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A 77-year-old man was referred to our hospital for abnormal thoracic radiographs. Computed tomography (CT) revealed a 20-mm subpleural ground-glass opacity in the right S 6 area. A CT-guided biopsy revealed lung adenocarcinoma. Fluorodeoxyglucose-positron emission tomography revealed multiple abnormal bone accumulations, and a subsequent biopsy of a left iliac bone lesion revealed chronic lymphocytic leukemia. A right lower lung lobectomy was performed for the lung adenocarcinoma (cT1bN0M0, stage IA2). An aggressive biopsy of the bone lesion confirmed a rare case of double primary malignancies, which determined the patient's treatment and outcomes.

Purpose: Smoking is reported to be a risk factor for postoperative complications. However, there is no consensus regarding the length of time for which patients need to give up smoking. Therefore, we examined the relationship between preoperative smoking status and postoperative complications in patients who underwent lobectomy for treatment of lung cancer., Methods: Between January 2009 and December 2014, 1380 patients underwent lobectomy for lung cancer at our institution. After excluding patients who had undergone induction therapy, 1248 patients were enrolled in this study. We examined the relationship between postoperative complications and preoperative smoking habitation., Results: Among the enrolled patients, 1210 (97%) underwent video-assisted thoracoscopic lobectomy and 38 (3%) underwent lobectomy via open thoracotomy. The incidence of postoperative complications was higher in smokers than in nonsmokers, and the frequency of respiratory-related complications increased along with the number of pack-years. However, there was no relationship between the length of the preoperative smoking cessation period and the frequency of postoperative complications., Conclusion: The risk of postoperative complications does not increase even if smoking is continued within 2 weeks before surgery. It seems unnecessary to delay the timing of surgery to allow patients to cease smoking, especially those scheduled for thoracoscopic surgery.

Objectives: When induction therapy followed by surgery for locally advanced non-small cell lung cancer results in pathological complete response, the prognosis is excellent; however, relapses can occur. We analyzed the predictive factors for achieving pathological complete response and reviewed the clinicopathological features and surgical outcomes of locally advanced non-small cell lung cancer with pathological complete response., Methods: Between March 2005 and January 2015, 145 resections after induction therapy for locally advanced non-small cell lung cancer were performed; 38 cases achieved pathological complete response. Predictive factors for achieving pathological complete response were analyzed, and the clinicopathological features and surgical outcomes of 38 cases with pathological complete response were retrospectively reviewed., Results: Of 145 patients, 98 underwent induction chemoradiation and 47, induction chemotherapy. Squamous cell carcinoma occurred most frequently (n = 64), followed by adenocarcinoma (n = 53). Only squamous cell carcinoma was positively associated with achieving pathological complete response (p = 0.009). Of 38 patients with pathological complete response, 33 were men and the mean age was 67.0 ± 6.3 years; the clinical stages were IIA (n = 3), IIB (n = 2), IIIA (n = 26), and IIIB (n = 3). One patient died within 30 days post-surgery (2.6%). Eight recurrences occurred during the follow-up period; brain metastasis occurred most frequently. The 5-year overall and recurrence-free survival rates were 79.5% and 72.6%, respectively., Conclusions: Squamous cell carcinoma was identified as a positive predictive factor for achieving pathological complete response. Among patients undergoing lung cancer surgery after induction therapy with pathological complete response, brain metastasis occurred most frequently.

The purpose of this study was to investigate the dependence of volume dose indices on dose calculation algorithms for volumetric modulated arc therapy (VMAT) for stereotactic body radiotherapy (SBRT) plans to treat peripheral lung tumors by comparing them with those of Monte Carlo (MC) calculations. VMAT-SBRT plans for peripheral lung tumors were created using the Eclipse treatment planning system (TPS) for 24 patients with nonsmall cell lung cancer. VMAT dose distributions for gross tumor volume (GTV), internal target volume (ITV), and planning target volume (PTV) were calculated using the analytical anisotropic algorithm (AAA), the Acuros XB (AXB) algorithm, and a MC algorithm. VMAT dose distributions of the 3 algorithms were compared using their volume dose indices from dose volume histograms (DVHs), a dose difference map, and 3-dimensional gamma analysis. The DVHs for GTV and ITV from AAA, AXB, and MC were in good agreement. The difference between the ITV and PTV volume dose indices from AAA and MC increased as D 98 , D 95 , D 80 , D 50 , and D 2 . In particular, the difference between D 98 for PTV from AAA and MC was up to 48%. A >5% difference between D 95 for PTV from AAA and MC was 11 patients, but only 2 patients for ITV. The volume dose indices for AXB were near those of MC. AAA tended to overestimate the PTV volume dose indices compared to AXB and MC. Thus, we propose that the volume dose indices for the ITV be used because they are independent of dose calculation algorithms., (Copyright © 2018 American Association of Medical Dosimetrists. All rights reserved.)

Background:  In the eighth edition of the TNM classification, the lung tumors that have the same solid components are categorized either as part-solid or pure-solid tumors. However, this is debatable since the tumors in the same T component categories were evaluated without considering this categorization, and was based on a more malignant behavior and a poorer prognosis of pure-solid tumors. The aim of this study was to investigate and compare the prognosis between part-solid and pure-solid tumors., Methods:  We retrospectively analyzed 530 patients who were diagnosed with clinical-T1a-cN0M0 non-small-cell lung cancer (NSCLC) and were treated surgically. The subjects were divided into part-solid and pure-solid tumor groups using thin-section computed tomography. The prognosis was compared between the groups., Results:  Although relapse-free survival (RFS) was significantly shorter in the pure-solid tumor group ( p  = 0.016), no significant differences were observed in the overall survival (OS) between the two groups ( p  = 0.247). In 137 propensity score-matched pairs, including variables such as age, gender, Brinkman index, body mass index, forced expiratory volume in 1 second/forced vital capacity, Charlson comorbidity index, carcinoembryonic antigen levels, clinical-T status, surgical procedure, and extent of surgery, no significant differences were seen in the RFS and OS between the two groups ( p  = 0.709 and p  = 0.517, respectively)., Conclusion:  In the eighth edition of the TNM classification of clinical-T1a-cN0M0 NSCLC, the prognosis of part-solid and pure-solid tumors showed no significant differences. Solid component size of the tumor is considered important prognostic factor in early-stage NSCLC., Competing Interests: The authors declare that they have no actual or potential conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Although surgical resection after induction therapy (IT) for locally advanced non-small cell lung cancer (NSCLC) is a possible treatment option, pneumonectomy may be avoided owing to high-surgical risks. However, reports exist that pneumonectomy after IT has acceptable safety and favorable outcomes. We reviewed pneumonectomies after IT in terms of surgical outcomes, perioperative management, and complications., Methods: Between April 2004 and March 2015, 15 consecutive pneumonectomies were performed for locally advanced NSCLC after IT. Surgical outcomes, perioperative management, and complications were retrospectively reviewed., Results: Thirteen patients were men, and 6 pneumonectomies were right-sided. One pneumonectomy was performed after induction chemotherapy and 14 followed induction chemoradiation. In all 15 cases the bronchial stumps were covered with autologous tissues. Pedunculated mediastinal fat pad and pedunculated intercostal muscles were used in 4 and 11 cases, respectively. Although postoperative complications were seen in 12 patients (80.0%), with major complications (Clavien-Dindo classification ≥ IIIa) in 5 patients (33.3%), there were no deaths within 30 days after pneumonectomy. Overall 3- and 5-year survivals were 80.0 and 57.1%, respectively., Conclusions: Owing to high-surgical risks and complication rates, careful surgical technique and postoperative management are essential for successful pneumonectomy after IT.

