In this study, we evaluated the efficacy and safety of our anticoagulant therapy during the perioperative period of lung cancer surgery for the prevention of thrombosis (pulmonary embolism and stroke). We examined 208 lung cancer patients undergoing surgery as an evaluation group and 155 previous patients as a control group. In the evaluation group, before surgery, we assessed the risk of thrombosis for each patient and classified them into three groups (high-, medium-, and low-risk groups). Twenty-eight patients underwent anticoagulant therapy in the perioperative period. For the high-risk group (seven patients), anticoagulant therapy was started before or during the intraoperative period (two with unfractionated heparin (UFH) and five with low-molecular-weight heparin (LMWH)). For the medium-risk group (twenty-one patients), anticoagulant therapy with low-dose unfractionated heparin (LDUH) was started immediately after the operation. For the low-risk group, anticoagulant therapy was not performed. In the control group, three patients suffered from thrombosis (two pulmonary embolisms and one stroke), but in the evaluation group, no patients suffered from thrombosis, showing a significant difference (p=0.044). Regarding intraoperative blood loss, there were no significant differences between UFH patients, LMWH patients, and the others (no anticoagulant therapy in the operative period), but the average blood loss of UFH patients was 914 g, much higher compared with the other patients. These results suggest that anticoagulant therapy based on our classification of the risk of thrombosis was effective to prevent thrombosis and safe. We recommend LMWH as the anticoagulant agent in lung cancer surgery and LDUH as the agent after surgery.

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Cold or tuberculous abscess of the chest wall is a rare entity. Although anti-tuberculosis chemotherapy is essential for the treatment of this disease, surgical treatment also plays an important role. We retrospectively reviewed 13 cases of tuberculous abscess of the chest wall that were surgically managed between January 2001 and September 2008 at Toneyama National hospital. We analyzed the surgical methods used, perioperative treatment, and results. The types of surgical treatment performed were as follows: complete excision and open drainage of the abscess followed by the implantation of chest wall muscles in 2 patients (15%), complete excision or debridement with the implantation of chest wall muscles in 5 patients (38%), complete excision or debridement without implantation in 5 patients (38%), and only abscess drainage in 1 patient (8%). Additional chest wall resection was performed in 9 patients (69%). Preoperative anti-tuberculosis chemotherapy was administered to 11 patients for more than 2 weeks. All patients were administered postoperative anti-tuberculosis chemotherapy for more than 6 months. In the mean follow-up period of 22.3 months, there was no recurrence of the abscess in 10 patients (75%). Thus, we recommend complete resection of the abscess along with the resection of a portion of the infected chest wall and a perioperative anti-tuberculosis chemotherapy regimen. We consider that these treatments reduce the postoperative recurrence of tuberculous abscess.

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Transient pulmonary infiltration appeared in five cases following lobectomy and mediastinal lymph node dissection. In each case, a chest radiograph showed an interstitial shadow in the residual lung on the operative side within two weeks after the operation. Chest computed tomography revealed interlobular septal thickening at the dorsal and supradiaphragmatic portions of the residual lung only on the operative side. We performed chest computed tomography after conversion of the body position in one of the five cases; the shadow moved downward due to gravity. We thought that the interstitial shadow was “pulmonary lymphedema” due to the congestion of lymph flow. The patients had no respiratory symptoms, and the shadow disappeared without any treatment in five months in all cases. We suggest that “pulmonary lymphedema”, which is identified as a transient interstitial shadow, disappears without any treatment.

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Objective. We made the clinical features of malignant peritoneal mesothelioma cases clear by compared with that of pleural mesothelioma cases. Subjects. From 1993 to March 2009, 12 patients of peritoneal mesothelioma and ninety-six patients of pleural mesothelioma from Okayama Rousai Hospital were enrolled. Results. There were more populations of female, epithelioid type and chemotherapy in peritoneal mesothelioma cases than in pleural mesothelioma cases. It was suggested that malignant peritoneal mesothelioma cases had been heavily exposed to asbestos because of their occupational history and complications of asbestosis and pleural plaque. Patients with malignant peritoneal mesothelioma exposed to asbestos in shorter periods and of heavier volume than pleural mesothelioma cases. On prognosis the median survival of malignant peritoneal mesothelioma cases and pleural mesothelioma cases were 12.0 months. The prognoses of malignant peritoneal mesothelioma cases appear to be as poor as that of pleural mesothelioma cases. Conclusion. There were more populations of female, epithelioid type in malignant peritoneal mesothelioma. Malignant peritoneal mesothelioma has a strong relationship with asbestos exposure. We must consider malignant peritoneal mesothelioma when detected asbestos exposure and ascites. The diffuse nature of mesothelioma makes it difficult for surgeons to perform radical resection. However, combined modality treatments have been attempted in order to reduce local recurrence and systemic spread.

