Yuko T. Yamashita

Elevated Serum Sialyl Lewis X-i Antigen Levels in Non-Small Cell Lung Cancer with Lung Metastasis

To evaluate the relationship between serum levels of sialyl Lewis X-i antigen and lung metastasis in patients with non-small cell lung cancer (NSCLC), we measured the serum level of the antigen in 299 patients with untreated locally advanced or metastatic NSCLC. Before treatment, serum levels of sialyl Lewis X-i antigen were significantly higher in patients with lung metastasis than in those without lung metastatis (p = 0.0001). Of 201 patients without lung metastasis at the time of primary diagnosis, 121 patients died between July 1987 and December 1995. Serum levels of sialyl Lewis X-i antigen in 21 patients who developed lung metastasis during the period were significantly higher than those in 100 patients who did not develop lung metastasis (p = 0.0171). Our results suggested that sialyl Lewis X-i antigen might be a good indicator for the presence or development of lung metastasis, and it might provide clinical information about the management of patients with NSCLC.

Angiocytotoxic Therapy in Human Non-Small Cell Lung Cancer Cell Lines: Advantage of Combined Effects of TNP-470 and SN-38

The combined effects of TNP-470, a promising antiangiogenic agent, and SN-38, a camptothecin derivative, were evaluated in four human cultured cell lines derived from non-small cell lung cancer (NSCLC). Cytotoxicity experiments were determined by using a tetrazolium salt (MTT) assay. The inhibitory effects of TNP-470 on cell proliferation were dose related and the 50% inhibitory concentrations on these cell lines were 47.3-139.8 microM. Evaluation of drug interactions with isobologram and the combination index values showed that sequential exposure to SN-38 followed by TNP-470 produced synergistic effects in the four cell lines tested. Our findings suggest that such an angiocytotoxic chemotherapy might be promising for the treatment of NSCLC.

Spontaneous regression of multiple emphysematous bullae

The etiology of emphysematous bullae is not well known; thus, the management of bullous lung disease is often difficult because of concomitant underlying emphysema and coexisting cardiac conditions. The present paper reports a case in which near complete resolution of multiple emphysematous bullae in the right lung occurred spontaneously. This case is of interest, not only because of the rarity with which spontaneous regression of multiple emphysematous bullae has been reported in the literature, but also because of the accompanying dramatic improvements in radiological results and pulmonary function of the patients.

Lung Cancer in the Octogenarian

Background: Older patients with lung cancer tend to have significant coexisting diseases and less aggressive treatment is often advisable. Objective: To investigate the clinicopathological features of lung cancer in patients aged 80 years and over. Methods: The medical records of 966 patients with lung cancer between 1976 and 1999 were reviewed retrospectively. Results: There were 56 (5.8%) patients 80 years old or over. Thirty-nine (70%) were male, and 22 (39%) patients had poor performance status (2–4). Some of the patients had a medical history of cardiovascular disease (n = 23; 41%), cerebrovascular disease (n = 5; 9%), diabetes mellitus (n = 11; 20%), or malignant disease (n = 8; 14%). Twenty-one (35%) patients were diagnosed as having surgically resectable disease and 20 patients underwent radiotherapy, but 25 patients only received supportive care because of concomitant illnesses. Only 9 and 2 patients, respectively, had chemotherapy and surgery. There was no statistical difference in the survival rate of the two groups of patients receiving radiotherapy or supportive care. Conclusion: Adequate palliative care to provide prolonged quality survival is an appropriate primary goal of therapy for lung cancer in the octogenarian until less invasive treatments are developed.

