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We present a 76-year-old man who underwent two lung resections for metastases originating from cancer of the Ampulla duodeni, 9 years-after pancreaticoduodenectomy with lymphadenectomy. Pancreaticoduodenectomy was performed in 2002; histological examination of the original tumor revealed a stage III tubular adenocarcinoma (pT3, N0, M0). Repetitive lung resection was performed in 2007 (left S8) and 2011 (right S1 and extirpation of a pericardial cyst). Although rarely performed, resection of bilateral pulmonary metastases from carcinoma of the papilla of Vater was done to improve the patient's chances for longterm survival.

We present a rare case of solitary pulmonary papillary adenoma. A man consulted our hospital because of abnormal chest radiography finding. Chest computed tomography demonstrated a well-defined, homogeneous nodular shadow 11 mm in size at the left lower lobe. The previous physician had considered it to be an old benign inflammatory granuloma and had kept it under observation. This mass was followed through chest radiographs at annual medical checkups for 4 years. In 2006, enlargement and lobulation were noted. We performed thoracoscopic partial resection of the left lower lobe. On postoperative pathology examination, the nodule was found to be a circumscribed nodule consisting of a papillary growth of cuboidal to low-columnar epithelial cells lining the surface of a fibrovascular stroma. The histological features were consistent with pulmonary papillary adenoma. Only 20 cases of pulmonary papillary adenoma have been reported in the literature.

OBJECTIVE: We evaluated the clinical outcomes of patients after lung resection with pulmonary artery (PA) plasty for non-small cell lung cancer (NSCLC). METHODS: From 1995 to 2006, 36 patients (26 males and 10 females) with NSCLC underwent lobectomy or segmentectomy with PA plasty at our institution. The mean age of the patients was 65.9 years old (range 45-87 years old). There were 17 left upper lobectomies, 10 right upper lobectomies, five left lower lobectomies, two right upper-and-middle bilobectomies, one right lower lobectomy, and one left upper division segmentectomy. Both bronchoplasty and PA plasty were performed in 15 patients. Six patients received preoperative chemotherapy, and one had preoperative radiotherapy. RESULTS: The postoperative morbidity rate was 27.8 % (10/36), and the mortality rate (30 days) was 2.8 % (1/36). One patient underwent completion pneumonectomy on postoperative day 13. Macroscopic residual cancer was identified in two patients at the thoracic wall and aorta, respectively; microscopic residual cancers were identified in two patients at the stumps of the pulmonary artery and in one patient at the bronchial stump. Postoperative radiation therapy was additionally given to those four patients, except one. The 5-year survival rate for all patients was 51.8 %. There was no significant difference in the 5-year survival rate between clinical N (cN) 0-1 patients and cN2 patients. However, in pathological N (pN) 0-1 patients, the 5-year survival rate was significantly better than that of pN2 patients (71.9 % versus 0.0 %; P < 0.001). CONCLUSIONS: PA plasty for NSCLC is acceptable and highly recommended for pN0-1 patients. Strict patient selection should be considered so as to avoid surgical operations in patients with pN2 staging.

Introduction: Thoracoscopic or video-assisted thoracic esophagectomies have been performed for the last 10 years. Nevertheless, some reports have showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease. This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patient with advanced esophageal cancer before thoracoscopic or video-assisted esophagectomy. Since introducing induction chemo-radiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esophagectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after the introduction of induction chemo-radiation therapy. Patients and Methods: Between November 1995 and December 2005, thoracoscopic and video-assisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent a surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). Ninety-one patients were men and 21 were women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%). Results: Before December 1999, port site recurrence occurred in three cases of those of 29 patients with clinical T2–T4 esophageal cancer from 3 to 6 months after surgery, and pleural dissemination was observed in two of those patients. Since January 2000, induction chemo-radiation therapy (low-dose fluorouracil and platinum + 40 Gy radiation) has been performed to 31 patients with clinical T2–T4 disease, and port site recurrence has not occurred in any patients who received trimodality therapy. Conclusions: We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of video-assisted thoracic surgery esophagectomy to confirm our findings.

Lung adenocarcinomas with micropapillary pattern (MPP) are associated with frequent nodal metastasis. However, little is known about the mechanisms that underlie MPP-associated nodal metastasis. In this study, we investigated how small micropapillary clusters of carcinoma cells present in tumoral alveolar spaces lead to increased lymph node metastasis. We analyzed 146 cases of pT1 lung adenocarcinomas with reference to the presence of MPP, small cluster invasion (SCI), and lymphatic involvement. SCI was defined as markedly resolved acinar-papillary tumor structures with single or small clusters of carcinoma cells invading stroma within fibrotic foci. The MPP-positive group (88/146 cases) was associated with significantly more frequent nodal metastasis and significantly worse survival. Moreover, SCI was significantly more frequent in the MPP-positive group (71/88 cases) than MPP-negative group (10/58 cases) and was significantly associated with lymphatic involvement (p < 0.0001) and nodal metastasis (p = 0.0073). The SCI-positive group showed significantly worse survival (5-year survival, 70%) than the SCI-negative group (91%, p = 0.0017). Carcinoma cells undergoing SCI demonstrated the same characteristic MUC-1 expression on the outer surface of cell clusters as those undergoing MPP. Thus, SCI could link MPP to nodal metastasis; carcinoma cells with MPP tend to undergo SCI in scars and invade lymphatics in pT1 lung adenocarcinomas.

Long-term survival, which extends beyond 5 years, is a desired outcome for colorectal cancer patients. In the present study, we retrospectively compared the 10-year overall survival between the control group and the polysaccharide kureha (PSK) group and analyzed the factors influencing the prognosis. The control group was treated exclusively with oral fluoropyrimidines, whereas the PSK group was treated with fluoropyrimidines, given in conjunction with PSK for 24 months. The 10-year survival rates for the PSK group (81.9%) were significantly superior to those of the control group (50.6%). In Dukes' C cases, the 10-year overall survival rates for the PSK group were also significantly higher than those of the control group. In cases with lymphatic invasion graded ly2-ly3 or venous invasion graded v2-v3, the 10-year overall survival rates were 80.6% in the PSK group, which were significantly superior, compared to 25.9% in the control group. Analysis by Cox's proportional hazard model showed a significant difference between the control and PSK groups. These results indicate that postoperative adjuvant immunochemotherapy with PSK greatly improves prognosis at 10 years. On the basis of these results, we recommend postoperative adjuvant immunochemotherapy combined with PSK for patients with Dukes' C and in cases with ly2-ly3 or v2-v3 invasion.

