A resected case of triple cancer in the uterus, lung and thyroid

A 62 year-old woman was admitted to our clinic for the treatment of lung cancer. Right middle and lower lobectomy was performed. Histological diagnosis was well differentiated adenocarcinoma in the right lower lobe (yp-T2N1M0, stage II). Forty-seven months before the pulmonary resection (at the age of 57 year-old), she had undergone hysterectomy for squamous cell carcinoma of the uterus (carcinoma in situ). Forty-three months after the pulmonary resection (at the age of 65 year-old), two minute thyroid cancer were resected. Twenty-one resected cases of triple cancer including lung cancer have been reported in Japanese literature.     

Surgical treatment for metastatic lung tumors with incidentally coexisting lung cancer.

We report four surgically resected cases of a metastatic lung tumors with incidentally coexisting lung cancer. Two patients (Cases 1 and 2) were admitted for surgical treatment for pulmonary metastases from colon cancer, and the other two (Cases 3 and 4) were for pulmonary metastases from renal cell carcinoma. In only one patient (Case 3), one lesion among the multiple shadows on the preoperative computed tomography examination was rather strongly suspected to be primary lung cancer. In three patients (Cases 1, 2 and 3), one of the resected lesions in each individual case was diagnosed as lung adenocarcinoma by an intraoperative examination using frozen sections, and was later histologically confirmed. In Case 4, one of the resected lesions was postoperatively determined to be lung adenocarcinoma. All coexisting lung cancers, treated with partial resection of the lung, were well-differentiated small-sized adenocarcinoma (T1N0), while the other lesions resected in each case were metastases from the individual cancer. Problems in preoperative diagnosis and surgical treatment for metastatic lung tumors with incidentally coexisting lung cancer are discussed.     

Surgical treatment for metastatic lung tumors with incidentally coexisting lung cancer

We report four surgically resected cases of a metastatic lung tumors with incidentally coexisting lung cancer. Two patients (Cases 1 and 2) were admitted for surgical treatment for pulmonary metastases from colon cancer, and the other two (Cases 3 and 4) were for pulmonary metastases from renal cell carcinoma. In only one patient (Case 3), one lesion among the multiple shadows on the preoperative computed tomography examination was rather strongly suspected to be primary lung cancer. In three patients (Cases 1, 2 and 3), one of the resected lesions in each individual case was diagnosed as lung adenocarcinoma by an intraoperative examination using frozen sections, and was later histologically confirmed. In Case 4, one of the resected lesions was postoperatively determined to be lung adenocarcinoma. All coexisting lung cancers, treated with partial resection of the lung, were well-differentiated small-sized adenocarcinoma (T1N0), while the other lesions resected in each case were metastases from the individual cancer. Problems in preoperative diagnosis and surgical treatment for metastatic lung tumors with incidentally coexisting lung cancer are discussed.     

Two cases of triple primary neoplasm and two cases of quadruple primary neoplasm including bladder cancer

Two cases of triple primary neoplasm and two cases of quadruple primary neoplasm including transitional cell carcinoma (TCC) of bladder are reported. The first case was a 70-year-old male who had bladder cancer, occult cancer of prostate (adenocarcinoma) and highly differentiated adenocarcinoma of pancreas. He died of cachexy. The second case was a 69-year-old male. This case was also triple primary neoplasm including bladder cancer, squamous cell carcinoma (SCC) of penis and SCC of larynx. The third case was a 78-year-old male who had bladder cancer, adenocarcinoma of prostate similar to that of the first case, adenocarcinoma of stomach, and SCC of lung. He died of obstructive jaundice and renal failure owing to massive metastases of gastric cancer. The fourth case was a 78-year-old male who had four primary neoplasms such as bladder cancer, branchiogenic epithelial carcinoma, SCC of buccal mucosa and adenocarcinoma of rectum.     

