One hundred and fifty patients with bilateral spontaneous pneumothorax (SP) were studied. There were 8 synchronous and 142 metachronous cases at our hospital from 2001 to 2009. The highest frequency occurred between the teens and twenties. The mean interval between the initial and contralateral SP was 47.3 months, ranging from 2 days to 32 years. The mean interval for those in their teens and twenties was shorter than in the group aged over 30 years. Regarding the results of treatment for metachronous SP, the rate of recurrence on the initial SP was low, and the rate of recurrence on the contralateral SP was high.

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Postoperative pneumonia is sometimes a life-threatening complication of surgery for lung cancer. We retrospectively reviewed patients who developed postoperative pneumonia after surgery for lung cancer in order to assess the clinical, microbiological, and therapeutic features of this complication. Between 2001 and 2009, 836 patients underwent pulmonary resection for lung cancer in our hospital. Postoperative pneumonia developed in 23 patients (2.8%). Diagnoses of pneumonia were performed on postoperative day 6.8 ± 3.4 (mean ± SD). Plain chest radiography revealed abnormal shadows on the operative side in 20 patients; 2 patients had bilateral pneumonia and 1 underwent pneumonectomy. Computed tomography was performed in 17 patients, and, among them, 13 patients (76.5%) had infiltrative shadows in the caudal or dorsal portion of the operative side of the lung. Nine patients (39.1%) were intubated in order to perform mechanical ventilation, and 4 of them died. Sputum cultures were performed in 12 patients, and pathogenic microorganisms were isolated in 4 (33.3%). The culturing of endotracheal specimens was carried out in 12 patients; among them, normal flora of the oral cavity was isolated in 4 patients (33.3%), no microorganisms were identified in 1 patient (8.3%), and pathogenic microorganisms were isolated in 7 patients (58.3%). The patients whose specimens tested positive for pathogenic microorganisms tended to develop severe pneumonia. We conclude that the insufficient drainage of respiratory tract secretions and silent aspiration after lung surgery are associated with the development of postoperative pneumonia. Further, obtaining and analyzing lower respiratory tract secretions is an important step in the management of postoperative pneumonia.

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Although video-assisted thoracoscopic surgery (VATS) has been the first-choice surgical procedure for spontaneous pneumothorax, the rate of post-operative recurrence has been reported to be relatively high. The cause was regarded as pneumothorax resulting from new bullae formation near the staple line after VATS with stapling resection. Therefore, to prevent post-operative recurrence, we have adapted a procedure of ligating the bullae with loops as a routine method to treat primary and secondary spontaneous pneumothorax. From January 1998 to December 2008, 654 VATS operations for spontaneous pneumothorax were performed involving 584 patients. Of these, 472 patients (530 sides) were treated using double loop ligation. A total of 81.0% of the surgeries were for spontaneous pneumothorax. In addition, loop ligation comprised up to 91.7% in those in their 10s-20s. The incidence of post-operative recurrence following thoracoscopic loop ligation was 5.8% (31 in 530 cases). The recurrence rate was significantly lower than that of thoracoscopic bullectomy (17.8%). Thoracoscopic double loop ligation of bullae was shown to be a safe, reliable, and cost-effective technique for spontaneous pneumothorax.

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Sublobar resection for small-sized lung cancer remains controversial. We herein propose a treatment algorithm for the limited resection of small-sized lung cancer on the basis of a retrospective analysis of the CT findings, tumor diameter, serum CEA level, and pleural invasion in 168 patients. The 5-year disease-free survival (5-Y-DFS) was 90.3%. Neither lymph node involvement nor recurrence was observed in 50 patients with ground glass opacity (GGO)-dominant lesions. One lymph node metastasis and two recurrences were found in 36 patients with solid-dominant lesions. Of 82 patients with solid lesions, 14 (17.1%) had lymph node metastases, which tended to be frequent in patients with high serum CEA levels. The 5-Y-DFS was 81.1%, and recurrence was significantly more frequent in patients with high serum CEA levels and pleural invasion. In conclusion, a lobectomy should be recommended for small-sized solid lesions larger than 1 cm, while a segmentectomy could be indicated for GGO lesions or solid-dominant lesions smaller than 1.5 cm. A sublobar resection for solid lesions smaller than 1 cm should be carefully considered.

