Chest physicians and home doctors may hesitate to refer cases of secondary pneumothorax involving elderly patients to surgeons because of the high operative risk. In the present study, we evaluated the impact of establishing a thoracic surgery division in a local medical center which had not had skilled thoracic surgeons on the treatment of secondary pneumothorax in elderly patients (≧ 65 years old). The number of patients who received surgical treatment increased from 6 in the first year to 9 in the second year after the opening of the thoracic surgery division. The total duration of treatment (from initial diagnosis to discharge after surgical treatment) was reduced from a median of 21 to 9 days. This reduction was due to a marked shortening of the number of days before admission to the thoracic surgery division. Primarily, this was related to an increase in cases directly and promptly referred from other medical institutes. Secondarily, in cases of indirect referral, a shortening of the hospital stay within the division of respiratory medicine also contributed to a faster decision regarding surgical treatment. We believe that thoracic surgeons could improve the chances of successful treatment of secondary pneumothorax in elderly patients.

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There have been only a small number of reported cases of slow-growing adenocarcinoma of the lung with a long clinical history. A 44-year-old man was diagnosed as having goblet cell-type lung adenocarcinoma after a 20-year observation. The patient was found to have a nodular lesion in the left lower lung field, and subsequently underwent anti-tuberculosis therapy. He was followed up thereafter as having a benign disease through chest radiographs at annual medical check-ups for 20 years. In 2006, changes in the size and shape of the abnormal lung shadow were noted. The mass lesion was diagnosed as goblet cell-type adenocarcinoma, and left lower lobectomy of the lung was performed. Without definitive evidence of tubeluculosis, some patients with an abnormal lung shadow were previously treated with anti-tuberculosis drugs, and were prone to be followed by simple examinations such as chest radiographs. The possibility of slow-growing lung carcinoma should be considered even in patients with a long history of medical observations. When a previously stable lung shadow reveals changes in size and shape, further examinations should be performed to facilitate a definitive diagnosis.

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A 26-year-old woman developed spontaneous pneumothorax of the right lung in the 36th gestational week. A thoracic catheter was placed after admission, but air leakage persisted. We considered whether VATS precedent to delivery or delivery precedent to VATS. She agreed with the latter plan. She delivered a healthy normal female infant, weighing 3,234 g by a Caesarean operation under chest drainage in the 39th gestational week. Video assisted thoracoscopic bullectomy was performed 7 days after delivery. The postoperative course was uneventful, and she was discharged on the 4th post operative day. Though the management of spontaneous pneumothorax in the third trimester of pregnancy is considered difficult, we suggested that VATS after delivery under chest drainage is safe and effective.

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An abnormal shadow was found in the chest of a 70-year-old man during a medical check-up in 2006. There were no symptoms such as a cough or bloody sputum. A chest radiograph identified a 3 cm, faint tumor shadow in the right lung. Computed tomography revealed a 3.5 cm tumor, and the patient underwent a bronchoscopic examination. However, no diagnosis was established, and he was referred to our hospital for an open chest biopsy and surgery. The patient underwent an FDG-PET examination, and the findings revealed a tumor in the middle lobe. The SUV value increased in the delayed image, indicating a malignant pattern. The tumor was thought to be primary lung cancer in the middle lobe. An open chest biopsy was performed, and a frozen section histology was conducted. The findings revealed that it was a non-neoplastic and infectious mass. A middle lobe excision was performed for the complete excision of the lesion. The pathological findings showed that the lesion was a non-neoplastic mass such as inflammatory granuloma, and the final diagnosis was lung Actinomyces.

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A 60-year-old man was referred to our hospital due to an abnormal shadow found on a chest radiograph. His chest CT scan showed a cystic tumor in the left upper mediastinal area. The preoperative diagnosis was neurinoma originating from the mediastinal vagal nerve. Video-assisted thoracic surgery was performed. The tumor arose from the mediastinal vagal nerve proximal to the recurrent laryngeal nerve, and tumor resection was performed. The histological diagnosis was neurinoma. His postoperative course was uneventful, and we could preserve the function of the recurrent laryngeal nerve.

