[Pulmonary blastoma--long-term survival of a patient with metastases]

We report a rare case of pulmonary blastoma. This 59-year-old woman has been apparently well with recurrent and metastatic tumors in her left lung for 9 years after the initial operation. On May 28, 1984, she underwent a thoracotomy of left upper lobectomy and lymph nodes dissection. The histologic diagnosis of resected specimen was pulmonary blastoma. In August 1986 (27 months after the initial surgery), chest X-ray revealed some nodules in the lungs. Then, the patient had two thoracotomies for the excision of 4 tumors and one chest wall resection of the tumor. In addition, she received systemic chemotherapy 28 times, directly intrapulmonary drug injection 3 times and radiation therapy once for recurrent and metastatic disease. Following some cycles of our combination chemotherapy consisting of cis-platinum and vindesine, some lesions had decreased in size and others previously seen on chest X-ray were no longer evident. She achieved an objective response with receiving two-drug chemotherapy. Our observation suggest that this intensive combination chemotherapy is effective in recurrent and metastatic disease of pulmonary blastoma as a surgical adjuvant.

[Clinical study of 8 cases of spontaneous esophageal rupture]

Among 8 patients with spontaneous esophageal rupture, mean age was 46.5 years, and there was only one female. Vomiting after drinking was the main cause of onset. In 4 patients who underwent drainage of the thoracic cavity or initial treatment by surgery within 24 hrs after onset, closure after layer-layer suture of the site of rupture was made in two patients in whom definitive diagnosis was obtained at the first medical examination and early discharge was possible. A definitive diagnosis was obtained after drainage of the thoracic cavity in the other two patients, and esophagectomy without thoracotomy was performed on the 55th day after onset in one and the other patient received only conservative treatment without surgery, both patients were discharged. Of 4 patients who underwent treatment after 24 hrs, two patients who recovered included one who received only conservative treatment and another who underwent closure by suture of the site of rupture and covering with a pedicled omental flap 12 days after onset. The other two patients died of MOF after operation. We propose the following guidelines for treatment of this condition; In patients in whom surgical treatment is possible within 24 hrs after onset, closure by layer-layer suture of the site of rupture may be indicated. In cases in which more than 24 hrs has elapsed after rupture spontaneous closure sometimes can be expected in patients with a rupture would less than 2 cm. In patients accompanied with progressing mediastinitis or pyothorax with drainage procedure surgical treatment is indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endoscopic surgery of airway lesions by Nd-YAG laser treatment]

Between April 1980 and November 1990, we treated 212 cases of airway lesion using an Nd-YAG laser via the fiberoptic bronchoscope. The Nd-YAG laser power output was usually 40 W (20-60 W) delivered in 2 sec. shots. The cases consisted of 98 primary lung cancer, 12 primary tracheal cancer, 53 metastatic airway lesion, 7 benign tumor, and 42 cicatricial and granulomatous lesions. The therapeutic effects of Nd-YAG laser treatment were evaluated based on alleviation of dyspnea, widening of airway, and curative vaporization for therapeutic purposes. Effectiveness was observed in 180 of a total of 212 cases (84.9%). Out of 75 emergency cases in which a lifesaving procedure was performed to widen the airway, effective results were obtained in 70 (93.3%) with dramatic improvement in condition. It was also effective in 90 of 109 cases (82.6%) in which the procedure was performed for staged (palliative) widening of airway. In 55 cases of advanced lung cancer (Stage III or IV, mainly non-small cell cancer) in which palliative widening procedure was performed, one year survival was 44%. In 13 of 18 cases (72.2%) in which the procedure was performed for curative vaporization of invasive cancer, successful results were obtained. In 7 cases of benign tumor in which vaporization was performed as a radical curative procedure, no recurrence was observed in any cases. In 53 cases of metastatic airway lesion, effective results were obtained 48 (90.6%). The primary lesions of these cases consisted of 14 cases of esophageal cancer, 9 cases of lung cancer, 7 cases of colo-rectal cancer, 7 cases of thyroid cancer, and 16 others.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of chest wall reconstruction with scapular flap and rib autotransplantation for recurrent esophageal cancer]

Subtotal esophagectomy was carried out for esophageal cancer in a 64-year-old male patient. The postoperative stage was a1, n2, stage III. From around 10 months after surgery, a recurrent tumor of first size was recognized at the right anterior lateral thoracic wall, corresponding to the site of the thoracotomy wound, and the tumor involved the right 4th 5th ribs and the subcutaneous soft tissue including the pectoralis major and latissimus dorsi muscles. Total layer chest wall resection including 3rd to 6th ribs, with the tumor was performed. In order to reconstruct the cutaneous soft tissue, a scapular skin flap with vascular pedicle of the circumflex scapular artery and vein was made. Moreover, for the purpose of reinforcing the osseous thoracic wall, a free autogenous rib was transplanted; namely, the 7th rib was cut in half lengthwise and then fixed like a bridge at the center of the defective site of the thoracic wall. Finally, the region was covered with the scapular skin flap for the chest wall reconstruction. After the surgery, supplemental ventilation was not necessary. Although fracture of the transplanted rib was recognized at month 2, the thorax was stable, even immediately after the surgery. Therefore, this method is considered to be useful for reconstruction after total layer chest wall resection.

