Objective: To confirm the feasibility of video-assisted thoracic surgery (VATS) for pathological stage IA (pIA) primary non-small cell lung cancer (NSCLC), we compared VATS and conventional thoracotomy (CT). Patients and Methods: From January 1986 through December 2004, 338 patients with pIA primary NSCLC underwent lobectomy or segmentectomy. Of these, 123 patients underwent VATS lobectomy and 215 patients underwent conventional thoracotomy. We evaluated the invasiveness of surgery by operating time, intraoperative blood loss, length of postoperative hospital stay, WBC and CRP levels in serum measured on postoperative day 3 and 7, and loss of vital capacity, safety by postoperative complication, and curability by number of dissected lymph nodes, 5-year survival rate and site of recurrence. Results: Intraoperative blood loss, length of postoperative hospital stay, WBC and CRP levels and loss of vital capacity were significantly less in VATS than in CT. But there were no significant differences in the number of dissected lymph nodes, the 5-year survival rate and the local recurrence rate. Conclusion: VATS for pIA NSCLC is less invasive and more safe than CT, and has the same curability as CT. VATS is a feasible technique for patients with pIA NSCLC.

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We investigated the bronchial stump closure techniques following lobectomy or segmentectomy for primary lung cancer. Previously, the autosuture devices (stapler) were used in our institution. From 1999, we applied the simple ligation method. We studied the usefulness of the simple ligation method compared with the autosuture method. In the "Autosuture device group" (519 cases), postoperative bronchopleural fistulas occurred in 5 cases (1.0%). In the other hand, there was no complication in the "Simple ligation group" (253 cases). In the cases of bronchopleural fistulas in the "Autosuture device group", it was suggested endoscopically that the complication was caused by the mismatch between the stapler and the bronchus. The merits of the simple ligation method are 1) it is a safe and simple procedure at VATS surgery, 2) it is cost effective, 3) equivalent pressure is applied around the bronchial stump, so there is less deformity, 4) since sutures are not exposed in the bronchial stump cavity, infections are less likely to occur. The results of the present study showed that the simple ligation method for lobectomy or segmentectomy is available.

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Eight cases of thymic cancer treated in our hospital were reviewed clinically. There were seven men and one woman, who ranged in age from 30 to 80 years (mean age, 64.5 years). The histological subtypes of thymic cancer were squamous cell carcinoma in five, combined carcinoma in two, neuroendocrine carcinoma in one. Two cases were in stageII, three cases were in stageIII, two cases were in stageIVa, one case was in stageIVb. Two cases with invasive tumor were treated by induction chemotherapy. In surgery, four cases were completely resected and two cases received exploratory thoracotomy. We have three recurrent cases in four completely resected, the location of which were in local lesion, pleural cavity, lung and chest wall which was a case of implantation by needle aspiration biopsy. 5-year survival was achieved in two cases with stageII, however one of them had metastasis and died as a result of their tumors 72 months after surgery. Another case is alive without recurrence for 10 years. It is important that combined therapy such as chemoradiotherapy and complete resection is established, for especially stageIII.

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Malignant pleural mesothelioma is a rare disease, and the standard method of treatment remains controversial. We examined 7 patients who had received extrapleural pneumonectomy between 1999 and 2003 in our hospital. Four to 6 cycles of chemotherapy (CDDP+GEM) were administered to all patients after surgery, and radiotherapy was also given to 6 of the patients. Recurrence was detected in 5 patients, and the average interval between surgery and recurrence was 535 days. Sites of recurrence were as follows: local recurrence in the ipsilateral chest wall in 3 patients, malignant ascites in one patient, and supraclavicular lymph node metastasis with malignant ascites in one patient. Chest wall tumors in the 3 patients were all resected again. Two patients have died, 2 patients are alive with tumors and 3 patients are healthy without tumors. The average postoperative survival is 694 days (118-1, 640) to date. We think this multimodality therapy including extrapleural pneumonectomy followed by chemotherapy and radiotherapy may be a useful method of treating malignant pleural mesothelioma.

