Elevations of serum C-reactive protein occur independently of circulating interleukin-6 concentrations in patients with lung-cancer

It has been suggested that a proportion of patients with cancer have an ongoing acute phase response indicated by a raised C-reactive protein (CRP). To examine whether an acute phase protein response is associated with circulating interleukin-6 (IL-6) concentrations in patients with lung cancer, we measured serum levels of CRP and interleukin (IL)-6 in 176 patients with lung cancer and 48 patients with other pulmonary diseases (28 diffuse pulmonary infiltrates, 15 benign lung tumors, and 5 bronchial asthmas). Serum CRP was detectable (greater-than-or-equal-to 2.5 mg/liter) in 57.4% of patients with lung cancer, 78.6% of patients with diffuse pulmonary infiltrates, 46.7% of patients with benign lung tumors, and 40.0% of patients with bronchial asthma. Serum IL-6 was detectable in all patients by a highly sensitive enzyme-immunoassay, the concentration ranging from 0.126 to 35.115 pg/ml. Although there was no significant difference in serum IL-6 levels among the histologic types of lung cancer, the IL-6 concentration was significantly higher in patients with advanced cancers than in those with early ones. Correlation analyses showed that there was no significant relationship between the CRP and IL-6 concentrations in the 176 patients with lung cancer (r=0.212, P=0.1243), while a highly significant correlation between both levels was observed in the 28 patients with diffuse pulmonary infiltrates (r=0.783, P=0.0005). These results indicate that the serum IL-6 level in patients with lung cancer is closely associated with the disease stage, but that a raised CRP concentration occurs independently of circulating IL-6 concentrations in patients with lung cancer.

Expression of variant CD44, exon 6 in patients with metastatic pulmonary tumor

High expression ratios of CD44 variant 6 (CD44 V6) in patients with metastatic pulmonary tumor were found in those with primary lesions of cancer of the colon, uterus, larynx, liver and osteosarcoma. It was clarified that patients showing expression of CD44 variant 6 likely revealed pulmonary metastasis at earlier time following operations of primary cancer (p<0.05). CD44 V6, an adhesion molecule, was a factor to participate in pulmonary metastases from various organ cancers. No significant correlation was observed in survival between patients with CD44 V6 positive versus negative tumors, except laryngeal tumor after resection of primary or metastatic lung tumor. CD44 V6 related to its invasive and further metastatic functions in metastatic lung tumor. We suggest that cancer cells expressing the CD44 molecule especially V6 may adhere to vascular endothelium and hyaluronic acid in the lung. And cancer cells without this molecule liberated from the primary focuses hardly adhere to the pulmonary tissues supposedly resulting in delayed metastases and proliferations in the pulmonary tissues.

Primary tumor levels of interleukin-6 in relation to tumor burden in human breast-cancer

To examine whether tissue levels of interleukin 6 (IL-6) are associated with the clinicopathologic status in human breast cancer, immunoreactive IL-6 concentration was measured in tumor extracts of 75 breast cancer patients. IL-6 was detectable in 69 of 75 tumor extracts by enzyme-linked immunosorbent assay, the concentration ranging from 10 to 10.690 pg/mg protein. When breast cancer specimens were categorized into four groups in terms of clinical stage of disease at diagnosis, IL-6 concentration (mean +/- SE) in tissue extracts was significantly higher in stage IV patients (2859 +/- 840 pg/mg protein) than in stage I-III patients (344 +/- 117, 350 +/- 150 and 564 +/- 230 pg/mg protein, respectively). Correlation analyses between IL-6 concentration and clinicopathologic factors showed that tissue levels of IL-6 were significantly higher in patients with distant metastasis compared with those without. Furthermore, IL-6 concentration was significantly higher in tumors of more than 5.0 cm in size as compared to less than 5.0 cm. However, no significant association was found between IL-6 concentration and age, histological type, histological grade, lymph node involvement, or hormone receptor status. These results suggest that primary tumor levels of IL-6 are closely associated with clinical stage in human breast cancer.

Prognosis of patients after pulmonary artery plasty for non-small cell lung cancer

OBJECTIVE

We evaluated the clinical outcomes of patients after lung resection with pulmonary artery (PA) plasty for non-small cell lung cancer (NSCLC).

METHODS

From 1995 to 2006, 36 patients (26 males and 10 females) with NSCLC underwent lobectomy or segmentectomy with PA plasty at our institution. The mean age of the patients was 65.9 years old (range 45-87 years old). There were 17 left upper lobectomies, 10 right upper lobectomies, five left lower lobectomies, two right upper-and-middle bilobectomies, one right lower lobectomy, and one left upper division segmentectomy. Both bronchoplasty and PA plasty were performed in 15 patients. Six patients received preoperative chemotherapy, and one had preoperative radiotherapy.

RESULTS

The postoperative morbidity rate was 27.8 % (10/36), and the mortality rate (30 days) was 2.8 % (1/36). One patient underwent completion pneumonectomy on postoperative day 13. Macroscopic residual cancer was identified in two patients at the thoracic wall and aorta, respectively; microscopic residual cancers were identified in two patients at the stumps of the pulmonary artery and in one patient at the bronchial stump. Postoperative radiation therapy was additionally given to those four patients, except one. The 5-year survival rate for all patients was 51.8 %. There was no significant difference in the 5-year survival rate between clinical N (cN) 0-1 patients and cN2 patients. However, in pathological N (pN) 0-1 patients, the 5-year survival rate was significantly better than that of pN2 patients (71.9 % versus 0.0 %; P < 0.001).

CONCLUSIONS

PA plasty for NSCLC is acceptable and highly recommended for pN0-1 patients. Strict patient selection should be considered so as to avoid surgical operations in patients with pN2 staging.

New trainer for video-assisted thoracic surgery lobectomy

BACKGROUND

Only a few simulators are available which offer training in video-assisted thoracic surgery (VATS). We have developed a VATS training model for surgeons.

METHODS

The simulator consists of a training module housing three disposable components: the lung (made of polyurethane), the bronchus, and the artificial circulatory pulmonary vessels (made of polyvinyl chloride), connected to a pump. VATS procedures were videotaped and evaluated using a checklist assessment method.

RESULTS

This unique module has been tested at several VATS seminars in Japan. In the questionnaire, training participants strongly agreed that the trainer was helpful and prepared them well for VATS lobectomy prior to performing actual surgery. Evaluation of the dexterity score for thoracoscopic surgery with our simulator correlated with the surgeons' experience with actual surgery. Technical factors were well taught using this model.

CONCLUSIONS

Our unique trainer may enhance the skill of VATS surgeons at a national level.