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Case 1: An 85-year-old man underwent an operation for pericostal tuberculosis 65 years previously. Case 2: A 49-year-old man had undergone antituberculosis chemotherapy for pulmonary tuberculosis until 8 months previous. In both cases, abscess cavities with sequestrum exhibited a growing trend after 1 month of antituberculosis chemotherapy. Therefore, resection of the abscess and ribs was performed guided by staining with indigo carmine solution. Both cases underwent continued antituberculosis chemotherapy after the operation, with no recurrence to date. Even though the opportunity to encounter pericostal tuberculosis cases has been reduced, we still need to bear in mind that pericostal tuberculosis is one of the differential diagnoses among chest wall tumors. It is important that radical resection is performed at an appropriate time with the concomitant administration of sufficient antituberculosis chemotherapy.

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Background: Bronchial atresia is a rare congenital bronchial disease. Recently, because of advances in diagnostic imaging techniques, the number of reports has increased. Case: The case was a 47- year-old woman, in whom a growing tumor-like shadow had been detected on a mass survey at 19 years old. Fiberoptic bronchoscopic findings showed the lack of a left upper division bronchus, and computed tomography showed hyperlucency of the left upper lung and that the upper lobe bronchus was dilated like a sausage. Three-dimensional computed tomography also revealed the lack of a left upper division bronchus. From the above findings, this case was diagnosed as bronchial atresia of the left upper division lobe bronchus. Left upper lobe lobectomy was performed because of the gradually increasing tumor size. The left upper division bronchus was funicular and did not open into the left upper bronchus. The peripheral dilated bronchus contained a mucous secretion, but bacterial culture of the resected specimen did not reveal infection. Conclusion: We reported a case of bronchial atresia treated by lobectomy after a long period of observation.

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A 32-year-old pregnant woman at 18 weeks of gestation was referred to our hospital because of right precordialgia and right pleural effusion. A CT scan revealed right hemothorax with a suspicion of vascular fistula in the right middle lobe. Video-assisted thoracic surgery was immediately performed to remove the massive residual clot and stop the bleeding. A ruptured pulmonary arteriovenous fistula on the surface of the right middle lobe and non-ruptured one on the right lower lobe were recognized. Wedge resections of the right middle and lower lobes were performed. The patient remained healthy throughout the rest of her pregnancy. Five months later, she delivered a healthy baby.

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A 69-year-old woman complained of a persistent cough. A radiograph, CT, and barium enema study revealed the herniation of the transverse colon into the right hemithorax through a retrosternal defect, confirming the presence of Morgagni hernia. Simultaneous thoracoscopical and laparoscopical repair was performed using three thoracoscopical and two laparoscopical ports. The transverse colon in the sac was easily reduced into the abdominal cavity with laparoscopic assistance, and the hernial sac was resected and diaphragm defect was closed by double continuous suture with thoracoscopic assistance. Simultaneous thoracoscopical and laparoscopical repair should be considerd as a novel technique for Morgagni hernia with abdominal contents.

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A 71-year-old man with lung cancer of the left upper lobe and a small thin-walled cystic lesion in the lower lobe underwent left upper lobe resection and mediastinal lymph node dissection in our hospital. One year after surgery, chest CT demonstrated that the cystic lesion had enlarged. Three years after surgery, growing ground-glass opacity was noted around this cystic lesion. Left S⁸ segmental resection was performed. Histological findings led to a diagnosis of bronchioloalveolar carcinoma with dilated bronchi. It was suggested that the cystic lesion was enlarged because of disruption of the cystic wall by tumor cells, check-valve obstruction of the bronchi by tumor cells and displacement of the residual left lower lobe.

