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We describe a patient with low respiratory function who underwent thoracoscopic sleeve segmentectomy to preserve lung function as much as possible. The patient had already used home oxygen therapy because of chronic obstructive lung disease. There was a squamous-cell carcinoma at inlet of right B6 bronchus, and cT1aN0M0 disease was diagnosed. Because respiratory function was poor, right S6 segmentectomy was scheduled. Moreover, to preserve the respiratory muscles as much as possible, a thoracoscopic approach was selected. We performed S6 sleeve segmentectomy, and sutured the lower bronchus and basal bronchus. There were some limitations in handling needles during thoracoscopy. To resolve these difficulties, we devised two techniques. One was to suture the bronchus with continuous sutures on the mediastinal side and simple interrupted sutures on the other side. The other was to create a working space for handling the needles to avoid entanglement of the sutures. These techniques allowed us to suture the bronchi relatively easily.

We report a 53-year-old man with metastases of alveolar soft-part sarcoma originated from the mediastinum. He was hospitalized due to lower extremities’ paralysis. Computed tomography scan findings revealed multiple nodules of bilateral lungs, swollen mediastinal lymph nodes, and osteolysis of thoracic vertebrae. We performed spinal decompression and biopsy from vertebra. And, we finally diagnosed this case as metastases of mediastinal alveolar soft-part sarcoma which was removed 10 years ago. Alveolar soft-part sarcoma is rare tumor accounted for 0.5%–1.0% of soft tissue sarcoma that often occurs primarily in the lower extremities and trunk. It is difficult to distinguish between alveolar soft-part sarcoma and paraganglioma, renal cell carcinoma and granular cell tumor morphologically. Periodic acid–Schiff stain and immunohistochemical staining of ASPL-TFE3 are useful in making a definitive diagnosis of alveolar soft-part sarcoma. This case is a rare case of alveolar soft-part sarcoma originated in the mediastinum with local recurrence and distant metastases 10 years after the initial surgery.

With the progress of antibiotic therapy, the mortality of lung abscess has been improved, and surgical intervention has declined. However, surgery is still required in selected cases that are intractable to antibiotic treatment. Video-assisted thoracoscopic surgery (VATS) is beneficial for treatment and/or diagnosis of pulmonary disease as it provides a less invasive surgical technique and reduces prolongation of post-operative recovery. However, the indication of VATS lobectomy for lung abscess is controversial as a result of particular complications, i.e. wet lung, intrapleural adhesion and ease of bleeding. We herein report a rare combination of lung abscess and osteomyelitis of mandible resulting from the same pathogen successfully treated with VATS lobectomy. We propose VATS lobectomy for lung abscess. This procedure might be the best treatment candidate for selected cases of lung abscess.

Primary lung cancer associated with an azygos lobe is extremely rare. Herein, we report the case of a 64-year-old woman with lung adenocarcinoma arising in the right upper lobe with an azygos lobe. The patient underwent a right upper lobectomy and lymph node dissection with video-assisted thoracoscopic surgery. Video-assisted thoracoscopic surgery lobectomy for lung cancer of this variant has yet to be reported. We demonstrate the intraoperative findings and the resected pulmonary lobe. This is the first case of primary lung cancer associated with the azygos lobe treated by lobectomy with video-assisted thoracoscopic surgery.

Insulin-like growth factor-1 receptor (IGF-1R) and matrix metalloproteinase-7 (MMP-7) have been reported to be related to tumor invasion and metastasis in various malignancies. The aim of this study was to evaluate the expression levels of IGF-1R and MMP-7 in resected non-small cell lung cancer (NSCLC) and to examine the relationship of such levels to clinical characteristics and survival. Expression was measured immunohistochemically. The percentage of stained cells was multiplied by the staining intensity. The sample was classified as high when the score was equal or higher than the median value or was otherwise considered to be low. High IGF-1R expression was associated with nodal metastasis and recurrence (P=0.034 and 0.006, respectively). High IGF-1R expression was associated with significantly poorer overall survival than low IGF-1R expression (P=0.011). MMP-7 expression did not significantly correlate with any clinicopathological factor. There was a trend toward slightly, but not significantly poorer survival in patients with MMP-7-high tumors than in those with MMP-7-low tumors (P=0.220). There was no significant correlation between IGF-1R expression and MMP-7 expression (P=0.184). Upon multivariate analysis, IGF-1R expression was independently related to the outcomes of patients with NSCLC. Overexpression of IGF-1R may be a useful predictor of lymph node metastasis, recurrence and post-surgical outcomes in patients with NSCLC.

