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OBJECTIVES The aim of this study was to analyse the long-term survival outcomes and prognostic factors of patients receiving epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) as first-line treatment for postoperative recurrent EGFR-mutated lung adenocarcinoma. METHODS Using a multi-institutional database, we performed a retrospective chart review to identify all patients who had undergone complete resection of stage I–III EGFR-mutated lung adenocarcinoma at 11 acute care hospitals between 2009 and 2016 and had received first-line EGFR-TKI treatment for postoperative recurrence. Adverse events, progression-free survival (PFS) and overall survival (OS) were investigated. Survival outcomes were assessed using Kaplan–Meier analysis. Cox proportional hazards models were used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for PFS and OS. RESULTS The study sample comprised 154 patients with a median age of 69. The total numbers of events were 101 for PFS and 60 for OS. The median PFS and OS were 26.1 and 55.4 months, respectively. In the multivariable analysis, EGFR ex 21 L858R mutation (HR: 1.71, 95% CI: 1.15–2.55) and shorter disease-free intervals (HR: 0.98, 95% CI: 0.96–0.99) were significantly associated with shorter PFS. Age (HR: 1.03, 95% CI: 1.00–1.07), smoking history (HR: 2.31, 95% CI: 1.35–3.94) and pathological N2 disease at the initial surgery (HR: 2.30, 95% CI: 1.32–4.00) were significantly associated with shorter OS. CONCLUSIONS First-line EGFR-TKI treatment was generally associated with favourable survival outcomes in patients with postoperative recurrent EGFR-mutated lung adenocarcinoma. EGFR ex 21 L858R mutation may be an important prognostic factor for shorter PFS.

Highlights • Rare aortic injury from a rib fracture, which is not found in primary evaluation. • Hemothorax with great vessel injury can be fatal and should be detected using computed tomography. • Some great vessel injuries cannot be detected through contrast-enhanced chest computed tomography. • Great vessel injury should be considered in hemothorax with multiple rib fractures., Introduction There are multiple causes of hemothorax in blunt chest trauma. However, a traumatic hemothorax with an uncertain cause is potentially life-threatening without treatment, because an undetected and hidden great vessel injury can remain unknown. Delayed diagnosis can lead to death. Presentation of case A 77-year-old man was transferred to a local hospital, after experiencing a 3-m fall. Contrast CT of the chest revealed a left clavicle fracture, multiple left rib fractures and hemopneumothorax, but no obvious signs of great vessel injury, such as aortic injury. His condition was stable, owing to the chest tube thoracostomy with 800 ml blood output and intravenous fluid. The patient was then transferred to our hospital for further treatment. However, his condition rapidly deteriorated in the ambulance on the way to our hospital, and he needed a blood transfusion. On arrival, he was in shock, with his vital signs compromised due to blood loss. Emergency open thoracotomy was performed to explore the bleeding point and stop hemorrhaging. Intraoperative findings revealed sharp edges of the fractured fourth and fifth left ribs to be protruding into the chest cavity toward the descending aorta and causing an aortic pinhole injury. Ruptured aorta was repaired with a pledget-armed sutures and the sharp fractured ribs were resected. The patient was discharged, uneventfully, 35 days after the operation. Conclusion This case suggests that even if great vessel injury is not detected on contrast CT at admission, it should always be considered especially in a hemothorax case with multiple rib fractures.

Background Therapy targeting programmed death-1 or programmed death-1 ligand-1 (PD-1/PD-L1) has been developed for various solid malignant tumors, such as melanoma and non-small-cell lung cancer (NSCLC), but this approach has little effect in the treatment of pancreatic cancer. Pancreatic undifferentiated carcinoma with osteoclast-like giant cells (UCOGC) is a rare pancreatic malignancy having unique morphology and is considered a variant of pancreatic ductal adenocarcinoma (PDAC). Although UCOGC has been reported to have better prognosis than conventional PDAC, the optimal treatment for UCOGC with distant metastases has not been determined. Case presentation A 66-year-old man was initially diagnosed with NSCLC with multiple intrapulmonary metastases and abdominal lymph node metastasis in the tail of the pancreas, and bronchial biopsy and diagnostic imaging were performed. Pathologic examination of the lung showed poorly differentiated adenocarcinoma cells expressing epithelial marker and PD-L1. Therefore, pembrolizumab monotherapy for NSCLC was given. The pulmonary lesions shrank markedly and were in complete remission after 8 months of anti-PD-1 therapy, though no therapeutic effect was observed in the pancreatic site. Distal pancreatectomy was then performed, and histopathological examination showed that the tumor was UCOGC originating from the pancreas. The histologic findings of the resected specimen mimicked those of the lung biopsy specimen, leading to the final assessment that the lung tumors were metastatic foci that migrated from the UCOGC, and only the metastatic lesions benefited from pembrolizumab therapy. Conclusion Immune checkpoint inhibitors have limited therapeutic effects on primary lesions of pancreatic cancer, but they may exert antitumor effects on pulmonary metastases of UCOGC.

