Recently, it has been reported that video-assisted thoracoscopic chest drainage is a useful treatment for acute empyema, but its indication has not been clarified. We retrospectively reviewed acute empyema patients by dividing them into 3 groups: operation group (7 patients), drainage group (6 patients), and antibiotic treatment group (9 patients), and then we evaluated the therapeutic strategy by examining the radiological findings, drainage period, and hospital stay. In the antibiotic treatment group, the ratio of pleural effusion on chest radiograph was under 1/4 in all patients. There were 5 patients who showed multilocular findings on chest CT, and all patients underwent an operation. Regarding the drainage period, the operation group showed a significantly shorter period than the drainage group. Concerning the hospital stay, the drainage group showed a significantly longer stay than the other 2 groups. The ratio of pleural effusion on chest radiograph was under 1/4, giving an indication for antibiotic treatment. With multilocular findings on CT, an indication for surgery is needed. Patients requiring drainage, which necessitates a long hospital stay, should be advised to consider surgery.

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A 35-year-old man was admitted to our hospital with an abnormal shadow on chest radiograph at an annual medical check-up. Chest CT showed a mass at his left hilum in which 18F-fluorodeoxyglucose (FDG) accumulated, with a maximum standardized uptake value of 2.63. An open biopsy of the mass was conducted through a thoracotomy, and frozen sectioning showed lymphoid infiltrations without malignancy. Then, the tumor itself was excised from the surrounding lung parenchyma. The final pathological diagnosis was Castleman's disease, hyaline vascular type. Because a differential diagnosis of Castleman's disease of hilar lymph node origin is often difficult, even employing modern imaging modalities, it is important to be aware of Castleman's disease on the differential diagnosis of a hilar tumor.

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A 71-year-old woman consulted a doctor because of an abnormal shadow of the right lung found on a chest radiograph taken during a medical check. Computed tomography revealed a 1.8-cm nodule in the right S³. Bronchoscopy yielded no specific histological or bacterial findings. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed a positive uptake at the lesion site, with a 3.82 maximum standardized uptake value. She was referred to our hospital for treatment of the tumor, with the possibility of lung cancer. Since a tumor needle biopsy by thoracotomy revealed no malignancy, wedge resection of the S³ was undertaken. The histopathological examination of the resected specimen revealed an epithelioid granuloma with caseous necrosis. Acid-fast bacilli were detected in a smear of pus, and Mycobacterium intracellulare was identified by the polymerase chain reaction method. She was discharged on the 9^th day after surgery with anti-tuberculous agents, and has experienced no recurrence. A solitary pulmonary nodule caused by M. intracellulare is rare, and it should be considered in the differential diagnosis of lung cancer, even with uptake on FDG-PET.

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An 18-year-old male presented with recurrent pneumonia localized to the right lower lobe. A chest CT scan revealed a tumor-like lesion in the anterior basal segment of the right lobe, about 20 mm in diameter. Fiberoptic bronchoscopy revealed a tumor with a rough surface obstructing the bronchial ostia of B8-10 in the right lower lobe, which was later diagnosed as a mucoepidermoid carcinoma. Since there were no signs of lymph node or distant metastasis, we considered the case to be surgically operable, and performed a right lower lobectomy with dissection of the hilar and mediastinal lymph nodes (ND2a). A final post-surgical pathological examination determined the tumor to be a low-grade-malignancy pulmonary mucoepidermoid carcinoma, pT1N0M0 stage IA. Although there are a few reported cases of low-grade-malignancy pulmonary mucoepidermoid carcinoma among young males, it is still extremely rare among patients as young as the present case. As in this case, the possibility of lung cancer should be considered in patients with recurrent pneumonia, even if they are young.