Identification of Lck-derived peptides applicable to anti-cancer vaccine for patients with human leukocyte antigen-A3 supertype alleles

The identification of peptide vaccine candidates to date has been focused on human leukocyte antigen (HLA)-A2 and -A24 alleles. In this study, we attempted to identify cytotoxic T lymphocyte (CTL)-directed Lck-derived peptides applicable to HLA-A11⁺, -A31⁺, or -A33⁺ cancer patients, because these HLA-A alleles share binding motifs, designated HLA-A3 supertype alleles, and because the Lck is preferentially expressed in metastatic cancer. Twenty-one Lck-derived peptides were prepared based on the binding motif to the HLA-A3 supertype alleles. They were first screened for their recognisability by immunoglobulin G (IgG) in the plasma of prostate cancer patients, and the selected candidates were subsequently tested for their potential to induce peptide-specific CTLs from peripheral blood mononuclear cells of HLA-A3 supertype⁺ cancer patients. As a result, four Lck peptides were frequently recognised by IgGs, and three of them – Lck₉₀₋₉₉, Lck_449−458, and Lck_450−458 – efficiently induced peptide-specific and cancer-reactive CTLs. Their cytotoxicity towards cancer cells was mainly ascribed to HLA class I-restricted and peptide-specific CD8⁺ T cells. These results indicate that these three Lck peptides are applicable to HLA-A3 supertype⁺ cancer patients, especially those with metastasis. This information could facilitate the development of peptide-based anti-cancer vaccine for patients with alleles other than HLA-A2 and -A24.

Comparison between a Case-Matched Analysis of Left Upper Lobe Trisegmentectomy and Left Upper Lobectomy for Small Size Lung Cancer Located in the Upper Division

BACKGROUND

Although an increasing number of approaches for pulmonary segmentectomy to treat early lung cancer are being used, there have been few reports on left upper lobe trisegmentectomy, which is midway between single segmentectomy and lobectomy, for lung cancer.

METHODS

We retrospectively reviewed the medical charts of 86 clinical stage I case-matched patients with a tumor size of less than 2.0 cm in diameter located in the left upper division who underwent resection between June 1998 and December 2005. The patients were divided into two groups as follows: LTS (31), left upper lobe trisegmentectomy; LUL (55), left upper lobectomy. We evaluated these groups with respect to several factors.

RESULTS

The characteristics of the two groups (LTS vs. LUL) demonstrated no significant differences with respect to gender, histological type, tumor size, or upstaging of pathological node, or the mode of video-assisted thoracic surgery (VATS). Patients with LTS had a significantly lower pulmonary function compared to the LUL group. There were no significant differences between the two groups with respect to factors such as blood loss and duration of chest tube drainage. Morbidity and recurrence rates did not differ between the two groups, and there was no mortality in our series. The overall survival rate at 5 years was 69.7 % in the LTS and 72.5 % in the LUL group. There was no significant difference in survival rates between the LTS and the LUL group after resection.

CONCLUSION

LTS may be suitable as a standard treatment if the tumor is small and the suspected margins are well away from the lingula.

[Successful treatment for descending necrotizing mediastinitis; report of a case]

A case of a 55-year-old man with descending necrotizing mediastinitis (DNM) after a tooth removal was reported. Chest computed tomography (CT) showed a fluid collection in the right thorax, in the cervical region and in the mediastinum. The patient underwent cervical drainage and thoracoscopic pleural dissective drainage. The cervical and right anterior thoracic drain was removed on the 6th day and posterior drain was removed on the 8th day after the operation. The patient was discharged on the postoperative day 13, and showed no recurrence.

[Clinical features of thoracic injury; special reference to diaphragmatic injury]

We investigated the clinical feature of thoracic injury patients, mainly with diaphragmatic injury. From 1993 to 2005, 739 patients with thoracic injury were treated at our life-saving emergency center. There were more blunt trauma patients than penetrating injury patients (693 cases vs 46 cases). Regarding the thoracic injury patients, the causes of trauma were traffic injury in 462 (62.5%), unexpected accident including work place accident in 153 (20.7%), suicide in 90 (12.2%), and assault in 34 (4.6%). As the numbers of injured organs increased, the mortality rate increased. Among 156 patients with cardiopulmonary arrest on admission, 155 patients died. This result suggested that saving the life of patients presenting with cardiopulmonary arrest on admission is extremely difficult. Thirty-eight cases (5.1%) required surgical treatment, and surgery to repair diaphragmatic injury was performed in 14 cases. In 6 cases of diaphragmatic injury, thoracoscopy was performed during the examination and/or surgery.

CONCLUSION

Urgently transporting thoracic injury patients to hospital before the onset of cardiopulmonary arrest is therefore essential in order to reduce the mortality rate of these patients. In addition, thoracoscopy is very useful for both examining and treating traumatic diaphragmatic injury patients.

[Airway injuries due to blunt chest trauma]

Although the incidence of blunt chest trauma is very high, the mediastinal tracheobronchial injuries are quite rare. The airway injuries are thought to be one of the most urgent clinical conditions in thoracic surgery, and we are requested to make not only a rapid and sharp diagnosis but also an appropriate treatment plan considering combined injuries. We present 9 cases of tracheobronchial injuries due to blunt chest trauma in recent years. The average age of these patients is 26.1 years, and they are consisted of 6 male and 3 female. The cause of trauma is traffic accident in 7, and occupational crane accident in 2. Bronchoplasty were done in 5 cases (right main bronchus in 2, left main bronchus in 1, trunks intermediate bronchus in 1, and the spur between middle and lower lobe in 1), membranous-tracheoplasty with right pneumonectomy in 1, left pneumonectomy in 1, conservative treatment in 2. Postoperative mortality is occurred in 1 case who was suffering from multiple injuries including severe head injury and contralateral lung contusion. Tracheobronchial plasties should be chosen if possible to preserve lung function for the patient suffering from airway injuries.

Prognostic significance of subcarinal station in non-small cell lung cancer with T1-3 N2 disease

BACKGROUND

Surgical resection may continue to offer the best chance of long-term survival for patients with non-small cell lung cancer (NSCLC). Generally, patients with N2 NSCLC have a poor prognosis. However, the surgical treatment of patients with N2 remains controversial as in these patients, some N2 subgroups have better prognoses than others. The objective of the current study was to evaluate the factors associated with N2, and to determine whether such factors are reliable predictors of survival.

METHODS

We retrospectively reviewed 142 non-small cell lung cancer patients with T1-3 N2 in whom a curative approach had been attempted between January 1994 and December 2003. The patients were consequently divided into four groups (NS-1, no subcarinal involvement and without N1; NS-2, no subcarinal involvement and with N1; SI-1, subcarinal involvement and without upper mediastinal site; SI-2, subcarinal involvement and with upper mediastinal site). We also evaluated two groups for N2 stations (single-station N2 versus multiple-station N2). Multivariate analysis by Cox's proportional hazards regression model was performed to identify the prognosis.

