Objective. We examined the clinical features, diagnosis, treatment, prognosis, and prognostic factors of malignant pleural mesothelioma. Subjects. Seventy-nine patients from the main center for asbestos-related disease for diagnosis and treatment, Okayama Rousai Hospital, were enrolled. Results. Of the 79 patients, 70 cases were male and 9 were female, with an average age of 65.5 years old. A past history of exposure to asbestos was identified in 66 patients (83.5%). Thirty-nine patients (49.4%) presented symptoms such as chest pain. Cytodiagnosis of pleural effusion was not useful for the diagnosis. Thoracoscopic pleural biopsy was the most effective diagnostic method. It required 4.6 months (median) from the first visit to establish the diagnosis of malignant pleural mesothelioma. Surgery was performed in 22 cases. Chemotherapy and/or radiotherapy were performed in 46 cases, while supportive care alone was carried out in 11 cases. The 1-, 2-, and 3-year survival rates overall were 50.7%, 26.9%, and 12.0%, respectively, while, the median survival was 12.0 months. Significant differences in survival were seen according to the clinical stage and surgery on univariate analysis, but only for the clinical stage with multivariate analysis. Conclusion. For a definitive diagnosis, thoracoscopic pleural biopsy should be performed promptly in cases with pleural effusion of unknown origin. The establishment of appropriate indications for surgery, the development of adjuvant therapy, and the development of effective chemotherapy are required for the improvement of survival in patients with pleural mesothelioma.

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Background: Pulmonary pleomorphic carcinoma is a rare non small cell lung cancer with a poor prognosis. This carcinoma belongs to the sarcomatoid carcinomas according to the Pathology & Genetics of Tumours of the Lung, Thymus and Heart (World Health Organization Classification of Tumours 2004). We investigated this rare disease to establish an appropriate treatment strategy. Materials and Methods: A total of 6 cases underwent surgical treatment between April 1999 and October 2007 in our hospital. There were four men and two women, with a mean age of 68.3 years (range: 61 to 77). Five cases had a smoking habit. No cases had a confirmed diagnosis before the operation, and all were diagnosed with pleomorphic carcinoma immunohistologically using resected specimens. Results: The locations of tumors were RUL (three cases), RLL (two cases), and LUL (one case). The median size of the tumor was 70 mm (range: 33 to 112 mm) in diameter. All cases exhibited necrotic lesions, and the median ratio was 30% (range: 10 to 100%). Pleural invasion factors were p0 (two cases), p2 (one case), and p3 (three case). Two cases showed lymph node metastasis to the mediastinal lymph nodes. Complete resection was conducted in five cases. However, one case did not undergo complete resection because of a direct invasion to the brachial plexus. Three cases showed recurrence (brain metastasis, bone metastasis, and chest wall recurrence). Recurrent or unresectable cases underwent radiotherapy or concurrent chemoradiotherapy. The chemotherapy regimen was CBDCA and paclitaxel combination. Although only radiotherapy cases showed a poor prognosis, chemoradiotherapy cases revealed a good response. Discussion: Pulmonary pleomorphic carcinoma is characterized by rapid growth, a peripheral site, invasion to the pleura or chest wall, and a poor prognosis. Pleomorphic carcinoma tends to occur in the upper lobe of the lung and peripheral regions. Almost all patients with pleomorphic carcinoma have a smoking habit. Therefore, pulmonary pleomorphic carcinoma may be associated with smoking. Patients with pulmonary pleomorphic carcinomas of stage I tend to show a longer survival than those with stage II or more. Although cases had undergone complete resection, disease recurrences occasionally occurred soon after the radical operation. Two cases showed a good response to concurrent chemoradiotherapy. This concurrent chemoradiotherapy is possibly an important part of the treatment strategy for pulmonary pleomorphic carcinoma. Conclusion: Pulmonary pleomorphic carcinoma has a poor prognosis. Early diagnosis and surgical treatment comprise the most effective therapy at this time. However, closely timed recurrences can occur even with a stage I pleomorphic carcinoma. Although many reports state that chemotherapy or radiotherapy is not effective, this report suggests that concurrent chemoradiotherapy (CBDCA+PAC) might be an effective treatment for pulmonary pleomorphic carcinoma.

