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Background: Viral infection is known to cause lung inflammatory disease, including bronchial asthma. The mechanisms of inflammatory cell accumulation into the airways after viral infection are not well understood. Eotaxin is a CC chemokine which is a potent and specific agonist for CC chemokine receptor 3 (CCR3). CCR3 is expressed on eosinophils, basophils and T lymphocytes. These cells are known to be key cells in the pathogenesis of asthma. Although it has recently been demonstrated that airway epithelial cells express eotaxin in vivo and in vitro, there are few data about its epxression in viral infection. We hypothesized that eotaxin may play an important role in attracting inflammatory cells to the airways after viral infection, and analyzed whether viral infection attracts eotaxin in bronchial epithelial cells in vitro. Methods: Human airway epithelial cells obtained from bronchial tissue at lobectomy for lung cancer were infected with influenza virus A (subtype H3N2). The cells and cultured media were collected 8, 24, and 48 h after infection. Eotaxin mRNA was analyzed with reverse transcriptase-polymerase chain reaction. Eotaxin protein levels in the culture media were analyzed by enzyme-linked immunosorbent assay. We also studied a blocking assay to analyze the intervention of proinflammatory cytokines in its production induced by influenza virus. Results: Eotaxin mRNA appeared to be expressed constitutively in uninfected cells but was expressed more clearly in infected cells. Eotaxin protein release into culture media significantly increased after infection. Anti-TNF-α and anti-IL-1β antibodies did not alter the eotaxin protein levels after viral infection. Conclusions: These results suggest that influenza virus A infection in airway epithelial cells activates the expression of eotaxin and that eotaxin may participate in the pathogenesis of airway inflammatory disease caused by viral infection, such as infectious type asthma.

Of a series of resected primary lung cancer at the hospital in a recent 9-year period from January 1986 to December 1994, 90 patients with non-small cell lung cancer underwent “absolutely curative resection” and 72 non-small cell lung cancers underwent “relatively curative resection”. In order to elucidate the prognostic factors, these cancers were evaluated for age, sex, tumor size, pathologic T factor, pathologic N factor, histopathological features, and method of detection. Fifteen of the 90 (17%) patients developed recurrence which was examined for the presence of vessel invasion and involvement of visceral pleura. All of these 15 recurrent cases had evidence of lymphatic vessel invasion. Six of these 15 cases (40%) also had blood vessel ilmvasion. The mean size of the tumors was significantly larger in the recurrent cases after absolutely curative resection than that in all resected cases. However, there was no significant difference between the recurrent cases and all cases of curative resection in the presence or absence of involvement of visceral pleura. Multivariate analysis of all risk factors revealed that the T factor and the presence of vessel invasion are only independent risk factors for recurrence after curative resection. In conclusion, it is important for preventing recurrence after curative resection to detect the tumor in smaller size, to avoid the growth or invasion of the tumor due to delayed treatment, and to perform complete resection with mediastinal lymph node dissection as early as possible.

To expand the cadaveric lung donor pool, protecting the endothelium and alveoli from warm ischemia and reperfusion injury is important. The effects of initial low flow reperfusion and surfactant administration were studied in non-heart-beating donor lungs. The rat heart-lung bloc was excised immediately (group 1) or 30 min (groups 2-4) after euthanasia (n = 6 in each group). The graft was ventilated and reperfused (50 ml/min) immediately after excision for 1 h in groups 1 and 2. In groups 3 and 4, the reperfusion flow rate was increased gradually to 50 ml/min, while ensuring that the pulmonary arterial pressure did not exceed 40 mmHg. Then the graft was reperfused for 1 h. Surfactant was introduced into the airway in group 4 before reperfusion. Airway pressure (AWP) and pulmonary arterial pressure were monitored during reperfusion. After reperfusion, the wet/dry weight ratio (W/D) of the right lung was calculated, and histologic examination using trypan blue staining of the left lung was performed. In group 2, lung failure appeared in all animals during reperfusion. In group 3, although all lungs were reperfused for 1 h, AWP and W/D were higher than in group 1. In group 4, AWP and W/D were lower than in group 3. Histologic examination showed that surfactant administration had attenuated the alveolar cell death. To avoid damage caused by high pulmonary arterial pressure associated with graft reperfusion, iniital low flow reperfusion was beneficial in cadaveric lungs. Surfactant administration before reperfusion was effective in preventing pulmonary edema.

