Treatments for hepatocellular carcinoma in cirrhosis : practical aspects]

A 44-year-old woman was admitted to our hospital for evaluation of an abnormal lung shadow. Chest computed tomography (CT) revealed a tumor surrounded by air-space and an infiltrative shadow in the right S2. Right upper lobectomy was performed and pulmonary sclerosing hemangioma was diagnosed. Usually, pulmonary sclerosing hemangioma shows a solitary round nodule on a chest CT scan. We report a case of pulmonary sclerosing hemangioma with an unusual shadow on a chest CT scan, and review the literature.     

A case of chronic necrotizing pulmonary aspergillosis successfully treated with combination therapy of antifungal drugs and ulinastatin

A 64-year-old woman with a history of old tuberculosis, had a fungus ball shadow with meniscus sign in the upper right lung field on a chest X-ray film in 1991. Based on the chest X-ray findings, pulmonary aspergilloma was suspected. Because the size of the intracavitary fungus ball increased, the patient was treated with itraconazole over one year in 1995, but there was no improvement. One month later, she was admitted because of fever, hemoptysis and productive cough, and chest X-ray showed an enlargement of intracavitary mass and infiltrative shadow in the right lung. Chronic necrotizing aspergillosis was diagnosed on the basis of her clinical and radiographic features, and positive serological test. Although itraconazol and amphotericin B were given, cavity and intracavitary fungus ball shadow kept growing. Combination therapy of antifungal drugs and ulinastatin markedly improved symptoms and resulted in complete disappearance of the fungus ball on chest CT scan.     

The pulmonary air meniscus sign in a case of sclerosing hemangioma

A 57-year-old woman was admitted to our hospital because of a slowly growing pulmonary tumor with a 34 year history. Chest roentgenogram on admission showed a 42 mm sharply demarcated solitary tumor in the left upper lobe. Chest CT revealed a slit-like pulmonary air meniscus. Left upper lobectomy was performed. A specimen from the resected lung histologically showed solid, papillary and hemorrhagic patterns, and the diagnosis of pulmonary sclerosing hemangioma was therefore made. Pulmonary air meniscus sign in pulmonary sclerosing hemangioma is rare. We think one possible mechanism in the production of an air meniscus sign in sclerosing hemangioma is bleeding in communication with a bronchus.     

A case of ectopic amylase-producing lung cancer

A case of amylase-producing lung cancer is reported. A 58-year-old man was admitted to our hospital because of abnormal shadow on chest X-rays. Transbronchial lung biopsy showed adenocarcinoma at the right upper lobe. Amylase levels were elevated to 915 IU/l in the serum and 960 IU/l in urine. Amylase isozyme pattern identified "salivary-type" amylase. Right upper lobectomy was performed. Both serum and urine, amylase levels were decreased within normal limits after operation. Enzyme labeled immunoperoxidase method on this specimen proved that tumor cells were producing amylase ectopically.     

Pulmonary lipomatosis: a variant of placental transmogrification

An unusual pulmonary lesion is presented. The patient is a 55-year-old white man with a 2-week history of pleuritic chest pain, shortness of breath, and bronchopneumonia. The patient had also a history of smoking and chronic cough for 12 years. Chest radiographic studies showed a 20-cm bulla in the left upper lobe. A left upper lobectomy was performed obtaining an almost completely collapsed lobe with destruction of the normal architecture by a meshwork of yellowish tissue. Histologically, there were strikingly papillary structures composed almost exclusively of mature adipose tissue with small collections of inflammatory cells. Minimal emphysema in the adjacent lung parenchyma was observed. The case herein presented most likely represents part of the spectrum of placental transmogrification or placentoid bullous lesions of the lung.     

A case of primary pulmonary B cell lymphoma confirmed by gene analysis

A 76-year-old man visited our clinic with chest radiographic evidence of a coin lesion in the right middle lung. Chest CT demonstrated an infiltrative shadow mainly in the S4 segment. Lymphoproliferative disorders were suggested by transbronchial lung biopsy. Middle lobectomy was performed. Pathological study showed massive proliferation of mature lymphocytes. Immunoperoxidase studies could not demonstrate a neoplastic monoclonal process. Pseudolymphoma was diagnosed. High molecular weight DNAs were extracted from frozen specimens. Whether genes of immunoglobulins and T-cell receptors were rearranged was investigated using DNA probes against JH and TCR beta-1 receptor gene. One rearranged band was found in the JH chain. No rearranged band appeared in TCR beta-1 chain. B cell lymphoma was diagnosed instead of pseudolymphoma.     

