Department of Surgery, Osaka Prefectural Habikino Hospital, Osaka, Japan A retrospective review was performed to evaluate patterns of failure and prognosis of pT3N0M0 patients with resected non-small cell lung cancer involving the chest wall (n=42). Tumor invasion was confined to the parietal pleura in 12 patients (Group A), to the subpleural soft tissue in 24 patients (Group B), and to the rib in 6 patients (Group C). The 5-year survival rates of patients with such invasion were 41.7%, 36.4%, and 33.3 %, respectively. In Group B and C patients, a better prognosis can be expected with adjuvant therapy.
The rates of recurrence (local: distant) of each group were (0: 9), (3: 7), (1: 3), respectively. In patients with involvement of only parietal pleura, the 5-year survival rate of parietal pleurectomy and en bloc chest wall resection was 40.0% and 42.9%, respectively (N. S.). Extrapleural dissection is a valid procedure for patients with only parietal pleura involvement however, an effective and systemic adjuvant therapy should be applied for treatment of lung cancer with chest wall invasion because of its high frequency of distant metastasis.

View full abstract

Recurrence of spontaneous pneumothorax after thoracoscopic surgery is an important problem. we examined 50 patients who had received thoracoscopic operations for spontaneous pneumothorax. In this study, we classified the groups into three categories from the thoracoscopic observations, and disscussed whether or not there was reappearance of a pneumothorax. We concluded that there is a tendency to recurrence in the group with multiple and skip leisions in the lung. It is necessary that we should perform operation carefully in such cases.

View full abstract

We reviewed 18 patients with pulmonary large cell neuroendocrine carcinoma (LCNEC), who had undergone resection of lung cancer in our hospital. In microscopic findings, neuroendocrine morphology and necrosis were detected in all cases. The average mitoses of all cases was 77/high-power field. In immunohistochemisty, neuroendocrine-marker expression was detected in 12 cases (67%). Lobectomy was performed in 15 patients, segmentectomy in 2 and partial resection in 1. There were 10 stage I-diseases, one stage II-disease, 6 stage III-diseases and one stage IV-disease. Overall 5-year survival rate of LCNEC was 60%. This result was between atypical carcinoid and small cell lung cancer in the group of pulmonary neuroendocrine tumor. In stage I and II disease, 5-year survival rate was 60% in LCNEC, 55% in adenocarcinoma, 55% in squamous cell carcinoma and 58% in large cell carcinoma. 5-year survival rate was not significantly different between LCNEC and other histological subtypes of non-small cell lung cancer. Our results suggested the surgical resection was the initial indication for the stage I, II disease of LCNEC.

View full abstract

Although pulmonary hamartoma is relatively common, cases of cystic degeneration are very rare. The patient was a 59-year-old man admitted to our hospital because of pulmonary cystic lesion, detected by chest computed tomography. (CT) during a health check up.rCT showed a cystic lesion with small nodules and slightly thickened walls in the left lower lung. Based on these findings we suspected malignancy or aspergiloma, and video assisted thoracoscopic surgery was used to resect the cystic tumor. Pathologically the tumor was composed of cartilage tissue, fat tissue, and bronchial epithelium. From the pathological findings, the tumor was diagnosed as chondromatous hamartoma with cystic degeneration.

View full abstract

Depertment of Surgery III, Nara Medical University We report a case of severe emphysema with pulmonary hypertension. The patient was a 76-year-old man whose forced expiratory volume in one second was 640 ml and Hugh-Jones classification was IV. We measured pulmonary artery pressure through a Swan-Ganz thermodilation catheter. The mean pulmonary artery pressure was 37 mmHg. He underwent bilateral staged lung volume reduction surgery. He was discharged from hospital after operation without major complications. Mean pulmonary artery pressure did not change at three months after operation. Bilateral staged lung volume reduction surgery is a useful procedure for severe emphysema with pulmonary hypertension.