The chemokine regulated on activation, normal T cells expressed and secreted (RANTES), is a C-C chemokine and a potent chemoattractant for monocytes, T lymphocytes, basophils, and eosinophils. Its expression by human airway epithelium has been demonstrated both in vitro and in vivo. We investigated whether RANTES is expressed by normal human airway epithelial cells after influenza viral infection and examined its bioactivity. Epithelial cells were obtained from bronchial tissue or nasal polyps of patients who had undergone lobectomy for lung cancer or polypectomy for nasal polyps. These cells were cultured by the outgrowth method. Cultured cells were infected with influenza virus A (subtype H3N2) after which the supernatants and the cells were collected 8 to 72 h after infection. RANTES mRNA (messenger RNA) was analyzed by the reverse transcriptase-polymerase chain reaction and Southern blot analysis of its product. Concentrations of RANTES in the supernatants were analyzed by enzyme-linked immunosorbent assay. RANTES protein and mRNA were not detected in the media of uninfected cells. PCR products for RANTES were clearly detected in nasal and bronchial epithelial cells 24 h after infection. Southern blot analysis confirmed that the PCR products were indeed specific for RANTES mRNA. Twenty-four to 72 h after infection, significant levels of RANTES protein were detected in culture media. We also investigated the chemotactic activity of the supernatant of cultured cells. The supernatant of the cells 48 h after infection had potent chemotactic activity for eosinophils, which was attenuated by the addition of anti-RANTES antibodies. These findings suggest that influenza virus infection may induce expression of bioactive RANTES by normal human bronchial and nasal epithelial cells.

右上葉切除後の中葉支口は扁平なものから円形のものまで様々あり, 如何なる症例が術後に扁平化しやすいかを検討した.23例を対象とし, 内視鏡メジャーを用いて, 中葉支入口部の短長径比と面積を術前後に求めた.術前に中葉支口が円形～楕円形であった11例のうち, 術後もほぼ同様であったA群6例に対して, 半月状に変形したB群5例では術前から小口径であったり上葉支断端が長く残存していた.術前から半月状～三か月状であった12例のうち, 術後さらに扁平化がみられるも軽度であったC群3例では, 扁平化が著しかったD群9例と比較して短長径比が大きかった.術前の中葉支入口部が円形～楕円形の場合には上葉支分岐根部で縫合すれば扁平化は軽度であるが, 半月状～三か月状の場合には上葉切除後に中葉支入口部の扁平化は免れず, 術前中葉支口の短長径比が45%以下の症例では, 術後に中葉支口の強度 (30%以下) 扁平化をきたす恐れがあるものと考えられた.

Gorham's disease is a rare disorder characterized by a non-malignant proliferation of thin-walled lymphatic vessels that result in progressive bony destruction and often extend into the surrounding soft tissues. Chylothorax is a common complication in cases of mediastinal involvement. Here we report a case of a 22-year-old male with Gorham's syndrome complicated by chyloma of the chest wall, but without chylothorax. To our knowledge, this is the first report demonstrating an abnormality of the parietal pleura prior to the clinical development of the chylothorax.

During a 15-year period between January 1, 1980 and December 31, 1994, 38 patients were admitted to the department for treatment of giant bulla. Of these 38 patients, 19 (50%) had spontaneous pneumothorax; and 14 had the lesion on the site of giant bulla and 5 on the contralateral site. The incidence of pneumothorax on the site of giant bulla tended to occur in the aged patients. There was no significant difference in the incidence of pneumothorax between existence of smoking habit and non-smoker. However, there were significant differences in the incidence of pneumothorax between upper lobe and another lobes which were the primary site of giant bulla. Of the five patients with contralateral pneumothorax, four were treated with axillary incision for the contralateral pneumothorax prior to operation for the giant bulla, and the remaining one case with conservative drainage because of chronic emphysema. Histopathological examination for the resected specimens showed an increase or interruption of the elastic fiber of the pleura. It is etiologically thought that pneumothorax in these cases might be caused not only by the structure of the pulmonary alveoli but also by weakened pleura.

Video-assisted thoracic surgery (VATS) is replasing standard thoracotomy in the management of many thoracic diseases. VATS that is superior to thoracotomy in terms of less surgical invasion and postoperative pain has been performed at our department from November 1, 1992. Recently we employed VATS for performing a pericardial resection in a 56-year-old man with recurrent pericardial effusion. There was a previous history of undergoing radiation therapy for a malignant lymphoma of the mediastinum 15 years before. The surgical procedure was performed under general anesthesia with doublelumen endobronchial intubation and placed in a lateral ducubitus position. After the thoracoscope was introduced, the phrenic nerve was identified and adequate pericardial resections (6×5cm, 4×2cm) were done. The pathological findings of resected specimens showed chronic inflammatory change without malignancy. No recurrence of pericardial effusion has been seen. The patients has been well 5 months postoperatively. In conclusion, VATS is minimally invasive techniques for the treatment of thoracic diseases, and adequate pericardial resection for pericardial effusion is a favorable indication for VATS.

