We examined the clinicopathological findings in 47 cases of indeterminate pulmonary nodules (mean diameter 18.1mm, range 5 to 45 mm) in which thoracoscopic or open excisional biopsy was performed. Tumors were mostly detected by abnormal shadows on roentgenograms at the occasions of physical examinations or regular checkups for other targeted diseases. As indications for surgery included suspected malignancy of the tumor based on shadow patterns in 33 cases, inability of ruling out malignancy in 5 cases, and growth of tumor in 9 cases. We reached the final diagnoses comprising 33 primary lung cancers, 4 metastatic lung tumors, 5 tuberculomas, 2 organised pneumonias and 1 intrapulmonary lymph node, granuloma and hamartoma, respectively. Out of 33 cases with primary lung cancer, 25 cases belonged to stagelA, with 4 cases in stagelB and 4 cases in above stagellA being also included. The rate of malignancy in nodules measuring 10mm or less was 60%. Accordingly, it is conceivable that positive lung biopsy under thoracoscopic surgery seems useful to detect lung cancer at early stages, against the lesions with findings suggestive of malignancy even though they are small tumors in sizes.

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Background. Although lobectomy by video-assisted thoracic surgery (VATS lobectomy) is a well-established and wide-spread therapeutic method for treating small peripheral lung cancer, few reports of ‘Complete’ VATS lobectomy with all work performed under thoracoscopy are available. Methods. We defined ‘Complete’ VATS lobectomy as the operation, in which all operative work of pulmonary lobectomy and nodal dissection was performed under thoracoscopy with no rib-spreader used. Twenty patients underwent this operation as the treatment for lung cancer in clinical stage I. Their operative data and postoperative conditions were reviewed. Results. Although the operation time of ‘Complete’ VATS lobectomy was longer than the conventional VATS, the other results were almost equivalent, partially being superior (average operation time: 260 minutes; blood loss: 95ml; No.of dissected lymph nodes: 32; chest drainage: 4.5days; hospitalization: 16day). All patients were discharged with no major complication. Conclusions. ‘Complete’ VATS lobectomy is a safe, definite and technically feasible operation for the patients with clinical stage I lung cancer, in which the superior results will be expected with increasing experiences and proficient techniques involved.

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Purpose: To investigate the most useful approach for fibrin adhesives in lung surgery.
Methods: In 233 patients who underwent lung excision and experienced air leakage, confirmed by a perioperative sealing test, the usefulness of four different pulmonary fistula closing approaches using fibrin adhesives was examined. Subjects were classified into the following four groups: Group A, consisting of 127 patients treated by frictional spraying; Group B, consisting of 23 patients treated with TachoComb^®; Group C, consisting of 43 patients treated by spraying alone; and Group D, consisting of 40 cases treated by the Morikawa 2 method. The following results were obtained:
Results: Compared with Groups C (spraying) and D (the Morikawa 2 method), Groups A (frictional spraying) and B (TachoComb^®) received higher evaluation scores, showing significantly faster postoperative disappearance of air leakage. The air leakage closing rate after operation was significantly higher at all of the time frames examined.
Conclusions: Both the frictional spraying and TachoComb^® approaches can be easily applied to thoracoscopic operations and now seem to be the most useful approaches for treating pulmonary fistula. Further improvements in closing techniques will make fibrin adhesives even more useful.

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A total of 20 patients underwent thoracotomy and those diagnosed with bronchopulmonary carcinoid were clinically examined. The 5-year survival was 86.6% for typical cases and 60% for atypical cases. All stage I typical cases survived without recurrence, regardless of the type of operation. All atypical cases underwent lobectomy with dissection of mediastinal nodes. All three stage I atypical cases survived without recurrence. One stage IIIA patient and One stage IIIB patient showed distant metastasis and first died 10 months and the second 61 months post-operatively. Our findings indicate a good potential for limited operations for patients with typical cartinoid despite of T2 size. They also make clear the need for effective multimodarity therapy for patients with stage III atypical cartinoids.

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Here we report a case of intralobar pulmonary sequestration resected by thoracoscopic surgery.
A 38-year-old woman was admitted to our hospital with an abnormal shadow in the right lower lung field on chest X-ray. Chest CT and angiography were done. The diagnosis is intralobar pulmonary sequestration in the right lower lobe with aberrant artery from right subphrenic artery, and with drainage vein into the right inferior pulmonary vein. An operation by thoracoscopic surgery was performed safely with 4-port method. Thoracoscopic surgery is a useful and safe procedure for intralobar pulmonary sequestration, under pre-operative detection and anatomical understanding of aberrant feeding artery and drainage vein.