This report describes the case of an ileal perforation secondary to clamping of the exomphalos minor in 3-day-old girl. Eighteen accidental clamping or cutting cases were found in the published work. It is thought that this defect resulted from either the clamping, ligation or cutting of the bowel in a small unrecognized omphalocele. These complications are extremely rare, but should be held in mind when performing an umbilical ligation.

Introduction The impact of thoracoscopic systemic lymph node dissection (LND) on loco-regional control of non-small cell lung cancer (NSCLC) with positive lymph node metastasis was investigated. Patients and methods Thoracoscopic lobectomy with systemic LND was performed for clinical stage I NSCLC. 340 patients were admitted for either a thoracoscopic (n = 98) or a standard open (n = 242) lobectomy with systemic LND. Of those 340 cases, 75 cases (20 thoracoscopic and 55 open) were pathologically diagnosed with node-positive disease. A retrospective chart review of these 75 cases was performed. Results No significant difference in the overall or loco-regional recurrence-free survival was observed between the groups. The results of a multivariate analysis of the overall and the loco-regional recurrence-free survival demonstrated that the significant factors were tumor size for overall recurrence-free survival, and sex and surgical procedure (use of thoracoscopic surgery) for loco-regional recurrence-free survival, respectively. Conclusion In general, thoracoscopic lobectomy for c-stage I disease may have no survival disadvantage over open procedures. It might, however, increase the risk of local recurrence when used to treat pathologically node-positive disease. Caution should be used when treating those cases with thoracoscopic surgery.

We experienced a very rare case of late pulmonary metastasis from ACC. The patient was a 40-year-old woman who had undergone a left adrenectomy 12 years earlier. Instead of a large metastatic lung tumor with hemothorax and the existence of metastases in other organs, combined therapy of repeated resections for metastases and adjuvant therapy allowed for almost a 36-month survival following the first recurrence and a good quality of life. In addition, a blood and pathological study revealed that the tumor in this case was an alpha-fetoprotein-producing ACC, which is, as far as we could ascertain, the first case of its kind.

【目的】食道癌症例に対する食道切除および3領域リンパ節郭清術後症例の早期気管チューブ抜去における気道管理を検討した。【症例と方法】2000年から2005年までの83例の食道癌切除および3領域リンパ節郭清症例を抽出した。術後気道管理のプロトコールは，1）原則として手術直後に手術室で気管チューブを抜去する。2）臨床症状や胸部レントゲン写真で異常がみられれば気管支鏡を用いる。3）これにより状況の改善みられなければミニ気管切開や気管切開を用いる。【結果】食道癌切除症例の術前呼吸機能による術後の気管支鏡施行回数やミニ気管切開施行例数に差はみられなかった。しかしながら反回神経麻痺がみられた症例群では有意にミニ気管切開施行例が多かった。【結論】食道癌症例に対する食道切除および3領域リンパ節郭清術後における反回神経麻痺群ではミニ気管切開が頻用され有用であった。

症例は60歳代男性で転落し左側胸部を打撲し搬送された．胸部CTで左気胸，左第5～12肋骨の多発骨折を認め肺への骨片の刺入が疑われ手術となった．手術時の所見から肋間ヘルニアが存在すると判断された．肺は還納されていたが第6肋骨直上の第5肋間で肋間筋が断裂しヘルニア門となっていた．S8先端に肺挫滅創を認めて肺部分切除を行った．胸郭欠損部をポリプロピレンメッシュで補強した．術後の胸郭動揺は無かった．肋間ヘルニアの報告例は比較的少ないため報告する．

A previous study documented the effects of maternal corticosteroid treatment on structural growth and functional development in fetal lungs associated with pathogenic conditions such as oligohydramnios using immunohistochemical and morphometric analyses. The purpose of the present study was to examine the effect of maternal dexamethasone treatment the expression of lamellar body in type II pneumocytes of the fetal rabbit lungs with hypoplasia induced by oligohydramnios using electron microscopy. Using an amniotic shunting rabbit model, pregnant rabbits were injected intravenously with either 0.1 ml of saline or 0.25 mg/kg/day of dexamethasone in 0.1 ml of saline 48 and 24 h before the delivery of fetuses, at day 30 of gestation. The number of lamellar bodies per type II pneumocyte was counted in each group using electron micrographs. The number of lamellar bodies per type II pneumocyte in the lungs of the shunted group that received saline was consistently and significantly less than that of the other three groups (5.49 +/- 2.07 vs. 7.34 +/- 2.27: shunted group that received dexamethasone, 7.58 +/- 2.08: non-shunted group that received saline, 7.79 +/- 1.90: non-shunted group that received dexamethasone; P < 0.01). These results suggest that maternal dexamethasone treatment accelerates the maturation of the surfactant system, especially the expression of lamellar bodies in type II pneumocytes, even in hypoplastic lungs induced by oligohydramnios.

To improve the efficacy of sonodynamic therapy of cancer using photosensitizers, we developed a novel porphyrin derivative designated DCPH-P-Na(I) and investigated its photochemical characteristics and sonotoxicity on tumor cells. DCPH-P-Na(I) exhibited a minimum fluorescent emission by excitation with light, compared with a strong emission from ATX-70, which is known to reveal both photo- and sonotoxicity. According to this observation, when human tumor cells were exposed to light in the presence of DCPH-P-Na(I) in vitro, the least phototoxicity was observed, in contrast to the strong phototoxicity of ATX-70. However, DCPH-P-Na(I) exhibited a potent sonotoxicity on tumor cells by irradiation with ultrasound in vitro. This sonotoxicity was reduced by the addition of L-histidine, but not D-mannitol, thus suggesting that singlet oxygen may be responsible for the sonotoxicity of DCPH-P-Na(I). DCPH-P-Na(I) demonstrated significant sonotoxicity against a variety of cancer cell lines derived from different tissues. In addition, in a mouse xenograft model, a potent growth inhibition of the tumor was observed using sonication after the administration of DCPH-P-Na(I) to the mouse. These results suggest that sonodynamic therapy with DCPH-P-Na(I) may therefore be a useful clinical treatment for cancers located deep in the human body without inducing skin sensitivity, which tends to be a major side-effect of photosensitizers.