Urokinase-type plasminogen activator in carcinomatous pleural fluid

Urokinase-type plasminogen activator (u-PA) is known to be secreted by malignant cells during proliferation and migration, and is associated with tumour cell invasion and metastasis. This study was undertaken to evaluate whether u-PA is significantly increased in carcinomatous pleural fluids compared to those due to other aetiologies, and to identify the cells in the pleural space that are involved in its accumulation. Using an enzyme-linked immunosorbent assay, we quantified u-PA in the pleural fluid specimens of 40 patients with carcinomatous pleuritis, 18 with tuberculosis, 18 with parapneumonic pleuritis and 11 with congestive heart failure (CHF). The level of u-PA was elevated in carcinomatous pleural fluid compared with the level in transudative pleural fluid from patients with CHF (p<0.0001). The levels of u-PA were not statistically different between patients with cancer and tuberculosis, or between patients with cancer and pneumonia. The levels of u-PA in patients who did not respond to chemical pleurodesis were significantly higher than those who had complete response (p=0.0001). In immunocytochemical and immunoblotting studies, cancer cells in pleural fluids as well as mesothelial cells contained u-PA. u-PA was detected in the culture supernatants of viable pleural cells in the majority of patients with carcinomatous pleuritis. Our results suggest that local release of urokinase-type plasminogen activator by viable cells, including cancer cells and mesothelial cells, may affect the levels of urokinase-type plasminogen activator in pleural fluids.

Pleural Metastasis of a Squamous Cell Carcinoma of the Gingiva

A 74-year-old man with a 30-pack-year history of smoking presented with swelling of the right lower gingiva, which was diagnosed as keratinizing moderately differentiated squamous cell carcinoma (SCC) on biopsy. There was no evidence of distant metastasis and he underwent radical resection of the tumor. Surgical margins were negative but direct invasion into the submandibular bone and metastasis to the regional lymph nodes were observed. Two months after the operation, he presented with a large right-sided pleural effusion. A thoracic CT scan demonstrated the presence of the effusion and a well-circumscribed mass in the right hemithorax (fig. 1). On percutaneous biopsy, it was found to be SCC with the same histological features as the previously resected carcinoma of the gingiva. No other distant metastasis was found on extended studies. He was treated only with chest tube drainage and pleurodesis because of his age and poor performance status. Oral cancer constitutes approximately 2–4% of all malignant tumors and accounts for 2% of male and 1% of female cancer deaths [1]. The most common malignant neoplasm of the oral cavity is SCC, which accounts for roughly 90% of the total number of malignant oral lesions [2]. Regional involvement of the cervical lymph nodes is frequently seen [3], however, distant metastasis from SCC of the gingiva is rare. It has been reported to occur via hematogenous spreading to lung, pharynx and bone [4]. According to Woolgar et al. [5], only 3% of 123 patients with SCC of oral and oropharyngeal mucosa died of systemic metastases [5]. This case is unique because of its presentation with large pleural effusion as a result of pleural metastasis without any other evidence of distant metastasis. Sun et al. [6] carried out a retrospective clinical study on 103 consecutive cases of oral and maxillofacial malignant conditions. Eight patients (8%) had pleural effusion, 3 of whom had a large accumulation of the fluid. To our knowledge, specific pleural metastasis from SCC of the gingiva has not been previously reported and this is the first case in the literature. Fig. 1. CT scan demonstrated a well-circumscribed mass (arrow) in the right hemithorax. The mass abutted onto the chest wall and was based on pleura with evidence of chest wall invasion.