Clinical study of double primary cancer involving the lung in resected cases

Among all cases of surgically resected lung cancer, there were 56 cases (16.1%) of double primary cancer. The common sites of the other primary cancer was the stomach (19 cases), followed by large intestine (9 cases), urinary bladder (7 cases) and pharinx-larynx (7 cases). One patient had triple cancers. In all cases of double primary cancer, 46 cases were metachronous, 10 of which were cases of initial lung cancer. The 5-year survival rate of double primary cancer was 39.7%. Good result was obtained in metachronous cases with initial lung cancer. Most of prognosis of double primary cancer was determined by that of lung cancer. In more than half of initial cancer, the second primary cancer was detected by symptoms. So, special attention to the possibility of double primary cancer in patients with resected lung cancer is necessary for improvement of prognosis.     

Surgical experience of bronchogenic early squamous cell carcinoma detected by sputum cytology in lung cancer screening

Eighty-one patients of roentgenologically occult lung cancer (all men, and squamous cell carcinoma) were detected by sputum cytology in lung cancer screening of "Miyagi Program". Sixty-seven patients were resected surgically, and sixty-four of them underwent absolutely curative resection. In fifty-six patients, carcinoma did not penetrate the bronchial wall, and all of them were free from lymph node involvement. In eleven patients, carcinoma penetrated the bronchial wall, and three of them were proved to have lymph node involvement. For that reason, carcinoma which did not penetrate the bronchial wall and was free from lymph node involvement, was defined as early squamous cell carcinoma. Fourty-two early squamous cell carcinoma were located on segmental or more proximal bronchi, but twelve were located on subsegmental or more peripheral bronchi. Five-year survival of fifty-six patients with early squamous cell carcinoma were 91.8%, seven of fifty-six early squamous cell carcinoma patients were multicentric, which were detected synchronously in four cases, postoperatively in two cases, and both synchronously and postoperatively in one case. Two of three postoperatively detected cases were resected surgically and alive without cancer. These results indicate the validity of surgical treatment for roentgenologically occult squamous cell carcinoma. As the most serious prognostic problem is multicentricity, careful localization of primary lesion and postoperative intensive follow-up should be considered.     

Studies of resected small lung cancer associated with intrapulmonary metastasis

We studied on intrapulmonary metastasis in 6 out of 136 cases where the resection for lung cancer was performed at Fukui Red Cross Hospital from 1984 to 1990. Four out of 6 were small lung cancer cases. The histological types were as follows: 4 adenocarcinomas and 2 squamous cell carcinomas. In adenocarcinoma cases, intrapulmonary metastasis tended to scatter to other pulmonary lobe and to increase in number. On the other hand, in squamous cell carcinoma cases, intrapulmonary metastasis was solitary and localized in the same pulmonary lobe as that of the primary lesion. Two squamous cell carcinoma cases were alive, and one of these was alive for more than 4 years in small lung cancer cases. It is suggested that in cases of intrapulmonary metastasis localized in the same pulmonary lobe as that of the primary lesion, to be expected metastatic route to be included in resected lobe, surgical operation is recommended, especially in squamous cell carcinoma cases.     

The significance of associated pre-invasive lesions in patients resected for primary lung neoplasms.