Background Although thoracoscopic surgery is widely performed for early-stage lung cancer, only a few small studies have evaluated the role of video-assisted thoracoscopic surgery in patients with locally advanced lung cancer who had received preoperative chemotherapy. Methods Among 1655 patients who underwent anatomical lung resection for lung cancer between January 2009 and December 2014 in our institution, we retrospectively examined the short- and long-term outcomes of 110 (6.6%) who had undergone induction therapy. Thoracoscopic surgery was performed in 79 of these patients and thoracotomy in 31. Results In the thoracoscopic group, conversion to a thoracotomy was required in 4 patients. More combined resections were included in the thoracotomy group, and combined resection of large vessels or the carina was carried out only via a thoracotomy. Postoperative complications of grade 3 or above were found in 15 (13.6%) patients, and there was no significant difference in the incidence of postoperative complications between the 2 groups. The 3- and 5-year survival rates for the patients overall were 58.6% and 50.3%, respectively. Although there was no significant difference in overall outcome between the 2 groups, the patients with postoperative ypN2 status in the thoracoscopic group had a significantly better outcome than those in the thoracotomy group. Conclusion Although video-assisted thoracoscopic surgery was not suitable for central advanced lung cancer requiring angioplasty or carinal resection, it seems to be useful for patients with locally advanced lung cancer who had undergone induction therapy, especially patients with peripheral lung cancer and mediastinal lymph node metastasis.

Objective: The aim of this study is to investigate the outcomes of induction chemoradiotherapy (ICRT) followed by surgery in patients with non-small cell lung cancer( NSCLC)., Methods: We retrospectively analyzed consecutive patients with NSCLC who underwent ICRT followed by surgery at our hospital between January 2006 and December 2015., Results: A total of 102 patients were eligible for evaluation (cStage/I B/II A/II B/III A/III B, 1/8/14/75/4). The median age was 66 years. Forty-one patients had adenocarcinoma, 42 patients had squamous cell carcinoma, and 19 patients had others. The regimen consisted of carboplatin and paclitaxel in 94 patients, and the others in 8 patients plus concurrent radiation at a dose of 28 Gy in 1 patient, 30 Gy in 28 patients, 40 Gy in 42 patients, 45 Gy in 3 patients, and 50 Gy in 28 patients. Major response was obtained in 84 patients. Grade 3/4 toxicity of ICRT reported in 57 patients. The 5-year relapse-free and overall survival rate was 51.4% and 62.7%, respectively., Conclusion: ICRT (carboplatin and paclitaxel plus concurrent standard radiation) followed by surgery in NSCLC can be safely performed and may contribute to satisfactory outcomes in locally advanced NSCLC. It is likely that 28~50 Gy radiation dose contributes to satisfactory outcomes in ICRT.

Background: Although the frequency of elderly patients undergoing surgery for lung cancer has been increasing, indications for surgery in elderly patients are still controversial. Low body mass index is a significant predictor of poor prognosis in elderly patients with various medical conditions. Then, we examined the long-term outcome of elderly patients who had undergone thoracic surgery for lung cancer, focusing especially on body mass index., Patients and Methods: Between January 2004 and March 2011, 1673 patients with lung cancer underwent surgical resection at our institution. Among these patients, we retrospectively examined 158 patients aged 80 years or older., Results: Perioperative morbidity and mortality rates were 41.8 and 1.3%, respectively. Among 149 patients who were completely followed up, 80 patients (53.7%) died. The overall postoperative survival rates at 3 and 5 years were 66.9 and 49.9%, respectively. Univariate analysis demonstrated that sex (female), smoking index (pack-years <20), histology (non-squamous cell carcinoma), pathological stage (stage I) and BMI (within normal BMI) were statistically significant factors associated with better outcome. Multivariate analysis revealed that patients with a low (<18.5 kg/m 2 ) or high (≥25 kg/m 2 ) body mass index had a significantly and poorer prognosis than patients with a normal body mass index., Conclusion: Body mass index is a more useful prognostic factor than other clinical factors including pathological stage in elderly patients. Because elderly patients with low and high body mass index have a significant poor prognosis, surgeons and pulmonologist should take this into account when consider surgical indication for such elderly patients.

Thoracoscopic S9-10 segmentectomy is more difficult than other segmentectomies because of the complexity of the peripheral pulmonary anatomies and the difficulty of dividing the intersegmental plane. In S9-10 segmentectomy, the intersegmental plane between segments S6 and S8 near the major fissure impedes division of the plane between segments S6 and S9-10, or S8 and S9-10. Dividing the intersegmental plane between segments S6 and S8 with stapling is difficult, because peripheral pulmonary anatomies are not exposed clearly. Herein, we describe the technique of stapler-based thoracoscopic S9-10 segmentectomy under indocyanine green fluorescence navigation., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 49-year-old man with left phrenic nerve paralysis caused by mediastinal tumor resection 28 years earlier was found to have a nodule in the right upper lobe. The right phrenic nerve was severed during right upper lobectomy but was reconstructed along with bilateral plication of the diaphragm. The patient was weaned from the ventilator during the daytime on postoperative day 13 and was discharged home on postoperative day 48. Three months postoperatively, chest fluoroscopic imaging showed recovery of movement of the right diaphragm. Nerve conduction studies showed improvement of function of the reconstructed right phrenic nerve., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background Adjuvant chemotherapy after complete surgical resection is currently the standard of care for patients with stage IB, II, or IIIA non-small-cell lung cancer. However, the generalizability of this treatment to elderly patients is controversial. We investigated the effects of adjuvant chemotherapy in patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer. Methods We retrospectively analyzed 246 consecutive patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer who underwent standard lung cancer surgery between January 2001 and December 2015. They were divided into 102 who had adjuvant chemotherapy and 144 who had none (control group). The outcomes were compared between the two groups, and prognostic factors were evaluated. Results Relapse-free survival and overall survival were significantly shorter in the control group than the chemotherapy group ( p = 0.006 and p = 0.008, respectively). In multivariable analyses, adjuvant chemotherapy was found to be an independent prognostic factor for relapse-free survival and overall survival (hazard ratio = 0.594, 95% confidence interval: 0.396-0.893, p = 0.012; and hazard ratio = 0.616, 95% confidence interval: 0.397-0.957, p = 0.031, respectively). After inverse-probability-of-treatment weighting adjustment using the propensity score for baseline characteristics, chemotherapy almost improved relapse-free survival and overall survival (hazard ratio = 0.652, 95% confidence interval: 0.433-0.981, p = 0.040; and hazard ratio = 0.657, 95% confidence interval: 0.429-1.004, p = 0.052, respectively). Conclusions Adjuvant chemotherapy improved the prognosis after standard lung cancer surgery in patients aged over 75 years with stage IB-IIIA non-small-cell lung cancer.

