Purpose: We retrospectively investigated the morbidity, 30-day mortality, and survival after pneumonectomy for non-small cell lung cancer (NSCLC). Patients and Methods: Forty-five NSCLC patients who underwent pneumonectomy from March 1993 to July 2003 at the Kagawa University Hospital were retrospectively analyzed. Results: Thirty-three (73.3%) patients showed more advanced stage than clinical stage III disease and 28 patients showed squamous cell carcinoma. The average operation time and postoperative stay were 281. 6 minutes and 46.8 days, respectively. On the other hand, 12 (26.7%) patients had postoperative complications and the 30-day mortality was 2.2% (1/45). However, there was no case of post-operative bronchopleural fistula. The overall 5-year survival rate after pneumonectomy was 32.1%. In addtion, induction chemoradiotherapy was associated with improved survival (31.7% vs 11.5%; p=0.0239). Conclusion: Pneumonectomy was performed with an acceptable risk of operative morbidity and 30-day mortality. The indication of pneumonectomy is aimed to perform a curative resection for advanced lung cancer after induction therapy.

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Purpose: The clinical significance of pulmonary rehabilitation (PR) for poor pulmonary function patients was investigated. Patients and Methods: Twelve poor pulmonary function (FEV1.0<=1.0l) patients who underwent pulmonary resection after PR were retrospectively analyzed. Results: PR was performed an average of 14.8±8.7 times in each patient. PR improved VC from 1.88±0.68l to 2.14±0.72l (p=0.0145), and FEV1.0 from 0.89±0.10l to 1.12±0.23l (p=0.0112). During operations, we performed 6 wedge resections, 2 segmentectomies, 2 lobectomies and 2 pneumonectomies. There were no major complications or mortality. Also no patients needed home oxygen therapy. The overall 5-year survival rate after pulmonary resection was 52.5%. Conclusion: PR may be a useful preoperative therapy that may extend the indication of surgery by improving pulmonary function and decreasing postoperative pulmonary complications in lung cancer patients.

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Although video-assisted thoracoscopic surgery (VATS) has been widely used in the treatment of spontaneous pneumothorax, the rate of post-operative recurrence is reported to be relatively high. One of the reasons is new bullae formation near the staple line after VATS. Therefore, we have performed a method of covering the staple line with a polyglycolic acid (PGA) sheet and autologous blood to prevent post-operative recurrence by the reinforcement of the visceral pleura. During 36 months, 100 patients under the age of 40 with primary spontaneous pneumothorax were treated by VATS. There were 58 patients without covering methods, 33 patients with a PGA sheet and autologous blood covering, and 4 patients with a PGA sheet and fibrin glue covering, and 5 patients with an only PGA sheet covering. Recurrent pneumothorax occurred in 11 patients, all of whom underwent only bullectomy without any additional method. The use of autologous blood is biologically safe and much less costly than fibrin glue, and the procedure may be effective in preventing post-operative recurrence of peumothorax.

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We performed video-assisted thoracic surgery (VATS) for 6 cases of spontaneous hemo-pneumothorax. Chest X-ray film revealed cord-like tissue in the upper field in two cases. Total blood loss ranged from 800 to 3750ml. Because of massive clotting and continuous bleeding, we performed emergent operations. We found bleeding from the apex of the chest wall in the 4of 6 cases. The post-operative course were uneventful in all cases. Emergent VATS is recommended for spontaneous hemo-pnemothorax.

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Mesothelioma rarely metastasizes to the skin. Most previously reported cases of cutaneous imvolvement by mesothelioma have been due to local extension or contamination of surgical sites. We report a case with subcutaneous metastasis of malignant pleural mesothelioma. A 52-year-old woman presented with a small skin nodule of the right chest. She had undergone extrapleural pneumonectomy for malignant pleural mesoshelioma 7 years before. Resection of the skin nodule was performed, and the diagnosis of subcutaneous metastasis of mesothelioma was confirmed with positive immunohistochemical stains for anti-calretinin, HBME-1, anti-cytokeratin, and EMA and negative stains for CEA.