背景．稀ではあるが，臓側胸膜浸潤のない肺癌症例でも，術中に存在する胸水中に癌細胞が証明されることがある．臨床病理学的にも病期診断に極めて重要な所見であり，癌進展の自然史としても興味深い病態であるが，その機序は明らかでない．症例．血痰を契機に発見された左上葉原発，肺腺癌の68歳・男性．臨床病期はstage IAであった．術中所見では，少量の漿液性胸水を認めた他は，臓側胸膜面の変化や播種巣などはなく，sT1bN0M0D0E1（+）少量・漿液性PL0PM0：stage IAと診断した．術後病理診断では葉気管支間リンパ節に転移を認めた．癌組織の臓側胸膜浸潤は認めなかったが，胸水細胞診にて癌性胸水と診断され，最終的にpT1bN1（#11）M1a（E+）：stage IVの診断となった．結論．癌性胸水の存在は，病期診断，術後の治療戦略上，極めて重要な所見である．術中に臓側胸膜表面に変化のない症例であっても洗浄細胞診を，また少量でも胸水が存在すれば胸水細胞診を積極的に施行すべきである．

症例は53歳, 女性. 7歳時より肺炎を繰り返していた. 近医通院していたが, 2001年12月上部消化管造影検査にて食道気管支瘻を疑われ, 当院紹介受診. 2002年5月手術目的で入院. 食道造影検査では胸部上部食道の拡張, 右気管支への造影剤の流出および右下葉末梢気管支の拡張があった. さらに上部消化管内視鏡および気管支鏡検査で瘻口が確認された. 経静脈下肺血管造影検査では右肺下葉の荒蕪肺に伴った右肺動脈の中葉前方枝, 下葉枝の閉塞が認められた. 食道気管支瘻および右肺下葉荒蕪肺の診断にて2002年5月右開胸で瘻管切除, 右肺下葉切除術を行った. 術後の食道造影検査にて瘻管切除部からの造影剤の流出はなく, 第12病日軽快退院した.

We evaluated the long-term outcome and symptoms after inguinal hernia repair using the Prolene Hernia System (PHS).We reviewed the medical records of all patients who underwent PHS surgery at our hospital to assess the postoperative complications and recurrence rates. Late symptoms were evaluated by a standardized interview using a questionnaire.A total of 395 hernias in 367 patients were studied. Postoperative complications developed after 20 repairs (5.1%), including a severe mesh infection in one patient. Seven (1.8%) patients suffered recurrence. Of 395 cases, 363 (91.9%) responded to the interview. After a median follow-up interval of 19.3 months (range 1.0-55.8), moderate pain and moderate discomfort were reported by only 1.9% and 0.8% of patients, respectively.Prolene Hernia System surgery is a safe and feasible procedure with low rates of complication, recurrence, and late symptoms.

Aims To examine four-node axillary sampling assisted by a blue dye (4NAS/dye) technique as a sentinel node biopsy (SNB) for breast cancer. Methods Lymphatic mapping was performed by injection of patent blue for 33 consecutive cases with breast cancer. Axillary sampling was performed until four nodes were obtained. This was followed by back-up axillary lymph node dissection to examine the feasibility of 4NAS/dye. The same study with 30 cases was conducted at an independent hospital to confirm the feasibility of this method. This method was then applied to 101 consecutive clinically node-negative patients to avoid axillary-node dissection, with intraoperative diagnosis made by frozen section examination. Results The median numbers of blue-stained nodes and nodes excised by 4NAS/dye were 1.7 and 3.4, respectively. The identification rate of sentinel lymph nodes (SNs) was 81.8% using the dye alone and 97.0% when the combination was used. Pathological examination revealed that the nodal status was correctly predicted by the dye alone in 62.5% of cases with metastasis, whereas in 100% by 4NAS/dye. The dye alone was not sufficient to identify SNs, especially in cases with prior excisional biopsy. The identification rate of SNs and the accuracy rate in another feasibility study were 100% and 92.5% in 30 consecutive cases, respectively. 4NAS/dye successfully detected SNs in 100 of 101 cases of the subsequent observational study with an acceptable post-operative axillary morbidity and thus succeeded as an SNB. Conclusions The 4NAS/dye method is reliable for the detection of SNs. This method could be applied to observational studies without radio-isotope.

We report a rare case of a solitary metachronous metastasis of renal clear cell carcinoma (RCC) presenting as a thyroid tumor 19 years after a nephrectomy. Our search of the English-language literature found only sporadic reports of late RCC metastases to the thyroid. Fine-needle aspiration biopsy of the thyroid tumor was not accompanied with thyroglobulin (Tg) staining, leading us to initially suspect a primary follicular thyroid carcinoma. The patient, a 77-year-old man, underwent a total thyroidectomy with modified neck dissection. Histological examination confirmed the tumor to be RCC metastasis, and immunohistochemical analysis revealed that both Tg and thyroid transcription factor-1 (TTF-1) were negative in the tumor cells. Thus, the possibility of late RCC metastasis to the thyroid should be considered, even in a patient with a remote history. Furthermore, TTF-1 is useful for identifying thyroid metastatic carcinomas.

