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We report on a 58-year-old man with an anomalous systemic artery to the basal segments of the left lung. The anomalous systemic artery originated from the descending thoracic aorta, distributed to the basal segments of the left lower lobe, and drained into the normal left inferior pulmonary vein. The pulmonary artery to the basal segments was not recognized. His bronchoscopic findings were normal. He underwent left lower lobectomy with division of the aberrant artery. The patient has remained well without any complications since surgery.

A 58-year-old male underwent right lung transplantation from a brain-dead donor, after which acute rejection developed that was resistant to steroid pulse therapy. Rabbit-derived anti-thymocyte globulin (rATG) therapy was successful for controlling the rejection. However, following that therapy, the patient was affected by an opportunistic infection and suffered from repeated empyema. It is important to pay attention to immunosuppressive agent levels in blood following treatment, because ATG is a potent immunosuppressive drug and its effects can continue for more than 6 months after administration.

Idiopathic pulmonary fibrosis (IPF) often accompanies lung cancer, and life-threatening acute exacerbation (AE) of IPF (AE-IPF) is reported to occur in 20 % of IPF patients who undergo lung cancer surgery. Pirfenidone is an anti-fibrotic agent known to reduce disease progression in IPF patients. A phase II study was conducted to evaluate whether perioperative pirfenidone treatment could reduce the incidence of postoperative AE-IPF patients with lung cancer. Pirfenidone was orally administered to IPF patients who were candidates for lung cancer surgery; pirfenidone was dosed at 600 mg/day for the first 2 weeks, followed by 1200 mg/day. Surgery was performed after at least 2 weeks of 1200-mg/day administration. The primary endpoint was non–AE-IPF rate during postoperative days 0–30, compared to the null value of 80 %, and the secondary endpoint was safety. Radiologic and pathologic diagnoses of IPF and AE-IPF were confirmed by an independent review committee. From June 2012 to January 2014, 43 cases were enrolled, and 39 were eligible (full analysis set [FAS]). Both pirfenidone treatment and surgery were performed in 36 patients (per protocol set [PPS]). AE-IPF did not occur in 37/39 patients (94.9 % [95 % confidential interval: 82.7–99.4 %, p = 0.01]) in the FAS, and in 38/39 patients (97.2 % [95 % confidential interval: 85.5–99.9 %, p = 0.004] in the PPS. A grade 5 adverse event (death) occurred in 1 patient, after AE-IPF; no other grade 3–5 adverse events were observed. Perioperative pirfenidone treatment is safe, and is promising for reducing AE-IPF after lung cancer surgery in IPF patients. This clinical trial was registered with the University Hospital Medical Information Network (UMIN) on April 16th, 2012 (Registration Number: UMIN000007774 ).

Background Thymic carcinoma (TC) is a rare type of malignant neoplasm that develops in the anterior mediastinum and associated with poor prognosis. Type B3 thymoma (B3) occasionally demonstrates malignant tumor characteristics, especially in the advanced stage. We investigated the expressions of tumor-related genes in resected TC and B3 specimens. Methods TC and B3 specimens resected from 1999 through 2012 were investigated. Tumor segments were collected from the specimens by micro-dissection to extract mRNA, then RT-PCR was performed according to Dannenberg’s tumor profile method for semi-quantitation of tumor-related gene mRNA. To compare with other types of cancer, data from lung cancer (LC) cases in our database were also examined. Results The gene expression levels of thymidylate synthase were significantly higher in TC and B3 as compared to LC specimens (p

Lung transplant recipients have an increased de novo cancer risk due to long-term immunosuppression and several oncogenic viral infections. In Japan, to date, there have been no national surveys of the incidence of de novo malignancy after lung transplantation.This national survey was conducted by the Japanese Society for Transplantation. The questionnaire was distributed to lung transplant institutions, asking about several clinical factors related to de novo malignancy patients transplanted from 2001 to 2010.179 cases of lung transplantation were performed by seven institutions in Japan between 2001 and 2010. De novo malignancies occurred in 18 patients (10.1 %). The most common malignancy was a lymphoproliferative malignancy (12 cases, including 1 double de novo cancer after tongue cancer), followed by cervical cancer (4 cases), breast cancer (2 cases), and tongue cancer (1 case). The mean time of occurrence after transplantation was 37.8 (range 4-148) months. Reduction and/or withdrawal of immunosuppression for the treatment of malignancy was seen in 14 cases. Death due to cancer occurred in 6 cases. The overall 5-year survival of 18 patients was 58.9 %. The 5-year survival of post-transplant lymphoproliferative disorder was not significantly different from that of other malignancies (47.6 and 62.5 %, respectively; p = 0.33).This is the first national survey of the incidence of de novo malignancy after lung transplantation in Japan. The incidence was 10.1 % and post-transplant lymphoproliferative disorder was the most common malignancy.

