Bronchioloalveolar carcinoma with acute respiratory failure due to hemoptysis; report of a case

A 69-year-old male was admitted to our hospital for hemoptysis and dyspnea. Because of his deteriorating respiratory distress, he was intubated and controlled by respirator for 3 days. He was diagnosed with adenocarcinoma of the lung by the sputum examination and chest computed tomography (CT) revealed an infiltration shadow in the peripheral superior ventral segment (S3) of the right upper lobe. He underwent right upper lobectomy with video-assisted thoracic surgery. Microscopic findings of the resected specimen measuring 10 x 10 x 7 cm revealed mucin-producing bronchioloalveolar carcinoma (BAC) with metastases in lymph nodes and the same lobe (S2b). We reported a rare case of BAC with hemoptysis.     

Mycobacterium avium complex (MAC) infection needed differential diagnosis of the recurrence after surgery for double lung cancer; report of a case

A 62-year-old woman had undergone video-assisted thoracic surgery (VATS) -right upper lobectomy and right S8 segmentectomy for double lung cancers (papillary adenocarcinoma and bronchioloalveoler carcinoma, stage IA). Four years later, chest computed tomography (CT) showed abnormal shadow, 20 mm in size, along the staple-suture line. The 3 months later, new lesion, 15 mm in size, was observed in right lower lobe. CT-guided biopsy revealed no malignancy. The patient underwent partial resection of the right lower lobe and tumorectomy. The tumor was solid and cystic mass. Histopathologically, the tumor was granuloma infected by Mycobacterium avium. The patient was discharged on 17th postoperative day, and doing well without new lesion for 9 months postoperatively.     

Mediastinal signet-ring cell carcinoma of unknown primary site; report of a case

The question whether the tumor is primary or metastatic sometimes arises in patients with intrathoracic tumor. Especially, adenocarcinoma presents more difficulties in distinguishing primary tumors from secondary or deciding its origin. We reported a case of mediastinal signet-ring cell carcinoma. A 51-year-old female was admitted because of an abnormal shadow during mass screening. Chest X-ray showed a semicircular, well-demarcated shadow on right cardiophrenic angle. Chest computed tomography (CT) revealed a homogeneous mass, approximately 4 cm in diameter. The investigations of whole body failed to reveal any other tumor. At operation, the tumor was adherent to the esophagus but easily resected. Histologically, the tumor was mainly composed of signet-ring cells. Immunohistochemically, surfactant apoprotein (SPA) was strongly demonstrated in tumor cells. SPA is specific to the lung and the tumor was diagnosed as the metastasis in mediastinal lymph nodes. The primary site was considered to exist in lung. But the primary site was not found over 46 months in spite of repeated further examinations.     

Induction chemoradiotherapy in small adenocarcinoma of the lung with bulky mediatinal lymph node metastasis

A 56-year-old man, who visited our hospital due to chest pain, was pointed out a large tumor, 60 mm in diameter, on the left superior mediastinum on the chest computed tomography (CT) scan. He was diagnosed as having mediastinal lymph nodes metastasis of adenocarcinoma through video-assisted thoracoscopic surgery (VATS) biopsy. He received induction chemoradiotherapy: cisplatin and paclitaxel were administered once per week for 2 weeks, and radiotherapy was simultaneously performed. No serious adverse reactions were noted. The ipsilateral mediastinal lymph nodes dissection was performed. Intraoperative frozen section analysis showed a small nodule in the left upper lobe, 5 mm in diameter, was adenocarcinoma. He was finally diagnosed as having mediastinal lymph nodes metastasis from the small adenocarcinoma of the lung, and left upper lobectomy was performed. Histopathological examination of the mediastinal lymph nodes showed no evidence of viable maligmant cell. Induction chemoradiotherapy with cisplatin and paclitaxel might be effective treatment for locally advanced non-small cell lung cancer.     