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From January 1997 to March 2001, we treated 159 cases with a spontaneous pneumothorax, 81 cases by normal video-assisted thoracic surgery (VATS), and 78 cases by Nd: YAG laser through a needle thoracoscope (mini-VATS). All cases underwent chest CT for preoperative examination. Normal VATS was performed for patients with bullae > 2 cm on chest CT. Mini-VATS was performed for the other patients. Recurrence occurred in 8 cases after mini-VATS (8/78, 9.8 %) and in 12 cases after normal VATS (10/78, 12.5 %). The recurrence rate was acceptable as it was similar to that in the 1990's. However, it is higher than that for thoracotomy. For better results, both mini and normal VATS require some additional techniques, for example, covering with something, reconsidering the appropriate method for the bullae condition, and so on.

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We retrospectively reviewed our institutional experience of pulmonary hamartomas. We analyzed the records of 23 patients with pulmonary hamartomas which were diagnosed by surgical resection. There were 12 males and 11 females. Their mean age was 53.5 years old (range: 28 to 71 years). Twenty patients were asymptomatic, 2 had chest pain and 1 had a cough. Twenty-two patients had solitary and only 1 patient had multiple lesions. The tumor sizes ranged from 0.5 to 3.0 cm (mean: 1.5 cm). Graphically, 6 patients had calcification which was not popcorn-like. We could not diagnose nodules by bronchoscopic biopsy, which was preoperatively performed in 17 patients. Surgery was performed because we could not rule out malignancy in all patients. Surgical procedures consisted of 6 enucleation, 16 wedge resection and 1 lobectomy. Video-assisted thoracic surgery was performed in 17 patients. To diagnose pulmonary nodule, whose malignancy is difficult to determine, surgical resection should be considered.

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Background: ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) is usually performed for the diagnostic staging of lung cancer. The number of patients with indeterminate pulmonary nodules is increasing because thin section computed tomography has become popularized. The treatment of non-small cell lung cancer depends on the clinical stage, which is often designated based on the results of integrated FDG-PET. Methods: In this report, we performed a retrospective case study of a consecutive series of 283 patients, evaluating the accuracy of FDG-PET in the diagnosis of pulmonary nodules, and for hilar and mediastinal lymph node staging if the nodule was malignant. Malignant tumors were considered to show maximum standardized uptake values (SUV max) of 2.5 or more. All patients had undergone pulmonary resection between July 2005 and June 2007 in our hospital. Results: The sensitivity and specificity of FDG-PET for the diagnosis of pulmonary nodules was 72.7% and 60.5%, respectively. In differentiating benignity from malignancy, small-sized nodules 20 mm or smaller in diameter and bronchioloalveolar carcinoma (BAC) revealed a strong tendency to give a false negative result on FDG-PET. On the other hand, solid dense tumors like squamous cell carcinoma or large cell carcinoma showed a positive result with a high SUV max. The sensitivity and specificity of FDG-PET for lymph node staging were 68.0% and 93.2%, respectively. Conclusion: FDG-PET detection of malignancy is limited for small-sized adenocarcinomas with high-level ground-glass opacity. The detection of lymph node metastasis showed marked specificity, whereas there were many false negative cases. We must employ FDG-PET for the diagnosis of lung nodules only with a firm grasp of its advantages and disadvantages.

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A 38-year-old woman had a pulmonary metastasis from sigmoid colon cancer, after prior pulmonary metastatectomy. She was not a surgical candidate because of preservation of the residual pulmonary function. Radiofrequency ablation (RFA) was performed. A multitined expandable electrode with a 2-cm diameter array was used. Then she suffered from pneumothorax after RFA, and she was treated with chest tube drainage. Because air leakage was continuous, surgery was performed on day 37 after RFA. Air leakage from the ablation site was proven, and this site was resected. Microscopic examination revealed viable cells almost in the part of the tumor. She is alive without further recurrence or pulmonary metastasis. Taking into consideration the remaining viable cells in a tumor, we conclude that repeated surgical resection is recommended for pulmonary metastases from colorectal cancer rather than RFA, in selected patients.

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A 25-year-old female with complaints of dry cough and general malaise was referred to our hospital. Chest X-ray revealed a mass shadow in the left lower lung field. A multiple cystic lesion was detected, extending from the upper mediastinum to the left lower thoracic cavity on chest CT and MRI. The left lobe of the thymus with multiple cystic lesions was resected using the VATS technique. Histopathological examination revealed that the mass was a multilocular thymic cyst which was reported by Suster, but with no neoplastic lesions. Multilocular thymic cyst-like changes are sometimes presented in association with thymic Hodgkin's disease or thymic seminoma. Malignant transformation and complication with some autoimmune diseases of thymic cyst were also reported (Sjögren's syndrome, myasthenia gravis, etc.). Thus, careful examination and evaluation for cystic lesions within the thymus are required.