Objectives Previous studies have suggested that a second malignancy often develops after resection of thymoma; however, it remains unknown whether this is applicable to thymic carcinoma. Methods A retrospective chart review was performed based on our multi-institutional database of resected thymic epithelial tumours between 1991 and 2016. A second malignancy was defined as newly diagnosed after thymic tumour resection. The cumulative incidence of and related death from a second malignancy after thymic and neuroendocrine carcinoma resections were estimated using a competing risk model and were compared to those of patients undergoing a thymoma resection. Results Two hundred and thirty-eight patients were identified (thymic carcinoma 59; thymoma 179). A second malignancy developed in 1 patient (1.7%) with thymic carcinoma and in 17 patients (9.5%) with thymoma. Deaths from second malignancies were noted in 7 patients with thymoma. There was a tendency towards a lower cumulative incidence of and a lower cumulative death from a second malignancy after thymic carcinoma resection (P = 0.139 and P = 0.20, respectively) than after thymoma resection. The cumulative incidence of a second malignancy in patients with thymic carcinoma was 2.8% at 5 years and at 10 years (8.0% at 5 years and 11.8% at 10 years in patients with thymoma). Conclusions After resection of thymic and thymic neuroendocrine carcinoma, the probability of developing a second malignancy, as well as mortality from a second malignancy, is very low. A prospective study with a larger sample size is required to validate our results.

Chronic pulmonary arterial obstructions are caused mostly by chronic pulmonary artery thromboembolism and rarely by vasculitis or intimal sarcoma of the pulmonary artery. We herein report an unusual case of a 42-year-old woman with a solitary obstruction of the pulmonary artery in the right lower lobe of her lung. Because we could not exclude the possibility of intimal sarcoma, middle and lower lobectomy was performed. The resected specimens revealed large vessel vasculitis (LVV) and an isolated lesion in the right lower lobe pulmonary artery. LVV should therefore be considered in the differential diagnosis for single pulmonary arterial stenosis or obstruction.

Background Previously reported prognostic tools for patients with resected non-small cell lung cancer (NSCLC) include factors found postoperatively, but not preoperatively. However, it would be important to predict patient prognosis before NSCLC resection. To suggest a novel preoperative prognostic tool, we evaluated the relationship of preoperative prognostic factors with the survival of patients with resected NSCLC. Methods We retrospectively reviewed the data of two independent cohorts of patients with completely resected NSCLC. To develop the prognostic index in one cohort, the overall survival (OS) was evaluated using the Cox proportional hazards model. We assessed the disease-free survival (DFS) and OS of three risk groups defined according to the prognostic index. Then, the prognostic index was validated in the other cohort. Results Seven independent risk factors for OS were selected: age ≥ 70 years, ever-smokers, vital capacity normal limit, non-usual interstitial pneumonia (UIP) pattern, and UIP pattern. Three risk groups were defined: low-risk (36.9%), intermediate-risk (54.0%), and high-risk (9.1%). In the derivation cohort, the 5-year DFS rate was 77.8%, 58.8%, and 22.6% (P

Living-donor lobar lung transplantation (LDLLT) has been successfully performed in Japan. In LDLLT, the recipient usually receives one lower lobe from each of two donors; however, finding two ABO-matched donors is often difficult. Solid organ transplants from donors with minor ABO-mismatches can be complicated by hemolysis. We investigated the incidence of de novo anti-ABO antibody production and hemolysis in patients receiving LDLLT across minor ABO-mismatches. We evaluated 23 patients who underwent LDLLT between June 2008 and December 2011, including 11 patients who underwent minor ABO-mismatched transplantation. We measured the anti-A/B antibody serum titers, hemoglobin concentrations and indirect bilirubin levels. None of the patients showed any clinical signs of hemolytic anemia (mean follow-up period; 16 months). Two of the 11 patients (18 %) receiving minor ABO-mismatched LDLLTs showed a small amount of de novo anti-B antibodies for a transient period. These patients showed gradual progression of anemia, and weak de novo anti-A/B antibodies were detected with column agglutination technology. The patients received only 2 U of washed type O red blood cells; thereafter, the hemolytic anemia did not develop further in either case. LDLLT across minor ABO-mismatches results in the transient appearance of weak de novo anti-A/B antibodies with a low incidence; thus, this procedure can be a safe treatment.