症例は, 39才男性.検診にて胸部異常影を指摘され, 当科受診.以前よりvon Recklinghausen病の診断を受けていた.胸部レントゲン写真において大動脈弓に接する腫瘤影を認め, 胸部MRIでは, 大動脈弓付近に左迷走神経の走向に一致する8×4×3cm大の腫瘤影を認めた.以上より, 神経原性腫瘍 (特に迷走神経由来) を考え手術を施行した.腫瘍は迷走神経の反回神経分岐部付近から発生していた.腫瘍を完全切除するために, 迷走神経と反回神経を切断し腫瘍を摘出した.腫瘍は, 8×4.5×3cm, 充実性で, 割面は乳白色であった.病理組織学的検査にて, 神経線維腫と診断され, 悪性所見は認めなかった.以上よりvon Recklinghausen病に合併した胸腔内迷走神経発生の神経線維腫と診断した.

症例は56才男性.右上葉肺癌, 胸壁浸潤の診断で, 2002年10月15日に右上葉切除+ND2a+胸壁合併切除 (第3-5肋骨部分切除) を肋横突起靱帯で行った.術後胸腔ドレーンの排液が, 漿液性淡々黄色で1日500ml以上の日が一週間以上続き, また術後6日目より頭痛・眩量・耳鳴等の症状が出現・継続したため, 髄液瘻の発生を疑った.脳槽シンチを行い確定診断を得た.胸腔内と脳脊髄腔内の圧格差が髄液痩発生の原因と考え, 気漏がないことを確認しドレーンをクランプした.胸水貯留による肺虚脱が起きないことを確認した後, クランプ後2日目にドレーンを抜去したところ, 抜去後6日目で症状は消失し, その後軽快退院した.二ヵ月後に再度脳槽シンチを行い, 髄液瘻が治癒していることを確認した.その後も特に問題なく経過観察中である.

We undertook a retrospective study in order to assess the risks and benefits of the use of cardiopulmonary bypass (CPB) during operative resection of non-small cell lung cancer (NSCLC). Eleven patients (nine male and two female with a median age of 62 years, range 28-76 years) underwent extended resection of locally advanced NSCLC using CPB. The indication for the use of CPB was resection of the left atrium (n=4), the aorta (n=3), the pulmonary artery (n=3), or for respiratory support (n=1). No deaths occurred during the first 30 days postoperatively. With exception of one hospital death due to MRSA mediastinitis and local recurrence, all the patients were discharged and returned to their social activities. Two patients are alive with recurrent disease at follow-up 37 and 41 months post-surgery, respectively. Eight patients died due to recurrence and the median postoperative survival time was 269 days (range: 112-1132 days). One patient who had no evidence of recurrence died of aspiration pneumonia 10 months after surgery. CPB is a safe and effective tool for use during extended resection of locally advanced NSCLC. However, careful consideration for the risk/benefit ratio should be required when assessing the indication for surgical intervention.

背景. 原発巣が不明で縦隔や肺門リンパ節のみに転移を認める症例を稀に経験するが, 今回, 縦隔リンパ節の癌の切除後3年9ヶ月を経て頸部リンパ節転移を起こした症例を経験したので報告する. 症例. 74歳男性. 1998年2月に健診で縦隔異常陰影を指摘され, 胸部CT上最大径4cmの気管分岐下リンパ節腫大を認めた. 気管支鏡下穿刺細胞診で扁平上皮癌と診断されたため, 肺, 消化管, 咽頭喉頭部の精査を行うも原発巣は不明であった. 他に明らかな転移巣を認めないため, 同年5月に開胸下で気管分岐下リンパ節の郭清術を行った. 術中の触診でも明らかな原発巣は認めず, 摘出標本の組織診断でも扁平上皮癌であった. 以後外来にて経過観察を行っていた. 2002年2月に右i頸部リンパ節に腫大を認めたため経皮穿刺細胞診を施行したところ, 扁平上皮癌と診断した. 再度全身精査を行うもやはり原発巣は不明であり, 2002年3月に右頸部～鎖骨上窩リンパ節郭清術を行った. 摘出標本でも扁平上皮癌と診断し, 前回摘出標本と組織像が同一であるため転移再発と診断した. 結論. 原発不明癌縦隔リンパ節転移症例には積極的なリンパ節切除・郭清を行い, 厳重な経過観察が必要と思われた.