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We report a case of schwannomatosis with mediastinal vagal nerve schwannoma resected employing video-assisted thoracoscopic surgery (VATS). A 52-year-old female was admitted to our hospital for a left supraclavicular tumor. Chest CT demonstrated a well-defined round mass adjacent to the chest vertebra. With a preoperative diagnosis of a neurogenic tumor from the right vagal nerve, VATS was performed. An encapsulated tumor was resected along with the right vagal nerve. Histopathological findings were consistent with schwannoma of the vagal nerve. To our knowledge, only three cases have previously been reported in the Japanese literature; schwannomatosis with mediastinal vagal nerve schwannoma is rare. Because FDG-PET sometimes shows a high uptake in schwannomatosis, it is important to perform other modalities, CT and MRI, to exclude metastatic malignant tumors.

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The management of acute empyema involves drainage and appropriate antibiotics to prevent the acute phase progressing into the chronic phase, which is intractable. We encountered five cases of acute empyema treated with video-assisted thoracoscopic surgery (VATS). We retrospectively reviewed the five cases, 3 males and 2 females, with a median aged of 61 years old. The duration of preoperative symptoms was 8.4±3.6 days. In all cases, VATS decortication and drainage were performed. The mean operating time and intraoperative blood loss were 131.8±14.6 minutes and 54±42.9 grams, respectively. Two of the five cases temporarily required noninvasive positive pressure ventilation (NIPPV) because of pulmonary edema immediately after extubation. After being weaned off NIPPV, their clinical course was favorable. The mean duration of postoperative drainage was 5.2±2.2 days, and the mean duration of postoperative hospitalization was 17.2±5.9 days. We are following up all patients, with no cases of relapse. VATS is low-invasive and effective in the management of acute empyema.

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A 72-year-old woman was admitted to our hospital for the closer examination of a chest wall tumor (epithelial malignant tumor). CT and PET/CT showed only a chest wall tumor, and no primary lesion was found. We carried out chest wall resection with partial resection of the right lower lobe. Based on the results of a pathological examination, adenocarcinoma was indentified in the chest wall. We diagnosed the case as chest wall carcinoma without a primary lesion. Although no primary carcinoma was found in the lung, the immunohistochemical findings suggested a pulmonary origin. We report this rare case and discuss the literature on carcinoma with an unknown primary site.

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A 62-year-old woman was referred to our hospital with an abnormal shadow on a chest radiograph. Both CT and MRI revealed a 70-mm mass that had invaded the chest wall and left upper lobe in the anterior mediastinum, as well as a 15-mm nodule in the left lower lobe. The mass was diagnosed after CT-guided percutaneous needle biopsy as a mesenchymal tumor, which was excised with partial resection of the chest wall, thymus, and left upper lobe due to severe invasion, but the pericardium and phrenic nerve were conserved. Histology of the tumor showed the proliferation of spindle-shaped cells with loose and highly cellular regions containing mitosis and necrosis. Immunohistochemically, the tumor cells were positive for vimentin and HBME-1, and negative for S-100, AE1/AE3, EMA, calretinin, and TLE1. The histological diagnosis was malignant peripheral nerve sheath tumor (MPNST).

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We encountered three cases of mediastinal lymph node carcinoma with an unknown primary site. Patient 1 was a 68-year-old male. Chest CT revealed mediastinal lymphadenopathy without any primary site. A mediastinal lymphadenectomy was performed, and the histological diagnosis was poorly differentiated adenocarcinoma. A left lung nodule appeared 7 years after the operation. A resection of the left upper lobe was performed, and the pathological findings were similar to the previous mediastinal lymph node carcinoma. Patient 2 was a 72-year-old male who presented with a chief complaint of hoarseness. CT revealed mediastinal lymphadenopathy without any primary site, and a biopsy of the lymph node was performed. The pathological diagnosis was squamous cell carcinoma, and chemoradiotherapy was performed after surgery. A left lung nodule appeared one year after the operation. Patient 3 was a 71-year-old female in whom right lung carcinoma was suspected, and a resection of right lung with both mediastinal and hilar lymphadenectomy was performed. The pathological findings revealed the primary lung tumor to be squamous cell carcinoma; however, the lymph nodes demonstrated large cell neuroendocrine carcinoma. Surgery may be appropriate for patients presenting with mediastinal lymphadenopathy without any primary site, because a diagnosis is necessary to select the optimal therapy and, moreover, lymphadenectomy might facilitate the complete resection of the lymph node and, thereby, lead to an excellent treatment effect.

