

Annual periodic increases in serum carcinoembryonic antigen concurrent with ground-glass opacity in the lung: report of a case

A 63-year-old woman underwent a video-assisted thoracoscopic lobectomy for cancer of the right lung in 1999. The following year, a lesion with ground-glass opacity was found in the left lung, and pathological examination after a partial lung resection revealed atypical adenomatous hyperplasia with expression of carcinoembryonic antigen (CEA). During postoperative screening tests for tumor recurrence, there were periodic increases in the serum CEA level by twofold above the normal levels in 2002 and 2003. Clinical evaluations, including laboratory tests, radiographic imaging, and endoscopy examinations, showed no evidence of a CEA-producing tumor, except for a new ground-glass opacity in the left lung. To our knowledge, this is the first report of periodic increases in serum CEA levels in a patient with ground-glass opacity in the lung, not reflecting recurrence of the lung tumor.

Catecholamine clearance from alveolar spaces of rat and human lungs

BACKGROUND

Although aerosolized beta-adrenergic agonists have been used as a therapy for the resolution of pulmonary edema, the mechanisms of catecholamine clearance from the alveolar spaces of the lung are not well known.

OBJECTIVE

To determine whether catecholamine clearance from the alveolar spaces is correlated with the fluid transport capacity of the lung.

METHODS

Albumin solution containing epinephrine (10(-7)M) or norepinephrine (10(-7)M) was instilled into the alveolar spaces of isolated rat and human lungs. Alveolar fluid clearance rate was estimated by the progressive increase in the albumin concentration over 1 h. Catecholamine clearance rate was estimated by the changes in catecholamine concentration and alveolar fluid volume over 1 h.

RESULTS

The norepinephrine clearance rate was faster than the epinephrine clearance rate in the rat and human lungs. In the rat lungs, amiloride (a sodium channel blocker) caused a greater decrease in alveolar fluid clearance and epinephrine clearance rate than propranolol (a nonselective beta-adrenergic antagonist). Although propranolol and phentolamine (an alpha-adrenergic antagonist), and 5-(N-ethyl-N-isoprophyl)amiloride (a Na+/H+ antiport blocker) changed neither the alveolar fluid clearance nor the norepinephrine clearance rate, amiloride and benzamil (a sodium channel blocker) decreased both clearance rates. As in the rat lungs, amiloride decreased alveolar fluid and norepinephrine clearance rates in the human lungs.

CONCLUSION

These results indicate that the catecholamine clearance rate from the alveolar spaces is correlated with alveolar fluid clearance in rat and human lungs.

Localized bronchioloalveolar carcinoma with small foci of active fibroblastic proliferation. A report of 2 cases

Localized bronchioloalveolar carcinoma (LBAC) without foci of active fibroblastic proliferation has been reported to be a pN0 disease. Predominantly, these tumors have not been associated with cancer relapse or death subsequent to surgery. Based on these observations, LBAC cases have been considered candidates for limited lung resection without lymph node dissection. However, this surgical option requires careful validation, and an accurate diagnosis is indispensable. The absence of foci of active fibroblastic proliferation must be confirmed by a thorough investigation. Nonetheless, these foci may escape detection, and even currently accepted diagnostic modalities may not be sufficient to accurately determine their absence. We illustrate this point by reporting 2 cases of LBAC with small but distinct foci of active fibroblastic proliferation.

Canine adiponectin: cDNA structure, mRNA expression in adipose tissues and reduced plasma levels in obesity

Adiponectin is a protein synthesized and secreted by adipocytes. Decreased adiponectin is responsible for insulin resistance and atherosclerosis associated with human obesity. We obtained a cDNA clone corresponding to canine adiponectin, whose nucleotide and deduced amino acid sequences were highly identical to those of other species. Adiponectin mRNA was detected in adipose tissues, but not in other tissues, of dogs. When 22 adult beagles were given a high-energy diet for 14 weeks, they became obese, showing heavier body weights, higher plasma leptin concentrations, but lower plasma adiponectin concentrations. The adiponectin concentrations of plasma samples collected from 71 dogs visiting veterinary practices were negatively correlated to plasma leptin concentrations, being lower in obese than non-obese dogs. These results are compatible with those reported in other species, and suggest that adiponectin is an index of adiposity and a target molecule for studies on diseases associated with obesity in dogs.

