Takao Morohoshi

Endobronchial hamartoma treated by an Nd-YAG laser: Report of a case

Endobronchial hamartomas are only rarely encountered. They cause irreversible lung damage due to bronchial obstruction if not diagnosed early and treated properly. Among the various treatments for this rare disease, a surgical resection remains the most popular. We herein report a case of a 53-year-old man presenting with an endobronchial hamartoma which was successfully excised by laser irradiation via a rigid bronchoscope, along with a review of 113 patients with this disease reported in the literature.

Influence of visceral pleural invasion on survival in completely resected non-small-cell lung cancer

OBJECTIVES Although the prognostic implications of visceral pleural invasion (VPI) are well established, it remains controversial whether the extent of VPI affects survival in patients with completely resected non-small-cell lung cancer (NSCLC). In addition, the impact of VPI according to nodal status is unclear. We evaluated the influence of the extent of pleural invasion on survival by analysing a multicentre retrospective database of patients who had undergone surgery for NSCLC. METHODS We retrospectively reviewed the clinicopathological characteristics and outcomes of 639 patients with NSCLC who underwent anatomic complete resection from 2005 to 2007 at nine hospitals affiliated with the Yokohama Consortium of Thoracic Surgeons. RESULTS The median follow-up was 65.0 months. The extent of pleural invasion was PL0 in 462 patients, PL1 in 135 and PL2 in 42. The 5-year overall survival rate was significantly higher in patients with PL0 tumours (75.9%) than in those with PL1 (63.6%) or PL2 tumours (54.1%). On subgroup analysis according to nodal status, PL0 was associated with a higher survival rate than that of PL1 or PL2 tumours in patients with N0 or N1 metastasis, but not in those with N2 metastasis. There was no difference between PL1 and PL2 in any subgroup. CONCLUSIONS Our results suggest that the presence of VPI, rather than the extent, has an impact on postoperative survival in patients with NSCLC who have N0 or N1 metastasis. Because very few previous studies have addressed the effects of VPI in patients with N1 disease, further re-evaluation of the prognostic impact of VPI is necessary in this subgroup of patients.

Morphologic Alterations and Cytokinetic Studies of Tracheal Autograft Epithelium in Rabbits

BACKGROUND Although tracheobronchoplasty has been used widely in the field of thoracic surgery, few details of the morphologic changes in and cytokinetics of the graft epithelium have been reported. The aim of this study was to focus on these aspects in autografted rabbit tracheas. METHODS Resected cervical tracheas were anastomosed immediately after removal, retrieved on postoperative days 1 through 28, and examined morphologically. Mitotic and bromodeoxyuridine-labeling indices of the graft epithelium were analyzed. RESULTS On postoperative days 1 to 4, the graft epithelium showed focal desquamation at the anastomoses. Ciliated cells disappeared during postoperative days 4 to 7 and then increased gradually. Nonciliated cells retained a somewhat columnar shape on postoperative days 4 to 7, except at denuded foci. Thereafter, the grafts were covered completely with pseudostratified mucociliary epithelium. On postoperative day 4, both indices were maximal and appeared higher at the anastomotic than midgraft sites. CONCLUSIONS Most of the graft epithelium was preserved during acute ischemia and then started to regenerate. The increased regenerative activity near the anastomoses may be attributable to mechanical damage or different nutritional conditions.