Acute exacerbation following bronchoalveolar lavage in idiopathic interstitial pneumonia

We report two cases of idiopathic interstitial pneumonia (IIP) with acute deterioration after bronchoalveolar lavage (BAL). Case 1 was a 54-year-old woman, and case 2 was a 75-year-old man. Both were diagnosed as having IIP, and hospitalized with complaints of high fever and dyspnea. After BAL, the degree of dyspnea increased. White blood cell count and lactate dehydrogenase were elevated, and PaO2 was decreased. Chest X-ray revealed consolidation of the upper lung fields and reticulo-granular shadows spreading through both lungs. BAL fluid examination showed an elevated neutrophil fraction (case 1: 6.5%, case 2: 35.2%), suggesting respiratory tract infection although bacteria could not be detected. Case 1 died of respiratory failure despite corticosteroid therapy. Autopsy revealed diffuse alveolar damage with focal pneumonia in the right S6 corresponding to the upper lobe consolidation. Case 2 improved after antibiotic therapy. These findings suggest that aspiration of infected fluid during BAL can cause acute exacerbation of IIP. It is important to recognize that the BAL procedure can induce an acute exacerbation of IIP.     

Pulmonary disease caused by Mycobacterium avium presenting as a solitary cavity with a thickened wall]

A 46-year-old man was admitted for evaluation of a solitary pulmonary cavity in the apey of the left lung. Because two transbronchial biopsies followed by brushing and washing and sputum cytology did not yield any diagnostic findings, the patient was treated with INH, RFP and SM under a tentative diagnosis of pulmonary tuberculosis. The shadow decreased over two months with combination therapy, but increased again after the dose of SM was decreased. We performed a left upper lobectomy to diagnose either multi-drug-resistant pulmonary tuberculosis or lung cancer. Pathological examination of the resected lung revealed epitheloid cell granulomas with areas of caseous necrosis. Smooth chromophoric colonies were isolated on an Ogawa egg medium, and were identified as M. avium by PCR and DDH. A diagnosis of pulmonary M. avium was made. A chest X-ray film taken two years later was normal. Pulmonary M. avium disease developed in this patient, who had no predisposing lung pathologies.     

Rounded atelectasis that disappeared after bronchoscopy

We describe a 70-year-old man who presented with a round opacity that disappeared after bronchoscopy. Chest computed tomograms (CT) showed a round opacity in the left lower posterior lung field. Brushings and washings of the left B10 through bronchoscope yielded neither malignant cells nor acid fast bacilli. The patient was diagnosed as having a benign tumor and was not medicated. Chest CT 1.5 months after bronchoscopy showed that the round opacity had disappeared. Although this course was unusual, this radiopacity was quite typical of round atelectasis on the basis of CT appearance.     

Relations between chest CT and pathologic findings in pulmonary infarction associated with lung cancer

Chest radiographic (mainly CT), and pathological findings in pulmonary infarction associated with lung cancer were studied to obtain information useful for the interpretation of CT findings, and to help determine the cause of infarction. Sixteen cases of lung infarction were chosen from among 518 cases of lung cancer. All patients were operated on between January 1980 and December 1990. Sixteen surgical cases and one autopsy case all with evidence of lung cancer and infarction were chosen. There were 13 men and 4 women with a mean age of 56 years. Adenocarcinoma was found in 8 cases, squamous cell carcinoma in 6, adenosquamous carcinoma in 2, and small cell carcinoma in 1. Chest radiographs and CT revealed infarction shadows in 8 of the 16 cases. Typical CT findings for pulmonary infarction were: shadows located in the same lobe and periphery as the cancer; ill-defined, 10-25 mm nodular shadows; and lesions located both in the subpleural zone and apart from the pleura. Lesion counts in each area were about the same. Observation of one patient for 2 months revealed a decrease in the size of the nodular shadows and clarification of their margins. In most cases, centrally extended cancer resulted in vascular stenosis and infarction.     