[A case of adenoid cystic carcinoma of the esophagus]

A 64-year-old male admitted with feeling of a foreign body at the esophagus in swallowing. Esophageal radiologic findings showed a serrated type shadow defect 6 cm in diameter at the middle thoracic esophagus. Endoscopic findings revealed a elevated type tumor at a site 32 cm from the incisor dentition. The biopsy specimens showed squamous cell carcinoma. The operation was performed with right thoracotomy, subesophagotomy, and reconstruction of gastric tube via substernum. Macroscopically, a elevated type tumor of 5.5 x 4.0 x 2.0 cm covered by normal esophageal mucosa at the periphery was recognized. Histologically, most of the tumor was adenoid cystic carcinoma differentiating to squamous cell carcinoma in the epithelium. Immunohistological stain of actin, S-100 protein indicated that the tumor may have originated from an esophageal gland. Histologic stage was mp, ly(-), v(-), n(-), stage I. Surgical curability was CIII. Postoperative irradiation for prevention of recurrence has been conducted. The patient survives without tumor at present 4 months later.

[A case report of fibromatosis originating from the right anterior scalene muscle]

Fibromatosis is rare and locally invasive tumor arising from musculoaponeurotic tissue, and also has a high postoperative recurrence rate. So, we must perform wide resection of the tumor and surrounding tissue. A case of fibromatosis originating from the right anterior scalene muscle was reported. A 31-year-old female in whom cervical fibromatosis had been pointed out by her home doctor, was referred to our hospital for treatment. CT scan, MRI and angiography showed that the tumor developed from the cervical lesion to the upper thoracic and invaded the right subclavian artery. The tumor originating from right anterior scalene muscle was found at operation. The combined resection consisted of the right anterior salene muscle with tumor, phrenic nerve, subclavian artery and vein, and chest, well including the first and second rib and clavicular bone, because of wide invasion of tumor to surrounding organs. Reconstruction of the subclavian artery and vein was performed by PTFE vascular prostheses. The postoperative course was uneventful, she is now in good health 8 months after operation with good blood flow via the reconstructed vessels confirmed by angiography, without any sign of recurrence.

[Clinical studies on reconstruction procedure of total layer chest wall resection]

The results of clinical studies on 16 reconstruction procedure after total layer chest wall resection in 14 cases of malignant tumor of the chest wall were reported. The 14 cases consisted of two cases with recurrent primary chest wall tumor, two cases of primary breast cancer, seven cases of recurrent breast cancer, and others. The reconstruction procedure after total layer chest wall resection was conducted using only various myocutaneous flaps (eight cases using latissimus dorsi of the resected side, three cases using the abdominitis of the resected side, three cases using latissimus dorsi of the non-resected side, and two cases using a pectoralis major myocutaneous flap of the non-resected side). reconstruction only using a myocutaneous flap proved to be satisfactory for preventing early stage postoperative respiratory distress and maintaining the stability of the chest wall and respiratory function during prolonged observation. Namely, use of myocutaneous flap is the best approach of reconstruction the chest wall after total layer chest wall resection. We confirmed that reconstruction with latissimus dorsi myocutaneous free flap of the non-resected side with microvascular anastomosis of thoracodorsal vessels was useful for posterior chest wall tumors invading the latissimus dorsi muscle. Also, our results demonstrated the insertion of an omental flap under the myocutaneous flap was useful for cases with secondary chest wall infection or vascular damage caused by preoperative high dose irradiation.

[A clinico-pathological study of resected lung cancer cases accompanied by pleural dissemination]

A total of 26 lung cancer cases accompanied by pleural dissemination were resected between June 1977 and June 1988. Of these 16 cases were male and 10 cases were female. Their age was 34-78, and the average age was 56.7 years. The histologic type was adenocarcinoma in 23 cases, 1 was large cell carcinoma, 1 was combined adenosquamous cell carcinoma, and 1 was combined adeno-small cell carcinoma. Of these 23 adenocarcinoma cases, 15 were well differentiated, 7 were moderately differentiated, and 1 was poorly differentiated. There was no correlation between tumor size and pleural dissemination. Pleural effusion was observed in 8, 5 had bloody effusion and the other 3 had yellow effusion. Exact preoperative diagnosis and evaluation of extent was very difficult in pleural dissemination cases except for the pleural effusion cases. Concerning the operation method in these cases pleuropneumonectomy was performed in 10, pleurolobectomy in 6, and lobectomy in 10. Prognosis of cases of resected pleural dissemination was very poor. The median survival time was 16 months, The 1-year survival rate was 56.3%, the 2-year survival rate was 23.2%, the 3-year survival rate was 15.4%, and the 4-year survival rate was 7.7%. There was no 5-year survivor in lung cancer cases of this group. Malignant pleural effusion cases had a poorer prognosis, with 6 of 8 cases dying within 1 year from operation. No remarkable therapeutic effects were achieved by adjuvant chemotherapy. In the single case of preoperative hyperthermia, histological therapeutic effect (Ef 2) was recognized. These results suggest that there is no indication of operation in malignant pleural effusion cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of omental pedicle flap plombage for fungus ball type pulmonary aspergillosis]