Case Presentation: A 65-year-old female patient with no clinical manifestations was hospitalized for examination and treatment of an anterior mediastinal tumor found at the time of a regular health checkup. Enhanced computed tomography (CT) and magnetic resonance imaging revealed a cystic lesion containing a solid tumor. Positron emission tomography-CT demonstrated increased uptake in the solid lesion. Tumor resection with total thymectomy was performed. A pathological diagnosis of thymic neuroblastoma within a thymic cyst was made. Micorscopic examination revealed that tumor cells of the solid component were lined with thymic epithelial cells of the inner cyst wall. Furthermore, some tumor cells of the solid component had melanin granules. These findings suggest that this tumor arose from progenitors of the thymic epithelial cells with the potential to differentiate along neural lines. Conclusions: Neuroblastoma commonly occurs in children. However, the diagnosis of neuroblastoma in adults has been reported in several case reports. We report an adult case of histogenetically informative thymic neuroblastoma within a thymic cyst. There are no standard treatment strategies and chemotherapy protocols. Complete surgical resection might be important for a better outcome.

Summary Warm ischemia-reperfusion injury related to donation after cardiac death donors is a crucial and inevitable issue. As surfactant function is known to deteriorate during warm ischemia, we hypothesized that surfactant inhalation during warm ischemia would mitigate warm ischemia-reperfusion injury. We used an isolated rat lung perfusion model. The rats were divided into three groups: sham, control, and surfactant. In the control and surfactant groups, cardiac arrest was induced by ventricular fibrillation. Ventilation was restarted 110 min later; subsequently, the lungs were flushed, and heart and lung block was recovered. In the surfactant group, a natural bovine surfactant Surfacten® was inhaled for 3 min at the end of warm ischemia. Then, the lungs were reperfused for 80 min. Surfactant inhalation significantly improved graft functions, effectively increased lung tissue ATP levels, and significantly decreased mRNA levels of IL-6 and IL-6/IL-10 ratio at the end of reperfusion. Histologically, lungs in the surfactant group showed fewer signs of interstitial edema and hemorrhage, and significantly less neutrophilic infiltration than those in the control group. Our results indicated that surfactant inhalation in the last phase of warm ischemia maintained lung tissue energy levels and prevented cytokine production, resulting in the alleviation of warm ischemia-reperfusion injury.

Summary Successful living-donor lobar lung transplantation (LDLLT) largely depends on donor outcome. We reviewed our experiences with LDLLT and focused on preoperative computed tomographic evaluations of donors. Twenty-five LDLLTs were performed in Kyoto University. As a routine preoperative assessment, high-resolution chest computed tomography (CT), and three-dimensional (3D)-CT angiography were performed. Preoperative evaluations, surgical procedures, and early postoperative outcomes were reviewed in 43 consecutive LDLLT donors. All donors were discharged home after the donor lobectomies. Severely incomplete fissures were intraoperatively identified in two donors, whose interlobar fissures were mostly not identified by high resolution CT preoperatively. Preoperative 3D-CT angiography was effective for the identification of the branches of the pulmonary artery and vein. Pulmonary arterioplasties were performed with auto pericardial patches in three left donors. The bilateral donors had to be exchanged because of an anomaly of the pulmonary veins in one donor. Small pulmonary arterial branches to the remaining lobes were to be sacrificed in 23 donors (53%). Early postoperative complications were ascertained in seven donors, and five of them presented air leak-related complications. Living donor lobectomies were safely performed with low morbidities in our institution. Preoperative computer tomographic evaluations might be useful in donor lobectomies.

Summary Successful living-donor lobar lung transplantation (LDLLT) largely depends on donor outcome; however, there are few studies that have assessed outcomes of LDLLT donors, particularly pulmonary function. We investigated the outcomes and pulmonary function after donor lobectomy in LDLLT donors. Retrospective evaluation of consecutive 33 LDLLT donors was performed. Preoperative characteristics and perioperative and postoperative variables were investigated. Evaluation of pulmonary function 3, 6 and 12 months after donor lobectomy was performed prospectively. All donors were well alive after donor lobectomies. Morbidity was found in five donors (15%). Postoperative complications consisted of re-accumulation of pleural effusion requiring readmission in three donors and prolonged air leakage in two donors. Sacrifice of pulmonary arteries was performed in 20 donors (61%) with 1.4 ± 0.6 branches. Forced vital capacity was 77.8 ± 6.1%, 84.8 ± 6.0% and 89.4 ± 6.6% of the preoperative value 3, 6 and 12 months after donor lobectomy, respectively. Forced expiratory volume in 1 s was 80.5 ± 7.8%, 85.6 ± 8.9% and 89.3 ± 8.7% of the preoperative value 3, 6, and 12 months postoperatively. Living-donor lobectomy was performed with low morbidity. Pulmonary function even after lobectomy was better preserved than expected.

