Naomichi Iwai

Prognosis of osteosarcoma with pulmonary metastases at initial presentation is not dismal.

Prognosis of osteosarcoma has been improved markedly with the introduction of effective, intensive chemotherapy. However, there are many reports that indicate that the prognosis of osteosarcoma with pulmonary metastases at the initial presentation is poor. One hundred seventeen patients with osteosarcoma involving the extremities were treated at the Chiba Cancer Center from 1976 to 1995. Of these, nine (7.6%) patients had pulmonary metastases at initial presentation; these nine patients are the subjects of this article. There was an average of 0.9 pulmonary metastatic lesions at initial presentation seen on plain chest radiographs, an average 2.9 lesions seen on computed tomograms of the chest, and an average 12.7 lesions found at thoracotomy in these nine patients. The pulmonary metastatic lesions that could not be detected by computed tomography of the chest were resected by thoracotomy. Three patients died, and six patients are alive, with the 5-year survival being 64.8%. Intensive chemotherapy and aggressive surgical therapy were done for these patients with osteosarcoma with pulmonary metastases at initial presentation, and it is thought that this improved the prognosis of these patients. Pulmonary metastases of osteosarcoma at initial presentation do not always indicate a hopeless prognosis.

A prospective study of indications for mediastinoscopy in lung cancer with CT findings, tumor size, and tumor markers

BACKGROUND Biopsies by mediastinoscopy remain the most reliable preoperative staging method for N2 lung cancer. Because it is neither practical nor economical to recommend mediastinoscopy for all candidates for surgery, we developed indicational criteria for video-assisted mediastinoscopy (VAM) and carried out a prospective study to validate its usefulness. METHODS Patients with resectable primary lung cancer were chosen for VAM when at least one of three clinical indicators was present: (1) computed tomographic evidence of mediastinal adenopathy, (2) elevated levels of serologic tumor markers, and (3) diameters of primary cancers (> 2 to 3 cm). Patients without positive nodes (group 2) underwent thoracotomy, and patients with positive nodes (group 3) received induction therapy. When none of these criteria were met (group 1), thoracotomy with R2b lymph node dissection was performed without VAM. RESULTS One hundred twenty-one men and 82 women (total, 203) were eligible for the study. The mean age of the patients was 64.4 years (range, 39 to 75 years) with primary lung cancer. The patients were comprised of 135 adenocarcinomas, 46 squamous cell cancers, and 22 other carcinomas. There were 78 patients in group 1, 87 in group 2, and 38 in group 3. The stages of group 2 patients were more advanced (chi2 = 63.2668; p < 0.001) than those of group 1. As the incidence of positive indicators for VAM increased, the ratios of N2 patients increased from 2.5% (all negative) to 90.4% (triple positive: p < 0.001). The correlation of our criteria with the pathology findings revealed a diagnostic sensitivity of 95.8% and a negative predictive value of 97.4%. Using three indicators for N2 prediction, we selected 96% (46 of 48) pN2, N3 patients and avoided 37% (76 of 203) unnecessary VAMs. CONCLUSIONS We established and validated currently useful criteria for VAMs in the management of primary lung cancer.

The significance of tumour markers as an indication for mediastinoscopy in non‐small cell lung cancer

Objective:  The purpose of this study was to verify the significance of tumour markers as indicators for mediastinoscopy in non‐small cell lung cancer.

Clear cell tumor of the lung: surgical and immunohistochemical findings

We encountered a clear cell tumor of the lung (CCTL) that was located peripherally, adjacent to the visceral pleura. The tumor could be directly observed during surgery. We believe that this case report describing the surgical and related pathological findings is highly informative. A chest radiograph during routine examination of an asymptomatic 65-year-old woman being treated for hypertension and hyperlipidemia revealed a nodular shadow in the left lung field. Wedge resection was performed by video-assisted thoracic surgery. The in vivo color of the tumor was red, suddenly changing to white after the tumor was clamped. Pathology examination showed a uniform pattern consisting of large clear cells without cytologic atypia or increased mitotic activity. Immunohistochemistry revealed tumor cells positive for vimentin and melanocytic markers (HMB-45 and melan-A) and negative for epithelial membrane antigen and cytokeratin. With the absence of clinical findings in both kidneys, the tumor was diagnosed as a benign CCTL.

Delayed diagnosis of traumatic diaphragmatic rupture

We report a case of late presentation of traumatic rupture of the diaphragm discovered incidentally on chest radiography (CXR) during an annual medical checkup. A 60-year-old man suffered severe blunt trauma from heavy steel frames collapsing against his back, resulting in pelvic and femoral fractures as well as pulmonary contusions. The patient recovered, but 10 months later CXR performed for lung cancer surveillance during an annual medical checkup revealed a traumatic rupture of the diaphragm. Video-assisted thoracic surgery was performed with reduction of the intestine and primary closure of the diaphragmatic defect. The patient recovered uneventfully. This report serves as a useful reminder that a medical history of severe blunt trauma should provoke a high index of suspicion for diaphragmatic rupture during annual medical surveillance.

