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Ultrasound diagnosis and severity assessment of pneumothorax were performed for 20 cases of spontaneous pneumothorax, with a collapse rate of 15% or more on chest radiograph, presenting at our hospital between October 2008 and March 2009. The severity was assessed by ultrasound observation of the lung sliding sign (LSS) at four points along the anterior and lateral chest wall (2^nd intercostal space at the midclavicular line, 4^th intercostal space at the anterior axillary line, and 6^th intercostal spaces at the midaxillary and posterior axillary lines). Ultrasound observations were compared with the degree of collapse noted on chest radiograph. LSS was absent in all cases studied at the 2^nd intercostal space, confirming the diagnosis of pneumothorax. In cases showing 16-40% collapse, LSS was present at some of the measurement points on the axilla. However, LSS was absent at every point of the axillary line in cases with a greater than 40% collapse, with only one exception. Ultrasound observations were consistent with radiographic findings. Our results indicate that ultrasonography may be useful for the diagnosis of pneumothorax as well as evaluation of the severity.

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This study aimed to confirm the clinical issues associated with malignant mediastinal germ cell tumors (MGCT). The records of eight patients with MGCT [seminoma (3), yolk sac tumor (1), embryonal carcinoma (1), adenocarcinoma with teratoma (1), others (2)] treated at Showa University group hospitals between 1993 and 2006 were reviewed. All patients were male. The median age was 30 years (range: 21-69). Six of the 8 tumors were located in the anterior, and two were in the middle mediastinum. Four of the 8 patients showed elevated tumor markers prior to the therapy. Two patients showed an elevation of AFP only, and one an elevation of HCG only. One patient exhibited an elevation of both markers. Biopsy was performed in 6 of the 8 cases: CT- guided needle biopsy in 4, mediastinoscopic biopsy in 1, and open biopsy in 1. One of the 6 patients who underwent biopsy received a diagnosis contradicting the final pathological finding of the resected specimen. Chemotherapy should be carried out initially when there is a high serum tumor marker level in cases of MGCT, which may occur in the middle mediastinum.

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A 73-year-old man underwent right lower lobectomy for lung adenocarcinoma. On day 9 after the operation, bronchofiberscopic findings showed ulcerative changes in the bronchial stump. On day 16, ulcerative changes and partial necrosis of the bronchial stump led to bronchopleural fistula formation. Surgical treatment was considered, but the patient was asymptomatic and the empyema cavity was very narrow; thus, we chose conservative therapy. Although aspiration pneumonia developed, the fistula healed spontaneously on day 43. Conservative therapy was successful, because the empyema cavity was very narrow, and the control of infection and the patient's nutritional condition were relatively favorable.

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A 58-year-old female presented to our hospital with a chief complaint of an abnormal shadow in the right upper lobe of the lung pointed out by CT during a health check. PET-CT disclosed a slight FDG accumulation at the same site. QuantiFERON-TB2G and β-D-glucan were negative. Under a diagnosis of adenocarcinoma (cT1N0M0, Stage IA), a right upper lobectomy and lymphadenectomy were performed by video-assisted thoracic surgery. The final pathological diagnosis was a typical carcinoid, 8×8×6 mm in diameter, metastasizing to the mediastinal lymph nodes (pT1N2M0, Stage III A). Lung carcinoid is classified into two types: typical and atypical. Typical type carcinoid is recognized as a case of small carcinoid low-grade malignancy. Herein, we report a case of small carcinoid with N2 lymph node metastases.

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We report a case of myelolipoma originating in the posterior mediastinum. A 62-year-old man with a history of essential hypertension and alcoholic liver dysfunction was referred to our hospital for further evaluation of an abnormal shadow identified on a routine chest radiograph. Chest CT revealed a well-encapsulated, 3×2-cm mass adjacent to the right side of the T10 thoracic vertebra. There was no evidence of bony destruction of the vertebra, pleural effusion, or invasion of surrounding tissues. The density of the mass on CT scan was inhomogeneous and consisted of a combination of fatty- and soft- tissue components. These findings were suggestive of a neurogenic tumor or other soft tissue tumors. Video-assisted thoracoscopic surgery was applied to resect the tumor. Macroscopically, the tumor had a thin capsule and was solid, soft, oval, and reddish-brown. Histopathologically, the tumor consisted of lobulated mature fat tissues interspersed with normal hematopoietic tissues including normoblasts, myeloblasts, and megakaryocytes. Since physical examination and laboratory data showed no evidence of hematologic disease, a myelolipoma arising from the posterior mediastinum was diagnosed.

