Problems in surgical treatment for secondary pneumothorax in patients with interstitial pneumonia (IP) include not only difficulty in repairing the pleural fistula but also the fact that the surgery itself can be fatal because of chronic steroid use and a severely impaired lung function. We report eight patients with intractable pneumothorax with IP who were treated mainly by video-assisted thoracoscopic surgery (VATS) in our institution. The patients comprised 6 men and 2 women (average age: 65 years), in whom 3 patients required continuous oxygen inhalation therapy, 4 had concurrent collagen disease, and 5 patients were given steroids preoperatively. One patient with bilateral pneumothorax underwent bilateral VATS repairs simultaneously. Three patients underwent open thoracotomy for air leak repair, and one of these three patients underwent pedicled omentopexy for intractable pneumothorax and empyema caused by methicillin-resistant Staphylococcus aureus (MRSA). Four patients required mechanical ventilation postoperatively. Two patients (25%) died due to postoperative respiratory failure caused by the exacerbation of IP. Difficulties in the intra- and postoperative management of the respiratory disorder resulted in these deaths.

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The purpose of this study was to evaluate the prognosis of primary lung cancer patients with pleural dissemination or malignant pleural effusion who underwent surgical intervention. We also evaluated the significance of the subclassification system of pleural dissemination (D factor) and malignant pleural effusion (E factor) in the current Japanese lung cancer staging system. Between 1992 and 2006, a total of 2,947 primary lung cancer patients underwent surgical intervention at our institution. Among them, 98 patients who had pathologically or cytologically confirmed malignant pleural effusion and/or pleural dissemination were enrolled in this study. The clinicopathological factors of each patient were reviewed, and the prognosis was evaluated retrospectively. In 98 patients, 79 had only pleural dissemination, 3 had only malignant pleural effusion, and 16 had both. Adenocarcinoma was the predominant histologic type, estimated at a rate of almost 80%. Resection of the main tumor (palliative resection or grossly-complete resection) was performed in 29 patients, and the remaining 69 patients underwent exploratory thoracotomy. The 3-year overall survival rate and median overall survival time of all 98 patients were 33.8% and 2.1 years, respectively. The overall survival rate of the 29 resected cases (3-year: 25.9%) was not significantly different from that of the 69 unresected cases (3-year: 37.8%, p=0.35). According to the D subclassification, the overall survival rate of the 30 D1 cases (3-year: 34.9%) was not different from that of the 65 D2 cases (3-year: 35.4%, p=0.79). Among 19 patients with malignant pleural effusion, few patients were subclassified into E2, and no patients were subclassified into Ep and Epn. Our present study indicated that resection of the main tumor does not improve the outcome of patients with malignant pleural effusion and/or pleural dissemination. Furthermore, the current D subclassification does not work as a prognostic indicator. With regard to E subclassification, information on the presence and cytological diagnosis of pleural effusion is sufficient as a prognostic factor.

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Between April 2002 and April 2009, bilateral one-stage thoracoscopic surgery was performed for 12 patients (7 patients: synchronous cases, 5 patients: metachronous cases) with bilateral spontaneous pneumothorax (SP). The age distribution of the patients was between 17 and 37 years. Indications for bilateral one-stage thoracoscopic surgery were all synchronous cases and selected metachronous cases. Selected metachronous cases were short-term cases from initial to contralateral SP. Regarding management before the operation, most patients needed drainage on only one side. Synchronous cases were operated on from the strongest side. Metachronous cases were operated on from the affected side. Both cases were converted, to operate on the opposite side. Hospitalization of 2.4 days on average was necessary after the operation. It is thought that the shortness of the hospital stay depends on differences in drain management.

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Thymic carcinoid is a rare tumor. A case of atypical carcinoid of the thymic is presented. A 77-year-old man, who was found to have an abnormal mediastinal shadow on a chest radiograph, was admitted. A computed tomography scan revealed a 16-cm mass shadow, which was hypervascular, in the anterior mediastinum. Tumor resection was performed through a median sternotomy. The phrenic nerve was resected due to tumor invasion. The histopathological diagnosis was an atypical carcinoma of the thymus. After the operation, the patient received radiation therapy (60 Gy) to the mediastinum. He has been well without any sign of recurrence for 2 and half years after surgery and irradiation treatment.