A 6-year-old girl with idiopathic interstitial pneumonia successfully underwent living-donor right single-lobe lung transplantation from her mother. Her mother's right lower lobe was 207% bigger than her right chest cavity, and attempting chest closure caused significant compression and narrowing of the right pulmonary vein anastomosis, as assessed by transesophageal echocardiogram. Her chest was temporarily closed without rib approximation. The following day, her chest could be completely closed. The pulmonary vein anastomosis, confirmed by transesophageal echocardiogram, was now patent. Currently, 7 months after the transplantation, she is well without limitations.

[Background.] One method of countering chronic lung donor shortages is the practice of donation after cardiac death (DCD). However, this technique inevitably leads to pulmonary dysfunction related to warm ischemia. One promising method of alleviating this problem is ventilation. However, it can rarely be initiated from the onset of cardiac arrest, particularly in uncontrolled DCD donors. We investigated the protective effect of the last 60 min of ventilation during a 240-min warm ischemic time. [Methods.] We rendered donor dogs cardiac dead and left them at room temperature. Six dogs received ventilation with 100% oxygen for 60 min starting at 180 min after cardiac arrest (ventilation group). Eight dogs received no ventilation. Lungs were harvested 240 min after cardiac arrest, then transplanted into recipient dogs. At 60 min after reperfusion, the right pulmonary artery was ligated, and the function of the left transplanted lung was evaluated. [Results.] In the ventilation group, all six animals survived for 240 min after reperfusion, whereas in the nonventilation group, only four of eight survived. The ventilation group demonstrated significantly better pulmonary oxygenation, shunt fraction, and wet-to-dry weight ratio. Furthermore, the ventilation group revealed significantly higher levels of high-energy phosphates in the lung tissues, fewer apoptotic cells, lower levels of tumor necrosis factor-α and interleukin-8 messenger RNA in the lung tissues, and lower levels of interleukin-6 messenger RNA in the serum. [Conclusion.] Our results suggest that ventilation during the late phase of the preprocurement period may ameliorate ischemia-reperfusion injury in DCD donors.

BACKGROUND: For patients with a thoracic malignancy whose peripheral veins are not suitable for blood access for chemotherapy, we evaluated a totally implantable central venous access port, in which the port is implanted in the ulnar side of the arm and the catheter is introduced via the basilic vein into the superior vena cava (TIAP-BV). METHODS: Twenty-five patients (21 with lung cancer, 2 with malignant pleural mesothelioma, and 2 with thymoma) receiving TIAP-BV were included. Indications, surgical complications, and long-term complications were analyzed. RESULTS: Indications for TIAP-BV were: chemotherapy (17 patients) and chemotherapy with parenteral nutrition (8 patients). The following surgical complications occurred: arrhythmia due to misplacement of the tip of catheter (1 patient); intraoperative conversion from the left to right arm (2 patients); and hematoma at the implantation site (1 patient). Short-term problems were: death 1 week after implantation without the use of TIAP-BV (2 patients). Long-term complications were: skin ulcer at the port site (1 patient); early removal of TIAP-BV because of port site infection (1 patient); catheter occlusion (1 patient); and venous thrombosis of basilic vein (2 patients). In the 22 patients who did not die early or have the device withdrawn early, the median duration of TIAP-BV use was 7 months (range, 1 to 20 months) without any break to the port system, leakage of drugs, or catheter-related infections. CONCLUSION: TIAP-BV can be employed for long-term use for chemotherapy and parenteral nutrition. However, a patient's expected prognosis and infectious disease status at the time of implantation surgery should be considered before the surgery proceeds.

