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Background In the Japanese clinical setting, the prevalence, potential cofounders of gastrointestinal (GI) bleeding from anticoagulant therapy, including direct oral anticoagulants (DOACs) and warfarin, and prognosis after GI bleeding are unclear.Methods and Results:We examined about GI bleeding from anticoagulant therapy using data from the SAKURA AF Registry, a prospective multicenter registry in Japan. Among 3,237 enrollees, 48.8% (n=1,561) were warfarin users and 51.2% (n=1,676) DOAC users. GI bleeding was identified in 68 patients (2.1%). No incidental differences in GI bleeding were observed between the DOAC and warfarin users (32 [1.9%] patients [0.67 events per 100 person-years] vs. 36 [2.3%] patients [0.75 events per 100 person-years], respectively; P=0.43). Multivariate Cox proportional hazard model analysis revealed that creatinine (hazard ratio [HR] 1.379, 95% confidence interval [CI] 1.091-1.743 P=0.007) and hemoglobin (HR 0.814, 95% CI 0.705-0.941, P=0.005) remained independent determinants of GI bleeding. Patients experiencing GI bleeding events had a higher risk of all-cause death (18%) than those without GI bleeding (6%) (P=0.045). Conclusions GI bleeding was strongly associated with anemia and renal impairment. Patients experiencing GI bleeding had higher risk for all-cause death than those without GI bleeding.

Background Relations between characteristics and outcomes of patients in Japan with atrial fibrillation (AF) and the type of medical facility providing their outpatient care are unclear. Methods and results We compared patient characteristics and outcomes between 2 university hospitals (n = 1178), 20 general hospitals (n = 1308), and 41 private clinics (n = 751) (follow-up: 39.3 months) in the prospective SAKURA AF Registry. Private clinic patients were significantly older than university hospital and general hospital patients (73.4 ± 9.2 vs. 70.3 ± 9.8 and 72.6 ± 8.9 years; p Conclusions Adverse clinical events at small to large hospitals appear to be higher than those at private clinics, suggesting that careful attention for preventing stroke/SE and cardiovascular events should be paid to patients at a university or general hospital.

Background: Liver diseases drive the development and progression of atrial fibrillation (AF). The Fibrosis-4 (FIB4) index is a non-invasive scoring method for detecting liver fibrosis, but the prognostic impact of using it for AF patients is still unknown. Herein, we evaluated using the FIB4 index as a risk assessment tool for cardiovascular events and mortality in patients with AF. Methods: We performed a post-hoc analysis of a prospective, observational multicenter study. A total of 3067 patients enrolled in a multicenter Japanese registry were grouped as first tertile (FIB4 index &lt, 1.75, n = 1022), second tertile (1.75 &le, FIB4 index &lt, 2.51, n = 1022), and third tertile (FIB4 index &ge, 2.51, n = 1023). Results: The third tertile had statistically significant results: older age, lower body mass index, increased heart failure prevalence, and lower clearances of hemoglobin and creatinine (all p &lt, 0.05). During the follow-up period, incidences of major bleeding, cardiovascular events, and all-cause mortality were significantly higher for the third tertile (all p &lt, 0.05). After multivariate adjustment, the third tertile associated independently with cardiovascular events (HR 1.72, 95% CI 1.31&ndash, 2.25) and all-cause mortality (HR 1.43, 95% CI 1.06&ndash, 1.95). Adding the FIB4 index to a baseline model with CHA2DS2-VASc score improved the prediction of cardiovascular events and all-cause mortality, as shown by the significant increase in the C-statistic (all p &lt, 0.05), net reclassification improvement (all p &lt, 0.001), and integrated discrimination improvement (all p &lt, 0.001). A FIB4 index &ge, 2.51 most strongly associated with cardiovascular events and all-cause mortality in AF patients with high CHADS2 scores (all p &lt, 0.001). Conclusions: The FIB4 index is independently associated with risks of cardiovascular events and all-cause mortality in AF patients.

Background: Although atrial fibrillation (AF) and coronary artery disease (CAD) are increasing in prevalence in Japan, real-world data regarding clinical outcomes in Japanese AF patients with CAD a...

