Objective. We assessed the outcome of surgical treatment for malignant pleural mesothelioma (MPM), and elucidated the surgical indication and surgical procedures. Patients. The subjects were 79 patients with MPM treated at the authors' hospital from 1993 to 2007. Results. We analyzed 22 patients with MPM who underwent extrapleural pneumonectomy. The 21 men and 1 woman had a mean age of 61.9 years old. Histological diagnosis was as follows: 11 patients were epithelial type, 3 patients sarcomatous type, 2 patients biphasic type, and 6 patients desmoplastic type. According to staging of the International Mesothelioma Interest Group, 11 patients had stage I disease, 3 stage II, and 8 stage III. The two- and 5-year survival rates were 52.8 and 44.0%, respectively. Sits of recurrence were lymph nods, anterior mediastinum, intrapericardium, lung and liver. Statistically, significant differences of survival were seen according to T-factor. There was no significant difference between surgery and chemotherapy in stage III. Conclusion. Extrapleural pneumonectomy could be an effective treatment for early stage malignant pleural mesothelioma. We must elucidate the surgical indication for stage III and new strategy for pleural mesothelioma.

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The incidence of non-tuberculous mycobacteriosis (NTM) has recently been increasing, and about 8,000 new cases occur every year in Japan. A curative, multidrug treatment regimen is selected first. However, there are many cases resistant to anti-bacterial medicine, including anti- tubercular drugs. We have operated on seven cases of NTM over the past 3 years, and obtained satisfactory results. There are few reports on surgical treatment for NTM. So far, there are some surgical indications for NTM both in and outside Japan. However, they are not based on clear evidence. Some cases which are considered to be indicated for surgical resection do not coincide with these indications. In the future, it will be necessary to conduct a detailed comparison and examination of actual surgical cases, and new surgical indications for NTM should be devised.

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The purpose to this study was to assess the morbidity, mortality and long-term survival following pulmonary resection for octogenarians with lung cancer (elderly group, n=28), in the comparison with younger patients than 80 years old (non-elderly group, n=298). There was no significant difference in the percentage of limited lung resection in the elderly group and non-elderly group (22.5% versus 30.8%). The percentage of the patients with modified lymph node dissection in the elderly group was significantly greater than that in the non-elderly group (80.8% versus 29.9%, p<0.0001). There were no significant differences in major postoperative morbidity, operative mortality and 5-year survival rate between the two groups. Limited pulmonary resection with modified lymph node dissection was considered to be one of the eligible treatments for octogenarians with lung cancer.

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Sixteen patients underwent thoracotomy for the treatment of pulmonary aspergilloma. They had several kinds of underlying diseases. Five patients had tuberculosis, four had leukemia, there was one patient each with bronchiectasis, pneumonia, lung cancer, and SLE, and three patients had no underlying disease. Seven patients (43.8%) had hemoptysis, and the other patients exhibited no symptoms. Several kinds of surgical procedures were performed. For simple aspergilloma, there were 3 lobectomies and 2 partial resections. For complex aspergilloma, there were 5 lobectomies, 4 segmentectomies, and 2 cavernotomies with muscle transposition and thoracoplasty. When we compare simple and complex aspergilloma regarding the postoperative days, operation time, and quantity of bleeding, simple aspergilloma showed significantly lower values. In addition, there was no severe complication in patients who underwent cavernotomy with muscle transposition and thoracoplasty. Therefore, we conclude that cavernotomy with muscle transposition and thoracoplasty was effective for patients who had pulmonary aspergilloma with high-level adhesion.

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Two patients with lung adenocarcinoma in the right upper lobe developed acute respiratory failure. Chest roentgenogram showed that the right lung was completely atelectatic, and the mass in the right upper lobar bronchus protruded centrally through the lumen of the main bronchus. The endoluminal tumor was removed emergently by coring it out with the tip of a rigid bronchoscope, and atelectasis was ameliorated. Then, right upper sleeve lobectomy was performed. Case 1 was a 46-year-old man whose carcinoma was at pathological stage III b (P-T4N2M0). He is free of tumor recurrence at 39 months after surgery. Case 2 was a 79-year-old man whose carcinoma was at pathological stage II b (P-T3N0M0). Although he could resume his daily life prior to respiratory failure, his tumor recurred and he died 5 months after surgery. Debulking of tumors with a rigid bronchoscope was found to be useful not only for the improvement of the quality of life of patients, but also for subsequent interdisciplinary treatment of lung carcinoma.