Introduction: Management of pulmonary metastasis of non-small cell lung cancer (NSCLC) remains controversial. We reviewed our surgical treatment for pulmonary metastasis of NSCLC. Methods: Seventy-six patients with pulmonary metastasis of NSCLC underwent pulmonary resections in two institutes during the past 10 years. Eighteen patients with simultaneous same lobe metastasis as the primary lesion underwent mostly lobectomies. Sixteen patients with simultaneous different lobe metastasis underwent combined margin-free resections. Forty-nine pulmonary metastasectomies were performed in 42 patients with recurrent lung cancer. Overall survival and disease-free survival in each group were examined, and factors affecting survivals were investigated. Results: In the patients with the same lobe metastasis 5-year survival was 79.6%, and median and 5-year disease-free survivals were 39.1 months and 41.3%. In the patients with simultaneous different lobe metastasis median survival and 5-year survival were 37.7 months and 30.7%, and median and 5-year disease-free survivals were 13.3 months and 12.5%, respectively. Multiple pulmonary metastasis and mediastinal node metastasis were identified as significant factors affecting survivals. In the patients with recurrent pulmonary metastasis median survival and 5-year survival were 40.0 months and 34.8%, and median and 5-year disease-free survivals were 23.7 months and 14.4%, respectively. Node metastasis, higher age, and shorter interval from the prior resection were identified as significant factors affecting survivals. Conclusions: These findings suggest that the simultaneous same lobe metastasis is under the same indication for the primary lesion, and that the simultaneous different lobe metastasis and recurrent pulmonary metastasis should be removed in selected patients.

Outcome for highly immunogenic lung transplantation remains unsatisfactory despite the development of potent immunosuppressants. The poor outcome may be the result of a lack of minimally invasive methods to detect early rejection. There is emerging clinical evidence that, paradoxically, expression of forkhead box P3 (FOXP3, a specific marker for the regulatory T cells) is upregulated within rejecting grafts.Orthotopic lung transplantation was performed using miniature swine without immunosuppression. Rejection was monitored by chest radiography and open lung biopsy. Expressions levels of FOXP3, perforin, Fas-L and IP-10 mRNA were quantified in the peripheral blood. In addition, rescue immunosuppressive therapy (steroid plus tacrolimus) was administered on post-operative day (POD) 4 or 6.Early rejection was detected by open lung biopsy, but misdiagnosed by chest radiography on POD 4. Expression of FOXP3 in the peripheral blood reached its highest value as early as POD 4, followed by a decline. Such an increase of FOXP3 was not observed in recipients given high-dose tacrolimus. Neither perforin, Fas-L or IP-10 in the peripheral blood exhibited significant fluctuations in the early phase of rejection. Rescue immunosuppressive therapy from POD 4, when peak FOXP3 was seen, prolonged graft survival (27.2 days, versus 9.1 days without immunosuppression, p0.001), in contrast to POD 6, when rejection was suspected by chest radiography (11.5 days, p = not statistically significant [NS]).In a miniature swine lung transplantation model, the FOXP3 mRNA level in the peripheral blood was upregulated at an early phase of rejection. The clinical implication of this finding remains to be elucidated.

suprahyoid release法を併用し気管管状切除術と同再建術を施行した気管腺様嚢胞癌の1例を経験したので報告する．症例は54歳男性．半年以上遷延する呼吸困難にて近医を受診．胸部X線写真， 胸部CT，呼吸機能検査にて中部気管腫瘍を指摘されたため，当院紹介受診．腫瘍針吸引生検にて気管腺様嚢胞癌の診断を得，suprahyoid release法を併用し，気管管状切除術（7ring 3.5cm）と同再建術を施行した．吻合部への張力を軽減するため，術後2週間前胸部と下顎を糸で固定し，術後4週間は調節式頸椎装具を着用した．術後気管支鏡検査では，気管吻合部に問題は認めなかった．suprahyoid release法は技術的に簡便で，気管切除術とその再建術に有用であった．

After lung transplantation, early detection of acute allograft rejection is important not only for timely and optimal treatment, but also for the prediction of chronic rejection which is a major cause of late death. Many biological and immunological approaches have been developed to detect acute rejection; however, it is not well known whether lung mechanics correlate with disease severity, especially with pathological rejection grade. In this study, we examined the relationship between lung mechanics and rejection grade development in a rat acute rejection model using the forced oscillation technique, which provides noninvasive assessment of lung function. To this end, we assessed lung resistance and elastance (RL and EL) from implanted left lung of these animals. The perivascular/interstitial component of rejection severity grade (A‐grade) was also quantified from histological images using tissue fraction (TF; tissue + cell infiltration area/total area). We found that TF, RL, and EL increased according to A‐grade. There was a strong positive correlation between EL at the lowest frequency (Elow; EL at 0.5 Hz) and TF (r2 = 0.930). Furthermore, the absolute difference between maximum value of EL (Emax) and Elow (Ehet; Emax − Elow) showed the strong relationship with standard deviation of TF (r2 = 0.709), and A‐grade (Spearman's correlation coefficients; rs = 0.964, P < 0.0001). Our results suggest that the dynamic elastance as well as its frequency dependence have the ability to predict A‐grade. These indexes should prove useful for noninvasive detection and monitoring the progression of disease in acute rejection., After lung transplantation, early detection of acute allograft rejection is important for both in timely treatment and prediction of chronic rejection which is a major cause of late death. We examined the relationship between lung mechanics and rejection grade development in a rat acute rejection model using the forced oscillation technique, which provides noninvasive assessment of lung function. Our results suggest that the dynamic elastance as well as its frequency dependence reflect the perivascular‐interstitial component of rejection severity grade (A‐grade), and this method should prove useful for noninvasive detection and monitoring the progression of disease in acute rejection.