Video-assisted thoracoscopic wedge resection for pulmonary sequestration

A 60-year-old woman underwent a video-assisted thoracoscopic wedge resection of intralobar pulmonary sequestration instead of a lobotomy because the lesion was localized in the right basal segment. Preoperative 3-dimensional computed tomography was useful for identifying an aberrant artery arising from the thoracic aorta and distributing to the lesion. A successful outcome more than 4 years after the surgery indicates that a wedge resection under video-assisted thoracoscopy may prove to be a therapeutic option for localized pulmonary sequestration.

Video-Assisted Bronchial Stump Reinforcement With an Intercostal Muscle Flap

For lobectomy patients at considerable risk of developing a postoperative bronchopleural fistula, the bronchial stump reinforcement with an intercostal muscle flap is sometimes performed. This procedure usually requires a standard thoracotomy, even if video-assisted thoracoscopic surgery (VATS) is better for the patient. Our patient was a 76-year-old male with lung cancer and severe diabetes mellitus. He underwent lobectomy and systematic nodal dissection combined with bronchial stump reinforcement using an intercostal muscle flap, performed as a VATS procedure. No postoperative complications were observed. This procedure is applicable to patients who are candidates for VATS lobectomy.

Cavernoscopic Removal of a Fungus Ball for Pulmonary Complex Aspergilloma

Lobectomy of the lung for aspergilloma is not always appropriate in elderly patients because of the high surgical risk. A 78-year-old male diagnosed with complex aspergilloma was referred to our hospital for recurrent hemoptysis. Because he refused lobectomy, we conducted a cavernoscopic removal of the fungus ball. The site of the skin incision was carefully designed preoperatively. After achieving access, the fungus ball was removed piece by piece under endoscopic view. Intraoperative blood loss equaled 30 mL. At 5 months postoperative follow-up, the patient had no evidence of recurrence. This procedure may be useful in some patients with complex aspergilloma.

[Lung cancer with ground glass opacity diagnosed by transbronchial lung biopsy using an ultrathin bronchoscope and virtual bronchoscopy]

Although thoracic computed tomography (CT) screening indicated that there are many patients who have pulmonary shadow with ground glass opacity, it is sometimes difficult to obtain the appropriate specimens for histological diagnosis of such patients. We herein report a lung cancer patient with ground glass opacity who was diagnosed preoperatively by an ultrathin bronchoscope and virtual bronchoscopy. A 78-year-old female was admitted to our hospital due to bacterial pneumonia. At the admission, CT showed another abnormal small shadow in her right middle lobe. Since the shadow was not visible by fluoroscopy, we reconstructed the images of virtual bronchoscopy using the data obtained by multidetector CT. The location of the shadow was determined in the peripheral area of a dorsal branch of right B4aialpha. Then the transbronchial lung biopsy using an ultrathin bronchoscope with simultaneous CT guidance was performed. The histological findings of the biopsy specimens revealed that the shadow was highly suspicious for malignancy. Therefore, the right middle lobectomy was conducted, and the tumor was diagnosed as an adenocarcinoma. An ultrathin bronchoscope with virtual bronchoscopy is useful to diagnose a pulmonary shadow with ground glass opacity.