Objective: To improve the postoperative results of limited resection for small lung cancer, we have developed a new operative method, pulmonary artery-guided segmentectomy. This resection begins with identification of the pulmonary arterial branches involved in the tumor, then the pulmonary tissue is divided along the pulmonary arteries (i.e. guided by pulmonary arteries) from the hilum toward the periphery by electrocautery. The advantages of this method include the facilitation of securing adequate margin from the tumor, and the feasibility of intralobar lymph node dissection during operation. To examine the efficacy of the new method of segmental resection, we retrospectively reviewed 74 cases of T1N0M0 disease who underwent the pulmonary artery-guided segmentectomy. Methods: From 1993 to 2000, 74 patients with pathological T1N0M0 lung cancer were treated by the pulmonary artery-guided segmentectomy. Forty-one patients (55.4%) who underwent the segmentectomy had been considered suitable candidates for lobectomy (intentional resection group). The other 33 patients (44.6%) were considered poor candidates for lobectomy because of poor cardiopulmonary reserve (compromised resection group). Results: The overall survival rate at 5 years was 82.0%. The 5-year survivals in the intentional and the compromised resection groups were 81.6 and 77.6%, respectively, and no significant differences were detected between the groups. According to tumor size, the 5-year survival rate for patients with tumors of 20 mm or smaller (92.9%, n ¼ 53) was higher than that for the patients with tumors of 21‐30 mm (63.0%, n ¼ 21), but the difference did not reach statistical significance. Median follow-up time of 27.0 months revealed eight locoregional recurrences and four deaths due to lung cancer. Sixty-three patients (85.1%) are alive with no evidence of disease, and six patients (8.1%) are alive with recurrent disease. Locoregional recurrences occurred in one of 53 patients (1.9%) with tumors 20 mm or smaller and in seven of 21 patients (33.3%) with tumors 21‐30 mm, the difference being statistically significant (P , 0:01). Conclusions: Our intermediate results demonstrated that the new pulmonary artery-guided segmentectomy could be an alternative method for selected patients with small lung cancer, particularly with tumors 20 mm or smaller in diameter. q 2002 Elsevier Science B.V. All rights reserved.

To evaluate the influence of p53 status on postoperative survival and incidence of apoptosis (apoptotic index, AI) in non-small cell lung cancer (NSCLC), a total of 185 pathologic stage I patients were retrospectively analyzed. It was demonstrated by univariate and multivariate analyses that aberrant expression of p53 was a significant factor to predict a poor prognosis, which was caused by a significantly higher proliferative index (PI) in tumor with aberrant expression of p53 (52.7%) than that in tumor without aberrant expression of p53 (37.9%, P0.001). In addition, for tumor without aberrant expression of p53, mean AIs of the lowest-, the lower-, the higher-, and the highest-PI groups were 12.6, 12.9, 31.3, and 35.1, respectively, showing that incidence of apoptosis was markedly increased in response to cell proliferation (P = 0.002). In contrast, for tumor with aberrant expression of p53, no increase in incidence of apoptosis in response to cell proliferation was documented. These results clearly demonstrated that active cell proliferation and reduced apoptotic cell death in response to cell proliferation resulted in the poor postoperative prognosis in tumor with aberrant expression of p53.

Study objective To examine the effectiveness of repeated intrapleural chemotherapy using an implantable access system (INFUSE-A-PORT; Horizon Medical Products; Manchester, GA) for the management of a malignant pleural effusion (MPE). Methods Twenty-two patients with histologically proven MPEs (11 men and 11 women; mean age, 63.8 years; age range, 51 to 81 years; performance status, ≤ 3) were enrolled in this study. There were 17 patients with MPEs resulting from primary lung cancer; of whom 7 had metastatic disease (stage IV), 3 had stage IIIB disease, and 7 had postoperative recurrences. Three patients had MPEs that were caused by mesothelioma, and two had MPEs caused by breast cancer. Intrapleural catheters were placed by a video-assisted thoracoscopic procedure. The intrapleural administration of 5-fluorouracil (5-FU; 250 mg per body) and cisplatin (10 mg per body) using the implantable access system was performed biweekly at the outpatient clinic. Drainage of the MPEs through the port was performed only when the patients had some manifestations that occurred due to increasing effusion. Results The mean total administered doses of 5-FU and cisplatin were 3,290 and 124 mg, respectively. The mean follow-up period was 431 days (range, 209 to 792 days). The median survival period was 403 days, and the longest survival period was 792 days. No treatment-related mortality, renal dysfunction, bone marrow suppression, or infection occurred. One patient experienced a hemothorax after eight instances of intrapleural administration. The port and the catheter were involved with the tumor in one patient. Conclusions Repeated intrapleural chemotherapy using the implantable access system is useful and safe for patients with MPEs. In the future, prospective randomized studies will be necessary to compare the efficacy of therapy for MPE using the implantable access system with that of pleurodesis.

