廣島 健三

A 71 year old man was admitted for the purpose of diagnosis of a right solitary pulmonary nodule. The size of the nodule was 18 x 18 mm in diameter 2 years ago, but it has become large, 25 x 25 mm in diameter. The nodule was resected by thoracotomy. Microscopically, eosinophilic amorphous, acellular substances were surrounded by inflammatory infiltrates. It stained with Congo red stain and showed green birefringence with polarizing microscopy. Amyloid fibrils were observed electron microscopically. Asbestos bodies were observed in the lung parenchyma around the nodule. This case shows that a nodule in nodular pulmonary amyloidosis can grow gradually and suggests the possibility of asbestos fibers as one of the etiologic factors in nodular pulmonary amyloidosis.

Background. The new classification of intrapulmonary metastases of lung cancer was proposed by the American Joint Committee on Cancer; however, the prognostic factors are heterogeneous and not yet fully clarified. In this study, the authors evaluated the prognostic factors for and the possible routes of intrapulmonary metastases. Methods. The factors influencing the prognosis of primary resected nonsmall cell lung carcinomas with intrapulmonary metastasis in the resected specimens were evaluated according to the Cox proportional hazards model using a total of 66 nonsmall cell lung carcinomas. The possible routes of tumor spread via the blood or lymphatic vessels also were evaluated. Results. The overall 5-year survival rate was 26.1%, and the statistical analysis of survival curves revealed a significant difference with regard to N classification (P = 0.042), site of intrapulmonary metastasis (P = 0.012), blood vessel invasion (P = 0.0046), and lymphatic vessel invasion (P = 0.0267); there were no significant differences in relation to age, sex, histology, differentiation, T classification, tumor size, stage, number of intrapulmonary metastases, or size of intrapulmonary metastasis. Multivariate analysis according to the Cox proportional hazards model identified a significant correlation between survival and blood vessel invasion (P = 0.044) and lymphatic vessel invasion (P = 0.042), suggesting independent prognostic significance. The correlation between site of intrapulmonary metastasis and the ratio of blood or lymphatic vessel invasion showed a significantly lower ratio of blood vessel invasion in cases with intrapulmonary metastases at sites central to the primary lesion or in different segment(s) compared with those in cases with intrapulmonary metastases at sites peripheral to the primary lesion or in ipsilateral different lobe(s), suggesting a possible lymphatic vessel route of tumor spread. Conclusion. Blood vessel and lymphatic vessel invasion are important clinical factors in evaluating prognosis and the route of tumor spread in primary resected nonsmall cell carcinoma with intrapulmonary metastasis.

症例は41歳の女性, 発熱, 咳嗽等の感冒様症状が出現し, 近医にて治療を受けていたが, 症状の改善がみられず, 気管支鏡検査を施行。左下幹入口部に内腔をほぼ閉塞する腫瘤を認めた。気管支鏡下生検検体の病理組織所見では, 腫瘍組織は気管支粘膜により被覆され, 腫瘍細胞の細胞質は豊かで好酸性の顆粒で充満しており, 顆粒細胞腫と診断された。腫瘍は, 有茎性, polyp状で, 気管支鏡的に呼吸性移動が認められた。また, 画像的には, 気管支壁外への浸潤性増殖の所見はみられなかった。本症例では, 気管支鏡下にNd : YAGレーザー約4000jouleによる焼灼, およびsnaringを併用し腫瘍を除去し得た。治療後約7ヵ月の時点で, 腫瘍基部は上皮化され再発の徴候は認められない。

