VATS right upper lobectomy

A 56-year-old male patient was admitted due to one small pulmonary nodule in the apicoposterior segment of the right upper lobe, which was found on his health screening one month ago. Preoperative examinations showed no distant metastasis, and his heart and lung functions could tolerate the lobectomy. Chest computed tomography (CT) showed one small pulmonary nodules on the apicoposterior segment of the right upper lobe, which was considered to be malignant lesions. No remarkably swollen lymph node was visible in the mediastinum. Therefore, VATS right upper lobectomy was performed and intraoperative frozen section confirmed the diagnosis of adenocarcinoma.     

A case of metachronous multiple primary lung cancers coexistent with atypical adenomatous hyperplasia]

A seventy-year-old woman was admitted for an abnormal chest shadow on a routine radiograph. She had undergone left upper lobectomy with mediastinal lymph node resection (R2a) for lung cancer (stage I), eight years before. We diagnosed this cancer as well differentiated papillary adenocarcinoma, and it coexisted with a focus of atypical adenomatous hyperplasia (AAH) in the resected material. We had been following up this patient with chest radiography, CT scanning, and tumor marker tests, but eight years after her first operation, we found a small nodular lesion in the left upper field (S6). This nodule was not diagnosed with fiberoptic bronchoscopy. Because we could not exclude primary lung cancer or intrapulmonary metastasis (eight years ago), we performed partial lung resection on the left S6 nodule. Histopathologically, the diagnosis was well differentiated papillary adenocarcinoma of the lung, coexisting with a small hyperplastic focus in the resected material. It was very difficult to diagnose whether these two cancers were metachronous multiple primary lung cancers, or one primary and its intrapulmonary metastasis. In a retrospective study, an immunohistochemical examination employing Ki-67, PCNA, p 27 and p 53 was performed in order to differentiate between metachronous multiple primary lung cancer and intrapulmonary metastasis. But we found AAH in the same resected lung eight years ago, and suggested the possibility that another small, atypical focus had developed into a malignancy. We report a case of metachronous multiple primary lung cancers and review the relevant literature.     

Case of acute bird fancier's lung caused by a yellow-shouldered Amazon bird associated with lung cancer]

A 69-year-old man was admitted to our hospital complaining of generalized weakness and cough for one month. Chest computed tomography (CT) demonstrated bilateral ground-glass opacities and a nodule in right S6 about 11mm in diameter with multiple mediastinal lymph node swellings. After admission the patient's symptoms improved without therapy and examination of the bronchoalveolar lavage fluid (BALF) and transbronchial lung biopsy (TBLB) revealed findings compatible with acute hypersensitivity pneumonitis. We did not consider that the acute hypersensitivity was caused by the patient's Amazon bird, because he had been breeding them for 40 years. However after obtaining a careful history, it became clear that close and frequent contact with the bird had occurred for the first time in the previous year. On the basis of the anti-bird excreta antibody found in the patient's serum and BALF, we diagnosed this case as a case of acute bird fancier's lung caused by the yellow-shouldered Amazon bird. We diagnosed the nodule in right S6 as lung adenocarcinoma by a thoracoscopic lung biopsy, and performed lower lobe lobectomy. We considered that the mediastinal lymph node swellings were caused by hypersensitivity pneumonitis.     

Synchronus presentation of early-stage small cell carcinoma and adenocarcinoma in the same lung lobe

A 73-year-old man with no symptoms was admitted to our hospital with a nodular shadow (>2 cm) in the left upper lung field on chest X-ray. A histological diagnosis (small cell carcinoma) was obtained by bronchoscopic examination including a transbronchial lung biopsy (TBLB). The preoperative clinical staging was T1N0M0 (StageIA). After preoperative chemotherapy (CDDP + CPT11) was carried out, a nodule in the left S(1+2) diminished remarkably, but a smaller nodule in the left S3 (>8 mm) remained unchanged. While the nodule in the left S(1+2) (small cell carcinoma) had become completely necrotic by the time the final diagnosis was made after resection of the left upper lobe, histological diagnosis of the nodule in the left S3 revealed a well differentiated adenocarcinoma. Synchronous presentation of early-stage lung cancer consisting of small cell carcinoma and adenocarcinoma was identified in the same left upper division of the lung. Because there have been the few previous reports regarding cases of synchronous presentation of early-stage lung cancer in the same lung lobe, we also report on the clinical characteristics, thus adding this case to the five previously reported cases.     