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The patient was a 19-year-old woman. She was introduced to us following a diagnosis of secondary pneumothorax caused by Lemierre syndrome due to decayed teeth at another hospital. Because the air leakage continued, we performed partial resection of the right lung and closure of the air leakage site. However, air leakage relapsed after the first operation, and we performed pediculated latissimus dorsi transposition. However, air leakage again relapsed after the second operation. After we repeated the intrapleural administration of a large amount of drugs, applied fibrin glue, and improved her nutritional status, the air leakage was finally controlled. Secondary pneumothorax caused by Lemierre syndrome is intractable, and combined modality therapy including surgery and improvement of the nutritional status is effective.

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A 30-year-old male was admitted because of right chest pain. Chest CT showed pneumothorax and a nodule inside a cavity of the right lung. The patient was diagnosed with aspergilloma based on a positive result for anti-aspergillus antibody and β-D glucan in the serum. Surgical resection (RUL) was performed. The resected lung contained necrotic tissue, a so-called fungus ball, and aspergillus was identified histopathologically.

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We report a rare case of a multilocular thymic cyst with calcification at its rim. A 29-year-old woman who experienced discomfort of the left anterior chest was referred to our hospital. Radiological examinations revealed a mass at the anterior mediastinum. The tumor was enhanced heterogeneously, accompanied by calcification at its rim, showing no invasion to the adjacent organs. We suspected that the tumor was a mature teratoma based on these findings, and performed VATS surgery to remove it. During surgery, the tumor, measuring 42×22×15 mm in size, was located in the left lobe of the thymus. Macroscopically, it showed a multilocular cyst containing yellowish keratinized material with a thickened, hard wall. Microscopically, cystic walls were lined with multi-layered keratinized squamous or cuboidal epithelium. There were no tissues such as those of skin, teeth, and nerves. Based on these findings, the tumor was diagnosed as a multilocular thymic cyst. Multilocular thymic cysts associated with some malignant or autoimmune diseases have been reported; however, our case did not show these complications.

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Gastrointestinal leiomyosarcoma is an infrequent tumor, comprising 0.1% of malignant colorectal tumors. We herein present the case of a metastatic lung tumor from leiomyosarcoma of the colon. The patient underwent an operation for colon leiomyosarcoma and liver metastasis. About 6 years after the colectomy, pulmonary lesions appeared in the right S1, S6, and S8 segments. Right S1, S6 partial resection and right lower lobectomy were performed. On postoperative pathologic examination, all lesions were diagnosed as lung metastases from the leiomyosarcoma.

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We encountered two cases of pulmonary eosinophilic granuloma incidentally diagnosed from surgical specimens which were obtained at the time of surgery for spontaneous pneumothorax. Case 1: The patient was a 54-year-old man complaining of dyspnea. He had smoked 20 cigarettes a day for 20 years and was being followed for a giant bulla. He was diagnosed with right pneumothorax. Following tube thoracostomy, VATS bullectomy was performed for prolonged air leakage. Case 2: The patient was a 23-year-old man complaining of dry cough. He had smoked 20 cigarettes a day for 5 years. He was diagnosed with right pneumothorax, which was improved conservatively. However, the recurrence of pneumothorax occurred after a month. Although a chest CT scan revealed no emphysematous lesions, VATS was performed for recurrence. An apical bleb was noted and resected. Both cases were diagnosed with pulmonary eosinophilic granuloma histopathologically. They quit smoking after surgery, and the progression of lung lesions and the recurrence of pneumothorax have not been noted. In surgery for pneumothorax, the smoking history and histological examination are very important to elucidate the etiology.

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The patient was a 70-year-old man who complained of difficulty in walking. A chest radiograph showed a tumor in the right hilar field. He was diagnosed with non-small cell lung carcinoma with paraneoplastic cerebellar degeneration. To improve neurologic symptoms, he underwent resection of the tumor. The paraneoplastic cerebellar degeneration was refractory, but his symptoms disappeared after surgery.