Background: Intratumoral lung abscess is a secondary lung abscess that is considered to be fatal. Therefore, surgical procedures, although high-risk, have sometimes been performed for intratumoral lung abscesses. However, no studies have examined the surgical outcomes of non-small cell lung cancer patients with intratumoral lung abscesses. The aim of this study was to investigate the surgical and survival outcomes of non-small cell lung cancer patients with intratumoral lung abscesses., Methods: Eleven consecutive non-small cell lung cancer patients with intratumoral lung abscesses, who had undergone pulmonary resection at our institution between January 2007 and December 2015, were retrospectively analysed. The post-operative prognoses were investigated and prognostic factors were evaluated., Results: Ten of 11 patients were male and one patient was female. The median age was 64 (range, 52-80) years. Histopathologically, 4 patients had Stage IIA, 2 patients had Stage IIB, 2 patients had Stage IIIA, and 3 patients had Stage IV tumors. The median operative time was 346 min and the median amount of bleeding was 1327 mL. The post-operative morbidity and mortality rates were 63.6% and 0.0%, respectively. Recurrence of respiratory infections, including lung abscesses, was not observed in all patients. The median post-operative observation period was 16.1 (range, 1.3-114.5) months. The 5-year overall survival rate was 43.3%. No pre-operative, intra-operative, or post-operative prognostic factors were identified in the univariate analyses., Conclusion: Surgical procedures for advanced-stage non-small cell lung cancer patients with intratumoral lung abscesses, although high-risk, led to satisfactory post-operative mortality rates and acceptable prognoses.

A 68-year-old man was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the nodule in the right upper lobe (S3), 17 mm in size. One month later, fluorodeoxyglucose-positron emission tomography (FDG-PET)/CT scanning revealed positive reaction in the right upper lobe lesion and new lesion close to another lobe. In addition, interloblar small nodules were detected, 5 mm and 7 mm in size. A transbronchial brush cytology by bronchoscopy was performed, and the microscopic findings demonstrated the presence of atypical cells, suspected adenocarcinoma. The video-assisted thoracoscopic surgery was performed to establish a diagnosis and a treatment. Histopathological examination showed no malignancy and organizing pneumonia with inflammation. In case of the PET-positive solitary nodule increasing in size, organizing pneumonia should be included in the differential diagnosis.

Objectives: Bronchial fistula is a severe complication after thoracic surgery. Although many methods of coverage using various autologous tissues including pedicled pericardial fat pad have been reported to be useful for the prevention of bronchial fistula, the ideal roles of these approaches and the coverage techniques yielding the best results still remain unclear. The clinical use of an autologous free fat graft has been reported in the various surgical fields including otolaryngology, orthopaedics and plastic surgery. Therefore, we have used a free pericardial fat pad (FPFP) as the material for covering the bronchial stump instead of a pedicled pericardial fat pad., Methods: Between January 2009 and December 2013, 1134 patients with lung cancer underwent pneumonectomy or lobectomy without bronchoplasty at our institution. Among them, 46 patients underwent bronchial stump coverage using a FPFP and we investigated the clinical results obtained retrospectively., Results: Bronchial fistula occurred in 5 patients during the study period. Although we performed bronchial stump coverage mainly in patients with several risk factors for bronchial fistula, no bronchial fistula developed in this group. To investigate the viability of the FPFP, we examined the fat tissue around the bronchial stump demonstrated by chest computed tomography retrospectively. Although fat tissue at the bronchial stump gradually decreased in size, it remained evident for 5 months and was identified in almost half of the patients even at 1 year after surgery., Conclusions: No bronchial fistula developed in the FPFP group. Although the FPFP is a free flap, it remains viable for many months after surgery and may contribute to good wound healing of the bronchial stump by offering a wet environment. A pericardial fat pad is easy to make, can be used anywhere in the thoracic cavity and may be useful for bronchial stump reinforcement., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Computed tomography (CT)-guided needle biopsy is a well-established and dependable procedure for the diagnosis of pulmonary lesions. Some tissue biopsy samples have loose cohesion and disintegrate into tiny pieces before formalin fixation. The purpose of this study was to assess the association between the fresh macroscopic appearance of samples obtained using CT-guided needle biopsy and the clinicopathological features of non-small cell lung cancer (NSCLC)., Methods: A total of 111 patients who underwent CT-guided lung needle biopsy at Osaka City University Hospital between May 2009 and May 2013 were enrolled. Macroscopic appearance was categorized as either loose or tight cohesion. Samples were evaluated using Azan staining to detect collagen fibers. The staining intensity was multiplied by the percentage of positive cells, and the specimen was categorized as having either low (<100) or high expression ( ≥100). Univariate and multivariate logistic regression models were used to evaluate significant covariates for tumor metastasis., Results: In the cohort of 111 patients, the diagnostic rates in loose and tight cohesions were 82.6% and 87.5%, respectively (p=0.509). In 60 patients diagnosed with NSCLC, Azan staining of collagen fibers was positive in 93.5% of the samples with tight cohesion and 28.6% of the samples with loose cohesion (p<0.001). In the multivariate logistic regression models, distant metastasis was significantly associated with loose cohesion (p=0.026)., Conclusions: These results suggest that the macroscopic appearance of CT-guided biopsy samples correlates with tumor metastasis in NSCLC.