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The patient was a 38-year-old woman. Chest X-ray showed an abnormal shadow in the left middle lung field and chest CT scan showed a 76×26 mm chest wall tumor surrounding the left 7^<th> rib in July 2003. In August 2003, biopsy under fluoroscopy was done but it did not define the diagnosis. On October 23, 2003, chest wall tumor resection was done. In the operation, 6 pleural lesions (each about 5 mm) were shown macroscopically. The patient was diagnosed with plasmacytoma of the chest wall with pleural dissemination on the pathological examination. After the operation, chemotherapy was performed. According to the classification of plasmacytoma, this case is similar to solitary plasmacytoma. This was a rare case of plasmacytoma of the chest wall and almost entirely local disease with pleural dissemination.

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A 69-year-old male with an abnormal shadow on chest X-ray film discovered in a mass examination was admitted to our hospital for further examination. The computer tomography and magnetic resonance imaging showed a unilocular and nonenhancing cystic mass with water fluid density located at the middle mediastinum and pressing forward to the superior vena cava. A video-assisted tumor resection was performed under a diagnosis of mediastinal cyst. The cyst contained serous fluid and a small calcified stone. Pathological examination revealed a pericardial cyst with thin connective tissues with dystrophic change and no epithelium inside the wall. Although there have been some reports of calcified walls of mediastinal cysts or thoracolithiasis, a case of pericardial cyst with calcified stone has not been reported. We consider the cause of the stone to be the deposition of destrophic substances such as the hyalinized epithelium of the wall.

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Here we report two resected cases of pulmonary arteriovenous fistula. Case 1: A 57-year-old man was admitted to a hospital because of cerebral infarction. Chest X-ray revealed an abnormal shadow in the left lung field. The patient was symptomatic and cyanosis, hypoxemia and polycythemia were recognized. Case 2: A 33-year-old, healthy man was referred to our hospital because of an abnormal shadow with enlarged pulmonary vessels in the left lung field incidentally detected in a medical checkup. In both cases, 3D-CT showed an excellent image of pulmonary arteriovenous fistula, a feeding artery and a drainage vein. Perfusion scintigraphy revealed extrapulmonary activity due to the right-to-left shunt. The postoperative course of the two patients was uneventful. When surgical intervention is considered for pulmonary arteriovenous fistula, anatomical assessment by 3D-CT and functional evaluation by pulmonary perfusion scintigraphy are non-invasive, useful modalities for preoperative study.

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Background: Flexible and rigid bronchoscope have often been used for retrieval of tracheobronchial foreign bodies. We report the failure to retrieve a foreign body in the left bronchus by flexible bronchoscope, followed by safe retrieval of the foreign body incarcerated in the opposite bronchus by rigid bronchoscope. Case: A 43-year-old woman aspirated a metal crown into the airway. Three days later, she developed a fit of coughing, and underwent a medical examination at another hospital. A metal crown was recognized in the left bronchus on chest radiograph. Under local anesthesia, the foreign body could not be retrieved. A few days later, she was intubated and retrieval of the crown by flexible bronchoscope with a wire basket was attempted under sedation. When she coughed, the metal crown became incarcerated in the right bronchus. She was refferd to our hospital, and the metal crown was safely retrieved by rigid bronchoscope under general anesthesia. Conclusion: It is important to select a flexible or rigid bronchoscope according to the site, nature and condition of the foreign bodies. A rigid bronchoscope is very useful for large and metallic incarcerated foreign bodies such as a metal crown.

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In December 2003, a 45-year-old woman, had her first episode of a right-sided spontaneous pneumothorax and was treated with pleural puncture. During video-assisted thoracic surgery after a second recurrence in April 2004, we found multiple perforations in the diaphragm. All lesions in the diaphragm were resected with endostaplers. We widely covered the diaphragm with absorbable mesh sheets (polyglactin mesh). Histologic examination confirmed an endometrial implant and hormonal therapy was started. After hormonal therapy was discontinued, right pneumothorax relapsed. Traditional therapy involving hormonal treatment or surgical treatment seems to be associated with a high rate of recurrence. We considered that the coverage of the diaphragmatic surface with polyglactin mesh contributed to the prevention of recurrence. But pneumothorax occurred again. We report this case to promote re-evaluation of surgical therapy for catamenial pneumothorax.