Brain metastasis as the first manifestation of lung cancer

To the Editor: Although the brain is a common site for metastasis in lung cancer (1– 4), it is rarely the first site of manifestation. We report the clinical findings of 21 patients who were admitted to Tsukuba University Hospital between 1976 and 2001, who presented with brain metastasis as the first manifestation of lung cancer. These patients comprised 2% of the 1041 patients admitted for lung cancer during that period. There were 16 men and 5 women, aged 29 to 77 years (median, 60 years). Fourteen had adenocarcinoma; 4 had small cell carcinoma; and 3 had large cell carcinoma. The brain was the only metastatic site in 16 patients. Three of the 21 patients had a primary lesion less than 30 mm in diameter, and 6 patients had either N1 disease (n 5) or no regional lymph node involvement (N0 disease; n 1). According to the performance status scale of the Eastern Cooperative Oncology Group (which ranges from 0 [fully active] to 4 [bedridden]), 8 patients had a performance of grade 1 and 13 had grades 2 to 4. Thirteen patients underwent brain irradiation and 8 underwent systemic chemotherapy; 5 of whom received both therapies. The median survival time for these 5 patients was 7 months (range, 2 to 9 months), compared with 6 months in the 21 patients. Four patients had surgical resection of the brain metastatic lesion, and their mean survival time was 5 months. Three of the 4 patients developed brain metastasis again in their clinical courses. Two of the 21 patients had supportive care. Seven patients died of respiratory failure; only 1 died of an increase in intracranial pressure. Brain metastasis usually occurs late in the course of the disease, often with widespread systemic metastases, and their occurrence generally portends a poor prognosis (5). In this series of patients, three fourths of patients who presented with brain metastasis as the first manifestation of lung cancer had the brain lesion as the only metastatic site. Brain metastasis occurred even when the primary lesion was small and there was no regional lymph node involvement. The patients who survived more than 1 year after the presentation had only brain metastasis and had been treated with combined therapy. Surgical intervention or stereotactic radiosurgery may be beneficial in improving survival for some patients whose presenting symptoms are due to brain metastasis. Katsunori Kagohashi, MD Hiroaki Satoh, MD Yuko T. Yamashita, MD Kiyohisa Sekizawa, MD Division of Respiratory Medicine Institute of Clinical Medicine University of Tsukuba Ibaraki, Japan

Curved chest tube for drainage of malignant pleural effusion

Thoracentesis with a chest tube insertion and drainage of large pleural effusion is widely performed in patients with malignant lung diseases. One potential problem with a conventional chest tube placement is occasional incomplete evacuation of effusion owing to inappropriate position of the tip where the drainage holes opened. We have developed a curved chest tube and evaluated the position of tip placement just after the placement and before removal on plain chest X-ray in 20 patients with massive pleural effusions due to lung cancer. In 15 of the 20 patients, the tip of the tube was successfully positioned at the paravertebral gutter in posterobasal with higher drainage efficacy compared with other patients whose tube tips happened to be positioned at other sites. There were no significant complications. This study suggested that the curved chest tube would be safe and useful in completing drainage of pleural effusion.

Late recurrence of small-cell lung cancer: a case report.

A 67-year-old man was admitted with small-cell lung cancer (SCLC).The patient was given four courses of platinum-containing chemotherapy followed by chest irradiation, and good partial response (PR) was obtained. The patient did well for 4 years, until he sought treatment for a painful subcutaneous tumor. Chest computed tomography scan revealed the mass extending from the tumor in lung parenchyma with osteolytic lesion of the third rib bone. Pathologic examination of the subcutaneous lesion revealed SCLC. The patient was given two courses of the same combination chemotherapy administered as initial therapy. Regression of the mass was observed, and the response was evaluated as a good PR. How to approach late recurrence of SCLC is discussed.

An Unusual Cause of a Persistent Pulmonary Infiltrate and Weight Loss

Accessible online at: http://BioMedNet.com/karger A 71-year-old smoker was admitted for investigation of suspected lung cancer. He had had a history of coughing for several weeks, the chest roentgenogram showed a vague infiltrate in the lingula and he was put on a course of oral antibiotics. Over a period of 2 months the patient lost 10 kg and the infiltrate did not resolve. Before bronchoscopy a CT scan (fig. 1) was performed, which confirmed the chest roentgenogram findings but did not reveal a tumor. Bronchoscopy surprisingly revealed a grain of maize at the entrance of each lingular segment (fig. 2). Both foreign bodies could be passed with the closed forceps and removed by drawing back the opened forceps with the help of a strong cough from the patient. The lingular infiltrate disappeared subsequently and while treating a painful buccal ulcer, a substantial increase in weight was noticed. In this case the combination of weight loss and a persistent pulmonary infiltrate was not the result of a bronchial tumor, as we expected, but due to an ill-fitting dental prosthesis, which caused the painful buccal ulcer and possibly also favoured aspiration. Our patient, who was very fond of maize salad, could not remember a coughing fit while eating in the past few days or weeks. Even without a typical history, aspiration should always be considered as a possible cause of a pulmonary infiltrate, especially in elderly patients. Figure 3 shows the moderately inflamed entrance to the lingular segments after the procedure. 2