Purpose: Intraoperative fine-needle aspiration biopsy (FNA) is one of the most important diagnostic tools for undiagnosed lung nodules suspected of being lung cancer; however, the sensitivity and safety of FNA, including the risk of intrapleural dissemination of cancer cells, have not been established., Methods: Between 2006 and 2008, 324 patients underwent lung resection for cancers located in the lung periphery. Intraoperative FNA for definite diagnosis was performed immediately after thoracotomy in 147 (45.4%) of these patients, but not in the other 177., Results: A diagnosis of lung cancer was obtained by the intraoperative FNA in 124 (84.4%) of the 147 patients. During a median follow-up of 55 months, pleural dissemination or malignant effusion ipsilateral to the operated side as the first recurrent site occurred in 11 (7.4%) of the 147 patients who underwent the needle biopsy and 10 (5.6%) of the 177 patients who did not. This difference was not significant (P = 0.5046)., Conclusion: Intraoperative FNA was safe and useful for the diagnosis of peripheral lung cancer and did not increase the risk of pleural dissemination in this series.

Purpose: To evaluate whether the combination of radiofrequency (RF) ablation and local injection of the immunostimulant Mycobacterium bovis bacillus Calmette-Guérin (BCG) induces systemic antitumor immunity., Materials and Methods: Japanese White rabbits with lung and auricle VX2 tumors were randomized into three groups: control (n = 8; no treatment), RF ablation only (n = 8; RF ablation to the lung tumor), and RF ablation with local BCG injection into the lung tumor (n = 8). Treatments were performed 1 week after tumor implantation. Survival was evaluated with Kaplan-Meier method and log-rank test. Weekly mean volume and specific growth rate (SGR) of auricle tumors were calculated, and comparisons were made by Mann-Whitney test., Results: Median survival of control, RF-only, and RF/BCG groups were 23, 41.5, and 103.5 days, respectively. Survival was significantly prolonged in the RF-only and RF/BCG groups compared with the control group (P = .034 and P =.003, respectively), but no significant difference was found between the RF-only and RF/BCG groups (P = .279). Only in the RF/BCG group was mean auricle tumor volume decreased 5 weeks after implantation. No significant difference in SGR was found between the control and RF-only groups (P = .959), but SGR in the RF/BCG group was significantly lower than in the control group (P = .005)., Conclusions: The combination of RF ablation and local injection of BCG resulted in distant tumor suppression compared with the control group, whereas RF ablation alone did not produce this effect. Therefore, the combination of RF ablation and local injection of BCG may induce systemic antitumor immunity., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

A 60-year-old woman was referred to our hospital because of an abnormal shadow in the chest roentgenogram. Chest computed tomography (CT) showed the mass with heterogeneous low attenuation in the right lower lobe (S6), 40 mm in size. Fluorodeoxyglucose-positron emission tomography (FDGPET)/CT scanning revealed slight positive reaction in the right lower lobe lesion. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Intraoperative finding showed the tumor was located between the left upper lobe and the left lower lobe, and the inflow of the vagal pulmonary branches. Histopathological examination showed no malignancy and neurinoma with a cystic formation derived from the vagus nerve.

Background: We present a case series of a palliative radiofrequency ablation (RFA) for the tumors that lead to the resolution of pain and motor function disorders. RFA is widely used on tumors in various organs and often reported in good outcome. There are some reports that RFA was performed as a palliative treatment but a few reports of RFA that performed for lung tumor as a palliative treatment. This case series includes two cases, palliative RFA for a sacrum and a lung tumor. The results of this case series presented that a palliative RFA is effective in improving the symptoms of patients., Case Presentation: Case 1. A 64-year-old Japanese woman with a chordoma at her sacrum presented with pain in her left leg and claudication. Though operations, radiation therapy and GS-TAE (gelatin sponge-transarterial embolization, via the L5 lumbar artery) were performed, the size of the tumor leading pain and claudication increased. RFA was performed for the sacral tumor, and these symptoms resolved one year after the procedure. Case 2. A 68-year-old Japanese man with a leiomyosarcoma at the apex of left lung presented with pain and motor function disorders of the left upper limb. Dissemination in the pleura was appeared after the operation for a leiomyosarcoma at the mediastinum. Though radiation therapy and a second operation were performed, the tumor at the apex of the left lung increased and pain and numbness of the left upper limb were appeared after the second operation. RFA was performed for the left lung tumor, and the symptoms resolved 3 months after RFA., Conclusion: RFA is effective as a palliative treatment and has a potential to salvage the patients from the symptoms of the tumors when conventional palliative treatments such as surgery, radiation therapy, and chemotherapy are difficult or contraindicated.

The validity of low-dose CT screening for lung cancer in heavy smokers was supported by the results of National Lung Screening Trials (NLST) conducted in the U.S.A. The present study investigated the appropriateness of the introduction of low-dose CT screening for lung cancer in Japanese smokers aged between 55 and 74 years old, in terms of cost-effectiveness and age. To examine changes in the shift from conventional chest radiography (CR) to low-dose CT (LDCT) screening for lung cancer, we estimated the incremental cost-effectiveness ratio (ICER) using Iinuma's mathematical model, and also conducted sensitivity analysis to determine the requirements for the introduction of a population-based screening. As the result, the incremental cost for one life-year saved was one million yen or lower when the costs of the screening were 8,000 and 6,000 yen and the recall rate was 10% for male and female smokers aged 55 to 59 years old, respectively. The recall rate was smaller when the interval between cancer screenings was two years, and the subjects were males. The higher the age of the subject, the smaller the incremental cost. In conclusion, at present, the mean cost of the LDCT test is approximately 10,000 yen in Japan. With a reduction in this cost by a few thousand yen, all Japanese smokers aged 55 to 74 years will be able to undergo LDCT screening for lung cancer annually.

Background: This study aimed to compare the outcomes of stereotactic body radiotherapy (SBRT) and surgery in elderly patients with cT1-2N0M0 non-small cell lung cancer (NSCLC)., Methods: Elderly patients (≥75 years) with cT1-2 (≤5 cm) N0M0 NSCLC who were treated with SBRT (n=35) or surgery (n=183) between January 2001 and December 2011 were analyzed., Results: The following radiation doses were administered: 48 Gy/4-6 fractions in 12 patients; 50 Gy/4-5 fractions in 20; and 60 Gy/8 fractions in 3. The following surgical methods were performed: pneumonectomy in 2 patients, lobectomy in 154, segmentectomy in 23, and wedge resection in 4. Patients in the SBRT group had a higher mean age, a worse performance status, and a lower percentage of forced expiratory volume in 1.0 s than those in the surgery group. The overall 5-year survival rates were 43.8% and 67.6% for the SBRT and surgery groups, respectively (p=0.057, log-rank test). Regarding tumor diameter, patients in the surgery group survived significantly longer than did those in the SBRT group (>20-mm tumors, p=0.027; >30-mm tumors p=0.043), whereas survival did not differ significantly between the groups for ≤20-mm tumors (p=0.982). Multivariate analysis confirmed the improved survival in the surgery group compared to the SBRT group for all tumors (p=0.034) and for >20-mm tumors (p=0.016)., Conclusions: Post-therapeutic survival among elderly patients might be better with surgery than with SBRT in NSCLC patients with tumors >20 mm., (Copyright © 2014 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

A 52-year-old man was diagnosed with lung adenocarcinoma in the left upper lobe (c-T1bN0M0). Preoperative bronchoscopy revealed a displaced anomalous B(1+2) arising from the left main bronchus. Multiplanar reconstruction computed tomography showed that the displaced B(1+2) was located behind the left main pulmonary artery, and the interlobar fissure was largely fused. Video-assisted thoracic surgery (VATS) left upper lobectomy was performed successfully. The "no-touch fissure" technique was efficient not only for avoiding accidental cutting of the displaced bronchus but also post-operative air leakage. This is the first reported case of VATS lobectomy for lung cancer associated with a displaced B(1+2).

