Roentgenographically occult lung cancers (ROLCs) are rare but are usually curable if they are properly diagnosed and treated. Between 1977 and 2000, we treated 51 patients with early hilar lung cancer (as defined by the Japan Lung Cancer Society) of ROLC form. If the occurrence of cancer is confined to segmental bronchi, we preserve the lung tissue as far as possible by using a sleeve segmentectomy. Eight of the 51 patients underwent sleeve segmentectomy. All 8 of these patients were men who were heavy smokers and had a mean age of 64.9 years (range, 59-74 years). The cancerous locations were R-B6 in 4 patients, L-B(1+2+3) in 2 patients, L-B(4+5) in 1 patient, and L-B6 in 1 patient. Two patients had double cancers (synchronous in one case and metachronous in the other). All 8 of the patients had squamous cell carcinoma, 3 of whose lesions were carcinoma in situ. The segments resected were R-S(6) in 3 patients, L-S(1+2+3) in 2 patients, L-S(4+5) in 1 patient, L-S(6) in 1 patient, and R-S6 combined with the middle lobe in 1 patient. There were no cases of morbidity or mortality. However, 1 patient who had undergone a left lower lobectomy for synchronous advanced squamous cell carcinoma 4 months before R-S(6) sleeve segmentectomy for contralateral early hilar lung cancer died of recurrence in the mediastinal lymph nodes 63 months after the first operation. Two patients died of other causes: one of pneumonia 61 months after L-S(4+5) sleeve segmentectomy and the other of myelopathy 36 months after L-S(1+2+3) sleeve segmentectomy. The remaining 5 patients are alive and well 178, 121, 109, 94, and 14 months after surgery. Sleeve segmentectomy is a curative operation for early stage squamous cell carcinoma of the segmental bronchus that preserves pulmonary function and should be used to treat patients carefully selected for the correct indications.

We report on a patient with primary pulmonary leiomyosarcoma and hepatic metastasis who was treated successfully with a single-stage surgical operation. As a cure for primary pulmonary leiomyosarcoma has only been achieved by surgical resection, primary radical treatment should be considered, even in advanced cases having distant metastases which are expected to be resectable.

The expression of mRNAs for vascular endothelial growth factor (VEGF) was examined in 42 cases of primary lung cancer tissues (18 adenocarcinomas, 18 squamous cell carcinomas, 2 large cell carcinomas, 3 small cell carcinomas, and 1 adenoid cystic carcinoma) and 4 human lung cancer cell lines. As seen by reverse transcription-PCR analysis, VEGF mRNAs were expressed predominantly as transcripts for the secretory forms of VEGF (VEGF121 and VEGF165), both in resected lung cancer tissues and in human lung cancer cell lines. The positive ratios of VEGF mRNA according to pathological type were 66.7% (12 of 18) in adenocarcinoma, 72.2% (13 of 18) in squamous cell carcinoma, 100% (2 of 2) in large cell carcinoma, and 67% (2 of 3) in small cell carcinoma. The relative antigen levels of VEGF detected by immunohistochemical examination almost coincided with the relative VEGF mRNA expression levels. Also, we examined the expression of basic fibroblast growth factor mRNA in the same tumor specimens. However, no significant correlation was found between the VEGF and basic fibroblast growth factor mRNA expression levels. We assessed the relationship between the VEGF121 mRNA expression level and the survival period in patients (n = 17) who underwent a curative operation at stage I of the disease. The median survival of the VEGF high-expression group was 8 months, and that of the VEGF low-expression group was 151 months. The 3- and 5-year survival rates of the high-expression group (n = 6) were 50.0% and 16.7%, respectively. On the other hand, those of the low expression group (n = 11) were 90.9% and 77.9%, respectively. The difference in survival between the two groups was significant (P < 0.05). Among eight cases of long-term survival beyond 5 years, seven cases had low or no VEGF121 mRNA expression. In contrast, among 18 cases with VEGF121 mRNA overexpression, 17 cases died due to recurrence. As a marker of tumor angiogenesis, the VEGF121 mRNA expression level may be a significant prognostic indicator of lung cancers in early stages.

Lipoma of the diaphragm is an extremely rare entity. A case of this disease is herein reported, together with the review of the literature. The patient described was a 70-year-old male, who was admitted to our hospital with an abnormal shadow on his chest X-ray film. The primary tumor, located above the left hemidiaphragm, was successfully resected by video-assisted thoracic surgery, and the final diagnosis of lipoma originating in the diaphragm was made.