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We describe a case of a 9-year-old female with a giant pulmonary bulla. She had chest pain, and her chest X-ray film and CT showed a right giant pulmonary bulla. A large bulla in the right lung has been recognized on her chest X ray obtained at 5 years old. The pulmonary arteriogram of 3-dimensional CT demonstrated narrowing of the truncus superior and ascending artery. The giant bulla was originated from the right S³ and was resected under thoracoscopy. The remnant lung was well expanded on the chest X-ray following operation.

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A 60-year-old male had received left nephrectomy for renal cell carcinoma. Follow-up computed tomography (CT) revealed bilateral lung nodules and partial lung resection was performed. Histological findings revealed metastases of renal cell carcinoma. Six months after the operation, CT showed bilateral lung nodules. We performed CT-guided RFA therapies nine times on nineteen nodules. There were complications including pneumothorax and lung abscess. Although RFA may become a less invasive and more effective therapy for the local control of pulmonary malignant tumors, we should bear in mind the associated complications.

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Background. Pulmonary sclerosing hemangioma is a benign and rare entity which sometimes presents as multiple nodules. Case. A thyroid tumor and bilateral multiple pulmonary nodules were incidentally found in a 52-year-old woman when she underwent extirpation of a benign cervical spinal tumor. Fine needle aspiration of the thyroid tumor failed to identify malignant cells but could not completely rule out a possible malignancy with metastatic pulmonary nodules, which led her to eventually undergo video-assisted partial lung resection. The resected specimens from the right lung were diagnosed as primary adenocarcinoma on intraoperative examination of the frozen sections, which led us to terminate the surgery without resection of the contralateral lesions. However, postoperative examination of the same specimens demonstrated histological findings compatible with those of sclerosing hemangioma. Conclusion. Multiple pulmonary nodules, even though they demonstrate features suggestive of benign nodules on imaging, are difficult to distinguish from metastatic tumors if an identifiable indeterminate mass lesion co-exists in an extrapulmonary site susceptible to a common malignancy. In addition, pulmonary sclerosing hemangioma is difficult to distinguish from papillary adenocarcinoma on examination of the frozen section in some cases, which may create intraoperative dilemmas for surgeons in cases of multiple lesions.

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A 71-year-old woman was admitted bec-ause of a high titer CEA and mediastin-al lymph node swelling. She underwent acomplete check, but no primary lesion w-as found. As CT and FDG-PET showed on-ly one swollen mediastinal lymph node (#6), we carried out a thoracotomy and pe-rformed a biopsy. According to the resul-ts of a pathological examination, anapla-stic carcinoma was identified and other lymph nodes that were resected during the operation did not show any maligna-ncy. We diagnosed the case as mediastin-al lymph node carcinoma without an ap-parent primary lesion. We performed co-ncurrent chemotherapy and radiation th-erapy (50Gy) for the mediastinum after the operation. She is currently alive wit-hout recurrence or appearance of the pr-imary site 21 months after resection.

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A 79-year-old man was admitted to our hospital for further examinations of an abnormal shadow of the right lung field pointed out on medical examination. Chest computed tomographic and magnetic resonance imaging films revealed a cystic mass in the upper mediastinum and another mass in the region corresponded to S⁷ of right lower lobe, with an abnormal vessel branching from the left gastric artery. Arteriography verified that the aberrant artery was from the left gastric artery. The diagnosis of a Pryce's type III intralobar pulmonary sequestration and an upper mediastinal cyst was made on the basis of these findings, and then operation was performed. The aberrant artery was cut, the sequestrated lung was resected, and the upper mediastinal cyst was removed by video-assisted thoracoscopic surgery. This case of an intralobar pulmonary sequestration with an abnormal artery branching from the left gastric artery coexistent with a mediastinal bronchogenic cyst is very rare. It was thought that an intralobar pulmonary sequestration may be a congenital disease originated from the accessory lung bud abnormally budded from the foregut in the early fetal stages, followed by an abnormal blood supply from systemic circulation secondarily.