肺内穿孔をきたし緊急手術を行った縦隔奇形腫の1例を経験した.症例は18歳, 男性.2001年4月の検診にて右肺門部に腫瘤陰影を認め同月の胸部CTで前縦隔腫瘍と診断し手術予定で外来経過観察をしていたが, 2001年5月17日より胸痛, 血痰, 高熱が出現し, 同年5月20日右中下肺野に浸潤影を認めたため当科緊急入院した.エコーガイド下縦隔腫瘍穿刺吸引による腫瘍内溶液の性状はアミラーゼ0IU/l, リパーゼ4U/l, トリプシン19ng/lと低値であり, 腫瘍内溶液は黄色ブドウ球菌に感染していた.全身状態の悪化が著しいと考えたため, 2001年5月22日縦隔腫瘍摘出術及び右肺中葉切除術を行った.摘出標本の病理組織学的検査で縦隔奇形腫と診断された.術前に上昇していたSCC抗原, CA19-9, 可溶性IL-2レセプターは術後正常化しており嚢胞内産生が考えられた.

症例は74歳男性.気管支喘息, 肺気腫にて通院治療中, 呼吸困難を主訴として, 左頸部腫瘤と胸部レントゲン写真で左上縦隔の腫瘤陰影を指摘され当院紹介受診となる.CTおよびMRIで上縦隔から左頸部に広がる腫瘤影を認め, 手術にて摘出を行った.摘出標本は10x9x6cmで被膜を有し, 外観は黄色で弾性軟であった.腫瘍は成熟脂肪細胞からなり, 胸腺組織や骨格筋組織を認めず, 頸縦隔型脂肪腫と診断した.頸縦隔型脂肪腫は比較的稀な疾患であり文献的考察を加え報告する.

局所進行非小細胞肺癌に, carboplatinとpaclitaxelの少量分割投与と放射線併用術前治療が奏効した2例を報告する.症例1は71歳男性.右肺上葉にcT3N2M0の扁平上皮癌を, 左肺S6にcTINM0M0の肺癌疑いの病巣を認めた.CBDCA (AUC1.25) とTXL (70mg/m2) をweeklyに6週投与後, 右腫瘍に放射線照射40Gyを行い奏効した.照射後発症した放射線性肺臓炎, 帯状疱疹の軽快後, 右肺上葉切除術, 6週後に, 左肺S6区域切除術を施行した.左右肺共に扁平上皮癌であった.周術期に重篤な合併症は認めなかった.症例2は65歳女性.cT4N2M0の左肺下葉腺癌にて, CBDCA (AUC1.25) とTXL (70mg/m2) のweekly投与を2週行い更にTXLを40mg/m2に減量し4週投与と放射線照射50Gyを同時施行後, 左肺全摘術を施行した.周術期に重篤な合併症は認めなかった.CBDCAとTXLによる放射線照射併用した術前治療は本症例に対し奏効し副作用も容認しうる範囲内であった事より局所進行非小細胞肺癌に対し有効な治療法であると期待できる.

症例は25歳男性.気胸にて近医で加療時に胸部異常陰影を指摘され当科紹介受診した.胸部レントゲン写真で左下肺野に腫瘤影及びそれに連続する塊状影を認めた.胸部CTでは左B9+10を閉塞する腫瘤影とmucoid impaction像を認めた.気管支鏡では左B9+10入口部に内腔をほぼ閉塞する腫瘤を認めた.術中迅速診断で粘表皮癌と診断され, 左下葉S9+10区域切除術+気管支形成術を施行した.切除標本では左B9+10を閉塞する35×35×40mm大の腫瘤を認め, 末梢気管支に著明なmucoid impactionを認めた.組織学的には, low-grade malignantな粘表皮癌で気管支壁内に限局し, リンパ節転移も認めなかった.術後2年, 再発を認めていない.本症例は, 同側の気胸を契機に発見されており, また, 著明なmucoid impactionも認め, 興味深い症例と考え報告した.

Long-term survival has become achievable after bone-marrow transplantation, but various pulmonary diseases due to chronic graft-vs.-host disease have been recognized. Particularly, bronchiolitis obliterans is a life-threatening complication with no effective remedy. Bilateral pneumothorax associated with bronchiolitis obliterans is rare, but it requires careful attention. In a 42-year old man with intractable pneumothorax after bone marrow transplantation and surgical procedures, extensive thoracolysis was effective as an acute treatment for this disease.

