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Purpose: Higher serum 25-hydroxyvitamin D (25(OH)D) levels are reportedly associated with better survival in early-stage non–small cell lung cancer (NSCLC). Therefore, whether vitamin D supplementation can improve the prognosis of patients with NSCLC was examined (UMIN000001869).Patients and Methods: A randomized, double-blind trial comparing vitamin D supplements (1,200 IU/day) with placebo for 1 year after operation was conducted. The primary and secondary outcomes were relapse-free survival (RFS) and overall survival (OS), respectively. Prespecified subgroup analyses were performed with stratification by stage (early vs. advanced), pathology (adenocarcinoma vs. others), and 25(OH)D levels (low, Results: Patients with NSCLC (n = 155) were randomly assigned to receive vitamin D (n = 77) or placebo (n = 78) and followed for a median of 3.3 years. Relapse and death occurred in 40 (28%) and 24 (17%) patients, respectively. In the total study population, no significant difference in either RFS or OS was seen with vitamin D compared with the placebo group. However, by restricting the analysis to the subgroup with early-stage adenocarcinoma with low 25(OH)D, the vitamin D group showed significantly better 5-year RFS (86% vs. 50%, P = 0.04) and OS (91% vs. 48%, P = 0.02) than the placebo group. Among the examined polymorphisms, DBP1 (rs7041) TT and CDX2 (rs11568820) AA/AG genotypes were markers of better prognosis, even with multivariate adjustment.Conclusions: In patients with NSCLC, vitamin D supplementation may improve survival of patients with early-stage lung adenocarcinoma with lower 25(OH)D levels. Clin Cancer Res; 24(17); 4089–97. ©2018 AACR.

Figure S1. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by 25(OH)D equal to or greater than 30 ng/mL. Figure S2. Kaplan-Meier curves of patients restricted only to adenocarcinoma, or both early stages (IA - IIB) and adenocarcinoma. Figure S3. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by SNPs of FokI. Mean (SD) of 25(OH)D in each genotype are as follows; FokI CC, 19.9 (6.2) ng/ml; CT, 21.8 (6.6) ng/ml; TT 21.4 (7.9) ng/ml. Figure S4. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by SNPs of BsmI. Mean (SD) of 25(OH)D in each genotype are as follows: BsmI AA, 15 (-) ng/ml; AG, 20.2 (6.4) ng/ml; GG 21.7 (6.8) ng/ml. Figure S6. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by SNPs of ApaI. Mean (SD) of 25(OH)D in each genotype are as follows: ApaI GG, 21.2 (7.2) ng/ml; GT, 21.4 (6.3) ng/ml; TT, 21.5 (7.7) ng/ml. Figure S7. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by SNPs of TaqI. Mean (SD) of 25(OH)D in each genotype are as follows: TaqI TT, 21.7 (6.7) ng/ml; TG, 20.4 (6.9) ng/ml; GG, - (-) ng/ml. Figure S8. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by SNPs of DBP1. Mean (SD) of 25(OH)D in each genotype are as follows: DBP1 TT, 21.3 (7.0) ng/ml; TG, 20.8 (6.0) ng/ml; GG, 23.6 (7.9) ng/ml. Figure S9. Relapse-free survival curves (A) and overall survival curves (B) of patients stratified by SNPs of DBP2. Mean (SD) of 25(OH)D in each genotype are as follows: DBP2 CC, 22.7 (6.6) ng/ml; CA, 20.0 (6.3) ng/ml; AA, 12.8 (1.5) ng/ml.

The aim of this study was to investigate the usefulness of laparoscopic surgery for patients with postoperative abdominal symptoms, including chronic recurrent small-bowel obstruction (SBO), and preoperative examinations of barium follow-through and computed tomography (CT) to predict the postoperative outcomes of laparoscopic surgery. Between 2016 and 2018, 49 patients with postoperative symptoms were treated by laparoscopic surgery at our institute. The data from two preoperative examinations were available for 42 patients. The patients were divided into 4 groups: CT-positive (CP, n = 18), barium follow-through-positive (BP, n = 1), both positive (AP [all positive] n = 13), and both negative (AN [all negative], n = 10). Among the 49 patients, 41 received pure laparoscopic surgery, 7 received laparoscopic-assisted surgery with mini-laparotomy, and 1 required conversion. Intra- and postoperative complications occurred in two and seven patients, respectively. Improvement of abdominal symptoms was observed in 40 patients. In terms of the medium-term outcomes, the rate of improvement of symptoms was poorer in the AN group than in the other three groups, but not to a significant degree. Laparoscopic surgery was safe and feasible for patients with chronic recurrent abdominal symptoms, including SBO. Furthermore, in patients with negative results on both preoperative examinations, laparoscopic surgery may yield only poor improvement of symptoms.

