Ryoichi Kondo

Intraoperative ultrasonographic localization of pulmonary ground-glass opacities

OBJECTIVES Ground-glass opacities are typically difficult to inspect and to palpate during video-assisted thoracic surgery. We therefore examined whether ultrasonographic assessments could localize ground-glass opacities and help to achieve adequate resection margins. METHODS An intraoperative ultrasonographic procedure was prospectively performed on 44 patients harboring ground-glass opacities of less than 20 mm in diameter to localize these lesions and to achieve adequate margins. We also examined whether there were any complications resulting from the intraoperative ultrasonogram, such as lung injury, heart injury, or arrhythmia. We excluded patients with both asthma and chronic obstructive pulmonary disease from this study inasmuch as the intraoperative ultrasonographic procedure is more difficult to interpret when residual air is present in the lung. RESULTS A total of 53 ground-glass opacities were successfully identified by intraoperative ultrasonography without any complications. Of the 20 mixed ground-glass opacities that we examined, 15 were found on palpation. However, only 4 (12.1%) of the 33 pure ground-glass opacities could be palpated. In all instances in which complete collapse of the lung was achieved (30/53 of these cases), high-quality echo images were obtained. Additionally, a strong correlation was found between the resection margins measured by ultrasonogram and the margins determined by histologic examination in the resected lung specimens (r(2) = 0.954, P < .001). CONCLUSIONS Intraoperative ultrasonography can both safely and effectively localize pulmonary ground-glass opacities in a completely deflated lung. This procedure is also useful for the evaluation of surgical margins in a resected lung. Hence, ultrasonography may assist surgeons to perform minimally invasive lung resections with clear surgical margins during the treatment of solitary lung ground-glass opacity.

Different efficacy of CT screening for lung cancer according to histological type: Analysis of Japanese-smoker cases detected using a low-dose CT screen

The efficacy of CT screening for lung cancers is still a controversial issue, although one of the recently publicized large randomized controlled trials of this methodology, the National Lung Screening Trial (NLST), reported a decrease in the lung cancer-specific mortality for heavy smokers. We here performed case-matched comparative analyses, as a retrospective study, of three lung cancer arms detected by CT screen, X-ray screen, and by individual analysis of the clinicopathological features and outcomes in smokers from a symptomatic-prompted group of patients. We also considered the impacts of various potential biases in this cohort. The total study cohort comprised 136 patients in the CT screen group, 263 in the X-ray screen group and 254 in the symptomatic-prompted group. The ratio of stage IA cancers in the CT screen group was 67.7% and the ratio of advanced cases (i.e. stages IIIB+IV) was 12.5%. The percentage of bronchioloalveolar carcinoma (BAC) was 28.7% in the CT screen group. The 5-year survival rates were 82.4% in the CT screen group, 38.0% in the X-ray screen group and 17.8% in the symptomatic-prompted group. CT screening was found to be an independent prognostic factor for lung cancer even when BAC cases were eliminated (HR 0.35, P<0.01). Based on our sub-analysis by individual histological sub-type, CT screen lung cancer cases had a better survival rate than non-screened patients, which included adenocarcinoma, squamous cell carcinoma and large/small cell carcinoma. However, by multi-variant analysis a CT scan would not be expected to reduce the risk of lung cancer mortality in patients with large/small cell carcinoma, although would be expected to reduce the risk of lung cancer death by 80% in cases of both adenocarcinoma and squamous cell carcinoma. In conclusion, our current findings indicate that CT screening for lung cancer is an effective strategy for smokers and that patients with adenocarcinoma and squamous cell carcinoma of all variant histological types may benefit from this test. In this regard, early stage large/small cell carcinomas are insufficiently detected by the existing annual screening system.

HRCT Features of Small Peripheral Lung Carcinomas Detected in a Low-dose CT Screening Program

RATIONALE AND OBJECTIVES To define high-resolution computed tomography (HRCT) features of lung cancers detected by computed tomography (CT) screening according to histopathology and prognosis. METHODS AND MATERIALS Tumor size, CT value, morphology, and tumor volume doubling time (TVDT) were determined for 10 atypical adenomatous hyperplasias (AAH) and 50 lung cancers followed between 1996 and 1998 to 2007. RESULTS For the 10 AAHs, the density less than -500 HU in all lesions (mean, -654 HU) and the size was up to 14 mm (mean, 9 mm); all patients remain alive. Focal bronchioloalveolar cell carcinomas (BAC) were denser (mean, -537 HU) than AAH and mostly less dense than -350 HU; all patients remain alive. All 22 adenocarcinomas (ADC) were denser than -450 HU (mean, -186 HU); 6 were problematic and measured >-150HU and >10 mm or had >10 mm of central denser zone (CDZ) (partly solid tumors) or tumor size (solid tumor). Two of four squamous cell carcinomas (SCC) measuring 15 and 10 mm, respectively, were problematic. Two patients with small-cell lung carcinomas (SCLC) measuring 15 and 23 mm, respectively, remain alive. AAH, BAC, ADC, and SCC lesions were in general polygonal in shape. SCLC lesions appeared as round nodules with excrescence. The mean TVDT for AAH, BAC, ADC, SCC, and SCLC was 1278, 557, 466, 212, and 103 days, respectively. CONCLUSION The CT features reflected tumor aggressiveness. Non-SCLC lesions of >-150HU and >10 mm (or >-100HU and >10 mm for the solid portion of the tumor) are associated with unfavorable prognosis. Timely interventions should be undertaken before problematic increase in number of cases.