View full abstract

Pneumothorax complicated with lung cancer is rare and we report here two cases of lung cancer detected at the time of pneumothorax. Both cases were incidentally found by chest X-ray and chest computed tomography during the treatment of pneumothorax. One patient was a 74-year-old man who developed left pneumothorax three times, a mass subsequent to which 20mm in diameter was detected on the right side. Left bullectomy was performed followed by partial lung resection for lung cancer 3 weeks later. The other patient was a 67-year-old man who developed left pneumothorax. After reexpansion of the left lung, chest CT showed a peripheral small nodule near a bullous lesion in the left lower lobe (S⁶). Frozen sections revealed lung cancer, and lobectomy with mediastinal lymphadenectomy was performed in one procedure to treat both pneumothorax and lung cancer. Both patients were heavy smokers. It is important to consider the possibility of the presence of lung cancer in patients who develop pneumothorax, particularly in elderly patients who are heavy smokers.

View full abstract

A 66-year-old man was admitted to the hospital, because of dyspnea on effort and left chest pain. Chest CT showed a mass surrounding the left lower lobe bronchus. Although bronchoscopy revealed severe bronchial stenosis in the left lower lobe bronchus, no malignant cells but only fibrosis were detected by bronchial wall biopsy of the lesion. Lung cancer was highly suspected through CT-guided needle biopsy, and was diagnosed as class Mb. Operative findings showed severe fibrosis in the left hilum of lung and atelectasis of the left lower lobe, and no cancer tissue was detected through several biopsies. Left lower lobectomy and sampling of some lymph nodes were performed. Pathological findings revealed sarcoidosis with epithelioid cells and granulomas in the bronchus and the lung.
Although sarcoidosis sometimes causes multiple bronchial stenoses, a tumor-like shadow suggestive of malignancy occasionally presents like in this case.

View full abstract

A case of posterior mediastinal cavernous hemangioma in a 74-year-old man is reported. He was admitted to our hospital for treatment of a thoraco-abdominal aortic aneurysm. Chest X-ray and CT revealed a huge mass in his right chest, which pushed down the liver and forced the heart to the left side. The tumor was resected en bloc without any organ resection. The resected specimen was a mediastinal cavernous hemangioma, weighing 1, 980 g and of 15×15×13 cm in size. This was the high old age case, and the tumor was the largest in size and weight of all the reported cases in Japan. Two months after the first operation, he was treated for an aortic arch aneurysm.

View full abstract

A 25-year-old man was admitted to our hospital with abnormal shadow on chest X-ray detected at the onset of spontaneous pneumothorax. Chest radiograph showed a mass shadow with linear shadow. Chest CT film showed a tumor obstructing the left B⁹⁺¹⁰ and a lesion suspected of being mucoid impaction in the distal broncus of the tumor. Bronchoscopy revealed an endobronchial tumor, which almost completely occuluded the orifice of left B⁹⁺¹⁰. Left lower segmentectomy with bronchoplasty was performed. The tumor was a polyp 35×35×40mm in size and obstructed left B⁹⁺¹⁰ with mucoid impaction. Histologically the tumor was a low grade malignant mucoepidermoid carcinoma, and neither extrabronchial extension nor any lymphnode metastases were detected. Two years has passed with no evidence of recurrence. This case is considered interesting because the patient was treated for spontaneous pneumothorax on the side ipsilateral to the tumor, and massive mucoid impaction was seen.

View full abstract

We report a 23-year-old man with congenital partial pericardial defect associated with left primary spontaneous pneumothorax who underwent video-assisted thoracoscopic surgery (VATS). The patient was examined at our hospital for chest pain, and chest X-ray film and chest computed tomography showed left pneumothorax and pneumopericardium. Under the diagnosis of congenital partial pericardial defect associated with left primary spontaneous pneumothorax, VATS was performed. Intraoperatively, a 5×4.5cm partial defect was noted and covered with the thymic tissue and surrounding fatty tissue. The left atrial appendage, left main pulmonary artery and pulmonary trunk could be observed through the defect. The post operative course was uneventful and the patient was discharged 6 days postoperatively. This is the second reported case of VATS used to treat a congenital partial pericardial defect in the Japanese literature and VATS may become the treatement of choice for patients with congenital partial pericardial defect.