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We report a difficult case who had repeated tracheal stenosis due to post-intubation tracheal stenosis. The patient was a 61-year-old woman with dyspnea due to severe heart failure. The patient was placed on artificial ventilation with tracheal intubation. A tracheal tube was removed 3 weeks later. Dyspnea occurred 3 weeks after tube retraction and the patient was again treated with endotracheal intubation, and referred to our hospital. The trachea was obliterated and torn 3 cm from 2 cm below the tracheostomied region. Additionally, there was subglottic stenosis. Following induction of a T-tube, a 3 cm sleeve resection of the trachea (4 tracheal cartilage rings) was performed with end-to-end suture using 17 stitches with a 2-0 absorbable monofilament. Pathological findings of the surgical specimen showed degeneration and necrosis of the tracheal cartilage with excessive growth of granulation tissues. A tracheostomy tube was intubated from the tracheostomied region postoperatively and removed on the 75th postoperative day. However, the patient complained of wheezing and dyspnea 3 months later. An emergent tracheostomy was necessary and regrowth of granulation tissues was found at the previously tracheostomied region. A self-expanding metallic stent was placed in the trachea, and a silicon tube was placed in the tracheostomied region. Although subglottic stenosis and mild stenosis of the tracheostomied region were observed postoperatively, stenosis was alleviated with various treatments. Currently, there has been no adverse effect on daily life.

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A 71-year-old woman was identified with a solitary nodule in the left lung during a mass-survey and referred to our hospital. A chest roentgenogram and CT scan showed circular nodule at left S^<1+2>. The nodule gradually increased and was suspected to be lung cancer. Left upper lobectomy was performed for this lesion. Postoperative pathological study revealed so-called pulmonary carcinosarcoma. Three months after pulmonary resection, moderate anemia was revealed. Endoscopic findings showed hemorrhagic gastric tumor and its biopsy specimen was diagnosed as the same as the lung lesion. Total gastrectomy was performed. She has been well without recurrence for five years after pulmonary resection.

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A 61-year-old woman was admitted to our hospital for surgical treatment of a right upper lobe adenocarcinoma. The patient had a right aortic arch with an aberrant left subclavian artery and a posterior left aortic innominate vein. Right upper lobectomy with mediastinal lymphadenectomy was performed via right thoracotomy. Although paratracheal and tracheobronchial lymph nodes were easily resected, there was difficulty resecting the superior mediastinal and pretracheal lymph nodes because of the aortic arch, aortic diverticulum and posterior left aortic innominate vein compression. Preoperative MDCT and FDG-PET are useful in planning the operative approach and likelihood of success.

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A 67-year-old man previously underwent amputation of the 2-5th digits because of right leg gangrene. After infection occurred in the right heel, he developed fever and heart failure, and was admitted to our hospital. Echocardiography showed vegetation on the mitral valve. We diagnosed infective endocarditis (IE) associated with leg gangrene and performed mitral valve plasty. Chest-computed tomography showed scattered nodules with various degrees of cavitation. We diagnosed septic pulmonary emboli (SPE) associated with leg gangrene and performed right leg amptation. Postoprative antibiotic therapy was performed and SPE was completely cured.

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The patient, a 36-year-old man with a giant mass in the right posterior mediastinum, was admitted to our hospital. The mass extended from the sternoclavicular joint level to the diaphragmatic level. The preoperative diagnosis strongly suggested lipoma, but the possibility of highly differentiated liposarcoma could not be ruled out. Therefore, it was considered that resection was necessary for diagnosis and surgical treatment. The mass, measuring 8×5×20cm, had not infiltrated other organs. When observed by thoracoscopy through the first port, the tumor had a soft, yellow capsule. We considered it a benign lipoma and resected it completely. It was pathologically diagnosed as a lipoma. The postoperative course was favorable, and the patient did not develop any postoperative complications or signs of recurrence. There were reports of recurrence of mediastinal lipoma. Therefore, we considered it essential to completely resect the mediastinal lipoma in our patient. We succeeded in completely resecting the giant mediastinal tumor in our patient by thoracoscopy, which provided a good field of vision even in a narrow thoracic cavity and thus enabled less-invasive surgery. Video-assisted thoracic surgery seemed to be well indicated in our patient, who had a benign giant mediastinal tumor.