Direct-acting oral anticoagulants (DOACs) are widely used in aged Japanese patients with atrial fibrillation (AF), but outcome data for such patients are limited. We compared outcomes between 1895 (58.5%) patients aged

Background Off-label dosing of direct oral anticoagulants (DOACs) is encountered clinically among patients with atrial fibrillation (AF), although data on the clinical outcomes of over- and under-dosing are lacking in Japan. Methods and Results: We examined the clinical outcomes of off-label DOAC dosing using the SAKURA AF Registry, a prospective multicenter registry in Japan. Among 3,237 enrollees, 1,676 under any of the 4 DOAC regimens were followed up for a median of 39.3 months: 746 (45.0%), appropriate standard-dose; 477 (28.7%), appropriate low-dose; 66 (4.0%), over-dose; and 369 (22.2%) under-dose. Compared with the standard-dose group, patients in the under- and over-dose groups were significantly older and had a higher stroke risk. After multivariate adjustment, stroke/systemic embolism (SE) and death events were equivalent between the standard- and under-dose groups, but major bleeding events tended to be lower in the under-dose group (hazard ratio [HR] 0.474, P=0.0739). Composite events (stroke/SE, major bleeding, or death) were higher in the over-dose than in the standard-dose group (HR 2.714, P=0.0081). Conclusions Clinical outcomes were not worse for under-dose than for standard-dose users among patients with different backgrounds. Over-dose users, however, were at higher risk for all clinical events and required careful follow-up. Further studies are needed to clarify the safety and effectiveness of off-label DOAC dosing in Japan.

BACKGROUND Although direct oral anticoagulants (DOACs) are widely used in Japanese patients with atrial fibrillation (AF), large-scale investigations into their use, with suitable follow-up times and rates, are lacking. Methods and Results: The SAKURA AF Registry is a prospective multicenter registry created to investigate therapeutic outcomes of oral anticoagulant (OAC) use in Japanese AF patients. We conducted a study involving 3,237 enrollees from 63 institutions in the Tokyo area being treated with any of 4 DOACs (n=1,676) or warfarin (n=1,561) and followed-up for a median of 39.3 months (range 28.5-43.6 months). Analyses of 1- and 2-year follow-up data available for 3,157 (97.5%) and 2,952 (91.2%) patients, respectively, showed no significant differences in rates of stroke or systemic embolism (SE), major bleeding, and all-cause mortality for DOAC vs. warfarin users (1.2 vs. 1.8%/year, 0.5 vs. 1.2%/year, and 2.1 vs. 1.7%/year, respectively). Under propensity score matching, the incidence of stroke or SE (P=0.679) and all-cause death (P=0.864) remained equivalent, but the incidence of major bleeding was significantly lower (P=0.014) among DOAC than warfarin users. CONCLUSIONS A high follow-up rate allowed us to obtain reliable data on the status of OAC use and therapeutic outcomes among AF patients in Japan. Warfarin and DOACs appear to yield equivalent 3-year stroke and all-cause mortality rates, but DOACs appear to reduce the risk of major bleeding.

The incidence and causes of death among patients in Japan treated for atrial fibrillation (AF), a major determinant of strokes and death, with direct oral anticoagulants (DOACs) are unclear. This study's aim was two-fold: to compare the incidence and causes of death between DOAC and warfarin users in Japan and to identify the factors associated with vascular and nonvascular death in the Japanese AF population.The study was based on the SAKURA AF registry, in which clinical events were tracked in 3267 enrollees from 63 institutions for 2-4 years. Enrollees included warfarin users (n=1577) and users of any of 4 DOACs (n=1690). The incidence, cause, and major determinants of death were analyzed.During a median 39.3-month follow-up, 200 patients died, with most succumbing to cardiac death (25%), malignancies (21%), or respiratory infections (20%). There was no significant difference in deaths from any cause between warfarin and DOAC users (108 vs. 92 patients, p=0.34). An age ≥75 years was found to be a major determinant of death, but the relative risk (vs.75 years) was greater for nonvascular death (hazard ratio: 2.85 and 4.97 for age 75-84 and ≥85 years, respectively) than vascular death (2.14 and 2.98 for 75-84 and ≥85 years, respectively). Heart failure, renal dysfunction, and the type of institution were major determinants of vascular death, and a male sex, weight50kg, and anemia were major determinants of nonvascular death.The results of our AF registry-based study, in which two thirds of the enrolled patients succumbed to cardiac death, malignancies, or respiratory infections within 2- 4 years and use of DOACs rather than warfarin did not reduce the mortality, indicated that a management of AF that includes prophylaxis for vascular and nonvascular events in addition to strokes is warranted.