Combined pulmonary fibrosis and emphysema (CPFE) is a unique disorder that is usually diagnosed on the basis of high resolution computed tomography (HRCT) findings. It is unclear whether CPFE is an independent prognostic factor in patients with non-small-cell lung cancer (NSCLC). Therefore, we conducted a retrospective analysis to assess the impact of CPFE on the prognosis of patients with completely resected NSCLC.We retrospectively reviewed 365 patients diagnosed with NSCLC who underwent complete resection at the Tazuke Kofukai Medical Research Institute, Kitano Hospital between January 2007 and December 2012. Patients were classified into four groups according to chest HRCT findings: those with CPFE, those with fibrosis, those with emphysema or those with a normal lung except for the presence of a tumour. We evaluated disease-free survival (DFS) and overall survival (OS) using the two-tailed log-rank test and the Cox proportional hazards model.The two-tailed log-rank test demonstrated that the four groups had significantly different DFS and OS (P0.01). In the multivariate analysis, CPFE was found to be an independent prognostic factor for DFS and OS compared with a normal lung [hazard ratio (HR): 2.52; 95% confidence interval (CI): 1.24-5.13; P = 0.01 and HR: 4.53; 95% CI: 1.91-10.7; P0.01, respectively].CPFE is a significant, unfavourable prognostic factor for NSCLC patients after curative resection.

An increased mean platelet volume (MPV) is an early marker of platelet activation. MPV was also shown to be associated with the pathophysiological characteristics of various types of cancer. A previous study demonstrated that MPV was significantly associated with the overall survival (OS) of patients with advanced non-small-cell lung cancer (NSCLC). However, there has been no analysis of the prognostic effect of MPV on patients with resected NSCLC. The aim of this study was to evaluate the contribution of MPV to the survival of patients with completely resected NSCLC. We retrospectively analyzed 308 consecutive patients with NSCLC who underwent curative resection at Kitano Hospital. The associations between MPV and clinicopathological factors were assessed. We also evaluated the effect of MPV on survival, using the two-tailed log-rank test and the Cox proportional hazards model. A MPV value of 8.50 fl was considered to be the optimal cut-off value for prognosis. A low MPV was not associated with any other clinicopathological factors. The two-tailed log-rank test demonstrated that patients with a low MPV experienced a shorter disease-free survival (DFS) and overall survival (OS) (P=0.011 and 0.001, respectively), compared to those with a high MPV. The multivariate analysis demonstrated that a low MPV was an independent unfavorable prognostic factor for DFS and OS [hazard ratio (HR)=1.713; 95% confidence interval (CI): 1.070-2.742, P=0.025; and HR=2.835; 95% CI: 1.304-6.163, P=0.009, respectively)]. Therefore, we demonstrated that a low MPV predicted an unfavorable prognosis in patients with NSCLC following curative resection.

症例は22歳,男性.腹痛,便秘を主訴に当科受診.生後2週間目で腸穿孔に対して手術施行.その後人工肛門造設・閉鎖術施行されているが詳細は不明.原因精査のため注腸造影施行し,嚢状に拡張したS状結腸を認めた.下部消化管内視鏡および内視鏡下造影にて同部位の管腔内に郭壁様の構造を認め,隔壁に2箇所の瘻孔を認めた.先天性巨大結腸症の可能性も考慮し拡張部分のendscopic mucosal resection (EMR) 施行したが, acetylcholinesterase (Ach-E) 染色では神経叢の分布に異常を認めなかった.以上よりS状結腸重複症を疑い, S状結腸切除術を施行.病理組織学検査では,拡張部分の粘膜に円柱上皮を認め,正常腸管と連続する平滑筋組織を認めた.消化管重複症は多くが幼少児期に発見され,成人(15歳以上)で発見されるのは比較的稀である.