INTRODUCTION The purpose of this study was to clarify the usefulness of SILS for right-sided colon cancer by evaluating the short-term and midterm outcomes. METHODS Between 2012 and 2017, 65 selected patients with right-sided colon cancer underwent ileocecal resection, right hemicolectomy, or transverse colectomy; all were enrolled in the study. The same well-trained surgeon performed each procedure by using a multi-instrument access port with three channels, which was placed at the umbilicus via an approximately 3-cm skin incision. RESULTS The pathological disease stage distribution was stage 0, 4 cases; stage I, 23 cases; stage II, 19 cases; stage III, 17 cases; and stage IV, 2 cases. The surgical procedures performed were ileocecal resection, 23 cases; right hemicolectomy, 35 cases; and transverse colectomy, 7 cases. The median operative time and intraoperative blood loss were 216 min and 10 mL, respectively. Although 18 cases needed additional ports, none required conversion to open surgery. The median number of harvested lymph nodes was 24. No major perioperative morbidities occurred in this patient series. The median postoperative hospital stay was 7 days. The median follow-up period was 30 months, and the 3-year relapse-free and overall survival rates were 100% and 100%, respectively, in the stage 0-I cases and 89% and 96% in the stage II-III cases, respectively. CONCLUSION We concluded that SILS is as feasible as multiport laparoscopic surgery and a reliable surgical option in selected cases of right-sided colon cancer.

Purpose: Higher serum 25-hydroxyvitamin D (25(OH)D) levels are reportedly associated with better survival in early-stage non–small cell lung cancer (NSCLC). Therefore, whether vitamin D supplementation can improve the prognosis of patients with NSCLC was examined (UMIN000001869). Patients and Methods: A randomized, double-blind trial comparing vitamin D supplements (1,200 IU/day) with placebo for 1 year after operation was conducted. The primary and secondary outcomes were relapse-free survival (RFS) and overall survival (OS), respectively. Prespecified subgroup analyses were performed with stratification by stage (early vs. advanced), pathology (adenocarcinoma vs. others), and 25(OH)D levels (low, Results: Patients with NSCLC (n = 155) were randomly assigned to receive vitamin D (n = 77) or placebo (n = 78) and followed for a median of 3.3 years. Relapse and death occurred in 40 (28%) and 24 (17%) patients, respectively. In the total study population, no significant difference in either RFS or OS was seen with vitamin D compared with the placebo group. However, by restricting the analysis to the subgroup with early-stage adenocarcinoma with low 25(OH)D, the vitamin D group showed significantly better 5-year RFS (86% vs. 50%, P = 0.04) and OS (91% vs. 48%, P = 0.02) than the placebo group. Among the examined polymorphisms, DBP1 (rs7041) TT and CDX2 (rs11568820) AA/AG genotypes were markers of better prognosis, even with multivariate adjustment. Conclusions: In patients with NSCLC, vitamin D supplementation may improve survival of patients with early-stage lung adenocarcinoma with lower 25(OH)D levels. Clin Cancer Res; 24(17); 4089–97. ©2018 AACR.

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Cigarette smoke (CS)–induced cellular senescence has been implicated in the pathogenesis of chronic obstructive pulmonary disease, and SIRT6, a histone deacetylase, antagonizes this senescence, presumably through the attenuation of insulin-like growth factor (IGF)-Akt signaling. Autophagy controls cellular senescence by eliminating damaged cellular components and is negatively regulated by IGF-Akt signaling through the mammalian target of rapamycin (mTOR). SIRT1, a representative sirtuin family, has been demonstrated to activate autophagy, but a role for SIRT6 in autophagy activation has not been shown. Therefore, we sought to investigate the regulatory role for SIRT6 in autophagy activation during CS-induced cellular senescence. SIRT6 expression levels were modulated by cDNA and small interfering RNA transfection in human bronchial epithelial cells (HBECs). Senescence-associated β-galactosidase staining and Western blotting of p21 were performed to evaluate senescence. We demonstrated that SIRT6 expression levels were decreased in lung homogenates from chronic obstructive pulmonary disease patients, and SIRT6 expression levels correlated significantly with the percentage of forced expiratory volume in 1 s/forced vital capacity. CS extract (CSE) suppressed SIRT6 expression in HBECs. CSE-induced HBEC senescence was inhibited by SIRT6 overexpression, whereas SIRT6 knockdown and mutant SIRT6 (H133Y) without histone deacetylase activity enhanced HBEC senescence. SIRT6 overexpression induced autophagy via attenuation of IGF-Akt-mTOR signaling. Conversely, SIRT6 knockdown and overexpression of a mutant SIRT6 (H133Y) inhibited autophagy. Autophagy inhibition by knockdown of ATG5 and LC3B attenuated the antisenescent effect of SIRT6 overexpression. These results suggest that SIRT6 is involved in CSE-induced HBEC senescence via autophagy regulation, which can be attributed to attenuation of IGF-Akt-mTOR signaling.