Pulmonary torsion of the lingula following a segmentectomy of the left upper division

We report a case of pulmonary torsion of the lingula. Thoracoscopic segmentectomy of the left upper division was performed on a 67-year-old woman. The chest radiograph on the first postoperative day showed consolidation in the left apical area. By the second postoperative day, the consolidation had increased in size. Bronchoscopy and chest contrast-enhanced computed tomography (CT) were conducted, and she was diagnosed with torsion of the lingula. We performed an emergency operation and resected the affected lung because of a gangrenous lobe. Although pulmonary torsion is a rare complication following lung resection, thoracic surgeons should always consider the risk. To prevent pulmonary torsion, we should confirm the correct position of the remaining lobes, and fixation of the lobes should be performed if there is little or no parenchymal bridge between contiguous lobes. A high index of clinical suspicion is necessary for early diagnosis, and rethoracotomy should be performed without delay.

Lymphoscintigraphy using technetium-99m HSA-DTPA with SPECT/CT in chylothorax after childbirth

Technetium-99m human serum albumindiethylenetriaminepentaacetic acid (HSA-DTPA) lymphoscintigraphy with single photon emission computed tomography combined with integrated low-dose computed tomography (SPECT/CT) is useful for evaluating chylothorax. We report a case of chylothorax that occurred 2 months after childbirth in a 24-year-old woman. Lymphoscintigraphy with SPECT/CT showed abnormal tracer accumulation in the right plural effusion, and chylothorax was diagnosed. Collateral branches of the thoracic duct were found to be ruptured during video-assisted thoracoscopic surgery performed for ligation.

Computed tomography attenuation predicts the growth of pure ground-glass nodules.

OBJECTIVES Cases of lung cancer with pure ground-glass nodules (GGNs) have been detected with increasing frequency since the advent of computed tomography (CT), and growth is sometimes noted during follow-up. The objective of this study was to evaluate the potential predictive factors for pure GGN growth. MATERIALS AND METHODS We retrospectively examined 124 cases involving pure GGNs. Patients were monitored for > 2 years using high-resolution CT. After a median follow-up period of 57.0 months, GGNs showed growth in 64 of the 124 cases. We compared the patient characteristics and tumor properties of cases with and without growth. The predictive value of the mean CT attenuation for GGN growth was evaluated using receiver operating characteristic curve analysis. RESULTS Univariate analysis revealed significant differences between mean CT attenuation values in patients with and without growth (-602.9 ± 90.7 Hounsfield units [HU] vs -705.7 ± 77.7HU, P < 0.0001). The final incidence of growth was estimated to be significantly higher for lesions with a mean CT attenuation value of ≥ -670HU (n = 62; 93.2%) than for lesions with values of < -670HU (n = 62; 31.6%; P < 0.0001). The sensitivity and specificity for predicting tumor growth using this cutoff value were 78.1% and 80.0%, respectively (area under the curve, 0.81). CONCLUSION The mean CT attenuation value could be useful in predicting the growth of GGNs.

The value of pleural lavage cytology examined during surgery for primary lung cancer

