We examined metastases to the lymph nodes dissected by a standard (ND2a) orgreater degree (ND2b, 3α, 3γ) of lymphadenectomy in 45 patients with small peripheral lung adenocarcinoma less than 2.0 cm in diameter. We also examined micrometastases to these lymph nodes diagnosed to be pathological NO.Lymph node metastasis was identified in 13 of 45 (28.8%) patients, andmicrometastasis to the lymph nodes was found in 4 of these patients. Thenodal involvement was classified as N1 disease in 3 cases, N2 in 7, andN3 in 3. Skip metastasis was revealed in 38.4% of the patients with lymph node metastasis. Furthermore, more than or over half of the patients with lymph node metastasis were underestimated as clinical NO, preoperatively. There was no nodal involvement diagnosed to be type A and Bin Noguchi's classification. In conclusion, a standard or greater degree of systematic lymphadenectomy is required for complete resection of nodal involvement in small peripheral lung adenocarcinomas less than 2.0 cm in diameter except for cases with type A and B of Noguchi's classification.

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We retrospectively reviewed the video-assisted thoracic surgery (VATS) approach for mediastinal tumor in our institution. Forty-one patients (16 males and 25 females aged 18 to 74 years) underwent VATS for resection of mediastinal tumors from 1992 to 2001. These cases included 6 thymomas, 6 thymic cysts, 12 neurogenic tumors, 7 bronchogenic cysts, 2 pericardial cysts, 2 teratomas, and 6 others. Seventeen tumors were located in the anterior, 8 in the middle, 13 in the posterior, and 3 in the superior mediastinum. The average tumor diameter was 4.6cm. In 20 patients, the resection was completed thoracoscopically; in 16, a small incision was performed for a minithoracotomy to assist the thoracoscopic procedure, andincisional biopsies were performed in 2. Conversion to thoracotomy was required in 3 cases. The mean number of surgical access ports was 3.1, andthe average operating time was 176±76 minutes. Intraoperative bleeding (114±214g), chest tube insertion period (1.2±0.8days), and postoperative hospital stay (8.0±4.1days) were significantly lower than in cases resected by median-sternotomy. Although post-operative complications occurred in 3 cases (7.3%), there was no post-operative death within 30 days. We concluded that VATS for mediastinal tumors is a less invasive and safer approach, and it is possible to resect mediastinal tumors in any location by VATS. However, we should limit the indication of this procedureto malignant tumors including invasive thymoma.

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We obtained satisfactory results in a 71-year-old woman using the transcervical, paratracheal approach, which is a minimally invasive method. The patient had an abnormal shadow on a chest roentogenogram in May 2000. The shadow was checked with chest roentgenograms and computed tomograms (CT) every 3 months. The patient sought surgical treatment in September 2001, because of slight enlargement of the abnormal shadow. A chest roentogenogram revealed a tumor in the left upper thoracic space. Thoracic CT revealed a round homogenous mass, 2.5×2.0 cm in size, in contact with the first and second left thoracic vertebrae. The tumor was diagnosed on imaging as a neurogenic tumor, and the patient underwent surgery in October 2001. Under general anesthesia in the supine position, a 7-cm left cervical incision was made. The platysma and left-sided anterior cervical muscles were cut, and the sternocleidomastoid muscle was spared. This muscle and the left carotid artery were retracted to expose the left pleural cupula region. The tumor arising from the sympathetic trunk was identified. The junction between the tumor and sympathetic trunk could not be freed. Therefore, the tumor was removed with the sympathetic trunk. The histological diagnosis of the tumor was schwannoma. The patient was discharged 5 days later, and the blepharoptosis disappeared 6 months after surgery.

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In recent years, with improvement in computed tomography (CT), the opportunity to find small ground-glass opacities has increased. We experienced three cases of synchronous bilateral multiple primary lung cancer in early stage. Chest X-ray revealed no abnormal shadow in any case. Chest CT revealed tumors with a diameter of 1 cm or less, and the clinical stage was stage IA in each. The standard medical treatment of synchronous bilateral multiple primary lung cancer has not been established. It is reported that there is no lymph node metastasis in the case whose tumor diameter is 1 cm or less in type A or type B of Noguchi's classification, and in order to preserve respiratory function, the limited operations (wide wedge resection, segmental resection) were performed. The tumors were diagnosed as well differentiated adenocarcinoma (bronchiolo-alveolar carcinoma) histologically in those three cases. In two of the three cases, atypical adenomatous hyperplasia (AAH) was also seen. Recurrence has not been seen for 20-27 months in each. The limited operation is considered to be an appropriate treatment for synchronous bilateral multiple primary lung cancers in early stage.

