From 1990 to 2005, 11 patients were operated on for malignant pleural mesothelioma. Out of the 11 patients, 8 cases were male and 3 cases were female, with mean age of 53.4 years old. A past history of exposure to asbestos was identified in 4 patients (36%). Seven patients (64%) presented with symptoms such as cough, chest pain, and dyspnea. For 4 of them, video-assisted thoracoscopic biopsy was the most effective method for diagnosis. extrapleural pneumonectomy was performed for 9 cases and other operations for 2 cases. We could not conclude the usefulness of trimodal therapy consisting of surgery, chemotherapy, and radiotherapy. The 2 year survival rate of 11 patients was 13.3%. For an earlier definitive diagnosis, thoracoscopic pleural biopsy should be done in cases with pleural effusion of unknown origin. Establishment of appropriate indications for operation, and the developments of effective chemotherapy and radiotherapy are needed for the improvement of the survival rate in malignant pleural mesothelioma.

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Since 1998, we have used a skin incision which resembles "Sasumata", a Japanese classical weapon, for surgery through median sternotomy, for cosmetic reasons. This study was performed to compare psychologic effect in patients who underwent surgery through a median sternotomy via Sasumata incision with those by conventional linear median skin incision. Methods: A U-shaped skin incision in the upper half of the chest and a vertical incision from the bottom of the U-shaped incision to just above the xyphoid process were made. The Sasumata incision group included 10 patients who had undergone surgery by Sasumata incision and were admitted to our hospital between July and September, 2001, and the conventional incision group included 8 patients who had undergone surgery by conventional linear median skin incision and were admitted to our hospital in the same period. For the comparison of psychologic and cosmetic effects, a questionnaire including three questions was used and observation of the extent of hypertrophic scar and measurement of the visible length of the chest under the sternal notch were performed. Results: The results of the questionnaire and extent of hypertrophic scar showed no significant differences between the two groups. However, visual length of the chest under the sternal notch of the Sasumata incision group was significantly longer than that of the conventional incision group. Patients with Sasumata skin incision showed more chest area than those with conventional linear median skin incision. It was supposed that the incision scar does not appear in the upper part of the chest by Sasumata skin incision. Conclusion: The Sasumata incision was cosmetically superior to the conventional linear median skin incision for median sternotomy.

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Background: In recent case reports and limited series, long-term survival has been reported after surgical treatment of a solitary distant metastasis from non-small cell lung cancer (NSCLC). However, the role and indications of surgical resection are still unclear. Our aim is to investigate the prognosis of patients after resection of distant metastases in various sites and to identify characteristics of patients who achieve prolonged survival. Patients and Methods: We retrospectively reviewed patients who had undergone surgical treatments for distant NSCLC metastasis between January 1998 and December 2003, according to the following criteria: primary NSCLC that was completely resected, and distant metastasis that was a solitary (or few) lesion, synchronously or metachronously diagnosed. Results: Thirty-five patients entered the study. Metastasectomy was performed for the following sites: brain (n=17), lung (n=10), adrenal gland (n=6), and chest wall (n=2). Other profiles of metastases were the following: synchronous (n=6, all in the brain), metachronous (n=29), solitary (n=30), and 2-3 lesions (n=5, all in the brain). The overall median survival time (MST) after metastasectomy was 43.1months, and the 2-year survival rate was 68.0%. According to the provisional pathologic stage, excluding the M factor, of the primary tumor, 2-year survival rates of stage I (n=16), II (n=14), and III (n=5) were 86.5%, 53.0%, and 60.0%, respectively. Concerning thoracic lymph node metastasis, patients with pN0 status had a 82.9% 2-year survival (MST: 50.9months) and significantly prolonged survival compared to patients with pN1-2 status (2-year survival: 50.3%, MST: 35.4months). Conclusions: This study suggested that surgical treatment for oligometastatic disease could be considered as an arm of multi-modal therapy in selected patients with early stage primary NSCLC and no lymph node metastases, and might prolong the survival in such cases.

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Currently, no specific item regarding endoscopic thymectomy for myasthenia gravis is listed in the standards of deciding medical service fees. To understand the present situation regarding the medical fee-for-service of endoscopic thymectomy, a questionnaire survey was conducted involving the institutions and members participating in the Japanese Association for the Research on the Thymus, Of 101 responding institutions, 18 institutions (18%) reported basically performing endoscopic thymectomy in all qualifying patients, while 32% of theinstitutions reported mainly performing median sternotomy, but sometimes performing endoscopic thymectomy. The methods of approaching endoscopic thymectomy varied among the institutions, but most of them included endoscopic clips or ultrasound-driven scalpels, as well as anterior chest wall lifting devices. A total of 214 patients underwent thymectomy in 2004 in the responding institutions, of which 77 patients (32%) underwent endoscopic thymectomy. Seventy-one percent of the responding institutions answered that a specific item regarding endoscopic thymectomy should be listed in the standards for deciding medical service fees.