A 70-year-old man was followed up at the surgery department of our hospital after colon polypectomy. It was pointed out that the level of carcinoembryonic antigen(CEA) was high at blood test. Chest computed tomography (CT) showed small nodule close to the pulmonary vein in the right lower lobe (S6-S10), 15 mm in size, in September 2011. Fluorodeoxyglucose-positron emission tomography( FDG-PET)/CT scanning revealed a positive reaction in the right lower lobe lesion. He was introduced to our department. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Histopathological examination showed no malignancy and chronic eosinophilic pneumonia(CEP).In a case of the solitary lung nodule patient with the past history of asthma or the atopic disease, CEP should be included in the differential diagnosis.

Purpose: To evaluate whether antitumor immunity is enhanced systemically by combining radiofrequency ablation (RFA) and local injection of an immunostimulant, OK-432., Materials and Methods: Experiments were approved by the institutional animal care committee. Experimental Japanese rabbits inoculated with VX2 tumors in the lung and the auricle were randomized into four groups of eight: control (supportive care), RFA (RFA of lung tumor), OK-432 (direct injection of OK-432 into lung tumor), and combination therapy (lung RFA and direct OK-432 injection into lung tumor). All procedures were performed 1 week after implantation of VX2 tumors (week 1). In addition, a VX2 tumor rechallenge test was performed in the RFA and combination therapy groups. Survival time was evaluated by means of the Kaplan-Meier method and by using the log-rank test for intergroup comparison. Mean auricle tumor volumes were calculated every week. Specific growth rates (SGRs) were calculated and compared by using the Mann-Whitney test., Results: The median survival times of the control, RFA, OK-432, and combination therapy groups were 23, 36.5, 46.5, and 105 days, respectively. Survival was significantly prolonged in the combination therapy group when compared with the other three groups (P <.05). The mean auricle tumor volume decreased only in the combination therapy group. The mean auricle tumor volumes of the combination therapy group from week 1 to week 7 were 205, 339, 264, 227, 143, 127, and 115 mm(3). SGR in the combination therapy group became significantly smaller than those in the other three groups (P < .05). In the rechallenge test, the volume of all reimplanted tumors decreased., Conclusion: Combining RFA with local injection of immunostimulant OK-432 may lead to indirectly activation of systemic antitumor immunity., (© RSNA, 2013.)

A 75-year-old woman was followed up at the urology department of our hospital after left nephrectomy for renal cell carcinoma. Chest computed tomography (CT) showed ground-glass opacity in the right lower lobe( S6), 6 mm in size, in December 2010. 3 months later, the tumor was enlarged and she was introduced to our department. Wedge resection was performed to establish giagnosis. Pathological diagnosis was atypical adenomatous hyperplasia( AAH) and many small spindle-shaped cell nests were found at the same tissue. Immunohistochemically, this nest was shown to be minute pulmonary meningothelial-like nodules(MPMNs). MPMNs are asymptomatic small pulmonary nodules incidentally found during pathologic evaluation of pulmonary specimens. Combinations of MPMNs with adenocarcinoma or AAH have been reported, and the genetic relation of MPMNs and AAH is suggested.

Objective: To establish a mouse xenograft model of metastatic prostate cancer (PCa) and investigate the relationship between metastasis and circulating tumor cells., Methods: Flow cytometry (FACS) was used to detect suitable PCa cells and markers for detecting circulating tumor cells in vivo. We orthotopically injected androgen receptor-positive and androgen-independent C4-2B PCa cells into 12 severe combined immunodeficiency (SCID) mouse prostates, including 1 vehicle control. We measured the serum prostate-specific antigen levels biweekly after tumor inoculation. Circulating tumor cells (CTCs) were measured qualitatively by fluorescent microscopy immediately after the mice were sacrificed. The mouse prostates and lungs were examined for tumor formation using immunohistochemistry because we found no apparent metastasis, except in the lung., Results: FACS analyses in vitro identified the marker, prostate-specific membrane antigen, and C4-2B cells to be appropriate for additional in vivo study. We confirmed that the serum prostate-specific antigen increase was dependent on time and prostate tumor weight in mice. Of the 11 mice, 6 could be used as the mouse PCa xenograft model. Fluorescent microscopy detected CTCs in the peripheral blood in 5 of the 6 mice constituting the PCa model. Human prostate-specific antigen expression was detected by immunohistochemistry in the prostates of all the mice and in the lung of 2 of the 6 mice, suggesting 2 mice with lung metastasis., Conclusion: We have shown the potential establishment of a mouse lung metastatic xenograft model of androgen receptor-positive and androgen-independent C4-2B PCa tumor. However, the present model requires improvement to be a more reproducible, accurate and complete experimental model. Additional study is necessary to verify the relationship between metastasis and CTCs., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: To retrospectively evaluate technical success, effectiveness, complications, patient survival, and prognostic factors with percutaneous radiofrequency (RF) ablation for pulmonary metastases resulting from hepatocellular carcinoma (HCC)., Materials and Methods: Thirty-two patients from six institutions were included, with a total of 83 pulmonary metastases treated in 65 sessions. RF ablation was always performed percutaneously with computed tomography (CT) guidance. Primary endpoints were technical success and technique effectiveness. Technique effectiveness was evaluated based on sequential follow-up CT images. Secondary study endpoints were complications, patient survival, and determination of prognostic factors. Complications were classified as major or minor. Prognostic factors were determined by analyzing multiple variables with the log-rank test., Results: Technical success rate was 100%. Primary technique effectiveness rates were 92% each at 1, 2, and 3 years. Major and minor complications occurred after 16 (25%) and 23 (35%) of the 65 sessions, respectively. The median follow-up period was 20.5 months. Overall survival rates were 87% at 1 year and 57% each at 2 and 3 years (median and mean survival times, 37.7 mo and 43.2 mo, respectively). Significantly better survival rates were obtained in cases of (i) no viable intrahepatic recurrence (P < .001), (ii) Child-Pugh class A disease (P < .001), (iii) absence of liver cirrhosis (P < .001), (iv) absence of hepatitis C virus infection (P = .006), and (v) α-fetoprotein level of 10 ng/mL or lower (P = .007) at the time of RF ablation., Conclusions: RF ablation appears effective, with an acceptable safety profile, in selected patients with pulmonary metastases resulting from HCC., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to retrospectively determine the local control rate and contributing factors to local progression after computed tomography (CT)-guided radiofrequency ablation (RFA) for unresectable lung tumor. This study included 138 lung tumors in 72 patients (56 men and 16 women; age 70.0 +/- 11.6 years (range 31-94); mean tumor size 2.1 +/- 1.2 cm [range 0.2-9]) who underwent lung RFA between June 2000 and May 2009. Mean follow-up periods for patients and tumors were 14 and 12 months, respectively. The local progression-free rate and survival rate were calculated to determine the contributing factors to local progression. During follow-up, 44 of 138 (32%) lung tumors showed local progression. The 1-, 2-, 3-, and 5-year overall local control rates were 61, 57, 57, and 38%, respectively. The risk factors for local progression were age (>or=70 years), tumor size (>or=2 cm), sex (male), and no achievement of roll-off during RFA (P < 0.05). Multivariate analysis identified tumor size >or=2 cm as the only independent factor for local progression (P = 0.003). For tumors <2 cm, 17 of 68 (25%) showed local progression, and the 1-, 2-, and 3-year overall local control rates were 77, 73, and 73%, respectively. Multivariate analysis identified that age >or=70 years was an independent determinant of local progression for tumors <2 cm in diameter (P = 0.011). The present study showed that 32% of lung tumors developed local progression after CT-guided RFA. The significant risk factor for local progression after RFA for lung tumors was tumor size >or=2 cm.