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We report a rare case of rounded atelectasis with pneumothorax that persisted over a prolonged period. A 56-year-old female demonstrated pneumothorax and a mass measuring 3 cm in diameter in the right upper lung field on radiographic screening in 2004. She declined more detailed examinations, and was simply followed thereafter. Pneumothorax persisted, and the mass gradually enlarged. She subsequently agreed to undergo detailed examinations in September 2008. Bronchoscopy did not identify malignant findings histologically. We performed surgery because of persistent pneumothorax and the gradually enlarging mass. The visceral pleura showed wide pleural thickening, and the mass occupied about two-thirds of the right upper lobe. We performed a right upper lobectomy. Pathological examination showed extensive thickening of the pleura and rounded atelectasis without other primary pulmonary disease. She has been followed postoperatively without pneumothorax for five months to date.

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We report a case of calcifying fibrous tumor (CFT) of the pleura, a very rare tumor, referred to as a “calcifying fibrous pseudotumor (CFPT)” until quite recently. CFT is characterized by the presence of dense collagenous tissue with psammomatous or dystrophic calcifications and lymphoplasmacytic infiltrate. A 40-year-old woman with no complaints consulted our hospital because of an abnormal shadow on a chest radiograph. Chest CT and MRI revealed a left pleural tumor. Resection of the tumor was conducted using VATS, and microscopic examination verified it to be CFT. The patient has remained healthy with no evidence of recurrence for 2 years after the operation.

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A 65-year-old man underwent right upper lobectomy and lymph node dissection (ND2a) for cancer of the right lung. On the first postoperative day, a milky-white pleural effusion was observed after the patient had lunch. He was diagnosed with chylothorax. He was subsequently placed on a fat-restricted diet, being allowed only medium-chain fatty acids, and received pleurodesis using OK-432. However, there was no reduction of pleural effusion. On the 25^th postoperative day, lymphangiography was performed. The thoracic duct changed its course near the tracheal bifurcation and ran an aberrant course toward the right venous angle. The main thoracic duct was interrupted at the apex of the thoracic cavity, and the leakage of lipiodol was observed. Ligation of the thoracic duct was performed on the 32^nd postoperative day based on lymphangiographic findings. Chylothorax improved soon after surgery. Lymphangiography confirmed an aberrant course of the thoracic duct and an injured site. Lymphangiography was very useful in ligation of the thoracic duct. We report herein this case with a review of the literature.

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A rare case of epicardial cyst is reported. A 77-year-old man with no complaints was diagnosed with early gastric cancer. A preoperative chest CT scan incidentally revealed a cystic lesion located in the anterior mediastinum. Video-assisted thoracoscopic surgery was performed. Bloody pericardial effusion was observed. A large cystic lesion was found to extend from the anterior wall of the right ventricle. The cyst was fenestrated and bloody fluid contents were drained, followed by excision of its wall. Pathological examination showed the cyst to be lined by a single layer of mesothelial cells. A diagnosis of epicardial cyst was made. The bloody pericardial effusion suggested the possibility of subclinical rupture of the epicardial cyst.

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A 62-year-old man was admitted to our hospital with a two-month history of swelling on the left side of his chest wall. A computed tomography scan revealed a 4×5 cm lesion associated with destruction of the left 8th rib. As no other lesions were present, we suspected it to be a primary rib tumor. The tumor was completely resected, and the chest wall defect was covered with a GORE-TEX^® sheet. The pathological diagnosis was a giant cell tumor of bone without significant cell atypia.

