Primary spontaneous hemopneumothorax (PSHP), occurring in 1 to 12 % of cases with spontaneous pneumothorax, is characterized by the accumulation of air and blood in the pleural cavity. Blood transfusion or emergency surgical intervation is often required due to extensive hemorrhage or massive blood clotting. From 1994 to 2007, we performed video-assisted thoracoscopic surgery (VATS) for 6 of 8 cases with PSHP within 1 day of chest tube drainage. There were no cases of blood transfusion, mortality, or recurrence. Early VATS should be considered in patients with PSHP, to avoid unnecessary blood transfusion and impaired lung reexpansion.

View full abstract

The postoperative recurrence rate of bilateral spontaneous pneumothorax (BSP) is believed to be higher than that of unilateral spontaneous pneumothorax (USP). However, risk factors for the postoperative recurrence of BSP remain unclear. We retrospectively analyzed the clinical characteristics of patients with spontaneous pneumothorax, who underwent surgical treatment in our hospital between January 1998 and December 2008, and investigated the risk factors for the postoperative recurrence of BSP. The postoperative recurrence rate in BSP patients was higher than that in USP patients (31.6 % (six of 16 patients) versus 7.1% (12 of 169 patients), respectively, p<0.001). In patients with postoperative recurrence, BSP patients were younger than USP patients (p<0.001), and comprised significantly more non-smokers (p<0.01). In BSP patients, postoperative recurrence was not related to the surgical procedure, but was significantly associated with fibrous adhesion between the apex of the lung and chest wall (p<0.01). To reduce the high rate of postoperative recurrence in BSP patients, the reconsideration of an appropriate method for adhesion is needed in their treatment.

View full abstract

Objective. The characteristics and prognosis of patients with asbestos- and pneumoconiosis-related lung cancer were evaluated. Methods. Patients with asbestos- and pneumoconiosis-related lung cancer in the period from 1998-2008 treated at Okayama Rousai Hospital were evaluated. Patients with other lung cancers except for asbestos- and pneumoconiosis-related lung cancer in Okayama Rousai Hospital were used for comparison. Results. Ninety-eight patients had asbestos-related lung cancer, 28 had pneumoconiosis-related lung cancer, and 491 patients other lung cancers. Significant differences in the clinic pathological factors were noted regarding the pathology and clinical stage between asbestos- and pneumoconiosis-related lung cancer patients. In patients undergoing surgery, the percentage of patients who underwent lobectomy for pneumoconiosis-related lung cancer was significantly lower and the prognosis was significantly poorer when compared to asbestos-related and other lung cancer patients. The median survival times of asbestos-related, pneumoconiosis-related, and other lung cancer patients were 20.4, 16.2 and 19.2 months, respectively. There were no significant differences in the overall survival between asbestos-related, pneumoconiosis-related, and other lung cancer patients. A multivariate analysis of all lung cancer cases revealed that exposure to asbestos and pneumoconiosis were not prognostic factors. Conclusion. It is suggested that the prognosis of asbestos- and pneumoconiosis-related lung cancer patients was as poor as those with other lung cancers.

View full abstract

We experienced a case in which lung dirofilariasis was accompanied by lung cancer. A 55-year-old male was admitted to our hospital for investigation of an abnormal chest shadow. Chest CT showed a node with well defined marginal shadow and poorly defined regular node shadow in the right S³, and an irregular mass shadow in the right S⁶. FDG accumulation was observed at the irregular mass shadow in the right S⁶, but not at the well-defined node mass in the right S³. The patient underwent a right lower lobectomy and partial resection of the right upper lobe under video-assisted thoracic surgery. The pathological findings revealed that the well-defined node in the right S³ and the irregular mass shadow in the right S⁶ were dirofilariasis and squamous cell carcinoma, respectively. Dirofilariasis might be considered as one of candidates in the differential diagnosis when a lung tumor presents a well-defined margin along with negative FDG-PET findings.

View full abstract

The micropapillary pattern has long been recognized as a poor prognostic factor for breast, ovarian, and bladder cancers, and micropapillary lung cancer has been increasingly reported in recent years. We recently encountered a patient with a small peripheral adenocarcinoma of the lung with lymph node metastasis. The patient was a 52-year-old man whose chest CT showed an irregularly bordered nodule in the left S³ segment, approximately 15 mm in diameter, with a pleural depression and spicula. Under a preoperative diagnosis of stage IA (cT1N0M0) adenocarcinoma of the left lung, left upper lobectomy with ND2a was performed. Histological examination revealed a micropapillary pattern lacking a fibrovascular core. Immunohistologically, the tumor cells were TTF-1 (+), CK7 (+), SP-A (+), and CK20 (-), leading to a diagnosis of primary lung cancer. Lymph node and intrapulmonary metastases were observed, and the pathological diagnosis was pT1N2M0, stage IIIA. Even a small pulmonary nodule should be promptly diagnosed, keeping in mind the presence of a histological pattern, as seen in this patient.