OBJECTIVES: Thoracoscopic thymectomy has gradually replaced conventional sternotomy for resection of thymoma; however, a thoracoscopic approach for thymoma remains controversial. We evaluated the oncological outcomes of thoracoscopic thymectomy for the treatment of stages I–III thymomas. METHODS: Sixty-two patients who underwent thoracoscopic thymectomy for the treatment of thymoma were retrospectively reviewed between July 2005 and September 2011 at Jikei University Hospital. Surgical outcomes and pathological results between stages I + II and stage III were compared. RESULTS: Twenty-nine patients had Masaoka stage I, 28 had stage II and 5 had stage III. Three stage III patients needed conversions to open surgery. Masaoka stage III comprised pathological type B3 in 3 patients and thymic carcinoma in 2. For all patients, the 5-year overall survival rate was 100%. Three recurrences, diagnosed as thymic carcinoma, were observed in the Masaoka stage II or III patients. The 5year disease-free survival rate was 94.2% for all patients, 100% for Masaoka stage I, 96.1% for stage II and 37.5% (55 months) for stage III (P= 0.002). The 5-year disease-free survival rate was 100% for the World Health Organization classification types A, AB and B1–3 and 0% for thymic carcinoma (P< 0.0001). Significant differences were found in the 5-year disease-free survival stratified by the Masaoka stage or WHO classification, but not by surgical procedures. CONCLUSIONS: Thoracoscopic thymectomy for Masaoka stages I and II thymomas presented acceptable oncological outcomes. Further investigation in a large series with longer follow-up is required. Masaoka stage III thymoma requires careful consideration of the approaches, including median sternotomy.

Autophagy, a process that helps maintain homeostatic balance between the synthesis, degradation, and recycling of organelles and proteins to meet metabolic demands, plays an important regulatory role in cellular senescence and differentiation. Here we examine the regulatory role of autophagy in idiopathic pulmonary fibrosis (IPF) pathogenesis. We test the hypothesis that epithelial cell senescence and myofibroblast differentiation are consequences of insufficient autophagy. Using biochemical evaluation of in vitro models, we find that autophagy inhibition is sufficient to induce acceleration of epithelial cell senescence and myofibroblast differentiation in lung fibroblasts. Immunohistochemical evaluation of human IPF biospecimens reveals that epithelial cells show increased cellular senescence, and both overlaying epithelial cells and fibroblasts in fibroblastic foci (FF) express both ubiquitinated proteins and p62. These findings suggest that insufficient autophagy is an underlying mechanism of both accelerated cellular senescence and myofibroblast differentiation in a cell-type-specific manner and is a promising clue for understanding the pathogenesis of IPF.

A 48-year-old woman had a left breast mass identified during routine breast cancer screening. The mammogram showed pleomorphic-segmental microcalcifications in the mediolateral-oblique view of the left breast. Ultrasonography showed a hypoechoic mass approximately 3.7 cm in diameter with multiple calcifications. Contrast-enhanced magnetic resonance imaging of the breast showed non-mass like enhancement of approximately 4 cm in diameter in the C area of the left breast. She was diagnosed with glycogen-rich clear cell carcinoma (GRCC) by ultrasound-guided vacuum-assisted biopsy. Nipplesparing mastectomy was performed along with sentinel lymph node biopsy. The intraoperative consultation suggested sentinel lymph node metastasis and we therefore performed axillary lymph node dissection. Pathological examination reported microinvasive carcinomas, 0.4 cm in maximum diameter, and extensive intraductal components, 5 cm in size. The tumor cells were stained on PAS staining, but the stains were digested with diastase. The cells were negative for adipophilin. GRCC was first reported by Hull et al. This is a rare type of breast carcinoma. There is no standard therapy for this disease or any data on the prognosis of breast cancer patients with GRCC.