症例は62歳の男性で, 2003年8月閉塞性黄疸・急性胆管炎のため前医を受診し, 当院へ紹介された. 初診時に, 経鼻胆道ドレナージチューブから粘液塊を含む胆汁排出を認めた. 腹部CTで, 下部胆管に胆管閉塞を伴う腫瘤像を認め, 肝S4に内部に充実性部分を伴う3.5cm大の嚢胞性病変を認めた. 胞性病変は, 胆管造影で胆管との交通を認め, 経皮経肝胆道鏡では嚢胞内腔壁にイクラ状の不整粘膜を認めた. 以上より, 粘液産生肝内胆管癌と下部胆管癌の重複癌と診断し, 2003年10月に肝左葉尾状葉切除, 膵頭十二指腸切除を施行した. 病理組織学的には, 肝内病変は豊富な粘液産生を示す乳頭腺癌であった. 下部胆管病変は高分化管状腺癌であった. 両病変間に連続性はなく, 最終的に粘液産生肝内胆管癌と肝外胆管癌の同時性重複癌と診断した. 患者は術後15か月現在, 無再発生存中である. 肝内胆管と肝外胆管の同時性重複癌の報告は初めてである.

A 47-year-old woman was admitted with recurrent pneumothorax. Preoperative chest computed tomography (CT) showed multiple lung nodules and cysts bilaterally. She had undergone enucleatic myomectomy 12 years earlier. Video-associated thoracoscopic biopsy was performed. Histopathologically, there were bulla-like dilated cystic changes, the walls of which showed spindle cell proliferation, causing pneumothorax. Hormone therapy was started after benign metastasizing leiomyoma resection; pneumothorax has not recurred in 7 months. Multiple residual lung nodules have decreased or disappeared on CT.

The expression of COX-2 participates strongly in polyp formation of adenomatous polyposis coli (APC)-mutated mice. However, the mechanism of growth inhibition by COX-2 inhibition remains unclear. The aims of this study were to assess the role of COX-2 during the process of polyp formation in APC(Delta474) knockout mice. Starting at 4 weeks of age, the treated group (T group) were given a diet containing JTE-522, a selective COX-2 inhibitor, and the control group (C group) were given a control diet. At 12 weeks of age, mice were killed and polyps located in a proximal 10 cm of the small intestine were classified into two morphological stages: large adenomas (>300 microm in diameter) which lacked normal villous structure, and small adenomas (

We experienced an extremely rare case of a thymoma in the middle mediastinum. A 42-year-old woman presented with a 4-cm-sized abnormal mass in the middle mediastinum by chest computed tomography. To resect this tumor, we performed surgery using the thoracoscopic lateral approach from the right side subsequently followed by a median sternotomy. After the resection of this tumor, the intraoperative quick pathological examination diagnosed this tumor as a thymoma. An extended thymectomy was performed additionally.

Objectives: To clarify prognostic factors in resected pathologic (p-) T1-2N1M0 non-small cell lung cancer (NSCLC). Methods: A total of 95 consecutive patients who underwent complete tumor resection and mediastinal dissection for pT1-2N1M0 NSCLC between 1976 and 1997 were retrospectively reviewed. p53 status and proliferative activity were evaluated immunohistochemically. Results: The extent of N1 stations and p53 status proved to be significant prognostic factors. The 5-year survival rate for tumor without hilar node (#10) involvement was 66%, significantly higher than that for tumor with #10 involvement (39%, P , 0:01). The 5-year survival rate for tumor with aberrant p53 expression was 37%, significantly lower than that for tumor without aberrant p53 expression (74%, P , 0:01). There proved to be no significant difference in the prognosis between pT1 disease and pT2 disease; the 5-year survival rates for pT1 and pT2 diseases were 62 and 56%, respectively. Age, gender, performance status, grade of tumor differentiation, histological type, or proliferative activity were not significant factors. Multivariate analysis of prognostic factors using Cox’s proportional hazard model confirmed these results. Conclusions: Involvement of the hilar node and aberrant p53 expression were significant factors to predict a worse prognosis in resected T1-2N1M0 NSCLC. q 2001 Elsevier Science B.V. All rights reserved.