OBJECTIVE: To evaluate the prevalence and clinico/prognostic significance of the presence of pre-invasive lesions in patients resected for primary lung neoplasm. METHODS: From 1993 to 2002, 1090 patients received resection for primary lung carcinomas. Of these, 73 presented an associated pre-invasive lesion in the surgical specimen distant from the primary tumour. Classification of pre-invasive lesions included Atypical Adenomatous Hyperplasia (AAH); Carcinoma In Situ (CIS) either diffuse or at the bronchial resection margin; Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH). Correlation between the presence of pre-invasive lesion and the following variables were calculated by logistic regression analysis: sex, age, median tumour size, histology, histologic differentiation, histologic evidence of invasiveness (vascular and perineural invasion), peritumoural lymphocytic infiltrate, pTNM, lobe location, history of previous malignancy. Survival rates were computed using Kaplan-Meier method and survival differences with the total patient population of resected lung carcinomas were tested using the log-rank method. RESULTS: There were 28 AAH, 42 CIS (5 at the bronchial resection margin) and 3 DIPNECH. Histology of the primary tumor included bronchioloalveolar carcinoma (9 patients), adenocarcinoma (19), squamous cell carcinoma (39), typical carcinoid tumour (3) and adenosquamous carcinoma (3). Overall prevalence of pre-invasive lesion was 6.7%. A strong correlation was found between the presence of AAH and the co-existence of either adenocarcinoma, bronchioloalveolar carcinoma or mixed adenocarcinoma-containing tumours (P = 0.00002) between CIS and squamous cell carcinoma (P = 0.009) and between DIPNECH and carcinoid tumours (P = 0.001). No significant correlation was found between the presence of any type of pre-invasive lesion and sex, age, median tumour size, histologic differentiation, histologic evidence of invasiveness, pTNM, lobe location and history of previous malignancy or the probability to develop a second primary lung carcinoma in the remaining lobe(s) after resection. Survival rates in the patients with AAH and CIS were not significantly different from those of patients without pre-invasive lesion (P = 0.3 and P = 0.1). CONCLUSIONS: Associated pre-invasive lesions in patients resected for primary lung neoplasms are not infrequent. AAH is associated with adenocarcinoma, CIS with squamous cell carcinoma, DIPNECH with typical carcinoid tumours. Our experience indicates that in these patients histology, stage distribution and survival do not differ from the total population of resected patients with lung tumors.     

Bronchoscopically undiagnosed small peripheral lung tumors

Small peripheral lung cancers (2 cm or less maximum diameter) are often surgically resected, and the survival rate of those patients has been reported to be significantly higher than that of patients with tumors 2.1 cm or more in diameter. We evaluated the status of these small tumors diagnosed during surgery, following unsuccessful transbronchial biopsy procedures. In a retrospective study, 84 consecutive patients, with a maximum diameter of 2 cm or less on chest computed tomography, were enrolled. All underwent surgery for diagnosis. Video-assisted thoracoscopic surgery was performed in 49 cases (58%), Video-assisted thoracoscopic surgery+mini-thoracotomy in ten cases (12%), and an open lung biopsy in 25 cases (30%). Primary lung cancer was found in 40 cases (48%), metastatic lung tumors in three cases (3%), and benign lung tumors in 41 cases (49%). Among the 40 primary lung cancer cases, adenocarcinoma was in 38, squamous cell carcinoma was in one, and small cell carcinoma was in one. The rate of stage IA was 90%. Surgical excision of undiagnosed small peripheral nodules without waiting is necessary if transbronchial biopsy diagnosis is unsuccessful, because of the high rate of stage IA non-small cell lung cancer.     

COPD increases the risk of squamous histological subtype in smokers who develop non-small cell lung carcinoma

BACKGROUND: Squamous cell carcinoma has a stronger association with tobacco smoking than other non-small cell lung cancers (NSCLC). A study was undertaken to determine whether chronic obstructive pulmonary disease (COPD) is a risk factor for the squamous cell carcinoma histological subtype in smokers with surgically resectable NSCLC. METHODS: Using a case-control design, subjects with a surgically confirmed diagnosis of squamous cell carcinoma were enrolled from smokers undergoing lung resection for NSCLC in the District Hospital of Ferrara, Italy. Control subjects were smokers who underwent lung resection for NSCLC in the same hospital and had a surgically confirmed diagnosis of NSCLC of any histological type other than squamous cell. RESULTS: Eighty six cases and 54 controls (mainly adenocarcinoma, n = 50) were enrolled. The presence of COPD was found to increase the risk for the squamous cell histological subtype by more than four times. Conversely, the presence of chronic bronchitis was found to decrease the risk for this histological subtype by more than four times. Among patients with chronic bronchitis (n = 77), those with COPD had a 3.5 times higher risk of having the squamous cell histological subtype. CONCLUSIONS: These data suggest that, among smokers with surgically resectable NSCLC, COPD is a risk factor for the squamous cell histological subtype and chronic bronchitis, particularly when not associated with COPD, is a risk factor for the adenocarcinoma histological subtype.     