大動脈遠位弓部合併切除を行った原発性肺癌の1例を経験した.症例は72歳男性で, 主訴は左背部痛.大動脈遠位弓部浸潤肺癌, cT4N1M0, Stage III Bの診断で左肺上葉切除, 大動脈遠位弓部合併切除, パッチ補填をおこなった.補助手段としてPercutaneous cardiopulmonar ysupport system (以下PCPS) 回路を用い, スパイラルポジションで右大腿動静脈間, 流量1.5～2.0L/minで部分体外循環を行った.大動脈は左総頚動脈分岐部末梢側の大動脈弓部と下行大動脈で遮断し, 遠位弓部大動脈壁の合併切除, 人工血管 (Gelseal®) パッチ縫着を行った.術中activated coagulation time (以下ACT) は200秒前後にコントロールし, 出血量は2000mlであった.Linac照射56.4Gyを行い, 術後2年を経過し, 再発や転移は認めていない.PCPSは比較的簡便な操作で用いることができ, 心大血管浸潤肺癌に対する手術に有用である.

当科で入院治療を行なった原発性肺癌220例のうち, 他疾患経過中に発見された39例 (他疾患群と略す) を対象とし, 臨床上の問題点を中心に, 検診発見 (検診群) や自覚症状発見 (自覚症状群) と比較検討した.他疾患群の平均年齢は69.4歳と高く, 末梢型肺癌が95%を占めた.平均腫瘍径は他疾患群が3.3cmに対し, 自覚症状群が4.5cmと有意差を認めた.手術施行率は他疾患群92%, 検診群98%で, 自覚症状群68%との間に有意差を認めた.他疾患の内訳は, 高血圧13例を筆頭に心筋梗塞や不整脈など循環器系疾患が56%を占め, 過去のレ線像見直しでは, 24例 (62%) に異常を指摘し得た.他疾患群の切除例は検診群と比べ僅かに5生率が良好であったが, 非切除例を含む全体の検討では, 検診群の方が良好であった.肺癌発生のhigh risk群に対しては, 他疾患経過中であっても, 原疾患を超えた配慮で検査を進める必要があるものと考えられた.

心臓手術における心筋局所冷却法は有効な心筋保護法であるが心嚢に氷水を満たすことによる横隔神経障害, 冠動脈スパズムによる心筋保護液の不均等供給などの問題も存在する. これらの冷却障害を回避するため心筋冷却を軽度とし, 増大する心筋酸素需要に対する酸素供給を目的として, 優れた酸素運搬能を持つ Perfluorochemicals (PFC) に心臓を浸漬し, 有効性を検討した. ラット摘出心 (心筋温20℃) での冠灌流遮断実験では, 遮断中PFCに浸漬しなかった群の心拍動持続時間は10±2分であったが, PFC浸漬群は20±4分であった. 心筋温30℃で cardioplegia による急速心停止を得た実験において, PFCに浸漬した群は非浸漬群および生食水浸漬群より再灌流後の心機能の回復は良好であった. 軽度心筋冷却 (30℃) 虚血下においてPFCに心臓を浸漬した場合, 冠循環を介さず心筋に酸素を供給し心筋保護効果を示したと考えられた.

Thymic carcinoma is a rare mediastinal malignant tumor, and in many patients, the tumor is detected in an inoperable advanced stage. Even when chemotherapy is administered to such patients, the patients show a poor response. We investigated new biomarkers of therapeutic molecular targets.This study included 44 patients diagnosed and treated for primary thymic epithelial tumors at Showa University Northern Yokohama Hospital, Showa University Hospital, and Showa University Fujigaoka Hospital from 2003 to 2011. We investigated new biomarkers of therapeutic molecular targets, such as the peroxisome proliferator-activated receptor γ (PPARγ), insulin-like growth factor 1 receptor (IGF1R), epidermal growth factor receptor (EGFR), estrogen receptor (ER), progesterone receptor (PgR), androgen receptor (AR), human epidermal growth factor type 2 (HER2)/neu, CD44, and L-type amino acid transporter 1 (LAT1), in thymic tumors.Immunohistochemical analysis showed that the PPARγ positivity rate in thymic carcinoma was 32 %, which was significantly higher than that in thymoma (4 %). The IGF1R positivity rate in thymic carcinoma was 73 %, which was significantly higher than that in thymoma (27 %).Therefore, by examining the expressions of PPARγ and IGF1R, it would be possible to identify therapy-responsive patients and to improve results of thymic carcinoma treatment.