The present study aimed to identify novel useful clinical biomarker of high grade lung neuroendocrine tumors (LNETs). Based on the results of QSTAR LC-MS/MS analysis, we selected complexin-2 (CPLX2) (upregulated 8.7-fold) as a potential biomarker in high grade human LNETs, and validated its expression immunohistochemically in comparison with non-small cell lung carcinomas (NSCLCs). CPLX2 was strongly positive in 16.3% of examined LNETs, but completely negative in all adjacent non-cancerous tissues and NSCLCs. Importantly, positive CPLX2 expression was associated with lymph vessel invasion (P=0.016), pathological stage (P=0.031), and poor disease-specific survival (P=0.004) of patients with LNETs. Preoperative serum CPLX2 level measured by ELISA was significantly elevated in high grade LNETs as compared with %NCs non-cancer controls (NCs) (P=0.002) and NSCLCs (P< 0.001). Receiver operating characteristic (ROC) curve analysis was used for separating high-grade LNET patients from NSCLC patients. The area under the ROC curve (AUC) was 0.825. The calculated optimal cut-off point for CPLX2 level in the serum was 17.8 pg/ml (Youden index=0.591), while sensitivity and specificity was 94.1% and 65.0%, respectively. CPLX2 is suggested as a novel potential clinically useful biomarker for the diagnosis, prognosis and adequate choice of therapy for patients with high grade LNETs.

A 58-year-old man underwent surgery for the treatment of lung adenocarcinoma at our hospital. He had a history of spinal caries at the age of 3 and frequent recurrent asthma-like symptoms thereafter. Chest plain radiography revealed an irregularly shaped mass in the left hilum and a thoracic cage severely deformed by kyphosis. A pulmonary function test demonstrated a severe restrictive ventilation pattern. He underwent a left upper lobectomy without mediastinal dissection. His asthma-like symptoms were exacerbated by difficulty in expectoration of sputum for several days after surgery, but the symptoms disappeared without any medical care. Dyspnea, hemoptysis, and intrathoracic hemorrhage were observed on the 8th postoperative day. Computed tomography revealed torsion of the residual left lower lobe, but the symptoms spontaneously disappeared in a week. The patient had complained of frequent coughing and mild dyspnea on exertion for years, but his quality of life was unchanged after the lobectomy. Bone metastasis was detected 3 years after the surgery, and the patient then underwent chemotherapy. However, he died of the disease 4 years 2 months after the surgery.

A method of videothoracoscopy-assisted extended thymectomy procedure performed through a movable small access window is introduced. The access window can be moved stepwise and longitudinally alongside full sternotomy to be upon the dissection site. The majority of the thymectomy procedure can be directly viewed and operated from the moving window. However, partial and complete thoracoscopic maneuvers are required for dissection of the lateral-most region near the phrenic nerve and the upper poles of the thymus, respectively.

This study was designed to determine the clinical characteristics and verify the results of surgical treatment for non-small cell lung cancer (NSCLC) in patients with hepatocellular carcinoma (HCC), from the results of retrospective analysis of the cases. We retrospectively reviewed our database of 751 patients who underwent curative surgical intervention for NSCLC from January 1993 to December 2006 and found 11 patients with NSCLC with coexisting or previously treated HCC at a perioperative period of lung cancer surgery. Postoperative complications and long-term outcome were analyzed. All cases had coexisting liver cirrhosis. The overall morbidity was 27.2% (n = 3). All complications were considered to be the result of liver cirrhosis-related conditions, such as liver failure (n = 2), postoperative bleeding from the thoracic tube (n = 2), and gastrointestinal bleeding (n = 1). There was no operative mortality. The 1-, 3-, and 5-year survival rates of patients with lung cancer were 88.9%, 74.1%, and 74.1%, respectively. The 1-, 3-, and 5-year survival rates for death from hepatic causes were 79.5%, 79.5%, and 39.8%, respectively. Overall survival rates were 70.7%, 58.9%, and 29.5%, respectively. Preoperative indicators of liver function, such as serum values of total bilirubin (P

