Myasthenia gravis (MG) was treated by sternum-lifting video-assisted thoracoscopic extended thymectomy (sternum-lifting VATS-ET) in 110 consecutive cases. The appropriateness of this technique as a standard operative procedure for MG was examined retrospectively on the basis of postoperative results and long-term outcomes. Evaluation was performed in 106 cases, excluding 4 cases in which sternum-lifting VATS-ET was intraoperatively switched to median sternotomy, over the last 9 year period. Early postoperative outcomes were favorable, with the average operative time being decreased by 181 minutes during the first 3 years and by 127 minutes during the last 2 years. The rates of remission and palliation for all patients with MG were 25% and 86% at 6 months, 28% and 85% at 1 year, 31% and 85% at 3 years, 37% and 87% at 5 years, and 50% and 100% at 8 years after surgery, respectively. The incidence of complications after sternum-lifting VATS-ET for patients with MG was 12.7%, with an incidence of left brachiocephalic vein laceration of 2.7%. Sternum-lifting VATS-ET is acceptable as a standard operative procedure for MG, as judged by postoperative results and outcomes at 8 years. However, a prospective comparison of long-term outcomes between this procedure and other operative approaches is needed to clearly demonstrate the validity of this procedure.

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Six cases of thymic cancer treated in our hospital (mean age: 57.7 years, four males and two females) were reviewed clinically. Histological subtypes of thymic cancer were clear cell carcinoma in one, squamous cell carcinoma in one, and undifferentiated carcinoma in four. One case was stage III, one case was stage IVa, and four cases were stage IVb. One stage IVa case with pericardial dissemination received induction chemoradiotherapy. All cases underwent total thymectomy and mediastinal lymph node dissection and were resected along with the lung, pericardium, pleura, innominate vein, superior caval vein, or phrenic nerve. Five cases excluding one stage IVa case were completely resected macroscopically. Five cases underwent postoperative adjuvant therapy: four with radiotherapy and one with chemotherapy. All long-term survivors were cases that had undergone radiotherapy. One stage IVb case has remained alive without recurrence for more than 9 years, and one stage III case has survived without recurrence for more than 7 years. On the other hand, chemotherapy was not effective in our cases. It is suggested that the establishment of combined therapy such as complete resection, radiotherapy, and more effective chemotherapy is important to obtain better results.

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The clinical efficacy of perioperative physical therapy (PT) for patients undergoing pulmonary resection for lung cancer was investigated. The subjects were 227 patients who underwent pulmonary resection for lung cancer; PT was performed in 85 of them. The content of PT consisted of breathing exercises, systemic training, and coughing exercises. Postoperative respiratory complications were significantly decreased in the PT group. FEV1 and VC were significantly improved by PT. Especially, marked improvement was found in patients with obstructive disease. The improvement of respiratory function was correlated with the duration of PT. Initiating perioperative PT was beneficial for patients undergoing lung resection, in terms of reducing the occurrence of postoperative complications and improving respiratory function.

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Object. We evaluated clinical and thoracoscopic findings of cases that underwent thoracoscopic biopsy for the diagnosis of malignant pleural mesothelioma. Patients. We reviewed 32 cases suspected of having malignant pleural mesothelioma from 2003 to 2006. Results. We made a diagnosis of malignant pleural mesothelioma via thoracoscopic biopsy (19 cases). The cut-off level of hyaluronic acid in malignant effusions, selected on the basis of the best diagnostic efficacy, was 100ug/ml. We can decrease the incidence of false negative cases by the combination of CT findings and the presence of hyaluronic acid in pleural effusion. In the pleural thickening type of thoracoscopic appearance, the parietal pleurae were thickened, and small nodules were rare. As for this type, tumor cells were histologically absent or confined to the submesothelial tissue. We considered that determinations of specific sites were difficult. Adequate tissue samples obtained via video-assisted thoracoscopy were necessary for diagnosis. Conclusion. We can decrease the incidence of false negative cases by the combination of the presence of hyaluronic acid in pleural effusion and thoracoscopic biopsy.