血漿や結合組織など生体内に広く存在するフィブロネクチン (FN) は癌患者尿中に多量に出現し, この尿中FN (UFN) は癌化, 癌細胞増殖, 宿主正常細胞の反応, 転移など様々な過程との関連が示唆されている. 今回我々はこれらの過程のうち, 生体内における癌細胞増殖とUFNとの関連を明らかにする目的で, マウスと交叉反応を示さないUFN測定キットを用い, ヒト肺癌細胞担癌マウスのUFNを測定した. その結果, 非担癌マウス, 癌細胞移植後腫瘍形成前, 腫瘍形成後の3群間でUFNは有意に増加した. また腫瘍形成後の腫瘍推定重量とUFNに相関がみられた. 病理学的に皮下腫瘍は癌細胞で構成され, FN染色陽性であった. 明らかな転移病巣はみられなかった. 癌化や転移, 宿主反応の影響を除外した生体モデルにおいてUFNが上昇したことより, 腫瘍細胞に由来するFNが尿中へ排泄され, UFNとして測定されていることが強く示唆された.

症例は52歳, 男性. 胸背部痛を主訴に紹介医を受診し, 左胸壁腫瘍を指摘され, 生検により肉腫型びまん性胸膜中皮腫と診断された. 急速な腫瘍の増大と胸水貯留を認め, 手術適応外と判断したが, 化学療法を選択した結果, 腫瘍の増大は認められず, 胸水も消失した. 遠隔転移もなく, 合併切除にて摘出可能と判断したことより, 手術目的に当科へ紹介入院となった. 胸膜肺全摘除横隔膜・胸壁合併切除術を施行. 術後胸壁ならびに横隔膜合併切除部位へ放射線照射を加え, 術後12カ月の現在, 再発転移徴候も無く社会復帰している. びまん性胸膜中皮腫の予後は不良であるが, 化学療法や手術療法, 放射線療法を組み合わせて治療に望むことが必要と思われた.

術前に確定診断を得られなかった肺腫瘤陰影の特徴を明らかにするため, 当教室における開胸生検例を検討した. 過去5年間の肺疾患手術204例のうち, 腫瘤陰影に対して開胸生検を施行した20例 (9.8%) を対象とした. 男性14例, 女性6例, 13～78歳, 腫瘤径は13～55mmであり, 画像診断に気管支鏡所見や病理診断などを加えて得られた臨床診断は,「悪性疑い」10例,「良悪性判定不能」10例であった. 開胸時の所見と術中迅速診から, 肺癌には肺葉切除術+縦隔リンパ節郭清, 良性疾患には核出術や肺部分切除術を中心とする術式を選択した. 術後病理診断は腺癌10例, 良性腫瘍5例, 結核腫5例であった. 術前「悪性疑い」10例のうち良性疾患は3例 (いずれも結核腫) であった. また「良悪性判定不能」10例のうち3例が腺癌であった. 術前に確定診断を得られなかった肺腫瘤陰影に対し, 積極的に胸腔鏡あるいは開胸による生検を行うことは意義のあることと考えられた.

A 52-year-old woman implanted with AAI-mode pacemaker for bradycardia at another hospital ten years before was seen at the hospital. With pacemaker implantation her bradycardia alleviated, but sometimes she had been suffering from dizziness. Electrocardiogram showed a good atrial pacing and Holter electrocardiogram also indicated no pacing failure. A chest X-ray film taken three months after her first visit revealed a dislocation of endocardial electrode without pacing failure. Reimplantation of a new endocardial electrode was done, and she has not been suffering from dizziness afterward.This case is rare in that the electrode did not adhere to the endocardium and repeated dislocation for more than 10 years, but any lethal complications were not accompanied by such situation.

We examined the efficacy and toxicity of a divided schedule of cisplatin and vinorelbine with concurrent radiotherapy followed by surgery in patients with locally advanced non-small cell lung cancer (NSCLC). Patients with clinical stage IIIA or IIIB NSCLC were eligible if they had a performance status of 0 or 1, were 75 years or younger, and had adequate organ function. Patients were treated with cisplatin (40 mg/m 2 ) and vinorelbine (20 mg/m 2 ) on days 1 and 8 every 3 weeks. Thoracic radiotherapy (2 Gy per fraction; total dose, 40 Gy) was given concurrently. Surgical resection was performed after induction therapy had been completed. If disease was considered clinically inoperable after induction therapy, patients received 2 additional cycles of the chemotherapy and 20 Gy of additional radiotherapy. Twenty-three patients (20 men and 3 women; median age, 63 years; age range, 45-72 years) were enrolled. The overall response rate was 78.3%. Although grade 3-4 toxicities included neutropenia in 95.7% of patients and anemia in 39.1%, no grade 3-4 radiation pneumonitis or esophagitis occurred. Thirteen patients (56.5%) underwent thoracotomy and complete resection. There were no treatment-related deaths. The median survival time was 36 months (range, 4-78 months), the 2-year survival rate was 74%, and the median time to disease progression was 15 months (range, 2-59 months). This trimodality therapy is effective and well tolerated and is an acceptable therapeutic option for patients with locally advanced NSCLC.