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Pulmonary arteriovenous malformations (PAVMs) are rare, mostly congenital, and are often associated with Rendu-Osler-Weber disease (ROW dis.=Hereditary hemorrhagic telangiectasia). PAVM is caused by an abnormal communication between the pulmonary arteries and veins. We present four cases of familial PAVM with ROW, which were successfully treated by three therapeutic options. Case 1: A 45-year-old woman with a solitary large PAVM, which was located centrally in lingular lobe, underwent bisegmentectomy with thorachotomy. Case 2: A 16-year-old man with multiple PAVMs, which were located in the rt. S^9b and S^10b, underwent wide wedge resection by video-assisted thorachoscopic surgery (VATS). Case 3: A 22-year-old woman with multiple small PAVMs, which are located in four lobes, undedrwent angiographic embolization. Case 4: A 21-year-old man with a solitary small PAVM, which was located in the lt. S^9b,underwent wide wedge resection by VATS. For most PAVMs, angiographic embolization is the standard therapy. Limited resection of the lung, with a low mortality, low morbidity and low recurrence rate, carries the same risk as angiographic embolization. In well-selected cases, i.e., when PAVMs are closely located and/or large, with a high risk associated with embolotherapy, surgery is preferable to angiographic embolization.

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A 76-year-old Japanese male without neurofibromatosis type 1 (NF type 1) was admitted to our hospital for treatment of a large mass, 13cm in the maximum diameter, at the posterior mediastinum. The tumor, compressing adjacent organs such as the heart, liver, lung, and inferior vena cava, was resected and diagnosed as MPNST. Additionally, multiple lung metastases of pancreatic cancer were recognized. This is the first report of a case without NF type 1 MPNST accompanied with pancreatic cancer.

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Primary liposarcoma of the mediastinum is very rare. We present a patient with a primary mediastinal liposarcoma which was characterized by dedifferentiation. Most parts of the tumor showed dedifferentiation, so histologic examination revealed a solitary fibrous tumor at the first operation. Eighteen months after the initial resection, computed tomographic scanning showed the presence of a mass in the posterior mediastinum. We resected the mass, of which the final pathologic diagnosis was recurrent dedifferentiated liposarcoma.

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A 73-year-old woman experienced sudden dorsal thoracic pain on October 28,2004. Acute aortic dissection was diagnosed with the aid of chest computed tomography, and ascending aorta replacement was performed on the same day in the Department of Cardiovascular Surgery at our hospital. The endotracheal tube was removed on the 2^nd postoperative day (POD) but was re-inserted due to respiratory failure attributable to hypoventilation. Chest X-ray showed marked elevation of the right hemidiaphragm, which was diagnosed as paralysis of the right hemi-diaphragm due to phrenic nerve injury during surgery. The patient was hemodynamically stable, but positive pressure ventilation was required, and refractory pneumonia was present. Diaphragm plication was performed in the Department of Respiratory Surgery at our hospital on November 29 to treat the paralyzed hemi-diaphragm; the diaphragm was relaxed and then plicated under thoracoscopic assistance with knifeless endostaplers. The diaphragm was markedly lowered, hypoventilation was improved after the operation, and the endotracheal tube was removed on the 3^rd POD. The inflammation decreased, the clinical course was uneventful, and the patient was discharged on the 10^th POD. Diaphragm plication using VATS is a minimally invasive, effective procedure that can be used when a patient cannot be weaned from ventilatory support because of unilateral diaphragmatic paralysis, as in the present case.

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Two cases of thymic hypertrophy with hyperthyroidism were reported. In Case 1, a 19-year old woman complaining of palpitation indicated a swelling thyroid and revealed an anterior mediastinal mass on chest CT. After administration to the hospital, hyperthyroidism was diagnosed. The mediastinal mass was diagnosed as thymic hyperplasia by percutaneous biopsy. After her thyroid function was normalyzed by anti-thyroid drug admisnistration, the anterior mediastinal mass shadow was reduced. In Case 2, a 52-year old woman indicated an anterior mediastinal mass and slight thyroid swelling on chest CT. Hyperthyroidism concomitant with thymic hypertrophy was diagnosed. Three months after antithyroid drug administration, the anterior mediastinal mass shadow had mostly regressed on chest CT. Thymic hyperplasia is considered to be a result of hyperthyroidism. Therefore, thymic hypertrophy associated with hyperthyroidism should be treated by anti-thyroid therapy and the thymus should be observed for some time before resorting to surgery.