Local therapy for stage I non-small cell lung cancer (NSCLC) is divided into surgical and radiation treatment, and given to patients unable to tolerate a lobectomy. A prospective phase II study of cases that received stereotactic body radio therapy (SBRT) (JCOG0403) revealed an overall 3-year survival rate (3-YSR) of 76.0 %, 3-year relapse free survival rate (3-YRFS) of 69.0 %, and rate of morbidity of grade 3 or greater of 9 %. However, few prospective multicenter studies have reported regarding surgery for high-risk stage I NSCLC patients. We investigated this issue in the setting of a prospective multicenter observational study. Thirty-two high-risk NSCLC patients (30 males, 2 females; median age 74 years, 61–85 years) were analyzed. Two (6.3 %) showed morbidity of grade 3 or greater, though there were no postoperative deaths. The margin local control rate was 97.0 % (surgical margin recurrence, 1) and local recurrence control rate was 75.0 % (ipsilateral thorax recurrence, 8), while the 3-YSR and 3-YRFS was 79.0 and 75.9 %, respectively. A sublobar pulmonary resection for patients unable to tolerate a lobectomy with stage I NSCLC was shown to be safe and provided results comparable with those of SBRT.

The number of lung cancer patients is increasing in association with the aging of society, and age is associated with the risk of undergoing a thoracotomy procedure. We prospectively investigated the efficacy of a functional operability algorithm that included pulmonary function and exercise test results for determining the indication for surgery in octogenarians. From April 2001 to October 2008, surgical indications for a total of 45 octogenarians were assessed using our algorithm, including forced expiratory volume in 1 s/forced vital capacity ratio, predicted postoperative percent of forced expiratory volume in 1 s, Hugh-Jones dyspneic index, and empirical anaerobic threshold obtained during an exercise test. Then the surgical results were reviewed. Thoracotomy was contraindicated in one patient; the remaining 44 patients underwent surgery. Axilloanterior thoracotomy (75%), lobectomy (84%), and mediastinal lymph node dissection (73%) were the major procedures. Altogether, 37 postthoracotomy complica-Received: 13 February 2011 / Accepted: 30 May 2011 © The Japanese Association for Thoracic Surgery 2012 tions occurred in 29 (65.9%) patients. The 30-day and hospital mortality rates were 2.3% and 4.5%, respectively, and overall and disease-specific 5-year survival rates for the 42 patients were 54.5% and 79.6%, respectively. Following careful selection with our functional operability algorithm, octogenarians were able to tolerate a standard lung resection for primary lung cancer with acceptable morbidity and mortality. Their survival was consistent with that of younger cancer patients.

背景．進行・再発肺癌に対する薬物治療法としてEGFR遺伝子変異陽性例についてはゲフィチニブの使用が推奨されているが，いずれ獲得耐性化することが多い．症例．65歳，女性．背部痛を主訴に受診．胸椎腫瘍を認め可及的切除術を施行された．胸部CTでは左下葉に結節影を認めた．病理組織所見から肺腺癌の胸椎転移と診断された（cT1N0M1，c-stage IV）．CBDCA+PTX 2コース施行後，ゲフィチニブを導入，肺腫瘍の縮小が得られたが6年のあいだに腫瘍は緩徐ながら再増大傾向を示した．気管支鏡下肺生検を施行し腺癌が検出され，EGFR遺伝子検査にてT790M耐性遺伝子を認めた．遠隔転移巣は制御されている一方，原発巣がゲフィチニブ耐性化したものと判断し左下葉切除術を施行した．術後1年8か月現在無再発生存中である．結論．胸椎転移巣の手術後，ゲフィチニブにより長期制御が得られたが耐性獲得化したため，サルベージ手術を施行し良好な結果を得たIV期肺癌の1例を経験した．獲得耐性部位が原発巣のみに限局している場合には，IV期進行肺癌であっても外科療法を考慮すべき余地があると考える．

Carinal resection and reconstruction for lung cancer, termed carinaplasty, is a rare operation, and the procedure remains challenging and few reports have been presented. We analyzed complications, local control, and manner of recurrence in patients who underwent a carinaplasty and compared the results to those who underwent an ordinary bronchoplasty. Among 766 patients who underwent surgery for primary lung cancer at our institutions, 82 bronchoplasty procedures were performed, while 6 of those who received a bronchoplasty underwent a carinaplasty. Three of 6 patients who received a carinaplasty underwent the montage method, and other 3 patients underwent the one-stoma method. There were no operative deaths in patients who underwent a carinaplasty, while there was 1 operative death in the group of patients who underwent an ordinary bronchoplasty. Complications in the anastomotic site were observed in 33% in the carinaplasty group and 5.3% in the ordinary bronchoplasty group (P=0.011). There was no significant difference in regard to local recurrence between the groups (P=0.620). In conclusion, our results show that a carinaplasty is a technically demanding but useful procedure to avoid a pneumonectomy in patients with locally advanced lung cancer.