The objective was to evaluate the prognosis of primary non-small cell carcinoma cases in a total of 794 cases resected during the past 10 years, including 64 cases with intrapulmonary metastasis (pm) and 730 cases without intrapulmonic metastasis (control). The overall 5-year survival rates in the pm group was 25% and there were no significant differences in survival between adenocarcinoma and squamous cell carcinoma, or between cases of T1, T2, T3 and T4 disease. However, the survival rates of cases with metastasis to primary lobe tended to be better than cases of ipsilateral metastasis to non-primary lobe(s). Furthermore, significant differences of survival curves were demonstrated between cases with N0 and N2 diseases and between cases with solitary and multiple metastasis (both P &lt 0.05, Cox-Mantel test). The survival rates of cases with intrapulmonary metastasis were reevaluated according to the classification proposed by the AJCC and no significant differences were demonstrated in T2N0, T3N0, T4N0, N1, N2 deseases between the pm group and control group without intrapulmonary metastasis, supporting the suitability of the AJCC stage criteria for intrapulmonary metastasis. © 1995, The Japan Lung Cancer Society. All rights reserved.

症例は41歳の女性, 発熱, 咳嗽等の感冒様症状が出現し, 近医にて治療を受けていたが, 症状の改善がみられず, 気管支鏡検査を施行。左下幹入口部に内腔をほぼ閉塞する腫瘤を認めた。気管支鏡下生検検体の病理組織所見では, 腫瘍組織は気管支粘膜により被覆され, 腫瘍細胞の細胞質は豊かで好酸性の顆粒で充満しており, 顆粒細胞腫と診断された。腫瘍は, 有茎性, polyp状で, 気管支鏡的に呼吸性移動が認められた。また, 画像的には, 気管支壁外への浸潤性増殖の所見はみられなかった。本症例では, 気管支鏡下にNd : YAGレーザー約4000jouleによる焼灼, およびsnaringを併用し腫瘍を除去し得た。治療後約7ヵ月の時点で, 腫瘍基部は上皮化され再発の徴候は認められない。

左上葉転位亜区域気管支より発生した肺扁平上皮癌の一切除例につき報告する.症例は52歳の女性.血疾を主訴に近医を受診し, 胸部X線写真上, 左上肺野に腫瘤影を指摘された.気管支鏡検査で左B¹⁺²aが左主気管支より分岐する転位気管支を認めた.腫瘍は異常気管支領域に存在し, 生検で扁平上皮癌と診断された.また胸部CTにて左肺尖部に著明な気管支拡張所見が認められた。臨床病期c-T2N2M0, StageIIIAと診断し, 左肺全摘除術を施行した.切除標本の病理学的検索では腫瘍は中分化型扁平上皮癌と診断され, また腫瘍より末梢の肺尖部の多数の拡張した気管支の上皮に癌細胞の浸潤を認め, さらに切除肺葉内転移も認められ, 術後病理病期はp-T2NIM1 (pm1), stageIVであった.術後, 10ヵ月現在経過良好にて外来通院中である.

A case of large cell carcinoma of the lung in a pulmonary cyst, preoperatively diagnosed by perctaneous needle biopsy (PCNB) under ultrasonographic (USG) guidance, is reported. A 66-year-old male complained of hemoptysis. The chest X-ray film and CT showed an abnormal shadow in a pulmonary cyst in the right lung field. MR imaging, performed 6 months later because of the rapid growth of the shadow, showed enlargement of the tumor and effusion in the cyst. Although transbronchial biopsy was negative, PCNB under USG guidance revealed that the tumor in the cyst was non-small cell lung cancer. Surgical treatment was performed and the tumor was pathologically diagnosed as large cell carcinoma of the lung. This case showed that PCNB under USG guidance is a useful method for the diagnosis of lung cancer in pulmonary cysts. © 1994, The Japan Lung Cancer Society. All rights reserved.