We retrospectively evaluated 136 patients underwent tracheobronchoplastic procedures for lung cancer and performed experimental study on extracorporeal lung resection(ECLR) with a dog model. Bronchoplasty without carinal resection was performed in 113 patients, including left second carinal resection without lung resection in 1, segmentectomy in 7. The overall 5-year survival rate was 54% and this rate was 80% in stage 0+I. Bronchoplasty with carinal resection was performed in 22 patients. Three of 18 patients with sleeve pneumonectomy survived for longer than 3 years and 2 patients with low-grade malignant tumors underwent carinal resection without lung resection are still alive. We concluded: 1)the limited bronchial resection can be applied to selected patients, 2)sleeve lobectomy is a safe and valuable procedure, 3)bronchial resection with carinal reconstruction may benefit selected patients, 4)ECLR could be a safe and useful procedure.

Adenosquamous carcinoma of the lung is an uncommon form of the lung cancer. Owing to the infrequent occurrence of this disease, no series reported to date (and to our knowledge) has been of adequate size for definitive statistical analysis. In this study, survival curves and background factors affecting prognosis in those with resected adenosquamous carcinoma of the lung were reviewed. In the period from 1973 to 1994, a total of 1,284 patients with primary lung cancer, including 44 cases (3.4%) of adenosquamous carcinoma, were surgically treated in our department. The cumulative 5-year postoperative survival rate, for all cases of adenosquamous carcinoma of the lung was 18.5%. When the survival rates were compared by histologic type, the outcomes of patients with adenosquamous carcinoma were statistically worse than for patients with squamous cell carcinoma and adenocarcinoma, owing to the highly aggressive pathologic stage of adenosquamous carcinoma. The background factors most closely associated with the survival rate in those with adenosquamous carcinoma, using Cox's proportional hazard model, were gender and the degree of nodal involvement. Five-year survival was obtained in seven patients as follows: T1N0M0 in one patient, T2N0M0 in three, T2N1M0 in two, and T3N0M0 in one. Of these seven patients, all had received complete resections, and five were N0 cases. Although our series is small, this study suggest that adenosquamous carcinoma of the lung is an aggressive tumor that grows rapidly.

The role of surgery in the management of lung cancer with pleural dissemination is controversial. We performed a retrospective analysis of our patients with lung cancer and pleural dissemination who were treated surgically. Between 1973 and 1993, 1,206 patients with lung cancer underwent pulmonary resection at Kanazawa University Hospital. Among them, 40 (3.3%) had pleural dissemination without pleural effusion. The 1-, 3-, and 5-year survival rates for 38 patients (except 2 patients undergoing exploratory thoracotomy alone) were 51.5%, 19.4%, and 19.4%, respectively. The 1-year survival rate in the 10 patients who underwent pleuropneumonectomy was only 20%, and 9 of these patients died within 18 months postoperatively (1 patient has survived for 25 months). In contrast, the 1-, 3-, and 5-year survival rates for the 14 patients who underwent resection of the primary tumor plus parietal pleurectomy were 85.1%, 35.5%, and 35.5%, respectively, a significantly better outcome (P < 0.01). Seven patients are still alive (the longest survival time is 65 months with the disease). The average survival time in the seven fatal cases was 18 months. In patients with lung cancer accompanied by pleural dissemination, it is quite possible that local excision plus pleurectomy will be justified.

Twenty-three patients underwent chest wall reconstruction in our department. The underlying disease was bronchial carcinoma in 14, urachus tumor in 2, breast cancer in 1, renal cancer in 1, thymic Hodgkin's lymphoma in 1, tuberculosis in 1, fibrosarcoma in 1, and pseudoaneurysm of the aortic arch caused by reconstructed material in 1. An average of 3.4 ribs were resected in 18 patients and sternectomies were performed in 5. Chest wall reconstruction was performed with Marlex mesh in 14, Marlex mesh with methyl methacrylate in 5, Marlex mesh with steel wire in 1, Marlex mesh with omentopexy in 1, Marlex mesh with A-O plate in 1, and net formation with catgut in 1. There was no operative death. Postoperative wound infection occurred in only 1 patient with Marlex mesh cleaned by irrigation and administration of antibiotics. Three patients with Marlex mesh and metyl methacrylate required removal of the prosthetic material postoperatively because of wound infection in 1, seroma in 1, and dislocation of the former reconstructed material in 1. One patient with Marlex mesh and steel wire had protrusion of the wire under the skin and the wire was removed. Eleven patients of lung cancer died at 2-17 months after surgery. In conclusion, chest wall reconstruction with Marlex mesh had excellent results, and chest wall resection and reconstruction for malignancy could be good palliation.