Video-assisted thoracic surgery left S1+2+3 segmentectomy for lung cancer

A 49-year-old female presented with a solitary pulmonary nodule on the chest screening computed tomography (CT) scan. The nodule was 1.3 cm in diameter and located in the apical segment of left upper lobe. The lesion was considered to be cT1aN0M0 non-small cell lung cancer (NSCLC) and a 3-port video-assisted thoracic surgery (VATS) wedge resection was performed. Intraoperative frozen sections revealed a lung adenocarcinoma. Therefore, sequential S1+2+3 segmentectomy of the left upper lobe was performed, also systematic lymph node dissection was carried out. The final pathological stage was pT1aN0M0 (Ia).     

Complete video-assisted thoracoscopic lobectomy of the left lower lobe and lung lymph node dissection

We describe herein a case of complete video-assisted thoracoscopic lobectomy of the left lower lobe and lung lymph node dissection. The patient was a 67-year-old man. A physical examination revealed a nodule in the left lower lobe that had been present for 7 years. According to the chest computed tomography (CT) report recently, a diagnosis of lung cancer was not excluded. Due to the surgical indications, he was underwent complete video-assisted thoracoscopic lobectomy of the left lower lobe and lung lymph node dissection. The frozen pathology report was consistent with adenocarcinoma. He recovered smoothly, without any perioperative complications.     

An intra-pulmonary lymphnode resembling typical pulmonary primary adenocarcinoma on high-resolution computed tomographic (HR-CT) chest images]

A 40-year-old man was admitted to our hospital for further evaluation of a pulmonary nodule in chest radiographs. The 8-mm nodular lesion was located in the right anterior basal lobe on a plain chest radiograph, and showed 1) spiculation, 2) pleural indentation and 3) a converging vessel formation in high-resolution computed tomography of the chest. The radiographic findings were highly suggestive of primary pulmonary adenocarcinoma and the patient underwent video-assisted thoracoscopic surgery (VATS) to obtain a precise diagnosis. The nodule was diagnosed histopathologically as an intrapulmonary lymph node. In cases with such radiographic findings, careful attention should be paid in the differential diagnosis to distinguish intrapulmonary lymph nodes from primary pulmonary adenocarcinoma.     

Two cases of multiple primary cancer involving the lung with old pulmonary tuberculosis]

We reported 2 relatively rare cases of multiple primary cancer including lung cancer accompanied by old pulmonary tuberculosis. Patient 1 was a 62-year-old man admitted to our hospital for further evaluation of an infiltrative shadow on chest X-ray films, and a cervical tumor noted 10 years earlier and thought to be thyroid cancer. A Transbronchial lung biopsy (TBLB) specimen disclosed poorly differentiated squamous cell carcinoma. A right upper lobectomy and thyroidectomy were performed. Histopathologic findings showed a neoplastic lesion adjacent to caseous necrosis with formation of granuloma consistent with tuberculosis. Also, the cervical tumor was considered to be a metastatic lymph node from thyroid papillary carcinoma. Patient 2 was a 73-year-old man with a 14-year history of treatment for transitional cell carcinoma of urinary bladder, who had been admitted to our hospital for further evaluation because of a nodular shadow observed on chest X-ray films. TBLB specimens disclosed adenocarcinoma. A right upper lobectomy was performed. Histopathologic findings revealed a neoplastic tumorlet in the same lobe. No detectable increases in serum TNF-alpha, IL-1 beta or IFN-gamma were observed in either patient. Phytohemagglutinin- and concanavalin-A-stimulated lymphocyte proliferation decreased in Patient 1. These findings suggested that the immunocompromised status of patients with cancer in addition to old pulmonary tuberculosis may contribute to the development of lung cancer.     