RESULTS

Lobectomy was carried out in 105 of the patients; bilobectomy in 10, and pneumonectomy in 27. The patients with T1-3 N2 disease showed survival rates of 34.1 % at 3 years and 24.1 % at 5 years. The overall survival rates at 3 years and 5 years were as follows: NS-1, 56.3 % and 43.2 %; NS-2, 35.4 % and 29.5 %; SI-1, 16.7 % and 0 %; SI-2, 15.4 % and 0 %, respectively. The NS-1 group had better prognoses than the other groups. There was a significant difference in survival rates within each group ( p = 0.0005). In univariate analysis, the type of surgery, type of subcarinal involvement, and multiple-station N2 were significantly associated with prognosis. Multivariate analysis showed that NS-1 was only found to be an independent prognostic factor in cases of T1-3 N2 disease ( p = 0.0018). NS-2 was not an independent factor but tended toward significance ( p = 0.0681). But multiple-station N2 was not an independent factor ( p = 0.1549).

CONCLUSIONS

Surgery for patients with T1-3 N2 NSCLC might be acceptable if subcarinal lymph node metastasis is predicted to be absent.

Less Vigorous Surgery for Second Primary Lung Cancer

BACKGROUND

Patients with second primary lung cancer (SPLC) have a heterogeneous background. The optimum modality of treatment for SPLC patients has not yet been determined. The objective of this study was to attempt to identify the value of less vigorous therapies such as segmentectomy or video-assisted thoracic surgery (VATS) in SPLC.

METHODS

We retrospectively reviewed the medical records of 46 patients who underwent resection for SPLC in Fukuoka University Hospital between January 1994 and April 2005. Patients were separated into two groups (LVT: less vigorous therapy including segmentectomy or VATS lobectomy; LCT: lobectomy with conventional thoracotomy). The characteristics of each group were evaluated and survival rates were analyzed at 5 years after surgery.

RESULTS

The mean amount of blood loss was found to be significantly different ( P = 0.0062) with 59.44 +/- 14.00 ml for LVT cases and 254.48 +/- 63.62 ml for LCT. None of the LVT patients experienced postoperative complications. The 5-year survival rate was 62.7 % for LVT and 57.7 % for LCT. There was no significant difference in survival rates between these groups.

CONCLUSIONS

Although differences were seen in the characteristics, less invasive surgery such as VATS or segmentectomy may be a feasible treatment for SPLC.

A Completely Thoracoscopic Lobectomy/Segmentectomy for Primary Lung Cancer - Technique, Feasibility, and Advantages

INTRODUCTION

A completely thoracoscopic lobectomy/segmentectomy for primary lung cancer was designed to maximize the benefits of this type of minimally invasive surgery. The technique, feasibility, and advantages of this surgical modality over the conventional procedure were investigated.

MATERIALS AND METHODS

Between January 2003 and December 2004, 38 patients underwent a lobectomy (n = 30) or segmentectomy (n = 8) for clinical stage IA primary lung cancer. A resection using a standard thoracotomy (Thoracotomy Group) was performed in 19 patients, and a completely thoracoscopic resection was performed in 10 cases (CTR Group). Conventional video-assisted thoracic surgery with a mini-thoracotomy was performed in 9 cases.

RESULTS

All CTR lobectomies or segmentectomies were carried out safely without any major complications. The number of resected mediastinal lymph nodes was similar in both groups. There was a tendency for the hospital stay to be somewhat shorter in the CTR Group. With respect to postoperative pain as evaluated by a visual analogue scale (VAS), the CTR Group showed a significantly lower level of pain in comparison to the Thoracotomy Group ( P = 0.024 on day 2).

CONCLUSIONS

We concluded that a complete thoracoscopic lung resection is a safe and technically feasible surgical procedure which enables us to make thoracoscopic lung resections less invasive.

The value of tumor volume in surgically resected non-small cell lung cancer

BACKGROUND

The aim of this study was to evaluate whether or not tumor volume (TV) has an impact on survival in non-small cell lung cancer.

METHODS

In a retrospective analysis of 385 cases with NSCLC who underwent curative surgery between 1994 and 2003, we calculated the tumor volume by using an ellipsoidal formula. The patients were grouped according to TV as determined by histograms. Gender, age, histology, nodal involvement, size, and TV were analyzed. Multivariate analysis by Cox's proportional hazards regression model was performed to identify the prognosis.

RESULTS

Cases of N0 showed a significantly lower TV than cases with other N statuses (p < 0.05). A significant difference was also observed between TV and histology or gender. The 189 patients belonging to the small volume group (SVG) (range, 0.105 to 9.265 cm3) had a significantly better overall survival rate than the other 196 patients in the large volume group (LVG) (9.266-366.522 cm3). With univariate analysis, gender, age, nodal involvement, size, and TV were significantly associated with prognosis. Multivariate analysis showed that only gender (p = 0.0184) and nodal involvement (p = 0.0001) were significantly independent prognostic factors. The size factor was not significant (p = 0.5285). However, TV was not an independent factor, but trending toward significance (p = 0.0801).

CONCLUSIONS

Although TV provides no independent prognostic information with multivariate analysis, TV in NSCLC should be considered using volumetric measurement with a three-dimensional CT approach prior to surgery or treatment planning.

[Surgical treatment for primary non-small cell lung cancer with synchronous brain metastases]

The brain is one of the most common sites of metastasis from lung cancer. The strategies of treatment for non-small cell lung cancer patient with synchronous brain metastases (stage IV) is controversial. We evaluate retrospectively the effectiveness of surgical treatment for these patients. Forty patients were divided into 3 groups on the basis of surgical treatment, group A of patients received both lung and brain resection, group B of patients received lung resection plus gamma knife therapy, group C of patients received brain resection. Median survival from the date of diagnosis of brain metastasis was as follows: group A 331 days, group B 151 days and group C 92 days. Univariate analysis revealed that adenocarcinoma histology and serum LDH significantly affected survival. Multivariate analysis found that only adeocarcinoma histology also affected the survival. It is concluded that surgical treatment may acceptable in selected group of non-small cell lung cancer patients with synchronous brain metastases.

[Review of the surgical treatment in superior sulcus tumor]

The rarity of the superior sulcus tumor has led to varying treatment techniques. Generally, radiation therapy followed by surgery has been used. En bloc resection combined with lobectomy and nodal dissection remains standard therapy. The unique location of this tumor, surgical approach thought to be important. Involvement of the anterior areas such as subclavian vessels can be resected by anterior transcervical approach, and vertebral body or brachial plexus through the classic Shaw Paulson approach. Preoperative computed tomography (CT) or magnetic resonance imaging (MRI) is beneficial to the evaluation of the vessels, nerves, and surgical planning. Recent studies showed that induction concurrent chemoradiation therapy improved the resectability and curability. This article reviews the treatment of superior sulcus tumor.

Lymphomatous polyposis of the gastrointestinal tract, including mantle cell lymphoma, follicular lymphoma and mucosa-associated lymphoid tissue lymphoma

AIMS

Lymphomatous polyposis (LP) is considered to represent mantle cell lymphoma (MCL) of the gastrointestinal (GI) tract. However, a few reports have suggested that some are follicular lymphoma (FL) or mucosa-associated lymphoid tissue (MALT) lymphomas. In this study, we analysed 35 patients and clarified the clinicopathological features of LP.