Reversible left ventricular wall motion abnormalities mimicking myocardial infarction have been reported in patients with a noncardiac illness. Their coronary angiograms do not demonstrate organic stenosis or epicardial coronary vasospasm. In this article, two cases of reversible left ventricular contraction abnormality are presented. Electrocardiography showed deep inverted T waves in precordial leads, and the echocardiography revealed diffuse akinesis of the apical region in the acute phase. Coronary angiography showed no significant stenosis or occlusion in either patient. Thallium scintigraphy showed no defect, while the metaiodobenzylguanidine scintigraphy demonstrated significant defects in the apex. The relative coronary flow reserve ratio, measured with an intracoronary Doppler flow wire, was significantly reduced in both patients. Myocardial contrast echocardiography revealed a reversible perfusion defect in the apex in the acute phase in case 2. Transiently impaired coronary microcirculation was thought to be involved in the pathogenesis of the reversible left ventricular dysfunction observed in these patients.

Azygos vein aneurysm is very rare and most cases are detected incidentally. We report a safe resection of azygos vein aneurysm by video-assisted thoracoscopic surgery (VATS) under preoperative evaluation of thrombus by multidetector computed tomography (MDCT). A 60-year old woman presented to our department due to a mediastinal mass revealed by enhanced CT. A dynamic enhanced-CT scan showed a dilated azygos vein with great enhancement in the early phase. Under the diagnosis of azygos vein aneurysm, we analysed the aneurysm by MDCT and confirmed that there was no thrombus within the aneurysm. The resection of the aneurysm by VATS was performed safely. She was discharged 4 days after surgery.

Objective: To clarify results of surgery for non-small cell lung cancer (NSCLC) based on the new tumor-node-metastasis (TNM) classification revised in 1997 and its time trend. Methods: A total of 921 patients operated from 1980‐1994 were retrospectively reviewed. For analysis of time trend, they were grouped into three periods by the year of operation (period (1): 1980‐1984, period (2): 1985‐1989, and period (3): 1990-19-94). Results: Concerning patients’ characteristics, recent increase in the ratio of patients whose tumor was discovered at mass screening (31% in period (1), 40% in period (2), and 50% in period (3)), and increase in the ratio of p-stage IA patient (16, 20, and 29%, respectively) were marked. Decrease in the ratio of operation-related death and the ratio of exploratory thoracotomy was significant. Concerning level of operation, decrease in the ratio of pneumonectomy, increase in the ration of sublober resection and that of tracheal or bronchoplastic procedures were significant. Postoperative survival for all patients was significantly better in period (2) or (3) than that in period (1); no significant difference was demonstrated between period (2) and (3) (5-year survival rates: 35% for period (1), 56% for period (2), and 56% for period (3)). Stratified p-stage, improvement of postoperative survival in recent years was demonstrated in p-stage IIA, IIB, IIIA, and IIIB diseases. Conclusions: Postoperative survival for all NSCLC patients has been improved with significant increase of earlystage (p-stage IA) patients. Concerning level of resection, recent increase in patients who underwent sublobar resection and bronchoplastic procedures was marked. q 2000 Elsevier Science B.V. All rights reserved.

Mycobacterium xenopi (M. xenopi) による呼吸器感染は本邦では極めて稀な非定型抗酸菌症である.肺癌を疑う結節状陰影を呈し手術によりM.xenopi感染症と診断された一症例を報告する.患者は51歳, 男性.重喫煙者で気腫肺であった.自覚症状はなく胸部X線とCTで右肺尖部に複数の空洞を伴う結節を認めた.喀疾検査, 気管支鏡下諸検査からも確定診断が得られなかった.Fluorodeoxyglucosepositron emission tomography (FDG-PET) で集積を認めたため肺癌が否定できず右肺上葉部分切除術を施行した.術中迅速診断で悪性所見を認めず, 肺結核腫を疑う乾酪壊死を伴った肉芽腫であった.術後, DNA-DNA hybridization法を用いてM.xenopi感染症と診断され, 約3ヵ月間の化学療法を行った.術後6ヵ月の現在も再発を認めず, 経過良好である.

背部刺創による脾損傷が腹腔内出血を全く来さず緊張性血胸のみを来した興味ある外傷性横隔膜ヘルニアの1例を経験したので報告する.症例は20歳, 男性.1996年7月, ガラス戸に倒れ込んだ際にガラス片が背部に刺さり, 呼吸困難となったため近医を受診.胸腹部X線, CT検査にて左血胸と診断され, 当科へ緊急入院となった.来院時, 緊張性血胸によるプレショック状態であり, 緊急手術を施行した.左低位後側方切開にて開胸すると, 胸腔内に約3, 000mlの血液を認めた.出血源を検索すると, ガラス片により損傷を受けた脾臓が, 横隔膜裂傷部より胸腔内へ脱出嵌頓した状態で出血していた.しかし, 腹腔内出血は全く認めなかった.脾摘を行い, 横隔膜は直接縫合し修復した.術後経過は良好で, 術後12日目に軽快退院した.