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We analyzed the clinical and pathological features of nine pulmonary sclerosing hemangiomas. The age of patients ranged from 47 to 68 years, and they were predominantly female. The tumor size ranged from 8 to 45 mm. All patients underwent surgical resection. Intraoperative biopsy (frozen section) was performed for eight cases. The sensitivity for the intraoperative diagnosis of sclerosing hemangioma was only 50% (four cases). When sufficient specimens could not be obtained or they showed a predominantly papillary pattern, they indicated the possibility of malignant tumors. All cases had an excellent prognosis without recurrence. Limited but complete resection can be a definitive, curative method for pulmonary sclerosing hemangioma. However, it is difficult to diagnose preoperatively and even intraoperatively. We have to understand the practical limitations of intraoperatively diagnosing pulmonary sclerosing hemangioma and review fixed, stained sections carefully.

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Abstract-Background: Pleomorphic carcinoma is a primary lung cancer with uncommon clinicopathological findings and a poor prognosis. We investigated the surgical outcome of pleomorphic carcinoma regarding the clinical characteristics and behavior. Subjects and Methods: A total of 25 patients who underwent operations for pleomorphic carcinoma between January 1999 and December 2008 were retrospectively evaluated. Results: The 25 study subjects consisted of 22 male and 3 female patients. The mean age was 64.5 years. In this study, the mean diameter of the tumor was 51.3 mm; tumors over 50 mm in diameter comprised 44% of all cases. Concerning the locations of the lesions, almost all tumors were present in the upper lobe (84%). In this study, twenty-two patients underwent lobectomy. As for the pathological stage, three cases were stage IA, and 10 cases were stage IB. The 3- and 5-year survival rates were 63.3 and 43.6%, respectively, after the operation for pleomorphic carcinoma. Conclusions: Pleomorphic carcinoma is a primary lung cancer with a poor prognosis. In cases of pleomorphic carcinoma that are node-negative, the prognosis may be improved by surgery.

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Lymphoepithelioma-like carcinoma (LELC) of the lung is a rare disease, classified as a variant of large cell carcinoma of the lung according to the World Health Organization's histologic typing of lung and pleural tumors. In a 74-year-old man, rectal carcinoma was diagnosed. Chest CT examination revealed a 10-mm nodular shadow in S2 of the right lung, suggesting either primary lung carcinoma or a metastatic lung tumor. A right upper lobectomy was performed under thoracoscopic surgery. The histopathological diagnosis was LELC, T1N0M0: stage I A. The association with Epstein-Barr virus was not be demonstrated by EBER in situ hybridization. The patient was free from the disease at 18 months after surgery. We report a rare case of LELC.

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A 57-year-old woman underwent right lower lobectomy and systematic lymphadenectomy for p-stage IA lung adenocarcinoma. Thirteen months after the operation, a CT scan showed a brain metastatic lesion, and she underwent radiation therapy and surgery. Regarding EGFR gene mutation, L858R in exon 21 was identified both in the primary lung tumor and brain tumor. Sixty-two months after the first operation, a PET-CT scan showed a lung metastatic lesion measuring 12 mm with abnormal FDG accumulation in the left S⁶. Sixty-four months after the first operation, she started the oral administration of gefitinib (250 mg/day). Sixty-eight months after the first operation, the lesion regressed to 8 mm in diameter. Subsequently, the size remained unchanged, which suggested acquired resistance to gefitinib. Seventy months after the first operation, she underwent partial resection of the left S⁶ because she presented neither new lesions nor the progression of brain metastasis. Exon 20 T790M, which is known to be associated with gefitinib resistance, was found in the lung metastasis. She was alive without recurrence as of 12 months after the second operation.

