Primary Mediastinal Germ Cell Tumor in a Middle-Aged Woman: Case Report and Literature Review

Although primary mediastinal germ cell tumors are found much more frequently among young males than among other people, we recently encountered a middle-aged woman with the disease. The patient was a 59-year-old woman who complained mainly of anterior chest pain. Chest CT scans revealed a nonhomogeneous mass measuring 7 x 7 cm in the anterior mediastinal area, accompanied by signs suggestive of mediastinal invasion of the tumor. Reduction surgery was performed. The pathologic diagnosis was mediastinal dysgerminoma. The patient received postoperative radiochemotherapy but died due to liver metastasis 11 months after surgery.

Gluteal Abscess Caused by Perforating Rectal Cancer: Case Report and Review of the Literature

An unusual case is described in which an abscess developed remote from a carcinoma of the rectum. A 52-year-old Japanese man developed a gluteal abscess six months after radiation therapy for unresectable carcinoma of the rectum. This case is presented with a review of the literature. Perforating carcinoma of the colon and rectum with abscess formation is best treated by preliminary total diversion colostomy and local drainage of the abscess. However, the mortality rate is still high.

Composite large cell neuroendocrine carcinoma and adenocarcinoma of the common bile duct

Large cell neuroendocrine carcinoma (LCNEC) is a high grade type of neuroendocrine tumour with an aggressive clinical course. This report describes the first case of LCNEC combined with an adenocarcinoma component in the common bile duct. A 68 year old man presented with jaundice. Severe stenosis of the bile duct was revealed by endoscopic retrograde cholangiography, and adenocarcinoma cells were detected by brush cytology. Pancreaticoduodenectomy was performed, and the patient died of disease three months after surgery. A tumour measuring 2.0 cm in diameter was located in the intrapancreatic portion of the bile duct. Histologically, the tumour consisted of a LCNEC component and a well differentiated adenocarcinoma component. There were transitional areas between the two components. Immunohistochemically, LCNEC cells were reactive for neuroendocrine markers, but no specific hormonal expression was found. Chromogranin A positive cells were found in some areas of the adenocarcinoma component. These findings are consistent with the theory that both of the carcinoma components originated from a common pluripotent stem cell.

[Chondromatous hamartoma of the lung with a unique demonstration on diagnostic imaging; report of a case]

A case of pulmonary hamartoma is reported with clinical, roentgenographical and histopathologic findings. The patient was a 53-year-old woman who had undergone right hemithyroidectomy for thyroid cancer 4 years before. An abnormal shadow, which was a non-clearly demarcated tumor, 2 cm in diameter, in the left middle lung field, was noted on her routine X-ray in February 2001. Physical examination and laboratory data revealed no significant findings, but computed tomography(CT) scans of the chest showed a gathering of small-sized high-density lesions in the nodule. She underwent left S8 segmentectomy on March 21, 2001. The pathology report on the frozen section was pulmonary hamartoma. Histopathologically, the lesion was characterized by a composition of bronchial epithelium, fat tissue and cartilage, with being diagnosed as a chondromatous hamartoma of the lung. The patient's postoperative course was uneventful, and she was discharged with no supportive therapy 14 days after the operation. To date, 14 months after the operation, the patient has been in good condition, without evidence of recurrence or distant metastasis on diagnostic imaging. This case is particularly interesting because a gathering of small-sized pulmonary hamartoma was demonstrated by imaging.

Immunohistochemical study of p53, c-erbB-2, and PCNA in barrett's esophagus with dysplasia and adenocarcinoma arising from experimental acid or alkaline reflux model

PURPOSE

An immunohistochemical study of p53, c-erbB-2, and proliferating cell nuclear antigen (PCNA) in Barrett's esophagus with dysplasia and adenocarcinoma, arising from experimental acid or alkaline reflux, was performed in dogs.

METHODS

Cardiectomy was performed in group A (n = 26) as an acid reflux model, and total gastrectomy was performed in group B (n = 24) as an alkaline reflux model. After surgery, the esophageal mucosa was observed and biopsied endoscopically every 3 months over a period of 6 years. Immunohistochemical staining of p53. c-erbB-2, and PCNA was performed, using biopsied specimens.