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A 78-year-old male was admitted to a local hospital because of fever and sputum production. Chest x-ray revealed a pulmonary cavity of 10cm in diameter in the right lower lobe, which was diagnosed as a lung abscess. Although antibiotics were administered for two months, the pulmonary cavity and clinical symptoms did not improve. Sputum cytology revealed adenocarcinoma. He was referred to our hospital, and was diagnosed as having lung cancer with massive necrosis and infection. Right lower lobectomy was performed along with intraoperative drainage of the cavity, which showed a whitish, mucinous fluid. Pathologic examination revealed bronchioloalveolar carcinoma with mucin production. Three months later, multiple small cavities appeared as a recurrence in both lungs, and they changed into a thin-walled, bulla-like shadow on chest CT in both lungs 8 months later.

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We report a case of solitary fibrous tumor of the pleura, which produced high molecular-weight insulin-like growth factor II (big IGF-II). A 82-year-old woman was referred to our hospital with a large mass in the right thorax. It was diagnosed as a solitary fibrous tumor by needle biopsy. The patient was primarily followed up with no therapy. Four months later, she was admitted to our hospital with a hypoglycemic attack. Endocrinological investigations revealed low values of urinary C-peptiede and serum IRI. Extirpation of the thoracic tumor was performed, because the hypoglycemia was suspected to be related to the tumor. After the operation, the hypoglycemic attack was completely resolved on the second postoperative day, and the endogenous insulin level returned to normal. We investigated the size of IGF-II in serum before and after the operation by Western immunoblot analysis. Most of the serum IGF-II in the patient was detected at 20.9kDa, whereas, after surgical resection of the tumor, the high molecular weight IGF-II was not detected in the patient's serum. At three years after the operation, there is no sign of recurrence. We suggest that the high molecular weight IGF-II was produced by SFT and caused hypoglycemic attack.

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A 76-year-old man underwent a left upper lobectomy and lymph node dissection for lung cancer in our hospital. His postoperative course was uneventful until postoperative day (POD) 3, but severe dyspnea occurred suddenly on POD4 and continued in spite of treatment with oxygen and antibiotics. The patient was supported with a mechanical ventilator in an intensive care unit. L. pneumophila serogroup 1 (SG1) antigen in the urine was tested, and the urine antibody titer was elevated, suggesting pneumonia caused by L. pneumophila SG1. The patient recovered with ciprofloxacin treatment and was discharged on POD44. No source of infection was identified in the hospital unit. Legionella pneumonia developed on the 9th hospital day (POD4). The incubation period of legionella's disease has been reported to be between 1 and 2 weeks. Thus, pneumonia was due to L. pneumophila SG1, which was probably acquired from the patient's home before admission.

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A 46-year-old male presented with elevated serum carcinoembryonic antigen (CEA) during periodic follow-up after total gastrectomy for early barrett's adenocarcinoma of the esophagus in 2002. Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed accumulation at only the bone (right 7^th rib) and lung (right upper lobe) sites on January 2006. We performed right 7^th rib partial resection and wedge resection of the right upper lobe for the purpose of making a definite diagnosis. Pathological findings showed adenocarcinoma at both the rib and pulmonary lesions. The patient was diagnosed as having primary lung cancer with bone metastasis, considering his clinical course. However, the lung cancer was preceded by a bone metastatic lesion on retrospective CT. This clinical course in the patient is very rare.

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A 58-year-old man was admitted with an abnormal shadow in the right cardiophrenic angle on a chest X-ray. Contrast-enhanced CT scan of the chest revealed a tumor shadow of about 2.5×3.0cm adjacent to the pericardium and diaphragm. Surgery was performed through a thoracotomy, under video-assisted thoracic surgery (VATS). The tumor was located in the junction between the diaphragm and pericardium, and protruded from the diaphragm into the chest cavity. The phrenic nerve was confirmed to run toward the tumor and be thickened in its vicinity. These findings suggested that the lesion was a neurogenic tumor originating in the phrenic nerve attached to the diaphragm. The tumor was extended to the diaphragm and histopathologically diagnosed as schwannoma. Total excision including the diaphragm should be performed. Schwannoma originating in the phrenic nerve is a rare disease, and only 21 cases, including our patient, have been reported so far in Japan. There is no report on schwannoma extending to the diaphragm and requiring excision together with a part of the diaphragm, as in our case, So it is considered to be an extremely rare case.