METHODS AND RESULTS

Paraffin-embedded tissue samples were stained immunohistochemically and analysed by tissue-fluorescence in situ hybridization (T-FISH) for IGH/CCND1 (cyclin D1) and IGH/BCL2. The average age of the patients was 58.3 years. Over half of the cases showed gastric, duodenal, small intestinal, ileocaecal and sigmoid colonic lesions (15, 19, 15, 16 and 16 cases, respectively). Phenotypically, cases were classified into three types of MCL (cyclin D1+ CD5+ CD10-) (n=12), FL (cyclin D1- CD5- CD10+) (n=14) and MALT (cyclin D1- CD5- CD10-) (n=9). T-FISH identified 11 of the 11 examined cases with MCLs to have IGH/CCND1, while seven of 10 cases with FL had IGH/BCL2, and none of the MALT cases were positive for IGH/CCND1 or IGH/BCL2. At the study endpoint, five of 12 patients with MCL were dead, two of 14 with FL and one of nine with MALT were dead of other disease. Event-free survival analysis showed significantly poorest outcome in MCL, followed by FL, while MALT was associated with a favourable outcome (P=0.0040).

CONCLUSIONS

Our study emphasizes the importance of differentiating MCL, FL and MALT of LP in evaluating prognosis and hence the most suitable therapeutic regimen.

Characteristic Differences between Patients Who Have Undergone Surgical Treatment for Lung Metastasis or Hepatic Metastasis From Colorectal Cancer

OBJECTIVE

The characteristic differences between patients with lung or liver metastases from colorectal carcinoma (CRC) have not yet been clarified. A small group of these patients demonstrate a better prognosis, and the selection criteria for resection of liver and/or lung metastasis are not well defined. It is important to compare and analyze the most common metastatic sites, which include liver metastases and lung metastases. The objective of this study was to compare the characteristics of the two groups in order to identify patients who benefitted from surgical resection of CRC.

METHODS

We retrospectively reviewed the medical charts of 80 patients who had undergone resection for liver or lung metastasis from CRC in Fukuoka University Hospital between June 1991 and December 2004. These patients were grouped according to surgical therapy received for the metastases, and separated into two groups, as follows: LUM, lung metastases resection; LIM, liver metastases resection. We evaluated these groups for a set of several factors.

RESULTS

The characteristic factors between the two groups (LUM vs. LIM) demonstrated significant differences according to histological differentiation, venous invasion, and lymphatic permeation. There was a statistical difference in the disease-free interval (DFI) between the two groups (947.06 +/- 840.39 days in LUM vs. 246.03 +/- 229.26 days in LIM). Although serum CEA levels at resection of metastasis showed significant differences between the groups (LUM, 13.25 +/- 31.55 ng/ml; LIM, 55.21 +/- 99.52 ng/ml), the primary serum CEA levels were not significantly different. Overall survival rates at 5 years were 37.0 % for LUM and 42.8 % for LIM. There was no significant difference in the survival rate of the LUM vs. the LIM group after resection of metastasis. The Cox proportional hazards regression model was used to determine serum CEA status at the time of the metastases and showed a significant difference indicating poor prognosis for patients with LUM, but the results were not significant for LIM cases.

CONCLUSIONS

Candidates for surgical treatment for lung or liver metastases from CRC may be an acceptable for the same valuable approach, even if characteristic differences were observed in each group.

Extended Resection of T4 Lung Cancer with Invasion of the Aorta: Is It Justified?

BACKGROUND

We report our 10-year experience of performing surgical resection of T4 lung cancer invading the thoracic aorta.

PATIENTS AND METHODS

From 1994 to 2004, sixteen patients with T4 primary lung cancer with local invasion of the thoracic aorta underwent tumor resection. Surgical resection included 8 pneumonectomies and 8 lobectomies. The histologic type was squamous cell carcinoma in 7 patients, adenocarcinoma in 7, large cell carcinoma in 1, and small cell carcinoma in 1. Complete resection of the tumor with mediastinal lymph node dissection was achieved in 8 patients (50 %), while the resection was incomplete in the other 8 cases.

RESULTS

The overall cumulative survival of the 16 patients at 3 and 5 years was 34.7 % and 17.4 %, respectively. The survival of the patients in the complete resection group was found to be 36.5 % at 5 years, with 2 patients surviving more than 5 years without a recurrence, which was significantly better than that of the incomplete resection group ( p = 0.005).

CONCLUSIONS

Extended aortic resection with primary lung cancer is complex and possibly high risk, but can achieve long-term survival in selected patients. Surgical resection should be considered as a treatment option for T4 lung cancer for this T4 subcategory.

Penetration to the aortic wall by a metallic airway stent. A successfully treated case with left pneumonectomy and aortic repair

Metallic airway stents were used widely at the beginning of airway stent use, but an accumulation of cases has revealed complications due to their use. A patient who received a Gianturco Z stent for bronchial tuberculosis suffered massive haemoptysis due to stent migration into the aortic wall. Left pneumonectomy with aortic repair was successfully performed. We suggest that metallic stents should not be used for benign airway palliation, as they may later cause life-threatening complications.

[Treatment strategy for patients, with locally advanced non-small cell lung cancer]

A total of 89 patients with locally advanced lung cancer (pT3-4N0-1) underwent pulmonary resection from April 1994 to April 2003 at our institutions. The overall 5-year survival rate of the 89 patients was 35.5%. No significant difference in the 5-year survival rate was found according to the following variables: histologic type, type of operation, number of resected organs, performance of adjuvant therapy and pulmonary function. In patients with pN1 disease, when patients with nodal metastasis were divided into patients with hilar (# 10) or lobar (# 11 approximately 13) metastasis, the survival rate of lobar metastasis group was superior to those of hilar metastasis group, but not significantly. In patients with pN1 disease, 5 patients were survived for more than 1,000 days. The histology was squamous cell carcinoma in 4 cases. According to the characteristics of pN1 involvement, all cases was involved only a single station.

Application of Dye-Enhanced Laser Ablation for Liver Resection

BACKGROUND

Dye-enhanced laser ablation (DLA) using a low-power diode laser for indocyanine green (ICG)-stained tissue has proven its effectiveness in dye-enhanced laser photocoagulation of retinal vessels or endoscopic surgical mucosectomy. We have applied DLA in hepatectomy and described its histological distinction in comparison with the cavitron ultrasonic surgical aspirator (CUSA).