Solitary recurrence of hilar cholangiocarcinoma in a mediastinai lymph node two years after curative resection

We recently encountered an unusual case of hilar cholangiocarcinoma in which a solitary recurrence in a mediastinal lymph node occurred two years after curative resection of the primary tumor. A 64-year old woman was admitted to our hospital with a complaint of right hypochondrial discomfort. After imaging studies demonstrated a hilar cholangiocarcinoma in the left hepatic duct, a curative resection of the tumor was performed, consisting of a left hepatic lobectomy along with caudate lobectomy, regional lymph node dissection, and resection of the extrahepatic bile duct. No nodal metastasis was observed histologically. Two years after surgery, the patient was found to have a nodule in the posterior mediastinum, which was thoracoscopically resected. No other swollen lymph nodes, local recurrence, or distant metastasis were noted. Histologically, the nodule proved to be a metastatic lymph node, and adjuvant chemoradiation therapy was initiated. The patient remained well for the four years following her first operation and had no evidence of disease recurrence 28 mo after her second operation. To our knowledge, this case is the first report of solitary recurrence in a mediastinal lymph node after curative resection of hilar cholangiocarcinoma.     

Hilar cholangiocarcinoma associated with sarcoid reaction in the regional lymph nodes

A 74-year-old woman was admitted to our hospital with a 2-week history of jaundice. Percutaneous transhepatic cholangioscopy revealed a nodular tumor originating in the upper part of the common hepatic duct, which was invading the confluence of the right and left hepatic ducts. Microscopic examination of biopsy specimens revealed adenocarcinoma. Abdominal ultrasonography and computed tomography demonstrated multiple enlarged lymph nodes around the extrahepatic bile duct and the common hepatic artery. Laparotomy revealed lymph node enlargement in the hepatoduodenal ligament, behind the pancreatic head, and along the common hepatic and left gastric arteries. Extended left hepatic lobectomy, caudate lobectomy, and resection of extrahepatic bile duct with extended lymph node dissection were performed. The histology of permanent specimen revealed no tumor metastasis but a sarcoid reaction in the lymph nodes. The patient is in good health 21 months after the operation, without any evidence of recurrence. This is the first successfully resected case of hilar cholangiocarcinoma associated with sarcoid reaction in the regional lymph nodes.     

Solitary recurrence of hilar cholangiocarcinoma in a mediastinal lymph node two years after curative resection

We recently encountered an unusual case of hilar cholangiocarcinoma in which a solitary recurrence in a mediastinal lymph node occurred two years after curative resection of the primary tumor. A 64-year old woman was admitted to our hospital with a complaint of right hypochondrial discomfort. After imaging studies demonstrated a hilar cholangiocarcinoma in the left hepatic duct, a curative resection of the tumor was performed, consisting of a left hepatic lobectomy along with caudate lobectomy, regional lymph node dissection, and resection of the extrahepatic bile duct. No nodal metastasis was observed histologically. Two years after surgery, the patient was found to have a nodule in the posterior mediastinum, which was thoracoscopically resected. No other swollen lymph nodes, local recurrence, or distant metastasis were noted. Histologically, the nodule proved to be a metastatic lymph node, and adjuvant chemoradiation therapy was initiated. The patient remained well for the four years following her first operation and had no evidence of disease recurrence 28 mo after her second operation. To our knowledge, this case is the first report of solitary recurrence in a mediastinal lymph node after curative resection of hilar cholangiocarcinoma.     

Four cases of cancer of unknown primary site that manifested as mediastinal metastatic lesions]

We encountered 4 patients with cancers of unknown primary sites that were manifested by mediastinal lesions. Patient 1 was a 58-year-old man with enlarged superior mediastinal lymph nodes. An exploratory thoracotomy yielded a diagnosis of lymph node metastasis of poorly differentiated adenocarcinoma. The patient was treated with chemotherapy and radiation therapy. Patient 2 was a 68-year-old man with a tumor in the right superior mediastinum. A total resection of the tumor was performed through a thoracotomy. The diagnosis was lymph node metastasis of squamous cell carcinoma, and treatment consisted of irradiation. A tumor shadow in the right upper lobe appeared 14 months after the thoracotomy, and was considered to be a primary lesion requiring a right pneumonectomy. The patient died of hepatic metastasis 6 months after the second operation. Patient 3 was a 59-year-old man with mediastinal and hilar lymph node swelling. Mediastinoscopic findings resulted in a diagnosis of squamous cell carcinoma. Because of the patient's insistence, only radiation therapy was performed. Patient 4 was a 65-year-old woman with a tumor in the right superior mediastinum who underwent a median sternotomy for total resection of the tumor. The pathological findings were strongly suggestive of metastasis of clear cell carcinoma. Patients 1, 3, and 4 were alive 33, 24, and 51 months, respectively, after their initial operation, without detectable primary sites. Patient 2 was considered to have had T 0 N 2 lung cancer.     