10年間に当科で異物誤飲, 誤嚥の診断または疑いで受診した118症例について検討を行った. このうち異物誤飲, 誤嚥と診断されたのは小児群 (15歳以下) 47例, 成人例 (16歳以上) 18例であった. 異物なしと診断された症例は小児群51例, 成人群2例であった. 消化管異物, 気道異物ともに乳幼児と高齢者に多い傾向を認めた. 消化管異物では小児群はボタン型電池, 硬貨などX線非透過性異物が多く, 成人群は義歯とPTP (press through pack) が多かった. 診断は比較的容易で, 合併症もみられなかった. 気道異物では小児群はピーナッツを含む豆類が多く, そのほとんどがX線過性異物であったが, 成人群では歯科用金属が多く, ほとんどがX線非透過性異物であった. 小児のピーナッツ症例は診断までに時間がかかり, 摘出後も重篤な合併症をきたしていた. 異物なしと診断された症例の中に, X線透過性異物が診断できなかった症例が含まれている可能性が考えられた.

外傷に伴う気管，気管支断裂に対する5手術例を検討した．年齢は18歳から28歳，男性4例，女性1例．受傷機転は，交通外傷4例，転落外傷1例であった．気管損傷部位はそれぞれ左主気管支，気管分岐部，右主気管支，右中下葉分岐部，右中間幹であり，そのうち前者4例は術前に気管支鏡を施行し，全例損傷部位を確認しえた．手術は全例開胸手術を施行．受傷後開胸手術開始時間は8時間から5日後までで，全例に気管，気管支形成術を施行した．縫合法は連続＋結節縫合1例，連続縫合2例，結節縫合2例で，術後吻合部狭窄は認めなかった．術後肺炎等の呼吸器合併症を認めたのは2例あったが，全例生存している．受傷後早期の外科的処置と集学的管理が救命の重要な要素と思われる．

症例は9歳の女児で，胸痛の為に撮影した胸部X線写真で右上肺野の透過性亢進を指摘された．胸部CTで右上葉を中心に巨大肺嚢胞を認め，3D-CTの血管構築で上幹，上行肺動脈の先細り像が認められた．5歳時の胸部X線写真でも同部に肺嚢胞を認めていた．右S3から発生した大きな気腫性肺嚢胞で右胸腔を占められており，胸腔鏡下肺部分切除を施行したが，残存肺の拡張は良好だった．稀な小児の巨大肺嚢胞に対する胸腔鏡下切除を経験したので報告する．

外科切除された10mm以下の末梢型肺腺癌21例を分析した．男：女＝5：16，平均年齢65.8才．非喫煙女性が13人（61.9％）と多くを占めた．18例（85.7％）がG1と高分化型であった．野口分類は，typeA 2例（9.5％），typeB 2例（9.5％），typeC 11例（52.5％），typeE 2例（9.5％），typeF 4例（19.0％）であった．CT上GGO 11例（52.4％），非GGO 10例（47.6％）であった．術前診断例は1例のみで，術中診断例が20例（95.2％）であった．術式は有併存症例が多く（71.4％），標準肺葉切除8例（38.1％），縮小手術13例（61.9％）と縮小手術の割合が多かった．全例cT1N0M0 stage IAであった．観察期間中（中央値16.6ヵ月）非GGOで標準肺葉切除を行った1例が73.4ヵ月で遠隔再発を起こしたが，この例を含めて全例生存中である．10mm以下でも血行性転移する進行癌も存在するので腫瘍の性質をよく考慮して治療法を検討する必要がある．

Background: It is not clear if more intense surveillance is associated with improved survival after curative resection for gastric cancer. Patients and Methods: A prospectively maintained gastric c

Postradiation sarcoma is a rare late complication of external radiotherapy. We herein present two cases with this disease. A 54-year-old man had undergone a lobectomy and chest wall resection for Pancoast type lung cancer 7 years previously. He had undergone irradiation with a total dose of 50 Gy. Computed tomography (CT) demonstrated a tumorous expansion of the right lateral thoracic wall. A pathological examination confirmed a diagnosis of osteosarcoma. A 60-year-old woman had undergone a resection of the lateral chest wall mass, which was diagnosed to be Hodgkin's disease in 1991. Chemotherapy was given postoperatively. A tumorous lesion arose again and irradiation was performed with a total dose of 110 Gy. In 2000, two tumors appeared in the irradiation field. A pathological examination showed a sarcoma with divergent differentiation. In 2003, a tumor recurred and was diagnosed to be a liposarcoma. Patients who have received radiotherapy should therefore be followed up while taking into consideration the possible development of postradiation sarcoma.

To ensure the suitable preservation of isolated lungs, a super-cooling system was used to cool water to temperatures as low as -5 degrees C without freezing.After lung tissues were obtained from patients with lung cancer, they were kept at -5 degrees C or 4 degrees C for as many as 5 days, and then they were histologically and biochemically examined. To evaluate biochemical stability, tissues after storage were passively sensitized with immunoglobulin E and then incubated with anti-immunoglobulin-E antibody.Although tissues preserved at -5 degrees C for 5 days had an almost normal appearance with intact cilia on bronchial epithelium and normal endothelium, tissues stored at 4 degrees C showed degradation of these structures. Single-stranded DNA, a sign of DNA cleavage, was frequently noted in tissues stored at 4 degrees C, but only rarely observed at -5 degrees C. A significant amount of cysteinyl-leukotrienes was generated from tissues stored at -5 degrees C for 3 days, but there was no response to antibody stimulation from tissues stored at 4 degrees C.Super-cooling systems may provide useful applications as a novel preserving method.