RESULTS

In group A, Barrett's esophagus developed in 14 of the 26 dogs. Low-grade dysplasia occurred in 5 of the 26 dogs, and in 1 of these 5 dogs, it developed into high-grade dysplasia. In this animal, adenocarcinoma arose 63 months after the operation. In group B, Barrett's esophagus developed in 10 of the 24 dogs. Low-grade dysplasia was observed in 4 of the 24 dogs. In 1 of these 4 dogs, the dysplasia became high-grade and adenocarcinoma occurred 66 months after the operation. In group A, PCNA was positive in adenocarcinoma; the PCNA labeling index (LI) was 58. c-erbB-2 and p53 were negative in all animals in group A. In group B, PCNA was positive in Barrett's esophagus with high-grade dysplasia and adenocarcinoma; the PCNA LI was 77. p53 was positive in adenocarcinoma. c-erbB-2 was negative in adenocarcinoma. CONCLUSIONS; The results of this study provided evidence of the dysplasia-carcinoma sequence arising from alkaline reflux, as well as from acid reflux. To the best of our knowledge, this is the first report of the use of an alkaline reflux model and a 6-year study using dogs to observe the course of Barrett's esophagus.

Intrathoracic free musculocutaneous flap after open-window thoracostomy for chronic empyema

An 85-year-old man was suffering from right pyothorax caused by methicillin-resistant staphylococcus aureus (MRSA). The empyema cavity was closed by intrathoracic implantation of a free rectus abdominis musculocutaneous (MC) flap using microvascular surgery 2 months after open-window thoracostomy (OWT). Compared with a pedicled MC flap, a free flap has the advantage that it can close a larger empyema cavity since the whole flap can be inserted into the cavity. Although the use of a free MC flap requires a two-stage operation, this method is believed to be more successful for controlling chronic empyema than any other established procedure, including decortication, thoracoplasty or pleuropneumonectomy.

Desmoid tumor of the chest wall following chest surgery: report of a case

Desmoid tumors of the chest wall following chest surgery are a rare occurrence. A case of this disease is reported herein together with a review of the literature. A 74-year-old man, who had previously undergone a right lower lobectomy for squamous cell carcinoma of the lung, was referred to our hospital with an abnormal shadow on his chest X-ray. The tumor, located in the right lateral chest wall, was successfully resected by an aggressive, wide extirpation, and a final diagnosis of a desmoid tumor originating in the chest wall was made. When following up patients after surgery for lung cancer, the possibility of desmoid tumors developing in the incised chest wall should therefore be kept in mind.

Lymphoepithelioma-like esophageal carcinoma: report of a case

We herein report the rare case of a patient suffering from lymphoepithelioma-like poorly differentiated squamous cell carcinoma of the esophagus. The patient was a 74-year-old woman in whom an esophageal tumor was found during an operation for thyroid cancer. After performing a subtotal thyroidectomy and cervical esophagectomy, esophageal reconstruction was performed using a free jejunal graft. Based on the results of the pathological examination, the esophageal tumor was diagnosed to be primary lymphoepithelioma-like esophageal cancer, not metastasis of either unknown nasopharyngeal cancer or thyroid cancer. Since surgery, she has survived postoperatively for more than 4 years with no evidence of recurrent disease.

Which relapse criteria best predict the mortality risk of treated alcoholics?

We examined which relapse criteria best predict the mortality risk of treated male alcoholics. The subjects were 172 male alcoholics who had previously been hospitalized. Using three criteria which defined relapse as failure to maintain abstinence from alcohol, alcohol abuse, or dependence, the relapse of each subject had been evaluated during a previous 3-year outcome study. Relative mortality risks in the next 3 years classified by the three relapse criteria were compared. The follow-up rate was 93.6% and 31 subjects died. The age-corrected relative mortality risk for subjects failing to maintain abstinence compared with abstainers was 5.32, while the relative mortality risks for the group abusing alcohol and for the group suffering alcohol dependence were 2.23 and 2.56, respectively. These results suggest that relapse defined as failure to maintain abstinence predicts a higher relative mortality risk than do criteria defining in terms of alcohol abuse and alcohol dependence.

Small intestinal metastasis from esophageal carcinoma associated with small intestinal obstruction: report of a case

The small intestine is rarely involved with metastatic tumors from outside the abdomen, and few case reports have been documented in the literature. We describe herein what to our knowledge is the third case of a solitary metastasis from squamous cell carcinoma (SCC) of the esophagus being found in the jejunum, causing small intestinal obstruction.