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The patient was a 54-year-old woman. An abnormal chest shadow was pointed out during a company medical examination in June, 2005. She consulted the Department of Respiratory Medicine of our hospital. Chest computed tomography (CT) showed a small irregular nodule in the right middle lobe, but the 18F-fluodeoxyglucose positron emmision tomography (FDG-PET)-CT finding was negative. However, lung cancer was suspected. Therefore, thoracoscopic surgery was carried out for the purpose of diagnosis and treatment in February, 2006. The histopathological diagnosis was solitary capillary hemangioma of the lung. After the operation, there have been no signs of recurrence.

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A 65-year-old man showed bilateral re-expansion pulmonary edema (RPE) following video-assisted hemi-thoracoscopic surgery. Mechanical respiratory support, and administrations of sivelestat sodium hydrate, ulinastatin, and prednisolone dramatically improved RPE without any further complication.

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An 86-year-old woman was admitted to our institute for palpitation, chest oppression, fever and cough caused by a large esophageal hernia. Chest X ray showed a huge stomach bubble and niveau in the mediastinum. Barium swallowing upper gastrointestinal examination revealed an esophageal hiatal hernia (a voluminous hiatal hernia (-VHH-)). Considering her age, we treated the VHH by laparoscopy using a modified Nissen fundoplication. She was able to ingest food four days after the operation. She left our institute 10 days after the operation. The patient died from the other disease two years after the operation. There has been no recurrence. Since chest surgeons sometimes encounter diaphragmatic hernias, relaxation of the diaphragm, and traumatic diaphragmatic hernia, it is important to manage esophageal hernia.

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We report a case of bronchial tumor which obstructed the airway by tension pneumothorax. He was a 30-year-old man. He has been regarded as bronchial asthma from his symptoms. He consulted his family doctor for severe cough. His doctor noted an abnormal shadow on chest X-ray. Therefore, he was referred to the Department of Respiratory Medicine in our hospital and admitted for more detailed examinations and treatment. Bronchoscopic findings showed a tumor originating from the left upper division bronchus, obstructing the left main bronchus, and projecting into the trachea. We performed a biopsy. The results identified fibroepithelial polyp. Our first round of treatment consisted of burning the part of tumor which had projected into the trachea by bronchoscopic snaring and YAG-laser treatment. When we were considering the next treatment, he suddenly developed respiratory arrest, so we were forced to intubate and performe bronchoscopy. Bronchoscopic findings showed a tumor which obstructed the trachea. In addition, left tension pneumothorax was discovered upon further examination via chest X-ray. He was moved to the Department of Respiratory Surgery, and underwent left upper lobectomy after left chest drainage. He is currently free of recurrence.

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A 72-year-old man was referred to our hospital for aspiration of a crab's leg. Chest CT scan confirmed a foreign body from the distal trachea to the left main bronchus. In spite of removal attempts with a flexible bronchoscope, it could not be removed as prickles on its surface were firmly adhered to the bronchial wall. Therefore, we decided to remove it via a thoracotomy. The right chest cavity was entered using the French-window thoracotomy technique under general anesthesia. An incision about 2 cm long was made in the lateral wall of the trachea parallel to the cartilaginous ring above the carina. Although we tried to pull it out with forceps, it still did not move because the prickles, facing the oral side, had stuck into the endobronchial surface. Therefore, the crab's leg was cut into several pieces with scissors to facilitate removal. Although an aspirated foreign body can usually be removed under bronchoscopy, there are rare cases in which thoracotomy is required.

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A 68-year-old woman with a history of chronic sinusitis was pointed out as having three pulmonary tumors of the bilateral lungs on chest computed tomography. The main round tumor of 5 cm in diameter was seen in the lower lobe of the right lung to be increasing in size, and had a cavitation at 5 months. Histology from a bronchoscopic examination revealed no malignancy. A right lower lobectomy was performed for the purpose of making a final diagnosis. The permanent section led to a diagnosis of diffuse large B-cell lymphoma (DLBL). The most characteristic feature of pulmonary lymphoma is its process of enlarging without destruction of the surrounding pre-existing structures, so it is rare of a cavitation in a pulmonary mass. There are a few reports of a cavitation in the tumor of primary pulmonary lymphoma, and all reports have given the diagnosis of DLBL. Primary pulmonary lymphoma is usually of low-grade mucosal origin associated with lymphoid tissue (MALT) lymphoma without necrosis, but it was suggested that rare cases of high-grade DLBL may include a cavitation secondary to necrosis.