A 79-year-old woman underwent video-assisted thoracic surgery (VATS)-left S6 segmentectomy for left lung cancer (papillary adenocarcinoma, pT1N0M0, stage IA), and were followed-up at our hospital. Chest X-ray and chest computed tomography (CT) showed ground-glass opacity (GGO) with thin-walled cavity in the right S1, 3 cm in size and small nodule in the right S2, S3 at 1st operation. The shadow in S1 was not changed but nodular lesion in S2, S3 enlarged 7 months later. CT-guided biopsy revealed well differentiated adenocarcinoma VATS-right upper lobectomy was performed and both lesions were diagnosed as "adenocarcinoma with mixed subtypes (BAC : acinar type), synchronous multiple lung cancer one of which formed thin-walled cavity" histopathologically. The patient was discharged on 20th-postoperative day and alive without any signs of recurrence for 16 months post-operatively.

The aim of this study was to evaluate prospectively the early treatment response after CT-guided radiofrequency ablation (RFA) of unresectable lung tumours by MRI including diffusion-weighted imaging (DWI). The study protocol was approved by the ethics committee of our hospital and signed consent was obtained from each patient. We studied 17 patients with 20 lung lesions (13 men and 4 women; mean age, 69+/-9.8 years; mean tumour size, 20.8+/-9.0 mm) who underwent RFA using a LeVeen electrode between November 2006 and January 2008. MRI was performed on a 1.5T unit before and 3 days after ablation. We compared changes in the apparent diffusion coefficient (ADC) on DWI and response evaluation based on subsequent follow-up CT. 14 of the 20 treatment sessions showed no local progression on follow-up CT, whereas 6 treatment sessions showed local progression (range, 3-17 months; mean, 6 months). For the no-progression group, the ADC pre- and post-RFA were 1.15+/-0.31 x 10(-3) mm(2) s(-1) and 1.49+/-0.24 x 10(-3) mm(2) s(-1), respectively, while the respective ADC values for those that showed local progression were 1.05+/-0.27 x 10(-3) mm(2) s(-1) and 1.24+/-0.20 x 10(-3) mm(2) s(-1). The ADC of the ablated lesion was significantly higher than before the procedure (p<0.05). There was a significant difference in the ADC post-RFA between no-progression and local progression groups (p<0.05). Our prospective pilot study showed that the ADC without local progression was significantly higher than with local progression after RFA, suggesting that the ADC can predict the response to RFA for lung tumours.

The purpose of this study was to investigate whether surgical treatment for non-small cell lung cancer (NSCLC) confers a survival benefit in octogenarians, and whether video-assisted thoracic surgery (VATS) is effective in terms of postoperative morbidity, mortality, and quality of life (QOL). Among 1684 patients with primary NSCLC who underwent pathologically complete resection, 95 were octogenarians. Operation was performed by the VATS approach (VATS group, n=58) or the standard thoracotomy (ST group, n=37). Although postoperative cardiopulmonary complications occurred in 20 cases (21.1%), all were manageable. In the ST group cardiopulmonary complications occurred more frequently than in the VATS group (P=0.030). The overall 5-year survival rate of the 95 octogenarians, including deaths from all causes, was 54.4%. The overall 5-year survival rate of patients with stage IA disease was 65.2%. These outcome data were not significantly worse than those for patients aged 79 years or under (P=0.136). There was no significant difference in overall 5-year survival rates between the ST group and the VATS group (P=0.144). The VATS approach for pulmonary resection is recommended for octogenarians with NSCLC. Surgical resection is the optimal treatment for stage IA NSCLC, and therefore, advanced age is not a contraindication for curative resection.

Objective: The seventh TNM Classification of Malignant Tumours will be published in 2009. The International Association for the Study of Lung Cancer has proposed a revision of the current pathologic staging system. We illustrated the effects of this new system and pointed out potential problems using a retrospective study of surgical cases of non-small cell lung cancer at our institution., Methods: Subjects were 1532 patients for whom current pathologic staging was possible. These data were migrated into the new staging system. The numbers of patients at various stages determined by using the current and new staging systems were, respectively, as follows: IA (n = 700, n = 700), IB (n = 338, n = 249), IIA (n = 49, n = 164), IIB (n = 129, n = 116), IIIA (n = 204, n = 234), IIIB (n = 77, n = 17), and IV (n = 35, n = 52). Prognoses were compared by using the current and the new systems., Results: By using the new staging system, 5-year survivals by T classifications were as follows: T1a, 82.6%; T1b, 73.3%; T2a, 63.5%; T2b, 50.1%; T3, 40.6%; and T4, 34.6%. There were significant differences between the new T1a and T1b (P = .0026), T1b and T2a (P = .0027), and T2a and T2b (P = .0062) classifications. In the current system 5-year survivals based on pathologic stages were as follows: IA, 84.8%; IB, 72.9%; IIA, 53.8%; IIB, 53.7%; IIIA, 31.8%; IIIB, 34.0%; and IV, 27.1%. There were significant differences between stages IA and IB (P < .0001) and stages IIB and IIIA (P = .0006). In the new system these were as follows: IA, 84.8%; IB, 75.2%; IIA, 62.4%; IIB, 52.1%; IIIA, 32.4%; IIIB, 15.2%; and IV, 30.6%. There were significant differences between stages IA and IB (P = .0004), IB and IIA (P = .0195), IIA and IIB (P = .0257), IIB and IIIA (P = .0040), and IIIA and IIIB (P = .0399)., Conclusion: Although the outcomes for stages IIIB and IV were reversed, the new pathologic staging system was considered valid based on our single-institution evaluation.