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We experienced a case of lung carcinoma with polypoid growth in the main pulmonary artery. A 74-year-old woman with a lung tumor of the left S1+2 was referred to our department. Chest CT scan revealed a tumor mass with cavity in the left S1+2 and left hilar lymph node swelling, and also revealed obstruction of the left main pulmonary artery. A perfusion lung scan image showed a defect of the left lung. We performed left pneumonectomy. We opened the pericardium, and the left main pulmonary artery was resected at the intrapericardial portion. The macroscopic findings of the resected specimen showed a polypoid tumor that had grown in the left main pulmonary artery. The tumor showed not only peripheral invasion, but also proximal extension up to the main pulmonary artery. The microscopic findings showed that neoplastic cells infiltrated the pulmonary artery via the metastatic hilar lymph node, but did not infiltrate the pulmonary vein or bronchus. We finally diagnosed her with squamous cell carcinoma, p-T3N1M0 stage III A. We could perform complete resection of this tumor through the identification of the intrapericardial portion of the left main pulmonary artery.

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A 37-year-old woman underwent rectal amputation for rectal cancer in November 2005 and adjuvant chemotherapy with uracil-tegafur and leucovorin for 6 months. In October 2007, thin-walled cavity lesions were found in the right S8 and left S1+2, respectively, and solid lesions were found in the left S6 and S8, respectively, on computed tomography (CT) of the chest. Therefore, video-assisted thoracoscopic (VATS) wedge resection was performed to make a definite diagnosis, and the pathological findings revealed a metastatic lung tumor from the rectal cancer. It is important to consider the possibility of metastatic lung tumors if the cavity lesions are enlarged, exist in multiple regions, or exist together with nodular lesions in cases where thin-walled cavity-forming lung nodules develop in patients with a history of malignancy.

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A 32-year-old male presented with new-onset memory loss and confusion. Chest radiograph and CT examination revealed an antero-mediastinal mass. No anti-Hu-antibody was found in the serum or cerebro-spinal fluid. Magnetic resonance imaging (MRI) of the brain showed an increased signal and swelling of the hippocampi on FLAIR. Paraneoplastic limbic encephalitis associated with thymoma was subsequently diagnosed. Gradually, his mental status and seizures worsened despite anticonvulsant therapy, and he was intubated and referred to our hospital for combined modality therapy. Surgery was performed. Intraoperative findings included an antero-mediastinal mass which started from the right lobe of the thymus and pleural implants. The tumor and pleural implants were resected passively. Pathological findings identified WHO typeB2 thymoma. After the operation, steroid pulse and radiation therapies were performed. The patient's clinical course improved markedly over the next 3 months. MRI showed a nomal signal, and 10 months after surgery, he was able to return to work.

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A 30-year-old woman complaining of sternum and back pain showed an abnormal shadow on a chest radiograph at a neighboring clinic. A swollen thyroid and mediastinal mass were detected on chest CT at our hospital. She was diagnosed with hyperthyroidism based on a thyroid function test. The mediastinal mass was homogeneous on both T1- and T2-weighted images of chest MRI, identified as a diffusely enlarged thymus. In addition, the mass showed a lower signal intensity on an out of phase T1-weighted image compared to an in-phase T1-weighted image on chemical shift MR imaging. This phenomenon reveals minimal fat in the mediastinal mass, and so this mass was diagnosed as thymic hyperplasia associated with hyperthyroidism. Ten months after the start of treatment with an antithyroid agent for hyperthyroidism, the size of the thymic hyperplasia clearly decreased. Chemical shift MR imaging can be used to differentiate thymic hyperplasia from thymoma. Thymic hyperplasia associated with hyperthyroidism should be treated conservatively using an antithyroid agent, and unnecessary thymectomy should be avoided.

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A 55-year-old man showed an abnormal shadow on a chest radiograph during a routine health examination. Chest CT scans revealed a well-circumscribed nodule of 2 cm in diameter with marked contrast enhancement in the left lower lobe. We performed wedge resection of the tumor for a diagnosis. Following the intraoperative diagnosis of a low-grade malignant tumor or adenocarcinoma, we performed left lower lobectomy and lymph node dissection. A postoperative diagnosis was made by immunohistochemical examination of sclerosing hemangioma with peribronchial regional lymph node metastasis. Although sclerosing hemangioma is a benign or very low-grade malignant tumor and lymph node metastasis is very rare, we consider that it is necessary to examine the regional lymph nodes during surgery.