Background Preoperative hypercapnia and hypoxemia are reportedly risk factors for postoperative complications. This study aimed to establish the long-term survival risk associated with abnormal preoperative arterial blood gases (ABGs) in patients with non-small cell lung cancer (NSCLC). Methods This study involved 414 patients with stage I NSCLC who underwent lobectomy/bilobectomy with mediastinal lymph node dissection. The patients were divided into groups with normal (n = 269) and abnormal (n = 145) ABGs. Results The patients in the normal ABG group (median age 67 years) were significantly younger than those in the abnormal ABG group (median age 70 years). There were no significant differences between the groups in gender, performance status, pathological stage, histology, postoperative complications, or preoperative comorbidity, except for chronic obstructive pulmonary disease/pulmonary fibrosis. The 3-, 5- and 10-year survival rates in the normal and abnormal ABG groups were 87, 77 and 56, and 78 , 63 and 42 %, respectively (p = 0.006). According to multivariate analysis, age, gender, performance status, non-adenocarcinoma, differentiation of resected tumor, pathological stage, any prior tumor and abnormal ABGs (risk ratio, 1.61) were independent prognostic factors. Conclusions Abnormal ABGs predict long-term survival risk in patients with NSCLC, which is important for planning therapeutic strategies.

Endobronchial inflammatory pseudotumor (EIP) is an uncommon, benign entity in the central airways, frequently causing acute respiratory insufficiency by occluding the trachea or main-stem bronchi. Surgical resection of the tumor is a treatment option; however, it is associated with high morbidity. W

A 73-year-old man who had undergone surgery for lingual cancer, followed by radiation therapy and chemotherapy, presented with severe dyspnea. A chest radiograph revealed a left tension pneumothorax. An immediate tube thoracostomy alleviated his dyspnea. A chest computed tomography scan showed multiple large cystic tumors in both lungs. Squamous cell carcinoma was cytologically proven in the pleural effusion. A malignant bronchopleural fistula due to a metastatic pulmonary tumor was diagnosed. Surgical interventions were tried twice. However, air leakage occurred when the rapidly recurring tumor caused bilateral pneumothoraces. Thus, bronchoscopic closure was conducted. A flexible video bronchoscope and a thin catheter were inserted into the targeted left bronchiolus. The lumen of the catheter was filled with water. Cyanoacrylate glue and lipiodol were mixed in 2 syringes, and the mixture was slowly injected and then flushed with water. As soon as the lipiodol accumulation was visualized by radiograph fluoroscopy, the air leakage stopped. Pleurodesis with the intrathoracic administration of OK-432 was added to both pleural cavities, and the left and right chest tubes were removed on the third and fifth days, respectively. The patient was discharged the following day. However, he died of the disease a month later.

To identify novel biomarkers for the diagnosis and prognosis of human primary lung squamous cell carcinoma (SCC), we compared the spectrum of proteins expressed in SCC and in the adjacent non-cancer tissue, using QSTAR Elite liquid chro- matography with tandem mass spectrometry (LC-MS/MS), coupled with iTRAQ technology. We identified 410 proteins differen- tially expressed in more than 75% of patients, and validated the expression of candidate target proteins by immunohistochemistry. Based on the results of LC-MS/MS, Ingenuity Pathway Analysis and immunohistochemical analyses, myristoylated alanine-rich C-kinase substrate (MARCKS) (upregulated 2.28-fold, p< 0.005) was selected as a potential biomarker of human lung SCC. In order to evaluate the association between patient prognosis and the expression of candidate biomarkers, univariate survival analysis was performed with disease-specific survival curves according to the Kaplan-Meier method, and differences in survival were assessed with the log-rank test. Immunohistochemical evaluation of MARCKS in 99 patients with lung SCC revealed a sig- nificant association between positive expression and poor prognosis compared with patients with negative expression (log-rank test; p = 0.024). These results indicate that MARCKS may represent a potential biomarker for the prognosis of primary lung SCC.