Modulation of morphology, proliferation and collagen synthesis in fibroblasts by the exudate from hypersensitive granulomatous inflammation in rats

We examined the effects of the exudate, collected from rats in which hypersensitive granulomatous inflammation was induced by methylated bovine serum albumin, on the function of inflammatory fibroblasts in culture. Addition of the exudate to the fibroblast culture induced changes in fibroblast morphology, identified by staining with antirat prolyl hydroxylase. Phase-contrast microscopy revealed that the exudate-treated fibroblasts became elongated and formed a network. Scanning electron microscopy showed that numerous long pseudopods covered the surface of the fibroblasts. Transmission electron microscopy revealed microfilament bundles with dense zones parallel to the long axis of the cell and nuclei with folds and indentations. Microfilaments were also visible in the elongated pseudopods. These features were consistent with those of myofibroblasts. The exudate also stimulated fibroblast proliferation and collagen synthesis. These findings suggest that the exudate contained certain factors that modulated fibroblast morphology, proliferation, and collagen synthesis. It is possible that putative endogenous factor(s) at the sites of inflammation modulate the development, contraction, and fibrosis of granulation tissue in hypersensitive granulomatous inflammation.

[Surgical treatment of thymoma--clinical evaluation]

Sixty-seven patients with thymoma were surgically treated during the past 19 years in our department. The 5-year, 10-year and 15-year survival rates of total cases with thymomas were 69.2%, 59.6% and 59.6%, respectively. Survival rates of thymoma with MG and without MG were not significantly different. According to clinical stages in Masaoka's classification, there were significant difference between Stage I and Stag III (p < 0.05), Stage I and Stage IV a (p < 0.01), and Stage I and Stage IV b (p < 0.01). We can conclude that complete resection of thymomas lead to better prognosis, and immunochemotherapy using cyclophosphamide, vincristine and OK-432 are effective.

Second surgical intervention for recurrent and second primary bronchogenic carcinomas

Second operations were performed in 1961-1990 on 23 patients with non-small cell bronchogenic carcinoma, constituting 2.5% of 906 who had undergone pulmonary resection for such tumor and 3.6% of the 641 with apparently curative surgery. The second operation was performed for recurrent tumor in 15 cases and for second primary tumor in eight. Five-year survival after the first operation was 30% in the former group and 88% in the latter (significant difference). Among the total 23 patients, this survival rate was 51%. The study indicates that an aggressive attitude to second surgical intervention is warranted. For early detection of second lesions, follow-up at maximally 6-month intervals should be continued for more than 5 years after the first operation.

Improved survival in left non-small-cell N2 lung cancer after more extensive operative procedure

The five-year survival rate of lung-cancer patients with left-sided N2 non-small-cell disease is worse than that for those with right-sided lesions and this is partly caused by inadequate nodal dissection due to anatomical limitations. To overcome the problem of performing nodal dissection in the left mediastinum, several modifications of the operative technique have been tried in the past 18 years. The survival rates of the patients treated by each procedure were retrospectively compared in this study. The dissection method for mediastinal nodes was modified at three periods (1973-1980, 1981-1985, and 1986-1990). The first period involved less extensive node dissection, in the second period more extensive dissection was enabled by mobilization of the aortic arch, and in the most recent systematic and extensive dissection was made possible by the use of a median sternotomy. The five-year survival rates of the left-sided N2 patients undergoing complete resection in the first and second period were 8.3%, and 15.4%, respectively. The three-year survival rate in the most recent period has risen to 30.8%. Complete and extensive dissection of the mediastinal nodes after performing a median sternotomy is the procedure of choice for lung-cancer patients with left-sided N2 disease.

Aggressive surgical intervention in N2 non-small cell cancer of the lung

An aggressive attitude toward surgical treatment was taken in patients with N2 non-small cell lung cancer in the past 10 years. Computed tomographic scanning was employed in the diagnosis of N2 disease, and had a true-positive rate of 57%. Among patients with N2 disease detected by computed tomographic scanning, surgical intervention was attempted except for those with unresectable disease. Of 190 patients with clinical N2 disease, 115 underwent surgical exploration: 9 patients had only an exploratory thoracotomy, 53 patients underwent a curative operation, and 53 had a noncurative operation. The overall 5-year survival rate of these patients was 16% and that of curatively resected patients was 20%. There were 47 patients whose N2 disease was not recognized before operation. The 5-year survival rate of this group was 20% overall and 33% in curatively resected cases. The overall 5-year survival rate of patients with N2 disease who underwent resection (106 with clinical N2 disease and 47 with clinically unrecognized N2 disease) was 17%, and that of the 84 patients undergoing curative operations was 24%. An aggressive attitude toward surgical intervention can be advocated for patients with N2 disease on the basis of our present results.