Summary The effect of human lung conditioned medium (HLCM) on the DNA synthesis in cultured human alveolar macrophages (HAM) was evaluated. The medium from human lung cultured for 3 days (3d-HLCM) promoted the DNA synthesis as well as the recombinant human GM-CSF does. On the other hand, that cultured for six days (6d-HLCM) did not promote the DNA synthesis but strongly suppressed GM-CSF induced DNA synthesis in HAM. This growth inhibitory effect was also observed when several macrophage like cell lines were cultured with 6d-HLCM. Partial purification of an inhibitory factor on gel permeation HPLC revealed two distinct peaks of activity with molecular weights of 38 kd and 110 kd.

当科で入院治療を行った巨大ブラ24例を対象とし, 診断・治療上の問題点を中心に検討した.年齢は24～72歳, 平均47.7歳で, 男22例, 女2例であった.ブラは両側3例を除き右18例・左3例と, 右側に多くみとめられた.また気胸合併は13例にみられ, このうち巨大ブラに起因する気胸は10例と多く, 気胸合併が必ずしも少なくないことを示唆した.さらに非気胸例に比べて重喫煙者例が多く, 気胸発症との関連性が示唆された.外科治療は Naclerio-Laiger法10例, 自動縫合器を利用した肺部分切除7例, ならびに肺葉切除4例, 計21例に施行し, 術後平均ドレナージ期間は10日間であった.60歳以上の症例は7例で, うち5例が巨大ブラ占有側の気胸発症であり4例に対して手術を施行した.高齢者例の術後ドレナージ期間は長期間となる傾向を示し, 高齢者手術に際してはより慎重な肺縫合を心掛けるべきであると考えられた.

肺腫瘍85例中, 気管支鏡など他検査法で確定診断を得られなかった肺野腫瘤病変13例 (15%) を対象としてCTガイド下経皮針生検を行い, その有用性などについて検討した.年齢は22～76歳, 平均56.2歳, 腫瘤陰影長径は15～30mm, 平均25.3mmで, 壁側胸膜から腫瘍外側縁までは0～20mm, 平均6.2mmであった.検査所要時間は30～55分, 平均36.2分間で, CTスライス数は7～16slices, 平均9.2slicesであった.このうち肺癌症例11例はいずれも肺癌としての確定診断を得たが, 肺過誤腫の2例は疑陽性が検出され, 開胸生検で確定診断を得た.検査に伴う合併症は気胸が1例 (7.7%) にみられたのみで, 血痰や喀血などはなかった.また, 針生検後4ヵ月～最長43ヵ月間の観察期間で, 生検施行部位 (穿刺部位) に腫瘍再発, 播種などの所見はみとめなかった.

Gingival metastasis from lung cancer is very uncommon. We report a case of distant metastasis of pulmonary adenocarcinoma in the mandibular gingiva. A 54-year-old man was admitted to our hospital on September 1, 1997 with hemoptysis. Right upper lobectomy with mediastinal lymph node dissection was performed on September 16. On the 14th postoperative day, the patient complained of a gingival swelling. In the lower right premolar area, a wide pedunculated mass was seen on the mandibular gingiva. Excisional biopsy of the tumor was performed, and histopathological examination revealed that the tumor was a metastatic lesion from the pulmonary adenocarcinoma. The patient received 46.8 Gy of linac irradiation to the tumor area and the entire oral condition improved markedly. However, bilateral adrenal gland metastases were recognized, and left inguinal lymph node metastasis was detected 2 months after lung resection. He developed tumor metastases to multiple organs and died of respiratory failure on December 12, 1997.