Small sclerosing hemangioma combined with primary lung cancer; report of a case

A 56-year-old woman underwent a surgery for right breast cancer when she was 51-year-old. In February 2002, computed tomography (CT) was performed as a part of a follow-up study and showed 2 small nodules in the lower lobe of her right lung: one was 10 mm nodule in S9, and another was 5 mm in S6. On a follow-up CT in March 2005, the S9 nodule had enlarged to 19 mm and was looked as ground glass opacity (GGO). We thought it was primary lung cancer. In contrast, the nodule in S6 had not enlarged and it was thought to be benign. In May 2005, right lower lobectomy was performed. The S9 nodule was diagnosed as adenocarcinoma, and the S6 nodule as sclerosing hemangioma.     

Clear cell adenocarcinoma with acomponent of well-differentiated fetal adenocareinoma; report of a case

A 69-year-old woman complaining of a cough was admitted to our hospital. Chest X-ray showed a mass in the right lower lung field. Chest computed tomography (CT) showed a tumor with notch, 3 cm in diameter, in the right lower lobe (S9-S10). The tumor was diagnosed as adenocarcinoma by the biopsy under chest CT. The patient underwent right lower lobectomy (ND2a). The tumor was whitish solid mass, 35 x 34 x 29 mm in size. Histopathologically, the tumor was diagnosed as clear cell adenocarcinoma with a component of well-differentiated fetal adenocarcinoma (WDFA), pT2N0M0, stage IB. The patient was discharged and received postoperative chemotherapy (UFT). The patient has been doing well without any tumor recurrence for 1 year postoperatively.     

A case with esophageal carcinoma associated with metastatic pulmonary tumor in lung cancer at seven years after the resection of lung cancer

A 69-year-old woman was admitted to our hospital because of dysphasia. The upper G-I examination showed a stenosis at the middle thoracic esophagus and poorly differentiated adenocarcinoma was revealed histologically. Chest CT scan showed a mass shadow in the right upper lobe of the lung. She had undergone a partial resection of right upper lobe because of lung cancer seven years before. She was diagnosed as metachrous double carcinoma of the lung and the esophagus. The method of surgery included right upper lobectomy of the lung, esophagectomy and intrathoracic esophageal reconstruction using the gastric tube. The patient manifested pneumonia due to the failure of the sutures after the surgery and died on the twentieth postoperative day. When conducting simultaneous resection of both cancer and esophageal reconstruction for the double cancer of the lung and the esophagus, it was considered necessary to conduct the anastomosis outside the thoracic cavity for the purpose of preventing the pulmonary complication due to the failure of the sutures.     

Pulmonary pleomorphic carcinoma; report of 2 cases

The 1st case was a 74-year-old male diagnosed as femoral neck fracture. Biopsy of the bone revealed metastatic adenocarcinoma. Chest computed tomography (CT) showed a mass lesion located in the right lower lobe. With a diagnosis of primary lung cancer (cT2N1M1), two-staged operation was performed. Pathological diagnosis was pleomorphic carcinoma [pT2N1M1 (OSS), stage IV]. He died 8 months after surgery due to metastasis to the thoracic spine. The 2nd case was a 80-year-old female who complained of lateral chest pain. Chest CT revealed a tumor in the right hilar region, which was diagnosed as adenocarcinoma by transbronchial lung biopsy. Only thoracic drainage was performed since metastases to the brain and the rib were demonstrated. She died 2 months after admission. Autopsy revealed pleomorphic carcinoma of the lung with metastasis to the brain, costa and mediastinal lymph nodes.     