View full abstract

We report a rare case of mediastinal lymphangioma. A 33-year-old female was pointed out as having a mediastinal tumor on chest radiograph. She had a varied previous medical history: cardiac tamponade, multiple liver cysts, and cerebral arteriovenous malformation. Computed tomography showed a large anterior mediastinal tumor involving the aorta and pulmonary artery, Since needle biopsy failed to facilitate a definitive diagnosis, surgical removal of the tumor was performed. Histopathological examination resulted in a diagnosis of lymphangioma, which is very rare in adults.

View full abstract

We report a case of video-assisted thoracoscopic extrapleural pneumonectomy for diffuse malignant pleural mesothelioma. A 55-year-old man had dyspnea due to right pleural effusion. Chest tube drainage was performed after admission. Cytology for pleural effusion was diagnosed as class V (adenocarcinoma). Because there was no primary malignant lesion, we performed a diagnostic thoracoscopic examination. Histology of the pleural biopsy showed malignant pleural mesothelioma of the epithelial type, and the preoperative stage was identified as stage I. An extrapleural pneumonectomy with reconstruction of the diaphragm and pericardium was successfully performed using video-assisted thoracoscopic techniques. All surgical procedures were performed using only three surgical wounds (5, 5, and 7 cm) without the use of a rib spreader. The patient was discharged on postoperative day 13 without any complications. He underwent 3 courses of adjuvant chemotherapy using cisplatin and pemetrexed 3 weeks or later after surgery. The patient is currently alive without signs of recurrence at 6 months after surgery. Video-assisted thoracoscopic extrapleural pneumonectomy may be feasible in selected patients in the early stage of diffuse malignant pleural mesothelioma.

View full abstract

A 71-year-old man was referred to our department with nodular opacity in the lower lobe of the right lung accompanying chronic expanding hematoma in the right pleural cavity. Nodular opacity was first noted on chest computed tomography in December 2007. The patient had a history of right spontaneous pneumothorax at 27 and sigmoid colon cancer at 68 years old. Preoperative radiographic and clinical features suggested that the nodular opacity was a malignant tumor metastasized from sigmoid colon. This diagnosis was based on the elevation of the serum CEA antigen level and computed tomography findings. We conducted decortication of the right lung and partial resection of the right lower lobe. Postoperative pathological examination of the nodular opacity confirmed necrotic tissue with no malignant component, and cultures of the contents were negative for both standard plate count bacteria and bacteria responsible for tuberculosis. The postoperative course was favorable, and the patient was discharged from the hospital on the 14th postoperative day.

View full abstract

Herein, we report a rare case of Pseudallescheria boydii in the thorax of a 65-year-old man. The patient was treated for rheumatoid arthritis with prednisolone for four years. Chest CT revealed a cavitary lesion with a fungus ball in the apex of the left lung. Under a diagnosis of aspergilloma, bisegmentectomy of the left lung was performed. However, a fungus ball was again recognized in the dead space after pulmonary resection. An open-window thoracostomy was performed with 3rd and 4th partial costal excisions. Pseudallescheria boydii was identified by culturing a specimen of the fungus ball. After sterilization, closure of the cavity with muscle flap transposition was successfully performed. The patient remains well with no evidence of recurrence.

View full abstract

A 59-year-old female with eventration of the diaphragm and acute bronchitis was referred to our hospital. Chest radiograph and computed tomography revealed the diffuse elevation of the left diaphragm and the protrusion of megacolon. She was operated on via a thoracotomy, and the abundant diaphragm was partially resected. The tenuous diaphragm was covered and reinforced with a polypropylene mesh sheet. The postoperative course was uneventful, and her respiratory symptoms were resolved soon without any abdominal problems.

View full abstract

The patient was a 74-year-old man. He underwent total gastrectomy for a gastrointestinal stromal tumor (GIST) of the remnant stomach 7 years after distal gastrectomy for gastric cancer. The histologic and immunohistochemical findings showed high-risk GIST, being c-kit- and CD34-positive. Five years and seven months later, he was diagnosed with a left chest wall tumor, and underwent tumor resection. The immunohistochemical findings showed that c-kit and CD34 were positive, and he was diagnosed with chest wall metastasis from GIST of the stomach. Chest wall metastasis from GIST of the stomach is extremely rare.

View full abstract

A 49-year-old male who had been diagnosed with a bronchogenic cyst was referred to our hospital due to acute distension of the cyst. His blood exam showed a mild inflammatory reaction, and a chest computed tomography scan revealed the enlargement of the subcarinal cyst. A month later, he was admitted to our hospital for an operation. A chest radiograph taken on the day of admission revealed the collapse of the cyst, and his blood exam results showed a return to normal ranges. The cyst was resected via a thoracotomy, and the postoperative course was uneventful. The change in the size of the cyst might have been due to an inflammatory reaction in the cyst.