OBJECTIVES The pleural invasion (PL) score is a useful prognostic indicator in lung cancer. However, in many cases, the cancer may exfoliate itself into the pleural cavity and may progress to a malignant pleural effusion without invading the parietal pleura. This stage is not currently evaluated, but it is detectable by means of the pleural lavage cytology (PLC). However, PLCs contribution to TNM staging has not yet been clarified. The purpose of this investigation was to demonstrate the usefulness of PLC in the precise staging of patients with such an occult pleural dissemination. METHODS A total of 3231 patients who were included in a multi-institutional database were studied retrospectively. PLC was performed by washing the thoracic cavity with a small amount of physiological saline immediately after opening the thoracic cavity during lung cancer surgery. RESULTS The incidence of positive PLC findings was 4.58%. In comparison with the negative group, the survival curves were significantly worse (P < 0.001) and the incidence of recurrence with pleuritis carcinomatosa was significantly higher (P < 0.001). According to the subset analysis, the survival difference was prominent in earlier stage groups and lower PL score groups. The positive findings were confirmed to be a significantly poor prognostic indicator (P = 0.016) by multivariate analysis using the Cox proportional hazard model (Cox analysis). However, integration of the positive findings with the PL score was attempted for the convenience of TNM staging. To find the accurate PL score for positive PLC findings, the Cox analysis was re-estimated using the PL score upgraded stepwise. The most reliable model with the highest score for the likelihood ratio χ(2) statistic was obtained by scoring positive findings as PL3. So, it was considered to be the most reliable conversion. CONCLUSIONS Examining PLC in clinical practice is useful for detecting occult pleural dissemination before the appearance of a malignant pleural effusion. Evidence of positive findings should be treated as supplemental information to the precise diagnosis of TNM staging. Scoring positive PLC findings as PL3 (=T3) was appropriate.

Clinical features of lung cancer in smokers with light and mild chronic obstructive pulmonary disease: a retrospective analysis of Japanese surgical cases.

OBJECTIVES We estimated the influence of chronic obstructive pulmonary disease (COPD) upon the clinicopathological characteristics of lung cancer (LC) in Japanese surgical cases by comparing LC cases in non-COPD smokers. METHOD A consecutive cohort comprising 157 COPD patients (78 in Global Initiative for Obstructive Lung Disease-1 (GOLD-1) and 79 in GOLD-2) and 374 non-COPD smoker-LC patients were enrolled in this study. Comparative analyses of the clinicopathological features of these two groups, including clinical outcomes, were performed. RESULTS By analyzing all cases, we found that LC patients with COPD were older on average, more likely to be male, and heavier smokers than LC patients without COPD. In sub-analysis involving matched patient backgrounds, histological differentiation grade of LC in smokers with COPD was lower than in LC smokers without COPD, although distribution of clinical stages and histological types of LCs did not differ between smokers with and without COPD. The 5-year-survival rate in COPD patients was poorer than in non-COPD smokers in terms of both overall (38% vs 54%) and cancer-related mortality (45% vs 63%). By single-variant risk analysis, COPD became a prognostic factor. CONCLUSION We concluded from our analysis that COPD-related LC may have a higher malignant potential than LC in non-COPD smokers, as the histological differentiation grade and clinical outcomes were poorer.

Pulmonary Nodules: Preliminary Experience with Semiautomated Volumetric Evaluation by CT Stratum

RATIONALE AND OBJECTIVES To evaluate the performance of custom-made software designed to quantify volume and weight of focal portions of lung tumors in regions of interest (ROI) and volume of interest on thin-section computed tomography (CT) images by stratum of CT values. METHODS AND MATERIALS Volume and weight of lung portions were measured three-dimensionally and semiautomatically by CT stratum and compared with standard manual measurements. One each of a partly solid tumor (including initial and follow-up high-resolution CT scans), partly solid tumor with most parts showing solid density, and nonsolid tumors in the mid-zone of the lung were analyzed. The doubling time (DT) of tumor volume and mass were calculated by stratum of CT values. RESULTS The software-measured tumor weight in lung periphery was reproducible, with and without trimming of intervening lung structures between borders of ROIs and tumor. For the lesion in the midlung zone, the fairly thick nearby pulmonary vessels degraded the measurements, with a higher measurement error, indicating the need to trim these structures off the ROI. Software measurements allowed quantification of tumor progress based on increase in tumor mass, without significant increase in tumor volume. The DTs for both tumor volume and mass were different among the four strata of CT values in the partly solid nodule. CONCLUSION Our semiautomated volumetric method involving measurement by CT stratum is promising for evaluation of lung tumor progress and aggressiveness.

Mucoepidermoid carcinoma of the anal canal: an immunohistochemical study

We present a case of mucoepidermoid carcinoma of the anal canal, with special reference to immunohistochemical analysis of the tumor to clarify its histogenesis. A 36-year-old man underwent surgery for mucoepidermoid carcinoma of the anal canal. Immunohistochemical analysis of the resected specimen was performed. Serial sections were stained immunohistochemically by the labeled streptavidin-biotin peroxidase method for various antigens, including epithelial membrane antigen (EMA); carcinoembryonic antigen (CEA); different types of cytokeratins, including CK10 and CAM 5.2; and p53 oncoprotein. The solid component of the tumor cells was immunohistochemically positive for EMA, CEA, and CAM 5.2, but negative for CK10. These staining patterns were different from those of anal squamous epithelium. These results confirm that mucoepidermoid carcinoma of the anus may arise from the anal transitional zone, and that it is biologically different from squamous cell carcinoma of the anus.