Non-small cell lung cancer invading the chest wall neighboring the vertebral body is difficult to completely resect because of its anatomical character. We evaluated the results of induction chemo-radiotherapy aiming to achieve the complete resection of cancer tissue. This regimen was carried out in 6 men with a median age of 57 years old. The clinical stage was IIB in 3 cases and IIIA in 3 cases, and the pathological diagnosis was adenocarcinoma in 3 cases and squamous cell carcinoma in 3 cases. Chemotherapy varied, with CDDP+TXT in 3 cases and CDDP+NVR in 3 cases, accompanied by radiotherapy of 40 Gy in 5 cases and 60 Gy in 1 case. Induction treatment was completely carried out in all cases, resulting in stable disease in 4 cases and partial response in 2 cases, followed by complete resection. The pathological efficacy was Ef0 in 1 case, Ef1 in 1 case, Ef2 in 3 cases, and Ef3 in 1 case. Recurrence occurred in 5 cases: 2 marginal recurrences (limited to cases of Ef0 or Ef1), 1 local recurrence (lung), and 2 distant metastases. The median survival time was 19 months and the 3-year survival rate was 22%, with a median follow-up period of 30 months. There is no statistical supporting, but this regimen may effectively reduce the risk of marginal recurrence in cases showing a good pathological response, while extended resection should be an option in cases exhibiting a poor pathological response.

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We retrospectively reviewed 12 patients, 10 males and 2 females (mean age: 66, range: 46 to 86 years) undergoing video-assisted thoracoscopic surgery for acute empyema in Matsue Red Cross Hospital from April 2002 through June 2006. The mean durations of post-operative drainage and post-operative hospital stay were 6.7 days (range: 3 to 17 days) and 20.5 days (range: 11 to 33 days), respectively. Post-operative courses were uneventful in all patients and no recurrence of empyema was observed. Video-assisted thoracoscopy is a safe and effective device to perform the operation for acute empyema.

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Surgery for treating atrial fibrillation by the Maze procedure has been successful. However, the Maze procedure requires a median sternotomy and a cardiopulmonary bypass; therefore, the procedure is complex and invasive. On the other hand, the thoracoscopic mini Maze procedure has become widespread throughout Western countries. This study aimed to evaluate the feasibility, safety, and effectiveness of the thoracoscopic mini Maze procedure. Seventeen patients with lone atrial fibrillation were evaluated. Under general anesthesia using a double lumen tube, two ports and a small thoracotomy were created, and pulmonary vein isolation and ganglion plexi ablation were achieved bilaterally by a radiofrequency device. Furthermore, the left atrium appendage was removed. The mean operation time was 311 minutes, and mean duration of hospitalization was 5.5 days. No deaths were reported. Postoperative complications were seen in only 2 patients (11.7%). The recurrence of atrial fibrillation has not been observed up to now. The thoracoscopic mini Maze procedure is considered minimally invasive, safe, and moreover, conclusive for treating atrial fibrillation.

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We conducted weekly administration of paclitaxel in the outpatient clinic as an adjuvant chemotherapy for non-small cell lung cancer. From 2001 to 2006, 19 patients were treated. A paclitaxel dose of 80mg/m² was administrated every week 12 times. Only 4 patients completed this protocol. The total administrated dose was 843±115mg/m² in 9 patients who completed 12 weeks of administration, and 390±213mg/m² in 10 patients who did not fully complete this protocol. Five patients died of cancer during 6-69 months of follow-up (average: 29 months), yielding a 5-year survival rate of 65.5%. Adjuvant chemotherapy with paclitaxel appears to have a potential to improve the prognosis of non-small cell lung cancer when administrated following a protocol with a good compliance rate.

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A clinical pathway (CP) for pulmonary resection is now used for perioperative management in many institutions. Although one of the purposes of using CP is shortening the length of hospitalization, the decision of discharge has been mainly entrusted to the discretion of each surgeon in our institution. This study focused on 19 patients who required re-hospitalization within 30 days after discharge and reviewed clinical features. Re-hospitalization in 70% was due to inflammation-related causes, including fever, pneumonia, bronchopleural fistula, empyema, and acute exacerbation of interstitial pneumonia. These re-hospitalizations occurred regardless of the length of postoperative hospitalization. The white blood cell count and serum C-reactive protein (CRP) showed significantly higher values in the re-hospitalization group compared with 95 control cases that matched several clinical factors. We should be careful when performing discharge when the white blood cell count and CRP show high values.