Introduction Secondary spontaneous pneumothorax (SSP) can be life threatening because patients often have severe lung disease with other coexisting diseases such as heart disease. In this study, we evaluate the feasibility of thoracoscopic surgery to treat SSP and discuss thoracoscopic techniques for managing complicated cases. Methods We retrospectively evaluated the outcome of thoracoscopic surgeries in 21 SSP patients. Results Fifteen patients had chronic emphysema, four had interstitial pneumonia, and two had inflammatory lung disease. All patients presented with persistent air leaks, and their median preoperative hospital stay was 11 days. All patients underwent thoracoscopic surgery. In 12 patients, the leaking bullae were excised by endoscopic stapling. Fibrin glue was used in 16 cases and polyglycolic acid sheets in 17. Polyglycolic acid sheets and fibrin glue without bullectomy were used in three cases. Air leaks were treated by simple stapling in four cases and by gelatin-resorcin formaldehyde glue in five. Median postoperative hospital stay was 8 days. No patients required conversion to open surgery. Postoperative complications such as persistent air leaks, pneumonia, and acute respiratory failure were observed in six patients. Four recurrences of pneumothorax were observed during the median postoperative follow-up period of 19.3 months. Conclusion Our results suggest that thoracoscopic surgery is feasible and less invasive than open surgery for high-risk patients, and it improves patient quality of life. Various techniques to stop air leaks enabled us to treat patients with refractory SSP.

Purpose This study aimed to evaluate the clinical outcomes of chest wall reconstruction using a relatively new expanded polytetrafluoroethylene prosthesis Gore-Tex(®) dual mesh. Methods We reviewed charts of 11 patients who underwent bony chest wall resection from April 2006 to January 2011. Results Six patients underwent three ribs resection, three patients underwent two ribs resection, and the other two patients underwent sternal resection. Of six patients after three ribs resection, three underwent reconstruction using 2 mm Gore-Tex(®) dual mesh, one using Gore-Tex(®), one using Bard composite E/X, and the remaining one used no prosthesis. Three patients who underwent two ribs resection underwent no chest wall reconstruction using prosthesis. Two patients who underwent sternal resection underwent chest wall reconstruction using dual mesh with or without a vascularized musculocutaneous pedicle flap. Immediate postoperative extubation was performed in all patients, except one who was extubated the following day. No postoperative deaths or cases with paradoxical respiration occurred. Conclusion Chest wall reconstruction using Gore-Tex(®) dual mesh demonstrated acceptable durability.

症例は23歳女性．2009年5月頃より左胸痛を自覚し，6月下旬より発熱を認めた．胸部X線上左下肺野に異常陰影および左胸水貯留を呈し，胸部CTでは左胸腔内に7cm大の境界明瞭な嚢胞性腫瘤影が確認された．採血では腫瘍マーカーCA19-9が異常高値を示した．画像上縦隔腫瘍を疑い，手術目的で当科受診した．完全胸腔鏡下手術により病変の完全切除が行われ，切除した検体の内腔には毛髪や皮脂を含み，組織学的には膵組織などを伴う成熟型嚢胞性奇形腫と考えられた．術前高値を示した血中CA19-9は術後正常値に戻った．

症例は47歳の男性．主訴は易疲労感，労作時の息切れであった．精査にて赤芽球癆および低ガンマグロブリン血症と診断し，胸部CT上，前縦隔に胸腺と一致して長径87mmの境界明瞭な腫瘤性病変を認めた．本症例に対し，われわれはintension to treatによる胸腔鏡下胸腺胸腺腫切除を施行した．手術時間は255分で出血量は100mlであった．切除検体は88×53×30mm，93g．病理組織検査にてWHO分類type AB，正岡分類II期の胸腺腫と診断した．本症は術後42病日に貧血を認め輸血を行い，現在，内科的治療にて経過観察中である．赤芽球癆および低ガンマグロブリン血症を合併した胸腺腫は非常に稀である．赤芽球癆は難治性自己免疫疾患で，胸腺腫合併例に対する胸腺全摘術は，赤芽球癆に対する内科的治療の抵抗性を改善させる．さらに，胸腔鏡下手術は従来の胸骨正中切開手術と比較し，低侵襲手術であり，自己免疫疾患と関連する胸腺疾患への適応拡大が期待される．本例と同様の症例に対する，胸腔鏡手術の術後成績の蓄積が必要と考える．

背景．縦隔に発生する嚢胞性病変には様々な疾患が存在するが，嚢胞壁に配列する上皮や構成成分を丹念に確認することが，病変の病理組織診断に役立つ．症例．胸部異常陰影で精査となった59歳，男性．画像では上縦隔の左右腕頭静脈に挟まれた領域に径4 cm大の単房性の嚢胞性腫瘤を認めた．右開胸アプローチにて，一部嚢胞壁が残存するも嚢胞摘出術を施行し，緊満した壁の薄い単房性の嚢胞が左右腕頭静脈血管に挟まれるように存在していた．病理組織学的には，嚢胞壁の内面は単層の線毛円柱上皮で覆われ，周囲の脂肪織内に一部退縮胸腺組織と思われる構造が認められた．免疫組織学的検索では，線毛円柱上皮の下層に血管・脂肪織に加え胸腺上皮細胞や未熟胸腺Tリンパ球を含む層が確認され，胸腺嚢胞との診断が可能であった．結論．ほとんどが線毛円柱上皮で裏打ちされ，気管支原生嚢胞との鑑別を要した胸腺嚢胞症例を経験し，（1）嚢胞壁における高度に菲薄化した胸腺組織は，薄い血管脂肪リンパ上皮層（vasculo-adipo-lympho-epithelial（VALE）layer）として存在すること，（2）胸腺組織の証明には免疫組織化学的な検索が有用であることを学んだ．