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A 64-year-old male received radiotherapy after right upper lobectomy for primary lung cancer invading the chest wall. Six months after the irradiation, he developed radiation pneumonitis in the right apex, and oral prednisolone was administered. Although chest X-ray showed improvement two months later, further chest X-ray analysis and chest computed tomography showed a cavity and surrounding infiltration in the right apex. Sputum culture grew Aspergillus fumigatus, and he was admitted to our hospital. The infiltration rapidly enlarged after the administration of antifungal agents, and complete right pneumonectomy was performed. The histologic findings showed that the fungal hyphae were only on the surface of the cavity wall, and that no fungal invasion of viable lung tissue was seen. The final diagnosis was non-invasive pulmonary aspergillosis. The patient has been followed-up as an outpatient for 10 months, and, so far, there has been no evidence of recurrence of pulmonary aspergillosis or lung cancer. Herein, we report this case with reference to the classification of pulmonary aspergillosis and new antifungal agents.

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We experienced a rare case of intramuscular hemangioma in the chest wall. The patient was a 71-year-old male with a thoracic tumor. We examined it by FDG-PET, the tumor showed accumulation, and diagnostic surgical resection was performed. Hemangioma is a common, benign, soft-tissue tumor, and most occur in the skin or subcutaneous tissue, being rare in skeletal muscle. Intramuscular hemangioma grows invasively into the skeletal muscle even though it is benign, and sometimes recurs after surgical resection. Recently, MRI has proved useful in preoperative diagnosis. It is rare that hemangioma occurs in the chest wall, but it should be included in the differential diagnosis of thoracic tumor.

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A 56-year-old male underwent right upper lobectomy with chest wall resection after induction chemotherapy for lung cancer. Acute renal dysfunction caused by hypercalcemia presented 2 months after the operation. Chest CT revealed a relapsed tumor invading the thoracic vertebra. High plasma PTHrP, low intact PTH, and low Vit. D led to the conclusion that the lung cancer produced PTHrP. The relapsed tumor was reduced and the level of serum PTHrP was improved by concurrent chemo-radiotherapy and bisphosphonate.

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Lipomas are a common type of benign tumor, but are rarely seen in the thoracic cavity. We report a case of resected intrathoracic chest wall-type lipoma with a distinctive form. The patient was a 72-year-old female with an abnormal shadow showing an increasing size on chest X-ray. CT showed a homogeneous, low-density mass of fat arising from the left chest wall. MRI revealed a high signal intensity mass on both T1- and T2-weighted images. Thoracoscopic view demonstrated a yellowish hemisphere tumor with an almost free form in the left thoracic cavity. The tumor was easily extirpated by thoracoscopic resection, and histologically diagnosed as a benign lipoma.

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Herein, we report an adenoid cystic carcinoma that arose from and localized within the peripheral airway area. A 57-year-old woman underwent a routine roentgenogram of the chest during an annual examination, which revealed an oval-shaped mass near the right hilum. Thereafter, chest CT scan findings led to a suspicion of lung cancer. Fiberoptic bronchoscopy showed a tumor in the right B⁶_c and a biopsy specimen from the tumor revealed adenocarcinoma. A right lower lobectomy and mediastinal lymph node dissection were performed, which revealed a tumor 3.6 × 2.6 cm in diameter arising from a peripheral bronchiole beyond the subsegmental bronchus, showing endobronchial growth, and localized within the bronchus . Histological findings demonstrated an adenoid cystic carcinoma, pT2N0M0 stage IB. Postoperative examinations of other organs, including the salivary glands, breasts, and uterine cervix, did not disclose the presence of neoplastic lesions.

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A 13-year-old girl received a bruise to the chest. The chest X-ray showed a mass adjacent to the heart in the left thorax. We resected the mass via a left thoracotomy with a thoracoscope. The thymus was preserved. The tumor was a mature teratoma that had developed from the thymus in the anterior mediastinum. On the 5th day after the thoracotomy, she developed acute appendicitis, and a left ovarian cyst was found by chance. On the 7th day after the thoracotomy, we resected the ovarian cyst and appendix. The left ovarian cyst was also a mature teratoma. This was a very rare case of two teratomas that developed in the anterior mediastinum and ovary concurrently.