Chondrosarcoma of rib origin is rare in Japan. We treated two cases of chondrosarcoma of rib origin. Case 1: A 68-year-old man with anterior chest wall mass and chest pain was underwent aspiration biopsy in Inami General Hospital. The histological examination showed Class V. Operation was done in our department and the histological diagnosis was chondrosarcoma. The tumor was 30 x 20 x 20 mm in size arising from the left fourth rib. The defect of bony chest wall was repaired with a double layer of Marlex mesh. His postoperative course was uneventful. Case 2: 66-year-old man noticed a tumor in left anterior part of the chest 7 months ago. He was underwent incisional biopsy and the histological diagnosis was chondrosarcoma. Radical resection was performed. The tumor was 70 x 50 x 50 mm in size arising from the left rib. His postoperative course was uneventful.

A retrospective study was conducted of 993 malignant tumors of the lung in 977 patients. The male-female sex ratio was 2.6:1. The age distribution of the males did not differ from that of the females and the overall mean age was 64.3 +/- 9.5 years (range, 13-85 years). Forty-three percent of the patients were in their seventh decade. The location was peripheral in 81% of the tumors and central in 19%. Of the central tumors, 85% were squamous cell (epidermoid) carcinoma (SCC), while 58% of the peripheral tumors were adenocarcinoma (ADENO). In males, 49% of all tumors were SCC and 36% ADENO, while in females 76% were ADENO. The incidence of positive lymph node metastasis increased in parallel with the pT status in both central and peripheral carcinomas. However, it was noted that, of peripheral lung carcinomas, no SCC with a diameter of 15 mm or less had lymph node metastasis, whereas 18.9% of the ADENO of this size were positive for lymph node metastasis. These results indicate that lymph node metastasis can occur even in small-sized peripheral ADENO less than 15 mm. Thus, early detection and surgery together with mediastinal lymph node dissection are necessary even for small-sized tumors to improve the prognosis in patients with peripheral ADENO of the lung.

From 1970 to 1993, 155 thoracotomies for metastatic lung tumors were performed on 113 patients in the Department of Surgery, Kanazawa University School of Medicine. Overall 30‐day mortality amounted to 0.9% (1/113). The cumulative 3‐ and 5‐year survival rates were 39.4% and 29.1%, respectively. The overall median survival was 24 months. The 5‐year survival rate for carcinoma was 37.2% and for sarcoma it was 14.5% (P < 0.01). The other significant predictors of better long‐term survival with metastatic lung tumors were solitary lesions, disease‐free interval (DFI) > 24 months, and tumor size ≤ 20 mm in diameter. There was no significant difference in survival based on the method of pulmonary resection. Repeat thoracotomy for recurrent metastases was performed in 27 patients, whose 5‐year survival rate after the first lung resection was 35.5%. For bilateral pulmonary metastases, we recently performed simultaneous bilateral thoracotomy via median sternotomy on 25 patients and transsternal simultaneous bilateral thoracotomy on 8 patients. The latter procedure provides a wide operative field and better survival. We conclude that resection of metastatic lung tumors is safe and effective, and that repeat thoracotomy is warranted in selected patients with recurrent pulmonary metastases. © 1995 Wiley‐Liss, Inc.

Giant cell carcinoma (GCC) of the lung is considered an aggressive form of lung cancer. Most patients with GCC have large tumors with widespread metastases on hospital admission. We describe a small GCC in the lower lobe of the right lung. Preoperative aspiration cytology showed numerous bizarre, giant epithelial cells, highly suggestive of GCC. The resected tumor measured 1.2 x 1.0 x 0.7 cm in diameter, with an ill-defined margin. Histologically the tumor was composed of pleomorphic mononucleate or multinucleate giant cells without adenocarcinoma or squamous cell differentiation. The tumor cells were loosely organized and noncohesive or free in the alveolar space. The histology was interpreted as GCC of the lung. The clinicopathologic features of giant cell carcinoma are discussed.

A 59-year-old man complained of fever due to infection in the intralobar pulmonary sequestration. On bronchoscopic examination, squamous cell carcinoma was found out at orifice of the left upper division bronchus. His pre-operative pulmonary function test showed low pulmonary reserve because of myelopathy. He underwent left S1 + 2 + S3 sleeve segmentectomy and S9 + 10 segmentectomy for intralobar pulmonary sequestration. He is well without any evidence of recurrence 10 months after surgery.