We report a rare case of sarcoidosis that developed during induction chemotherapy for primary lung cancer, mimicking progressive disease. A 63-year-old man had an abnormal shadow in the right upper lung, and a bronchoscopic examination revealed a squamous cell carcinoma. Swelling of a pretracheal lymph node was also noted. Thus, we gave induction chemotherapy consisting of paclitaxel (days 1, 8) + carboplatin (days 1, 8) for two cycles under clinical staging of T2N2M0. After induction chemotherapy, (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed positive accumulation of FDG in mediastinal and bilateral hilar lymph nodes that had been negative in a previous FDG-PET examination, which led us to suspect disease progression. Transbronchial lymph node biopsy results showed sarcoid granulomas in the specimens. Following complete resection of the lung cancer, sarcoid granulomas were revealed in both nonneoplastic lung tissue and lymph nodes, which resulted in a diagnosis of lung cancer accompanied with sarcoidosis.

Background The risk of perioperative mortality is greater for patients undergoing a pneumonectomy than for a sleeve lobectomy. At our institution, we perform an extended sleeve lobectomy, an atypical sleeve resection of more than one lobe, to avoid a pneumonectomy in patients with locally advanced lung cancer. The purpose of this study was to analyze the risks of complications and local control in patients who underwent an extended sleeve lobectomy procedure. Methods Patients who underwent an extended sleeve lobectomy procedure were retrospectively analyzed in regard to operative mortality, complications, and local recurrence. Results A total of 23 patients underwent an extended sleeve lobectomy: one lobe + segment in 15, two lobes in 7, and two lobes + segment in 1. There were no operative deaths within 30 days or hospital deaths. Two (8.7%) of the 23 patients had complications at the anastomosis site, a stricture in 1 and bronchopleural fistula in 1, whereas 2 (8.7%) others had local control failure, relapse at the anastomosis site in 1 and staple line relapse in 1. Long-term survival was similar to that of those who underwent a pneumonectomy during the same period. Conclusions Our extended sleeve lobectomy procedure is useful to avoid a pneumonectomy in patients with locally advanced lung cancer.

Objective: Postoperative acute interstitial pneumonia is a subset of post-surgical acuterespiratory distress syndrome(ARDS) and is responsible for one third of in-hospital deaths following lung resection in patients with primary lung cancer. We evaluated the usefulness of computed tomography (CT) for detection of interstitial pneumonia (IP) as a risk factor of postoperative ARDS. Methods: Preoperative chest CTof patients who underwent thoracotomy for primary lung cancer was reviewed retrospectively and IP findings in the chest CTwere detected. Results: A total of 1148 patients with primary lung cancer underwent thoracotomy. Fifteen patients (1.3%) developed postoperative ARDS. Eleven of these 15 patients died of ARDS. Three of 41 patients who received induction therapy developed postoperative ARDS. Induction therapy was a risk factor of postoperative ARDS (p < 0.01). Eleven out of the 15 patients who developed postoperative ARDS had IP findings (10: localized, 1: diffuse) in their chest CT. Two of three patients who had postoperative ARDS after induction therapy also had IP findings. Chest CTs of 834 patients were retrospectively analyzed; 91 patients (10.9%) had IP-findings (diffuse 1.8%, localized 9.1%). Postoperative ARDS occurred in 8.8% of IP-positive patients, and in 0.4% of IP-negative patients (p < 0.001). Conclusion: Detection of IP by chest CT is useful for the selection of high-risk patients who may have postoperative ARDS following thoracotomy. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Objective: We prospectively investigated the efficacy of opioid rotation from oral morphine to oral oxycodone in cancer patients who had difficulty in continuing oral morphine treatment because of inadequate analgesia and/or intolerable side effects. Methods: Twenty-seven patients were enrolled and 25 were evaluated. The rate of patients who achieved adequate pain control, which provided an indication of treatment success, was evaluated as primary endpoint. The acceptability and pharmacokinetics of oxycodone were evaluated in addition to the assessment of analgesic efficacy and safety during the study period. Results: In spite of intense pain, the morphine daily dose could not be increased in most patients before the study because of intolerable side effects. However, switching to oral oxycodone allowed 1.7-fold increase as morphine equivalent dose. Consequently, 84.0% (21/ 25) of patients achieved adequate pain control. By the end of the study, all patients except one had tolerated the morphine-induced intolerable side effects (i.e. nausea, vomiting, constipation, drowsiness). Common side effects (.10%) that occurred during the study were typically known for strong opioid analgesics, and most were mild to moderate in severity. A significant negative correlation between creatinine clearance (CCr) value and the trough concentrations of the morphine metabolites was observed. On the other hand, no significant correlation was found between CCr value and the pharmacokinetic parameters of oxycodone or its metabolites. Conclusions: For patients who had difficulty in continuing oral morphine treatment, regardless of renal function, opioid rotation to oral oxycodone may be an effective approach to alleviate intolerable side effects and pain.