View full abstract

A case of paraffin moving into the subcutaneous tissue 38 years postoperativery is reported. A 79-year-old woman was referred to our hospital with left lateral chest pain. She had received extraperiosteal paraffin plombage for pulmonary tuberculosis in 1961. The movement of the inserted paraffin into the subcutaneous tissue occurred 20 years after operation. Recently she had developed dermatitis at the tip of the moving paraffin. Chest X-ray showed plombe material with calcification without evidence of expansion. Under general anesthesia, the paraffin was removed with the infected dermis to a depth of about 10 mm. The defect was filled with a part of the anterior serratus muscle. Twenty-one months after postoperatively no signs of recurrence were noted.
Long-term follow-up is necessary after extraperiosteal paraffin plombage. Only the removal of the moving paraffin and reinforcement of the hole should be sufficient, if no evidence of expansion is observed.

View full abstract

A 70-year-old man with an abnormal shadow in the S⁸ of the right lung was diagnosed to have pulmonary squamous cell carcinoma by TBLB. Under thoracotomy, an aberrant artery branching from the diaphragm was found feeding the S¹⁰ of the right lower lobe and a right lower lobectomy (ND2a) was performed. In our case, the final diagnosis was made during the surgical operation. Histological examination of the S¹⁰ revealed pulmonary hypertension.

View full abstract

Solitary fibrous tumors of the pleura were initially described as localized mesothelial proliferations, and they have been called a variety of names, including fibrous mesothelioma, benign mesothelioma, localized mesothelioma, subpleural fibroma, and localized fibrous tumor of the pleura. Solitary fibrous tumors of the pleura that show no evidence of mesothelial cells should not be classified as mesotheliomas, since their mesothelial nature is not definitely established and it has been proposed to term these neoplasms “localized fibrous pleural tumors, ” since this does not imply a mesothelial nature.
Video-assisted thoracoscopic surgery (VATS) was performed to excise a solitary fibrous tumor in three cases. Case 1: A 74-year-old-woman who had a 6.3×5.2×3.8cm tumor originating from the visceral pleura of the left upper lobe. Case 2: A 74-year-old-woman who had a 3.5 ×3.1×1.8cm tumor originating from the visceral pleura of the left lower lobe. Case 3: A 62-year-old-woman who had a 4.9×3.3×2.0cm tumor originating from the parietal pleura of the right thoracic cavity.
In cases 1 and 3, it was noted that the mass lesion on chest roentgenogram moved with changes in body position and respiration, and we made a diagnosis of pedunculated benign localized pleural tumor. Surgical removal by VATS was safely and easily performed, and the patients obtained complete cure without recurrence.

View full abstract

A 53-year-old man with alcoholic liver cirrhosis underwent left lower lobectomy for primary lung cancer, well differentiated adenocarcinoma, pT1N2MO-IIIA. He received postoperative radiation therapy of a total dose of 50 Gy in 25 fractions to the bilateral hilar, mediastinal and supuraclavicular regions. A week after the completion of radiation therapy, he developed radiation pneumonitis, and prednisolone, at a dose of 30mg/day, was initiated. While tapering prednisolone, the pneumonitis was exacerbated. Although the patient responded immediately to methylpredonisolone pulse therapy, the condition exacerbated again when maintenance therapy of prednisolone was started after pulse therapy. Subsequently, the patient developed acute respiratory insufficiency. Adding methylpredonisolone pulse therapy improved the pneumonitis, and prednisolone was tapered gradually from 60mg/day and the withdrawal of glucocorticoids was successful. At the second exacerbation, Cytomegalovirus and Candida antigens were seropositive. In treating radiation pneumonitis with glucocorticoids, the possibility of steroid-withdrawal radiation pneumonitis and secondary infection should be considered.