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We herein report a case of pulmonary MALT-lymphoma operated on after long-term follow-up. A 70-year old man was admitted to our hospital for chemotherapy to treat pulmonary MALT-lymphoma, which was diagnosed by TBLB. An abnormal shadow of the right lung was pointed out 20 years ago, however, he refused further diagnosis and treatment. Tumor of his right middle and lower lobes gradually enlarged and caused pneumothorax following admission. We performed right middle and lower lobectomy with mediastinal lymph node dissection. Patients with pulmonary MALT-lymphoma require close follow-up. A wide range of treatments are being used for pulmonary MALT-lymphoma, resulting in good outcomes.

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A 50-year-old man was admitted to our hospital because of hemosputum. Chest X-ray and CT scan revealed a 5 cm nodular shadow with a cavity in the right upper lobe. Bronchofiberscopy was performed, and aspergillosis was diagnosed bacteriologically. He had no history of lung nor immunological disease. We diagnosed the case as primary pulmonary aspergilloma, and performed right upper lobectomy. The post-operative course was uneventful. Four months after the operation, there is no sign of recurrence. Primary aspergilloma is rare, but there is a high risk of hemoptysis. Radical resection is needed to avoid hemoptysis.

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A 54-year-old woman was pointed out as having a small adenocarcinoma measuring 14 mm in the left S1+2, and underwent a left upper division segmentectomy by video-assisted thoracoscopic surgery. The patient's postoperative course was initially unremarkable, but on postoperative day 3, sudden dyspnea with intense cough appeared and an air space above the diaphragm was identified on chest roentgenogram. Broncoscopic findings revealed a 90-degree counterclockwise torsion of the left bronchus. We performed a rethoracotomy to successfully reduce the torsion of the left lung without completion pneumonectomy. Afterwards, she has been without complications. There are some reports of lung torsion following lung resection, but that of the left lung is comparatively uncommon. This is the first reported case of lung torsion following segmentectomy of the left lung.

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We report one case of mediastinal germ cell tumor with Down syndrome. The case was in his late twenties. An abnormal shadow was recognized on the chest X-ray film during follow-up study of Down syndrome. The tumor noted in the anterior mediastinum on chest CT was diagnosed as a germ cell tumor by CT-guided needle biopsy. After two courses of preoperative chemotherapy (BEP), an extended thymectomy combined with resection of the pericardium was performed. The diagnosis of germ cell tumor consisted of both non-seminomatous and teratomatous components yielded histopathologically. Most of the tumor was reduced by chemotherapy, but some viable components of mature teratoma were noted. The patient is currently alive and well without any relapse four years since initial treatment. Several cases of mediastinal germ cell tumor accompanied by Klinefelter syndrome have been reported, but a tumor accompanied by Down syndrome could not be found in the literature.

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We describe two cases of pulmonary amyloidosis with Sjögren's syndrome. Case 1: A 67-year-old man had a nodular shadow of 15 mm in diameter with heavy calcification in the left lower lobe. Lung biopsy specimens showed amyloid deposits, so we finally diagnosed the case as AA amyloidosis. Primary Sjögren's syndrome was subsequently diagnosed. Case 2: A 42-year-old woman with Sjögren's syndrome and chronic hepatitis showed multiple nodules in the bilateral lungs. The nodules were diagnosed as pulmonary AL amyloidosis, and were identified by open lung biopsy. Pulmonary amyloidosis associated with Sjögren's syndrome has rarely been reported.

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An 81-year-old woman was pointed out as having an abnormal shadow on chest X-ray. Computed tomography revealed a highly calcified mass lesion in the right anterior mediastinum that was 40 mm in size, and another in the left 30 mm in size. She underwent mass resection with extended thymectomy. Neither mass showed severe adhesion to adjacent organs and both could be completely resected except for the left phrenic nerve. Pathological findings of the left mass showed small round tumor cells, and further immunohistological staining revealed that the tumor cells were positive for neuron-specific enolase, S-100 protein and synaptophysin but negative for cytokeratin, MIC-2, UCHL-1 and L-26, therefore we diagnosed this tumor as a neuroblastoma. Pathological findings of the right mass showed only necrosis and calcification, with no viable cells. Following the operation, 46 Gy of irradiation was performed. About four years after the resection, she died due to the recurrence in the left hemithorax and multiple bone metastases. Neuroblastoma found in an octogenarian is extremely rare, and that arising in the anterior mediastinum is also uncommon.