A case of cytokeratin-negative sarcomatoid malignant pleural mesothelioma

To the Editor: A positive cytokeratin status is particularly important for diagnosis of sarcomatoid malignant pleural mesothelioma (MPM). In the 2015 World Health Organization (WHO) atlas, it is stated that sarcomatoid MPMs are almost always stained, at least focally, with the AE1/AE3 broad spectrum antikeratin antibody cocktail and pancytokeratin antibodies OSCAR and KL1, as well as CAM5.2. However, cytokeratin-negative MPM may be encountered in 5%, and in 10% of tumours with heterologous elements (SuppInfo reference S1). We encountered a patient with sarcomatoid MPM that was difficult to diagnose because it was cytokeratin-negative and negative for other conventional positive markers of MPM. The patient was an 87-year-old male with a history of a variant angina, diabetes mellitus, hypertension, hyperlipidaemia, knee osteoarthritis, and spinal canal stenosis. He had smoked a pack of cigarettes every day for forty years, and had been exposed to asbestos while working in production of thermal insulating materials. He was referred to our hospital with a complaint of progressive dyspnea. A chest X-ray revealed massive left pleural effusion. Tumour markers of lung cancer were within normal ranges, but hyaluronic acid in pleural fluid was elevated to 603,000 ng/ mL. The pleural fluid cytology revealed no malignant findings of sections made from cell blocks. Chest computed tomography (CT) after a thoracic drain was inserted revealed left pleural plaque, left slight pleural thickening, and a left pleural nodule (Fig. 1a). Thoracoscopy under local anaesthesia showed the presence of a parietal pleural nodule in contact with pleural plaque and with proliferation of surrounding blood vessels (Fig. 1b). Biopsy was also performed for the nodule, but there were no malignant findings. In other parietal and visceral pleurae, no tumour mass lesions were found, but pleural thickening was observed in part of the parietal pleura. CT-guided biopsy showed no malignant findings. Careful course observation was selected at the patient0s request. After eleven months, CT showed development of a new subcutaneous tumour mass at the site of drain insertion (Fig. 1c). After one year and two months, CT showed that the left pleural nodule had enlarged, left pleural thickening had progressed, and a subcutaneous mass had developed. MPM was suspected based on the clinical course, and the subcutaneous mass was biopsied. Macroscopically, the tumour was a solitary elastic hard mass. The cut surface of the resected specimen showed a grayish-white, solid mass, measuring 11 10mm with focal haemorrhage. Histologically, proliferation of atypical cells with an oval or short spindle shape was observed. The growth pattern mostly showed no specific pattern and cellular and nuclear pleomorphism was discernible (Fig. 1d). Tumour cells were infiltrating the fibroadipose tissue. The tumour cell morphology was mostly homogeneous, but a mitotic figure was frequently noted (Fig. 1e). Sarcomatoid MPM, solitary fibrous tumour (SFT), pleomorphic carcinoma, spindle cell carcinoma, malignant peripheral nerve sheath tumour and spindle cell rhabdomyosarcoma were potential differential diagnoses based on the findings in hematoxylin-eosin staining. Immunohistochemically, the tumour cells were positive for vimentin and negative for AE 1/3, CK 7, CK 20, CAM5.2, CK34bE12, CK 5/6, CEA, TTF-1, p63, calretinin, D2-40, WT-1, Glut-1, EMA, SMA, desmin, CD34, and S-100. An analysis of p16 deletion using fluorescence in situ hybridization detected heterozygous deletion at a rate of 79%. Cytokeratin and other positive markers of MPM were negative, and no specific tendency for differentiation was noted. For differentiation from lung sarcomatoid carcinoma, we performed MUC4 and GATA binding protein 3 (GATA3) staining. MUC4 was negative and GATA3 was partially positive (Fig. S1a). Based on these immunostaining results and the localization and growth pattern of the lesion, diagnoses of pleomorphic carcinoma, spindle cell carcinoma, malignant peripheral nerve sheath tumour and spindle cell rhabdomyosarcoma were excluded. CD34 was negative, but considering the histological findings, SFT was considered to be the most important differential diagnosis. Therefore, for more detailed differentiation for SFT, we investigated the presence of NGFI-A binding protein 2 (NAB2)-signal transducer and activator of transcription 6 (STAT6) fusion gene using RT-PCR and STAT6 expression by immunohistochemistry. No NAB2ex4-STAT6ex2/3 or NAB2ex6-STAT6ex16/17 fusion gene was detected, and STAT6 was negative; therefore, SFT was ruled out. In addition, the case was confirmed to have loss of BRCA associated protein 1 (BAP1) in immunostaining (Fig. S1b). Pleomorphic sarcoma of chest wall origin could not be completely ruled out, but based on a comprehensive evaluation of the clinical course, macroscopic growth pattern, and immunohistochemical findings, it was concluded that managing the tumour as sarcomatoid MPM was most appropriate. Since the patient was an elderly person

Thoracoscopic lobectomy for lung cancer in a patient with a partial anomalous pulmonary venous connection: a case report

BackgroundA partial anomalous pulmonary venous connection is a rare congenital defect in which blood from the pulmonary vein is returned to the right atrium. Asymptomatic patients with a partial anomalous pulmonary venous connection with a small left-to-right shunt do not require surgical treatment. If such patients require a major lung resection, the surgical procedure could precipitate fetal right heart failure if the anomalous venous connection remains uncorrected.Case presentationA 59-year-old man was found to have an abnormal shadow on chest roentgenogram. Chest computed tomography imaging showed a mass in the right upper lobe. At the same time, we incidentally found an anomalous vessel. We diagnosed the abnormality as a partial anomalous pulmonary venous connection. Because the mass may have been lung cancer, a right upper lobectomy was performed using video-assisted thoracoscopic surgery. The right upper lobe vein drained into the superior vena cava. The anomaly was not corrected and the surgery was successful. His postoperative course was uneventful without cardiac failure.ConclusionsBefore performing a major lung resection, surgeons should be aware of this rare anomaly and carefully interpret clinical images of all pulmonary veins.