View full abstract

A 68-year-old man, who had undergone an operation to remove the right kidney due to renal cancer, was admitted to our hospital with bloody sputum. Bronchoscopy revealed tumors at the inlet of the right upper bronchus and the inlet of the right B⁶, and a diagnosis of endobronchial metastasis of renal cancer was made. Surgically the right upper lobe and the right S⁶ were excised with bronchoplasty, and he was discharged from the hospital, 17 days postoperatively with favorable progress.
It is rare for bronchoplasty to be required in two separate locations in a single lung simultaneously, and the results in this case suggest that bronchoplasty can be successfully applied to two locations in a single lung, in one operation.

View full abstract

We report a surgical case of primary pulmonary non-Hodgkin's lymphoma (NHL) occurring in pneumoconiosis. The patient was a 75-year-old man. Chest X-ray and CT showed a mixed pattern of calcification, linear and reticular shadows, and tumorous shadows. A diagnosis of NHL was made based on CT-guided needle biopsy findings obtained from the enlarged tumor in the right S³. Thallium (T1)-scintigram showed radionuclide accumulation only in the right S³ mass shadow during both early and late phases. Partial resection of the right upper lobe following additional radiotherapy was performed. At 23 months after surgery, the patient remains well without recurrence of NHL. In conclusion, T1-scintigraphy was useful for diagnosing localized NHL admixturing with chronic inflammatory shadows in lungs complicated by pneumoconiosis.

View full abstract

We present here a successful case of rib resection by thoracoscopic surgery. A 50-year-old woman was diagnosed with a rib tumor by a chest x-ray. Chest CT showed an osteogenic tumor protruding from the posterior portion of the right third rib. Thoracoscopic finding showed a 1 cm-sized fine white nodule protruding from the chest wall. From another port, an electric drill was inserted and the third rib was resected in a thoracoscopic procedure. Pathological findings revealed a calcified fibrous nodule in the lymph node of the chest wall with no degenerative changes in the cortex or periosteum of the rib. Its origin was suspected to be old tuberculous lymphadenopathy of the chest wall. The patient was discharged on the 18th postoperative day and is doing well without complications 6 months postoperatively. Thoracoscopic surgery using an electric drill was an accessible and efficacious procedure for rib resection in an area difficult to reach with a conventional minimized incision.

View full abstract

The incidence of tracheobronchial disruption injury in cases of blunt chest trauma is low, but the associated mortality rate is high. However, accurate pathologic assessment using appropriate diagnostic imaging and early treatment may be useful in reducing the mortality rate in patients with this injury. We report here the case of the eighteen-year-old male of a motorcycle accident patient for whom chest roentgenogram on admission aided the diagnosis of injury of the right main bronchus (Japanese Association for the Surgery of Trauma in Japan, Tracheobronchial Injury Classification Ib) Tracheobronchial stripe, emphysema shadows around the trachea and the right main bronchus, the continuous diaphragm sign, and right Naclerio's V-sign were observed on the chest roentgenography, suggesting mediastinal emphysema. In addition, the shadow of the right main bronchus near the azygos vein was blurred, and a shadow indicative of hematoma was observed around the lateral azygos vein. Based on these two findings in particular we made a diagnosis of disruption injury of the right main bronchus. The injured site was closed by direct suture repair and postoperatively the patient's condition is good.

View full abstract

A 63-year-old woman was admitted with a mediastinal tumor that was incidentally diagnosed after an examination for palpitation.
Ultrasonocardiography revealed a large mass in the mediastinum, and chest CT showed a solid tumor, more than 10 cm in diameter, in the middle mediastinum. Extirpation of the tumor was performed via a thoracoscopic procedure. Pathological examination revealed that the tumor was composed of spindle cells with bizarre hyper chromatic nuclei and showed a high mitotic rate. A part of the tumor was connected to the esophagus wall.
Immunohistochemically, the tumor did not show differentiaton toward either smooth muscle or nerve, and these findings confirmed that the tumor was gastrointestinal stromal tumor (GIST), uncommitted type. The uncommitted type is regarded as malignant or potentially malignant, and rarely arises from the esophagus. It is necessary to consider this disease in the differential diagnosis of mediastinum tumor.

View full abstract