Background Few reports have described surgery for lung cancer in patients with liver cirrhosis. The objective of this study was to clarify the efficacy of surgical treatment and evaluate its postoperative outcome. Methods We retrospectively reviewed the medical charts of 17 patients between 1985 and 2005 who were found to have nonsmall cell lung cancer (NSCLC) with liver cirrhosis. The grading of the severity of liver cirrhosis was made according to the Child-Pugh classification. Results Four patients were classified as Child-Pugh class A, whereas another 13 patients were classified as Child-Pugh class B. Of these 17 patients, 11 underwent lobectomies, 3 underwent pneumonectomies, and 3 underwent wedge resections. The only patient who experienced hospital death (5.9%) was a male patient with Child-Pugh class B cirrhosis. There were five respiratory-associated postoperative complications including pneumonia, bleeding from the staple line, and prolonged air leak. The morbidity rate was 29.5%. Median duration of chest tube insertion was 6.8 days, and mean volume of pleural effusion was 1,015.0 mL at 3 days total postoperatively. A total of 9 deaths occurred during follow-up (3 from cancer, 4 from hepatic failure, 1 from cardiac causes, and 1 unknown). The overall survival was 87.8%, 57.0%, and 45.6% at 1, 3, and 5 years, respectively. None of the patients experienced morbidity or mortality in Child-Pugh class A, but class B had 30.8% morbidity and 7.6% mortality. Conclusions Surgical treatment may be an acceptable and valuable approach for NSCLC patients who also have low severity liver cirrhosis.

Background The outcomes of a video-assisted thoracoscopic surgery lobectomy for lung cancer, with a special focus on its locoregional control, were compared with a conventional lobectomy. Methods We performed a retrospective review of 160 patients who had undergone a lobectomy either by means of thoracoscopic surgery (n = 81) or a standard thoracotomy (n = 79) for clinical T1N0M0 nonsmall-cell lung cancer. The overall, disease-free, and locoregional recurrence-free survival were compared. In a separate multivariate analysis, the ability of numerous clinical and surgical factors, including the surgical approach, to predict locoregional recurrence was investigated. Results The total recurrence of the primary disease occurred in 28 cases (12 locoregional and 14 distant). In the 12 documented local recurrences, 8 belonged to the thoracoscopic surgery group and 4 were in the standard thoracotomy group, without significant differences (p = 0.229). The overall 5-year survival rates associated with the thoracoscopic and standard procedure were 89.1% and 77.7%, respectively (p = 0.149). No significant differences in the disease-free or locoregional recurrence-free survivals were observed between the groups. The results of a multivariate analysis for the incidence of total and locoregional recurrence demonstrated that two covariates, lymph node metastasis and the surgical side (right or left lung), were significant factors for both total and locoregional recurrence. No significant relationship was found between thoracoscopic surgery or standard thoracotomy, and the incidence of locoregional recurrence. Conclusions Our findings suggest that thoracoscopic surgery is not inferior regarding its ability to achieve locoregional control in comparison with the standard procedure.

Human pulmonary dirofilariasis is a rare zoonotic infection caused by the dog heartworm Dirofilaria immitis, which is transmitted via a vector/intermediate host, generally the mosquito. The authors present a case of histologically diagnosed human pulmonary dirofilariasis, in which the lesion was resected using video-assisted thoracic surgery (VATS). The authors also review 24 cases of such zoonosis reported in Japan from 1998 to 2004. Of these 24 patients with human pulmonary dirofilariasis, 12 (50%) were men (mean age 54 years, range 29-80 years) and 67% were asymptomatic. Most patients (83%) had a solitary lung nodule, 95% of the lesions were

Background Surgical resection may continue to offer the best chance of long-term survival for patients with non-small cell lung cancer (NSCLC). Generally, patients with N2 NSCLC have a poor prognosis. However, the surgical treatment of patients with N2 remains controversial as in these patients, some N2 subgroups have better prognoses than others. The objective of the current study was to evaluate the factors associated with N2, and to determine whether such factors are reliable predictors of survival. Methods We retrospectively reviewed 142 non-small cell lung cancer patients with T1-3 N2 in whom a curative approach had been attempted between January 1994 and December 2003. The patients were consequently divided into four groups (NS-1, no subcarinal involvement and without N1; NS-2, no subcarinal involvement and with N1; SI-1, subcarinal involvement and without upper mediastinal site; SI-2, subcarinal involvement and with upper mediastinal site). We also evaluated two groups for N2 stations (single-station N2 versus multiple-station N2). Multivariate analysis by Cox's proportional hazards regression model was performed to identify the prognosis. Results Lobectomy was carried out in 105 of the patients; bilobectomy in 10, and pneumonectomy in 27. The patients with T1-3 N2 disease showed survival rates of 34.1 % at 3 years and 24.1 % at 5 years. The overall survival rates at 3 years and 5 years were as follows: NS-1, 56.3 % and 43.2 %; NS-2, 35.4 % and 29.5 %; SI-1, 16.7 % and 0 %; SI-2, 15.4 % and 0 %, respectively. The NS-1 group had better prognoses than the other groups. There was a significant difference in survival rates within each group ( p = 0.0005). In univariate analysis, the type of surgery, type of subcarinal involvement, and multiple-station N2 were significantly associated with prognosis. Multivariate analysis showed that NS-1 was only found to be an independent prognostic factor in cases of T1-3 N2 disease ( p = 0.0018). NS-2 was not an independent factor but tended toward significance ( p = 0.0681). But multiple-station N2 was not an independent factor ( p = 0.1549). Conclusions Surgery for patients with T1-3 N2 NSCLC might be acceptable if subcarinal lymph node metastasis is predicted to be absent.

Background The aim of this study was to analyze on a multivariate basis the prognostic significance of pre-resection and post-resection pleural lavage cytologies in surgically resected primary non-small cell lung cancer (NSCLC) patients, in relation to pathologic TNM factors in a large cohort of almost 1,200 patients. Methods From August 1992 through March 2001, pleural lavage cytology (PLC) was performed in 1,214 NSCLC patients without pleural effusion or dissemination undergoing pulmonary resection. The cytologic evaluation was classified into three categories: negative, suggestive, and positive. To investigate the impact on patient survival, PLC results were analyzed with conventional clinicopathologic factors. Results Definitive pre-resection PLC result was obtained in 1,194 patients and 38 had a positive result. The 5-year survival rates were 27% if pre-resection PLC was positive and 71% if negative. Of 1,198 patients 54 had a positive post-resection PLC result. The 5-year survival rates were 10% if post-resection PLC was positive and 73% if negative. On multivariate analysis, post-resection PLC was an independent prognostic factor as significant as established clinicopathologic factors. Conclusions Pre-resection and post-resection PLC should be recognized as an essential prognostic factor and should be performed in NSCLC patients without pleural effusion and dissemination. Post-PLC, compared with pre-PLC, had a greater and independent impact on survival and needs to be incorporated in the pathologic staging of NSCLC in the future.