We report 3 patients with lung cancer complicated with interstitial pneumonia who were treated by percutaneous computed tomography-guided radiofrequency ablation. Patient 1 recovered from a pneumothorax without chest drainage. Patient 2 presented with a progressive pneumothorax after discharge from the hospital and required readmission for air drainage. In patient 3, the pneumothorax did not improve by chest drainage and pleurodesis, and the patient died of acute exacerbation of interstitial pneumonia. Radiofrequency ablation of intractable lung cancer with complicating interstitial pneumonia requires careful consideration because a progressive pneumothorax may require surgical intervention or result in acute exacerbation of interstitial pneumonia.

A 56-year-old man visited another hospital complaining of hemoptysis. A chest radiograph showed expansion of the left upper mediastinum which seemed to be a mass-like lesion. He was referred to our hospital for further investigations. Before further examination, however, he presented to the emergency room with sudden onset of severe back pain. Rupture of a thoracic aortic aneurysm was suspected because of the clinical symptoms and the findings of emergency enhanced CT scanning. Emergency surgery was performed at the other hospital, and frozen section results indicated that the lesion was a non-small cell lung cancer. The pathology report of the surgical specimens revealed poorly differentiated adenocarcinoma of the lung with infiltration of the aortic wall. Postoperative chemotherapy was added, and the patient is doing well 10 months after operation. Some cases of tumor mimicking aortic aneurysm have been reported. We reported this case of lung cancer mimicking the rupture of a thoracic aortic aneurysm.

Purpose: The aim of this study was to evaluate the technical success, complications, and effectiveness of re-radiofrequency (re-RF) ablation for recurrent lung tumors previously treated with RF ablation., Materials and Methods: Reenlargement at the site of ablation seen on follow-up computed tomography (CT) is defined as local progression. CT-guided re-RF ablation was performed during 11 treatment sessions (mean tumor size 2.6 cm diameter) in 10 patients. The treated lesions consisted of five recurrences of primary lung cancer and six metastatic lung tumors from the esophagus (n = 2), bladder (n = 2), kidney (n = 1), and colon (n = 1)., Results: At 3 of the 11 treatment sessions there were no relapses; at 8 of the 11 sessions local progression was seen at a median of 7 months (range 3-17 months). The local progression rate was significantly higher for tumors > 2.5 cm (P < 0.05). Minor complications included pneumothorax not requiring drainage (n = 3), subcutaneous emphysema (n = 1), and self-limited hemoptysis (n = 2)., Conclusion: Re-RF ablation for lung tumors was feasible without any major complications. Although our study comprised only a few cases with a short follow-up period, patients with re-RF ablation were at higher risk of local progression.

The purposes of this study were to examine the usefulness of the biopsy of the sentinel lymph nodes (SNs) for the accurate and effective detection of lymph node micrometastasis in early lung cancer and to clarify the spread of lymph node micrometastasis. One hundred and thirty-three c-stage IA non-small cell lung cancer patients in whom SNs could be identified by radioisotope (RI) method were enrolled. All dissected lymph nodes were stained with cytokeratin AE1/AE3 for the examination of micrometastasis. A total of 1375 lymph nodes including 220 SNs were dissected from the 133 patients. From the 220 SNs, 35 (15.9%) were found to be positive for metastasis. Of the other 185 SNs negative for metastasis, 19 (8.6%) were positive for micrometastasis. When patients were limited to those with pN0, there were no lymph nodes positive for micrometastasis other than SNs. In pN1-2 patients, micrometastasis to non-SNs were observed in 2.3-13.2%. In patients with pN0, micrometastasis was limited to SNs, and the results of the examination of SNs for micrometastasis accurately represented those of the examination of all lymph nodes. With advancement of the stage, micrometastasis was not limited to SNs and showed an irregular distribution.

Objective: Postoperative recurrence is a major obstacle to achieving a cure and long-term survival in patients with non-small lung cancer. However, prognostic factors and the efficacy of therapy after recurrence remain controversial. We evaluated the clinical outcomes of patients with resected lung cancer for postrecurrence prognostic factors., Methods: Patients who underwent complete resection with systematic lymph node dissection for stage I non-small cell lung cancer were selected. Cases of low-grade malignancy, preoperative therapy, history of previous malignancy or death within 30 days of operation were excluded. A total of 397 patients were retrospectively reviewed., Results: Out of 87 patients who had recurrence after surgery, 45 had symptoms at the initial recurrence. The initial recurrent site was local in 30 patients and distant in 57. Single-site recurrence was detected in 48 patients and multiple-site recurrence was seen in 39. The recurrent site was the ipsilateral thorax in 49 patients, the contralateral thorax in 32, the cervico-mediastinum in 15, brain in 12 and bone in 11. Surgery was performed in 20 patients, whereas non-surgical therapy was performed in 55 (chemotherapy, 16; radiation therapy, 33; chemo-radiation therapy, 6). Prognostic analysis of factors related to recurrent status demonstrated that symptoms at the initial recurrence, cervico-mediastinal metastasis, liver metastasis and postrecurrence therapy were significant prognostic factors in both univariate and multivariate analysis., Conclusions: Symptoms at the initial recurrence, cervico-mediastinal metastasis and liver metastasis were worse prognostic factors after recurrence. Postrecurrence therapy for the initial recurrence may prolong survival after recurrence.

An 82-year-old woman was admitted to our hospital with cough and back pain. A chest radiograph showed a solitary nodular lesion in the right lower lung field. It was diagnosed by a transbronchial biopsy as lung metastasis of a papillary adenocarcinoma of the thyroid. However, her cervical CT and ultrasonography showed only a cyst in a right lobe of the thyroid, and its biopsy did not show evidence of malignancy. In addition, multiple bone metastasis and pituitary metastasis were revealed. We therefore diagnosed this case as systemic metastasis of papillary adenocarcinoma of the thyroid. She was given best supportive care and she died seven months later. Autopsy revealed two tiny lesions (3mm and 6mm) in the thyroid right lobe to be papillary adenocarcinoma. We report this case because occult thyroid cancer caused systemic metastasis and the chest X-ray showed lung metastasis from the thyroid cancer as a solitary nodular lesion.