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We report a case of lung metastasis of adrenocortical carcinoma removed 18 years after initial surgery. The patient was a 66-year-old female with a chief complaint of a growing mass lesion noted on chest radiograph. She had undergone resection of a left adrenal gland for Cushing syndrome. Eighteen years later, a repeat chest radiograph revealed an enlarged mass in the right lower lung field. Employing video-assisted thoracic surgery, resection of the tumor was performed. Pathologic examination was consistent with the recurrence of adrenocortical carcinoma. We conclude that even in the presence of a long disease-free interval, we should consider the possibility of metastasis when we encounter an isolating lung tumor.

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A 65-year-old female was admitted to our hospital for an anterior mediastinal tumor. A CT scan revealed an anterior mediastinal tumor and a solitary nodule in the left lower lobe. (superior segment: S6). The patient requested only resection of the anterior mediastinal tumor; therefore, extended thymectomy with partial resection of the right upper lobe was performed. The histological diagnosis of the anterior mediastinal tumor was thymic squamous cell carcinoma. After two-years postoperative follow-up, CT scan revealed a growing solitary nodule in the lower lobe (S6). A left lower lobectomy for the lung tumor was performed as a second operation, and the histological diagnosis was primary lung adenocarcinoma. Six months after the second surgery, the patient is alive without recurrence. Cases of synchronous thymic carcinoma and primary lung cancer are rare; hence, we report this case.

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We report a case of primary clear cell adenocarcinoma of the lung resected employing video-assisted thoracic surgery (VATS). This patient was a 69-year-old female. A chest CT scan showed an abnormal shadow at S⁸ of the right lung. The nodule was 23 mm in diameter, with hilar and mediastinal lymph node swelling. We suspected primary lung cancer with lymph node metastasis. A right lower lobectomy with mediastinal lymph node dissection was performed using VATS. Postoperative pathological examination revealed clear cell adenocarcinoma and 19/23 lymph node metastasis. Furthermore, immunohistologically, this tumor was positive for thyroid transcription factor-1 and CEA. The pathological diagnosis was pT1aN2M0 Stage III A. A following the operation, the patient receives adjuvant chemotherapy with UFT after cisplatin and vinorelbine.

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Thoracolithiasis is a relatively rare disease. On a literature search, only 26 cases of thoracolithiasis were identified. We report 2 cases of thoracolithiasis diagnosed during the follow-up of malignant tumors. Case 1: A 74-year-old man with a suspicion of intrahepatic cholangiocarcinoma underwent chest CT. It revealed multiple pulmonary nodules in both lung fields. PET/CT showed accumulation in them; therefore, pulmonary metastasis from intrahepatic cholangiocarcinoma was suspected. During thoracotomy, 2 grayish-white nodules in the right thoracic cavity were found, but no intra-pulmonary tumor was detected. The samples measured 7×7×5 and 4×4×3 mm. Histopathological examination revealed a nodule including black spotted substances at the center that was concentrically surrounded by fibrotic tissue. The pathological diagnosis was thoracolithiasis. Four months after the first operation, he underwent video-assisted thoracic surgery (VATS) and partial pulmonary resection for a nodule in the left lung field. The pathological diagnosis was metastasis from intrahepatic cholangiocarcinoma. Case 2: A 69-year-old man with an undetermined pancreatic tumor underwent chest CT. It revealed multiple nodules in both lung fields. Pulmonary metastasis was suspected. During thoracotomy, 3 white nodules in the right thoracic cavity and one nodule attached to the surface of S⁸ of the right lung were identified. Histopathological examination revealed hyaline fibrotic tissue that was concentrically surrounded by collagen fibrous tissue. The pathological diagnosis was thoracolithiasis. In both cases, a definite preoperative diagnosis by imaging was difficult. VATS exploration was very useful for the diagnosis.