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A 37-year-old man was referred to our hospital for right chest pain caused by an infected bulla. Chest radiograph and computed tomography revealed intrabullous fluid in the right upper lung lobe. A right upper lobectomy was performed, because the lung was severely affected. Histologically, epithelioid granuloma with Langhans' giant cell presence, negative for Ziehl-Neelsen staining, was seen in the dense fibrous cystic wall. Fluid culture was negative for general bacteria, but positive for Mycobacterium avium. Cases of infected bulla caused by mycobacteria are very rare.

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We examined a 39-year-old male who had lost consciousness, and a mediastinal tumor was incidentally detected. He had a fever and increased leukocyte/CRP levels but did not respond to antibiotics, and neoplastic fever was suspected. Chest CT scanning showed a mass lesion in the upper mediastinum. Mediastinoscopic biopsy suggested squamous cell carcinoma. Although complete resection was attempted after medial sternotomy, resection was impossible due to extensive infiltration. Postoperative histological examination demonstrated thymic carcinoma (lymphoepithelioma-like carcinoma). The postoperative serum G-CSF level was high (276 pg/ml). Immunostaining for G-CSF was positive, confirming it to be a G-CSF-producing tumor. After the operation, he underwent a course of chemotherapy in our hospital, and was then transferred to another hospital for radiotherapy.

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A 59-year-old female was referred to our hospital with an abnormal chest shadow. Chest computed tomography showed a tumor surrounded by ground-glass opacity measuring over 3 cm. Fiberoptic bronchoscopy revealed a tracheal tumor below the vocal cords. Cervical magnetic resonance imaging showed a thyroid tumor next to the tracheal tumor. We planned a one-stage operation for the primary tumors of the thyroid, trachea, and lung. First, after general anesthesia with a laryngeal mask airway, the patient underwent right hemithyroidectomy and sleeve resection of the trachea through a collar incision. Then, after intubation of the endotracheal tube from the operative field, we carried out tracheal anastomosis of only the posterior wall. Subsequently, after the oral intubation of a double-lumen tracheal tube by guiding in the operative field, we performed tracheal anastomosis of the residual anterior wall, and total thoracoscopic right upper lobectomy and nodal dissection in the lateral decubitus position. There was no surgical or postoperative complication, and healing of the tracheal anastomosis was satisfactory.

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A 74-year-old woman was referred to our hospital because of ease of fatigability and blepharoptosis, and was diagnosed with generalized myasthenia gravis. Chest CT and neck ultrasound revealed no definite mediastinal tumor, but showed a thyroid tumor and an approximately 15-mm mass adjacent to its caudal portion. Myasthenia gravis and thyroid cancer with lymph node metastasis were suspected, and the patient was scheduled for extended thymectomy, thyroid tumor resection, and lymph node resection. No thymoma was identified at the time of surgery. The thyroid tumor was a follicular adenoma, and the mass caudal to it contained thymic tissue. The patient developed myasthenic crisis on the third postoperative day, and was placed on a ventilator, which was soon withdrawn. She was discharged under her own volition on the 44^th postoperative day. Thus, we encountered an extremely rare case of ectopic thymoma with myasthenia gravis. In patients with myasthenia gravis, it is necessary to conduct a complete medical evaluation, bearing in mind the presence of not only anterior mediastinal thymoma but also ectopic thymoma.

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Regarding surgical treatment for second lung cancer, it is difficult to achieve radical cure while preserving the lung function. Case. A 57-year-old man. We had undergone right upper lobectomy and lymph node dissection for peripheral squamous cell carcinoma of the right S³; this tumor, of 21 mm in diameter, was diagnosed as pT1N0M0, stage I A. An endobronchial tumor was pointed out on chest CT six months postoperatively. It was diagnosed as central squamous cell carcinoma located at the bifurcation of the left upper and lower lobe bronchus and passed outside the bronchial wall based on bronchoscopic examination and biopsy. We thought that this tumor was a second lung cancer, but hesitated over the treatment method. To reduce the tumor size, we administered two courses of chemotherapy (carboplatin + weekly paclitaxel). The tumor size was reduced to 4 mm, and we performed sleeve resection of the bifurcation of the left upper and lower lobe bronchus with the left S⁶ and reconstructed the site through bronchoplasty with double-barrelled anastomosis. The final pathology was pT1N1M0, stage II A, but the patient has been recurrence-free for 5 years while undergoing regular follow-ups. When second lung cancer is of the central type, we should consider choosing the surgical procedure carefully based on the site of the tumor without compromising radical cure by combining chemotherapy and bronchoplasty with limited lung resection.