症例は７６歳男性．健診の胸部X線単純写真で肺野異常陰影を指摘された．胸部CTで右S2に１５×１２×１３mm大の辺縁不整な腫瘤像とその内部の石灰化像を認めた．経気管支肺生検で肺腺癌の診断が確定したため右肺上葉切除術（ND2a）が施行された．組織学的検査では微小乳頭構造を伴う腺癌で，内部に骨髄腔を伴う骨化所見が認められた．原発性肺腺癌が骨化を伴うことは非常に稀であることから，若干の文献的考察を加えて報告した．

(症例1) 51歳,男性.腹痛にて救急搬送された.絞扼性イレウスを疑い緊急手術を施行したが, Treitz靱帯より270cm肛門側の小腸に腸内容物による閉塞が判明した.用手的に肛門側へ異物の移動を試みたが,困難であり切開をいれイレウスバッグを挿入し大量のピーナッツ片を認めた. (症例2) 43歳,男性.腹痛,嘔吐を主訴に来院.問診, CT画像にてピーナッツによる食餌性イレウスを疑い手術を施行.回腸末端より180cmの小腸が腹壁に癒着しており,同部から口側の腸管拡張あり豆のようなものを透見した.癒着剥離後,用手的に結腸まで移動させた.イレウス症例に対するCT画像で,含気を有する液体像を認めた場合はピーナッツによるものも念頭におく必要があり,加えて詳細な問診が有用であると考えた.

MRIにて術前診断しえた左傍十二指腸ヘルニアの1例を経験したので報告する.症例は, 30歳,女性.間欠的な左側腹部痛,嘔気を主訴に当科を受診.左上腹部に圧痛を認めたが,筋性防御はなかった.腹部CT検査所見において胃背側に腫瘤像を認めた. MRIにて内部が腸管と同信号かつ腸管壁構造が鮮明に描出されたことより陥入した小腸と判断し,左傍十二指腸ヘルニアと診断した.その後も間欠的なイレウス症状を繰り返すため開腹下にヘルニア門の閉鎖を行った.傍十二指腸ヘルニアは,特有な症状に乏しいが,間欠的なイレウス症状を有する場合は本疾患の存在を念頭に置く必要があり,その確定診断においてMRIが有用と考えられた.

OBJECTIVE: The characteristic differences between patients with lung or liver metastases from colorectal carcinoma (CRC) have not yet been clarified. A small group of these patients demonstrate a better prognosis, and the selection criteria for resection of liver and/or lung metastasis are not well defined. It is important to compare and analyze the most common metastatic sites, which include liver metastases and lung metastases. The objective of this study was to compare the characteristics of the two groups in order to identify patients who benefitted from surgical resection of CRC. METHODS: We retrospectively reviewed the medical charts of 80 patients who had undergone resection for liver or lung metastasis from CRC in Fukuoka University Hospital between June 1991 and December 2004. These patients were grouped according to surgical therapy received for the metastases, and separated into two groups, as follows: LUM, lung metastases resection; LIM, liver metastases resection. We evaluated these groups for a set of several factors. RESULTS: The characteristic factors between the two groups (LUM vs. LIM) demonstrated significant differences according to histological differentiation, venous invasion, and lymphatic permeation. There was a statistical difference in the disease-free interval (DFI) between the two groups (947.06 +/- 840.39 days in LUM vs. 246.03 +/- 229.26 days in LIM). Although serum CEA levels at resection of metastasis showed significant differences between the groups (LUM, 13.25 +/- 31.55 ng/ml; LIM, 55.21 +/- 99.52 ng/ml), the primary serum CEA levels were not significantly different. Overall survival rates at 5 years were 37.0 % for LUM and 42.8 % for LIM. There was no significant difference in the survival rate of the LUM vs. the LIM group after resection of metastasis. The Cox proportional hazards regression model was used to determine serum CEA status at the time of the metastases and showed a significant difference indicating poor prognosis for patients with LUM, but the results were not significant for LIM cases. CONCLUSIONS: Candidates for surgical treatment for lung or liver metastases from CRC may be an acceptable for the same valuable approach, even if characteristic differences were observed in each group.

Aims: Lymphomatous polyposis (LP) is considered to represent mantle cell lymphoma (MCL) of the gastrointestinal (GI) tract. However, a few reports have suggested that some are follicular lymphoma (FL) or mucosa-associated lymphoid tissue (MALT) lymphomas. In this study, we analysed 35 patients and clarified the clinicopathological features of LP. Methods and results: Paraffin-embedded tissue samples were stained immunohistochemically and analysed by tissue-fluorescence in situ hybridization (T-FISH) for IGH/CCND1 (cyclin D1) and IGH/BCL2. The average age of the patients was 58.3 years. Over half of the cases showed gastric, duodenal, small intestinal, ileocaecal and sigmoid colonic lesions (15, 19, 15, 16 and 16 cases, respectively). Phenotypically, cases were classified into three types of MCL (cyclin D1+ CD5+ CD10–) (n = 12), FL (cyclin D1– CD5– CD10+) (n = 14) and MALT (cyclin D1– CD5– CD10–) (n = 9). T-FISH identified 11 of the 11 examined cases with MCLs to have IGH/CCND1, while seven of 10 cases with FL had IGH/BCL2, and none of the MALT cases were positive for IGH/CCND1 or IGH/BCL2. At the study endpoint, five of 12 patients with MCL were dead, two of 14 with FL and one of nine with MALT were dead of other disease. Event-free survival analysis showed significantly poorest outcome in MCL, followed by FL, while MALT was associated with a favourable outcome (P = 0.0040). Conclusions: Our study emphasizes the importance of differentiating MCL, FL and MALT of LP in evaluating prognosis and hence the most suitable therapeutic regimen.