During a 54-year-old woman's visit to a hot-spring resort, she suffered a fever and became dizzy and unable to speak clearly. She was admitted to our hospital due to serious pneumonia and respiratory failure type I. She was treated with antibiotics, but her condition became worse and developed into acute respiratory distress syndrome (ARDS). She was intubated and received artificial ventilation. Her blood pressure gradually decreased and she suffered septic shock probably due to endotoxin with gram negative coccus infection. Subsequently, she was treated with a direct hemoperfusion using a polymyxin B immobilized fiber column (PMX-DHP), which resulted in an improvement of oxygenation. However, her pneumonia led to the development of septic shock with gram negative coccus infection, and PMX-DHP treatment was resumed. After PMX-DHP re-treatment, she recovered gradually in intensive care including prone positioning ventilation.

デスモイド腫瘍は小児や比較的若年者層の筋や腱膜などの軟部組織に発生し, とくに腹壁外に発生したものでは周囲組織へ浸潤性に増殖する傾向が強いため, 浸潤部位によっては致命的となりうる疾患である.今回教室において胸壁に発生した本症を経験したので文献的考察を加えて考察する.症例は22歳, 女性.左側胸部腫瘤を主訴に来院.胸部レ線, 胸部断層撮影, X腺CT, MRI-CT, 骨シンチならびに経皮針生検を行い, これらより, aggresive fibromatosis (extra-abdominal desmoid) が強く疑われた.腫瘍は第4, 5肋間への浸潤をみとめ肋骨との剥離も困難であったため, 第4～6肋骨を含む10×7cmの胸壁合併切除を行い, 欠損部位については2枚重ねにしたMarlex mesh にて補填した.術後経過は良好であり, 12ヵ月後現在, 再発徴候もみられていない.

A 33-year-old asymptomatic woman was referred to our hospital for evaluation of an abnormal shadow on a chest radiograph. A chest-computed tomogram revealed a cystic, partially solid tumor in the right inferior mediastinum. Following an initial diagnosis of cystic teratoma, surgery was performed. The tumor, a well-encapsulated, thin-walled cyst located within the right inferior lobe of the thymus, was extirpated by partial resection of the thymus. The cut surface revealed a unilocular cyst containing multiple grayish-white tumors on the inner cyst walls. Some tumors detached from the wall owing to loose connections. Microscopic findings revealed that the cyst was lined with squamous epithelium. The tumor on the cyst wall was diagnosed to be a type B1 thymoma. Based on these findings, we diagnosed this case as a thymoma originating from the wall of a thymic cyst, accompanied by intracystic dissemination from the tumor.

Tracheoesophageal fistula (TEF) or bronchoesophageal fistula may be congenital, inflammatory, neoplastic, or secondary to trauma. Congenital TEF or bron-choesophageal fistula is usually associated with eso-phageal atresia and is readily diagnosed in infancy. But if it is not associated with esophageal atresia, it may persist until adulthood. Some theories have been proposed to explain this delay in diagnosis. We present a case of a 70-year-old man with congenital TEF. The TEF was successfully diagnosed by multidetector-row CT esophagography.

A 55-year-old man was admitted complaining of hemosputa, fever and dyspnea. The chest radiographs and computed tomography showed a diffuse alveolar filling pattern; suggesting alveolar hemorrhage. Laboratory data demonstrated renal dysfunction with hematuria and proteinuria and serum MPO-ANCA was also elevated. Respiratory failure progressed rapidly within two days. Steroid pulse therapy and plasmapheresis was performed. Thereafter, symptoms and chest radiograph findings improved dramatically. However proteinuria persisted as steroid administration was tapered. Renal biopsy demonstrated gromeluronephritis and interstitial lymphocyte infiltration. After administering a second course of steroid semi-pulse therapy, her proteinuria improved. C-reactive protein and MPO-ANCA decreased to normal levels after the initial steroid therapy, but serum amyloid A protein (SAA) gradually elevated. The second course of steroid pulse therapy normalized SAA, and proteinuria improved. Based on these findings, SAA seems to be a more sensitive marker for steroid tapering than either CRP or MPO-ANCA.

Completion pneumonectomy (CP) is a difficult operation in which the surgeon must use techniques such as intrapericardial ligation of the pulmonary vessels. We report herein a case of CP for a patient with recurrent lung cancer. A 63-year-old man was admitted to our hospital for evaluation of abnormal shadows in the right lung field in October 2002. Right middle lobectomy with mediastinal lymph node dissection had been performed in February 1993. Computed tomography (CT) revealed a hilar mass in the right upper lobe the day after admission. Bronchofiberscopic cytology revealed squamous cell carcinoma. Right completion pneumonectomy was performed on suspicion of metachronous multiple lung cancers 4 days later. Histopathologically, resected specimens represented adenosquamous carcinoma similar to the prior lesion from the middle lobe, and examination revealed that the tumor represented a recurrence following middle lobectomy. The patient remains well as of 19 months postoperatively.