A case of metachronous lung cancer in which tumor developed within the different ipsilateral lobe over a short period of time and completion pneumonectomy was required]

A 51-year-old man underwent a middle-lower lobectomy for squamous cell carcinoma on February 8, 1996. In July, 1997, a computed tomography revealed a mass shadow in the right upper lung field. Completion pneumonectomy was performed. Histopathological examination showed poorly differentiated adenocarcinoma. This case was the shortest time to occurrence of second tumor in our metachronous lung cancer cases. We must always give attention to exist second primary lung cancer and double primary lung cancer after resection of primary lung cancer.     

Aggressive Surgical Treatment of Multiple Primary Lung Cancers

A case of triple primary lung cancers - squamous cell carcinoma, adenocarcinoma and large-cell carcinoma - is presented. Surgical treatment comprised, respectively, left pneumonectomy, partial resection of the right upper lobe and completion right upper lobectomy. The postoperative courses were uneventful and the patient remains well, with no sign of recurrence, 20 months after the third operation.     

Should mediastinal nodal dissection be routinely undertaken in patients with peripheral small-sized (2 cm or less) lung cancer? Retrospective analysis of 225 patients.

OBJECTIVE: We retrospectively reviewed nodal status of the patients with peripheral small-sized lung cancer grouped by cell type and tumor size to evaluate the necessity of systematic nodal dissection in this group of patients. METHODS: From 1973 to 1998, 1713 patients underwent pulmonary resection for primary lung cancer in Kanazawa University. Among them, 225 patients (13.1%) with peripheral small-sized (2 cm or less) lung cancer underwent lobectomy and systematic nodal dissection were retrospectively reviewed. The maximum diameter of the tumor was measured on formalin-fixed surgical specimens. RESULTS: The histological types were adenocarcinoma in 170 (75.6%), squamous cell carcinoma in 20 (8.9%), small cell carcinoma in 19 (8.4%) and others in 16 (7.1%). Among 170 adenocarcinoma patients, 38 (22.4%) showed hilar or mediastinal lymph node metastases. No mediastinal lymph node metastasis was encountered in all squamous cell carcinoma (n = 20), adenocarcinoma < or = 1 cm (n = 16), small cell carcinoma < or = 1 cm (n = 4), and adenocarcinoma of Noguchi's classification type A or B (n = 24). CONCLUSIONS: Mediastinal nodal dissection would be unnecessary in the patients with peripheral small-sized lung cancer fulfilling these criteria: (1) squamous cell carcinoma < or = 2 cm; (2) adenocarcinoma < or = 1 cm; (3) localized bronchioloalveolar carcinoma < or = 2 cm without foci of active fibroblastic proliferation in histology (Noguchi's classification type A or B adenocarcinoma); (4) small cell carcinoma < or = 1 cm. Candidates fulfilling above criteria were 28.4% (64/225) of small-sized lung cancer and 10.9% of stage IA patients. The establishment of a universally accepted therapeutic strategy for small-sized lung cancer is indispensable in the clinical spread of various sort of limited resections.     

Single primary lung cancer consisting of three cancer cell types (small cell carcinoma, adenocarcinoma, and squamous cell carcinoma) in which each had metastasized to different lymph nodes

We report a case of a 70-year-old male smoker with a single primary tumor 2.5 x 3.0 cm in size in the right lung lower lobe. A transbronchial lung biopsy revealed squamous cell carcinoma of the lung. We performed right lower lobectomy with lymph node dissection (ND2a). The resected specimen consisted of three different cell types; small cell carcinoma, adenocarcinoma and squamous cell carcinoma (in a ratio of 70: 20: 10). Each cancer cell types had metastasized to different lymph nodes. The final diagnosis was a combined small cell carcinoma in the lung. Combined small cell carcinoma is uncommon, but is nevertheless a well-described diagnostic category in lung cancers.     