We herein report a case of type I congenital cystic adenomatoid malformation of the lung (CCAML) with non-immune hydrops fetalis (NIHF), a mediastinal shift and polyhydramnios diagnosed at 24 weeks' gestation by ultrasonography. The fetus was treated with a cyst-amniotic shunt at 29 weeks' gestation. Following a postnatal whole resection of the right lung, postpneumonectomy syndrome appeared and, as a result, the infant died 13 months after delivery due to respiratory failure. Only 19 cases demonstrating CCAML associated with NIHF have been reported previously in Japan. Four cases showed a spontaneous resolution of NIHF, while 5 cases with type I CCAML, which all underwent fetal intervention, demonstrated an excellent outcome.

Aims: A micropapillary pattern (MPP) in lung adenocarcinoma, characterized by papillary structures with epithelial tufts lacking a central fibrovascular core, has been reported to be a new pathological marker of poor prognosis. However, its clinicopathological and prognostic significance in small lung adenocarcinomas (≤20 mm) remains undetermined. A new histological classification of small lung adenocarcinoma proposed by Noguchi et al. has been found to be useful since it has defined surgically curable bronchioloalveolar carcinoma (BAC)-type tumours (Noguchi's type A and B) based on the absence of active fibroblastic proliferation. However, BAC-type tumours with active fibroblastic proliferation (Noguchi's type C), which is adenocarcinoma with mixed subtypes including BAC and invasive carcinoma in the new World Health Organization (WHO) classification, account for most of the small adenocarcinomas and represent a heterogeneous group ranging from minimal to overtly invasive cancer with variable prognoses. Therefore, in this study the aim was to investigate whether MPP can be an additional histological marker(s) to subclassify this heterogeneous group in small lung adenocarcinoma. Methods and results: One hundred and twenty-two cases of small lung adenocarcinomas (≤20 mm in maximum dimension) classified according to the new WHO classification and Noguchi's proposal were analysed with reference to the presence of MPP. Of the 122 cases, 67 (55%) were MPP-positive and 55 (45%) were MPP-negative. Lymph node metastasis and pleural invasion were significantly more frequent in the MPP-positive group: 74% and 66% in the positive group versus 26% and 34% in the negative group, respectively. The 5-year survival of the MPP-positive group was 54%, whereas that of the MPP-negative group was 81% (P = 0.024). The 5-year survival rates of BAC (Noguchi's type A and B) (n =14), mixed BAC and invasive adenocarcinoma (Noguchi's type C) (n = 85) and invasive adenocarcinoma (Noguchi's type D and F) (n = 23) were 100%, 68% and 36%, respectively. In patients with mixed BAC and invasive adenocarcinoma (Noguchi's type C tumours), the 5-year survival of the MPP-positive group (n = 51) was 54%, significantly lower than that of the MPP-negative group (n = 23) of 100% (P = 0.02). Conclusions: MPP is a simple and distinct pathological marker to subclassify tumours with a significantly poor prognosis within small (≤20 mm) mixed BAC and invasive adenocarcinoma (Noguchi's type C tumours).

OBJECTIVE The surgical indications for non-small cell carcinoma (NSCLC) with chronic obstructive pulmonary disease (COPD) are not well known. A classification of severity in COPD has been newly recommended by the US National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO). Therefore, based on this new system of classification, we review here a series of NSCLC patients with COPD who underwent lung resection at our hospital and attempt to identify the survival and morbidity of such patients. METHODS We retrospectively reviewed the patients with NSCLC treated at our hospital between January 1994 and December 2002. Among these 640 patients, a curative approach was attempted in 50 with COPD (31 lobectomies, 11 segmentectomies, 8 bilobectomies). The patients were consequently divided into two groups (moderate group and severe group) according to the Global Iinitiative for Chronic Obstructive Lung disease (GOLD). Lung function was evaluated by FEV1 and FVC, and the survival rates were analyzed at 5 years. Postoperative morbidity was also compared between the two groups. RESULTS FEV1 was 1.527 +/- 0.311 L in the moderate group compared with 1.025 +/- 0.224 L in the severe group ( p < 0.001). Postoperative decrease in FEV1 was lower compared to the predicted data of patients who underwent surgery for NSCLC with COPD. Postoperative pulmonary support such as mechanical ventilation or tracheotomy were necessary more frequently in the severe group. A significant difference was observed between the two groups in respiratory support ( p = 0.0102). Overall 5-year survival rate for NSCLC with COPD was 73.9 %, although there was no statistically significant difference between the moderate and severe groups in terms of survival. Lobectomy and segmentectomy show a remarkable advantage for the patients with bilobectomy, although this difference was not statistically significant. On the other hand, gender, degree of COPD, and histological type were shown to be not significant factors. Survival rate of these NSCLC patients with COPD were demonstrated to be comparable to those of the NSCLC patients without COPD in stages I and II. CONCLUSION Stringent selection of candidates among NSCLC patients with a severe grade of COPD based on GOLD could be an acceptable and valuable approach compared to conventional patients without COPD, although NSCLC with severe COPD patients more frequently needed respiratory support.

An unusual case of biliary atresia with jejunal atresia is herein described. Only 12 cases demonstrating biliary atresia associated with a jejunal atresia have been previously reported in Japan. The pathogenesis of biliary atresia is thought to be secondary to the influence of jejunal atresia.

Inflammatory myofibroblastic tumor (IMT) is a rare neoplasm that usually occurs in children and young adults. Anaplastic lymphoma kinase (ALK) abnormalities in IMT, determined using immunohistochemistry and/or molecular genetic studies, including fluorescence in situ hybridization (FISH), have almost been limited to children and young adults. In elderly cases of IMT, these ALK abnormalities are very rare. We report on a case of IMT arising in the posterior mediastinum of a 59-year-old Japanese man that showed ALK abnormalities determined using immunohistochemistry and FISH, suggesting the neoplastic nature of a subset of IMTs in older patients similar to those in younger ones and the presence of an additional mechanism(s) that allows them to start to grow late.