METHODS

A diode laser (UDL-60 Laser unit, Olympus, Tokyo, Japan) with 810 +/- 20 nm wavelength was employed for this study. The ICG dye (Diagnogreen, Daiichi Pharmaceutical, Tokyo, Japan) with a peak absorption wavelength at 800-810 nm was injected topically into the resection plane of the liver. The liver tissue was divided by touching the tip of the diode laser. Three different concentrations of ICG solution such as 2.0, 1.0 and 0.5 mg/ml were tested in the preliminary animal experiment. The use of a low-power diode laser at 10 W with an ICG concentration of 0.5 mg/ml was the appropriate combination for liver resection. In the clinical series, 27 hepatectomies were performed by DLA, and 10 with CUSA.

RESULTS

DLA demonstrated smooth cutting and good hemostasis in liver resection. Among the hepatectomy cases given DLA, no postoperative hemorrhage or bile leakage was noted. The postoperative hospital stay was significantly shorter in the DLA than the CUSA group. The cut surface of the liver was sealed microscopically with a layer of protein coagulum.

CONCLUSIONS

A layer of protein sealant on the cut surface of the liver contributes to the short postoperative hospital stay when using DLA.

[Primary pulmonary meningioma; report of a case]

Primary pulmonary meningiomas are quite rare, and their occurrence has been reported only sporadically. A 49-year-old, asymptomatic female was hospitalized for the evaluation of a coin lesion in the left lung radiography. She has no history of previous neoplasm or symptom referable to the central nervous system. Chest computed tomography (CT) demonstrated a 9 x 14 mm, round, noncalcified, well-demarcated lesion in the left upper lobe of the lung (S(1+2)). For diagnostic purposes, enucleation of the tumor was performed. The resected specimen revealed histologically classical typical meningioma. Because postoperative magnetic resonance imaging (MRI) of the brain did not show any intracranial mass, this case was and diagnosed as a primary pulmonary meningioma. The patient was discharged with no complication, and alive without recurrence of disease 14 months after surgery.

Surgical Treatment for Lung Cancer with COPD Based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD)

OBJECTIVE

The surgical indications for non-small cell carcinoma (NSCLC) with chronic obstructive pulmonary disease (COPD) are not well known. A classification of severity in COPD has been newly recommended by the US National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO). Therefore, based on this new system of classification, we review here a series of NSCLC patients with COPD who underwent lung resection at our hospital and attempt to identify the survival and morbidity of such patients.

METHODS

We retrospectively reviewed the patients with NSCLC treated at our hospital between January 1994 and December 2002. Among these 640 patients, a curative approach was attempted in 50 with COPD (31 lobectomies, 11 segmentectomies, 8 bilobectomies). The patients were consequently divided into two groups (moderate group and severe group) according to the Global Iinitiative for Chronic Obstructive Lung disease (GOLD). Lung function was evaluated by FEV1 and FVC, and the survival rates were analyzed at 5 years. Postoperative morbidity was also compared between the two groups.

RESULTS

FEV1 was 1.527 +/- 0.311 L in the moderate group compared with 1.025 +/- 0.224 L in the severe group ( p < 0.001). Postoperative decrease in FEV1 was lower compared to the predicted data of patients who underwent surgery for NSCLC with COPD. Postoperative pulmonary support such as mechanical ventilation or tracheotomy were necessary more frequently in the severe group. A significant difference was observed between the two groups in respiratory support ( p = 0.0102). Overall 5-year survival rate for NSCLC with COPD was 73.9 %, although there was no statistically significant difference between the moderate and severe groups in terms of survival. Lobectomy and segmentectomy show a remarkable advantage for the patients with bilobectomy, although this difference was not statistically significant. On the other hand, gender, degree of COPD, and histological type were shown to be not significant factors. Survival rate of these NSCLC patients with COPD were demonstrated to be comparable to those of the NSCLC patients without COPD in stages I and II.

CONCLUSION

Stringent selection of candidates among NSCLC patients with a severe grade of COPD based on GOLD could be an acceptable and valuable approach compared to conventional patients without COPD, although NSCLC with severe COPD patients more frequently needed respiratory support.

Micropapillary pattern: a distinct pathological marker to subclassify tumours with a significantly poor prognosis within small peripheral lung adenocarcinoma (<=20 mm) with mixed bronchioloalveolar and invasive subtypes (Noguchi's type C tumours)

AIMS

A micropapillary pattern (MPP) in lung adenocarcinoma, characterized by papillary structures with epithelial tufts lacking a central fibrovascular core, has been reported to be a new pathological marker of poor prognosis. However, its clinicopathological and prognostic significance in small lung adenocarcinomas (</=20 mm) remains undetermined. A new histological classification of small lung adenocarcinoma proposed by Noguchi et al. has been found to be useful since it has defined surgically curable bronchioloalveolar carcinoma (BAC)-type tumours (Noguchi's type A and B) based on the absence of active fibroblastic proliferation. However, BAC-type tumours with active fibroblastic proliferation (Noguchi's type C), which is adenocarcinoma with mixed subtypes including BAC and invasive carcinoma in the new World Health Organization (WHO) classification, account for most of the small adenocarcinomas and represent a heterogeneous group ranging from minimal to overtly invasive cancer with variable prognoses. Therefore, in this study the aim was to investigate whether MPP can be an additional histological marker(s) to subclassify this heterogeneous group in small lung adenocarcinoma.

METHODS AND RESULTS

One hundred and twenty-two cases of small lung adenocarcinomas (</=20 mm in maximum dimension) classified according to the new WHO classification and Noguchi's proposal were analysed with reference to the presence of MPP. Of the 122 cases, 67 (55%) were MPP-positive and 55 (45%) were MPP-negative. Lymph node metastasis and pleural invasion were significantly more frequent in the MPP-positive group: 74% and 66% in the positive group versus 26% and 34% in the negative group, respectively. The 5-year survival of the MPP-positive group was 54%, whereas that of the MPP-negative group was 81% (P=0.024). The 5-year survival rates of BAC (Noguchi's type A and B) (n=14), mixed BAC and invasive adenocarcinoma (Noguchi's type C) (n=85) and invasive adenocarcinoma (Noguchi's type D and F) (n=23) were 100%, 68% and 36%, respectively. In patients with mixed BAC and invasive adenocarcinoma (Noguchi's type C tumours), the 5-year survival of the MPP-positive group (n=51) was 54%, significantly lower than that of the MPP-negative group (n=23) of 100% (P=0.02).

CONCLUSIONS

MPP is a simple and distinct pathological marker to subclassify tumours with a significantly poor prognosis within small (</=20 mm) mixed BAC and invasive adenocarcinoma (Noguchi's type C tumours).

[Thoracoscopy and intraoperative upper gastrointestinal endoscopy was effective for Boerhaave syndrome; report of a case]

Boerhaave syndrome is a rare disease and needs an exact diagnosis and a proper treatment plan because of its terrible clinical course. We experienced a case of Boerhaave syndrome that thoracoscopy and intraoperative upper gastrointestinal (GI) endoscopy was very effective. Sixty-four-year-old man realized chest and back pain after vomitting. Esophageal perforation was suspected, but 64 hours had passed already when we started a surgical treatment. By the thoracoscopy and intraoperative endoscopy, lower esophageal perforation and infectious pleural effusion were found. Therefore, we selected a surgical treatment under the assistance of thoracoscopy. Secondly, a simple closure and intracostal muscle overlapping was performed with small incisional thoracotomy. Postoperative complication, such as mediastinal abscess, has not occurred. Thoracoscopy and intraoperative upper GI endoscopy was effective for an appropriate diagnosis and treatment of Boerhaave syndrome.