Successful video-assisted thoracoscopic bullectomy and Nd-YAG laser ablation

We report here two cases of giant/multiple emphysematous bullae treated with video-assisted thoracoscopy. The first case was a 35-year-old male who was referred to our hospital because an abnormal shadow was casually pointed out in a chest roentgenogram. Chest computed tomographic scan showed giant bulla in the left upper lobe. The second patient was a 37-year-old male who had a symptom of shortness of breath on exertion. Chest roentgenogram and computed tomographic scan revealed multiple bullae at bilateral apical regions. They were performed resection of bulla with stapler and Nd-YAG laser ablation to the emphysematous surroundings using video-assisted thoracoscopy. They had recovered sufficiently to be discharged from our hospital. We think Nd-YAG laser ablation is effective to prevent postoperative air leakage and recurrence of bullae because it makes surrounding tissue tight and continuous.     

Massive adrenal hemorrhage secondary to metastasis of lung cancer

Hemorrhagic adrenal metastasis from lung cancer is extremely rare, although adrenal involvement is common in widely disseminated cancer. We report a case of massive adrenal hemorrhage secondary to metastasis of lung cancer. A 47-year-old female was treated by left upper lobectomy and mediastinal lymph node resection for an adenocarcinoma with intrapulmonary metastasis in the left upper lobe. Eight months later, she presented with right flank and back pain, and abdominal ultrasonography and computed tomography showed a right solitary adrenal tumor with massive hemorrhage. The tumor was not resectable and partially responded to chemotherapy. A massive adrenal hemorrhage, secondary to metastasis of lung cancer, presents with nonspecific clinical signs and symptoms. In lung cancer patients with an acute flank or back pain, hemorrhagic adrenal metastasis should be considered in the differential diagnosis.     

Effective treatment of thymic carcinoma with operation and combination chemotherapy against acute monocyte leukemia: case report and review of the literature

Thymic carcinoma associated with acute monocyte leukemia (AMoL) and a history of choriocarcinoma was diagnosed in a 58-year-old female. We found no other such case in a literature search. She was first treated with DCMP therapy: daunorubicin, cytosine arabinoside, 6MP-riboside, and prednisolone against AMoL. After induction chemotherapy, complete AMoL remission was attained. Chest CT scan after chemotherapy revealed regression of the mediastinal tumor. Resection of the tumor included the left upper lobe of the lung, phrenic nerve and pericardium. Pathological diagnosis showed poorly or moderately differentiated squamous cell carcinoma. Although the patient died of pneumonia during chemotherapy for relapsed AMoL, chest X-ray and CT revealed no recurrence of the mediastinal tumor after the original operation. Judging from this case and other successful cases of chemotherapy, we feel that intensive chemotherapy may be a beneficial strategy against thymic carcinoma.     

Pryce type I interlobar pulmonary sequestration with anomalous return to the left inferior pulmonary vein

A 50-year-old woman was examined because of chest discomfort. Chest X-ray films disclosed a tumorous shadow behind the heart. Chest computed tomography (CT) scans revealed a mass connected to the descending aorta, with increased blood flow in the left basal segment. The patient was admitted for further examination. Chest CT scans and cardioscintigrams were very useful as diagnostic tools, but the final diagnosis was made on the basis of angiography. An anomalous tortuous artery ran from the descending aorta into the left basal segment and returned to the left inferior pulmonary vein. The left pulmonary arterial trunk had no basal branch (A8-A10). A loop corresponding to the superior vein (V6) ran beneath the anomalous tortuous artery. To our knowledge, this is the second case of Pryce type-I interlobar pulmonary sequestration with anomalous return to the left inferior pulmonary vein to be reported in Japan. A left inferior lobectomy was performed. Histological finding from the excised tissues showed prominent interstitial fibrosis, atypical adenomatous hyperplasia, and atherosclerosis. Following surgery, the patient's PaO2 increased from 80.4 Torr to 95.8 Torr, suggesting that left inferior lobectomy was an appropriate treatment.     

A case of mediastinal teratoma discovered availing of pneumonia

A 42-year-old woman was admitted to our hospital with hemosputum and an abnormal shadow on chest X-ray. Although her hemosputum disappeared after the treatment of pneumonia, the abnormal shadow was not improved. Chest CT showed a mediastinal mass. She underwent thoracotomy and the tumor, measuring 6 x 5 x 5 cm in size, was resected. Pathological diagnosis was a mature type teratoma with direct invasion to the lung. We have to take mediastinal teratoma into consideration as one of the causes of pneumonia.     