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An 81-year-old man was referred to our hospital for an abnormal shadow found on a chest radiograph. Chest computed tomography revealed a nodular shadow in the left upper lobe. Bronchoscopic examination revealed abnormal broncheal mucosa limited to within the right intermediate bronchus, and the squamous cell carcinoma was resected. Double primary lung cancer was suspected, and left upper lobectomy was performed. Intraoperatively, it was shown that the superior pulmonary vein did not drain into the left atrium but the left brachiocephalic vein. The anomalous vein was ligated and the left upper lobe was resected uneventfully. The post-operative diagnosis of the left lung tumor was adenocarcinoma. Radiation therapy was performed for the right lung cancer. PAPVC is a congenital anomaly in which parts of the pulmonary vein drain into the right atrium or its tributaries. When the anomaly exists in the residual lung, the loss of the lung with normal blood flow possibly induces post-operative right heart dysfunction. Therefore, chest surgeons should be fully aware of this rare anomaly.

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We report two cases of seminomatous germ cell tumor originating in the anterior mediastinum. Case 1: A 67-year-old man was referred to our hospital for further evaluation of an abnormal mediastinal shadow identified on a routine chest radiograph. Chest computed tomography (CT) scan revealed a 10.0×8.0×8.0-cm mass in the anterior mediastinum. Surgical resection of the tumor which involved the right upper lobe of the lung was performed with a diagnosis of suspected invasive thymoma. An immunohistopathological examination showed the tumor to be a primary mediastinal seminoma. Postoperative radiotherapy was performed with a total dose of 50 Gy. Nine months after surgery, local recurrence was found, and complete right upper lobectomy of the lung was performed. The patient was treated with two cycles of chemotherapy consisting of cisplatin, etoposide, and bleomycin. He is now disease-free at 7 years and 6 months after the salvage surgery. Case 2: A 25-year-old man visited our hospital for further examination of an abnormal shadow on chest radiograph. CT scan demonstrated a 9.6×8.6×8.5-cm mass in the anterior mediastinum, and CT- guided needle biopsy of the tumor was performed. Immunohistological evaluation of the biopsy specimen showed findings of seminomatous germ cell tumor. The patient received four cycles of systemic chemotherapy with a combination of cisplatin and etoposide, and then underwent surgical resection of the residual tumor. Histopathologically, there was no viable malignant cell in the resected specimen. He is now disease-free at 14 months after surgery, receiving no adjuvant chemotherapy. The standard strategy for the treatment of malignant germ cell tumors is cisplatin-based systemic chemotherapy. Therefore, in cases of suspected malignant germ cell tumors, confirmation of the histological diagnosis is required before initial treatment.

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A 68-year-old man was admitted to our hospital due to repeated hoarseness. He had experienced hoarseness three years earlier due to left recurrent nerve paralysis of unknown etiology, but it disappeared spontaneously. This time, he showed left recurrent nerve paralysis with an abnormal shadow in his left upper lung region on chest radiograph. Chest computed tomography revealed a total of 6 nodules, around 11 to 26 mm in diameter, with some showing evacuated regions, distributed in the right lower and left upper lobes. The patient underwent left upper lobectomy to establish a definite diagnosis and for further treatment. Pathological analysis revealed granulomatous inflammation and necrotic vasculitis compatible with typical Wegener's granulomatosis. Hoarseness due to recurrent nerve paralysis is extremely rare as a symptom of Wegener's granulomatosis, and the spontaneous disappearance of the symptom has rarely been reported. This report describes a case of Wegener's granulomatosis who presented with repeated hoarseness due to left recurrent nerve paralysis.

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A 26-year-old man was referred to our hospital because of dull pain in the right hypochondrium. Chest radiograph showed a mass in the right lower lung field. A chest radiograph taken one year earlier had shown a faint patchy shadow at the right cardiophrenic angle. Chest CT-scan revealed a cystic mass on the thoracic side of the right diaphragm, with a feeder vessel branching out from the celiac artery. Abdominal angiography identified an abnormal artery branching from the celiac artery and entering the mass. During the venous phase, the blood from the tumor drained into the left atrium via the inferior pulmonary vein. With a diagnosis of pulmonary sequestration, the patient underwent a right lower lobectomy. The abnormal artery was palpable in the pulmonary ligament, and was resected using a stapler. The resected specimen revealed that the cystic mass consisted of an enlarged bronchial lumen of the sequestrated lung, lined with a layer of bronchial epithelium and filled with a large amount of blood clots. On intralobar pulmonary sequestration, rapid size increase due to intrabronchial hemorrhage can develop without any infectious symptoms, sometimes progressing to fatal hemothorax due to perforation. Hemorrhaging intrapulmonary sequestration should be taken into consideration for a patient with a rapidly enlarging cystic pulmonary mass.