Adrenal metastasis of lung adenocarcinoma with unusual sites of lymph node metastasis and concomitant renal cell carcinoma: a case report

A 58-year-old male presented to a clinic with general weakness. Right adrenal tumor was found by computed tomography and he was referred to our hospital. Imaging studies revealed right adrenal tumor (8 cm) with marked swelling of surrounding lymph nodes and synchronous left renal tumor (2 cm) that was weakly enhanced by contrast media. Needle biopsy of the left kidney proved to be clear cell type renal cell carcinoma (RCC) and the preoperative diagnosis was left RCC and right primary adrenal cancer with lymph node metastasis. We performed right adrenalectomy, lymph node dissection and left radical nephrectomy. Pathological findings of right adrenal tumor and lymph nodes were both metastatic adenocarcinoma, which was not consistent with RCC or adrenal-derived carcinoma. Then, we extensively reviewed preoperative radiological examinations and found a small lesion in the left upper lung. This lesion was attached to the mediastinal shadow and there was no obvious lymph node swelling around this lesion. According to pathological findings and an elevation of carcinoembryogenic antigen, the adrenal lesion was diagnosed as adrenal metastasis of lung adenocarcinoma.     

Two lung adenocarcinomas in the same lobe: multiple primaries or intrapulmonary metastasis?

Abnormal nodules were found in the left lung of a 52-year-old woman in segments 6 and 10 on a chest CT. These nodules showed no changes for 18 months, and we discontinued follow-up. Almost 5 years later, an abnormal shadow was found in her left lower lung field on a medical check-up chest X-ray. Chest CT revealed that the left segments 6 and 10 nodules had grown. We diagnosed these lesions as synchronous double primary lung cancers in the same lobe based on the disease history and performed a left lower lobectomy and lymph node dissection. Pathological examination of both tumors revealed adenocarcinoma of a mixed subtype with papillary and bronchioloalveolar carcinoma. Epidermal growth factor receptor gene mutations were examined, and the 2 lesions shared an L858R mutation. Although we expected EGFR gene mutation analysis would help us distinguish the 2 lesions from each other, it was of little help. Disease history can be more important in evaluating multiple pulmonary cancers.     

Pulmonary pleomorphic carcinoma; report of a case

We report a case of a 64-year-old man with pleomorphic carcinoma of the lung and thymic cyst. He was admitted to our hospital because of an abnormal shadow observed on chest X-ray. Computed tomography (CT) showed a mass lesion located in the right upper lobe and a non-invasive anterior mediastinal tumor adjacent to the left brachiocepharic vein. On enhanced CT, the lung mass showed central low-attenuation areas with a substantial enhancement in the periphery. Preoperative transbronchial blushing cytology of the mass revealed adenocarcinoma. With a diagnosis of primary lung cancer (cT3N0M0) and mediastinal tumor, an operation was performed through a median sternotomy. The mediastinal tumor was excised and a right upper lobectomy and were also accomplished, because the lung tumor did not show adhesion or pleural invasion. Histopathologic examination of the resected specimen revealed that the lung tumor composed of a mixture of spindle and giant cell features and contained a component of adenocarcinoma and squamous cell carcinoma. This finding yielded a pathological diagnosis of pleomorphic carcinoma (pT2N0M0). The mediastinal tumor was diagnosed as thymic cyst. The postoperative course was uneventful, and he is currently well 6 months after surgery.     

Lesions in patients with multifocal adenocarcinoma are more frequently in the right upper lobes

OBJECTIVES Opportunities to treat multifocal lung cancers, mostly adenocarcinoma, are increasing due to the development of imaging technologies. The optimal therapy modality to treat multifocally growing lung cancers remains obscure. To determine the features of multifocal lung cancers, we retrospectively reviewed patients with multiple lung lesions. METHODS Clinical, pathological and genetic characteristics of 31 patients with multifocal lesions were compared with those of patients who had had radical lung resection for solitary lung cancer. Gene mutation analyses for EGFR, KRAS and P53 were performed on three tumours of each of the patients who had four or more lesions. RESULTS Of the 31 patients, 17 had double tumours, 4 had triple tumours and 10 had 4 or more lesions. Patients with four or more lesions were significantly more likely to be females and never smokers. All of the histologically confirmed tumours of the cases with four or more lesions were adenocarcinoma in situ or lepidic predominant adenocarcinoma. The number of lesions in the right upper lobes when compared with the right lower lobes was significantly higher in patients with four or more lesions than in patients with double or triple lesions (P?=?0.013). Five of the 12 tumours were positive for the EGFR mutation L858R in exon 21. No KRAS mutation was found. CONCLUSIONS Lesions in patients with multifocal adenocarcinoma are more frequently in the right upper lobes. Genetic analysis suggested that the specific EGFR mutation L858R in exon 21 might be the main factor contributing to lung carcinogenesis in multiple lung cancers. Further investigation of the right upper lobe in those patients compared with the lower lobes might provide more insights into lung carcinogenesis.     