There is increasing evidence that Glasgow Prognostic Score (GPS), based on systemic inflammatory response and albumin level, is a useful predictor of overall survival in patients with various types of cancer. Patients with lung metastasis from colorectal carcinoma who underwent a lung metastasectomy from 2000 to 2015 were retrospectively investigated. Routine laboratory measurements including serum C-reactive protein (CRP), albumin, and the tumor marker carcinoembryonic antigen were performed before the metastasectomy. Ninety-nine patients underwent 132 lung metastasectomy procedures during the study period. Kaplan–Meier analysis revealed that GPS (p = 0.017), number of metastases (p = 0.004), and the presence of liver metastasis (p = 0.010) were associated with overall survival, while univariate analysis selected GPS (p = 0.028), number of metastases (p = 0.005), and liver metastasis (p = 0.014) as predictive factors associated with overall survival. Multivariate analysis also indicated GPS (p = 0.004), number of metastases (p = 0.004), and liver metastasis (p = 0.013) as predictive factors associated with overall survival. In addition to number of metastases and liver metastasis, GPS is an important predictor of overall survival in colorectal cancer patients who undergo a lung metastasectomy.

Acute exacerbation (AE) of idiopathic interstitial pneumonia (IP) is a potentially fatal postoperative complication following lung cancer resection. Postoperative pyothorax (PP) following development of a bronchopleural fistula (BPF) after lung surgery induces continuous inflammation and may affect the occurrence of AE. We investigated the relationship between AE and PP in patients who underwent pulmonary resection for lung cancer.A total of 941 patients who underwent lung resection due to primary lung cancer from 2006 to 2015 at our hospital were investigated.Of the 941 enrolled patients, 137 (14.6 %) had idiopathic IP and were predominantly male (p 0.01). Pathological stage Ia and adenocarcinoma were observed at significantly high rates in the non-IP group (p 0.01). Patients with IP showed a tendency for a higher percentage of PP (p = 0.054). Of the 137 patients with IP, 17 (12.4 %) showed postoperative AE. Furthermore, PP was observed in three cases in the AE(+) group and two in the AE(-) group. PP had a correlation with a significantly higher incidence of AE (p = 0.007).PP was found to be a significant risk factor for postoperative AE in lung cancer patients undergoing a pulmonary resection. Since IP itself is likely a risk factor for PP, prevention of BPF is important for patients with IP, as it can lead to PP.

原発性非小細胞肺癌完全切除例の遠隔転移巣に対する外科治療後の予後をretrospectiveに検討した．対象は1998～2003年の期間に原発巣切除と同時あるいは異時性に一臓器のみに認められた数個以内の初遠隔転移巣とした．症例は35例．転移部位は脳，肺，副腎，胸壁がそれぞれ17，10，6，2例，原発巣病理病期（同時転移は考慮せず）はI，II，III期がそれぞれ16，14，5例であった．転移巣術後の2年生存率は全体で68.0％（中間生存期間43.1ヵ月），原発巣病理病期別ではI，II，III期がそれぞれ86.5，53.0，60.0％であった．pN因子別比較ではpN0，pN1-2がそれぞれ82.9，50.3％と有意にpN0症例が予後良好であった．単発あるいは少数個の遠隔転移巣に対する外科治療の有効性はリンパ節転移を認めない原発肺癌早期症例において存在し，その予後の向上に寄与する可能性が示唆された．

Background Catamenial pneumothorax (CP) is a type of spontaneous pneumothorax due to thoracic endometriosis occurring in reproductive women, and usually involves the right side of the thorax showing diaphragm lesions. For the present study, we defined juvenile CP (JCP) as patients with CP who were 19 years old and younger. Institutional findings and a systematic literature review are presented. Methods We retrospectively enrolled all patients with CP treated at our institutions from January 2002 to June 2013. In addition, we conducted a search of medical literature published using the PubMed and Japanese Ichushi databases with “catamenial pneumothorax” as the search term. Results Thirteen female patients with CP, 1 on the left side, were treated at our institutions. The patient with left-side CP was classified as JCP, while that was also identified in 29 of 451 CPs reported in our literature review. Pneumothorax occurred more frequently on the left side in JCP as compared to usual CP (p

A 71-year-old woman was referred to our department for a nodular lesion in the left lung. She had been followed by urology department in our hospital for 6 years since right nephrectomy for ureter cancer. Chest X-ray and computed tomography (CT) scan demonstrated a small nodular shadow in the left lower lobe. The lung tumor was removed by wedge resection, and pathologically diagnosed during the operation as a metastasis from the ureter cancer. The lung tumor consisted of clear cells similar to the ureter cancer. However, the final pathological diagnosis changed to a primary lung cancer based on the findings of stratified differentiation and cancer cell nests in the tumor. Immunohistochemical staining for ureter epithelium-related antigens confirmed the diagnosis. Although we recommended left lower completion lobectomy, the patient refused additional surgery. She is suspected to have local recurrence in the left lower lobe 18 months after the surgery.