A 73-year-old woman was followed up with high-resolution computed tomography (HRCT) from 2000 through 2002 because an area of ground-glass opacity in area S1 + 2 of the left upper lobe was found on HRCT in August 2000. The opacity was present on ordinary CT scans obtained in 1993, but had not been recognized. Thoracoscopic partial resection of the left lung was performed on October 8, 2002. Pathologic examination of the resected specimen showed localized bronchioloalveolar carcinoma (Noguchi's type B). Tumor doubling time was 1718 days from 1993 to August 2000 and 273 days from August 2000 through 2002. This case of adenocarcinoma with bronchioloalveolar growth was characterized by initial slow growth followed by accelerated growth, no mucin production, and a long interval from the detection of opacity to surgery.

PURPOSE Our purpose was to examine perioperative alterations in hemodynamic changes with head-up tilt (HUT) in patients undergoing endoscopic thoracic sympathectomy (ETS). METHODS The subjects were 11 patients with essential hyperhidrosis scheduled to undergo ETS (ETS group) and 9 age-matched volunteers undergoing minor surgery (control group). HUT was performed (40 degrees; 5 min) before and after the surgery, under nitrous oxide anesthesia. Orthostatic hypertension and hypotension in response to HUT were defined as changes of 10% or greater in systolic blood pressure. RESULTS The increase in heart rate in response to HUT was significantly reduced after surgery in the ETS group (from 34 +/- 18 to 14 +/- 11 beats.min(-1); P < 0.001), but not in the control group (from 23 +/- 18 to 22 +/- 12 beats.min(-1); P = 0.911). Orthostatic hypertension disappeared completely after ETS (from 5 of 11 to none of 11 patients; P = 0.035), whereas the prevalence of orthostatic hypotension increased significantly after ETS (from 3 of 11 to 9 of 11 patients; P = 0.030). In the control group, the prevalence of neither orthostatic hypertension nor orthostatic hypotension changed after surgery. CONCLUSIONS ETS attenuates autonomic circulatory response under nitrous oxide anesthesia.

Tumors with a maximum dimension of 3 cm are categorized as T1, whereas those greater than 3 cm are T2 by TNM classification. Some physicians suggest that early-stage peripheral lung cancer should have a maximum tumor diameter of 2 cm and that limited surgery (segmentectomy without lymph node dissection) is acceptable for the patients. In this study, the relationship between the tumor dimension and prognosis was analyzed in 207 patients with surgically treated primary non-small-cell lung cancer (SCLC). The 5-year survival rate of those with tumors 3 cm or less and without lymph node (LN) metastases was 86%, which was significantly higher than that of those with tumors more than 3 cm and without hilar and mediastinal LN metastases (65%) (p < 0.05). However, 33% of the patients with tumors 3 cm or less had LN metastases, and the 5-year survival rate did not differ between those with tumors 3 cm or less (60%) and those with tumors more than 3 cm (54%). Twenty-eight percent of patients with tumors 2 cm or less had LN metastases, and the 5-year survival rate of the patients with tumors 2 cm or less was 62%. The 5-year survival rate of those with tumors 2 cm or less and without LN metastases was 88%. Forty-six patients with tumors 2 cm or less included 5 cases with an intrapulmonary metastasis in the same lobe (11%). In conclusion, a size of 3 cm is an appropriate boundary as the T factor. Because those with tumors 2 cm or less have a relatively high percentage of LN metastases, intraoperative frozen sections of LN should be considered for those undergoing limited surgery for primary non-SCLCs 2 cm or less. Intrapulmonary metastases also should be considered for those undergoing limited surgery even if the maximum dimension of the primary tumor is less than 2 cm.

The serum concentrations of squamous cell carcinoma antigen (SCC-Ag) obtained from 124 surgically treated primary non-small cell lung cancer patients, including 75 adenocarcinomas (AD) and 49 squamous cell carcinomas (SQ), were studied. The changes in the SCC-Ag concentration, which were obtained before and one month after surgery, were analyzed. The 5-year survival rate of the patients with AD who were positive for SCC-Ag preoperatively (32%) was lower than that for those who were negative for SCC-Ag preoperatively (57%, p0.05). Meanwhile, in those with SQ, the 5-year survival rate of those who were positive for SCC-Ag preoperatively (59%) was not different when compared with those who were negative for SCC-Ag preoperatively (73%). The 5-year survival rate of patients with AD who were positive for SCC-Ag preoperatively and negative postoperatively was 53% versus 17% for those who remained positive postoperatively (p0.05). In those with SQ, the 5-year survival rate of those who were positive for SCC-Ag preoperatively and negative postoperatively was 76% while it was 0% for those who remained positive postoperatively (p0.01). In patients with negative SCC-Ag postoperatively, 5-year survival rates were not different between the patients who had positive antigen preoperatively and the patients who had negative antigen preoperatively both in AD (53% and 57%, respectively) and SQ (76% and 75%, respectively). In conclusion, though SCC-Ag is widely used for SQ, preoperative SCC-Ag did not reflect the prognosis. In AD, the survival rate was lower in antigen-positive than antigen-negative patients. Survival rate was higher in antigen-positive patients who became antigen-negative following resection than in patients who remained antigen-positive for both AD and SQ. In the patients who were negative for SCC-Ag postoperatively, survival was the same regardless of the preoperative SCC-Ag positivity in both AD and SQ.