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There are two types (uni-or multilocular) of echinococcosis. Both types are mainly observed as liver lesions, and pulmonary unilocular echinococcosis is rare in Japan. A 25-year-old Chinese woman was pointed out as having a tumor in the left lung. The tumor's maximal size was 4 cm, and she underwent lingular segmentectomy by VATS. The postoperative course was good, and we finally diagnosed her with pulmonary unilocular echinococcosis. Pulmonary unilocular echinococcosis is rare in Japan, but a large number of cases have been reported around the world. So, the number of cases may increase in Japan. VATS operation was found to be useful.

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An 87-year-old male with serious chronic obstructive pulmonary disease (COPD) was safely and effectively treated for the presence of empyema following thoracoscopic decortication. He had been on mechanical ventilation before the operation. The empyema was in the fibrinopurulent phase and it was found to be nontuberculous. We treated the empyema first with thoracic drainage, but this procedure was not successful. As a result, we decided to treat it by means of video-assisted thoracoscopic surgery (VATS) and the results were satisfactory. The patient has been in good condition and is doing well without any recurrence of the empyema for 10 months postoperatively.

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Bronchogenic cysts are commonly located in the middle mediastinum. We report the rare case of a bronchogenic cyst in the thymus. A mass in the anterior mediastinum was detected by thoracic CT scan in a 65-year-old woman during human dry dock. We preoperatively diagnosed the mass as a thymic cyst or thymoma. We performed a thymectomy with median sternotomy. The tumor was located in the left lobe of the thymus, and had a cystic character with milky-white and turbid fluid. Histologically, there was a layer of ciliated epithelium lining the inner side of the cyst. We finally diagnosed the tumor as a bronchogenic cyst.

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We herein report a rare surgical case of intercostal pulmonary herniation. A man in his sixties was brought to our hospital by ambulance after sustaining blunt chest trauma on falling from a roof. Chest CT showed left multiple rib fractures and pneumothorax. Emergency operation was performed, leading to the discovery of intercostal pulmonary herniation. The pulmonary hernia orifice was the 5th intercostal space. The lung injury was treated by partial resection of the lung, and the chest wall was reconstructed by a polypropylene mesh sheet. The frail chest was not found postoperatively.

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A 26-year-old man with right pneumothorax was admitted to our hospital. Chest X-ray and chest CT revealed a mass arising from the fourth rib. During thoracoscopic surgery, we found a mushroom-like mass and bulla adjacent to the scar of the right middle lobe caused by the mass. We resected the mass and part of the right middle lobe. Pathological findings of the mass proved osteochondroma. The postoperative course was uneventful. Pneumothorax caused by costal osteochondroma is rare.

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We experienced a case of lung cancer with a foreign body consisting of a fish bone. A 60-year-old man consulted our clinic for an abnormal shadow on a routine chest X-ray and cough in November 2006. Chest CT showed a nodule near the orifice of the right lower bronchus and distal volume loss. Bronchoscopic examination revealed a yellowish-white lesion obstructing the right basal bronchus and peripheral granulation. Inflammation caused by infection was suggested and the symptom and image findings improved by conservative medical treatment, so, we subsequently performed follow-up. He complained of fever and cough in March 2007. Chest CT showed an enlargement of the nodule and obstructive pneumonia. Although brushing and washing cytology did not show malignant findings, we diagnosed lung cancer with a foreign body and peripheral granulation, and performed operation. The foreign body was in the right B8+9 and the nodule was in a peribronchial lesion of right lower bronchus in a sample. On pathological study, the foreign body was identified as a fish bone, and well-differentiated adenocarcinoma was noted in the nodule lesion. There was no lymph node metastasis. When we observe an endobronchial lesion, it is important that we consider the possibility of a foreign body, and that the malignant disease might be complicated.