We report a case of systemic arterial supply to normal segment of the lung without sequestration in a 27-year-old man with intermittent and massive hemoptysis. Multidetector-row CT scan demonstrated that dilated basal pulmonary venous branches and an aberrant artery connecting lower thoracic aorta and running toward the medial basal segment of right lung. Angiography showed a dilated aberrant artery with mild shunts to basal pulmonary venous branches connecting an anomalous pulmonary vein. Transarterial embolization of the aberrant artery was occluded by multiple 0.035-in. coils under balloon occlusion technique. Hemoptysis has been ceased after transarterial coil embolization which is useful and safe in the treatment of this rare congenital anomaly and may be alternative to surgical intervention.

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

症例は80歳女性.67歳時右乳癌にて手術を施行された.術後13年目の2000年8月胸部Xpにて右下肺野に腫瘤陰影を認めた.胸部CTにて右S10胸膜直下に辺縁平滑で石灰化は認められない直径1cm大の腫瘤を認めた.診断治療目的にて2000年11月胸腔鏡下肺部分切除術を施行.術中組織診断にて悪性細胞を認めず.永久標本にて肺犬糸状虫症と診断された.肺犬糸状虫症は術前診断がなされることは少なく, 開胸肺生検がなされる.確定診断に侵襲の少ない胸腔鏡下肺生検を用いることは有用であり, 肺野末梢結節影の鑑別疾患の1つとして考慮すべきと思われる.

To examine whether efficacy of postoperative oral administration of UFT, a 5-fluorouracil derivative chemotherapeutic agent, may be influenced by incidence of apoptosis (apoptosis index) or apoptosis-related gene status (p53 and bcl-2) of the tumour, a total of 162 patients with pathologic stage I non-small cell lung cancer were retrospectively reviewed. UFT was administrated postoperatively to 44 patients (UFT group), and not to the other 118 patients (Control group). For all patients, 5-year survival rate of the UFT group (79.9%) seemed higher than that of the Control group (69.8%), although without significant difference (P = 0.054). For patients with higher apoptotic index, 5-year survival rate of the UFT group (83.3%) was significantly higher than that of the Control group (67.6%, P = 0.039); for patients with lower apoptotic index, however, there was no difference in the prognosis between these two groups. Similarly, UFT was effective for patients without p53 aberrant expression (5-year survival rates: 95.2% for the UFT group and 74.3% for the Control group, P = 0.022), whereas not effective for patients with p53 aberrant expression. Bcl-2 status did not influence the efficacy of UFT. In conclusion, apoptotic index and p53 status are useful factors to predict the efficacy of postoperative adjuvant therapy using UFT. © 2001 Cancer Research Campaign http://www.bjcancer.com

We report a rare case of multiple endocrine neoplasia (MEN) type 1 with thymoma. A 57-year-old woman with a chronic duodenal ulcer and hypoglycemia had been seen at a nearby clinic. Abdominal echogram revealed two nodules in the pancreas and she was referred to our hospital for evaluation. Her diagnosis was MEN type 1, gastrinoma and hyperparathyroidism with anterior mediastinal tumor. There were high calcium levels in the blood and urine. Gastrin was quite high. A chest X-ray revealed a retrosternal tumor. Computed tomography revealed an anterior mediastinal tumor without sign of invasion to the surrounding organs, and two small masses in the pancreas. Cervical echogram revealed a few masses in both sides behind the thyroid. From these findings, her preoperative diagnosis was MEN type 1 with thymic carcinoid or thymoma. We performed thymectomy and parathyroidectomy concomitantly. The mediastinal tumor was diagnosed as invasive thymoma.

Omentopexy has improved the treatment of chronic empyema and postpneumonectomy bronchopleural fistula, which otherwise are difficult to manage. However, omentopexy is not effective in some patients. Four of 17 patients who underwent omentopexy in our institution between January 1978 and March 1994 did not respond to the treatment and died. In two patients, a dead space remained after surgery and there was insufficient sterilization. In one patient, a dead space appeared after surgery and it was impossible to control infection. The fourth patient had dehiscence of the anastomosis triggered by postoperative acute gastritis. All four patients in whom omentopexy was not successful died. When omentopexy is used for empyema, the space should first be sterilized. If sterilization is insufficient, muscle filling and thoracoplasty must be performed and no dead space left.