Lung adenocarcinoma with coexisting pulmonary cryptococcoma

A 73-year-old female was referred to our hospital in June 2000 for the evaluation of an abnormal shadow in the left upper lobe of her lung and two other shadows in the left lower lobe. A computed tomography examination revealed an ill-defined tumor with ground glass opacity in the left upper division segment, suggesting a primary lung adenocarcinoma, and two well-defined nodules in the left lower lobe, suggesting metastatic carcinomas. A transbronchial lung biopsy of the tumor in the upper division segment confirmed the presence of an adenocarcinoma but failed to provide a histological diagnosis for the nodules in the lower lobe. A partial resection of the left lower lobe using video-assisted thoracoscopy revealed granulomatous tissue with no signs of malignancy. A curative resection of the adenocarcinoma in the left upper division segment was therefore performed. Histologically, the resected specimens obtained from the left lower lobe were diagnosed as cryptococcomas. The patient was diagnosed as having a stage IA lung adenocarcinoma and two cryptococcomas. The patient is presently well and has not experienced any recurrences or relapse for 3 years since the resection.     

Rational lymph node dissection for lung cancer according to the occurrence lobe and histological type]

Between January 1989 and December 1998, 134 cases of squamous cell carcinoma and 244 cases of adenocarcinoma underwent surgical resection of the lung with systematic lymph node dissection in our hospital. The cN diagnosis by CT scan and pN diagnosis were compared. In squamous cell carcinoma pN 2-3 cases were only one patient (2%) out of 60 patients with cN 0, 5 patients (18%) out of 28 patients with cN 1, and 21 patients (46%) out of 46 patients with cN 2-3. On the other hand in adenocarcinoma pN 2-3 cases were 27 patients (14%) out of 193 patients with cN 0, 3 patients (25%) out of 12 patients with cN 1, and 24 patients (62%) out of 39 patients with cN 2-3. The pathways of the lymphatic metastases to the mediastinal nodes were analized in 27 patients with squamous cell carcinoma and 54 patients with adenocarcinoma undergoing systematic lymph node dissection. All patients had histologically proven mediastinal metastasis. Histologically there was no difference in pathways of the lymphatic metastases to the mediastinal nodes. 1. The dominant lymphatic drainage from the right upper lobe flowed into the superior mediastinal nodes. The direct metastatic passages to the superior mediastinal nodes were observed (47%). Subcarinal and inferior mediastinal node involvement was rare (3%). 2. The dominant lymphatic drainage from the middle and the lower lobe flowed into the subcarinal nodes (85%). The involvement of the superior mediastinal nodes occurred in 53% of subcarinal node positive patients on the right side. 3. The dominant lymphatic drainage from the left upper lobe flowed into the subaortic or paraaortic nodes (69%). Subcarinal and inferior mediastinal node involvement was rare (6%). We conclude that subcarinal and inferior mediastinal lymph node dissection is not necessary for upper lobe lung cancers, and that superior mediastinal lymph node dissection can be omitted in middle and lower lobe lung cancers without hilar and subcarinal lymph node involvement, especially in the cases of cN 0.     