This report describes a rare case of IgG4-related lung disease that was difficult to distinguish from lung cancer. CT revealed a well-demarcated round tumor in S10 of the right lung of a 56-year-old man suspected of having lung cancer. PET revealed high fluorodeoxyglucose uptake with a maximum standardized uptake value of 14.0. Because primary lung cancer was strongly suspected, lower lobectomy was performed via the thoracoscopic approach without mini-thoracotomy. Histopathology showed lymphoplasmacytic infiltration. Immunostaining revealed numerous IgG4-positive plasma cells diffusely infiltrating the tumor. Serum IgG4 levels increased, thereby confirming the diagnosis of IgG4-related lung disease.

Mediastinal hemangioma is a rare tumor, accounting for 0.5% or fewer of all mediastinal tumors in most reports. We herein report a case of thoracoscopic resection of venous hemangioma in the middle mediastinum. A 48-year-old man was referred to our hospital for dysphagia. A chest computed tomography scan showed the mass to have a smooth surface and heterogeneous contents. Magnetic resonance imaging demonstrated the morphology of the vascular tumor to be a hyperintense mass on a T2-weighted image. Using thoracoscopic surgery, the tumor was completely extirpated and confirmed histologically to be a venous hemangioma. In this case, thoracoscopic surgery provided a satisfactory view and facilitated correct handling for the mediastinal venous hemangioma.

Study objective: To compare the usefulness of MRI and CT in the detection of brain metastases during preoperative evaluation and postoperative follow-up. Design: A prospective and sequential comparison. Patients and methods: Of 332 patients with potentially operable non-small cell lung cancer who were free of neurologic signs and symptoms, brain CT was performed preoperatively on 155 patients (CT group) and brain MRI on 177 patients (MRI group). Patient characteristics in both groups were comparable. In 279 patients with complete resection of the primary lung tumor, intensive follow-up with CT and MRI was performed in the respective groups. The preoperative detection of brain metastases, postoperative intracranial recurrence rates, and characteristics of detected brain tumors were compared between the two groups. The survival of patients with brain metastases was also compared. Results: From the first evaluation to 12 months after surgery for primary lung cancer, brain metastases were observed in 11 patients (7.1%) from the CT group and 12 patients (6.8%) from the MRI group. MRI detected brain metastases preoperatively in 6 of the 12 patients (3.4% of the total MRI group), whereas CT detected brain metastases preoperatively in 1 of the 11 patients (0.6% of the total CT group). MRI showed a tendency toward a higher preoperative detection rate of brain metastases than CT (p 5 0.069). Furthermore, the mean (6 SD) maximal diameter of the brain metastases was significantly smaller in the MRI group (12.8 6 9.1 mm) than in the CT group (20.3 6 7.0 mm) (p 5 0.041). However, the median survival time and 2-year survival rate after treatment of detected brain metastases, respectively, were 10 months and 27% in the CT group and 17 months and 28% in the MRI group. There was no significant difference between the groups in survival time. Conclusions: Preoperative evaluation and intensive follow-up with MRI could facilitate early detection of brain metastases in patients with potentially operable lung cancer. However, further studies on detection and treatment of the metastatic tumors are considered necessary. (CHEST 1999; 115:714 ‐719)

Mitochondria are dynamic organelles that continuously change their shape through fission and fusion. Disruption of mitochondrial dynamics is involved in disease pathology through excessive reactive oxygen species (ROS) production. Accelerated cellular senescence resulting from cigarette smoke exposure with excessive ROS production has been implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD). Hence, we investigated the involvement of mitochondrial dynamics and ROS production in terms of cigarette smoke extract (CSE)-induced cellular senescence in human bronchial epithelial cells (HBEC). Mitochondrial morphology was examined by electron microscopy and fluorescence microscopy. Senescence-associated β-galactosidase staining and p21 Western blotting of primary HBEC were performed to evaluate cellular senescence. Mitochondrial-specific superoxide production was measured by MitoSOX staining. Mitochondrial fragmentation was induced by knockdown of mitochondrial fusion proteins (OPA1 or Mitofusins) by small-interfering RNA transfection. N-acetylcysteine and Mito-TEMPO were used as antioxidants. Mitochondria in bronchial epithelial cells were prone to be more fragmented in COPD lung tissues. CSE induced mitochondrial fragmentation and mitochondrial ROS production, which were responsible for acceleration of cellular senescence in HBEC. Mitochondrial fragmentation induced by knockdown of fusion proteins also increased mitochondrial ROS production and percentages of senescent cells. HBEC senescence and mitochondria fragmentation in response to CSE treatment were inhibited in the presence of antioxidants. CSE-induced mitochondrial fragmentation is involved in cellular senescence through the mechanism of mitochondrial ROS production. Hence, disruption of mitochondrial dynamics may be a part of the pathogenic sequence of COPD development.