Radical Resection for Second EGFR-mutated Primary Lung Cancer Following Immune Checkpoint Inhibitor Monotherapy for Stage IV Lung Adenocarcinoma

A 78-year-old woman with multiple lung nodules, epithelial growth factor receptor (EGFR) exon 20 insertion mutations, and diagnosed with advanced lung adenocarcinoma (cT4N3M1a, stage IVA), was referred to our hospital. She received immune checkpoint inhibitor (ICI) therapy. The therapy showed remarkable antitumor effects; only a single nodule remained in the right upper lobe. The nodule was diagnosed as adenocarcinoma through a biopsy. We subsequently performed right upper lobectomy for multiple primary lung cancer (MPLC). The surgical specimen contained EGFR exon 19 deletion mutations and not exon 20 insertion mutations.     

Large cell neuroendocrine carcinoma of the lung incidentally found at surgery for pulmonary aspergillosis]

We report a 56-year-old man with pulmonary large cell neuroendocrine carcinoma (LCNEC) incidentally found at the surgery for pulmonary aspergillosis. In 1991, an abnormal chest radiographic shadow was found on a mass screening. A diagnosis of pulmonary aspergillosis was made by bronchoscopic examination. The patient was then followed up without treatment. He had hemoptysis in 2005, and was referred to our hospital. Chest CT scan revealed a cavitary lesion with an air crescent sign and an irregularly shaped nodule in the right apex. Wedge resection of these lesions was performed under video-assisted thoracoscopic surgery. Pathological examination revealed not only aspergilloma, but also an LCNEC 11 x 7 mm in size, which was located close to the aspergilloma. Microscopically, nests of tumor cells were distributed peribronchially. Right upper lobectomy and mediastinal lymph node dissection was performed, and the pathological stage was IIIA (T1N2M0). The patient received four cycles of adjuvant chemotherapy with carboplatin and paclitaxel. No recurrence has been observed since surgery. This is the first report describing co-existence of pulmonary aspergilloma and LCNEC.     

An autopsy case of adenocarcinoma of the lung with signet ring cells, manifesting with aphasia and hemiparesis due to nonbacterial thrombotic endocarditis

A 42-year-old male was admitted to Tokyo University Hospital because of confusion, aphasia and right hemiparesis. Cranial computed tomography and cerebral angiography demonstrated cerebral infarction due to occlusion of the left middle cerebral artery, while chest roentgenography disclosed a nodular shadow in the right upper lobe and swelling of right hilar and paratracheal lymph nodes. These findings suggested carcinoma of pulmonary origin and tumor-associated cerebral thrombosis, but a possibility of gastric cancer was raised by the finding of cervical lymph node biopsy which revealed signet ring cells in metastatic adenocarcinoma. He developed disseminated intravascular coagulation syndrome and died on the 83rd hospital day. Autopsy revealed adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis which appeared to be responsible for the cerebral infarction. The relationship between adenocarcinoma of the lung with signet ring cells and non-bacterial thrombotic endocarditis was discussed.     

A case of asymptomatic racemose hemangioma treated by bronchial artery embolization]

A 69-year-old man had an abnormal shadow on chest X-ray and bronchoscopic examination showed that left B4 was completely occluded by a tumor. A non-pulsatile polypoid nodule was also found in right B'. The tumor in the left B4 was diagnosed as carcinoid, but the nodule in right B' was suspected to be hemangioma and biopsy was not performed. Bronchial arteriography revealed hypervascularization with dilated vessels distributing to the lingular lobe and convoluted and a dilated bronchial artery extending to the right upper lobe. From these findings, we diagnosed racemose hemangioma of the bronchial artery of the right upper lobe. After bronchial artery embolization of the right and left bronchial arteries, he underwent segmentectomy of the lingula and was discharged without complications. Two months after the operation, bronchoscopic examination showed that the racemose hemangioma had shrunk and the swelling in the surrounding mucosa had decreased. If a submucosal small nodule is observed during bronchoscopy, biopsy should be performed after bronchial arteriography, and if the nodule is diagnosed as racemose hemangioma, bronchial artery embolization should be performed.     