Prognostic significance of E-cadherin and beta-catenin in resected stage I non-small cell lung cancer.

OBJECTIVES: E-cadherin and its associated intracellular molecules, catenins, are important for cell-cell adhesion. Impaired expression of these molecules are frequently observed in several cancers. E-cadherin and beta-catenin are often expressed in non-small cell lung cancers. The aim of this study was to investigate the expressions of E-cadherin and beta-catenin and their significance as prognostic markers in pathological stage I non-small cell lung cancer. METHODS: Paraffin embedded tumor tissue blocks were obtained from 141 patients who underwent resection without preoperative radiotherapy or chemotherapy with pathological stage I non-small cell lung cancer. Tumor samples were prepared in tissue microarrays and they were stained by immunohistochemistry with antibodies against E-cadherin and beta-catenin. The expressions of E-cadherin and beta-catenin were analyzed with relation to the clinico-pathological data. The median follow-up period of the patients was 41 months (range, 2-88 months). RESULTS: Preserved expressions of E-cadherin and beta-catenin were observed in the membrane and the cytoplasm of normal epithelial cells and tumor cells. Absent or reduced expression for E-cadherin and beta-catenin were observed in 60% and 45% of all the patients, respectively. There was a significant positive correlation between E-cadherin and beta-catenin expression (P<0.01). Absent or reduced expression of E-cadherin was observed in 72.5%, 36.6%, and 60.0% of squamous cell carcinoma, adenocarcinoma, and bronchioloalveolar carcinoma, respectively. There was a significant decrease of E-cadherin expression in squamous cell carcinoma compared to adenocarcinoma (P<0.01). Patients with reduced expression of beta-catenin had poor recurrence free survival in adenocarcinoma, but not in squamous cell carcinoma. CONCLUSION: Decreased expressions of E-cadherin and beta-catenin were closely correlated in resected stage I non-small cell lung cancer. Reduced expression of E-cadherin and beta-catenin indicates tumor cell dedifferentiation and reduced expression of beta-catenin had poor recurrence free survival in adenocarcinoma of the resected stage I non-small cell lung cancer.     

Second surgical intervention for contralateral recurrence or second primary lung cancer

Resection of contralateral lung cancer (6 cases of pulmonary metastasis from the first lung cancer and one case of second primary lung cancer) were evaluated retrospectively in terms of postoperative complication, pulmonary function and survival rate. Out of 691 cases with resected non small cell lung cancer, 7 cases (1.0%) had contralateral lung cancer which were resected as the second operation. Six cases were squamous cell carcinoma and one case was adenocarcinoma. The interval between the first and the second operation was 12 months to 10 years (average 46 months). The post-operative stage of first lung cancer were stage I in 5 cases and stage IIIB in 2 cases, but no case had lymphadenopathy at the first operation. Operative procedures for contralateral lung were as follows; one case of lobectomy----lobectomy, one case of lobectomy----segmentectomy, two cases of lobectomy----partial resection, two cases of pneumonectomy----partial resection. For a metachronous lung cancer, right upper sleeve lobectomy was done as the first operation followed by left lower sleeve lobectomy as the second cancer five years later. Contralateral lung resection impaired pulmonary function, but all cases well tolerated the second operation. The five-years survival rate after second operation was 40.0%.     