The systemic inflammatory response syndrome (SIRS) is well known to occur in patients who have suffered organ damage or trauma, or undergone surgery. SIRS provides useful information in patients with morbidity after surgery. To date, there has been no report of SIRS after surgery in patients with lung cancer. Therefore, based on this new concept of the syndrome, we review here a series of T3 and T4 NSCLC patients who underwent extended resection at our hospital, and attempt to identify the value and correlation of SIRS in predicting the morbidity of such patients.We retrospectively reviewed the patients with NSCLC treated at our hospital between January 1994 and August 2003. Among these 720 patients, a curative approach was attempted in 144 with advanced stage (T3, 100; T4, 44) cancer. The patients were consequently divided into three groups (G1, negative or less than 3 days in SIRS following surgery; G2, less than 7 days; G3, continued over 7 days). Pre- or peri-operative factors were evaluated, and the 5-year survival rates were analyzed. Post-operative morbidity was also compared between the three groups in association with SIRS.Pre-operative counts of WBC were 8848.28+/-3879.21/microl in G3 compared with 7383.33+/-3132.98/microl in G2 and 6778.31+/-3184.89/microl in G1. Values in G3 were significantly higher than those in the other groups (P0.001). Predicted %FEV1 in G3 was significantly lower than those in the other groups. Duration of SIRS after lung surgery was associated with high levels in WBC and low %FEV1. Post-operative morbidity such as bronchial fistula or ARDS were more frequent in the G3 and G2 groups than in G1. The 1-year survival was as follows; G1, 75.4%; G2, 47.9%; G3, 38.1%. Overall 5-year survival rate for NSCLC with T3 and T4 was 32.2%, and the difference between G3 and the other groups in terms of survival was statistically significant (P0.0001).The concept of SIRS have been associated with post-operative complications and survival in NSCLC. Surgical candidates should be carefully according to the predicting factor of SIRS.

目的. 大動脈合併切除を施行した原発性肺癌症例を検討する. 方法・対象. 当施設で大動脈合併切除を施行した原発性肺癌5症例を対象とした. 大動脈合併切除の必要性は術前診断にCT・MRIを用い, 術中所見にて最終的な判断を行った. 臨床・病理病期は肺癌取扱い規約に準じた. 結果. 全例が男性の喫煙者. 平均年齢は57歳. 術式は左肺全摘術が4例, 左肺上葉切除術1例. 合併切除部位は大動脈外膜1例 (再建なし), 大動脈弓部1例 (パッチ補填), 下行大動脈3例 (人工血管置換術) であった. 術後合併症は2例 (肺炎, 不整脈) に認めたが, 手術関連死は認めなかった. 組織型は扁平上皮癌2例, 腺癌1例, 大細胞癌1例, 小細胞癌1例であった. 病理病期pT3N0M0 (IIB) 2例, pT3N2M0 (IIIA) 1例, pT4N0M0 (IIIB) が2例であった. 病理学的に大動脈壁への浸潤を2例に認めた. 大動脈浸潤2症例の予後はそれぞれ3年2ヶ月, 7年2ヶ月無再発生存中である. 結語. 原発性肺癌の大動脈浸潤を術前に診断することは困難であった. 腫瘍の浸潤が大動脈壁に留まりリンパ節その他への浸潤転移がない症例において良好な切除成績を期待できる可能性が示唆された.

We present a case report of a 63-year-old male who underwent lung resections for metastases originating from gastric cancer 18-year after total gastrectomy with lymphadenectomy. The gastrectomy was performed in 1994; histological examination of the original tumor revealed stage II poorly differentiated adenocarcinoma [pT2 (MP), N0, M0]. Chest X-ray and computed tomography in 2012 showed a well-defined tumor, 9 mm in size, at the left S3 of the lung. Thoracoscopic partial resection was performed. The tumor was diagnosed as poorly differentiated carcinoma, most likely metastatic gastric adenocarcinoma. Although rarely performed, resection of pulmonary metastases from carcinoma of the stomach was done to improve the patient’s chances for long-term survival.

BACKGROUND Surgical efficacy is still unsatisfactory for small lung cancer; accordingly, minimal resection has recently been the focus of increased study. The objective of the current study was to evaluate the factors associated with small lung cancer, and to determine whether such factors are reliable predictors of long-term survival. METHODS We retrospectively investigated 130 patients with histologically confirmed non-small cell carcinoma, whose treatments were primarily surgical, with no chemotherapy or radiotherapy prior to surgery. All tumors were located peripherally and were less than 20 mm in diameter. Follow-up was performed for five-year and eight-year survivors and multivariate analysis with Cox's proportional hazards regression model was performed. RESULTS Of all 130 patients, the 5-year survival rate among patients with tumors less than 15 mm was 82.5 %, vs. 57.4 % of patients with tumors with a diameter of 16 - 20 mm. The 5-year survival rate of patients who were node negative was 73.9 % while it was 28.5 % for node-positive patients. Status of nodal invasion was also significantly associated with survival in small-size tumors ( p < 0.0001). Furthermore, the 5-year survival rate among patients with pleural involvement was 55 % vs. 83.8 % for patients without pleural involvement. Using multivariate Cox analysis, lymph node involvement ( p = 0.0004), size ( p = 0.0475), and pleural invasion ( p = 0.0482) were found to be independent prognostic factors in cases of tumors 20 mm or less in diameter. CONCLUSIONS The results of this study at least demonstrate that the optimal therapy for patients with nodal involvement or patients with tumors of 16 - 20 mm must be carefully determined even in cases of small lung cancer.

In vitro study using ultrasound and sonosensitizer has been investigated as a new cancer therapy. This combination effect has been called sonodynamic therapy (SDT). However, most studies were in vitro experiments. We performed SDT for three patients with cancer for whom every possible chemotherapy and radiation therapy were ineffective. Ultrasound and drug used in clinical study was 0.9 MHz at intensity below 4 W/cm 2 , and porfimer sodium, respectively. No side effects caused by SDT were observed in those three patients. Inhibition of tumor growth was seen in two patients. Accumulation of patients treated with SDT is mandatory to evaluate combination effect of ultrasound and sonosensitizer.