To identify a useful biomarker for human lung squamous cell carcinoma (SCC), the expression of cytokeratin19 (CK19) in human SCC tissue was investigated. In addition, we examined the significance of CK19 expression levels by immunostaining and CYFRA21-1 levels in preoperative serum, and their correlation with the clinicopathologic features of human lung SCC.To identify proteins in cancerous and non-cancerous tissues for the diagnosis and prognosis of SCC, QSTAR Elite LC-MS/MS was used. Immunostaining for CK19 was classified as either "CK19-strong" or "CK19-weak". Correlations between prognosis and both CK19 expression in tumor tissues and serum concentrations of CYFRA 21-1 were analyzed in 107 cases of lung SCC.The upregulation of CK19 in human squamous cell carcinoma tissues was observed by LCMS/MS. The weak expression of CK19, as determined by immunostaining intensity, was a significant predictor of poorer disease-specific survival (p = 0.032). The prognosis was significantly poorer for patients with weak CK19 immunostaining in tumor tissues and a high serum concentration of CYFRA21-1 compared with the other groups (p = 0.003).The combination of weak CK19 expression and high serum CYFRA21-1 levels is a predictor of poorer prognosis for patients with human lung SCC.

Background Radical segmentectomy has been performed for small-sized non-small cell lung cancer (NSCLC). However, underestimation of mediastinal lymph node metastasis in the absence of hilar or interlobar metastasis (skip N2) affects surgical strategy. Our aim was to investigate preoperative and intraoperative predictors of skip N2 in clinical stage (c-stage) IA NSCLC. Methods From 1998 to 2011, 279 patients (155 men and 124 women) with c-stage IA NSCLC (230 pN0, 17 pN1, 12 skip N2, 20 non-skip N2) underwent systematic lobectomy (R0 resection) at our institute. We compared preoperative serum concentrations of carcinoembryonic antigen, cytokeratin 19 fragment, sialyl Lewis X (SLX), and pre- and intraoperative clinicopathological features of pN0 and skip N2 patients. Receiver operator characteristic (ROC) curve analysis was performed to distinguish between the two patient groups. Results The 5-year survival rate of skip N2 patients was 78.6%, higher than that of non-skip N2 patients (44.9%), and not significantly different than that of pN0 (86.7%) or pN1 patients (82.4%). The mean serum SLX concentration in skip N2 patients (28.0 U/ml) was elevated compared to that in pN0 patients (22.9 U/ml). In ROC analysis of SLX, the area under the curve was 0.710, and the optimal cut-off value was 21.4 U/ml (sensitivity, 91.7%; specificity, 51.7%). In multivariate analysis, SLX was an independent predictor of skip N2 in patients with c-stage IA NSCLC (odds ratio, 9.43; p = 0.006). Conclusions Skip N2 metastasis is common in patients with c-stage IA NSCLC with high serum SLX, and lobectomy with complete dissection of hilar and mediastinal lymph nodes should remain the standard surgical procedure for these cases.

A 75 year-old man underwent right hemicolectomy for colon cancer 3 yrs and 6 months ago, followed by chemotherapy with capecitabine. One year and 10 months later, solitary liver metastasis was resected. Five months later, a bulky mediastinal mass of 6 cm in diameter was detected by chest computed tomography and he was referred to our department. The tumor was successfully extirpated by videothoracoscopy-assisted right axillary approach. Histopathology disclosed poorly-differentiated tubular adenocarcinoma and diagnosed as metastatic mediastinal lymph node from the colon cancer. He was discharged on the day 5 and alive without disease 13 months after the mediastinal surgery.