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A 20-year-old man was admitted due to left spontaneous pneumothorax. We observed the lung by infrared thoracoscopy (IRT) with indocyanine green (ICG) intravenous injection and performed bullectomy via normal thoracoscopy. A bulla and an emphysematous area around the bulla were observed as white, while the normal lung was observed as blue by IRT with ICG intravenous injection. Histologically, the white area was revealed as a bulla and emphysematous lung. IRT with ICG injection was useful to identify the bulla and emphysematous lung that was difficult to identify by normal thoracoscopy. This procedure may reduce the postoperative recurrence rate of pneumothorax.

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We have experienced two young patients of high grade malignancy mucoepidermoid carcinoma (High-grade MEC) which is reported to be rare. Case 1, a 31-years-old man with abnormal shadow on chest X-ray underwent left upper lobectomy. Case 2, a 37-years-old man with high fever was visited to our hospital. Atelectasis of the left upper lobe was found and complete obstruction of the left upper lobe found by bronchoscopy. Sleeve left upper lobectomy was performed. Preoperative diagnoses of both two patients were adenocarcinomas and postoperative histological examination revealed High-grade MECs with N2. After operation, both two patents had recurrence soon and died.

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We report a case of video-assisted thoracoscopic surgery for recurrent pneumothorax with Marfan syndrome. This case was a 37-year-old female, who had a history of sternotomy for the rupture of annulo-aortic ectasia, right thoracotomy for right pneumothorax, and left pneumothorax. A chest tube was inserted for right pnemothorax in December, 2006. Because of persistent air leakage, video-assisted thoracoscopic surgery was performed. We could identify the bullous lesion at the apical lung after dissecting the adhesion between the right upper lobe and chest wall, and pleural intensification was done after resecting the lesion. The postoperative course was uneventful, and she was discharged on postoperative day 6.

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We report the case of a 71 year old male with a history of artificial pneumothorax. He had been followed up for accumulation of left pleural effusion. Subsequently, he developed fever, coughing, and bloody sputum, and was admitted to our hospital with a diagnosis of chronic thoracic empyema with fistula. Chest drainage was performed. The treatment alleviated the inflammatory symptoms, but chest CT revealed a 7×5cm tumor in the left upper lobe. A biopsy was performed under CT guidance, and the patient was diagnosed with a malignant tumor. Left pleuropneumonectomy was performed, with the pathological diagnosis of malignant lymphoma. Furthermore, elevated serum anti-EBV antibodies and the presence of EBV in tumor cells were detected. The post-operative course was uneventful, and he is now being followed up without post-operative chemotherapy.

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Complication associated with pulmonary dilofiraliasis has been rarely reported. We report a case of pulmonary dirofilariasis with complicated pulmonary suppuration. A 57-year-old man was admitted with an abnormal shadow on his chest X-ray. Computed tomographic scan showed a subpleural nodular lesion in the right lower lobe 20mm in size. Transbronchial biopsy was not diagnostic. On the fourth day after bronchoscopic examination, the patient developed a fever, and the lung nodular lesion showed enlargement. We considered this situation as complicated pulmonary suppuration. The patient underwent video-assisted thoracoscopic surgery after an antibiotic therapy. Frozen-section examination during the operation revealed no malignancy, and wedge resection of the lung was performed. Histopathological examination revealed coagulation necrosis surrounded by an abscess, and necrotized microfilariae that had embolized an adjacent peripheral pulmonary artery. The lesion was diagnosed as pulmonary dirofilariasis with complicated pulmonary suppuration. Documentation indicates that pulmonary suppuration secondary to pulmonary infarction can be serious. We could successfully treat the patient after surgery in the early stage of complicated pulmonary suppuration. The patient is doing well without exacerbation of the suppuration after the surgery.

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[in Japanese]

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