Background Anomalous systemic arterial supply to the basal segments of the lung is a rare anomaly. This study aimed to evaluate the outcomes of thoracoscopic surgery for this anomaly. Methods We reviewed patients who underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung between October 2007 and September 2012 at our institution. Results Four patients (mean age 37.5 years; range, 22 to 54) underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung. The mean diameter of the anomalous arteries was 14 mm (range, 10 to 16 mm). Two patients underwent thoracoscopic segmentectomy, 1 of whom had a complicated anomaly that necessitated conversion to thoracotomy. The other 2 patients underwent thoracoscopic lower lobectomy of the left lung. One of them had an aneurysm in the anomalous artery; therefore, endovascular devices were kept on standby in case massive hemorrhage occurred. The anomalous arteries were divided uneventfully using a vascular stapler in all patients. No patient had severe postoperative complications. Conclusions Thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung is feasible, safe, and minimally invasive, with confirmed effectiveness in typical cases.

This report describes a rare case of IgG4-related lung disease that was difficult to distinguish from lung cancer. CT revealed a well-demarcated round tumor in S10 of the right lung of a 56-year-old man suspected of having lung cancer. PET revealed high fluorodeoxyglucose uptake with a maximum standardized uptake value of 14.0. Because primary lung cancer was strongly suspected, lower lobectomy was performed via the thoracoscopic approach without mini-thoracotomy. Histopathology showed lymphoplasmacytic infiltration. Immunostaining revealed numerous IgG4-positive plasma cells diffusely infiltrating the tumor. Serum IgG4 levels increased, thereby confirming the diagnosis of IgG4-related lung disease.

This study aimed to evaluate the clinical outcomes of chest wall reconstruction using a relatively new expanded polytetrafluoroethylene prosthesis Gore-Tex(®) dual mesh.We reviewed charts of 11 patients who underwent bony chest wall resection from April 2006 to January 2011.Six patients underwent three ribs resection, three patients underwent two ribs resection, and the other two patients underwent sternal resection. Of six patients after three ribs resection, three underwent reconstruction using 2 mm Gore-Tex(®) dual mesh, one using Gore-Tex(®), one using Bard composite E/X, and the remaining one used no prosthesis. Three patients who underwent two ribs resection underwent no chest wall reconstruction using prosthesis. Two patients who underwent sternal resection underwent chest wall reconstruction using dual mesh with or without a vascularized musculocutaneous pedicle flap. Immediate postoperative extubation was performed in all patients, except one who was extubated the following day. No postoperative deaths or cases with paradoxical respiration occurred.Chest wall reconstruction using Gore-Tex(®) dual mesh demonstrated acceptable durability.

栃木県立がんセンタ-で10年計画で実施された経年施設検診の肺癌部門の結果を検討した. 2500人を対象に, 年1度の胸部写真と高危険群には喀痰細胞診を施行した. 延べ総受診者26129名, 要精検者938名 (3.6%) 精検受診数908名 (96.6%) で発見肺癌は16例 (10万人対比61) であった. 13人に完全切除術が施行され, 最終病期は1期7例, IIIA期7例, IIIB期1例, IV期1例であった. 15例が肺野発生型で腫瘍径は平均2.6cmで小型病変を発見した割には, 1期例の割合が少なかった. 喀痰細胞診の延べ総受診者は2555名で肺野型腺癌の1例のみにD判定が得られた. 初回検診発見群と経年検診発見群の問には平均腫瘍径, 病期の大差は認められなかった. 今後より早い時期の肺癌を検診で発見するためには, さらに小型の肺野病変を指摘することに他ならない. 現在CT検診の導入を予定しており, これにより1期肺癌の発見を増加させ切除率を高めたいと考えている