Right lung cancer with right aortic arch

An abnormal shadow was detected on chest X-ray mass screening in an asymptomatic 63-year-old man. The further examinations revealed the shadow to be primary lung cancer (Rt. S6. adenocarcinoma, cT2N0M0, c-stage IB) with right aortic arch. We used 3 dimentional-computed tomography (3D-CT) to assess an anatomical feature of vessels in detail. The right lower lobectomy and the dissection of medi astinal lymph nodes was performed. We confirmed no abnormal anatomy of pulmonary artery and vein at surgery, and it was possible to perform right lower lobectomy with the common procedure. Since lymph node was found by intraopetrative pathological examination, since no metastasis from interlobar to subcarinal lymph node was found, we did not perform dissection of upper mediastinal dissection, which was equivalent to ND2a lymph nodes dissection of the left lung cancer in General Rule for Clinical and Pathological Record of Lung Cancer. The patient with right aortic arch is known to have variant anatomy of other intrathoracic vessels occasionally. 3D-CT was quite useful in assessing anatomical feature, and enabled us to perform safe operation.     

Simultaneous resection of pulmomary metastasis of colon cancer and primary lung cancer

A 70-year-old woman was admitted with a complaint of weight loss and an abnormal shadow on the chest X-ray. On palpation, the unmobilized mass, measuring 5 cm, was located in the left lower abdomen. The barium-enema examination showed the filling defect of the sigmoid colon. Chest computed tomography (CT) showed a tumor, measuring 20 x 20 mm, located in the right upper lobe (S3) and a nodule, measuring 3 mm, located in the right lower lobe (S8). At first, we performed sigmoidectomy (D 3) for the colon cancer. Next, performed right upper lobectomy and a partial resection of the right lower lobe. Histopathologically, the one is a primary lung cancer, the other is a metastatic lung cancer. With an increase in colorectal and lung cancer, similar cases as ours seem to increase in number. When we treat multiple lung nodules with malignancy of other organs, we should consider 3 types of cases, 1) only primary, 2) primary and metastatic, 3) only metastatic.     

Peripheral small squamous cell carcinoma (9 mm) of the lung with metastasis to mediastinal lymph nodes

A 61-year-old man was pointed out a small peripheral lung nodule and mediastinal lymph node swelling on the chest computed tomography (CT). At the operation, it was diagnosed squamous cell carcinoma and right upper lobectomy and nodal dissection were done. The tumor was 9 mm in size and diagnosed as well differentiated squamous cell carcinoma with metastasis to mediastinal lymph nodes. Postoperative radiotherapy was done (50 Gy). The patient is doing well without apparent recurrence 33 months after surgery. We reported a case of peripheral small squamous cell carcinoma (9 mm) of the lung with metastasis to mediastinal lymph nodes.     

Successful management of postoperative acute respiratory distress syndrome in a patient with lung cancer

Acute respiratory distress syndrome after pulmonary resection for lung cancer frequently has a lethal outcome. Treatment with a combination therapy of neutrophil elastase inhibitor and steroid administration was used to achieve good control, without impairing lung function, in a patient with postoperative acute respiratory distress syndrome. A 74-year-old man was diagnosed with lung cancer and referred to the outpatient department of Chiba University Hospital with double primary lung cancers located in the right upper lobe that were staged at T2N0M0 (stage IB). He underwent right upper lobectomy with hilar and mediastinal lymph node dissection. After 10 postoperative days, he had acute respiratory distress syndrome. He was given a corticosteroid and a neutrophil elastase inhibitor, which resulted in rapid improvement without lung dysfunction.     

Synchronous tumors consisted of bronchial carcinoid and adenocarcinoma of the lung

We report a case of synchronous tumors consisted of bronchial carcinoid and adenocarcinoma of the lung. A 58-year-old female was referred to our hospital after screening, because an abnormal shadow was noted in the right lung on her computed tomography (CT) of the chest. CT scans showed a peripheral pulmonary mass in the right middle lobe and a nodule around the right lower lobe bronchus. The nodular lesion like swollen lymph node was diagnosed as bronchial carcinoid originated in B6 by bronchoscopy. The pulmonary mass was diagnosed as adenocarcinoma by using core needle biopsy during operation. Right middle and lower bilobectomy and mediastinal lymph node dissection were performed. Coincidence of a bronchial carcinoid and an adenocarcinoma of the same side of the lung is a rare occurrence.     

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.