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Pulmonary thromboembolism (PTE) after pulmonary resection is one of the most severe complications. Due to the large decrease in the pulmonary vascular bed, PTE after pneumonectomy becomes severer than other pulmonary resections. We present the case of a 69-year-old man with a past history of left upper lobectomy for squamous cell carcinoma 10 years ago, admitted with a second primary lung carcinoma or local recurrence. Completion pneumonectomy was performed. The early postoperative course was uneventful; however, he developed dyspnea and shock on the 10th day after completion pneumonectomy. PTE was suspected based on serum chemistry and an echocardiogram, and thrombolytic and anticoagulation therapies with urokinase and heparin sodium were immediately started. A postoperative lung blood flow scintigram 11 days after the onset of PTE showed a mild perfusion defect mainly in S6. The patient was discharged on the 43rd postoperative day.

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The patient was a 49-year-old woman. An anterior mediastinal tumor showing a slow progression for the last two years was recognized on chest CT during serial observation over eight years for a solitary ground-glass opacity (GGO) in the left upper lobe. The tumor was 33×25×60 mm, located at the ventral part of the ascending aorta, and showed a comparatively uniform enhancing effect. MRI revealed a soft tissue tumor with an intermediate signal on T1WI, low signal on T2WI, and an enhancing effect. She was strongly suspected of having thymoma, and we performed thymectomy with tumor resection through a median sternotomy. The pathological diagnosis was ALK-negative anaplastic large cell lymphoma (ALCL), which has a high-malignancy potential. We report this rare case showing slow progression with no symptoms for two years preoperatively.

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We report the rare case of a 40-year-old man with an anterior mediastinal tumor diagnosed postoperatively as atypical thymic carcinoid in sporadic multiple endocrine neoplasm-type 1. He had a history of diabetes mellitus, and an asymptomatic anterior mediastinal tumor was demonstrated on routine radiography. Chest computed tomography revealed an anterior mediastinal mass of 5.5 cm in diameter. Diagnostic tumor resection was performed employing video-assisted thoracoscopic surgery. The tumor was located in the right lobe of the thymus. The tumor was completely encapsulated, and no sign of local invasion was found. The preliminary pathological diagnosis during the operation was thymic carcinoid or type A thymoma. The diagnosis was confirmed as atypical thymic carcinoid based on the permanent preparation, and there was microscopic invasion into the capsule. Therefore, an additional operation was scheduled and extended total thymectomy was performed through a median sternotomy. The mediastinal regional lymph nodes and fibroadipose tissue were resected. No lymph node metastasis was identified in the permanent specimen. The patient received adjuvant mediastinal irradiation. A parathyroid tumor and pancreatic tumor were pointed out on examination for increases in calcium, intact-PTH, growth hormone, gastrin, and prolactin. The diagnosis of multiple endocrine neoplasm type 1 (MEN-1) was confirmed. Total parathyroidectomy with autotransplantation of the parathyroid gland was performed, and pathological examination revealed hyperplasia. The pancreatic tumor was small, and has been under observation, being suspected to be a gastrinoma. He is currently alive and no sign of recurrence has occurred to date at 19 months after the initial detection and treatment. His glucose tolerance improved after thymectomy and parathyroidectomy. Extended total thymectomy at an early stage in combination with radiotherapy can be effective for patients with MEN-1-related thymic carcinoid.

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A 55-year-old woman presented with a nodule in the apical region of the right lung, with computed tomography findings suggesting a neoplasm. She had never been exposed to asbestos. She underwent surgical resection, which revealed rounded atelectasis. Non-asbestos-related rounded atelectasis in the upper lobes is rare, especially in the apical region, so it was difficult to avoid surgery even if the biopsy had shown no malignant features.