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The present patient was a 68-year-old man who was referred to our department after an abnormal shadow was observed in the right middle lung field on chest radiograph. Chest CT revealed nodular lesions in the S6 and S4 segments of the right lung. Upper gastrointestinal endoscopy performed for preoperative systemic examination revealed erosion of the entire stomach as well as a large ulcer in the lesser curvature of the upper part of the stomach. Biopsy suggested malignant lymphoma (diffuse large B-cell lymphoma). Intraoperative pathological examination showed tumor cells similar to those observed in the gastric biopsy. The present case further stressed the importance of preoperative systemic examination.

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Primary costal chondrosarcoma is relatively rare. A 77-year-old woman was aware of the chest wall tumor ten years ago. At first she had been observed under the diagnosis of chondroma. Later, she was diagnosed with chondrosarcoma and referred to our hospital for the surgical treatment. The operation consisted of the wide resection of the tumor and reconstruction of the chest wall defect. We employed the vertical rectus abdominis flap procedure on reconstruction. Pathological analysis revealed a highly malignant grade II chondrosarcoma. The patient is alive 2 years without recurrence.

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A 34-year-old woman with difficulty in breathing was referred to our hospital. She underwent surgery for bilateral pneumothorax. Regarding her family history, there were many cases of pneumothorax on her father's side. Chest CT showed a collapsed right lung and multiple bullae located predominantly in the interlobar, mediastinal, and bottom region. Because pneumothorax had not improved in spite of tube drainage, we performed surgery after confirmation of the leakage point by contrast-enhanced examination of the pleural space. However, there was a nonspecific feature on histopathological findings. After surgery, Birt-Hogg-Dubé syndrome was diagnosed, attributable to an autosomal dominant gene aberration on genetic examination. In addition, intrathoracic endometrium was confirmed by biopsy from the diaphragm at the same time. This is a rare case of Birt-Hogg-Dubé syndrome associated with intrathoracic heterotopic endometriosis. Birt-Hogg-Dubé syndrome is a risk factor of kidney cancer or other organ tumors. Accordingly, a more careful observation of patients with Birt-Hogg-Dubé syndrome must be performed. In addition, female pneumothorax requires a more careful assessment of the basal disorder, as various disorders might be concealed in the background.

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Wound dehiscence is mainly caused by surgical site infection (SSI), but may involve other factors. We describe our experience of 3 patients treated at our center who experienced wound dehiscence that was associated with opening of the thoracic cage and not caused by SSI. We discuss the potential causes. Patient 1 had diabetes mellitus. Dehiscence involving all layers of a thoracotomy wound occurred 28 days after resection of a tumor arising in the chest wall. Patient 2 underwent full-dose chemoradiotherapy and then a left upper lobectomy. A marked alveolar air leak developed on postoperative day 13. Operation revealed dehiscence of the thoracotomy incision. Patient 3 also received full-dose chemoradiotherapy, followed by a left upper lobectomy. An alveolar air leak developed on postoperative day 17 and did not respond to conservative therapy. Surgery was thus performed. Dehiscence of the thoracotomy wound was confirmed on surgery. All 3 patients had risk factors associated with delayed wound healing, such as diabetes mellitus and preoperative chemoradiotherapy. In all patients, the chest was closed in a Z-shaped pattern using absorbable sutures. Close inspection of the severed sutures revealed that they had broken at the crossover point. Severing of the suture widened the intercostal space. A tear apparently developed in the lung adhering to the thoracotomy site, leading to the development of a marked pulmonary fistula. On the basis of these findings, we have stopped using Z-pattern sutures to close the chest. We now perform simple ligation with 4 or more stitches to close the thoracic cage, and no wound dehiscence has occurred since switching to this technique.