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Descending necrotizing mediastinitis is an unusal and severe disease with a high associated mortality unless early appropriate treatment is performed. A sixty-seven-years of woman who has undergone hemodialysis three times a week for twelve years complained at a clinic about fever, sore throat, and right neck swelling. She was admitted to the clinic for acute tonsillitis. She progressively deteriorated and underwent tracheotomy on the fourth hospital day. She was transferred to the department of otorhynolaryngology at our hospital because of descending necrotizing mediastinitis accompanied by tonsillitis two days after the tracheotomy. CT scan revealed that the right neck abscess extended to the lower mediastinum around the pericardium. The next day, we performed neck drainage and video-thoracoscopic mediastinal drainage for these abscesses. She was uneventfully discharged on the forty-sixth day after the operation. Video-thoracoscopic drainage for descending necrotizing mediastinitis is safe and usefull for compromised patients such as those with chronic renal failure.

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A 62-year-old man felt discomfort in his throat after eating a fish, with pain on swallowing appearing 20 days later, followed by dyspnea two days after that, therefore, he consulted the emergency department of our hospital. He was diagnosed with stricture of the upper airway resulting form acute epiglottitis, with findings of hoarseness, prolonged inspiration, and tachypnea. Although epinephrine inhalation was instituted immediately, since dyspnea continued to worsen, an urgent tracheotomy was performed. After hospitalization, his general condition improved with medical treatment including an antibiotic, but C-reactive protein levels were elevated on the 12^th day of hospitalization, and he was diagnosed with descending necrotizing mediastinitis by CT scan. CT scan revealed an abscess in the upper mediastinal space above the carina, and we performed mediastinal drainage using the cervical approach. Postoperative progress was satisfactory and without complication. Transcervical mediastinal drainage should be considered as the first choice of surgical treatment for mediastinitis limited to the region above the tracheal bifurcation. Moreover, it is important to make an early diagnosis of descending necrotizing mediastinitis extending from inflammation of the neck.

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We report a case of solitary fibrous tumor of the pleura (SFT) which recurred 9 years after the initial operation. The patient was a 67-year-old male with a chief complaint of growing mass lesions on chest computed tomography (CT). He had undergone resection of benign SFT originating from the parietal pleura of the right thoracic cavity in October, 1995. Nine years later, a repeat chest CT revealed two enlarged pleural-based lesions in the right thoracic cavity. Under right thoracotomy, resection of the tumors including the pericardium was performed. Pathologic examination was consistent with the recurrence of benign SFT with no malignant transformation. We concluded that even though no malignant findings were shown on SFT histopathologically, patients should be followed up with long-term radiological examination.

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We report a rare case of VATS for pneumopyothorax due to ruptured lung abscess. The patient was a 63-year-old man who had liver cirrhosis and diabetes mellitus (DM). He was admitted to our hospital for the control of DM. After admission, he had a cough and fever, chest CT showed a lung abscess in the left lower lobe and antibiotics were administered. Ten days after admission, the patient suddenly complained of dyspnea, and chest CT showed a left pneumopyothorax due to ruptured lung abscess. Video-assisted thoracoscopic debridement and decortication for the empyema cavity and drainage for the abscess cavity were performed. Three weeks after operation, bronchial occlusion by bronchoscopy was performed in the intractable bronchopleural fistula. Though the empyema and abscess were improved, he died due to liver failure on post operative day 48. Ruptured lung abscess is rare and may occur in patients with severe complications. We suggest that early and low invasive surgical treatment should be performed in such cases.

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We experienced a rare case of primary malignant lymphoma originating from the chest wall without preceding pleural disease or chronic pyothorax. A 48-year-old woman was admitted to our hospital complaining of left chest pain and an expanding tumor on the left side of the chest wall. The diagnosis was not definitive by percutaneous ultra sound-guided needle biopsy. Because the mass rapidly grew in a short period and presented as a solitary chest wall mass, we performed an exploratory resection of the tumor. Histological diagnosis of this tumor was confirmed as B cell malignant lymphoma of diffuse large cell type originating from the chest wall. A combination of chemotherapy and radiation therapy were added in the postoperative period. To date, 47 months after the operation, the patient remains well with no evidence of recurrence or metastasis. Generally, primary malignant lymphoma originating from the chest wall shows resistance to chemotherapy and radiation therapy, with a poor prognosis. Additionally, on account of the rapid growth of the bulky mass and the difficulty in accurate pretherapeutic diagnosis by usual biopsy, surgery is often required for diagnosis and initial treatment. In well-chosen cases, surgical treatment before chemotherapy and radiation therapy may successfully improve the prognosis and should also be taken into consideration as the initial treatment.