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A 63-year-old male showed thickening of the parietal pleura and mass formation in the thoracic cavity after right upper lobectomy for lung cancer. Characteristic findings on chest radiograph, chest computed tomography scan, and a positive serologic test led to a diagnosis of aspergilloma. We performed thoracoscopic cavernostomy and removed the mass. The mass was cultured, and Pseudomonas aeruginosa was isolated. The patient was therefore diagnosed with empyema due to Pseudomonas aeruginosa. Even after the operation, infection was not controlled, and open-window thoracostomy was necessary. He subsequently showed a good systemic recovery and blood inflammatory markers disappeared. This is the first report of a case of Pseudomonas aeruginosa infection forming a mass-like fungus ball in the thoracic cavity.

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A 58-year-old female was admitted to our hospital for further examination of an abnormal shadow on chest radiograph and chest computed tomography (CT). Chest CT revealed an anterior mediastinal tumor of 11×7 cm with the deviation of the trachea to the right. The anterior mediastinal tumor was diagnosed as intrathoracic goiter by CT-guided needle biopsy. A median sternotomy was performed for the extirpation of the anterior mediastinal tumor. The tumor was separated from the thyroid gland and completely extirpated without any dissection of the adjacent structures. We report the case of a patient with aberrant mediastinal goiter, which is rare.

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We encountered a patient with life-threatening severe tracheal stenosis caused by an unknown-origin malignant tumor, successfully treated by bare expandable metalic stent implantation followed by curative radiation therapy, who subsequently developed a massive and uncontrollable tracheoesophageal fistula caused by the bare EMS 6 years after EMS implantation.

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A 40-year-old male was referred to our hospital because of an abnormal shadow on a chest radiograph. Ten years ago, he underwent an operation for an immature teratoma arising in the anterior mediastinum. During follow-up, chest CT showed a homogenous tumor of 6.0 cm in diameter in the anterior mediastinum without calcification, adjacent to the three vessels branching from the aortic arch. The tumor showed fibrous adhesion around the vessels, and was completetely resected. Pathological examination revealed a cavernous hemangioma. We report a surgical case of cavernous hemangioma of the anterior mediastinum, with a review of the literature.

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We report a case of resected pleomorphic carcinoma that showed multiple metastases 1 month postoperatively. A 51-year-old woman was admitted because of hemoptysis. Chest CT scan confirmed a mass in the left lower lung field. A left lower lobectomy with mediastinal lymph node dissection was performed in December 2006. Histopathologically, the tumor consisted of short-spindle cells and multinucleated giant cells, and tubular-adenocarcinoma in a part. Lymph node metastasis under the bifurcation of the trachea was noted. The tumor was diagnosed as pleomorphic carcinoma, and the pathological stage was IIIA (T2N2M0). Multiple metastases of the lung, bone, and bilateral kidneys were recognized 30 days postoperatively, and radiation and molecular target therapies were performed, however she died at 90 days postoperation.

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Intersternum lung hernia is extremely rare, with no previously published report. A 76-year-old man was referred to our unit due to lung hernia after debridement for mediastinitis that developed as a complication of total arch replacement for thoracic aortic aneurysm, and suction of drainage tube was performed continuously. He had a fever and hemosputum, and chest computed tomography revealed an intersternum hernia of the right middle lobe of the lung, right pleural effusion, and subcutaneous emphysema. He underwent an emergent operation. We identified the locking of the lung intersternum through the right pleura which was injured by the sternal edge, sharpened by the second debridement, and injury of the lung pleura with air leakage. This site was resected, and the sternum space was filled with bilateral greater pectoral muscle flaps. The postoperative course was favorable. He was discharged a month after the operation. However, mediastinitis recurred two months after discharge, and he died of sepsis. We think he developed the intersternum lung hernia due to the following. First, when the previous operation was performed, the intersternal space was not filled. Second, countinuous suction of the drainage tube after second debridement was performed, which might have worsened the locking of the lung intersternum. Third, the pleura was injured by debridement for mediastinitis. As a result, the passage of the lung to the intersternum was created. Fourth, the edge of the sternum following debridement was sharp enough to injure the lung that herniated to the intersternum. Fifth, the retention of right pleural effusion was observed without drainage. It is very important to avoid this condition through careful examination and prompt treatment.