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Primary laryngotracheal anastomosis for subglottic stenosis is a challenging procedure. We herein report three different types of surgical procedure for this condition. Case 1: A 19-year-old female with anastomotic stenosis after traumatic dissection of the trachea underwent primary laryngotracheal anastomosis with laryngofissure. The temporary T-tube was successfully removed 5 months after the operation. Case 2: A 52-year-old female with postintubation stenosis underwent primary laryngotracheal anastomosis with the subtotal resection of cricoid cartilage. A temporal tracheostomy which was positioned for postoperative supraglottic edema was successfully removed six months after the operation. Case 3: A 63-year-old male with posttracheostomy stenosis underwent primary laryngotracheal anastomosis with the partial resection of cricoid cartilage. The postoperative course was uneventful. Primary laryngotracheal anastomosis for subglottic stenosis in experienced centers is feasible for suitable patients.

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The covering of apical visceral pleura with polyglycolic acid (PGA) sheets was introduced for needle thoracoscopic laser ablation (needle VATS). From April 2006 to March 2008, we treated 21 patients (18 males, 3 females, mean age: 23.3 years old) with spontaneous pneumothorax and bullas smaller than 2 cm using needle VATS with covering. The bullas were ablated through 3-mm ports with a non-contact Nd: YAG laser beam at a setting of 10 W; then, the apical visceral pleura was covered using the sheets which were introduced into the thoracic cavity using 'intra-port loading'. With this method, the port is loaded with a PGA sheet outside the body, then inserted into the chest wall and pulled into the thoracic cavity with an endoscopic grasper. The mean postoperative drainage period was 1.3 days, and mean postoperative hospital stay was 2.8 days. No recurrence was observed during the mean follow-up period of 403 days. The addition of PGA covering to needle VATS may reduce the recurrence rate of pneumothorax, although additional reports and long-term follow-up studies of patients are needed.

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Abstract-Objectives. To publicize clinical results of Japanese lung cancer patients registered in 2002. Study design. In 2002, The Japanese Joint Committee for Lung Cancer Registration conducted a prospective observational study for lung cancer patients registered at starting treatments with follow-ups in 2004 and 2009. At first, 18,552 cases were registered from 358 institutes, while we analyzed 14,695 samples whose living periods could be identified. Results. There were two times males as many as females with a mean age of 67.1 years. The most frequent histology was adenocarcinoma in 56.7%, following squamous cell carcinoma in 25.7% and small cell carcinoma in 9.2%. Clinical stage was IA in 29.3%, IB in 15.3%, IIA in 1.4%, IIB in 6.2%, IIIA in 11.8%, IIIB in 14.6% and IV in 21.0%. Surgery was performed in 8,454 cases (57%). Five-year survival rate was 44.3% for all patients, 14.7% for cases of small cell carcinoma, 46.8% for non-small cell carcinoma, 59.6% for surgery cases, 8.5% for no surgery cases, 37.7% for males and 59.0% for females. The rates in clinical stage settings in cases of small cell carcinoma and non small cell carcinoma, was 52.7% and 79.4% for IA, 39.3% and 56.7% for IB, 31.7% and 49.0% for IIA, 29.9% and 42.3% for IIB, 17.2% and 30.9% for IIIA, 12.4% and 16.7% for IIIB and 3.8% and 5.8% for IV, respectively. Conclusion. An analysis of Japanese lung cancer patients registered in 2002 revealed that the most frequent histology type was adenocarcinoma following squamous cell carcinoma and small cell carcinoma. Prognosis in 5 years was superior in cases of female, non small cell lung cancer and surgery to those of male, small cell lung cancer and no surgery, respectively. Further investigation is needed with respect to dependences of those survival differences.

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[in Japanese]

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