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A 24-year-old female was admitted to our hospital with recurrent fever and chest pain. Chest radiography and CT demonstrated a cystic lesion with septa and fluid collection in the left lower lobe. Neither aberrant artery nor fistula to the esophagus was found on either aortography or esophagography. Partial resection of lower lobe was performed with video-assisted thoracic surgery (VATS). The cystic lesion was histologically diagnosed as a multilocular cyst because no bronchial cartilage was included in the wall of cyst and there was no aberrant artery found to the lesion. However, the wall of cyst was lined by pseudostratified ciliated epithelium. We concluded that this case was a congenital bronchial cyst based on the clinical findings.

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We have recently encountered a very rare case of delayed diaphragmatic hernia presenting with intestinal strangulation following thoracic surgery. A 61-year-old female began to experience cough and back pain fifteen months after resection of the left lower pulmonary lobe due to aspergillosis. Thereafter the symptom became aggravated over time. During the previous operative procedure, wide dissection between the pulmonary lobe and diaphragm was performed because of severe adhesion. Subsequently she was admitted to our hospital on October 5, 2001 complaining of severe stomach and back pain. Chest X-ray on admission showed an abnormal shadow in the left lower lung field. Successive chest computed tomography finally demonstrated that the gastrointestinal tract was escaped into the left thoracic cavity. Surgery was immediately performed under a diagnosis of strangulated diaphragmatic hernia. At surgery, the stomach and omentum had projected into the left thoracic cavity through a laceration about 3 cm in diameter in the diaphragm. We successfully repaired the laceration of the diaphragm directly using an interrupted suture. The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day and is doing well.
We should consider the possibility of delayed presentation of diaphragmatic hernia following thoracic surgery during which an invasive technique involving the diaphragm was undertaken.

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A 70-year-old man was admitted to our hospital for an abnormal shadow in the left superior mediastinal area on chest X-ray, after complaining of general fatigue. Computed tomography demonstrated a cystic tumor with calcifications in the left superior mediastinum. Blood pressure and serological examinations (catecholamine, noradrenaline, adrenaline) were elavated on the admission. Extirpation of the tumor was perfomed by thoracotomy. Post operatively, blood pressure and serological examinations improved to the normal ranges. Histological findings was suggested a mediastinal cavernous hemangioma. However, the final pathological diagnosis was functional paraganglioma of the mediastinum due to positive immuno-histological staining for S100 and NSE.

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We review the literature and discuss the relation between multiple chondromatous hamartomas of the lung and Carney's triad. A 20-years-old woman was admitted due to two abnormal chest shadows. She had undergone partial gastrectomy for gastric leiomyosarcoma about 9 years ago and adjuvant chemotherapy was performed. Abnormal chest shadows have been demonstrated since 16-years-old and then gradually increased. The chest CT scan showed two tumor shadows in left S³ and S⁹. Tumor resection was performed because metastatic lung tumor from gastric leiomyosarcoma was suspected preoperatively. The histological diagnosis was chondromatous hamartoma of the lung. We diagnosed her as Carney's triad.

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Pulmonary lymphangioleiomyomatosis (LAM) is an uncommon disease afflicting women of childbearing age. The disease is characterized histologically by proliferation of smooth muscle in the lung. LAM is generally diagnosed with chest computed tomography (CT) scan, video-assisted thoracoscopic surgery (VATS), autopsy, transbronchial lung biopsy (TBLB). The patient was a 36-year-old female with chest pain. She was admitted because of spontaneous pneumothorax diagnosed on X-ray. There was no characteristic lesion on chest CT, or diffuse cystic change detected after chest tube drainage. Air leakage persisted. We performed VATS because of persistent air leakage after chest drainage. VATS persisted that the presence of multiple small granular nodules and telangiectasia on the surface of the right upper lobe. Histologically, the biopsy specimen demonstrated emphysema-like lesions and smooth muscle proliferation in the lung. Smooth muscle actin (SMA) was positive. Human melanoma black (HMB)-45, estrogen receptor, and progesterone receptor were negative. We diagnosed this patient as being in the early stage of LAM. We conclude that VATS is useful for diagnosing the early stage of LAM and lung biopsy with VATS is necessary for pneumothorax in women of childbearing age.

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We report three surgical cases of desmoid tumor of the chest wall. Case 1: A 47-year-old man underwent chest wall resection for desmoid tumor of the left lateral chest wall. After 12 months, he developed local recurrence, and underwent wide resection. At 10 years after the initial surgery he is doing well. Case 2: An 18-year-old woman underwent tumor resection for desmoid tumor in the left apex of the chest wall. Postoperative radiotherapy of 60 Gy was given because the surgical margin was positive. She has remained free of recurrence for 30 months postoperatively. Case 3: A 49-year-old woman underwent tumor resection of the right anterior chest wall. She was administered no adjuvant therapy. She is doing well without recurrence at 12 months after the surgery. Surgical treatment of primary desmoid tumor of the chest wall requires wide local resection. In cases of recurrence or inadequate resection, multimodality therapies should be considered.