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We report two cases who underwent extrapleural pneumonectomy for malignant mesothelioma after induction chemotherapy with GEM+CDDP. Case 1 was a 50-year-old man. Case 2 was a 52-year-old man. Both cases were epithelial type, and judged to be c-II from the IMIG classification. Induction chemotherapy with GEM+CDDP was performed, and case 1 was PR, and case 2 was SD. Continuously, extrapleural pneumonectomy was performed with the two cases undergoing complete resection. There were no postoperative complications, and no recurrence. So, a long-term satisfactory prognosis is expected for both patients. Because there have been some cases where chemotherapy with GEM+CDDP is remarkably successful, and there have been no reported postoperative complications after induction chemotherapy, it was thought that a promising result could be expected in adding surgical treatment to malignant mesothelioma after induction chemotherapy by GEM+CDDP.

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Anthracotic and anthracosillicotic spindle cell proliferation (AASCP) is a rare reactive proliferative lesion of phagocytic histiocytes of the hilar and mediastinal lymph nodes. Recently, Fluorodeoxyglucose-positron emission tomography (FDG-PET) has been used for the clinical diagnosis of lung cancer and its lymph node involvement. However, reports dealing with false positivity of lymph node metastasis have been increasing in number. We report a case of AASCP exhibiting false positivity on FDG-PET imaging. A 75-year-old Japanese woman with lung adenocarcinoma underwent left upper lobectomy with mediastinal lymph node sampling. After ten months, chest CT revealed a contralateral hilus lymph node enlargement. A high accumulation in the lesion was detected with FDG-PET, and it was thought to be a recurrence of the lesion. Radical lymph node dissection with median sternotomy was performed. The histological diagnosis of the lesion was consistent with AASCP. In hilar and mediastinal lymph nodes of lung cancer patients, AASCP could be a cause of false-positivity on FDG-PET imaging.

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A 48-year-old Japanese female received upper lobectomy on the right side and dissection of regional lymph nodes for the treatment of typical carcinoid. Though the tumor was 19 mm in maximum diameter, metastasis to the mediastinal lymph nodes was recognized. Two courses of postoperative chemotherapy with Paclitaxel plus Carboplatin were performed. There was swelling of the paraaortic lymphnodes gradually nine months after operation. Biopsy of the lymphnodes was performed and sarcoid-like reaction was recognized in those lymphnodes. It is necessary to perform lymph node dissection of N2b even in surgery for typical carcinoid, <2cm in size. This is a rare case of typical carcinoid with swelling of the mediastinal lymphnodes postoperatively caused by sarcoid-like reaction.

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This paper describes the satisfactory outcome of reconstruction using Marlex mesh after resection from the sternum for a solitary metastatic sternal tumor of prostatic cancer in a 70-year-old man. There was a history of chemotherapy for prostatic cancer in September 2002 at the department of urology. When follow-up bone scintigraphy showed marked uptake in the lower part of the sternal body, the patient wasreferred to our department. The tumor measured 2.5×2.0cm. Partial resectionof the body sternum was performed. Defect in the anterior chest wall was reconstructedwith double folded Marlex mesh. It is now 30 months since surgery, and therehave been no signs of local recurrence. Long-term follow up is necessary inthis case.

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A 32-year old woman consulted a local doctor because of a cough. An abnormal shadow was found on chest x-ray, and the patient was referred to our department. Chest CT showed an abnormal mass in the posterior mediastinum. Therefore, we performed a thoracotomy. Milky fluid (chyle) filled the resected tumor which was diagnosed as a thoracic duct cyst. The superior and inferior pedicles of the thoracic duct cyst were ligated and the operation was finished. The postoperative course was uneventful and 18 months later, the patient was doing well. Thoracic duct cyst of the mediastinum is a very rare disease, and only 28 operative cases have been reported.

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A 72-year-old woman had undergone left upper lobectomy of the lung for a rapidly growing metastatic solitary fibrous tumor (SFT). Chest X-ray was normal on POD1, but the well defined nodule appeared in the left upper lung field on POD7. We thought that it represented a careless oversight or a rapid recurrence of SFT, and performed further partial resection of the nodule on POD14. However, histopathologic examination led to its identification as a subpleural hematoma. Subpleural hematoma should be detected at the end of surgery to avoid its misdiagnosis as a careless oversight or a rapidly growing recurrence.