Wedge resection for tissue diagnosis of indeterminate lung tumors that is strongly suspected of being lung cancer, is sometimes difficult, and lobectomy, followed by a thorough pathological examination, is required. In the present report, four cases are presented, and the following indications, which have never been discussed before, are recommended for lobectomy without a pre-resectional diagnosis. First, where larger tumors are involved, and lobectomy is expected to result in a more favorable patient status and second, where the lesions are deeply located near major pulmonary vessels, or the patient is not a candidate for wedge resection or segmental resection. In each case, tolerance to surgery and detailed, informed consent for potentially complete resection are mandatory.

A 66-year-old man presented with a one month history of hoarseness. Left recurrent nerve palsy and a left upper mediastinal mass were observed by an otorhinolaryngologist who referred the patient to our department. Chest computed tomography showed a superior mediastinal mass, which seemed to involve the left common carotid and left subclavian arteries from the greater curvature of the aortic arch. The innominate vein was compressed, and collateral circulation was well developed. The left upper lobe of the lung was also seemed involved. A mediastinal biopsy conducted via left thoracoscopy revealed a malignant spindle cell tumor. The mediastinum was irradiated (40 Gy), and surgical extirpation was subsequently undertaken 3 weeks later. The tumor was successfully removed without the use of extracorporeal circulation. Because only smooth muscle actin was focally but strongly expressed immunohistochemically, leiomyosarcoma was confirmed. The patient was discharged on day 14. A solitary left pleural metastasis was observed and resected 12 months after the surgery and the patient is well without further recurrence 16 months after the initial surgery.

Background and objectives We investigated various tumor markers in patients with surgically treated small cell lung cancer (SCLC) to identify the markers closely correlated to pathological staging and to predict survival by retrospective analyses. Methods Reviewing database records between 1990 and 2007 revealed 36 patients with SCLC, that were grouped according to clinical and pathological stages. Receiver operating characteristic (ROC) curves were calculated for serum levels of various tumor makers to predict the pathological stage. The cut-off value was calculated from the ROC curve of the significant marker. Survival in patient groups divided by the new cut-off value was calculated. Results Serum levels of various tumor makers were not significantly different between the pathological stage groups, except for serum sialyl Lewis X (SLX). ROC curve of SLX was significantly correlated to pathological stages (P = 0.0136). The calculated SLX cut-off value was 25.1 U/ml, with 80% sensitivity and 70% specificity. Five-year survival of patients selected by this new cut-off was 82.5%, whereas that with the standard cut-off (38.0 U/ml) was 55.9%. Conclusions Serum SLX values were associated with pathological stage and survival after surgery in SCLC patients. J. Surg. Oncol. 2012; 105:818–824. © 2011 Wiley Periodicals, Inc.

Our aims were to evaluate (1) the result of surgical treatment of limited-stage small cell lung cancer (SCLC) by examining long-term survival and prognostic factors, (2) the diagnostic role of surgery by comparing clinical and histopathological diagnoses and staging, and (3) the impact of preoperative diagnostic accuracy on survival.We retrospectively reviewed the clinical profiles of 37 patients treated at our institution between January 1990 and December 2007 for SCLC diagnosed using surgical specimens.The median follow-up period was 41.2 months, and the 5-year survival rate was 57.5%. Lobectomy or wider resection was performed alone in 33 cases and with mediastinal dissection in 29 cases. Fifteen patients did not receive chemotherapy. SCLC was diagnosed preoperatively or intraoperatively in 75% and non-SCLC in 25%. Clinical stage 1 disease was diagnosed in 29 patients; however, pathological stage 1 was seen in only 20. Patients at pathological stage 1 disease showed better survival than those at stage 2, but a similar result was not obtained in the case of clinical stage of the disease. Tumor size and nodal stage were the only significant factors influencing survival in a multivariate analysis. The adequacy of preoperative clinical diagnosis of tumor extensiveness, nodal involvement, and clinical stage did not significantly influence survival.Surgery for limited-stage SCLC was associated with a favorable survival rate and provided important pathological information that can help predict survival. Accuracy of preoperative diagnoses showed no apparent impact on survival for surgically treated SCLC patients.