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Pulmonary lymphangioleiomyomatosis (LAM) is a rare disease that occurs primarily in women of childbearing age. In addition, pulmonary LAM is an important basal disease in the occurrence of spontaneous pneumothorax in women. We report two cases of pulmonary LAM that followed different courses. Case 1: a 26-year-old woman with a right renal tumor developed spontaneous pneumothorax. Chest CT scans revealed multiple thin-walled cystic lesions in both lung fields. A partial pulmonary excision was performed by thoracoscopic surgery and pleurodesis was performed by pleura paratripsis. The pathological diagnosis was pulmonary LAM. The right kidney tumor was removed by total extirpation of the right kidney, and a liver tumor was treated by partial hepatectomy. The pathological diagnosis of the tumor specimens was angiomyolipoma. Case 2: a 45-year-old woman was admitted to our hospital for sudden dyspnea and left chest pain. Chest CT scans revealed left spontaneous pneumothorax, with multiple thin-walled cystic lesions in both lung fields. A partial pulmonary excision was performed by thoracoscopic surgery and pleurodesis was performed by pleura paratripsis. The pathological diagnosis was pulmonary LAM. Currently, Case 1 shows a mass recurrence in the liver and lungs during one year after the partial hepatectomy, while Case 2 does not show evidence of recurrence during one year after the partial pulmonary excision. These two cases show that the clinical course of LAM varies. Therefore, for every case, an appropriate choice of regimen and performing complete follow-up examinations are important.

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A 79-year-old man was stabbed in the left back with a sharp knife and was transported to our hospital by ambulance. On admission, he went into shock, but soon recovered after extensive infusion. We diagnosed a left hemothorax by chest X-ray. About 2000 ml of hemorrhagic pleural effusion was released when we inserted a thoracic drainage tube into the left thoracic cavity. Chest enhanced computed tomography showed pleural effusion in the left thoracic cavity and leakage of contrast medium from the left lower lobe to the thoracic cavity. We diagnosed a hemothorax caused by left lung damage. He immediately went into shock again. We decided to perform an emergency operation. He underwent cardiac arrest when he reached the operating room. Because of a blockage in the drainage tube, we suspected a tension hemothorax. So, we urgently performed a thoracotomy in the supine position and removed the massive hematoma. The heartbeat was restarted and he recovered from shock. We performed a left lower lobectomy for hemostasis at the right lateral decubitus. He was discharged without complications. We report this case including consideration of other cases of chest injures that we have managed at our hospital.

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Non-tuberculous mycobacterial infection frequently occurs in a sequela after pulmonary tuberculosis etc., but rarely occurs in the pulmonary suture line. We report a 68-year-old male who contracted non-tuberculous mycobacterial infection along the pulmonary suture line after partial resection of the right upper lobe for aspergilloma 5 years ago. He had been under treatment for diabetes mellitus. Increased nodule size was detected during follow-up. The recurrence of aspergilloma was suspected due to its location and increase in size. Therefore, we performed right upper lobe lobectomy. Through the pathological and bacteriological examination, we diagnosed the nodule as a guranuloma infected by Mycobacterium avium. We should consider non-tuberculous mycobacterial infection as a differential diagnosis in cases in which a nodule occurs along the pulmonary suture line.

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An FDG-PET scan as part of a medical check-up showed a solitary focus of an intense tracer in the right hilum in a 67-year-old man. He had undergone endoscopic mucosal resection for early gastric cancer 3 years before. A chest CT demonstrated a 2 cm nodule adjacent to the right lower lobe bronchi. Enlargement of the mass over 2 months suggested malignancy, and a thoracotomy was carried out. The mass showed invasion to the basal segmental artery, and so a right lower lobectomy with mediastinal lymph node dissection was performed. Pathological examination revealed a lymph node with poorly differentiated adenocarcinoma. No metastasis was found in the other lymph nodes. Immunohistochemical stainings showed positive results for thyroid transcription factor-1 and cytokeratin 7 and negative results for cytokeratin 20. Although no primary carcinoma was found in the resected right lower lobe histologically, the immunohistochemical findings suggested a pulmonary origin.