Rapid enlargement of a mediastinal mass: thymoma hemorrhage into a thymic cyst

A 52-year-old man was admitted to Matsudo City Hospital because of an anterior mediastinal mass. One month prior, when he suddenly suffered chest pain, computed tomography (CT) showed a 4 × 3 cm mass in the chest. On admission, the symptom disappeared. However, chest CT revealed rapid enlargement of the mass to 10 × 6 cm. Based on the CT findings, we suspected a tumor. Therefore, we performed a thymothymectomy. The mass, measuring 12 × 8 × 6 cm, contained a solid tumor and a fl uid-filled cyst. Pathology showed a thymoma and a multilocular thymic cyst. We speculated that hemorrhage from the thymoma spread into the multilocular thymic cyst and enlarged the mass.

Completion Pneumonectomy of the Residual Left Lung to Treat Lung Cancer in a Patient with Hemophilia A : Report of a Case

Hemophilia A is a sex-linked recessive hereditary disease that is relatively rare and the number of patients with this disorder who undergo major surgery is limited. Although replenishing coagulation factors can allow hemophiliac patients to undergo similar surgery to that performed for patients without hemophilia, there have been few reports on major surgery and none on the resection of lung cancer in patients with hemophilia A. We recently performed completion pneumonectomy of the left lung in a 70-year-old man with hemophilia A, for squamous cell carcinoma in the residual left lung. The administration of a recombinant DNA coagulation factor VIII preparation allowed this operation to be successfully carried out. This case serves to demonstrate that the recombinant DNA coagulation factor VIII preparation described may enable us to safely perform major surgery on hemophiliac patients, since there is no risk of viral infection or any other adverse effects, such as deterioration of immunocompetence or hemolysis, which are occasionally encountered with human plasma-derived preparations.

Factors influencing survival after endoscopic Nd:YAG laser surgery for unresectable advanced malignancies of the trachea

The effects of endoscopic Nd:YAG laser surgery were studied in 36 patients with unresectable advanced primary and metastatic malignancies in the trachea with special reference to the factors influencing long-term survival. Overall effectiveness of YAG laser treatment was demonstrated in 34 of the 36 patients (94 per cent), while the overall 1, 3 and 5 year survival rates after the first laser treatment were 25 per cent, 13 per cent and 13 per cent, respectively. Neither histologic type nor the severity of clinical symptoms before laser treatment showed any significant influence on the survival curves, however, endoscopic findings of stenosis, the effect of laser treatment and irradiated longitudinal length were all significantly correlated with the survival curves. In other words, endoscopically protruding type tumors with a longitudinal length of irradiation of 3.0 cm or less, and good responses not only to laser treatment but also to other combined modalities are favorable factors for achieving long-term survival in patients with tracheobronchial malignancies undergoing endoscopic Nd:YAG laser treatment. Endoscopic Nd:YAG laser surgery is considered to be a promising part of the multi-modality treatment for unresectable advanced primary and metastatic malignancies of the trachea.

Indications of Video-assisted Mediastinoscopy for the Comprehensive Management of Primary Lung Cancer.

原発腫瘍径, GTでの縦隔リンパ節腫大の有無, 初診時の腫瘍マーカーを参考にして縦隔鏡 (Video-assisted Mediastino-scopy: VAM) の適応基準を作り, これに則ったVAMを施行することにより, 肺癌の治療方針決定に寄与し得るかを検討した. 対象は当科に入院し治療を受けた原発性肺癌217例のうち75歳以下, 病期IIIA期までの総合的治療プログラムに適応した111例である. このうちVAMの適応になった症例が66例, ならなかった症例は45例で, 前者はVAMを行い, 45例が陰性でそのうち43例に手術が行われ, 21例の陽性例は化学療法2クール後, 効果判定により9例が手術, 残り12例には放射線照射を行った. VAM非適応の後者はそのまま手術を行った. VAM陰性の43切除例のうち3例にN2が認められたが, 1例は左肺癌の#5 (ボタローリンパ節) 転移でありその他2例はfalse negativeの誤診例であった. VAM非施行例で切除になった45例のうち2例がN2であったがいずれも右上葉肺癌の# 3リンパ節転移であった. 縦隔鏡の適応基準を設けることで肺癌の治療方針決定に寄与し得ると考える.

A case of mediastinal germ cell tumor radically operated on after neoadjuvant chemotherapy-combined resection of the superior vena cava and reconstruction with expanded-PTFE graft

A case of primary mediastinal germ cell tumor, which was radically treated with reconstruction of the superior vena cava (SVC) after neoadjuvant chemotherapy, is reported herein. This tumor, accompanied with SVC syndrome, was initially unresectably advanced and chemotherapy, using cis-dichlorodiamine-platinum, vindesine and bleomycin, was administered, resulting in a partial response with a 65 per cent tumor regression. The serum human chorionic gonadotropin, which originally had a high value, became reduced in parallel with the tumor regression to within the normal range. Complete tumor resection with reconstruction of the SVC using an expanded polytetrafluoroethylene (EPTFE) graft was successfully performed. The patient has now returned to productive employment and the graft is patent without any clinical symptoms of recurrence, 15 months post-operatively. Neoadjuvant chemotherapy is considered to be vitally important for the treatment of germ cell tumors originating in the anterior mediastinum and an EPTFE graft with external ring support seems to be acceptable as an artificial substitute for SVC replacement.