Changes in the dimensions of inhaled asbestos fibers in the lung and translocation of intrapulmonary asbestos fibers into mesothelial tissues were investigated in 17 baboons (5 exposed to amosite, 4 to chrysotile, 5 to crocidolite, and 3 unexposed). The animals received different cumulative doses of asbestos by inhalation, followed by varying recovery periods (0-69 months). All asbestos types induced pulmonary asbestosis with severity directly related to the cumulative dose. There were a larger number of asbestos bodies in the lung of the amphibole-exposed animals than in those exposed to chrysotile. A tissue burden study, using transmission electron microscopy on 25-mum paraffin sections, ashed in a low-temperature asher, was performed. Intrapulmonary amosite fibers were shorter in geometric mean length compared with a standard amosite sample (UICC) (3.3 mum). In explanation, it was considered that long fibers might not be able to reach the lower respiratory tract and/or long fibers might be fragmented into shorter fibers. Further, in the amosite-exposed group, the mean length of intrapulmonary fibers increased with the extension of recovery period, suggesting that shorter fibers had been cleared from the lung. The chrysotile standard sample (UICC) had a shorter geometric mean length (1.1 mum) than amosite. The mean length of intrapulmonary chrysotile did not noticeably change with the extension of inhalation and recovery periods; however, the mean width decreased with the extension of these periods. This finding strongly suggested that separation of thick chrysotile fibers had occurred in the lung. The crocidolite standard sample (Transvaal) had a shorter geometric mean length (1.4 mum) than amosite. The mean length of intrapulmonary crocidolite fibers increased with the extension of inhalation and recovery periods, suggesting that shorter fibers had been cleared from the lung during both the inhalation and recovery periods. There was no specific tendency of size distribution among four distinct interstitial locations (peribronchiolar, alveolar septal, subpleural, and interlobular connective tissue) within the same lung exposed to either amosite, chrysotile or crocidolite. In four animals, malignant mesothelioma developed in the pleura (2 amosite and 1 UICC crocidolite) and the peritoneum (1 UICC crocidolite). Asbestos fibers were found in the mesotheliomas. Their size distribution in mesotheliomatous tissue and lung was not significantly different in two animals, but the fibers were shorter and thinner in another two. The presence of fibers in the neoplasms was confirmed, and translocation of fibers from the lung into the pleura or the peritoneum was strongly suggested.

Dimensional changes of asbestos bodies and uncoated fibers and the leaching of magnesium from the surface of chrysotile after a single intratracheal injection (1 mg) were investigated in male hamsters. The animals were sacrificed at 1 day, 6 months, 1 and 2 years later. In addition to histopathological observation, asbestos tissue burdens were investigated in 25 mum thick sections of the lungs. The sections were ashed in a low-temperature asher to be extracted with carbon film. The carbon extracted ashed sections were investigated by high resolution analytical electron microscopy to characterize asbestos fibers and asbestos bodies. Pulmonary interstitial and pleural fibrosis were observed after 6 months and later on. Light microscopically, asbestos bodies were observed after 6 months; their incidence subsequently increased with the lapse of time after the injection. Asbestos bodies measured on light micrographs became longer with the lapse of time. This suggested that the coating of chrysotile fibers had been continuously progressing in the lung. Geometric means of length and width of uncoated chrysotile fibers seen by transmission electron microscopy in animals at 1 year (length: 1.4 mum; width: 0.05 7 mum) or 2 years (1.2 mum, 0.047 mum) were greater compared with those of animals at 1 day (0.9 mum, 0.041 mum) or 6 months (0.9 mum, 0.037 mum) after instillation. These findings suggested that short and thin chrysotile fibers were cleared from the lung. Energy dispersive X-ray spectrometry revealed that the ratio of the content of magnesium to that of silicon was slightly lower in the fibers detected in the animals with a recovery period of 6 months and longer (6-12%), suggesting that magnesium had been leaching from the surface of chrysotile fibers although its amount was small.

A 34-year-old man with persistant cough was admitted to our hospital. Bronchoscopic examination revealed a polypoid tumor with smooth surface which almost completely obstructed the right main bronchus. The tumor was removed by transbronchial snaring forceps and histologically confirmed as neurofibroma. Residual tumor was excised by biopsy forceps and further endoscopic Nd-YAG laser vaporization was performed. This is the first case in our country in which bronchoscopic treatment was performed for bronchial neurofibroma. Bronchoscopic removal might be the preferred treatment in the present case, although long-term follow-up is also required.