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The patient was a 66-year-old female. She had acute myocardial infarction and a coronary artery bypass operation was performed by the department of cardiac surgery of our hospital. She had postoperative right hemothorax and hematoma excision was carried out on postoperative day 6 (POD6) via a 7^th postlateral thoracotomy. Moreover, she was diagnosed with right empyema, and an open-window thoracostomy with a 6-9th postlateral partial costal excision was performed on POD31. While we exchanged gauze in the empyema cavity every day, natural deciduation of a large quantity (10×5cm) of the necrotic lung was observed on POD94. Intrathoracic implantation of an abdominal rectus muscle flap was performed by us and plastic surgeons on POD229. However, after surgery, the pulmonary fistula persisted. Therefore, bronchial embolotherapy was done three times, but resulted in only temporary improvement. Closure of pulmonary fistula with thoracotomy was performed on POD275. An abdominal rectus muscle flap requires plastic surgery, but if omentum and latissimus dorsi muscle cannot be used, intrathoracic implantation of an abdominal rectus muscle flap into empyema cavity is useful. Also, natural deciduation of a large quantity of necrotic lung after open-window thoaracostomy is thought to be rare in the literature.

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We report a patient with intrathoracic malignant peripheral nerve sheath tumor (MPNST) associated with hemothorax. A 22-year-old woman with von Recklinghausen's disease was admitted to our hospital because of chest pain and dyspnea. Computed tomography revealed the shape of a tumor with a diameter of 12cm and bloody pleural effusion in the left pleural cavity, and needle biopsy demonstrated with a MPNST. We combined tumor resection with the left lower lobectomy , and the patient was discharged 7 days after surgery. MPNST has a poor prognosis even on careful surveillance, because it may cause hemothorax and take a fatal course.

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We report two cases of pulmonary arteriovenous fistula (PAVF). A 79- and 59-year-old-woman presented at our facility with abnormal shadowing on chest X-ray film. Physical examination showed no abnormal symptoms or findings. They were also no symptoms or family histories associated with Rendu-Osler-Weber syndrome. Imaging of the chest using computed tomography (CT) with contrast media revealed vascular malformations in the right lungs resembling PAVFs. Three-dimensional CT (3D-CT) revealed PAVFs along the feeding arteries and drainage veins. We performed partial pulmonary resection by video-assisted thoracoscopic surgery (VATS) for these patients. Histological diagnoses confirmed PAVF. Their post-operative clinical courses were good. It was confirmed that 3D-CT was useful to evaluate the structure of PAVFs and select the treatment procedures. Our cases were good indications for VATS because of solitary PAVFs with diameters of about 2 cm just under the pleura. This surgical procedure is an established option from the point of prognosis. Furthermore, the use of VATS to treat PAVFs could avoid the higher morbidity rates associated with thoracotomy. Therefore, VATS is given active consideration to treat PAVFs when the indication is present.

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Surgical resection of pulmonary aspergilloma prevents recurrence of hemoptysis in the literature. The most common indication of surgery for aspergilloma is also hemoptysis. The principal previous pulmonary illness was tuberculosis. We present a patient who underwent right completion pneumonectomy after right upper lobectomy due to tuberculosis and single-stage complete muscle flap closure of the pneumonectomy space with anterior serratus muscle flaps. The patient was suffering from bronchial fistula on the 27^th day after the first operation, and recieved further surgery for it. To prevent empyema and bronchopleural fistula, careful bronchial stump reinforcement with the greater omentum flap was employed. The postoperative course was uneventful. There was no recurrence of aspergillosis or hemoptysis for 13 months. Pneumonectomy for complex aspergilloma is associated with high morbidity rates such as bleeding, bronchopleural fistula, and empyema. It is indicated that the omentum is particularly effective in buttressing the closure of bronchopleural fistulas for poor-risk patients.

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Mediastinoscopy has been widely adopted as a useful modality of biopsy for mediastinal tumor and lymph nodes because of its less surgical complications and stress. We applied the mediastinoscopy for the extirpation of mediastinal cyst successfully. A 72-year-old man was referred to our hospital with a complaint of right upper limb numbness. The chest MRI revealed a tumor in the right side of trachea, showing high intensity under T2 condition by chance. The enhanced chest CT also depicted the low density tumor about 3cm in diameter in the same site. These findings suggested that the tumor is a mediastinal cyst. Mediastinoscope was inserted into the anterior mediastinum via a 3cm suprasternal transverse incision, and a cystic lesion was recognized in the right paratracheal area. The cyst was dissected fully from surroundings, and extirpated without difficulties by an alligator forceps. There is no intraoperative complication, such as bleeding and pneumothorax, and the postoperative course was satisfactory free from severe pain. Mediastinoscopy is useful for the extirpation of mediastinal cysts in invasiveness and safety.