An 80-year-old woman had an asymptomatic chest wall tumor. She had undergone thoracotomy to treat a benign lesion 11 years previously. Chest computed tomography revealed a convex lens-shaped mass 7 cm in diameter in the chest wall. Positron emission tomography demonstrated mild accumulation of F-deoxyglucose. We performed an exploratory thoracotomy; however, no mass lesion was found. Therefore, we thought that the soft tissue of the back was drawn into the pleural cavity through the widened intercostal space during the previous thoracotomy. We simply aligned the ribs using heavy surgical sutures. The patient has experienced good recovery, with no recurrence since the surgery.

We aimed to determine the factors predicting liver cirrhosis-related complications in the early postoperative period after lung cancer surgery in patients with liver cirrhosis. We retrospectively reviewed the medical records of patients who underwent curative surgery for primary lung cancer in our institute from January 1990 to March 2007, finding 37 cases with comorbid liver cirrhosis. These patients were divided into two groups, according to whether liver failure, bleeding, and critical infection had occurred postoperatively. Various clinical parameters were analyzed statistically between the bigeminal groups. Liver cirrhosis-related complications occurred in seven of the 37 patients (18.9%). Transient liver failure occurred in two patients (5.4%) after pulmonary resection. Acute intrathoracic bleeding occurred in four cases (10.8%). Two patients died (5.4%) in both cases due to sepsis. Preoperative total bilirubin (P

Gradually growing cystic lesion of the lung is commonly encountered in daily clinical practice. Thin-walled cavitary lung cancer is a rare entity; however, it could be a pitfall in the diagnosis of such radiographically benign-looking lesions, especially without an obvious solid, nodular, or tumorous appearance in the lesion. We herein report a rare case of lung cancer successfully treated by surgical resection that appeared as a gradually growing cystic lesion mimicking benign emphysematous disease, with a review of the literature. A 68-year-old man with a 24-year history of hypothyroidism presented with an abnormal cystic shadow in the left lung on routine chest X-ray. Twelve months later, occasional bloody sputa had started and was gradually getting worse. The patient was then referred to our department for surgical intervention. He received clarithromycin by daily oral administration, and the bloody sputa soon disappeared. However, a malignancy was still suspected because the wall was slightly thickened unevenly in comparison with the previous chest X-ray and computed tomography findings. Thus we performed a left lower lobectomy followed by mediastinal dissection because a squamous cell carcinoma was diagnosed by intraoperative frozen section. The patient postoperatively received 4 courses of paclitaxel-carboplatin therapy. Twelve months after surgery, he survives without recurrence.

We report two cases of lung cancer in nonagenarians successfully treated by pulmonary resection and assess the feasibility of surgical treatment in such an old population. Case 1. An asymptomatic 93-year-old man was diagnosed as having non-small cell lung cancer with clinical T1N0M0 stage IA disease, and a right upper lobectomy was performed via video-assisted thoracoscopic surgery. Mediastinal dissection was omitted. He was discharged on postoperative day 16, and he remains well without recurrence 6 months after the operation. Case 2. A 92-year-old man was diagnosed as having non-small cell lung cancer with clinical T2N0M0 stage IB disease and diminished pulmonary function. A right lower lobectomy with complicated partial resection of the diaphragm was performed via axillary thoracotomy with thoracoscopic support. He was discharged on postoperative day 28 and is well 42 months after the surgery. Although the feasibility of pulmonary resection in a nonagenarian could not be confirmed from only these two cases, pulmonary resection is a possible treatment option for lung cancer in selected nonagenarians.

An 18-year-old woman presented with hemoptysis during long-distant running. A chest computed tomographic scan revealed a well-demarcated, round-shaped, solitary mass (3.0 cm in diameter) in the left pulmonary hilum. The bleeding was getting more often and a left upper lobectomy was carried out to avoid critical airway bleeding. A solid proliferation of short spindle cells with a remarkable whorl pattern was demonstrated histologically. Immunohistochemical studies showed positive for vimentin and S-100, and focally positive for epithelial membrane antigen. Primary pulmonary meningioma was thus diagnosed. The patient is well without recurrent disease 15 months after surgery.