View full abstract

A 55-year-old man was admitted, complaining of right shoulder pain and showing an abnormal chest shadow. A mass in the right pulmonary apex with invasion to the chest wall was confirmed on chest CT. A definitive diagnosis was not established by bronchoscopy. He underwent tumor biopsy under VATS, and a diagnosis of non-small cell carcinoma was made. He underwent right upper lobectomy with chest wall resection. The pathological diagnosis was pulmonary pleomorphic carcinoma stage 2B (pT3N0M0). Radiation therapy was started after the operation and the patient has followed a favorable course for 30 months without signs of recurrence.

View full abstract

A 27-year-old asymptomatic woman was admitted to our institution for a solitary pulmonary nodule detected on routine chest radiograph during a medical examination. Chest CT revealed a coin lesion which measured 2 cm in diameter, was well-circumscribed, and showed a homogenous density. For the purpose of diagnosis and treatment, partial resection of the lung was performed. The histopathological diagnosis was alveolar adenoma. Alveolar adenoma is an extremely rare benign neoplasm. Microscopically, alveolar adenoma displays multicystic growth patterns consisting of alveolar structures lined mainly by type II pneumocytes, which is very characteristic. Complete resection of the lesion is recommended for an accurate diagnosis. We have to be aware of alveolar adenoma when an accurate diagnosis cannot be obtained by biopsy of a lesion suspected as being a benign tumor on imaging.

View full abstract

We report a rare case of pulmonary metastasis from breast cancer with an 18-year disease-free interval, together with a review of the literature. At an annual examination, a 64-year-old female who had undergone a left modified radical mastectomy for breast cancer 18 years previously exhibited an abnormal shadow on a chest radiograph. The chest CT films demonstrated a nodule of 1 cm in diameter with a well-defined and irregular margin in S¹ of the right lung. The nodule was suspected to be either metastatic or primary lung cancer, and so thoracoscopic surgery was selected. The intraoperative frozen sectional diagnosis was pulmonary metastasis from breast cancer. In Japan, only 9 cases of pulmonary metastasis from breast cancer with a long disease-free interval of over 15 years have been reported in the literature. We reviewed the literature and discussed the clinical features

View full abstract

We report an empyema patient with a bronchopleural fistula, pulmonary aspergilloma in the destroyed lung after surgery for lung cancer, and empyema infection with MRSA/Pseudomonas aeruginosa in whom thoracoplasty with extended thoracic wall resection, complete pleuropneumonectomy, omental plombage, and fixation of a free thigh fascia flap (tensor muscle of the fascia lata + tractus iliotibialis) to the thoracic wall to prevent postoperative flail chest were performed after fenestration. In treatment for empyema with a bronchopleural fistula, it is important to sterilize the empyema and eliminate the residual cavity. When the lung is destroyed, infection may frequently occur; therefore, pneumonectomy should be performed in patients in whom the cardiopulmonary function is maintained. In addition, the timing of radical surgery must be selected while improving the general condition including nutrition. Extended thoracic wall resection has cosmetic limitations. However, the visual field is favorable, and the duration of surgery and volume of blood loss are restricted, facilitating the complete elimination of a postoperative dead cavity. To prevent postoperative flail chest, we additionally performed fixation of a thigh fascia flap. To our knowledge, no study has reported this procedure.

View full abstract

We report our recent experience with a case of Morgagni hernia contained adipose tissue of the falciform ligament. It is difficult to distinguish between mediastinal neoplasm and Morgagni hernia. The patient was a 48-year-old woman. She underwent medical examination because of her stomachache. Chest radiograph showed an abnormal shadow. For detailed examination, she visited our department. Computed tomograms and magnetic resonance imaging revealed a fat-density mass in her right anterior mediastinum. We suspected that it was a mediastinal neoplasm or diaphragmatic hernia, and an operation was performed. We diagnosed it as Morgagni hernia, because thoracoscopy demonstrated adipose tissue in her chest cavity and it was connected to the abdomen through a hernial orifice. We additionally performed laparotomy, and the adipose tissue was excised. The orifice of the hernia was closed by direct suture. The content of the hernia was adipose tissue of the falciform ligament. This was the second case whereby the contents of Morgagni hernia comprised adipose tissue from a falciform ligament.