A 72-year-old man with a history of brain infarction presented with left sided anterior chest pain secondary to a thymic carcinoma. He received induction radiotherapy, 45 Gy. Preoperative computed tomography showed the tumor was adherent to a thoracic aortic aneurysm (TAA) which had extensive mural thrombus and calcification. To obtain adequate exposure without exerting tension on the fragile aneurysmal wall, ribs were resected to allow us to separate the tumor from the TAA, after which median sternotomy was performed uneventfully, creating generous exposure. The tumor had invaded the sternum, ribs, innominate vein, phrenic and recurrent laryngeal nerves, and lung. The tumor was removed en bloc, and the chest wall was reconstructed. Intra- and post-operative brain infarction and rupture of the TAA were avoided. The patient is alive and well without recurrence 10 months after surgery.

Background: Pulmonary metastases of thymomas are relatively rare. We report on two patients who underwent surgery for resection of pulmonary metastases. Methods and results: One patient was a 74-year-old man. A chest CT scan showed a mediastinal mass and a hilar nodule in the left lung. The patient underwent surgical resection of both of these lesions. The histological diagnosis was type A thymoma with intrapulmonary metastasis, classified as stage IVb. He did not receive any adjuvant therapy following the operation because the resection was complete. There has been no evidence of recurrence in four years. The other patient was a 68-year-old man with myasthenia gravis. At the age of 61 years, he underwent extended thymectomy with combined resection of the surrounding involved structures. The histological diagnosis was type B3 thymoma, stage III. Adjuvant radiation (40 Gy) was administered postoperatively; however, a pulmonary nodule occurred seven years following the initial operation (patient age, 68 years). He subsequently underwent right lower lobectomy and a diagnosis of intrapulmonary metastasis of thymoma was made. There has been no evidence of recurrence in two years. Conclusions: Long-term follow-up is important to detect recurrence in any cases of thymoma. Lung metastases should be operated upon if they appear to be completely resectable and this can achieve long-term survival.

A 29-year-old woman who underwent evaluation for a 3-month history of left-sided back pain proved to have a left pleural tumor accompanied by a bloody pleural effusion (cytological class II). Three years previously, a chest roentgenogram had been normal. The tumor originated from the parietal pleura at the level of the first three intercostal muscles and was excised completely in continuity with these muscles, including a margin of normal muscle. The tumor measured 15×12 cm and the pathologic diagnosis was benign solitary fibrous tumor; while the tumor invaded the intercostal muscles, no histologically malignant features were present. Long-term follow-up is planned because a possibility of local recurrence exists.

Localized solitary plasmacytoma of the bone (SPB) is a rare disease and is characterized by only one or two isolated bone lesions with no evidence of disease dissemination. A previously healthy 44-year-old male was admitted for evaluation of an abnormal radiographic shadow in the left middle lung field with symptoms of left back pain. Radiological evaluation revealed a peripheral opacity in the left chest wall, which was highly suspected to be a chest wall tumor. CT-guided transcutaneous needle biopsy of the tumor was performed and the specimens showed a monomorphous population of mature plasma cells. The bone marrow biopsy findings revealed no evidence of myeloma and bone scanning revealed only abnormal accumulation in the left seventh rib. He had mild M-proteins in a urine sample and Bence-Jones protein was detected. Immunoelectrophoresis revealed mild biclonal gammopathy of Bence-Jones protein of both the kappa and lambda light-chain types. Under a diagnosis of solitary bone plasmacytoma, preoperative radiation therapy with doses of 40 Gy for the tumor was performed. He underwent complete en bloc resection of the chest wall, including one-third of the left sixth and seventh ribs, the intercostal muscle and the parietal pleura. The protein abnormalities in the urine sample disappeared following surgical resection. Adjuvant chemotherapy using melphalan and prednisolone was performed. He is doing well without evidence of tumor recurrence 2 years following his initial diagnosis.