A resected case of combined small cell lung carcinoma with carcinosarcoma.

To the Editor: A 73-year-old male with a previous abdominal aortic aneurysm was referred to our institution for a further examination of a pulmonary tumor found one month earlier on a routine health check-up. His history included smoking 20 cigarettes a day for 50 years (B.I = 1000). The blood chemistry data were unremarkable, except for a carcinoembryonic antigen (CEA) level of 10.4 ng/ml (normal range, 0–5 ng/ml). Chest computed tomography (CT) demonstrated a well-defined tumor with inner heterogeneity measuring 3.2 cm in diameter in the left lower lobe (Fig. 1a). The border with the upper lobe was indistinct, and permeation to the upper lobe was suggested. No marked enlargement of the lymph nodes was observed. A bronchoscopic examination showed obstruction of Ba. The histological diagnosis of the biopsied specimen was adenocarcinoma. Head magnetic resonance imaging (MRI), abdominal CT and bone scintigraphy detected no signs of distant metastases (cT2aN0M0-stage IB). VATS left lower lobectomy, combined left upper lobe wedge resection and lymph node dissection (ND2a) were performed. A histopathologic examination revealed combined small cell carcinoma and carcinosarcoma (adenocarcinoma + squamous cell carcinoma + small cell carcinoma + chondrosarcoma). The histological staging was as follows: grade 4, pl3, pm0, Ly1, v1, R1, disseminated nodule in the pleural cavity (pM1a), surgical margin (-), pT2aN0M1a stage IV. The patient received adjuvant chemotherapy consisting of CDDP+VNR. A CT scan performed two months after surgery revealed anterior mediastinal lymphoid swelling. Anterior mediastinal lymph node dissection (#3a, #4 L), thymectomy and left upper lobe wedge resection via median sternotomy were performed three months after the first surgery. A histopathologic examination showed that the #3a LN was positive for metastasis, although #4 L was negative, and the cancer had invaded the thymus with a positive surgical margin. No invasion was observed in the left upper lobe. There was a residual tumor in the dorsal left upper lobe. The patient received three courses of CBDCA+VP-16. Because an evaluation after chemotherapy revealed progressive disease (PD) in a CT scan, he received heavy particle radiotherapy (72 G/16 Fr) for the residual tumor. This achieved a partial response (PR) with a cytoreductive effect consistent with Response Evaluation Criteria in Solid Tumors (RESIST) on a CT scan. Routine follow-up chest CT performed 14 months after the first surgery showed pleural dissemination.

A Surgically Treated Case of Squamous Cell Carcinoma Developing in a Bulla.

症例は73歳男性. 健康診断の胸部X線写真にて気腫肺の診断で経過観察中であったが, 右上肺野に腫瘤状陰影を指摘された. その後の胸部CTでは右上葉およびS6の多数の嚢胞とともに右肺S2領域に存在する辺縁明瞭な充実性腫瘤を認められた. この胸部CTを以前のものと比較したところ, 2ヵ所の肺嚢胞が新たに充実性腫瘤に置き換わっていた. 腫瘤は嚢胞壁より発生し, 嚢胞の内腔を満たすように発育していったものであると思われた. 比較的急速に腫瘤が発育したことより悪性を疑い開胸手術を施行した. 手術所見は, 嚢胞周囲に炎症性と思われる強固な胸膜癒着を認め, 術中迅速診断にて嚢胞内に壊死物質と扁平上皮癌を認めたため右上葉切除 (R2a) を行った. 肺嚢胞性疾患患者に対しては肺癌の合併を念頭に置き, CTを中心とした画像診断による定期的な経過観察を行い, ひとたび肺癌を疑った場合には開胸肺生検をはじめとした積極的な検索が必要であると思われた.