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A 62-year-old woman suffered from prolonged bronchial fistula after resection of her right middle and lower lobes. She had received induction chemo-radiotherapy before the operation because of advanced-stage lung cancer. A bronchial fistula developed 14 months after the operation, and she underwent a muscle plombage operation, but eighteen months after the second operation, the bronchial fistula recurred. Closure of the bronchial fistula was attempted under bronchoscopy several times, but the fistula could not be closed. Therefore, omentopexy assisted by thoracoscopy was performed, and after the third operation she is free of fistula symptoms and well with no evidence of recurrence. Thoracoscopy was useful even in treatment of bronchial fistula.

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A 44-year-old woman visited our hospital because of an abnormal shadow measuring 15×8mm in the right lower lung field on chest roentgenogram. Chest computed tomographic scan showed a mass measuring 10×10 mm with irregular margin in the right S⁹ segment. TBLB revealed no histologically diagnostic findings. After 8 months of follow-up, slight increase in size of the mass was observed. Because the possibility of lung cancer could not be ruled out on chest CT scan, partial resection of the right lower lobe was performed for diagnostic purposes. Histological examination revealed sinusoid structures of various sizes. Immunohistochemically, cells lining the inner lumen were stained with anti-CD34 antibody. Considering these results, a diagnosis of cavernous hemangioma was obtained. Cavernous hemangioma of the lung is rare, and is herein reported.

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A 61-year-old female was admitted to our hospital because of hemoptysis. Esophagogram revealed an esophago-bronchial fistula with diverticulum. Bronchofiberscopy showed stenosis of the bronchialis intermedius. During the operation, the fistula communicated with the bronchialis intermedius behind the hilum. The neck of the diverticulum was divided with endostapling and cutting device. And we performed lower bilolectomy because of lower lobe atelectasis and recurrent pneumonia. In Japan, 41 adult cases of acquired esophago-bronchial fistula with esophageal diverticulum were reported in the literature. We reviewed the literature and discussed the clinical figures.

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The patient was a 63-year-old man who had been on hemodialysis for the past 10 years. The CT scans on admission showed atelectasis of the left lung due to complete obstruction of the left main bronchus with cancer. Induction therapy combined with thoracic irradiation (20Gy) and bronchial artery infusion treatment using CDDP was performed. Hemodialysis was started simultaneously with the infusion of CDDP. Hemodialysis was repeated successively for the first two days after BAI and then returned to a regular hemodialysis. Because the tumor was remarkably reduced in size after treatment, pneumonectomy was performed successfully. Histologically, no viable cells were detected in the resected specimen and the academic effect was judged to be Ef.3. The patient is alive and well 12 months after the operation. Combination chemotherapy and radiotherapy may be a better treatment for lung cancer even in patients with chronic renal failure.

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A 45-year-old man was admitted to our hospital for further examination of a hemispheric tumor on the left chest wall on chest X-ray. The tumor could be identified from at least 1999 on chest X-ray, and has gradually enlarged as seen in annual examinations. Chest CT scan showed a smooth-surfaced tumor on the chest wall, enhanced heterohomogeneously. We suspected it was a malignant tumor from the chest wall or a mesothelioma, and resected it by video-assisted-thoracoscopy. The tumor took the shape of two adhered balls, one against the other, covered with parietal pleura. We resected it from the layer of the intra-intercostal muscle with a distance of 20-30 mm from the edge. It was immunoreactive with CD34 and bcl-2. A diagnosis of solitary fibrous tumor was made histopathologically. It showed a proliferation of spindle cells with connective tissue in the proximal part, and hypocellularity with spindle cells in a mixoid loose matrix in the distal part. We report this case because it was a rare case growing to an unusual shape observed for four-years with annual X-ray films.

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We report a 73-year-old man with lymphoma of mucosa-assocated lymphoid tissue (MALT) and lung cancer in the same tumor of the lung. He was admitted to our hospital for three months with corticosteroid therapy due to bronchiolitis obliterans organizing pneumonia in right upper lobe in 1994. Chest x-ray showed a mass in the same site of the lung in December 1997. Because the tumor was getting bigger, partial resection of the right upper lobe was performed. The tumor was histologicaly diagnosed as lymphoma of mucosa-assocated lymphoid tissue (MALT). He had no additional therapy. A new mass was detected on chest x-ray film perfomed as a routine check in May 2001. The lesion was 2.5cm in diameter and was located in the margin of the previously partialy resected lesion. As the tumor was diagnosed as adenocarcinoma by transbronchoscopic lung biopsy, we performed right upper and middle lobectomy with lymph node dissection (ND2a). The lung tumor was histologicaly diagnosed as well-differentiated adenocarcinoma with relapse of lymphoma of mucosa-assocated lymphoid tissue (MALT). The cancer cells were positive for keratin and the cancerous lymphocytes were positive for CD20 (pan B).