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A 59-year-old female was referred to our hospital because of intractable peritonsillitis and pharyngolaryngitis. Initially, antibiotic therapy was started. Soon, local findings of tonsillitis and pharyngolaryngitis remitted, but high-level fever continued. Moreover, symptoms of heart failure appeared. At that time, computed tomography (CT) was carried out, leading to a diagnosis of descending necrotizing mediastinitis (DNM). DNM can complicate oropharyngeal infection, and has a high associated mortality. To realize successful treatment, diagnosis needs to be prompt and surgical drainage adequate. To diagnose the condition earlier, it should be suspected based on typical symptoms, and CT should be performed. However, in this case, because antibiotics were effective, the typical symptoms were masked. So, we report this rare and suggestive case of DNM.

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A 76-year-old male underwent left upper lobectomy for primary lung cancer. Perioperative routine prophylaxis for pulmonary embolism was conducted. His postoperative course was without complications, and he was discharged on postoperative day (POD) 16. On the same day, he presented with dyspnea but stayed at home. Since the symptom did not improve, he came to the outpatient clinic 4 days later. He was readmitted with dehydration and slightly high CRP levels in laboratory tests. After hydration and low-level oxygen administration, his symptom markedly improved. On POD 26, a definitive diagnosis of pulmonary thromboembolism (PE) and deep vein thrombosis was made based on contrast-enhanced chest CT and lower extremity venous ultrasound. Anticoagulant therapy followed by IVC filter placement was performed immediately. The thrombi in the pulmonary vessels disappeared 3 weeks later, but there was no improvement in lower extremity venous thrombosis. The patient was discharged with the IVC filter in place. In the present case, it took almost one week to reach the final diagnosis after admission. In the case of postoperative dyspnea with nonspecific clinical findings in a thoracic surgery patient, we should always be aware of and actively suspect the possibility of PE, and effective treatments should be initiated immediately after its diagnosis.

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We report a patient who underwent chest wall tumor resection and thoracic wall reconstruction using GORE-TEX Dual Mesh. The 78-year-old man, with a chest wall tumor of the right posterior-inferior wall, underwent tumor resection. The defect area of the chest wall was 10 × 11 cm, and was reconstructed with GORE-TEX Dual Mesh suturing to the ribs. The postoperative course was uneventful, and neither paradoxical respiration nor respiratory failure was observed. GORE-TEX Dual Mesh is a useful material in chest wall reconstruction.

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A 59-year-old woman presented with an abnormal chest shadow on a chest radiograph. A chest computed tomography (CT) scan showed a mass shadow measuring 59×31×28 mm in the superior mediastinum. A positron emission tomography (PET)-CT scan showed the accumulation of FDG (SUV max 7.34) in the mass. Tumor resection was performed through a median sternotomy, and the tumor was resected completely. The pathological findings revealed that the tumor fulfilled the criteria for a diagnosis of large-cell neuroendocrine carcinoma of the thymus, and was classified as a stage III tumor based on Masaoka's classification. Two months after the operation, she was readmitted to the hospital and received adjuvant radiotherapy (50 gray/25 Fr) to the mediastinum. She has been well without any sign of recurrence for 6 months after surgery. Large-cell neuroendocrine carcinoma arising in the thymus is very rare, with only 10 case reports being published in Japan. It is essential to accumulate further case reports to understand this disease, so we reported this case with some references.

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A 74-year-old woman underwent left S6 segmentectomy for the surgical diagnosis and treatment of lung tumor. After general anesthesia had been induced, a 35 Fr left-sided double lumen tube was introduced. During surgery, we observed a longitudinal rupture of the left mainstem bronchus. An emergency left thoracotomy was performed following surgical repair of the rupture. No problem of note occurred during the postoperative period. Bronchial rupture is a rare and critical complication of intubation with a double lumen tube. We discuss and report this case with some literature references.