症例は29歳, 男性. トラック運転中に居眠りをして大型トラックに追突, ハンドルで前胸部を強打した. 近医に搬送され気管分岐部裂傷の診断を得て, 当科に紹介された.気管支鏡検査上, 気管分岐部竜骨の左右主気管支接合部が損傷し直径約8mmの裂孔が認められた.受傷約24時間後に手術を開始.竜骨の損傷が比較的広範なため, 明らかな損傷部のみのdebridementと単純縫合閉鎖では術後縫合不全や肉芽性狭窄の危険性が高いと考え, 気管分岐部を切除しMontage型再建術を行った.術後, 気管・気管支吻合部合併症をきたすことなく良好に経過し第29病日に退院した.気管分岐部損傷に対する分岐部切除再建術の報告はこれまでないが, 竜骨の広範な破壊を伴う症例に対しては, 積極的にこの術式を考慮してよいと考える.

A mediastinal Mullerian cyst was initially reported as a new category of congenital cyst by Hattori, et al. in 2005. We treated a 53-year-old female referred to us with a posterior mediastinal tumor found at the Th5 prevertebral level by chest-computed tomography during a medical check-up. She had a history of mediastinal teratoma, which was removed at the age of 35. Chest magnetic resonance imaging revealed homogenous, high-intensity signals in T2-weighted images. The lesion was resected using a thoracoscopic procedure, and histologic and immunohistochemical staining revealed a ciliated cyst of Mullerian origin. The newly established mediastinal Mullerian cyst should be included in the differential diagnosis of posterior mediastinal cysts.

The establishment of a sufficiently wide and functional blood-gas interface is of critical importance in lung development, but development of the intrapulmonary vascular system including alveolar capillary vessels still remains unclear. In this study, we first characterized the structural development of the vascular system in accordance with that of airways in human fetal lungs at the pseudoglandular phase (8, 13, and 16 weeks gestation) by examining the immunohistochemical distribution of CD34 and alpha-smooth muscle actin (SMA). Using double immunohistochemistry and 3-dimensional reconstruction techniques, endothelial cells in the developing lung could be classified into two different types according to the characteristics of their adjacent cells (presence or absence of SMA-positive cells) and their distribution (proximal or distal lung parenchyme). Endothelial cells without SMA-positive cells developed into a capillary network surrounding the budding components of distal airways during the mid-pseudoglandular phase before communicating with proximal vessels. We then examined the immunoreactivity of thrombomodulin and von Willebrand factor (vWF) in endothelial cells. Endothelial cells of the capillary network were mainly positive for vWF during the early gestational stages, but altered their phenotypes to those of mature lungs (vWF negative and thrombomodulin positive) during the terminal sac phase. We subsequently determined the immunohistochemical distribution of vascular endothelial growth factor (VEGF). Epithelial cells of the most distal airways were intensely positive for VEGF. These results suggest that VEGF present in airway epithelial cells is involved in the maturation as well as proliferation of capillary endothelial cells. Epithelial-endothelial interactions during lung development are considered very important in the establishment of the functional blood-gas interface.

目的. 80歳以上の症例に対する標準手術 (肺葉切除+2群郭清)・郭清縮小手術 (肺葉切除以下+1群郭清以下) と予後の関係を検討した. 方法. 対象は, 1981-99年に当施設にて原発性肺癌に対し肺切除を施行した80歳以上の超高齢者35例 (男: 女=29: 6) である. 結果. 術式は, 標準手術 (ND2群) 22例 (肺摘除2例, 肺葉切除20例), 郭清縮小手術 (ND 0-1群) 13例 (肺葉切除11例, 区域切除以下2例) であった. 手術関連死はなかった. 全死因で検討した5年生存率は, 全体でND2群22.2%, ND 0-1群43.8%. I期でもND2群 (13例) 30.8%, ND 0-1群 (9例) 50.0%とND2群で予後不良であった. 長期予後ではND2群で他病死が多かった. 術後合併症はND2群で術後不整脈が有意に多かった (p

Lung transplantation is the final lifesaving option for patients with pulmonary complications after hematopoietic stem cell transplantation (HSCT). Patients undergoing HSCT for hematologic diseases are thought to be high-risk candidates for lung transplantation; therefore, few lung transplants are performed for these patients, and few studies have been reported. This study aimed to describe the characteristics and outcomes of lung transplantation in patients with pulmonary complications after HSCT.We retrospectively investigated 62 patients who underwent lung transplantation after HSCT. All data were collected from 6 lung transplant centers in Japan.Seventeen patients underwent cadaveric lung transplantation, whereas 45 underwent living-donor lobar lung transplantation (LDLLT). In the LDLLT group, 18 patients underwent LDLLT after HSCT in which one of the donors had also served as a donor for HSCT. Seven patients underwent single LDLLT for which the donor was the same as the patient from whom stem cells were obtained for HSCT. Preoperative hypercapnia was observed in 52 patients (84%). Thirteen patients (21%) required mechanical ventilation preoperatively. Fifty-five patients underwent HSCT for hematologic malignancies, and 4 (7%) relapsed after lung transplantation. The 5-year survival rate was 64.2%. In a multivariable analysis, patients younger than 45 years and those with the same donor for both procedures exhibited significantly better survival (P = 0.012 and 0.041, respectively).Lung transplantation for pulmonary complications after HSCT was performed safely and yielded better survival, especially in younger recipients for whom both lung transplantation and HSCT involved the same donor.