Uridine 5'-triphosphate stimulates alveolar fluid clearance in the isolated rat lungs

Uridine 5'-triphosphate (UTP) increases chloride secretion followed by fluid movement into the proximal airspaces. However, little is known about whether UTP affects fluid movement in the distal airspaces. We studied the effect of UTP on basal and stimulated alveolar fluid clearance in the isolated rat lungs. Isosmotic 5% albumin solution was instilled into the alveolar spaces of isolated rat lungs, which were then inflated with 100% oxygen at an airway pressure of 7 cmH(2)O. Alveolar fluid clearance was measured by the progressive increase in albumin concentrations over 1 h. Although UTP (10(-9) - 10(-6) M) did not increase alveolar fluid clearance, UTP (10(-5) - 10(-3) M) and isoproterenol (10(-5) M), a beta-adrenergic agonist, increased alveolar fluid clearance by 40% and 120% of the basal values, respectively. A combined treatment of UTP (10(-4) M, 10(-3) M) and isoproterenol increased alveolar fluid clearance by 280% of the basal value. The effects of UTP in the presence and absence of isoproterenol were abolished by blockers of a P2 purinoceptor and chloride channels. These results indicate that UTP stimulates alveolar fluid clearance in the distal airspaces of rat lungs.

Malnutrition impairs alveolar fluid clearance in rat lungs

Inadequate nutrition complicates the clinical course of critically ill patients, and many of these patients develop pulmonary edema. However, little is known about the effect of malnutrition on the mechanisms that resolve alveolar edema. Therefore, we studied the mechanisms responsible for the decrease in alveolar fluid clearance in rats exposed to malnutrition. Rats were allowed access to water, but not to food, for 120 h. Then, the left and right lungs were isolated for the measurement of lung water volume and alveolar fluid clearance, respectively. The rate of alveolar fluid clearance was measured by the progressive increase in the concentration of Evans blue dye that was instilled into the distal air spaces with an isosmolar 5% albumin solution over 1 h. Malnutrition decreased alveolar fluid clearance by 38% compared with controls. Amiloride (10−3M) abolished alveolar fluid clearance in malnourished rats. Either refeeding for 120 h following nutritional deprivation for 120 h or an oral supply of sodium glutamate during nutritional deprivation for 120 h restored alveolar fluid clearance to 91 and 86% of normal, respectively. Dibutyryl-cGMP, a cyclic nucleotide-gated cation channel agonist, increased alveolar fluid clearance in malnourished rats supplied with sodium glutamate. Terbutaline, a β2-adrenergic agonist, increased alveolar fluid clearance in rats under all conditions (control, malnutrition, refeeding, and glutamate-treated). These results indicate that malnutrition impairs primarily amiloride-insensitive and dibutyryl-cGMP-sensitive alveolar fluid clearance, but this effect is partially reversible by refeeding, treatment with sodium glutamate, or β-adrenergic agonist therapy.

A Prostacyclin Analogue, OP-41483a-CD, Restores the Ability of a � 2 -Adrenergic Agonist to Stimulate Alveolar Fluid Clearance in Rats

PURPOSE

It is not yet known whether a prostacyclin analogue can affect alveolar fluid clearance. According to recent studies, high-dose (10(-3) M) terbutaline, a beta(2)-adrenergic agonist, failed to increase alveolar fluid clearance. Therefore, we examined the effects of OP-41483alpha-CD, a prostacyclin analogue, on alveolar fluid clearance in the presence of high-dose terbutaline in rats.

METHODS

Albumin solution containing Evans blue dye and various drugs was instilled into the alveolar airspaces of isolated rat lungs, which were then inflated with 100% oxygen at an airway pressure of 8 cmH(2)O. Alveolar fluid clearance was measured by the progressive increase in dye concentrations over 1 h.

RESULTS

Although 10(-5) and 10(-4) M terbutaline increased alveolar fluid clearance, 10(-3) M terbutaline did not. OP-41483alpha-CD restored the ability of 10(-3) M terbutaline to stimulate alveolar fluid clearance. The effect of OP-41483alpha-CD was consistent with the effect of atenolol, a beta(1)-adrenergic antagonist. The effect of OP-41483alpha-CD on alveolar fluid clearance was unchanged in lungs inflated with nitrogen. Prostaglandin E (PGE)(1) and PGE(2) analogues had similar effects to OP-41483alpha-CD on alveolar fluid clearance.