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We report a case of complete surgical resection of a solitary plasmacytoma from the chest wall. A 75-year-old man developed left lower back pain. Chest computed tomography (CT) revealed a chest wall tumor of 90×75×80 mm, mainly in the left 10th rib. The osteolytic tumor infiltrated the 9th, 10th, and 11th ribs and the 9th and 10th thoracic vertebrae. The tumor, 9th, 10th, and 11th ribs, and 9th and 10th thoracic vertebrae were resected. A thoracic vertebral implant was inserted, and the chest wall defect was repaired with Marlex^® mesh. On the basis of the immunostaining results, we diagnosed the patient with solitary plasmacytoma of the bone.

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We successfully treated metastasis of breast cancer to the sternum in a 65-yo female for whom an extended mastectomy was carried out 10 years ago. After the mastectomy, chemotherapy, but not hormonal therapy, was carried out because hormonal receptors were negative in the first excised specimen. However, since the metastatic tumor enlarged in the short term and then became malodorous due to rupture and infection of the tumor, we carried out resection of the metastatic tumor in combination with reconstructive surgery employing a vertical rectus abdominis musculo-cutaneous flap. First, since the metastatic tumor was 8 cm in maximum diameter, had destroyed the entire sternum, protruded into the pleural space, and invaded the fat tissue in the mediastinum, a combined excision of the tumor, sternum, and three costal cartilages was carried out. Second, the reconstructive surgery was followed by the application of a pedicled right rectus abdominis myocutaneous flap in association with an anastomosis between the left deep inferior epigastric vessels and right internal thoracic vessels. Since the surgery was successful, there is little shift of the chest wall during respiration, with little deterioration of the respiratory function, and there has been no finding of recurrence for 28 months after the second surgery.

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A 55-year-old female experienced chest discomfort. Chest radiography and computed tomography showed a large homogenous tumor, 80 mm in diameter, in the middle mediastinum compressing the trachea and left lobe of the thyroid gland. The tumor was successfully resected via a cervical approach. Histologically, parathyroid tissue was seen in the cyst wall, and values of parathyroid hormone (PTH), intact-PTH, and PTHrP in the fluid were very high, without elevations of their values in the serum. An Internet search was conducted, and 133 cases of mediastinal parathyroid cyst were found in the literature. Fifty-nine percent of tumors were non-functional, and 23% were located in the middle mediastinum. Although a cervical approach has rarely been applied to the tumor in the middle mediastinum, this approach could be a surgical option for patients without local symptoms.

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A 56-year-old woman consulted us regarding a tumor shadow in the anterior mediastinum in May 2009. Chest CT showed a mass in the anterior mediastinum consisting of fat with slight enhancement. Chest MRI showed a mass consisting of fat and solid components. She was diagnosed with a mature teratoma, and underwent surgery. The tumor was resected by median sternotomy and diagnosed as a mucinous neoplasm based on a perioperative pathological study. The specimen was a yellow mass. On postoperative pathological analysis, a mixed liposarcoma was identified.

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We treated a 53-year-old woman with an anterior mediastinal tumor which had been observed for 46 years after being incidentally found at the age of 7. The tumor was suspected to be a teratoma based on the findings of chest radiograph. The patient and her family declined surgery despite repeated recommendations. Hemoptysis began to manifest at the age of 40, and serum CEA has been elevated for the last two years, with some parts of the tumor shown to be positive by FDG-PET. On referral to our department, CT demonstrated a spherical 12-cm mass showing an inhomogenous density located in the anterior mediastinum, severe collapse of the right upper and middle pulmonary lobes due to the tumor, and bronchiectatic change in the upper lobe. The patient eventually agreed to undergo surgery because of persistent hemoptysis and the possibility of malignancy. The tumor was extirpated with combined resection of the right upper and middle lobes, and was histologically diagnosed as a mature cystic teratoma. The postoperative course was uneventful, serum CEA decreased to a normal level, and hemoptysis disappeared. Patients with mediastinal teratoma usually undergo surgery shortly after the diagnosis is established. Our case represents an extremely unusual case of a mediastinal teratoma, based on the fact that the tumor had been observed for more than four decades.