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A 57-year-old man presented with thyroid tumor. Chest computed tomography (CT) demonstrated a small circular lesion in the right S⁶. CT-guided needle biopsy was performed, and histopathological examination suggested neuroendocrine cell tumor. Under a provisional diagnosis of lung cancer, concomitant lobectomy and thyroidectomy were planned. However, preoperative CT revealed the right S⁶ mass shadow changing to a band-like shape. As the lesion changed shape, CT-guided point marking was performed on the day before surgery. Thoracoscopic partial resection of right S⁶ was performed concomitant with left hemithyroidectomy. Pathological examination of the surgical specimen demonstrated pulmonary cryptococcosis. After surgery, the patient was followed without treatment and experienced no complications due to pulmonary cryptococcosis.

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We herein reported a case of incomplete cervical tracheal disruption due to blunt trauma. The patient was a 55-year-old male who fell from a cliff in a bulldozer and crashed against the bottom. On admission, severe subcutaneous and mediastinal emphysema was noted in addition to multiple injuries in the head, lumbar spine, shoulder, and chest. Incomplete disruption of the cervical trachea was suspected on bronchoscopic examination and computed tomography of the neck. Urgent surgery was performed on the day following the accident. The cervical trachea was nearly transected between the cricoid cartilage and the first tracheal ring with the remaining small parts of anterior and posterior wall intact. The cervical trachea was anastomosed directly in an end-to-end fashion. Although laryngeal edema was observed for two weeks after surgery, the patient recovered completely without anastomotic stenosis.
We analyzed 28 cases of cervical tracheal disruption from blunt trauma reported in the Japanese literature. Our analysis revealed that prompt airway control and immediate repair were essential to obtain good results.

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We report a case of pulmonary infarction in a 44-year-old woman who was referred for a mass lesion in the periphery of the left upper lobe. Bronchofiberscopy and percutaneous needle biopsy were performed, but they did not permit a definite diagnosis. The indication for surgery was suspicion of malignancy. We inserted a Greenfield vena cava filter for the prevention of pulmonary embolism. Following this management, a left upper lobectomy was performed. After the operation the clinical course was uneventful. Because pulmonary embolism is an often lethal complication after operation, it is most important to prevent it in the perioperative management for high risk patients.

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Two nontuberculous acute empyema cases with a thick pleural peel were successfully treated by thoracoscopic surgery. The patients were 59 and 52 year old males, for whom the surgery was performed on the 38th and 17th day from the onset of empyema symptoms respectively. Thickened purulent thoracic wall was suspected before surgery in both cases. Because of the thick peel, sufficient lung decortication was considered difficult to accomplish by direct thoracoscope insertion into the purulent thoracic cavity. Therefore the thoracoscope was inserted into the layers outside the purulent cavity, namely into the gap between the purulent thoracic wall and visceral pleura, under thoracoscopic view, to break adhesions between the purulent wall and visceral pleura (outer approach to purulent thoracic cavity). After the entire purulent thoracic wall was checked from the outside of the purulent thoracic cavity, the thickened peel was safely removed. Even for acute thoracic empyema with a thickened peel, thoracoscopic surgery can be successfully performed by this approach as long as visceral pleura can be detached from the adjoining purulent wall.

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A 75-year-old man was referred to our hospital for further investigation and treatment of a cystic lung shadow noted on the chest X-ray. The chest CT scan showed a large cystic lesion with niveau in the right lower lobe. Transbronchial lung biopsy of the B¹⁰ revealed adenocarcinoma. Right lower lobectomy of the lung with hilar and mediastinal lymphatic dissection was performed. Macroscopically, the cystic lesion was 8.0×6.5×6.0cm in size. The cyst wall was composed of both an irregularly thickened part and a thin part without necrotic lesion. The cancer mainly localized in the thickened part. Papillary adenocarcinoma invaded the parenchyma of the lung and bronchioloalveolar carcinoma grew along the alveolar walls. On the other hand, the thin part of the cyst wall was composed of fibrous tissue and was lined by normal ciliated columnar epithelium, atypical bronchial epithelium, and adenocarcinoma in situ. The atypical bronchial epithelium and adenocarcinoma in situ were scattered in the normal ciliated columnar epithelium lining the wall, suggesting bronchogenic cyst epithelial cells developed into carcinoma. So we considered that the pathogenesis of the cystic formation in this case was not caused by central necrosis, liquefaction and drainage, but infiltration of cancer cells to the pre-existing bronchogenic cyst. This evidence suggests that epithelial cells of bronchogenic cysts have the potential for malignant changes. It may be prudent to recommend complete resecsion of any bronchogenic cyst.

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