A case report of well differentiated fetal adenocarcinoma]

A 32-year-old female, who was admitted with complaints of cough and an abnormal shadow in the left lower lobe, was diagnosed as adenocarcinoma of the lung by TBLB. She underwent left lower lobectomy and lymph node dissection. Histopathological findings showed well differentiated fetal adenocarcinoma (WDFA). Well differentiated fetal adenocarcinomas are considered to have a histogenesis similar to that of pulmonary blastoma and may be a tumor with one-sided development of pulmonary blastoma showing only an epithelial component.     

Three resected cases of pulmonary cryptococcosis

Case 1 was a 53-year-old female who had a small nodule in the right S3 segment on chest CT. As she was not diagnosed by transbronchial lung biopsy (TBLB), open thoracotomy was performed. Case 2 was a 65-year-old female who had a nodule with pleural indentation in the right S6 segment. As this nodule showed difficulty to differentiate from small lung carcinoma, thoracoscopic surgery was performed. Case 3 was a 63-year-old female who had multiple lesions with cavity in the left S4 and S5 segments, which was preoperatively diagnosed by TBLB. She was performed thoracoscopic partial resection of the lingular segment because of poor response to antimycotic agents. All cases received preventive antimycotic agents for one or two months after the operation. There was no recurrence or postoperative meningitis. Thoracoscopic surgery is the effective procedure for the diagnosis and treatment of the localized pulmonary cryptococcosis.     

Left partial anomalous pulmonary venous connection found during a lobectomy for lung cancer: report of a case

We report herein the case of a 68-year-old man in whom a partial anomalous pulmonary venous connection (PAPVC) was found during an operation for primary lung cancer. The preoperative clinical findings did not suggest a vascular shunt, and intraoperatively the anomalous vein was seen to drain only from the left upper lobe into the left innominate vein. The lower pulmonary vein connected normally, and there was no atrial septal defect nor any other anomalous condition. A left upper lobectomy with ligation of the anomalous connected vein was performed uneventfully. This type of PAPVC is extremely rare, and is especially noteworthy because there were no clinical signs.     

A functional chimeric modular polyketide synthase generated via domain replacement

We report here a case in which for hemoptysis during menstruation (catamenial hemoptysis) right middle lobectomy was performed thoracoscopically under a preoperative diagnosis of pulmonary endometriosis with a successful outcome. The patient was a 27-year-old housewife who from the age of 24 years experienced hemoptysis during menstruation, and was diagnosed as having pulmonary endometriosis on the basis of detailed examinations including bronchoscopy and chest CT. From the age of 26 years hormone therapy was administered, but the hemoptysis recurred with the menstruation following its cessation. After admission to this department bronchoscopy performed at the time of menstruation revealed bleeding from right B4 while chest CT showed an abnormal shadow in right S4 b. Right middle lobectomy was then performed thoracoscopically under a diagnosis of right middle lobe endometriosis. In the resected specimen findings of pulmonary hemosiderosis, granulomatous phlebitis and micrometastases from a thyroid cancer were noted. The postoperative course was favorable with no further episodes of hemoptysis occurring. In this case histological proof of endometriosis could not be obtained, but the diagnosis of pulmonary endometriosis was strongly suggested by the clinical course and objective findings such as pulmonary hemosiderosis.     

A case of huge abscess extended from anterior neck to left lung and lateral chest wall

62-year-old woman admitted our hospital with pain of left upper extremity from the left chest and dysphasia. Chest X-ray showed the huge mass shadow in the left lung field. Diabetes mellitus and inflammatory reaction such as high fervor, leukocytosis, CRP and ESR accentuation were recognized. Conservative therapy was done at first, but mass shadow on X-ray increased, and swelling appeared from the neck to the left lateral chest wall. And the same site appeared like subcutaneous emphysema. Computed Tomography showed mass shadow which was enlarged and spread in lung parenchyma and left chest wall with bubble image. Incision and open drainage was performed for the left chest wall but origin bacteria was detected in neither anaerobic nor aerobic culture of pus. Inflammation and mass shadow of left upper lung field have decreased gradually. The patient discharged without bronchoalveolar fistula. Abscess extending from the neck or chest wall with diabetes mellitus is very rare.