[Diaphragmatic eventration resulting from phrenicectomy treated with surgical method; report of a case]

The case was a 59-year-old man who has a history of left mediastinal tumor resection with left phrenicectomy. The elevated diaphragm revealed by chest X-ray 7 years after the operation led to diagnosis of diaphragmatic eventration. Since any symptom was seen in the early period, "wait and watch" strategy was done for management. Both the abdominal enlarged feeling and the dyspnea on effort were appeared 10 years after the operation. Under the speculation of these symptoms related to the elevated abdominal organs came up with diaphragmatic eventration, surgical method the plication of the diaphragm was performed. The diaphragm was plicated by interrupted suture as opening the diaphragm to avoid injury the abdominal organs, and reinforced with the Marlex mesh. We used artificial mesh to reinforce the thin diaphragm with exceptation of prevent the postoperative recurrence, because a result of the etiological process of the case was considered as disuse atrophy of diaphragm after phrenicectomy.

Biosorbable poly-L-lactide rib-connecting pins may reduce acute pain after thoracotomy

OBJECTIVE

Conventional thoracotomy is currently used as a standard procedure, and is often required to treat numerous diseases. Additionally, rib resections are occasionally required to maintain an adequate field of view for surgery. The benefits of using rib pins for chest closure following such procedures have not yet been established. This study sought to evaluate the usefulness of rib pins in reducing acute postoperative pain.

METHODS

Thirty-three consecutive patients with lung cancer underwent lobectomies using the posterolateral approach. The patients were rib-resected and reconstructed with two techniques: 21 patients with absorbable rib pins (ARP group) and 12 patients by ligation with absorbable sutures (LAS group). Intensity of pain was assessed during the 3 days immediately following surgery. The two groups were assessed using the visual analogue scale (VAS) as a pain scale, amounts consumed of patient-controlled analgesics (PCA), and additional chest x-rays.

RESULTS

On the first day following surgery, the mean VAS intensity of the ARP group for patient motion was 2.71 +/- 2.14, compared to 5.33 +/- 2.99 in the LAS group. After three days, the mean score for the ARP group was 1.98 +/- 1.89, compared to 4.60 +/- 1.97 in the LAS group. Scores in the ARP group were significantly lower than in the LAS group one day and three days following thoracotomy. The LAS group (55.0 +/- 15.9 times) made more frequent requests than the ARP group (16.1 +/- 10.3 times). The PCA requirement was also significantly lower in the ARP group. Excessive derangement of the rib (grade 2) was found in one case (4.7 %) in the ARP group compared to five cases (41.6 %) in the LAS group. Rib shifts were seen in numerous cases in the LAS group compared to the ARP group as measured by chest x-rays.

CONCLUSIONS

Use of absorbable rib pins reduced postoperative pain and may improve long-term prospects for the post-thoracotomy course.

[Pleuropneumonectomy for pulmonary tuberculosis and chronic tuberculous empyema]

Surgical intervention is often necessary to treat either the active pulmonary tuberculosis or its sequelae such as destroyed lung, tuberculous empyema, and bronchial stenosis. Pleuropneumonectomy, which has been reported to be associated with high mortality and morbidity, is performed when the pleural space is completely obliterated due to previous inflammation or when preoperative empyema is complicated. In this article we report 3 patients receiving pleuropneumonectomy for pulmonary tuberculosis or chronic tuberculous empyema in recent 3 years. The mean operation time is 5 hours and 56 minutes, and the mean volume of intraoperative bleeding amounted to 1,417 ml. Autologous blood transfusion was prepared for all 3 patients and transfused them during the operation. No mortality, but postoperative complications were seen in 2 patients (67%) with a history of diabetes mellitus. They were sternum infection and bronchopleural fistula, which were successfully treated conservatively. Diabetes mellitus is thought to be a major risk factor for not only tuberculous disease itself, but also postoperative morbidity. As for surgical techniques, wide skin incision with multiple thoracotomy is necessary to keep a good operative field, and special care must be taken for great vessels and nerves at extrapleural dissection. We conclude that pleuropneumonectomy is relatively risky but effective surgical procedure for adequately selected patients with destroyed lung and tuberculous empyema.

Results of Surgical Treatment for Non-Small Cell Lung Cancer of 20 mm or Less in Diameter

BACKGROUND

Surgical efficacy is still unsatisfactory for small lung cancer; accordingly, minimal resection has recently been the focus of increased study. The objective of the current study was to evaluate the factors associated with small lung cancer, and to determine whether such factors are reliable predictors of long-term survival.

METHODS

We retrospectively investigated 130 patients with histologically confirmed non-small cell carcinoma, whose treatments were primarily surgical, with no chemotherapy or radiotherapy prior to surgery. All tumors were located peripherally and were less than 20 mm in diameter. Follow-up was performed for five-year and eight-year survivors and multivariate analysis with Cox's proportional hazards regression model was performed.

RESULTS

Of all 130 patients, the 5-year survival rate among patients with tumors less than 15 mm was 82.5 %, vs. 57.4 % of patients with tumors with a diameter of 16 - 20 mm. The 5-year survival rate of patients who were node negative was 73.9 % while it was 28.5 % for node-positive patients. Status of nodal invasion was also significantly associated with survival in small-size tumors ( p < 0.0001). Furthermore, the 5-year survival rate among patients with pleural involvement was 55 % vs. 83.8 % for patients without pleural involvement. Using multivariate Cox analysis, lymph node involvement ( p = 0.0004), size ( p = 0.0475), and pleural invasion ( p = 0.0482) were found to be independent prognostic factors in cases of tumors 20 mm or less in diameter.

CONCLUSIONS

The results of this study at least demonstrate that the optimal therapy for patients with nodal involvement or patients with tumors of 16 - 20 mm must be carefully determined even in cases of small lung cancer.

[Extrapleural pneumonectomy for malignant pleural mesothelioma and primary lung cancer]

The extrapleural pneumonectomy for 6 patients with malignant pleural mesothelioma and 2 patients with primary lung cancer have been performed in our unit in those 10 years. Range of the age was 48-57 year-old. All of them were male and have been in occupational asbestos exposure. The mean survival time after extrapleural pneumonectomy was 620 days. In those, we experienced a case of malignant mesothelioma with excellent reduction by induction therapy of cisplatin+docetaxel hydrate, who underwent the extrapleural pneumonectomy continuously. We mentioned more over about the role of extrapleural pneumonectomy for primary lung cancer with pleural dissemination, and intrapleural perfusion hyperthermo-therapy for malignant mesothelioma.