CONCLUSION

These results indicate that a prostacyclin analogue restores the ability of high-dose terbutaline to stimulate alveolar fluid clearance.

A prospective evaluation of transbronchial ultrasonography for assessment of depth of invasion in early bronchogenic squamous cell carcinoma

In order to determine the appropriate treatment modality for roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC), it is essential to evaluate the depth of invasion, because ROSCC invading beyond the cartilaginous layer cannot be effectively treated by photodynamic therapy (PDT) due to spread of disease. Transtracheal endoscopic ultrasonography (TUS) was useful for predicting the depth of invasion in some ROSCCs. In order to assess the actual significance of TUS as a diagnostic tool for predicting the depth of carcinoma invasion, we have conducted a prospective trial with 22 lesions of ROSCCs. We ultrasonographically classified the degree of the depth of invasion into two groups; A: "invasion does not reach cartilaginous layer" and B: "invasion involves cartilaginous layer". Then the patients were treated by irradiation, PDT, or surgical resection. Pathological findings were also classified into A or B. In order to calculate the sensitivity for evaluating the depth of invasion by TUS, the cases without any tumor and/or malignant cells after PDT were regarded as pathological A. In the evaluation of the depth of carcinoma invasion staying inside the cartilaginous layer, the sensitivity and the positive predictive value were 85.7%, the specificity was 66.7%, and the accuracy was 80.0%. With TUS, preoperative evaluation of the depth of invasion would be more accurate, and the decision of treatment modality would be more appropriate, compared with the conventional bronchoscopic observation alone.

Surgical treatment of stage I non-small cell lung carcinoma

In stage I non-small cell lung cancer (NSCLC), the cancer is localized to the lung. For this early stage NSCLC, therefore, surgery is considered to be the treatment of choice. In this report, we reviewed the surgical treatment approaches for stage I NSCLC, placing emphasis on limited resection and video-assisted thoracic surgery (VATS). In regard to limited resection, sublobar resection (wedge resection and segmentectomy) may yield a good long-term outcome in selected cases, as does lobectomy. No strong evidence to recommend this procedure has, however, been published. On the other hand, many descriptive studies have indicated that VATS may be useful for the treatment of NSCLC, although the results have not shown any statistically significant differences from those of resection by conventional open thoracotomy. In addition to the low invasiveness, the curability of NSCLC using the VATS approach has been recognized to be similar to that of the standard thoracotomic approaches in clinical practice. Well-controlled studies with strong statistical results are needed to provide strong supportive evidence for the use of VATS for NSCLC. (Ann Thorac Cardiovasc Surg 2003; 9: 283-9)

The efficacy of lung cancer screening conducted in 1990s: four case-control studies in Japan

The efficacy of lung cancer screening is still controversial. In order to evaluate efficacy of mass screening for lung cancer in 1990s, the Japanese Ministry of Health and Welfare planned to conduct four independent case-control studies in four different regions; Miyagi, Gunma, Niigata, and Okayama Prefecture. The study design of all the four studies was a matched case-control study in which the decedents from lung cancer were defined as cases. In Gunma Prefecture, a screening examination is annual miniature chest X-ray only, whereas sputum cytology is added for high-risk screenees in others. Matching conditions were gender, year of birth, smoking histories (except Okayama), and municipality. Smoking adjusted odds ratio (OR) of dying from lung cancer for those screened within 12 months before case diagnosis compared with those not screened ranged 0.40-0.68. Three of four studies revealed statistically significant reduction of the risk for lung cancer death. OR of pooled analysis, where all sets were combined and analyzed, was 0.56 (95% confidence interval: 0.48-0.65). Recent mass screening program for lung cancer in Japan could reduce the risk for lung cancer death. However, the possibility exists that some confounding factors affected the results. In order to elucidate whether the results can be applied to Western countries, further studies will be required.