Objective: The modality of treatment for patients with brain metastasis from non-small cell lung cancer (NSCLC) has not yet been established. Among these patients, few survive longer than 3 years. However, a small group of these patients demonstrate a better prognosis. The objective of this study is to clarify the efficacy of treatment and evaluate factors affecting long-term patient survival. Methods :W e retrospectively reviewed the medical charts of 70 patients found to have brain metastasis from NSCLC in Fukuoka University Hospital between 1994 and 2002. These patients were grouped according to therapy received for the brain and lung and separated into two groups, as follows: LBR, lung and brain resection; LR, lung resection without brain resection. We also evaluated these groups for a set of several factors. Risk score was calculated with reference to the data from multivariate analysis, which can estimate survival. Results: The number of patients who underwent lung surgery plus brain surgery was 41. In this LBR, the 1- and 3-year survival rates after treatment of brain were 66.4 and 22.9%, respectively. We found that a therapeutic strategy including surgery for primary lung and brain can afford patients an extended survival time compared to the survivals of other LR group. The 3-year survival of patients with high carcinoembryonic antigen (CEA) was 0 vs. 39.6% among patients normal for CEA. Some factors, including histological type, nodal metastasis, serum LDH and CEA, were associated with survival. The multivariate Cox model identified both adenocarcinoma histological subtype, node status and high serum CEA as independent prognostic factors, whereas serum LDH was not found to be significant. Risk score was determined in our study to estimate prognosis according to the multivariate data. From this equation, previously we can expect 1- or 3-year survival of each patient with brain metastasis from NSCLC, refer to the risk score. Conclusions: Stringent selection, i.e. low-risk score (adenocarcinoma, node-negative and normal level of CEA) of candidates for surgical treatment for primary lung and brain metastasis from NSCLC may be an acceptable and valuable approach. q 2004 Elsevier B.V. All rights reserved.

Objective: The best indicators for VATS are not well known. Therefore, we review here a series of patients who underwent VATS lobectomy and segmentectomy at our hospital, and we attempt to identify the factors that influence the survival of VATS patients and the backgrounds of such patients. Methods: A thoracoscopic curative approach was attempted in 140 patients (100 lobectomy, 40 segmentectomy) from January 1994 to December 2002. We retrospectively reviewed the VATS patients with non-small cell lung cancer (NSCLC). All patients were subject to lobectomy or segmentectomy, including dissection of hilar and mediastinal lymph nodes that were in pathological stage (p-Stage) I or II. Our VATS approach was a hybrid technique, employing three ports and a small (7 cm diameter) utility thoracotomy to allow access for the instrument and a view. Results: The Kaplan ‐ Meier probabilities of survival at 5 years were VATS, 77.3%. According to a univariate analysis of survival curves, the significant prognostic factors ðP , 0:05Þ in the patients with VATS in p-Stage I and II were gender, type of histology, and T factor. In addition, the grades of differentiation, surgical procedure (lobectomy vs. segmentectomy), and extent of metastasis to the hilar lymph node (N0 vs. N1) in VATS were not found to be significant prognostic factors. A multivariate prognostic factor in VATS showed that the histologic cell type, gender, and T factor were predominant. All of the VATS cases that included these three favorable factors (adenocarcinoma, T1, female) were alive. Conclusion: Stringent selection of candidates for VATS in NSCLC at pathological stages I and II could be an acceptable and valuable approach. q 2004 Elsevier B.V. All rights reserved.

78歳男性呼吸困難で近医受診し, 胸部X線写真で左気胸を指摘され入院した.胸腔ドレーン挿入後気漏が持続するため入院後5日目に分離肺換気麻酔下に胸腔鏡下左肺部分切除術を行なった。術後ドレーンからの気漏は消失し全身状態も良好だったが, 術後1日目の胸部X線写真上, 右横隔膜下に腹腔内遊離ガス像を認めた.上部消化管内視鏡では特に異常は指摘されず, 腹部CTで右横隔膜下と肝門部にガス像を認めた.自覚症状はなかったが消化管穿孔を念頭に置き絶飲食, 抗潰瘍薬投与で管理した.腹腔内遊離ガス像は徐々に吸収され術後2週間で退院となった.経過により気腹症と診断した.気胸に対する胸腔鏡手術後に発症した気腹症の1例を経験した.

肝癌治療中に併発した胆汁性肝嚢胞(biloma)が心嚢内穿破をきたしたまれな症例を報告する.症例は60歳,男性.原発性肝細胞癌に対して,肝拡大右葉切除術を施行した.その後,残肝再発に対して,肝動脈塞栓術(TAE)および経皮的マイクロ波凝固療法を併用し,複数回の治療を繰り返し経過した.術後8カ月目,閉塞性黄疸と胆管炎が出現した. TAE後の胆管壊死が原因と思われる,左肝管基部狭窄およびその末梢肝管の拡張認めたため,チューブステント留置にて改善した.その後,外側区にbilomaが出現するも,経過観察していたところ,術後14カ月目,突然の前胸部痛および呼吸苦が出現した.画像上, bilomaの心嚢内穿破による心タンポナーデと診断し,心嚢穿刺ドレナージ術を施行し,持続低圧吸引を続け, 3日後チューブ抜去が可であった.その後生存中,経皮的膿瘍ドレナージチューブを留置のまま,肝不全による死亡まで術後約20カ月間QOLを維持した生存期間を得た.

症例は60歳男性.10年前に肺気腫症と診断された.内科的治療を受けていたが改善せず, 外科治療目的にて当科受診となった.Hugh-Jones分類III度であり, 胸部X線写真にて横隔膜の平坦化, 肺血管陰影の消失を胸部CT検査では両側肺野全般, 特に肺尖部に高度な気腫性変化を認めた.当科での手術適応基準を満たし, また本人の手術に対する強い希望があったことから, 胸腔鏡下肺容量減少術 (lung volume reduction surgery, LVRS) を施行した.肺機能パラメーターは術後著明に改善したにもかかわらず, 心不全によるコントロール困難な胸水貯留, 低酸素血症を認め, 呼吸状態が改善せず, これらに対する治療を行った.現在呼吸状態は著明に改善している.本術式は合併症を高率に伴うが, 慎重な術後管理を行うことにより良好な結果が得られると考えられた.