Because the shortage of donor organs is especially serious in Japan, since 2002 a unique partnership between transplant consultant physicians and local physicians has been developed to maximize the organ utilization rate. Since 2011, more than 25 lung consultant physicians have been registered to specifically assess donor lungs and provide advice on intensive respiratory care to donors. In this study, we retrospectively reviewed the efficacy of this system for lung transplantation opportunities and outcomes. One hundred eighty-seven brain-dead lung donor candidates were chronologically divided into 3 phases: I (May 1998-November 2006) and II (December 2006-January 2011), before and after medical consultants requested that local physicians administer aggressive bronchial suctioning using bronchoscopy, respectively; and phase III (February 2011-January 2013), after the emergence of lung consultants. The lung utilization rate, Pao2/Fio2 ratio at the first and second brain death examinations and at the tertiary assessment before recovery, and graft survival were analyzed. The lung utilization rate was significantly higher in phases II and III than in phase I. In phases I and II, the Pao2/Fio2 ratio at the tertiary assessment was significantly lower than that at the first or the second brain death examination, whereas it did not worsen with time in phase III. Graft survival was significantly better in phases II and III than in phase I. Graft death due to primary graft dysfunction was significantly more frequent in phase I than in phases II and III. In conclusion, this system is effective in improving lung transplantation opportunities and outcomes.

Background Pulmonary pleomorphic carcinoma (PPC) is a rare type of non-small-cell lung cancer that belongs to the family of sarcomatoid carcinomas and is associated with poor prognosis. We investigated the expressions of tumor-related genes in resected PPC specimens. Methods Specimens resected from patients with PPC from July 2006 through April 2012 were investigated. Tumor segments were collected from the specimens by micro-dissection to extract mRNA, then RT-PCR was performed according to Dannenberg’s tumor profile method for semi-quantitation of tumor-related gene mRNA. To compare with other types of lung cancer, data from stage-matched adenocarcinoma (AC) and squamous cell carcinoma (SCC) cases in our database were also examined. Results The gene expression levels of thymidylate synthase were significantly higher in PPC and SCC as compared to the AC specimens (p

The number of organ donations after brain death has significantly increased since the revised Japanese Organ Transplant Law took effect in July 2010. Sixty-one lung transplantations were conducted throughout Japan in 2013, including 20 living-donor lung transplantations and 41 brain-dead-donor lung transplantations (23 bilateral lungs, 17 single lungs, and 1 heart-lung transplantation). The number of lung transplant candidates newly registered at the Japan Organ Transplantation Network also increased to 126 in 2013, suggesting a severe donor shortage in Japan. More than 60 % of offered brain-dead-donor, lungs were used for transplantation, indicating the effort of Japanese lung transplant centers to overcome the challenge of donor shortage. After lung transplantation, patients generally enjoyed a good quality of life with excellent survival of 86.2 % at 1 year, 79.6 % at 3 years, and 73.7 % at 5 years post-transplantation. There was no significant difference in patient survival between living-donor and brain-dead-donor lung transplantation. Early mortality of lung transplant recipients within 90 days was attributable to graft failure followed by infection, while long-term mortality was mostly explained by chronic lung allograft dysfunction (chronic rejection), infection, and malignancy. Eight lung transplant centers are currently approved to conduct lung transplantation in Japan (Tohoku, Dokkyo, Chiba, Kyoto, Osaka, Okayama, Fukuoka, and Nagasaki Universities). These centers are expected to continue to make a special effort to save critically ill patients waiting for lung transplantation.

We report a case of isolated unilateral absence of a pulmonary artery. The first clinical symptom that was manifested in the patient was recurrent hemoptysis, and subsequent angiography revealed that the main pulmonary artery was absent in the right lung, which was being fed only from the systemic circulation. Right pneumonectomy was performed, and neither the main pulmonary artery nor its remnant was detected in the resected right lung. Histologically, there were many muscular vessels in the resected lung, with intimal proliferation, or with plexiform-like lesions. The alveolar septum was moderately thickened and alveolar capillary vessels were dilated. We examined the alveolar capillary endothelial cells of the resected lung for immunoreactivity to thrombomodulin (TM) and von Willebrand factor (vWF). The endothelial cells were negative for TM and positive for vWF, while in the normal lung control group, these cells were positive for TM and negative for vWF. We considered that the hemodynamics of the systemic circulation in the resected lung caused the alteration of immunohistochemical characteristics in alveolar capillary endothelial cells.