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A 60-year-old woman consulted our hospital for bronchial tumor. PET scan revealed no uptake but the original tumor. Bronchoscopic examination revealed a polypoid tumor in the left lower trunk. Left lower lobectomy was performed because a trans-bronchial biopsy specimen was diagnosed as a “malignancy”. Histological study of the resected specimen was diagnosed as typical carcinoid. The post operative course was uneventful, but multiple liver metastases were confirmed by transcutaneus liver biopsy. Distant metastasis of typical carcinoid was reported as 3.9%. We herein report a rare case of typical carcinoid with liver metastases.

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A 46-year-old female was referred to our hospital with complaints of right dorsal pain and dyspnea. Chest X-ray suggested right hemopneumothorax, and she was admitted as an emergency. We performed tube thoracotomy, but hemorrhage persisted. Therefore, emergency surgery was performed. During thoracoscopic surgery, a hemorrhagic point was observed at the rupture site of a cord-like adhesion in the apex of the lung. On the diaphragm, blueberry spots and pore defects were noted, and this site was partially resected. Histopathological examination of the resected diaphragm suggested endometriosis. The patient had a history of right hemopneumothorax, which had remitted during conservative therapy. She had undergone hysterectomy and bilateral adnexectomy under a diagnosis of catamenial pneumothorax. Briefly, the present case indicates the onset of hemopneumothorax after hysterectomy, and may be useful for clarifying the pathogenesis of catamenial pneumothorax. In addition, it suggests the possibility of active endometriosis after oophorectomy. We investigated 5 patients with catamenial pneumothorax who underwent surgery in our hospital.

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We experienced a case of prolonged pneumothorax with complications involving destroyed lung in which wrapping by a pediculed intercostal muscle flap was useful. Regarding the case, a 62-year-old man had been admitted to another hospital for integration dysfunction syndrome. However, he developed spontaneous pneumothorax in the left lung in May 2004. Accordingly, he was admitted to our hospital through introduction. We inserted a drain into the thoracic cavity and performed suction drainage continuously for two weeks. However, air leak did not resolve. We operated on him on the fifteenth day since he was admitted to our hospital. During the operation, we found a pulmonary fistula about 5 mm in diameter in the left lower lobe S⁹. Because the pulmonary fistula was complicated with destroyed lung, we wrapped it with a pedicled intercostal muscle flap. The postoperative course has been good, and there has been no recurrence of pneumothorax to date. The destroyed lung is a state in which the structure and function no longer exist. Due to poor circulation and anoxia, healing of the wound is delayed. Therefore, we thought that wrapping by tissue rich in blood flow was useful.

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We report two surgical cases of right squamous cell lung cancer involving the right aortic arch. Both of the cases were anomalous in that the aortic arch and the descending aorta ran into the right chest cavity. No other cardiac malformations were found. The first case (case 1) was of pathological stage T3N0M0 stage IIB, where a tumor in the right upper lobe invaded the chest wall directly, with no metastases detected in the lymph nodes or distant organs. The second case (case 2) was a pathological stage T2N2M0 stage IIIA tumor arising from the intermediate bronchus that obstructed the bronchial lumen, resulting in atelectasis of the right middle and lower lobes. The subcarinal nodes were found to be metastatic. In both these surgeries, the right pharyngeal recurrent nerve had branched up from the right vagus nerve and hooked around the right aortic arch. This case report suggests that we should pay close attention to the anatomical displacement of the right recurrent nerve during surgery, as well as associated malformations in perioperative management when treating right-side lung cancer involving the right aorta.