We present a case of benign pediculate mucinous cystadenoma in a 60-year-old man. The tumor, which was connected with the lung parenchyma, was difficult to distinguish from a pleural tumor radiographically. Initially, computed tomographic-guided needle aspiration biopsy was performed to confirm the diagnosis, but this was unsuccessful. Therefore, surgical resection was performed to diagnose and treat the tumor, and pathologic examination of the specimen revealed mucinous cystadenoma. The problems associated with the diagnosis and treatment of pediculate mucinous cystadenoma are discussed in light of this case.

A 69-year-old man had undergone right S6 segmentectomy for lung cancer (poorly differentiated adenocarcinoma, pT2N0M0, stage IB). One years later, computed tomography (CT) showed abnormal shadow in the right paravertebral muscle of 7 x 5 cm in size. The patient underwent resection of the tumor. The tumor was white, solid and elastic hard mass. Histopathologically, the tumor was paravertebral muscle metastasis from lung cancer. The patient was discharged on 23rd postoperative day, but died of other disease after 1 and a half month postoperatively.

Objective: To retrospectively determine the frequency and risk factors of various side effects and complications after percutaneous computed tomography-guided radiofrequency (RF) ablation of lung tumors., Methods: We reviewed and analyzed records of 112 treatment sessions in 57 of our patients (45 men and 12 women) with unresectable lung tumors treated by ablation. Risk factors, including sex, age, tumor diameter, tumor location, history of surgery, presence of pulmonary emphysema, electrode gauge, array diameter, patient position, maximum power output, ablation time, and minimum impedance during ablation, were analyzed using univariate and multivariate analyses., Results: Total rates of side effects and minor and major complications occurred in 17%, 50%, and 8% of treatment sessions, respectively. Side effects, including pain during ablation (46% of sessions) and pleural effusion (13% of sessions), occurred with RF ablation. Minor complications, including pneumothorax not requiring chest tube drainage (30% of sessions), subcutaneous emphysema (16% of sessions), and hemoptysis (9% of sessions) also occurred after the procedure. Regarding major complications, three patients developed fever >38.5 degrees C; three patients developed abscesses; two patients developed pneumothorax requiring chest tube insertion; and one patient had air embolism and was discharged without neurologic deficit. Univariate and multivariate analyses suggested that a lesion located < or =1 cm of the chest wall was significantly related to pain (p < 0.01, hazard index 5.76). Risk factors for pneumothorax increased significantly with previous pulmonary surgery (p < 0.05, hazard index 6.1) and presence of emphysema (p <0.01, hazard index 13.6)., Conclusion: The total complication rate for all treatment sessions was 58%, and 25% of patients did not have any complications after RF ablation. Although major complications can occur, RF ablation of lung tumors can be considered a safe and minimally invasive procedure.

Percutaneous computed tomographic (CT)-guided radiofrequency (RF) ablation is a minimally invasive and promising procedure for unresectable lung tumors. In general, the procedure is safe and its complications are minor. A few cases of serious complications, however, have been reported. The authors report on a case of air embolism during electrode insertion into a metastatic lung tumor. The patient became unresponsive; however, he recovered 10 minutes later and the air embolism disappeared spontaneously. Although air embolism during RF ablation of a lung tumor is a rare complication, radiologists performing the percutaneous procedure should be aware of this complication and be familiar with the appropriate management.

A 62-year-old woman had undergone video-assisted thoracic surgery (VATS) -right upper lobectomy and right S8 segmentectomy for double lung cancers (papillary adenocarcinoma and bronchioloalveoler carcinoma, stage IA). Four years later, chest computed tomography (CT) showed abnormal shadow, 20 mm in size, along the staple-suture line. The 3 months later, new lesion, 15 mm in size, was observed in right lower lobe. CT-guided biopsy revealed no malignancy. The patient underwent partial resection of the right lower lobe and tumorectomy. The tumor was solid and cystic mass. Histopathologically, the tumor was granuloma infected by Mycobacterium avium. The patient was discharged on 17th postoperative day, and doing well without new lesion for 9 months postoperatively.

A 37-year-old man with von Recklinghausen's disease admitted to our hospital because of chest abnormal shadow. He had underwent extended radical tumorectomy for malignant peripheral nerve sheath tumor (MPNST) in left lower limb 33 months before. Chest X-ray and computed tomography (CT) scan revealed solitary tumor on right S10. Tumor was resected under thoracoscopic surgery. Histological diagnosis was metastasis of MPNST. MPNST with lung metastasis showing very poor prognosis. The patient is doing well 2 years after pulmonary resection without recurrence. Careful follow up is important for MPNST.

The population of patients with N1-stage II disease is small among non-small cell lung cancer patients and there have been relatively few studies regarding prognostic factors for the disease. We retrospectively evaluated the clinicopathological features of the disease to identify prognostic factors. The clinical records of 85 patients with N1-stage II non-small cell lung cancer who underwent lobectomy or pneumonectomy with systematic lymph node dissection or sampling were retrospectively reviewed. The study population comprised 64 men and 21 women, among whom 49 had adenocarcinoma, six had squamous cell carcinoma and two had large cell carcinoma. The prognosis was significantly better for p0 vs. p2-3 disease (P=0.029), pneumonectomy vs. lobectomy (P=0.027) and direct extension vs. metastasis to N1 lymph nodes (P=0.015). On the other hand, there was no significant difference in survival regarding the number or level of the involved lymph node stations. A multivariate analysis for prognostic factors revealed that status of lymph node involvement as well as gender and pleural factor was a significant independent prognostic factor (P=0.026). Our results have revealed that direct extension to N1 lymph nodes is an independent favorable prognostic factor as opposed to metastasis for surgically-treated patients with N1-stage II disease.

A 42 year old female was admitted to our hospital due to abnormal shadow on her chest X-ray. She had no symptoms. Chest X-ray and computed tomography (CT) scan revealed solitary nodule on left S10. Bronchofiberscopy was perfomed, but it could not establish pathological diagnosis. Thoracoscopic surgery was performed. It revealed that solitary nodule was Mycobacterium avium infection. Majority cases of Mycobacterium avium infection showed multiple nodules or infiltration shadows on bilateral lungs. But in our case, CT scan showed a solitary nodule, causing differential diagnosis from lung cancer to be difficult.