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We report a case of pleomorphic carcinoma with a bubble-like appearance on chest CT, resected after long term follow-up. The patient was a 73-year old female. In a chest radiograph taken during a medical check-up, an abnormal shadow was pointed out in the left upper lung field. This shadow was followed up as an inflammatory change for 4 years. The size of the shadow gradually increased, so she was referred to our hospital for close examination. Computed tomography showed the tumor, 6 cm in size, with a bubble-like appearance in the left upper lobe. Bronchoscopic examination was performed, but we could not make an exact diagnosis. However, we strongly suspected lung cancer based on this image and performed surgical resection, a left upper lobectomy. The final diagnosis was pleomorphic carcinoma, pathological pT2bN0M0 Stage II A. If we note a tumor shadow with a bubble-like appearance, we should take lung cancer into consideration.

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A 37-year-old woman was admitted to our hospital after an abnormal shadow was detected on a chest radiograph during a routine checkup. She had a history of coughing that gradually worsened over the previous 9 months. Chest computed tomography revealed a mass shadow in the left upper lobe of the lung and anterior mediastinum. Although bronchoscopy revealed that the polypoid mass observed in the left B³ contained gray hairs, a definitive diagnosis could not be made. After her readmission to our department, we confirmed the bronchoscopic findings, and suspected a teratoma perforating the lung. Total resection of the tumor and partial resection of the left upper lobe were performed empolying a transthoracic approach, and a diagnosis of a mature teratoma was made histopathologically. The post-operative course was uneventful, and she has shown no sign of recurrence. This case exhibited an interesting developmental pattern in that the solid component of the mature teratoma progressed along the peripheral bronchial lumen after perforating the lung.

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A 60-year-old man with colon cancer, showing multiple lung and liver metastases (Stage IV), had been treated with chemotherapy. Dyspnea on exertion appeared, and a tumor of the left main bronchus was detected on chest CT. A polypoid tumor obstructing the left main bronchus was observed on diagnostic bronchoscopy. The pathological findings of the tumor led to a diagnosis of metastasis from colon cancer. Nd-YAG laser ablation and high-frequency electrosurgery using a flexible bronchoscope under general anesthesia were performed for the treatment of airway obstruction. The patency of the bronchus and relief from symptoms could be achieved without complications. We report our experience of the local treatment of endobronchial metastases from colon cancer using bronchoscopic Nd-YAG laser ablation and high-frequency electrosurgery. Endobronchial metastases, although rare, must be considered in the surveillance of distant recurrence in cancer patients, especially those with respiratory symptoms. Indications for complete surgical resection are extremely limited; however, bronchoscopic intervention to prevent airway constriction is very important to maintain the quality of life, even in advanced cancer patients.

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A 62-year-old woman with a history of Sjögren's syndrome was pointed out as showing ground-glass opacities in the right middle lobe. A lesion obtained by VATS wedge resection was diagnosed as lymphoid hyperplasia. Chest CT showed multiple ground-glass opacities in the right lower lobe 2 years after the first operation. A lesion obtained by re-VATS resection was diagnosed as low-grade B-cell lymphoma of the MALT type (MALToma). The residual lesions disappeared 7 months after the second operation by the administration of Rituximab. Lymphoid hyperplasia with collagen disease might be an antecedent disease of pulmonary MALToma.

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We describe a case of pulmonary epithelioid hemangioendothelioma (PEH), previously known as intravascular bronchioalveolar tumor, in a 78-year-old woman. In most of the previous PEH cases, chest CT showed several well-demarcated nodules, but, in this case, chest CT showed well-demarcated calcified nodules of the left upper lobe (in segment S¹⁺²) and poorly demarcated nodules with pleural indentation in the right lower lobe (in segment S⁹). FDG-PET/CT revealed an increased uptake in the latter; therefore, the S⁹ nodule was suspected as lung cancer. Partial resection of the lung was performed for the S⁹ lesion; however, an intraoperative cytologic examination led to a diagnosis of PEH.

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The anatomical resection of posterior segments of the lower lobes is difficult because arteries and bronchi are located in the deep parenchyma. Using 3-dimensional multi-detector computed tomographic images for surgical simulation, we simplified the procedure of lateral posterior basal bisegmentectomy of the lower lobes.

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