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A 52-year-old man, who was going to undergo an operation for squamous cell carcinoma of the lung, was found to have a history of frequent spontaneous epistaxis and a family history of von Willebrand's disease in his nephews. Laboratory data showed a normal platelet count, normal prothrombin time, and normal activated partial thromboplastin time. Further examination, however, revealed a prolonged bleeding time (5 minutes, 30 seconds) and a decrease in von Willebrand factor (<6%) and factor VIII (65.3%), and a diagnosis of von Willebrand disease was established. After confirming an improvement of the bleeding time to 2 minutes with the intravenous administration of factor VIII/von Willebrand factor compound (Confact F), pulmonary resection was successfully carried out. With the daily administration of Confact F during the perioperative period, the postoperative course was uneventful and no clinical bleeding occurred.

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Here, we report two cases of lung cancer presenting a solitary cavity both in the first and second lesions. Case 1: A 62-year-old man complaining of hemosputum underwent left upper lobectomy because of pulmonary adenocarcinoma in 1997 at 53 years old. Three years after the operation, a newly-developed tumor with a small cavity was detected on chest CT scan, and left S⁶ segmentectomy was performed. Case 2: A 70-year-old man with hemosputum underwent right lower lobectomy for pulmonary squamous cell carcinoma in 2005 at 68 years old. The following year, a similar lesion with a cavity was recognized in the contra-lateral lung, and left lower lobectomy was performed. Histopathologically, growth of the cancer was demonstrated along with airways around the cavity in every lesion of these two cases. The check valve mechanism seemed to be contributory to the formation of cavities.

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A 31-year-old man came to the hospital complaining of hemosputum. Chest X-ray and CT scan showed an extrapleural mass on the right side of the vertebra, diagnosed as a neurogenic tumor. He underwent thoracoscopic surgery, and a round but uncapsulated mass was found in the right side of thoracic vertebra. Intraoperatively, caseous pus was discharged from the mass, and it was diagnosed as a tuberculous abscess histopathologically. A solitary paravertebral tuberculous abscess is rare, and it is very difficult to correctly diagnose preoperatively. It is considered that the thoracoscopic procedure is useful to diagnose and complete resection to treat intrathoracic extrapulmonary tuberculosis.

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We report a case of mediastinitis caused by an aberrant wooden foreign body in the mediastinum after a suicide attempt. A 31-year-old female was emergently admitted to our hospital for hematemesis after having attempted to hang herself, on being found in a woodland by her husband in May 2005. Chest X-ray showed a filling defect on the left side of the neck, and chest computed tomography (CT) showed bilateral neck and mediastinal emphysema. Bronchoscopy revealed a small swelling in the hypopharynx, and lesions in the trachea and bronchus. She reported a pain on the left side of her neck 3 days after admission, and three-dimensional (3D) CT showed a wooden foreign body 12 centimeters in length and 1.5 centimeters in diameter. We diagnosed mediastinitis caused by the foreign body, and performed an emergency operation to incise the cervix, verify the wooden foreign body between the left carotid artery and the cervical esophagus, cut the foreign body, and remove it. We then converted to a right-sided lateral position and opened the mediastinal pleura with respect to the left under video assisted thoracoscopic surgery, and mediastinum drainage was performed. 3D-CT was effective in the diagnosis of an aberrant wooden foreign body inside the mediastinum.

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We encountered a rare case of lung cancer in pulmonary sequestration. A 79-year-old man with hemoptysis who was suspected of having lung cancer by sputum cytology was admitted to our hospital. Enhanced chest CT revealed a solid tumor in the left lower lobe and an abnormal artery arising from the descending thoracic aorta. Squamous cell carcinoma originating from the pulmonary sequestration was diagnosed by TBLB. Left lower lobectomy with mediastinal lymph node dissection (ND2a) was performed and the pathological stage was T2N2M0. The postoperative course was uneventful and the patient has been in good health without recurrence.