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The da Vinci Surgical System is a telerobotic system consisting of 4 components, including the Insite vision system with a true 3-dimensional endoscope providing a high-resolution binocular view of the surgical field, and the Endo Wrist instrument system, which is capable of 7 degrees of freedom and 2 degrees of axial rotation to replicate human wrist-like movements. Right upper lobectomy + mediastinal lymph node dissection was performed in a 56-year-old woman with cT1bN0N0 stage IA lung adenocarcinoma. The operating time was 6 hours 48 minutes, and the blood loss was 234 g. The da Vinci Surgical System has useful advantages over conventional VATS surgery concerning the precise dissection of hilar structures and mediastinal lymph nodes. With further innovations in the future, the da Vinci Surgical System has the potential to facilitate technically difficult surgery employing conventional VATS techniques.

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Some reports have shown that thoracoscopic surgery for fibrinopurulent empyema with multiloculation and fibrinous and viscous fluid often leads to complete drainage. However, some patients cannot undergo surgical treatment because of their poor condition. Some papers have indicated that the intracavitary instillation of urokinase is a useful method for these cases. However, this has not been investigated sufficiently to become a standard method. In this paper, we report five patients who underwent the intracavitary instillation of urokinase for fibrinopurulent empyema. All patients showed empyema with multiloculated empyemic fluid and pleural thickening. Four of the five patients could achieve the relief of fluid accumulation after urokinase instillation (120,000 IU X 6-9 times). The other patient recovered after the instillation of urokinase followed by surgical treatment. The intracavitary instillation of urokinase was performed 1-16 days after the onset of empyema in the former 4 patients, and one month after in the latter one. All patients recovered without major complications. This procedure might be useful for the treatment of fibrinopurulent empyema in high-risk patients.

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A 39-year-old woman noted a nodule at the right lower anterior neck. Fine-needle aspiration cytology showed squamous cell carcinoma. We performed surgical resection of the tumor. On immunohistochemical examination, tumor cells stained positively for CD5, CD56, CD117, CEA, c-kit, CK7, chromogranin A, and synaptophysin. We diagnosed her with carcinoma showing thymus-like differentiation (CASTLE). CASTLE is a rare malignancy that occurs in the soft tissues of the neck or thyroid gland. Complete resection is important to improve the long-term survival and locoregional recurrence rates.

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A 69-year-old man was admitted to our hospital for the resection of a chest wall tumor. At the age of 26, he underwent the excision of cervical and mandibular cavernous hemangioma, and his left mandibula was repaird using the right 6^th rib in another hospital. At the age of 65, he underwent the excision of mediastinal cavernous hemangioma believed to represent regrowth of the residual tumor. At that time, a chest wall tumor under the scar of the right 6^th rib was recognized; however, the tumor was left untreated, enlarging over 4 years. Tumor resection was subsequently performed, with a diagnosis of cavernous hemangioma. The tumor grew from the periosteum of the resected 6^th rib, and the blood supply was via dents in the periosteum. Cavernous hemangioma does not cause metastasis; therefore, this case was thought to have been caused by the operation 43 years previously.