With the progress of antibiotic therapy, the mortality of lung abscess has been improved, and surgical intervention has declined. However, surgery is still required in selected cases that are intractable to antibiotic treatment. Video-assisted thoracoscopic surgery (VATS) is beneficial for treatment and/or diagnosis of pulmonary disease as it provides a less invasive surgical technique and reduces prolongation of post-operative recovery. However, the indication of VATS lobectomy for lung abscess is controversial as a result of particular complications, i.e. wet lung, intrapleural adhesion and ease of bleeding. We herein report a rare combination of lung abscess and osteomyelitis of mandible resulting from the same pathogen successfully treated with VATS lobectomy. We propose VATS lobectomy for lung abscess. This procedure might be the best treatment candidate for selected cases of lung abscess.

Ischemia and reperfusion cause the production of oxygen free radicals. These damage grafts or disrupt normal vascular homeostatic mechanisms, with a parallel reduction in endothelial nitric oxide and adenosine 3′,5′-cyclic monophosphate levels. We hypothesized that lung preservation failure may be related to these events. To improve lung preservation, we prepared a new ET-Kyoto solution, which contains N -acetylcysteine (a radical scavenger), nitroglycerin (to elevate the nitric oxide level), and dibutyryl adenosine 3′,5′-cyclic monophosphate (to elevate the adenosine 3′,5′-cyclic monophosphate level) and examined its efficacy in a canine single-lung transplantation model. Lungs were flushed with new ET-Kyoto solution (group I, n = 9), basal ET-Kyoto solution (group II, n = 6), basal ET-Kyoto solution plus ethanol and propylene glycol (solvents of nitroglycerin; group III, n = 6), or low-potassium dextran glucose solution (group IV, n = 6), and stored at 4º C for 30 hours. After left single-lung transplantation, the right main bronchus and right pulmonary artery were ligated and the functions of the transplanted lung were assessed for 6 hours. Arterial oxygen tension was significantly higher in group I than in groups II, III, and IV ( p < 0.05). Peak inspiratory pressure and wet-to-dry lung weight ratio were significantly lower in group I than in groups II and IV ( p < 0.01). Histologic and ultrastructural studies showed better preservation in group I than in groups II, III, and IV. We conclude that the new ET-Kyoto solution provides enhanced 30-hour lung preservation. (J THORAC CARDIOVASC SURG 1996;112:569-76)

Before tracheal transplantation can be applied clinically, several problems must be solved: immunosuppression, blood supply to grafts, and reliable long-term preservation of grafts. We have conducted experiments on tracheal transplantation to solve these problems. In the present study, we tried a new operative procedure to accomplish reliable revascularization of transplanted tracheal grafts. It has been reported that transplantation of a 10-ring length of trachea is difficult even with omentopexy. Long tracheal allografts can be transplanted with use of direct revascularization, but this technique is extremely troublesome. Thus we developed a new operative procedure, “split tracheal transplantation,” in which grafts are divided at the midportion and covered with omentum, after demonstrating that the blood supply to tracheal grafts can be reestablished around the suture lines. Two groups of dogs were used. In group A (control, n = 4), a 10-ring length of trachea was autotransplanted. The anastomotic sites and grafts were covered with omental pedicles. In group B (split tracheal transplantation, n = 10), tracheal grafts 10 rings long were autotransplanted. These grafts were divided at the midportion, a piece of omentum was inserted between the two halves, and the midportion was sutured. Grafts were observed regularly by bronchoscopy and examined histopathologically after the animals died or were killed. In some animals, microangiography of the bronchial circulation was done. In the control group, necrosis, stenosis, or malacia of the grafts was observed in three of the four animals. In the split transplantation group, all animals survived for at least 2 months, all grafts were incorporated, and none showed ischemia, stenosis, or malacia. Microscopic examination and microangiography revealed that neovascularization of the graft was promoted by omentum inserted at the midportion of the graft. Split transplantation of the trachea is an easy and reliable way to extend tracheal resection. (J Thorac Cardiovasc Surg 1996;112:-8)

We previously reported that cryopreservation of tracheas for 1 month was possible in a canine tracheal autotransplantation model with use of a preservative solution containing trehalose. Realizing that the allogenicity of many organs is decreased by freezing, we examined the possibility of immunosuppressant-free canine tracheal allotransplantation after long-term cryopreservation. Six to 10 rings of the trachea were removed from donor dogs ( n = 12), immersed in the preservative solution, and cryopreserved in a deep freezer at -85o C for 285 ± 28 days (cryopreservation group). Five rings of the mediastinal trachea of recipient dogs were removed. The cryopreserved tracheas were thawed and transplanted to replace the excised mediastinal tracheas. In a control group ( n = 6), the graft was preserved in Euro-Collins solution at 10o C for 16 to 17 hours. Allotransplantation of tracheas was done as in the cryopreservation group. The anastomotic site and graft were covered with an omental pedicle in both groups. In the cryopreservation group, every animal, except one that was killed for pathologic examination, survived more than 2 months. All the grafts of this group were viable, and no stenosis or tracheomalacia was observed. In the control group, most of the animals died within 1 month of tracheal stenosis caused by rejection. These findings reveal that immunosuppressant-free canine tracheal allotransplantation was consistently possible after long-term cryopreservation of the graft in a preservative solution containing trehalose. This simple method could solve both donor shortage and immunosuppression problems. (J THORAC CARDIOVASC SURG 1996;111:930-4)