A 61-year-old male presented with advanced gastric cancer with lymph node swelling around the root of superior mesenteric artery lymph nodes and invasion of pancreas. We thought a complete resection would be difficult, so he was given neo-adjuvant chemotherapy in combination with S-11 20 mg/body/day (3 weeks administration and 1 week rest) and paclitaxel (PTX) 80 mg/m(2) (day 1, 8, 15). After 2 courses of this neo-adjuvant chemotherapy, the tumor and lymph node swelling decreased in size. Total gastrectomy, Roux-en Y and D1+beta type nodal dissection were performed. Intraoperative findings included tumor exposure on the serous membrane and enlarged lymph nodes on the lesser curvature; however, no marked pancreatic invasion was observed and the lymph nodes had become scarred. The changes with neo-adjuvant chemotherapy were judged to be grade 2. After the operation, there was no side effect, though he received the same chemotherapy as an outpatient in three courses. Five years passed from the first medical examination. The patient remains alive, and the neo-adjuvant chemotherapy proved effective.

138 Background: Nanoparticle albumin-bound paclitaxel (nab-PTX) has a high transitivity into tumor tissue compared to solvent-based paclitaxel (sb-PTX). In a phase III study in patients with metastatic breast cancer, nab–PTX demonstrated nearly double the response rate and significantly longer time to tumor progression than paclitaxel. However, the current problems are that nab-PTX is a higher rate of discontinuation and sensory neuropathy than sb-PTX. We sought to evaluate the efficacy and safety of nab-PTX followed by FEC. Methods: In this study, patients were received 4 cycles of nab-PTX (80 mg/m2) q1w (days 1, 8, and 15 of each 4-week cycle) followed by 4 cycles of FEC q3w. The primary endpoint was pCR rate (ypT0/is ypN0). The secondary endpoints included clinical response rate, disease-free survival, breast-conserving surgery rate, and safety. Results: Forty patients were enrolled; the median age was 53 (range 33-81), postmenopausal women were 62.5%. ER positivity, PgR positivity and HER2 positivity were 62.5%, 52.5% and 37.5%, respectively. Clinical stage for I, II and III were 30%, 62.5% and 7.5%, respectively. The pCR rate (ypT0/is ypN0) was 40% (16/40). In the subtype subset, pCR rates were Luminal A 20% (1/5), Luminal B (HER2 negative) 15.4% (2/13), Luminal B (HER2 positive) 60% (6/10), HER2 enrich 80% (4/5) and TNBC 42.9% (3/7). The breast-conserving surgery rate was 77.5% (31/40). The clinical response rates were cCR 20.0% (8/40), cPR 52.5% (21/40), cSD 25% (10/40) and cPD 2.5% (1/40) after 4 cycles of nab-PTX, cCR 32.5% (13/40), cPR 42.5% (17/40), cSD 20% (8/40) and cPD 5% (2/40) after nab-PTX followed by FEC. Ninety-eight percent patients completed 4 cycles of planned protocol dose of nab-PTX and 62.5% completed FEC. The Grade3/4 hematologic toxicity of nab-PTX was only neutropenia 2.5%. Grade1/2 non-hematologic toxicity were neuropathy 12.5%, arthralgia 7.5% and myalgia 7.5%. Grade3/4 non-hematologic toxicity was no reported. Conclusions: This is the first study to evaluate weekly nab-PTX (80 mg/m2) followed by FEC for operable breast cancer. Our results demonstrated that weekly nab-PTX (80 mg/m2) followed by FEC was well-tolerated and resulted in increased pCR rate than reported data of nab-PTX. Clinical trial information: UMIN000011048.

Transdermal fentanyl patch represents a new administration route for cancer pain relief. We reported here a successful experience with a high-dose of transdermal fentanyl for cancer pain therapy. A 71-year-old woman suffering from metastatic lung cancer to bone had already been treated with radiation at a different hospital. She suffered from severe lumbar pain upon admission to our hospital. During the past 15 months, she has been treated with 30 mg or more of transdermal fentanyl for cancer pain relief. No severe side effects were observed, and she experienced a better quality of life at home using this patch long-term.

We herein present a patient with Morgagni hernia which was diagnosed by magnetic resonance imaging (MRI). The patient had a progressively enlarging mass in the right cardiophrenic angle on chest roentgenogram. On computed tomography (CT) scans, the mass was revealed to have fat density and therefore was suspected to be either a lipoma or liposarcoma. MRI clearly demonstrated that the mass shadow was composed of omental fat herniating into the right thorax through the diaphragmatic hiatus. MRI is thus considered to be a useful noninvasive modality for the evaluation of lower anterior mediastinal masses demonstrating fat density on CT.