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An 81-year-old male consulted a doctor due to a tumor shadow of 3.5 cm in diameter in the apex of the right lung found on chest radiograph at his 2008 health check. Bronchoscopy did not yield a diagnosis of lung cancer. However, swollen bilateral adrenal glands were noted. He was referred to our hospital for diagnosis and treatment. On plain CT, tumor of the apex of the right lung with ipsilateral hilar lymphadenopathy and swollen bilateral adrenal glands were detected, and subsequent FDG-PET confirmed abnormal accumulation in the same regions. These data suggested he had advanced lung cancer with metastases to the bilateral adrenal glands as well as hilar lymph nodes, cT3N1M1 stage IV. CT-guided needle biopsy to determine the tissue type of the cancer for the planning of chemotherapy showed no malignancy but granulation tissue of unknown origin with caseous necrosis. In order to reach a definitive diagnosis, VATS was performed, and examination of the resected specimen resulted in the pathological diagnosis of epithelioid granuloma. Although acid-fast bacteria were not detected by PCR of the specimen, M. avium complex was isolated on 3-week culture; thus, a diagnosis of pulmonary atypical mycobacteriosis was finally reached. Excision biopsy is a significant strategy in cases of pulmonary lesions mimicking advanced lung cancer.

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A 33-year-old man was admitted to our hospital because of hemoptysis. Bronchoscopic examination revealed coagulated blood at the lingular segmental bronchus. After removing the coagulated blood, no abnormal neoplastic lesion or aneurysm could be seen. Chest CT showed no chronic inflammatory disease of the lung, nor bronchodilatation. Hemoptysis recurred, and enlarged bronchial arteries could be observed by 3D-CT. Bronchial artery embolization was considered, but not performed, because of possible systemic embolization with high-flow shunting. Instead, bilateral ligation of the bronchial artery was performed employing video-assisted thoracic surgery (VATS). After surgery, hemosputum ceased by the 10^th post-operative day. No hemoptysis occurred for 5 months after surgery. Eight cases of ligation of the bronchial artery in Japan have been previously reported in the literature, of which 7 were for racemose hemangioma of the bronchial artery, and one for bronchial aneurysm. Hemoptysis recurred in 2 of these 8 cases between 1 and 14 years after surgery. Although ligation of the bronchial artery is an effective treatment, long-term observation is needed to monitor the possible recurrence of hemoptysis.

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We report a rare case of atypical carcinoid of the thymus. A 77-year-old man was referred to our hospital because of precordialgia and an abnormal chest shadow. A CT scan demonstrated an anterior mediastinal mass, measuring 8.0 cm in diameter. Preoperative FDG-PET showed abnormal accumulation in the lesion. The diagnosis of atypical carcinoid of the thymus was confirmed based on pathological findings from biopsy material. We performed extended thymectomy with mediastinal lymph node dissection. The postoperative pathological diagnosis revealed atypical carcinoid of the thymus and no metastases of mediastinal lymph nodes. The patient was free of clinically evident recurrence 2 years after treatment. Preoperative diagnosis is necessary for systematic nodal dissection and an adequate surgical margin. Moreover, we think that FDG-PET is useful as an adjunct to the diagnosis and follow-up of thymic carcinoid.

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Pulmonary inflammatory myofibroblastic tumor is a rare lung disease, regarded as a benign or low-grade malignant tumor. A 23-year-old woman was noted to have an abnormal shadow on chest radiograph during a medical check-up, and was referred to our hospital. Chest CT revealed a 17-mm, well-defined, homogeneously dense nodule in S¹ of the right lung. Preoperative bronchoscopy suggested lung sarcoma, and the patient underwent surgery. The lung lesion was diagnosed again as lung sarcoma on intraoperative frozen section examination, and right lung upper lobectomy with lymph node dissection was performed. Postoperative histopathological examination showed the dense proliferation of spindle-shaped cells and infiltration of inflammatory cells such as lymphocytes and plasma cells. Although there was mild nuclear atypia, no mitotic figures or necrosis was noted. The MIB-1 index was about 5-10%. The tumor was positive for α-SMA and ALK, and was diagnosed as a pulmonary inflammatory myofibroblastic tumor. This disease is often difficult to diagnose pre- and intraoperatively. In the diagnosis and treatment of this condition, it is important to completely resect the tumor. We describe this and other cases reported in Japan, which required differentiation from lung sarcoma.

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We describe a method of thoracoscopic evacuation for fibropurulent empyema or retained hemothorax. We overcame the difficulties in suctioning the gelatinous contents of such cases using the new device with a simple combination of commercially available flexible connecting tubes and a stainless steel trocar.

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