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A 43-year-old female was admitted to our hospital because of a mediastinal tumor identified by chest X-rays. Computed tomography showed an anterior mediastinal tumor contained in soft tissue, with fluid and cystic components and high serum carbohydrate antigen 19-9 (CA19-9) levels (108 U/ml). Surgery was performed, and the tumor was found to strongly adher to the left upper lung lobe. Thymectomy was conducted with a left lung partial resection. Histological findings showed a mature teratoma with a pancreas tissue gland. The high serum CA19-9 level decreased to normal after the operation. Therefore, we suspect that a mature teratoma may have caused the high serum CA19-9 levels. Futhemore, even if patients are asymptomatic on diagnosis, we should keep in mind the possibility of the combined resection of involved organs because of the risk of adhesion to the adjacent tissue.

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We report a case of osteomyelitis on the anterior chest wall after resection and radiation therapy for breast cancer. A 65-year-old woman underwent radical mastectomy with postoperative irradiation for breast cancer 24 years ago. A radiation-induced ulcer on the right anterior chest wall was noted. About 2 years ago, a full-thickness ulcer with rib exposure developed, and bleeding was seen 3 months ago, and so she was admitted to our hospital. Anterior chest wall resection and reconstruction using a latissimus dorsi myocutaneous flap was performed. She is currently well without any evidence of recurrence.

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We report a case of a huge malignant solitary fibrous tumor compressing the cardiac ventricle, with massive intrathoracic hemorrhage. The patient was 72 years old, and his complaints were chest pain and respiratory distress. Visually, the tumor was completely resected, and histological examination revealed that the tumor was a malignant solitary fibrous tumor. Six months later, we detected local recurrence and right lung metastasis. Actually, it is very difficult to perform complete resection for the huge and invasive tumor, so the possibility of local recurrence and metastasis should be considered. We need to conduct further examinations concerning the use of adjuvant chemotherapy for SFT.

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A 60-year-old woman came to our hospital complaining of right back pain. Although the cause was unclear at first, chest computed tomography (CT) and magnetic resonance imaging (MRI) revealed an intramuscular mass shadow in the right paravertebral region and a solitary subpleural pulmonary nodule in the right upper lobe of the lung. The former was not diagnosed correctly by percutaneous biopsy, and the latter was diagnosed as adenocarcinoma by frozen section analysis of an intraoperative needle biopsy and surgically removed by thoracoscopic lobectomy with lymph node dissection as a primary lung cancer. The postoperative pathological diagnosis of this tumor turned out to be an epithelioid hemangioendothelioma (EHE). After a six-month follow-up, the patient again came to our hospital with severe right back pain and cytologically positive right pleural effusion. The dorsal intramuscular mass had increased in size, and, this time, was diagnosed as EHE via CT-guided percutaneous biopsy, which suggested that this tumor was primary and that it had caused pulmonary metastasis and then pleuritis. Gefitinib (Iressa) or interleukin-2 injection was given to the patient, with no therapeutic effect. With deteriorating right back pain, the patient died of suspected meningitis two months after disease progression. Recently, epithelioid hemangioendothelioma (EHE) is considered to be a low-grade, malignant tumor originated from vascular endothelial cells, and can arise in any part of the body, especially the lungs, liver, bone, or soft tissue. Although the primary tumor of this patient is considered to have originated from the erector muscles of the right back, multi-centered EHEs, which are also often reported, cannot be denied. Pulmonary EHE (PEH), which was once known as intravascular bronchioloalveolar tumor (IVBAT), is often encountered in daily clinical levels, and PEHs of limited numbers can be treated successfully with complete surgical resection. However, other EHEs are hard to cure surgically due to local advancement, distant metastasis, or multi-centricity. Chemotherapy or radiation therapy for EHE has yet to be proven effective. Herein, we report an interesting case of soft-tissue-oriented EHE which presented various clinical states.

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Surgical indication for blunt chest injury with multiple rib fractures has been discussed extensively. However, an optimal strategy for treatment remains controversial. Unremitting pain and dislocation of fractured ribs leading to chest wall change, which are not factors directly related to the prognosis, may cause suffering and influence the quality of life for a long time. Therefore, indications for surgical intervention should be decided on in consideration of these factors. Young patients may also suffer from operational scars from surgical intervention. We performed rib stabilization using Mennen plates with minimal skin incision for pain resolution and repair for the dislocation of fractured ribs, and the patient was cured satisfactorily.

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A 77-year-old man was admitted to our hospital to undergo resection of a lung tumor. Because the tumor was small and indeterminate, a hook wire was inserted percutaneously into the peritumor at a depth of 3 cm from the pleura under computed tomography guidance. After the insertion, he walked with a stagger. Intraleft ventricular gas and intrapulmonary artery gas was noted by computed tomography immediately thereafter. The patient recovered spontaneously without any additional complications. Although air embolism is a rare complication, we must always be aware of this complication when performing lung puncture.

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