Video-assisted thoracoscopic surgery (VATS) segmentectomy for small peripheral lung cancer tumors: intermediate results

BACKGROUND

We investigated the feasibility and suitability of video-assisted thoracoscopic surgery (VATS) segmentectomy for curing selected non-small cell lung cancer (NSCLC) with this less invasive technique.

METHODS

We performed VATS segmentectomy for small (< 20 mm) peripherally located tumors and pathologically confirmed lobar lymph node-negative disease by frozen-section examination during surgery. Of the 34 patients who underwent this limited resection, 22 were treated with complete hilar and mediastinal lymph node dissection (intentional group), whereas 12 patients who were deemed to be high risk in their toleration for lobectomy underwent VATS segmentectomy with incomplete hilar and mediastinal lymph node dissection (compromised group). The surgical and clinical parameters were evaluated and compared with those of segmentectomy under standard thoracotomy to evaluate the technical feasibility of VATS segmentectomy.

RESULTS

We found that VATS segmentectomy could be performed safely with a nil mortality rate and acceptably low morbidity. The mean period of observation was relatively short at 656.7 +/- 572.1 and 783.4 +/- 535.8 days in the intentional and compromised groups, respectively. At the time of writing, all intentional patients remain alive and free of recurrence. There were two cases of non-cancer-related death in the compromised group. Clinical data indicated that VATS segmentectomy caused the same number or fewer surgical insults compared with segmentectomy under standard thoracotomy.

CONCLUSIONS

The present results are intermediate only; the rate of long-term survival and the advantages of the less invasive procedure still need further investigation. Nevertheless, we believe that VATS segmentectomy with complete lymph node dissection is a reasonable treatment option for selected patients with small peripheral NSCLC.

Mediastinal Solitary Fibrous Tumor: Report of a Case with Direct Invasion to the Trachea

The solitary fibrous tumors in the pleura are a rare entity that is usually adhesive and sometimes invasive. Because of its benign feature, complete surgical resection is generally considered. We describe a very rare case of mediastinal solitary fibrous tumor arised or invaded into the tracheal wall, which was surgically resected with combined cylindrical resection of the trachea.

Evaluation of lung volume reduction surgery (LVRS) based on long-term survival rate analysis

OBJECTIVE

Lung volume reduction surgery (LVRS) is an effective therapy for some patients with end-stage emphysema. In most cases, functional improvement is maximized during the first 6 months after surgery and decreases steadily afterwards. This study was aimed at gaining further understanding of the optimal candidates for LVRS and survival rates.

METHODS

62 patients with LVRS were selected according to the inclusion criteria. Changes in lung function were evaluated by FEV1, VC, RV, TLC, DLCO, PaO2, and PaCO2, and survival rates were analyzed at 12, 24, 36, and 48 months. Patients with LVRS were divided into two groups--those surviving after 48 months and those not surviving after 48 months--and analyzed according to group.

RESULTS

The overall survival rate at 2 years and 4 years was 81.0 % and 67 %, respectively, with LVRS. VC, FEV1, TLC, DLCO, PaO2, and PaCO2 were potential factors leading to mortality according to univariate analysis. Multivariate analysis demonstrated that DLCO was the only independent factor that could predict the post-LVRS prognosis; the other factors failed as independent factors. Preoperatively, the FEV1 percentage predicted gave a good index for post-LVRS survival.

CONCLUSIONS

Patients with higher preoperative FEV1 values had higher survival rates. These favorable long-term survival rates might justify LVRS for treating selected patients with severe emphysema. Additionally, DLCO turned out to be the only predictive factor for high mortality risk 4 years after LVRS. DLCO may thus be a very important marker in surgical planning.

Clinicopathological analysis of 143 primary malignant lymphomas in the small and large intestines based on the new WHO classification

AIM

To study the clinicopathological and immunohistochemical features of 143 cases of primary small and large intestinal non-Hodgkin's lymphoma (NHL) in Japanese patients who presented between 1981 and 2000.

METHODS AND RESULTS

The new World Health Organization (WHO) classification was used to classify NHL. The patients included 109 males and 34 females, with an average age of 54.1 years. Tumour sites were as follows: ileocaecal (n = 51, 35.7%), ileum (n = 29, 20.3%), rectum (n = 13, 9.1%), and duodenum (n = 11, 7.7%). Macroscopically, 124 cases (86.7%) were classified as tumorous type, 12 (8.4%) as diffuse infiltration type (erosion, superficial ulceration), five (3.5%) as polyposis type, and only two cases (1.4%) as ulceration type. Immunohistochemically, 122 lesions (85.3%) were of B-cell phenotype and 21 lesions (14.7%) were of T-cell phenotype. According to the WHO classification, of the B-cell lymphomas, 84 cases (68.9%) were large cell, 16 (13.1%) were Burkitt, 10 (8.2%) were marginal zone B-cell lymphomas of mucosa-associated lymphoid tissue (MALT), and seven (5.7%) were mantle cell tumours. Among the T-cell lymphomas, 15 (71.4%) were of unspecified type, two (9.5%) were natural killer type, two were anaplastic large-cell lymphomas, one was lymphoblastic, and one was an adult T-cell leukaemia lymphoma. The survival rate for T-cell lymphomas was poorer than for B-cell lymphomas. Among the B-cell lymphomas, mantle cell lymphoma tended to have a poorer prognosis, whereas MALT lymphomas had a better prognosis than other B-cell tumour types.

CONCLUSIONS

Our retrospective study of patients with primary malignant lymphomas in the small and large intestines has illustrated the clinical features and outcomes of patients with this disease.

Video-assisted thoracic needle aspiration cytology for malignancy of the peripheral lung

BACKGROUND

The technique of video-assisted thoracic fine-needle aspiration cytology (VAT-FNA) to the lung has been described in very few publications, and its diagnostic role has not been evaluated so far. Thus current studies focus on whether the diagnostic role could be applied usefully to VAT-FNA of peripheral lung lesions.

METHODS

Between January 1995 and January 2000, a total of one hundred and twenty-eight cases of VAT-FNA on lung tumors were reviewed retrospectively. The superficial lung was visualized a part of directly or indirectly by scope and a 22-gauge needle inserted for FNA. Material was expressed onto glass slides, and smears were stained by our modified quick-stain method. The cytological diagnoses based on VAT-FNA were reviewed and compared with the final histopathological diagnoses.

RESULTS

The cytological diagnosis was true positive in 100 cases (93.5% sensitivity), whereas the true negative result in 20 cases was 95.2% specificity. The false-positive rate was 4.8%, and false-negative results were 6.5%. The accordance in all malignant cases between cytology and histology was 73.8%. VAT-FNA caused no difficulties in any of the cases.

CONCLUSION

The application of VAT-FNA to the peripheral lung lesion is not only useful, cost-beneficial, safe and minimally invasive but also accurate. Especially, this method may play an important role in cases of suspected malignancy in peripheral cases.