Background. We analyzed the operative outcome of extensive surgery for invasive thymoma, especially in those with thymomas invading the superior vena cava, the left innominate vein, or both. Methods. We treated 41 patients with invasive thymoma, including 34 stage III, 5 stage IVa, and 2 stage IVb thymomas. Thirty-eight patients received radiotherapy preoperatively or postoperatively. In 12 patients with invasion of the superior vena cava or innominate vein, we performed angioplasty, reconstruction, or both. Results. The overall 5-year survival rate was 77% and the 10-year survival rate was 59%. In the stage III group, there was a significant difference between those with complete and those with incomplete resection. Ten of 12 patients who had angioplasty with or without reconstruction of the superior vena cava or innominate vein survived without recurrence of the tumors. Conclusion. Angioplasty and vascular reconstruction are recommended because successful treatment for invasive thymomas depends on complete resection of the tumors.

症例は50歳の女性.検診時の胸部X線写真にて左胸部腫瘤様陰影を指摘され, 精査・治療目的で入院した.胸部X線写真, 胸部CT写真より左舌区の肺腫瘍が疑われたが, 気管支鏡検査では確診に至らなかった.そこで診断をかねて胸腔鏡下に腫瘤摘出を試みたが肺と胸壁の間の癒着が強いため開胸した.舌区の肺胸膜と胸壁の間に線維性癒着が強くその線維の間に乳白色の遊離物質が存在し, 肺内には腫瘤は認めなかった.遊離物質は径約2.0×1.0×1.0cm, 表面平滑で光沢を有し, 乳白色で軟骨様硬の球状のものであった.病理組織学的には中心部にはDustを含んだ結合織が存在しその周囲を硝子様化結合組織が同心円状に層状に取り囲んでいた1これは「胸腔内遊離結石」の前駆物質と考えられ極めて稀な症例である.

症例1は45歳, 女性, 症例2は50歳, 男性, いずれの症例も検診で肺野に孤立性銭形陰影を発見された来院した.その他の諸検査で異常を認めなかったが, 肺癌を否定できないため肺部分切除を行った.病理組織で壊死を伴う肉芽腫様組織中に犬糸状虫の虫体を認め肺犬糸状虫症と診断した.肺犬糸状虫症の報告は近年増加しているが, 特異的所見に乏しく非観血的診断が困難である。銭形陰影を呈する肺病変, 特に肺癌との鑑別診断に肺犬糸状虫症を考慮する必要がある.

症例は, 56歳, 女性.10年来の発作的な上背部痛を自覚していた.初診時の胸部X線写真, 胸部CTにて左上縦隔に5.0×3.5cmの腫瘤を認め, 神経鞘腫を疑い後縦隔腫瘍摘出術を施行した.腫瘍は暗赤色で被膜に包まれ腫瘍内は血管に富んでいた.病理学的検査にて豊富な血管を取り巻く小型核を有するuniformな細胞がシート状に認められ, グロムス腫瘍と診断した.52歳時に摘出した左足部腫瘍組織と比較したところ同様の病理所見が認められ多発性グロムス腫瘍と考えられた.両部位とも摘出後に癖痛は消失した.後縦隔に発生したグロムス腫瘍は非常にまれであり, さらに長い経過で多発性に認められた稀有な症例を経験したので文献的考察を加えて報告した.

症例は56歳, 女性.咳嗽, 体重減少を主訴に近医を受診し, 胸部異常陰影を指摘された.CTを中心とした画像診断を行い, 前縦隔腫瘍と診断し, 手術目的で当院に入院した.腫瘍摘出術を施行したところ, 腫瘍は左S3b領域の臓側胸膜に有茎性に付着していた.病理診断の結果, 腫瘍は紡錘形細胞と線維組織からなり, 限局性線維性胸膜中皮腫であることが判明した.術前に腫瘍の位置が縦隔か胸腔内かを, 画像上で区がするのは困難であったが, 術後の再検討の結果, MRIでは縦隔脂肪織がよく描出され, CTに比べ鑑別に有効だと考えられた.有茎性の胸膜中皮腫は肺内腫瘍との鑑別が困難であることが多いが, 今回の症例のように縦隔腫瘍との鑑別が困難な例は稀であり, 報告した.