Chronic hypoxia causes pulmonary hypertension and right ventricular hypertrophy associated with pulmonary vascular remodeling. Because hypoxia might promote generation of oxidative stress in vivo, we hypothesized that oxidative stress may play a role in the hypoxia-induced cardiopulmonary changes and examined the effect of treatment with the antioxidant N-acetylcysteine (NAC) in rats. NAC reduced hypoxia-induced cardiopulmonary alterations at 3 wk of hypoxia. Lung phosphatidylcholine hydroperoxide (PCOOH) increased at days 1 and 7 of the hypoxic exposure, and NAC attenuated the increase in lung PCOOH. Lung xanthine oxidase (XO) activity was elevated from day 1 through day 21, especially during the initial 3 days of the hypoxic exposure. The XO inhibitor allopurinol significantly inhibited the hypoxia-induced increase in lung PCOOH and pulmonary hypertension, and allopurinol treatment only for the initial 3 days also reduced the hypoxia-induced right ventricular hypertrophy and pulmonary vascular thickening. These results suggest that oxidative stress produced by activated XO in the induction phase of hypoxic exposure contributes to the development of chronic hypoxic pulmonary hypertension.

肺癌手術後の致死的合併症として急性問質性肺炎 (AIP) は重要であり, その発症に限局性のinterstitial pneumonia (IP) の関与が指摘されている. 今回, 特に限局性IPに着目し, 術前CTから術後AIP発症の高危険群を同定しうるかを目的とし, 病理学的なIPに相当するCT所見 (IP所見) の有無を検討した. 当科にて96年から98年までの3年間に手術を施行した肺癌症例は553例. この間の術後AIP発症例は9例 (1.6%) であり, 死亡例は6例であった. 9例のうち8例に術前CT上限局性IP所見を認めたが, 術前に問質性肺炎と診断されていた症例はなかった. 一方, 術前胸部CTを再読影し得た303例の検討では, IP所見を肺癌切除例の11.9%に認めた (びまん性2.3%, 限局性9.6%). 術後AIP発症率は, IP所見を認める症例から11.8%, IP所見を認めない症例から0.2%と, 有意に術前CTにてIP所見を有するものに発症率が高かった. 限局性であっても術前CTにてIP所見を有するものは, 術後問質性肺炎を発症する可能性があり, 注意が必要と考えられた

The use of 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) for staging nonsmall cell lung cancer is widely recognized, whereas the value of fluorodeoxyglucose-positron emission tomography imaging in the evaluation of response to induction chemotherapy is still controversial. We describe a case of a 57-year-old man who had a sarcoid-like reaction develop during induction chemotherapy for a pathologically proven N2 lung cancer. Re-evaluation of the nodal status using fluorodeoxyglucose-positron emission tomography showed false-positive accumulation in the mediastinal and hilar lymph nodes, which led us to suspect lung cancer progression after induction chemotherapy.

肺切除術後肺機能に及ぼす呼吸補助筋温存の効果, 意義について検討した.気管支鏡にて可視範囲に異常所見がない直径3cm以下の未梢型肺癌にて一葉切除を受けた症例を対象とし, 術前, 術後4週目に肺機能諸量, 動脈血ガス分析を施行した.術前肺機能値と肺血流比から, 術後肺機能予測値を術前値× (1-術側肺血流比×切除肺区域数/術側肺区域数) にて算出し, 術後実測値に対する割合を, 術後実測値/予測値にて求めた.TLC, FRCは, 前鋸筋温存群, 聴診三角切開群で, 標準切開群に比し有意に高値であり, FVC, FEV1.0, Peak Flowは, 標準開胸術群に比し, 前鋸筋温存群, 聴診三角切開群において高値である傾向を認めた.呼吸補助筋温存術式では, 標準開胸術式に比し胸郭コンプライアンス低下の抑制, 予備呼気量の増加がもたらされることから, 術前肺機能低下のある症例では試みられるべき術式と考える.

症例は76才女性, 主訴は労作時呼吸困難2年前より胸部異常陰影を指摘されていたが, 症状が軽度のため放置していた.数ヵ月前より症状が増悪したため来院した、精査の結果横行結腸, 大網を内容とするMorgagni孔ヘルニアと診断した.一般的には, 呼吸機能の低下した横隔膜ヘルニアに対しては開胸術による呼吸機能の低下を避けるために, 開腹経路による根治術が行われることが多い.しかし今回我々は, ヘルニア嚢による圧迫により無気肺が認められること, 胸腔内に癒着の可能性があることから開胸経路による手術を施行した.術後呼吸機能は低下せず, むしろ著明に改善したことより, Morgagni 孔ヘルニアの術式として, 開胸術が, 必ずしも呼吸機能の低下を来すわけではなく胸腔内での癒着や, 無気肺などが疑われる症例に対しては積極的に開胸経路による手術を施行しても良いと考え報告した.

症例は72歳女性.胸部異常陰影を主訴として来院した.画像診断では, 上前縦隔に内腔に突出する充実性腫瘤の部分を有する嚢胞性病変であった。左腕頭静脈は嚢胞の尾側を回り込むようにして下大静脈下部に流入していた.タリウムシンチグラフィーでは充実性腫瘤の部分に取り込みがあった.血中SCCは1.8ng/mlと軽度上昇していた.以上の所見をもとに腫瘤摘出術を施行した.病理学上, 胸腺嚢胞に合併した胸腺扁平上皮癌であった.本症例は右腕頭静脈の走行より先天性嚢胞と考えられ, 同部に胸腺癌を併発したものと思われた.