The usual surgical treatment for fungus ball type pulmonary aspergillosis is lobectomy, but in cases of aspergillosis located in a post-lobectomy space a second lobectomy is difficult because of the accompanying inflammatory process. A 53-year-old male underwent left upper lobectomy for pulmonary tuberculosis eight years ago. Six year postoperatively, he developed fungus ball type aspergillosis in the post-lobectomy space with bronchopleural fistula and recurrent hemoptysis. We performed an omental pedicle flap plombage via the post-sternal route to resect the pleural cavity fungus ball. The post operative course was uneventful and clinically the bronchopleural fistula was closed.

[Endoscopic Nd-YAG laser treatment in lung cancer]

Authors have treated a total of 199 cases consisting of 92 lung cancer cases, 14 primary tracheal cancer, 50 metastatic airway lesions and 43 benign airway lesions. In 167 of which effective results were obtained. Out of 92 effective results were obtained in 73, 79% in lung cancer cases. Out of 30 emergency cases in which the procedure was performed to widen the airway, effective results were obtained in 29. It was also effective in 35 of 48 cases in which the procedure was performed for staged (palliative) widening of airway. In 9 of 13 cases in which the procedure was performed for curative vaporization of cancer invasion and 1 of 2 cases in which procedure was performed for hemostasis, successful results were obtained.

[Endoscopic Nd-YAG laser treatment and adjuvant therapy of metastatic lesions of airway]

Endoscopic Nd-YAG laser treatment and adjuvant therapy were performed in 44 cases with metastatic lesions of airway. The best results were obtained in 31 cases (93.9%) out of 33 cases complaining of ventilatory disturbance in which endoscopic Nd-YAG laser treatment was indicated as an emergency procedure. In most of these cases with metastatic lesions of airway consisted of respiratory tract invasion from mediastinal lymph nodes in cases of esophageal cancer or lung cancer. In these cases, after laser treatment for ventilatory disturbance, the patients condition improved to the extent that adjuvant therapy could be performed. Adjuvant therapy was performed in 38 cases, there were 7 cases treated surgically (resection of the metastatic lesions of airway in 3 cases, tracheal tube stent operation in 4 cases 0, 28 radiotherapy in 28 cases (Linac irradiation in 24 cases, 60Co intraluminal irradiation of the trachea in 4 cases 0, and 32 cases were treated with chemotherapy. Tracheal tube stent operation was useful for maintenance of the tracheal lumen following laser treatment, and 60Co intraluminal irradiation was effective for the residual intratracheal tumor. The 1-year survival rate of 44 cases with metastatic lesions of airway was 42% and the 2-year survival rate was 22%, so this result suggested endoscopic Nd-YAG laser treatment and adjuvant therapy for metastatic lesions of airway was useful to prolong survival time. However the main value of this modality is for the rapid relief of severe ventilatory disturbance due to obstructive airway lesions.

[A diagnostic imaging system for cancer localization using an excimer dye laser]

Hematoporphyrin derivative has an affinity for malignant tissue and emits a red fluorescence when exposed to excitatory light. Therefore it is theoretically possible to make a diagnosis of cancer localization by observation of this fluorescence. The authors have been developing a new imaging system for cancer diagnosis using an excimer-dye laser. The excimer pulse has a 308 nm ultraviolet beam emitted by XeCl. Simplification and accuracy of the fluorescence diagnostic procedure was achieved by utilizing the nature of the pulse and a polychrometer. The diagnostic system permits endoscopic examination under ordinary observation light. Investigations have been performed in animal tumor models including FM-mouse (breast cancer) and beagle dog (esophageal cancer). Tumor tissue showed a distinct fluorescence, but no fluorescence could be observed in normal tissue, 72 hours after hematoporphyrin derivative administration.

Photodynamic therapy with hematoporphyrin derivative in cancer of the upper gastrointestinal tract

An historical overview is given of the development of photodynamic therapy (PDT) with hematoporphyrin derivative for the treatment of malignant tumors. Results in patients with superficial, and non-superficial esophageal cancer and with early gastric cancer is described, with case illustrations and follow-up. Due to the difficulty in early stage diagnoses and in determining all cases of lymph node involvement, this form of treatment should be employed primarily in inoperable early-stage cancer, to reduce the extent of resection, or to render previously inoperable cases operable. Combination with other treatment modalities and the effects of PDT on histologically different tumor types, need to be further examined.