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We report a resected case of pulmonary infection caused by Mycobacterium abscessus (M. abscessus) in a 58-year-old man with a previous history of bronchiectasis. In July 2007, he was admitted to our hospital because of left chest pain, fever, and dyspnea. Chest radiograph and CT revealed left pleural effusion and left atelectasis. The left pleural effusion increased in spite of antibiotic therapy. Even with left chest drainage, re-expansion of the left lower lobe was insufficient. A large amount of viscous sputum was collected from the left lower bronchus using bronchoscopy. Culture examination of the sputum revealed acid-fast bacilli, identified as M. abscessus by DNA-DNA hybridization. After treatment with CAM, RFP, and EB, left lower lobectomy was performed, with satisfactory results. No relapse has occurred to date.

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A 65-year-old female was admitted to our hospital because of progressive dyspnea. Physical examination revealed wheezing audible through the neck and back. Laboratory test values for the blood, urine, feces, liver, and kidney were normal. CT scan and MRI depicted a mass in the anterior cervical trachea, while there were no specific findings around the trachea, in the thorax, or mediastinum. Bronchoscopic examination showed that the mass had almost occluded the lumen of the trachea. Biopsy of the tumor was not performed for fear of choking the patient. We carried out a thoracic surgical operation. The anterior wall of the trachea was promptly exposed by a collar incision under local anesthesia. An endotracheal tube was inserted into the distal part of the operative field. The resection of four tracheal rings and end-to-end anastomosis were performed. Histologically, the mass was diagnosed as primary malignant lymphoma of the trachea. The postoperative course was uneventful, and there has been no sign of recurrence either clinically or radiologically. Primary malignant lymphoma of the trachea is very rare. We report this case with a review of the literature relevant to it.

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A 41-year-old asymptomatic woman was referred to our hospital for a right pneumothorax noted incidentally on a chest radiograph. She had undergone surgery, radiation at a total dose of 60 Gy, and adjuvant chemotherapy therapy for right breast cancer 14 months previously. A chest tube was inserted into the right pleural cavity. Although the right lung expanded immediately, air leakage increased gradually and the right lung collapsed again three days after drainage. Computed tomography (CT) revealed the thickening of the frontal pleura of the right lower lobe, which resulted from radiation therapy, with chest tube compression and no blebs. We selected video-assisted thoracic surgery (VATS). The thoracoscopic view showed air leakage from the pleural fissures compressed by the chest tube. Plication was performed for this lesion and air leakage was stopped. No findings of recurrence have been noted since the operation.

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A 71-year-old man was scheduled to receive chemotherapy for malignant lymphoma. Because he developed mycosis of the left lung, prior to chemotherapy, left upper lobectomy was performed via a posterolateral thoracotomy. Due to severe adhesion, the fourth rib was detached on the dorsal side, and the fifth rib was resected. Because the scapula covered the thoracic wall defect sufficiently, no reconstruction was performed. However, the patient's respiration was unstable after surgery, and artificial ventilation was required for two days. Once sedation wore off, the patient experienced left shoulder pain. CT showed that the left scapula had invaginated into the pleural cavity through the thoracic wall defect. The scapula was reduced under general anesthesia, and the thoracic wall was reconstructed. The postoperative course was favorable. Although invagination of the scapula into the pleural cavity is a rare complication, we must keep it in mind when postoperative artificial ventilation is required.

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A 75-year-old woman with progressive dyspnea was referred to our hospital. Chest CT revealed a cystic mass of 87 mm located just beneath the bifurcation of the trachea, severely compressing the right pulmonary artery and intermediate bronchus. Since the patient presented with respiratory failure, a semi-emergent operation was performed. The cystic mass was partially resected employing video-assisted thoracoscopic surgery, and, histopathologically, the mass was found to be a bronchogenic cyst. Just after the operation, the patient became asymptomatic, and was discharged from the hospital on the 2nd postoperative day.