Results of surgical treatment in patients with stage IIIB non-small-cell lung cancer

From 1973 to March 1989, surgical resection was performed in 83 stage IIIB non-small-cell lung cancer patients (81% of all admitted stage IIIB patients). There were 2 operative deaths (2.3%), and complete resection was accomplished in 33 patients. The five-year survival rate of the patients undergoing complete resection was 25%, whereas that of the incomplete resection group was nil (p less than 0.05). Among the 26 patients with invasion of mediastinal structures who underwent complete resection, 3 patients survived for over five years. Two had squamous-cell carcinoma and one had adenocarcinoma, and their tumors involved the left atrium, pulmonary arterial trunk, and superior vena cava, respectively. Among the 6 patients with T4 lesions due to carinal invasion, two patients (one with mucoepidermoid carcinoma and one with squamous-cell carcinoma) have survived for over 8 and 4 years, respectively, after complete resection. There were no long-term survivors among the patients with malignant pleural effusion. Pleuropneumonectomy did not improve survival. Extended lymph-node dissection for N3 disease was only commenced in recent years, so it is not yet clear whether it will affect the survival rate or not. However, 6 out of 19 patients who underwent extended lymph-node dissection including the contralateral lymph-node compartments are still alive, with 23 months being the longest survival. To date, there are 6 three-year survivors among our present series of stage IIIB patients who underwent operative treatment. From these results, it can be concluded that stage IIIB patients should not be uniformly excluded from consideration for surgery, but rather should be evaluated with regard to the possibility of performing complete resection.

[Evaluation of surgical indication for the small lesion of advanced lung cancer]

This report analyzes the operative indication for the small lesion of advanced lung cancer. The subjects consisted of 25 patients with T1N2 lung cancer, one T1N3, four T1M1 and five small lung cancer lesion with dissemination, which was regarded as the small lesion of advanced lung cancer. The cumulative 5-year survival rate after operation for 25 patients with T1N2 lesion was 30.6%. Of 25 patients, 18 were selected patients who underwent a curative operation with a 5-year survival of 37.0%. In the remaining 7 patients, who underwent a non-curative operation, 5-year survival was 0%. As to mediastinal lymph node involvement, it is possible that metastasis to more than two levels of mediastinal lymph nodes or to the upper mediastinal lymph nodes (#1-3) are poor prognostic factors in T1N2 lesion. Another group except T1N2 could not be the comparative materials because they were much fewer in number. But T4 cases associated with small lung cancer lesion with dissemination and T1M1 cases associated with intrapulmonary metastasis encountered at thoracotomy could be expected to have a long-term survival. We conclude that T1N2 patients with metastasis to within one level of mediastinal lymph node, which will possibly have a curative operation, is a proper operative indication for the small lesion of advanced lung cancer.

[A case of completion pneumonectomy of adenoid cystic carcinoma which recurred 10 years after sleeve lobectomy]

A 62-year-old woman with adenoid cystic carcinoma which recurred 10 years after sleeve middle lobectomy was reported. Completion pneumonectomy was performed and her postoperative course was uneventful. If pulmonary function permits, reoperation for recurrent lung cancer should be attempted.

[A surgical case of mediastinal cystic lymphangioma]

A surgical case of a 33-year-old male with mediastinal cystic lymphangioma is reported. He was referred to our hospital for examination of mediastinal tumor. Chest X-ray film revealed an abnormal shadow in the left aorto-pulmonary window. CT scan of the chest visualized a smooth-walled, homogenous structure of this mass. MRI showed same findings as CT scan but could not suggest further information. He was operated on under the diagnosis of Castleman's lymphoma or thymic cyst. On thoracotomy, a bulging cystic mass was found in the middle mediastinum just beneath the aortic arch. The cyst was completely removed, and his postoperative course was uneventful. Pathological diagnosis was a mediastinal cystic lymphangioma. Cystic lymphangioma usually occurs in the neck, and rarely occurs in the mediastinum. Only about 30 cases of mediastinal cystic lymphangioma have been reported in the Japanese literatures.

Evaluation of femoral neck fracture healing in man by serial 99mTc-diphosphonate scintimetry

99mTc-diphosphonate uptake was measured in thirty-four patients with intracapsular fractures of femoral neck and in sixteen patients with trochanteric fractures during their healing process. A peak value in count ratio was recorded in all patients 4 to 6 weeks after fractures. Fifty patients were classified into a normal healing group and a delayed or non-union group. Namely, 99mTc-diphosphonate uptake was significantly higher in the delayed or non-union group than in the normal healing union group 10 weeks after injury. The application of 99mTc-diphosphonate scintimetry seems to make it possible to differentiate objectively the normal healing union from the delayed or non-union.