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A 57-year-old woman had undergone right S³ segmentectomy for Stage 1A lung cancer in December 2000. In December 2004, a routine chest roentogenogram showed a mass in the right upper lobe, suggesting the local recurrence of lung cancer. We performed right upper and middle lobectomy in December 2004. The mass was white, and the inside showed an abscess. Mycobacterium avium was detected by the culture of the abscess. It was thought to be a granuloma caused by nontuberculous mycobacteriosis occurring in the staple we used for right S³ segmentectomy for lung cancer.

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We report a case of intrathoracic multiple schwannomas originating in a single intercostal nerve. A 34-year-old man was admitted to our hospital for the treatment of a posterior mediastinal tumor, which had grown slowly during the follow-up period of 5 years and 5 months. Radiological examinations revealed a mass, 3 cm in diameter, with a regular margin located in the posterior mediastinum, which was suspected to be a neurogenic tumor. During surgery, the tumor was found along the right ninth intercostal space. In addition, a smaller tumor was noted near the larger one, and the two tumors originated from a single intercostal nerve. Both tumors were resected and histologically diagnosed as schwannomas with no malignant components. Intrathoracic schwannomas are solitary in general, and multiple cases, especially originating from a single nerve, are quite rare. Reports describing similar cases as ours are reviewed and discussed.

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We experienced 2 cases of pulmonary sclerosing hemangioma showing different findings on FDG-PET. Case 1. A 65-year-old man with a lung tumor of the right S9 was referred to our department. The tumor revealed a high uptake (SUV 4.49) of FDG-PET. We performed partial resection of the right S9. The specimen of this tumor had a characteristic of sclerosing hemangioma, and solid and papillary patterns were dominant. Positive cells comprised about 8.5% on MIB-1 staining. However, no difference in distribution in each part was observed on MIB-1 staining. Case 2. A 43-year-old woman with a lung tumor of the right S4 was referred to our department. FDG-PET showed no uptake. She underwent partial resection of the right S4. The specimen of this tumor had a characteristic of sclerosing hemangioma, and a solid pattern was dominant. Positive cells comprised less than 1% on MIB-1 staining. Sclerosing hemangioma, that reveals both a high uptake of FDG-PET and a high percentage of MIB-1 staining, is required of careful follow because it has malignant potential.

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We herein report two cases of pulmonary metastasectomy of malignant phyllodes tumor of the breast. Case 1: A 55-year-old woman underwent left lower lobectomy for multiple pulmonary metastases from malignant phyllodes tumor of the breast 3 months after left mastectomy. One month later, she underwent local excision of a recurrent tumor and received irradiation of 50 Gy for local chest wall recurrence. Three months later, she underwent metastasectomy of a tumor of the round ligament of the liver. She is currently alive without recurrent diseases 3 years after initial pulmonary metastasectomy. Case 2: A 56-year-old woman underwent wedge resection of the left upper lobe for solitary pulmonary metastasis from malignant phyllodes tumor of the breast 8 months after right mastectomy. Six months later, she underwent wedge resection of the right upper lobe for contralateral pulmonary metastasis. One month later, she underwent metastasectomy of a tumor of the brain. We scheduled a local excision of the subcutaneous metastatic tumor: however, she developed a small bowel obstruction due to metastasis to the small intestine. She underwent an emergency partial resection of the small intestine. She died because of recurrent diseases 9 months after initial pulmonary metastasectomy. Cases may show a good prognosis by repeated complete metastasectomies for recurrent malignant phyllodes tumor of the breast.

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We had successfully treated a 36-year woman with a thymic cancer invading great vessels. Her primary complaint was cough. An anterior mediastinal tumor with a length of 6cm in diameter was found on chest CT. A CT-guided needle biopsy revealed the tumor was thymic cancer. Since the tumor was regarded as having invasion to a superior vena cava, chemoradiotherapy was chosen for an initial treatment. The tumor reduced in size after chemoradiotherapy. A thymectomy combined with a superior vena cava resection followed by a left brachiocephalic vein-right auricle bypass operation was carried out through a median sternotomy. Her postoperative course was uneventful. A surgical treatment should be considered with an effective induction chemoradiotherapy for a thymic cancer invading surrounding vessels.

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