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A 69-year-old man was pointed out as showing a mass-like shadow of 30×15 mm at the right S2 on chest CT one year after undergoing a distal gastrectomy for gastric cancer. Chest CT was performed 3 months later, showing the shadow had grown to 30×20 mm. The results of bronchoscopy didn't indicate lung cancer. However, FDG-PET showed a high accumulation (SUVmax: 5.97) around the tumor shadow, suggesting lung cancer. The definitive diagnosis following right S2 segmentectomy was pulmonary actinomycosis. In conclusion, it is necessary to consider pulmonary actinomycosis if a mass-like shadow is not characterized by bronchoscopy, along with a suspicion of lung cancer.

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FDG positron emission tomography has been used to quantify tumor metabolism. However, little is known about FDG uptake in benign tumors. We report a case of intrathoracic schwannoma showing a high uptake of FDG on PET. A 50-year-old female was referred to our hospital because of an abnormal shadow on a chest radiograph. Chest computed tomography scan revealed a posterior mediastinal tumor. The tumor showed high uptake on FDG positron emission tomography, and was resected under video-assisted thoracic surgery. The histological diagnosis of the frozen section was schwannoma. Because intrathoracic schwannoma sometimes shows a high level of FDG uptake, the tumor cannot be excluded when considering the differential diagnosis.

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A woman in her fifties underwent an operation for rectal cancer in 1999. Three years after the operation, she received surgery for bilateral lung metastasis twice. In 2006, a chest CT scan again showed nodules in her right lung. We diagnosed these as metastatic tumors of rectal cancer, and she underwent FOLFOX therapy. After that, her serum CEA level was reduced to normal, but the nodule of the right lung did not decrease in size. Some examinations including a FDG-PET study were performed, and these studies revealed that only the lesion in her right lung was present. Her general condition and lung function were good, so we performed right completion pneumonectomy. She is currently alive one year and three months after the operation, and her ADL has not been reduced compared to preoperation.

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We report a surgical case of bronchogenic cyst with hoarseness. A 28-year-old man was admitted to our hospital with hoarseness, dry cough, and chest and back pain. Chest CT and MRI showed a cystic mediastinal tumor of 23×16×25 mm in the area of the trachea, esophagus, and right subclavian artery. We performed thoracoscopic tumor removal. The pathological diagnosis was bronchogenic cyst. Although hoarseness remained for six months postoperatively, it disappeared by one year. Laryngoscopy confirmed that the right vocal cord function had completely recovered. There have been six reports of bronchogenic cyst with hoarseness including our presented case. In these cases, hoarseness had improved completely in only two cases. Even if a cystic mediastinal tumor near the recurrent nerve is asymptomatic, tumor removal should be considered to avoid irreversible recurrent nerve paralysis.

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We report a rare case of mediastinal schwannoma with massive pleural effusion. A 20-year-old female was admitted to our hospital with complaints of dyspnea and dry cough. Left pleural effusion was observed on chest radiograph. Chest CT scan and MRI showed a posterior mediastinal tumor with massive pleural effusion. The tumor was diagnosed as schwannoma by CT-guided percutaneous needle biopsy. Left thoracotomy was performed through the 7^th intercostal space, and the tumor was diagnosed as schwannoma with rupture into the pleural cavity.

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We present a rare case of solitary pulmonary papilloma. A 74-year-old woman consulted our hospital because of blepharoptosis. Chest CT and MRI demonstrated a tumor in the thymus and a small mass lesion in the lower division of the right lung. We performed extended thymothymectomy and partial resection of the right lower lobe. On postoperative pathologic examination, the tumor in the thymus was diagnosed as thymoma of type B, and the nodule of the lung was mixed squamous cell and glandular papilloma. The postoperative course was excellent, without any complications. Peripheral pulmonary papilloma is rare, with only eight cases being reported in the literature. We have to consider treatment with or without surgery because it is difficult to diagnose the lesion as benign or malignant on preoperative examination. Furthermore, we should strictly observe the postoperative course because papilloma has the possibility of becoming malignant.

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