(18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) plays an important role in many oncological settings. In this study, we assessed the utility of (18)F-FDG-PET for predicting the histological classification, stage and survival of thymic epithelial tumors.We retrospectively analyzed 37 patients with thymic epithelial tumors who underwent PET before surgical resection and investigated the relationship between the maximum of standardized uptake value (SUVmax) of each tumor and the WHO classification, recurrence-free survival, and tumor-related gene expressions.The study included 15 males and 22 females, ranging in age from 22 to 81 years (mean 64 years). The tumor histology of 31 tumors was thymoma and that of the remaining tumors was thymic carcinoma. The Masaoka tumor stage was as follows: stage I in 18, II in 9, III in 5 and IV in 5 patients. The patients were divided into three groups according to a simplified histologic classification: low-risk thymoma (types A, AB and B1, n = 21), high-risk thymoma (types B2 and B3, n = 10) and thymic carcinoma (n = 6). The SUVmax of low-risk group (SUVmax ≤4.27) was significantly lower than that of high-risk group (p = 0.0114) and that of thymic carcinomas (SUVmax4.27) was also significantly higher than that of thymomas (p0.0001). The group of high SUVmax (SUVmax4.27) had significantly inferior recurrence-free survival to that of less value (SUVmax ≤4.27) (p = 0.0009). The SUVmax were not correlated with tumor-related gene expressions.The SUVmax of (18)F-FDG-PET reflects WHO classification of thymic epithelial tumors. High SUVmax predicts lower recurrence-free survival of the tumors.

A 68-year-old woman was referred to our hospital due to a left chest abnormal shadow on chest film. She had a history of occupational exposure to organic solvent for about 30 years until 10 years ago. Computed tomography (CT) scan demonstrated a nodular shadow 12 mm in diameter in the left lower lobe. As a lung cancer was suspected, partial resection of the lobe including the small lesion was performed. Since mucosa-associated lymphoid tissue(MALT) lymphoma was diagnosed by intraoperative pathological examination, we finished the operation without any more lung resection. The diagnosis was finally confirmed by histological finding of small lymphoid cell proliferation and positive staining for CD20. Chronic inflammation, such as Helicobacter pylori infection, is considered to be a cause of MALT lymphoma. We speculate that the long term exposure to organic solvent may develop the disease by continuous chemical stimulation to bronchus.

Resection of lung cancers with tracheal and carinal involvement is rare and its role remains uncertain. We review our experience with tracheocarinal resection and reconstruction. Seven tracheocarinal resections were performed without anastomotic complications, local recurrence, or operative mortality. Six carinal reconstructions (3 using the montage method and 3 the single-stoma method) were performed without local recurrence or operative mortality. Two of the 6 had anastomotic complications. One case of stenosis required metallic stent insertion, and another case of hemoptysis underwent complete pneumonectomy. Tracheocarinal resection and reconstruction provide acceptable results in terms of local control and operative mortality, except for anastomotic complications. Patients should be carefully selected for surgery when there is anticipated mediastinal lymph node invovement.

Because pulmonary metastasis is considered to be systemic spread of hepatocellular carcinoma (HCC), indication of pulmonary resection as a treatment for it is not well-described. We retrospectively reviewed clinical records of the patients who underwent pulmonary resection for metastases from HCC in our hospital. Seven patients, 6 men, 1 woman, and the mean-age 65.4 year-old, underwent pulmonary resection from April in 2001 to March in 2010. During the same period, we carried out pulmonary resection for 122 patients with metastases from other malignant diseases. Therefore, pulmonary resection for HCC metastases accounted for 5.4% of the total pulmonary metastasectomy. One of the 7 patients, a 70 year-old man, survives for 69 months after right middle lobectomy for solitary HCC metastasis. Other 6 patients with multiple pulmonary metastases or with increased level of alpha-fetoprotein (AFP) before pulmonary resection died of systemic recurrence. The mean survival time of 7 patients was 20 months and was 11.8 months except the long-time survivor. From our results, patients with multiple pulmonary metastases from HCC or with increased serum level of AFP before surgery should be carefully selected as candidates for pulmonary metastasectomy.

We report a case with lung cancer during pregnancy, which has a very poor prognosis.A 34-year old female at 30 weeks of pregnancy came to us with a cough and right lower chest pain. Chest computed tomography revealed a mass in the right lower lung lobe and the diagnosis of adenocarcinoma cT2aN1M0 was made. We performed a right sleeve pneumonectomy, as the tumor had progressed to the right main bronchus near carina. Histological sections of the specimens revealed a poorly differentiated adenocarcinoma that infiltrated surrounding structures. The pathological stage of lung cancer was T4N2M0 stage IIIB. Immunohistochemistry findings for estrogen receptor β were positive in the nuclei of the adenocarcinoma. She had a rapid recurrence in spite of chemotherapy, and she died 7.5 months after operation. The positive estrogen receptor and hormonal condition during pregnancy might promote cancer and result in her poor prognosis.