View full abstract

The patient was a 70-year-old female who underwent radical hysterectomy for uterine cancer in a hospital two years earlier. On preoperative examination, the patient was found to have a mass lesion in the anterior mediastinum. Postoperatively, the lesion had increased in size, and the tumor marker CA125 had increased. Therefore, she underwent systemic chemotherapy for the lesion under a diagnosis of mediastinal lymph node metastasis of uterine cancer. Although the lesion continued to increase in size after the chemotherapy, the tumor marker decreased. She was then introduced to our institute for the purpose of radiotherapy for the lesion. Radiologically, the lesion was thought to be a primary tumor in the mediastinum rather than mediastinal lymph node metastasis. The patient underwent expanded thymectomy through a median sternotomy. Pathologically, the lesion was diagnosed as a capillary hemangioma in the mediastinum. Mediastinal hemangioma is rare, and the incidence is reported to be less than 0.5% of all mediastinal tumors. Radiologically, a preoperative diagnosis of this disease is usually difficult.

View full abstract

The patient was a 47-year-old male who visited our clinic with a chief complaint of dyspnea and a subcutaneous mass in the left anterior chest wall. An abscess was found in the left anterior chest wall with left pleural effusion on a chest radiograph and a CT scan. The left 6^th rib was in contact with the mass, and displayed a pathological fracture. Thoracic cavity drainage was performed on the left side, and a cruciate incision was made in the skin immediately above the abscess. Since a positive result was obtained for the contents of the abscess on PCR for Mycobacterium tuberculosis, the patient was diagnosed with chest wall tuberculosis. Anti-tuberculosis chemotherapy was started, and, consequently, the size of the abscess was reduced and the left pleural effusion disappeared. However, since the abscess drainage was not satisfactory, the abscess was resected two weeks after starting of treatment. A partial resection was also performed on the area around the fracture of the left 6^th rib. No local relapse has been observed for three months since anti-tuberculosis chemotherapy was restarted. Throughout the course, no past tuberculosis infections or co-existing lesions were detected. Since chest wall tuberculosis is a rare form of tuberculosis, there are few reports available regarding diagnosis and treatment. When making diagnoses of chest wall masses, chest wall tuberculosis has to be differentiated by assessing past tuberculosis infections or co-existing lesions, the presence of Mycobacterium tuberculosis, and the presence or absence of rib fractures. With regard to the treatment of chest wall tuberculosis, a combination of medical and surgical management is considered to be effective.

View full abstract

A 15-year-old male, with a past history of splenic hemangioma treated with radiotherapy in his infancy, was diagnosed with idiopathic left chylothorax. Ligation of the thoracic duct at the level of Th7 was not effective, and he was admitted to our hospital. Ligation at the level of the diaphragm resulted in bilateral pleural effusion and ascites. Based on his past history, lymphangiography showing multiple points of leakage from the diaphragm and intraoperative findings of lymph proliferation along the mediastinal pleura, delayed chylothorax due to irradiation was diagnosed. Octreotide was administered for 30 days. Pleural effusions and ascites gradually decreased, and meals were started without reappearance.

View full abstract

A 69-year-old woman treated for an asthma attack elsewhere, was incidentally pointed out as showing an abnormal chest shadow. Chest computed tomography (CT) showed a nodule in the right upper lobe and atelectasis of the middle lobe associated with pleural effusion. She was referred to our hospital for further examination. After pleural drainage, re-expansion of the middle lobe was obtained with improvement of pulmonary function, and new nodules in the middle and the right lower lobe were pointed out. Video-assisted middle lobectomy and partial resection of the upper and lower lobes were performed. Unexpectedly, the cause of atelectasis was a giant thymic cyst and not pleural effusion. The histopathological diagnosis based on all pulmonary lesions was bronchioloalveolar carcinoma, Noguchi's type B, and the cyst was lined with monolayered columnar epithelium containing adipose tissue with a thymic gland in the wall. The patient is currently free of disease at 30 months postoperatively. We herein report a case of synchronal multiple pulmonary adenocarcinoma concealed by a giant thymic cyst.

View full abstract

A 55-year-old woman became aware of general fatigue in 2003. A health check-up at our hospital revealed a high level of CRP in 2005. Because her symptom had been getting worse, she was admitted to our hospital in 2006. Laboratory data showed anemia, a rise in CRP and IL-6 levels, and hypergammagloblinemia. An enhanced chest CT scan revealed a 1.5 cm, well-circumscribed tumor in the anterior mediastinum surrounded by the chest wall, heart, right lung, and diaphragm. We resected the tumor with surrounding fatty tissue by video-assisted thoracic surgery. Histopathologically, the tumor was diagnosed as Castleman's disease of the plasma cell type, and there were several lymph nodes which had the same features as the main tumor in the en block resected tissue. After surgery, her symptom and abnormal data improved. Cases of localized Castleman's disease are predominantly of the hyaline vascular type. We report a rare case of Castleman's disease of the plasma cell type, which was classified as localized Castleman's disease because only one mediastinal compartment was affected on computed tomography, and there was no clinical or radiographic evidence of additional disease in extrathoracic locations.

View full abstract