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A 71-year-old male was found to have an abnormal shadow at a mass survey roentogenogram. The tumor was diagnosed as pulmonary adenocarcinoma and right upper lobectomy was performed. On postoperative day 3, remarkable hyponatremia, low plasma osmolarity, high plasma ADH level and high urinary sodium excretion with disorientation were appeared. He was diagnosed as SIADH. His clinical symptoms were improved by fluid restriction and hypertonic saline infusion. In this case the direct cause of SIADH was not detected, but we speculated he had pathogenesis of SIADH potentially and postoperative intra-pleural inflammation and surgical stress after pulmonary resection influenced the appearance of SIADH.

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This case involved an 83-year-old man with empyema due to bronchopleural fistula from a lung abscess that developed during a previous bout of pulmonary tuberculosis. Since the patient also had diabetes mellitus, we considered that traditional treatment would impose a severe burden. Therefore, we treated the lung abscess with antibiotics and by washing out the empyemic cavity, until the cavity became sterile. Following this, thoracoscopy was used to perform decortication without fenestration. The patient's postoperative course was good, and he was discharged without a relapse of a empyema. We suggest that this procedure is a treatment option for a compromised host.

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A boy was diagnosed with juvenile myasthenia gravis (JMG) at 1.5 years old years old. Prescription of the predonisolone (PSL) was started at 4 years old. At 9 years old, his height and weight was under -2SD level, and was diagnosed with failure to thrive due to long-term prescription of PSL. At 13 years old, thymic hyperplasia was detected on chest computed tomography, and extended thymectomy (ET) was performed. After the surgery, the dosage of the PSL could be reduced and serum acetylcholine receptor (AChR) antibody went down gradually. Now, at 16.5 years old, AChR antibody is in normal range. In the Japanese guideline for treatment of myasthenia gravis, ET was recommended for patients over 12 years old. But the ET may be performed for more young patients with high AChR range and thymic hyperplasia to control JMG and prevent the failure to thrive due to long-term prescription of PSL.

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A 63-year-old male complained of hemosputum and chest-computed tomography showed a mass in the left lung. Fiberoptic-bronchoscopy revealed a tumor obstructing the left lower bronchus and a tumor over the right upper bronchus and the second carina. Both tumors were squamous cell carcinomas. A left lower sleeve lobectomy was performed without postoperative complications. One month after the initial operation, a right upper sleeve lobectomy was performed. Both tumors were pathological T2N0M0 and stage-IB. The patient is disease-free and well 3 years after the operation. Bilateral sleeve lobectomy is a treatment option for synchronous multiple lung cancer.

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A 52-year-old woman was admitted to our hospital with hemoptysis. Bronchofiber scope showed no abnormal findings in the bronchial tree except for obstruction of left B^<9+10> with coagula. Chest computed tomogram and magnetic resonance imaging films revealed an abnormal vessel branching from the descending thoracic aorta. Pulmonary arteriography showed the absence of blood flow to the basal segment and aortography verified the abnormal vessel from the descending thoracic aorta supplying the basal segment. The diagnosis of anomalous systemic arterial supply to the basal segment of the left lung was made on the basis of these findings, and then operation was performed. At surgical exploration, the borderline of a normal area and an abnormal area was not able to be determined due to telangiectases in the whole surface of the left lower lobe. So the abnormal vessel was ligated and cut, and then left lower lobectomy was performed. The pathological findings of the resected specimen showed pulmonary hypertension in the basal segment, and degeneration changes in the S^6. Although we performed left lower lobectomy under open thoracotomy on the basis of safety-first, segmentectomy of the basal segment was possible by the pathological findings.

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We herein reported two cases of non-small cell lung cancer with negative fluorine- 18 fluorodeoxyglucose positron emission tomography (FDG-PET) scanning. FDG-PET is very sensitive to the detection of lung cancer which appeared as a solid nodule on chest computed tomography (CT), even though pure bronchioloalveolar carcinomas which show a ground glass opacity on chest CT often show negative FDG-PET scanning. In our cases, well-defined solid nodular shadows on chest CT with negative FDG-PET scanning were diagnosed as adenocarcinoma by open lung biopsy. Mucin or low density of malignant cells can be a cause of false-negative FDG-PET scanning.

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