Multiple primary lung carcinomas: prognosis and treatment

From 1955 to 1990, 111 patients have been treated for multiple primary lung carcinomas. Criteria for diagnosis were: (1) different histology (n = 44); or (2) same histology, but disease-free interval at least 2 years (n = 39), origin from carcinoma in situ (n = 19), or metachronous disease in different lobe (n = 9) with no cancer in common lymphatics or extrapulmonary metastasis at the time of diagnosis. The second cancer was synchronous in 33 patients (30%) and metachronous in 78 (70%). Metachronous disease developed at a median interval of 48 months. Five-year survival for patients with metachronous and synchronous disease from the time of initial diagnosis of cancer was 70% and 44%, and 10-year survival was 42% and 23%, respectively. Survival after the development of a metachronous lesion was 23% at 5 years. Survival from the time of initial diagnosis was significantly better for metachronous versus synchronous, late (24 month disease-free interval) versus early metachronous disease, and adenocarcinoma versus epidermoid carcinoma. The first cancer was completely resected in 103 patients (93%), but complete resection of a metachronous tumor was possible in only 54 patients (69%). Complete resection of second primary cancers resulted in significantly (p less than 0.0001) prolonged 5-year survival compared with incomplete resection (38% versus 9%). Excluding patients requiring pneumonectomy, initial resection limited subsequent resection in only 7 patients (9%) with metachronous disease. We conclude that patients surviving treatment of primary lung cancers require lifelong screening for multiple primary lung carcinoma, and complete resection is recommended whenever possible.     

Multiple lung adenocarcinomas showing ground-glass opacities on thoracic computed tomography

It is difficult to distinguish multiple primary lung cancers from pulmonary metastasis. We experienced a case of surgically resected lung tumors that showed multiple ground-glass opacities on thoracic computed tomographic scan. There were eight nonsolid and two part-solid ground-glass opacities in the bilateral lungs. Surgical resection was performed because all tumors had a ground-glass opacity appearance on computed tomographic scan, which is compatible with a finding of primary lung adenocarcinoma. The postoperative pathologic diagnoses were two cases of invasive adenocarcinoma, six cases of bronchioloalveolar carcinoma, and eight cases of atypical adenomatous hyperplasia. The patient remains alive without any evidence of recurrence 40 months after surgery. A ground-glass opacity appearance on computed tomographic scan could be interpreted as supportive evidence for multiple primary lung adenocarcinoma rather than pulmonary metastases.     

胸段食管鳞癌的多学科综合治疗

食管癌患者就诊时大多已为中晚期,第七版UICC食管癌新分期Ⅲ期以上肿瘤单纯手术切除往往疗效不满意,系统性的多学科治疗至关重要.越来越多的证据表明术前同期放化疗是最为有效的诱导治疗方式,可使肿瘤降期并提高根治性切除率;针对食管鳞癌中常见的多组、多野淋巴结转移患者,术前诱导化疗不失为可行的选择.对于已根治性手术切除的局部进展期肿瘤,术后辅助放疗或有助于弥补手术清扫范围的不足以加强局控;术后辅助化疗的作用亦有待进一步深入研究.胸段食管鳞癌与西方国家常见的食管下段腺癌有本质的不同,需要积累更多的前瞻性临床研究,以形成适合我国食管癌患者的综合治疗模式.     

Expression of vimentin in surgically resected adenocarcinomas and large cell carcinomas of lung

The expression of vimentin in pulmonary carcinomas was studied in 285 cases of surgically resected lung cancer from our hospital files. Formalin fixed, paraffin-embedded sections were studied by immunoreactive staining techniques using two monoclonal antibodies against vimentin. Cases demonstrating vimentin positivity by the avidin-biotin-peroxidase method included 11 of 129 adenocarcinomas studied (8.5%), and 15 of 61 large cell carcinomas studied (24.6%). Vimentin expression was not seen in any of the 51 squamous cell carcinomas or 35 small cell carcinomas in our series. The positive cases of adenocarcinoma were in moderately and poorly differentiated cancers. Four of the eight giant cell carcinomas (50%) demonstrated vimentin expression. All cases that exhibited vimentin positivity were studied for cytokeratin expression. Coexpression of vimentin and cytokeratin was demonstrated not only within the same tumor but also within the same cells in some cases stained by double antibody technique, including both adenocarcinomas and large cell carcinomas. Similar immunoreactive methods were also applied to sections from human lung cancer transplants grown in the nude mouse. Of 28 tumors studied, four of 11 adenocarcinomas (36%) and all 4 large cell carcinomas demonstrated coexpression of vimentin and cytokeratin, while none of the five squamous cell carcinomas or eight small cell carcinomas expressed vimentin.