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We report a 51-year-old man with malignant fibrous histiocytoma (MFH), treated with pleuropneumonectomy. The patient suffered from severe dyspnea (grade IV of Hugh-Jones' classification). Chest X-ray and chest computed tomography (CT) showed a huge mass that occupied the whole of the right thorax. We performed a pleuropneumonectomy on suspicion of chondrosarcoma. The tumor was yellowish and gelatinous, and weighed 8 kg. Pathologically, the tumor was diagnosed as myxoid malignant fibrous histiocytoma (MFH). After the operation, he made a remarkably untroubled recovery, free from dyspnea (grade I). Clinical examination 6 months postoperatively showed the man to be well with no MFH recurrence.

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We report a case of pulmonary cryptococcosis in a renal transplant recipient. A 53-year-old woman with living kidney transplantation had been receiving immunosuppressive therapy with tacrolimus and methylprednisolone. During a regular checkup, a nodular shadow was detected on her chest X-ray film. The chest CT scan revealed a solid nodule in the region of rt. S² and showed a slightly increased diameter during follow-up. FDG-PET demonstrated an accumulation corresponding to the lesion with an SUV of 3.7 at 60min and 4.2 at 120min post-injection, indicating a possible malignancy. The nodule was resected under video-assisted thoracoscopic surgery and a diagnosis of pulmonary cryptococcosis was obtained. It is sometimes difficult to distinguish lung cancer from pulmonary cryptococcosis because pulmonary cryptococcosis often shows similar image characteristics to lung cancer. In this case, the increased diameter and positive accumulation on FDG-PET suggested malignancy rather than inflammation. Careful differentiation between malignancy and inflammation are necessary in post-transplant patients with abnormal chest shadows.

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A 57-year-old man with a chest wall tumor and right pleural effusion was referred to our hospital. Cytological analysis of the pleural effusion and biopsy of the parietal pleura had already been performed, but no fixed diagnosis was made. The chest wall tumor and the tissue along the tracts of the biopsy needles were removed, and a subsequent thoracoscopic examination was performed. The histological findings of the chest wall tumor led to a diagnosis of biphasic malignant mesothelioma. The clinical stage was T3N0M0 stage III on IMIG-TNM classification. A right extrapleural pneumonectomy was performed. In this case, the histological findings of the chest wall tumor facilitated the final diagnosis.

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A metastatic tumor with osteosclerosis from prostate or breast cancer is common, but not from colon cancer. We report a case of bone metastasis with osteosclerosis from colon cancer. The case was a 73-year-old Japanese woman who underwent transverse colectomy in November, 2000, for colon cancer. In November, 2001, she underwent partial resection of the left lung for pulmonary metastasis, and RFA was performed for liver metastasis in October, 2003. In March, 2004, she experienced chest pain and chest x-ray showed a calcified tumor on the chest wall. A bone tumor with osteosclerosis on the 6th rib was suspected on chest CT. The chest wall tumor was resected in April, 2004. The tumor was 8cm in length on the 6th rib, and the chest wall was resected by 20 cm to obtain a sufficient free margin for reconstructing the chest wall with Marlex mesh. The post-operative pathologic diagnosis was metastasis of colon cancer. She has maintained a good condition without recurrence to date.

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A 69-year-old man presented with dyspnea. Chest CT showed a 1.5cm nodule in the right upper lobe and a 6cm subcarinal mass. PET scan showed FDG uptake in both lesions, indicating primary lung cancer with mediastinal lymph node metastasis. After the biopsy of the subcarinal mass through mediastinoscope and thoracoscope resulted no evidence of malignancy, the patient underwent a right upper lobectomy with mediastinal lymph node dissection including the excision of the subcarinal mass. Pathological examination revealed the right upper lobe nodule as adenocarcinoma with hilar nodes metastasis (pT2N1M0) and the subcarinal mass as Castleman's disease. It was difficult to distinguish Castleman's disease from mediatinal lymph node metastasis of lung cancer with PET scan. Attention should be paid in staging of lung cancer when such a lymph node disease is combined.

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A 31-year-old man suffered from discomfort on swallowing. Tracheal deviation to the right side by chest radiograph and a superior mediastinal mass by chest CT were observed. We performed thyroidectomy of the left lobe, left recurrent nerve resection and reconstruction, and 8-ring tracheal resection. Pathological diagnosis was thyroid cancer with mediastinal lymphnode metastasis. He experienced no problems with anastomosis in his clinical course. He has had no recurrence within one-year. Thyroid cancer should be considered as a differential diagnosis of mediastinal mass.

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[in Japanese]

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