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Oro-pharyngeal aspiration is an increasingly recognized complication after pulmonary resection, especially among elderly patients. We report a patient with dysphagia and aspiration who was successfully managed using an alternative nutrition method called intermittent oro-esophageal tube feeding. An 84-year-old man with no particular history of aspiration developed pneumonia five days after undergoing right upper lobectomy for primary lung cancer. Videofluorography revealed severe dysphagia with massive, silent aspiration, but no recurrent laryngeal nerve palsy was identified. Despite sustained dysphagia, the patient refused percutaneous endoscopic gastrostomy placement. He was transferred to the rehabilitation hospital where oro-esophageal tube feeding was administered twice a day. He regained the capacity for total oral ingestion 7 months after the pulmonary surgery, and was discharged home without a relapse of pneumonia.

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A 16-year-old asymptomatic man was admitted to our institution for an abnormal shadow in the left upper mediastinum identified on a routine chest radiograph during a medical examination. Chest CT revealed an anterior mediastinal mass, which measured 7 cm in diameter, and a coin lesion in the upper lobe of the left lung. For the purpose of diagnosis and treatment, both resection of the mass and partial resection of the lung were performed. The histopathological diagnosis of both was cavernous hemangioma. Cavernous hemangioma in the thoracic field is comparatively rare, and simultaneous appearance in the mediastinum and lung is likely to be extremely rare.

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A 65-year-old man consulted our hospital because of an abnormal mass shadow, which was identified on a chest radiograph during a health check program. Chest CT revealed a 25-mm nodule in the left lung, and positive FDG uptake was confirmed by PET-CT. So, we clinically diagnosed this nodule as lung cancer. Bronchofiberscopic examination also revealed a displaced anomalous lingular bronchus branching from the stem of the left lower bronchus. Hyperlobulation between the upper and lingular divisions was noted during the operation, but without normal upper-lower lobulation. So, we performed left upper segmentectomy. The tumor was histologically diagnosed as large cell neuroendocrine carcinoma (T2aN1M0, stage IIA). Postoperative chemotherapy (CBDCA+VP16, CPT-11) was performed, but he died from respiratory failure due to IPF five months after the surgery.

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We report a rare case of mucoepidermoid carcinoma of the thymus which mimicked a benign tumor on preoperative imaging diagnosis, including an FDG-PET study. A 60-year-old female was pointed out as showing an abnormal chest shadow on screening chest radiograph. Further examinations, such as chest CT, chest MRI, and FDG-PET, suggested that she had a stage I thymoma (Masaoka staging system). She was admitted to our hospital, and underwent surgical resection. The postoperative pathological diagnosis revealed that the tumor was a thymic mucoepidermoid carcinoma, of which the clinicopathological features were those of a low-grade histology and low-stage (Stage I) disease. We suggest that the low-grade histology of this case led to a low SUVmax on FDG-PET, whereas previous reports noted that thymic mucoepidermoid carcinoma showed a high SUVmax. As the prognosis of thymic mucoepidermoid carcinoma is said to depend on its histological grade and clinical stage, she has a good prognosis, and showed no signs of recurrence as of 30 months after the initial treatment.

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A 71-year-old man was transferred to our hospital for the treatment of refractory chronic thoracic empyema and bronchial fistulae following severe pneumonia. Bronchial occlusion using silicone fillers (Endobronchial Watanabe Spigot: EWS) combined with thoracoplasty successfully controlled the thoracic empyema, which culminated in the discharge of the patient following thoracic drain removal. Chest computed tomography following the recurrence of the bronchopleural fistulae five months after the initial operation revealed pleural effusion, aspiration pneumonia, and EWS migration into the thoracic cavity. Fenestration was performed after the improvement of aspiration pneumonia following thoracic drainage, and the infected wound was periodically cleaned in the outpatient department. In this case, bronchial occlusion using EWS was effective in the treatment of refractory thoracic empyema with bronchial fistulae; however, further investigations are required to evaluate indications for the use of EWS in infected airways, and the optimal timing of EWS elimination after treatment.

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[in Japanese]

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[in Japanese]

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