Twelve cases of carcinoid tumors of the thymus were reviewed in terms of clinicopathologic, histochemical, and immunohistochemical features and DNA ploidy patterns. The collective consisted of nine male and three female patients, aged 34 to 74 years, of whom five (42%) had symptoms. Eleven patients underwent surgical resection, and one with systemic metastases was autopsied. In the 11 resected patients, tumors had invaded surrounding structures in four cases, and mediastinal lymph node metastases were detected in six. Recurrence occurred in two of the resected patients (18%), and the 5-year survival rate was 82%. Histologically, all tumors showed an organoid growth pattern with delicate fibrovascular stroma. In addition, three tumors had unusual morphologic features such as combined features of carcinoid tumor and thymoma and solid growth pattern with occasional large tumor cells. Mitotic counts ranged from 1 to 14 per 10 high-power fields with a mean count of 4.9. Central necrosis within solid nests was observed in nine tumors. Classification of this series using the WHO histologic classification system resulted in categorization of all 12 tumors as atypical carcinoids. All tumors were positive for Grimelius staining and for cytokeratin. Immunohistochemical staining documented the presence of moderately to strongly positive neuroendocrine markers such as neuron-specific enolase, chromogranin A, synaptophysin, and neural cell adhesion molecule. No correlation between proliferative activity based on the Ki67 labeling index and prognosis or lymph node metastasis was found. Concerning DNA ploidy patterns, only one tumor with multiple lymph node metastases was considered to be aneuploid. In conclusion, although all of our cases were histologically classified as atypical carcinoid tumors of the thymus, most were diploid, and the patients enjoyed a relatively good prognosis.

The authors report a case of recurrent thymoma displaying endobronchial polypoid growth. Initially, the patient had invasive thymoma with intracaval growth into the right atrium. He was treated with multimodality therapy consisting of chemotherapy, surgical resection, and radiotherapy (50.4 Gy). Both 3 years and 6 years after the initial treatment, the tumor recurred outside the reconstructed superior vena cava. The patient was treated with repeated radiotherapy (50.4 Gy and 40 Gy), and remission was achieved. Eight years after the first therapy, an endobronchial polypoid lesion was detected in the right upper lobe bronchus and was histologically found to be thymoma. Endobronchial high-dose rate brachytherapy (20 Gy at 3 mm/5 fractions) was carried out for palliation because the recurrent tumor occurred outside of the superior vena cava area, which had been reirradiated. After the treatment, the endobronchial tumor shrunk remarkably in size without adverse effects. No tumor regrowth has been noted after a follow-up of 10 months.

An operative case of localized mesothelioma of the pleura developed in a 17-year-old female was reported. She was admitted to our hospital complaining of right chest pain. A chest X-ray film showed a huge mass in the right lower field of the lung. After the embolization of the right inferior phrenic artery, which was the main feeder to the tumor, it was then successfully resected combined with the right diaphragm and the right lower lobe of the lung. Histologically, the tumor was diagnosed as benign localized mesothelioma (solitary fibrous tumor of the pleura). Further histological and immunohistochemical study revealed that it had developed from the connective tissue under the parietal mesothelium of the diaphragm. As chest roentgenograms had been undertaken during past two years, the tumor volume doubling time was calculated at 153 days. Despite the short tumor volume doubling time as like primary lung cancer, she is alive without recurrence 5 years after the operation.

Background Marked accumulation of alveolar macrophages (AM) conferred by apoptosis resistance has been implicated in pathogenesis of chronic obstructive pulmonary disease (COPD). Apoptosis inhibitor of macrophage (AIM), has been shown to be produced by mature tissue macrophages and AIM demonstrates anti-apoptotic property against multiple apoptosis-inducing stimuli. Accordingly, we attempt to determine if AIM is expressed in AM and whether AIM is involved in the regulation of apoptosis in the setting of cigarette smoke extract (CSE) exposure. Methods Immunohistochemical evaluations of AIM were performed. Immunostaining was assessed by counting total and positively staining AM numbers in each case (n = 5 in control, n = 5 in non-COPD smoker, n = 5 in COPD). AM were isolated from bronchoalveolar lavage fluid (BALF). The changes of AIM expression levels in response to CSE exposure in AM were evaluated. Knock-down of anti-apoptotic Bcl-xL was mediated by siRNA transfection. U937 monocyte-macrophage cell line was used to explore the anti-apoptotic properties of AIM. Results The numbers of AM and AIM-positive AM were significantly increased in COPD lungs. AIM expression was demonstrated at both mRNA and protein levels in isolated AM, which was enhanced in response to CSE exposure. AIM significantly increased Bcl-xL expression levels in AM and Bcl-xL was involved in a part of anti-apoptotic mechanisms of AIM in U937 cells in the setting of CSE exposure. Conclusions These results suggest that AIM expression in association with cigarette smoking may be involved in accumulation of AM in COPD.