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A 24-year-old woman experienced sudden hemosputum and hemoptysis during her menstruation period in October 2002. Her past history was dilatation and curettage at 23-years-old. She showed repeated catamenial hemosputum during every menstruation period. Chest CT revealed infiltrative shadows in the left S³, right S⁸, and right S⁶ areas. Bronchoscopic examination revealed hemorrhage from a left B³a bronchus but a transbronchial lung biopsy was not able to confirm ectopic endometrial tissue. After follow-up over the proceeding three months due to the persistence of hemosputum, video-assisted thoracoscopic surgery (VATS) was performed. A lesion was identified as the hemorrhage site under the visceral pleura via the thoracoscope, and diagnosed as pulmonary endometriosis pathologically. VATS may be considered as one of the useful procedures for the diagnosis and treatment of pulmonary endometriosis. It is important that the lesion causing hemoptysis or hemosputum is identified by chest CT and bronchoscopy during the menstruation period for reliable determination of the region which should be resected.

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A 47-year-old man consulted our hospital for a coin lesion on a routine chest X-ray with no complaints. Chest CT showed a nodule in the right lower lobe. Bronchoscopic examination revealed no malignancy and the nodule had not changed in size nor character. Because lung cancer had not been ruled out radiologically and pathologically, thoracoscopic partial resection was performed. At first, pulmonary cryptococcosis was suspected, but immunohistochemistry was not compatible. At last, it was diagnosed as pulmonary histoplasmosis by the detection of rRNA of H. capsulatum from a paraffin-embedded tissue sample. Pulmonary histoplasmosis is rare in Japan. Because the number of imported mycoses in Japan is expected to increase, pulmorary histoplasmosis should be considered in the differential diagnosis and therapy of pulmonary nodules.

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We treated a case of invasive thymoma with pleural dissemination and hepatic metastasis. Hepatic metastasis was treated by microwave coagulation therapy and stereotactic radiation therapy. Furthermore, pleural dissemination was treated via surgery combined with hyperthermic perfusion chemotherapy. He is currently alive 6 years and 3 months following the diagnosis of pleural dissemination and hepatic metastasis, and well controlled medically. Long-term survival is enhanced by conducting multimodality treatment for cases of invasive thymoma with distant metastasis.

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Cholesterol granulomas are common in the mastoid region, but have rarely been reported in other areas. We report the case of a 55-year-old man who had a cholesterol granuloma in the mediastinal region. It was pointed out by chest Xp as a round smooth tumor behind the heart during a health check-up by chance. Chest enhanced CT showed a 5cm cystic mass without enhancement in the mediastinal region. We suspected it to be a bronchiogenic cyst, teratoid tumor, or neurinoma. We performed video-assisted thoracic surgery (VATS). It was finally diagnosed as a cholesterol granuloma, of which the origin was unknown.

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We herein report a rare case of mixed germ cell tumor of mature teratoma and seminoma. A 39-year-old male was hospitalized because of chest pain and persistent cough. Chest computed tomography revealed a mass of about 13cm in diameter in the anterior mediastinum. We could not obtain a preoperative diagnosis by percutaneous needle biopsy. Thus, we performed a biopsy of the tumor via a small incision from the anterior chest wall under general anesthesia. The diagnosis was carvernous hemangioma. We performed tumorectomy with median sternotomy. The final diagnosis was mixed germ cell tumor of mature teratoma and seminoma. The teratoma component comprised the anterior part of the tumor, with the seminoma component comprising the posterior part of it. The unique conformation of the tumor made it difficult to make an accurate diagnosis. He received adjuvant chemotherapy. At 7 months after surgery, he is alive without any recurrence.

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The patient was a 79-year-old woman who underwent artificial pneumothorax for pulmonary tuberculosis 62 years ago. She experienced dyspnea at rest from 3 months ago and needed artificial ventilation due to CO₂ narcosis. Chest CT revealed a huge heterogeneous mass growing from the left thoracic cavity and expanding to the retroperitoneum, compressing the heart and right lung. Under a clinical diagnosis of chronic expanding hematoma of the thorax (CEH), the patient underwent pleuropneumonectomy and the resection of 9 rib seqments through supine position and L-shaped anterior approach, Then, thoracoplasty was completed with musculocutaneous flap to fill and cover residual space. The hematoma measured 25 cm and weighed 2300 g. It is suggested that anterior approach in the supine position is suitable for extrapleural pneumonectomy against CEH.

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