[Surgical treatment for esophageal cancer in elderly patients over 75 years of age]

We performed 127 esophageal resections for the esophageal cancer patient from December 1995 to September 2001. It was separated to under 70 years old patients group (group I), 71-74 years old patients group (group II), and over 75 years old patients group (group III).

RESULTS

Postoperative complication was occurred in 53 cases (41.7%) within all of 127 esophageal resected cases. It was 33.7% in group I, 53.6% in group II, 62.5% in group III. Four years survival rate of each group is 38.3% in group I, 44.6% in group II, 31.3% in group III. It is significantly better in group II rather than in group III. Operative death rate is 12.5% (2 cases) in group III, 7.1% (2 cases) in group II, 3.6% (3 cases) in group I, and it is gradually higher and higher by patient's age.

CONCLUSIONS

(1) In the esophageal cancer patient over 75 years old, postoperative complication rate is higher than under 74 years old patients, and prognosis is significantly poor rather than in 70-74 years old patients group. (2) In the esophageal cancer patient over 75 years old, we considered it is good indication of esophagectomy for stage I and stage II patient without preoperative complication, however, there are no operative indication for stage III and stage IV patient.

[Surgical therapy for patients with thymoma or thymic carcinoma; based on WHO classification]

The treatment strategy for patients with thymoma or thymic carcinoma still has not been confirmed, and the molecular biologic characteristics of these tumors have not been defined also. We have emphasized the clinical significance of this classification so far by the research cooperation with professor Müller-Hermelink, the institute of pathology, Würzburg University. This time, We introduced clinico-pathological findings based on the new WHO classification in 59 Case of thymic epithelial tumor and reffered the treatment strategy for patients with thymic cancer.

An immunohistochemical examination of basaloid squamous cell carcinoma of the esophagus: report of a case

We recently encountered a patient with basaloid carcinoma of the esophagus with extensive node involvement. The patient died of hematogenous metastasis 6 months after surgery. The tumor expressed cytokeratin but did not express either Type IV collagen or laminin. Both tumor cells and metastatic lesions in the regional lymph nodes expressed p53, Bcl-2, and Ki-67 proteins, but did not express cyclin D1 proteins.

[Result of surgical treatment to early stage peripheral non-small cell lung cancer]

In the lung cancer, the announcement of the definition, the clinical behavior and the treatment result of the central early stage lung cancer, especially in situ lung cancer, have been seen. However, the definition and a clinicopathological concept of the peripheral lung cancer are still uncertain. The so-called small lung cancer of the tumor diameter 20 mm or less are peripheral lung adenocarcinoma. These patients' prognosis is excellent better, in contradiction to the prognosis of the patients with positive for pleural involvement or vessels invasion is worse. We studied the clinicopathological features, the Noguchi's classification, and prognosis of the 101 patients with small lung adenocarcinoma which were performed the operation, and refere about the selection of the operation method including the VATS and the limited operation.

Glutathione S-transferase mu1 null genotype is associated with K-ras gene mutation in lung adenocarcinoma among smokers

Glutathione S-transferase mu1 (GSTM1) plays a role in the detoxification of benzo[a]pyrene (BP) diol epoxide in tobacco smoke. Individuals who genetically lack the GSTM1 gene are likely to have an increased risk of smoking-related lung cancers, however, the target oncogenes for mutation are unknown. To investigate the relation between GSTM1 genotype and K-ras gene mutation we examined 193 adenocarcinomas and 119 squamous cell carcinomas of lung. The GSTM1 genotype was determined by PCR and K-ras gene mutations at codons 12 and 13 were detected by dot-blot hybridization analysis using sequence-specific oligonucleotide probes. K-ras gene mutations were found in 29 of 312 (9.3%) tumors. All of them arose in patients who were habitual smokers. Mutations of the K-ras gene were detected in 6 of 100 (6%) and 15 of 93 (16.1%) adenocarcinoma cases with the GSTM1(+) and GSTM1(-) genotypes, respectively, and the difference was statistically significant. These findings suggest that the cause of K-ras gene mutation in smokers with lung adenocarcinoma may be in part an accumulation of BP diol epoxide which is not well detoxified in individuals with the GSTM1 null genotype.

New technique for the cystic mediastinal tumor by video-assisted thoracoscopy

Thoracoscopic operations for benign mediastinal tumors have been useful. However, it is difficult to remove cystic mediastinal tumors completely because of their cystic structure. We herein describe a useful technique of tumor cannulation that allows for the simple and safe removal of these tumors.

[Less invasive treatment for lung carcinoma]

Today, less invasive treatments for lung carcinoma are divided to two categories. One is the surgical option which includes 1. surgery by muscle sparing thoracotomy, 2. reduced operation represented by segmentectomy or partial resection, 3. so-called VATS (video-assisted thoracoscopic surgery), and 4. sentinel node navigation surgery. Other options such as photodynamic therapy or brachytherapy are also very useful for the treatment of superficial malignancies at the hilar zone, because of their lower level of invasiveness.

[Video-assisted thoracoscopic surgery lobectomy for lung carcinoma]

Video-assisted thoracoscopic surgery (VATS) has been utilized worldwide for the treatment of various types of thoracic disease, in particular for lung carcinoma. The following criteria are accepted as the operative indications for VATS lobectomy: i) clinical T1N1M0: ii) tumor located in the peripheral zone; and iii) non-small cell carcinoma. Videoscopic surgery has the merit of being less invasive, resulting in a low level of postoperative chest pain, short incisional scar, and short duration of hospital stay. Right-side upper mediastinal lymph node dissection is easy under the thoracoscope, although compared with standard thoracotomy it is not always possible to perform complete level II dissection on the left, because of the difficult approach to lymph nodess No. 3 and No. 4 under the aortic arch via the thoracoscope. The postoperative 5-year survival rate after VATS lobectomy is superior to that after standard thoracotomy. It is expected that the indications for VATS will be expanded to include T2 or N1 disease as thorascopic instruments and techniques improve.

K-ras gene mutations in non-small cell lung cancer in Japanese

To evaluate the association of mutations in the K-ras gene with the incidence of non-small cell lung cancer (NSCLC) in Japanese patients, 410 patients treated surgically were studied. DNA was extracted from frozen specimens, and polymerase chain reaction-sequence specific oligonucleotide probe (PCR-SSOP) hybridization assay was used to examine K-ras mutations in codons 12, 13 and 61. K-ras mutations were found in 33 patients (8.0%), and all were smokers or ex-smokers. There were no significant differences in clinical or pathological stage between wild-type cases and mutant cases. The most frequently identified mutation was a G-->T transversion (25/33, 75.8%) that resulted in the substitution of a glycine for a cysteine or a valine. Previous studies have shown that the majority of K-ras mutations among smokers are G-->T transversion. In our study, K-ras mutations were found only in smokers, and there was a high frequency of G-->T transversions. A clear correlation exists between smoking and K-ras gene mutations.