Pulmonary Mycobacterium avium disease with a solitary pulmonary nodule requiring differentiation from recurrence of pulmonary adenocarcinoma

A 56-year-old man with a past history of surgical resection of a primary pulmonary adenocarcinoma in the right upper lobe was admitted to our hospital because of a rapidly increasing solitary nodule (50x30 mm) in the right S5 followed on the chest computed tomography (CT) for three months. Although we suspected recurrence of the pulmonary adenocarcinoma and performed a CT-guided lung biopsy, we could not make a definite diagnosis. Therefore, to rule out recurrence of the primary pulmonary adenocarcinoma completely, a partial surgical resection of the right middle lobe was performed and a caseating epitheloid granuloma with acid-fast bacilli was found. As the causative pathogen, Mycobacterium avium complex (MAC) disease should be considered in the differential diagnosis of a rapidly increasing solitary nodule through this peculiar case of pulmonary MAC disease.     

The separate-lesion type combined hepatocellular carcinoma and cholangiocarcinoma

The separate-lesion type of combined hepatocellular carcinoma and cholangiocarcinoma is particularly rare. We treated two such patients with hepatic resection after performing dynamic computed tomography. In case 1, a 64-year-old Japanese man with chronic hepatitis C underwent right hepatic lobectomy for two hepatic tumors; both tumors originally were thought to be hepatocellular carcinomas because both were hypervascular. However, histologic examination revealed that one tumor was hepatocellular carcinoma and another tumor was tubular adenocarcinoma. In case 2, a 73-year-old man, a second lesion was detected 8 months after transcatheter arterial embolization for hepatocellular carcinoma associated with chronic hepatitis C. The newer lesion in case 2 showed delayed enhancement by dynamic computed tomography. We diagnosed the lesion as cholangiocarcinoma and performed right hepatic lobectomy and dissection of lymph nodes in the hepatoduodenal ligament. Histologic examination confirmed that the new lesion was tubular adenocarcinoma. Case 1 and 2 respectively represent synchronous and metachronous occurrence of the separate-lesion variety of combined hepatic cancer.     

Bronchioloalveolar carcinoma complicated by a lesion resembling bronchiolitis obliterans organizing pneumonia in the opposite lung]

A 50-year-old woman with abnormal shadows in her chest radiograph was admitted for a more detailed examination in April 2000. A chest CT scan showed infiltrates surrounded by ground-glass opacities in the right upper lobe, and ground-glass opacities with partial infiltrative changes in the left lower lobe. A diagnosis of adenocarcinoma like bronchioloalveolar carcinoma (BAC) was made for the lesion in the right upper lobe by means of a transbronchial biopsy. However, the specimen from the left lower lobe showed nonspecific changes, and bronchiolitis obliterans organizing pneumonia (BOOP) or a metastatic lesion from the BAC was suspected. We prescribed steroids for the short term. Since the lesion in the left lobe disappeared, we performed a right upper lobectomy. In cases of primary lung carcinoma, BOOP in the opposite lung is rare and it was difficult to decide on the operability. We concluded that steroid therapy is useful for distinguishing between inflammatory and tumorous lesions in cases in which a detailed examination is difficult.     

A case of intrapulmonary teratoma presenting with expectoration of white hair and cheese-like material]

A 41-year-old man presented with expectoration of white hair and cheese-like material. The chest radiograph showed a round shadow adjacent to the right hilum. Bronchofiberscopy revealed strands of white hair and an obstruction consisting of sebaceous material in the right B3b bronchus. Right upper lobectomy was performed. Histological examination confirmed the diagnosis of intrapulmonary mature teratoma. This characteristic clinical presentation and the bronchofiberscopic findings may have been specific for the diagnosis of teratoma in this case.