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The patient was a 59-year-old male. He underwent inferior sleeve lobectomy and anastomotic covering with pedunculated pericardial fat pad in January 1999 for the treatment of primary squamous cell carcinoma in the lower lobe of the left lung. Computerized tomography (CT) scanning of the chest at one year and nine months after the surgery revealed a tumor shadow in the anterior mediastinum on the operated side, and later its size continued to increase. In December 2000, tumor biopsy was performed under CT, but no malignant finding was observed. In February 2001, he underwent another surgery via median sternotomy. There were no invasions to the adjacent organs, and the cyst and thymus gland were excised. A cyst measuring 2.0×2.0 cm in size was observed in the left inferior pole of the thymus. There were no invasions to the adjacent organs, and macroscopically it was a unilocular thymic cyst. Histopathological examination revealed that the cyst wall consisted of a monolayer of cuboidal epithelium in addition to squamous metaplasia associated with lymphocytic invasion and hyperplasia, aggregated histiocytes, and hyperplastic fibrous connective tissues with epithelial desquamation. As small cysts were observed in the adjacent thymic tissues, we have diagnosed this case as acquired multilocular thymic cysts following to the use of the pericardial fat pad coverage during the surgery of lung cancer or induced by the tracheal anastomosis covering with the fat pad. Herein, we report on this case.

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Migration of orthopedic fixation wires into the thoracic cavity is an uncommon complication. We report two cases of intra-thoracic migration of Kirschner wires used for the treatment of sternoclavicular joint dislocation or clavicular fracture. First case is 56-year-old male, a chest X-ray film taken at the admission for the treatment of the other disease revealed a metallic foreign body in the mediastinum. A chest CT scan localized the object in the anterior mediastinum adjacent to the aortic arch. A 35-mm-long Kirschner wire was removed with a video-assisted thoracoscopy. Thirty-four years previously, the patient had undergone the fixation of the left sternoclavicular joint dislocation. Second case is 71-year-old female, the patient had undergone the fixation of the right clavicular fracture with two Kirschner wires. Three months later, the intra-thoracic migration of fixation wires was found by the X-ray examination for the fever. Right thoracotomy was performed in this patient, because one wire penetrated into the lung and the other wire tip migrated to the soft tissue between the right subclavian artery and the brachio-cephalic vein. A favorable outcome was observed in both patients. Prompt diagnosis and surgical removal is necessary to prevent serious complications such as perforation of the vital organs.

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A 70-year-old woman was referred to our hospital for the right hilar abnormal shadow on chest X-ray. A chest CT scan showed a 45 mm diameter cystic mass adjacent to the right atrium. We suspected a neurogenic tumor originating from the right phrenic nerve, but wouldn't rule out a thymic cyst or a pericardial cyst. Finally, without a definitive diagnosis, we performed VATS. By macroscopic findings and frozen section examination, we diagnosed it as the neurogenic tumor originating from the rt phrenic nerve and resected the tumor preserving as much neuron fiber as possible. Schwannoma of the phrenic nerve is a rare lesion. Including this report, only 12 cases have been reported in Japan. We present a case and a review of the literture.

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A 63-year-old woman, with an abnormal shadow on chest images in June 2002 was referred to our department. Chest CT and MRI showed a giant mass on S¹⁰ of the right lung and a mass between the upper and middle lobes of the right lung. Transcutaneous biopsy showed that the tumor consisted of cartilage.
Video-assisted surgery was performed for diagnosis. The giant tumor was located on S¹⁰ and many nodules were located on both the visceral and parietal pleura. We resected the giant tumor and one of the pleural nodules. Intraoperative histological diagnosis indicated chondromatous hamartoma. Multiple chondromatous hamartomas located on both visceral and parietal pleura are very rare.

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A 74-year-old male was admitted to our hospital because of an abnormal shadow on chest X-ray and CT, which had been detected by chance. A chest CT revealed a tumor shadow measuring around 1cm in diameter in the right upper lobe of the lung. Although the bronchofiberscopic study revealed no apparent malignancy, lung cancer was strongly suspected and resection was performed. First the right upper lobe of the lung was partially resected and the tumor was biopsied, revealing squamous cell carcinoma and adenocarcinoma with sarcomatous components consisting of chondrosarcoma and osteosarcoma. Then right upper lobectomy and lymph node dissection were performed. Histologically, this tumor was a true carcinosarcoma consisting of poorly-differentiated squamous cell carcinoma, adenocarcinoma, well-differentiated chondrosarcoma and osteosarcoma. The immunohistochemical staining confirmed this diagnosis. No lymph node metastasis was found, and the pathological staging was pT1N0M0. Postoperative therapy was considered unnecessary. Now, 23 months postoperatively, he is alive with no recurrence.
A true pulmonary carcinosarcoma is quite rare, and because it usually is found as an advanced cancer, the prognosis is poor in general. In this case, we can expect a good life expectancy, in view of the limited size and no metastasis, which we found worth reporting.

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