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We report a case of postoperative lung torsion, a relatively rare but serious complication of lung surgery. A 52-year-old male patient was diagnosed with adenocarcinoma (T2N1M0 c-stage IIB) via transbronchial lung biopsy, and underwent left upper lobectomy and mediastinal lymphadenectomy. On chest X-ray, decreased transparency was noted in the left lung field from postoperative day 1. The patient developed fever and abnormally elevated levels of inflammatory markers on postoperative day 3. Bronchoscopic examinations revealed stenosis in the left lower lobe bronchus, and torsion of the remaining lower lobe was suspected. Therefore, rethoracotomy was performed. The lung was found to be swollen and dark red, and had twisted approximately 180 degrees around a bronchial tube. The remaining lobe was removed. The patient underwent postoperative respiratory rehabilitation and was discharged from hospital on postoperative day 20, having made satisfactory progress. The likely causes of the lung torsion included division of the pulmonary ligament, failure to take into account the suture direction during bronchial separation when carrying out automated suturing, and failure to check the position of the remaining lobe at the time of closing the chest.

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Computed tomography examination of a 17-year-old male who complained of frequent episodes of fever and chest pain revealed an anterior mediastinal tumor. This tumor was diagnosed to be a non-seminomatous germ cell tumor based on the elevated level of AFP in the serum and by percutaneous needle biopsy. After two courses of chemotherapy with CDDP and VP-16, the serum AFP level reduced to almost the normal limit. However, the tumor size was found to have increased on a CT scan, and the patient complained of dyspnea. We completely resected the tumor via a median sternotomy. Pathological findings revealed a mature teratoma with massive necrosis, a certain amount of embryonal carcinoma, and immature mesenchymal tissue. Four months after the operation, the patient complained of arthalgia of the limbs and low-grade fever. Close examination revealed no sign of tumor recurrence or metastasis, and the AFP level was normal. However, the number of platelets in the peripheral blood had decreased, and the serum LDH level was apparently increased. A bone marrow biopsy revealed megakaryocyte-like atypical cells. These cells were CD31- and CD41-positive; therefore, acute megakaryoblastic leukemia (M7) was diagnosed. The features of the atypical cells were similar to those of the immature mesenchymal cells in the germ cell tumor, which were also CD31- and CD41-positive. From these results, it is supposed that the atypical cells in the bone marrow were clones of the mesenchymal cells in the germ cell tumor. In other words, the etiology of M7 was considered to be bone marrow metastasis.

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A 73-year-old man was referred to our hospital because of an abnormal shadow in the left upper lobe of his lungs. Cytodiagnosis suggested adenocarcinoma. The preoperative serum level of progastrin-releasing peptide was elevated (80.4 pg/ml). Preoperative computed tomography demonstrated an ill-defined tumor with a diameter of 35 mm at S1 and S2 in the left lung. Left lobectomy and lymph node resection were performed under video-assisted thoracoscopy. Histopathological examination by hematoxylin-eosin staining revealed a tumor composed of small, round, atypical hyperchromatic cells in a solid and trabecular arrangement with frequent rosette formation. The tumor expressed chromogranin A. These findings suggested typical pulmonary carcinoid tumor. The serum level of progastrin-releasing peptide decreased after surgery and has been within a normal range since the second post-operative month. There are few reports of cases of typical pulmonary carcinoid tumor with elevation of preoperative serum progastrin-releasing peptide.

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We report three cases of pleomorphic carcinoma of the lung. The first case was a 72-year-old male. A tumor in the right lower lobe was diagnosed as cT2N2M0 non-small cell lung cancer, and right middle and lower lobectomy was performed. The pathological diagnosis was pleomorphic carcinoma. He died of metastatic disease 5 months after surgery. The second case was a 42-year-old female. She had a solitary tumor in the left upper lobe, and a single brain metastasis. Despite chemoradiotherapy, she died 9 months later. The third case was a 86-year-old male. Although he was diagnosed as pT2N0M0 after left upper lobectomy, he died of metastatic cancer 8 months later. Pleomorphic carcinoma is a rare type of non-small cell lung cancer. The preoperative diagnosis is often difficult, and the clinical course is aggressive with a poor prognosis.

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We present a surgical case of pulmonary carcinoma in a patient with complete situs inversus. A medical check-up showed a solitary focus in the right upper lung field in a 72-year-old man. A CT scan revealed a nodule, 3.5 cm in diameter, in the right upper lobe and complete situs inversus. Squamous cell carcinoma was confirmed by transbronchial lung biopsy. A left-sided double lumen bronchial tube was used for differential lung ventilation. On thoracotomy, the right lung possessed two lobes, and pulmonary arteries and veins corresponded to the usual left-sided pattern. Right upper lobectomy was successfully carried out.

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[in Japanese]

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