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Chylothorax is a rare but potentially serious complication after aortic surgery. We report the successful thoracoscopic ligation of a thoracic duct after persistent chylous drainage related to a prior aortic surgery. Briefly, a 70-year-old man underwent the open graft replacement of a descending thoracic aneurysm. He showed persistent drainage from his left-sided chest tube and also required a right-sided chest tube for a large pleural effusion identified on postoperative day 3. His bilateral pleural effusions as well as the character of the chest tube drainage was consistent with chylothorax. Drainage was persistent. Pleurodesis successfully treated his left side, but, after 22 days of conservative management, his right-sided chylothorax still persisted. Therefore, the patient underwent thoracoscopic ligation of the thoracic duct. Ligation was achieved via a right thoracoscopic approach. After the thickened parietal pleura at the level of the 11th thoracic vertebra was dissected free, the thoracic duct was exposed between the azygous vein and aorta before it was ligated. The patient exhibited no further chylous leakage. We conclude that a right-sided thoracoscopic thoracic duct ligation for persistent chylothorax after aortic surgery is safe and effective.

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We report a case of metastatic pleural solitary fibrous tumor. The original tumor was a parapharyngeal tumor dissected more than 10 years ago. In addition, a retroperitoneal tumor dissected following surgery for the pleural tumor was revealed to be a metastatic solitary fibrous tumor of the same origin. It is very rare for metastatic solitary fibrous tumors to occur in the pleura and retroperitoneal spaces after more than 10 years since the original parapharyngeal solitary fibrous tumor was completely dissected.

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Sleeve segmentectomy for central-type squamous cell carcinoma of the lung was performed in three patients with impaired lung function. All patients were male, and their preoperative FEV_1.0 (FEV_1.0%) was 1,070 ml (37.8%), 1,020 ml (41.0%), and 1,240 ml (51.2%), respectively. Since the predicted postoperative FEV_1.0 after lobectomy was estimated to be less than 700 ml/m² in each case, sleeve segmentectomy was performed to preserve the lung function as much as possible. The surgical procedures were S⁶ segmentectomy with bronchoplasty, sleeve segmentectomy of the left superior segment, and sleeve segmentectomy of the left apical segment (S¹⁺²). The pathological stage was I B, II B, and I A. Two patients were alive without any evidence of recurrence fifty and eighty-one months after surgery. One patient died of gastric cancer without the recurrence of lung cancer.

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Case. In February 2008, a 57-year-old woman was referred to our hospital for the investigation of an abnormal shadow detected on a chest radiograph and an increased serum CA19-9 level. Computed tomography revealed a tumor in the left dome of the diaphragm; the tumor showed fluorodeoxyglucose (FDG) uptake on FDG-positron-emission tomography (PET). During tumor resection, an aberrant artery was found to supply the tumor, which was diagnosed as an extralobar pulmonary sequestration and resected. After the operation, the serum CA19-9 level decreased. Conclusion. We have reported a rare case of extralobar pulmonary sequestration presenting with an increased serum CA19-9 level.

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We report the case of a patient who underwent complete resection for solitary plasmacytoma of the sternum. A male septuagenarian was referred to our hospital for further examination of an anterior chest wall tumor. Chest computed tomography revealed an osteolytic tumor of 6×6 cm in the episternum. FDG-PET showed an abnormal accumulation of FDG in the chest wall tumor. Resection of the episternum was performed, and the chest wall was reconstructed with a patch product made of ePTFE sheet combined with polypropylene mesh and greater pectral muscular flaps. Histopathological studies revealed the neoplastic proliferation of plasmacytes, and the tumor was diagnosed as solitary plasmacytoma of the sternum.

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We present a surgical case of lung cancer in a patient with complete situs inversus. A medical check-up showed a solitary focus in the left upper lung field in a 58-year-old man. A CT scan revealed a nodule, 2 cm in diameter, in the left upper lobe and complete situs inversus. Under a preoperative diagnosis of stage I A (cT1N0M0) cancer of the left lung, VATS partial resection was performed. The intraoperative rapid pathological diagnosis was adenocarcinoma, so we carried out a VATS left upper lobectomy. Regarding intraoperative findings, the left lung had three lobes and pulmonary vascular situs inversus. So, we performed surgery with a mirror image of the right upper lobectomy.

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