An experimental study of tracheal reconstruction using a separate piece of bronchus was performed in 6 dogs. After right upper lobectomy, a five-cartilage-ring length of the trachea extending from five cartilage rings above the carina was circumferentially resected; the right bronchus was transected just below the carina and above the second carina to provide the piece of bronchus, which was then interposed between the distal end of the upper trachea and the proximal end of the lower trachea by end-to-end anastomoses. One-stoma type carinal reconstruction (an anastomosis between the carina and the right intermediate bronchus) was performed. After completion of the airway reconstruction, the anastomotic site was wrapped with an omental flap. One dog died 14 days after operation due to anorexia and weakness, the necropsy in this dog revealed severe ischemic change of the interposed bronchus and ulcer formation at the stump of the upper bronchus. The other 5 dogs survived the operation. Bronchoscopically, the findings for the interposed free bronchus revealed severe ischemic change immediately after the operation, but almost normal findings were observed four to five weeks after the operation. The clinical relevance of this method of tracheal reconstruction is discussed.

During the treatment of five cases of thymic carcinoma, we conducted a clinicopathological and immunohistochemical study. The patients included four males and one female, whose ages ranged from 50 to 69 years. The histologic breakdown was squamous cell carcinoma in four and small cell carcinoma in one. Immunohistochemically, the squamous cell carcinomas were positive for cytokeratin (intermediate molecular weight) and keratin. However, staining was negative for Leu-7 and chromogranin. A complete resection was achieved in only one case. In all four of the remaining cases, the resection was incomplete due to invasion into adjacent organs and disseminated lesions. Thymic carcinoma is a tumor for which a higher response rate can be expected from multidisciplinary therapy than that for lung cancer. Therefore, it is desirable, from the clinical view, to determine clinical staging and to establish standard operative procedures comprising mediastinal lymph node dissection as well as effective chemotherapy. With respect to pathology, it is hoped that an improved histologic classification will be developed.

During the past 20 years, 1,064 cases of non-small cell lung cancer underwent resectional surgery in which all accessible mediastinal lymph nodes were dissected. Among 288 patients with histologically proven N2 disease, 182 underwent complete dissection of the mediastinal lymph nodes; 77 had one-level and 105 had multi-level metastases. Fifteen percent of the patients having primary lesions with a maximal diameter between 21 and 30 mm had N2 disease. Nodal metastases to the lower mediastinum from upper lobe cancer (nonregional metastasis) were frequently observed as were metastases of lower lobe cancer to the upper mediastinum. In addition, there were often skip metastases to the nonregional parts of the mediastinum without regional nodal involvement in the mediastinum. Among left-lung cancer patients, the group that underwent nodal dissection after mobilization of the aorta by dividing the Botallo's ligament frequently had a verified metastatic node at the tracheo-bronchial angle (#4) which might not have been detected without that procedure. In addition, many N2 and N3 diseases were detected by additional dissection through a median sternotomy. From the results of the present study, it appears that extensive mediastinal dissection should be recommended in surgery for lung cancer irrespective of the location and the size of the primary tumor.

Bronchogenic cancer in the pediatric age group is extremely rare and less than 100 cases have been reported in the world literature. We report a 13-year-old girl with simultaneous occurrence of lung adenocarcinoma and osteosarcoma. The patient was admitted with lower leg pain, and an abnormal shadow in the right fibula was noted on X-ray examination. Further examination of the fibular lesion including tumor biopsy revealed an osteosarcoma. Following completion of the first course of preoperative chemotherapy, multiple lung shadows were found on chest X-ray films. After five courses of preoperative chemotherapy, however, all lung shadows except one in the right lower lobe disappeared. The fibular tumor was then resected. Postoperatively, an additional six courses of chemotherapy was given. However, the lung shadow in the right lower lobe was still present. Exploratory thoracotomy was performed. Pathologically, the lung tumor measured 0.8 cm in diameter with an ill-defined border, and histological examination revealed a well differentiated papillary adenocarcinoma. To our knowledge, only a few cases of pediatric lung cancers have been reported to be associated with congenital cystic malformation of the lung. However, this combination of pediatric lung adenocarcinoma and osteosarcoma has not been previously reported.

Pulmonary actinomycosis is rare at present. A 11-year-old girl complained of left anterior chest pain and chest wall swelling. A radiograph of the chest revealed a consolidation in the left upper lobe. Sputum cultures showed normal flora and sputum cytology was negative for malignant disease. On 16 days after admission, the infection involved the bronchocutaneous fistula. Surgery was necessary to curettage. Histopathological specimen of resected necrotic tissue showed typical "sulfur granule" of actinomycosis. We administered penicillin for 3 months and the consolidation disappeared.