The Journal of the Japanese Association for Chest Surgery
Online ISSN : 1881-4158
Print ISSN : 0919-0945
ISSN-L : 0919-0945
Volume 25 , Issue 4
Showing 1-23 articles out of 23 articles from the selected issue
  • Hiroki Hayashi, Jituo Usuda, Tatsuo Ohira, Masaki Kawahara, Norihiko I ...
    2011 Volume 25 Issue 4 Pages 352-355
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    Fourteen patients (over 75 years old) with a mediastinal tumor who underwent surgery were retrospectively reviewed. Postoperative complications occurred in 4 of them. Two of the four patients over 80 years old developed postoperative delirium. There was no postoperative delirium in 70-79-year-old patients. The shortest hospitalization period was 7 days, and the average was 30.3 days (longest: 164 days). The incidences of postoperative complications and delirium were high in the elderly patients. Surgical indications of mediastinal tumor should be more strictly limited, and less invasive surgery should be applied to older patients as much as possible.
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  • Takako Matsumoto, Masato Kanzaki, Manabu Amiki, Toshihide Shimizu, Hid ...
    2011 Volume 25 Issue 4 Pages 356-362
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    There are several types of practicable three-dimensional (3D) image formulation software, including those attached to computed tomography (CT) devices. Based on the images taken by 64-section multi detector-row CT, we formulated three 3D images using 3 different software programs (Advantage Workstation Volume Share4, OsiriX, and CTTRY), and performed surgery with reference to these 3D images in 5 patients. In this study, the characteristics, advantages, disadvantages, and utility in the operative field were compared among the images formulated using each program. Consequently, there were no marked differences in the vessel images at the segmental level, and all software programs were deemed useful. However, there were differences in visualization at the sub-segmental level among the 3 software programs.
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  • Shinji Takeshita, Takashi Muramatsu, Mie Shimamura, Motohiko Furuichi, ...
    2011 Volume 25 Issue 4 Pages 363-366
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    Recently, the use of a portable thoracic drainage kit (Thoracic Egg®) has been increasing in the outpatient treatment of spontaneous pneumothorax. Therefore, we studied 46 patients with spontaneous pneumothorax treated over the last two years. Forty-three patients showed minor to moderate collapse. Three patients showed severe collapse. At first, we studied 34 patients, excluding 12 patients with elective surgery. Twenty-one patients (61.8%) were treated as outpatients only. Thirteen patients (38.2%) were hospitalized due to poor expansion. Of these, 12 patients (35.3%) underwent surgery for persistent air leaks. The average length of these outpatient observation periods was 8.6 days. On the other hand, the average hospitalization period of the 12 patients with elective surgery was 8.25 days. Hospitalization could be shortened using Thoracic Egg®. We believe that Thoracic Egg® is useful for the minor to moderate collapse of spontaneous pneumothorax. We consider the outpatient observation period to be about 7 to 9 days. If expansion is poor in the latter period, we consider that patients should be hospitalized for treatment.
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  • Kohei Ando, Takamitsu Maehara, Shizu Saito, Toru Aoyama, Hiroyuki Adac ...
    2011 Volume 25 Issue 4 Pages 367-372
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    To examine whether it is possible to predict the recurrence of primary spontaneous pneumothorax, we analyzed 218 cases of primary spontaneous pneumothorax treated with conservative therapy at the first episode of pneumothorax, dividing the cases into a recurrent group (74 cases) and non-recurrent group (144 cases). Patient characteristics: the average age was 24.5 years old, male/female 199/19 cases, history of pneumothorax on the contralateral side yes/no 21/197 cases, smoking habit yes/no/unknown 93/75/50 cases. Cases under 24 y.o. (recurrence rate: 42%), a female gender (63%), history of pneumothorax on the contralateral side (57%), and a non-smoker status (55%) were associated with a significantly higher recurrence rate on univariate analysis. On multivariate analysis, a non-smoker status was an independent predictive factor of recurrence (p=0.006, odds ratio: 2.410). Based on the above findings, we think that non-smoking patients with initial primary spontaneous pneumothorax, after consideration of their wishes, can be treated surgically, because they have a high risk of recurrence. Moreover, we infer that there is difference between smokers and non-smokers regarding the mechanism of how spontaneous pneumothorax occurs.
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  • Yoshihisa Kobayashi, Takayuki Fukui, Shimon Ito, Shunzo Hatooka, Tetsu ...
    2011 Volume 25 Issue 4 Pages 373-378
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    Pulmonary embolism (PE) is a fatal disease. We report three cases of PE after pulmonary resection for lung cancer. A 64-year-old woman developed dyspnea and hypotension on postoperative day (POD) 1. She was diagnosed with PE on pulmonary arteriography. Catheter embolectomy and anticoagulant therapy were performed. Although hemothorax occurred, she recovered and was discharged on POD 22. An 84-year-old man developed dyspnea on POD 11. He was diagnosed with PE on contrast-enhanced CT (CECT) on POD 21. Anticoagulant therapy was performed, and he was discharged on POD 36. An 81-year-old man developed dyspnea on POD 5. He was diagnosed with PE on CECT on POD 6. Anticoagulant therapy was performed, and he was discharged on POD 33 with home oxygen therapy. The clinical presentation of PE is often varied and nonspecific. PE occurs either suddenly or develops over a period of days. We should always keep the possibility of its development in mind. Once suspected, the D-dimer test and CECT should be performed without delay for immediate intervention.
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  • Keizo Misumi, Yoshinori Yamashita, Hiroaki Harada, Masaoki Ito
    2011 Volume 25 Issue 4 Pages 379-382
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 45-year-old man without symptoms was pointed out as showing an abnormal shadow on a radiograph examination. A chest computed tomography (CT) scan revealed an encapsulated 38-mm mass in the anterior mediastinum. Surgical resection of the tumor which had adhered to the right middle lobe was performed employing VATS from the right-sided thorax. During the operation, a thymic carcinoid was suspected histopathologically; however, the mediastinal lymph node was not dissected because there was macroscopically no invasion to adjacent organs and preoperative evaluation revealed no lymph node metastases. The postoperative histopathological diagnosis was atypical carcinoid of the thymus with microinvasion to fat tissue. (WHO-TNM stage II). No adjuvant therapy was administered. He was alive without any evidence of recurrence one year after surgery.
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  • Taketo Kato, Kunio Narita, Keiji Ohara
    2011 Volume 25 Issue 4 Pages 383-387
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 28-year-old woman visited our hospital because of swelling of the right lateral chest wall. Chest and abdominal CT and MRI revealed multiple cysts in the chest and abdominal walls; therefore, hemangioma was suspected. During the operation, we first incised the skin just above the chest wall tumor along the rib. The chest wall tumor, which was enclosed by a thin membrane, was resected from the serratus anterior and intercostal muscle. Subsequently, we extended the incision to the abdominal wall and transected the costal arch. Then, we performed a laparotomy. The abdominal wall tumor, which mainly contained cysts, was partially connected to the chest wall tumor and pressed upon the liver from outside the peritoneum. Thus, the abdominal tumor was also resected. The pathological diagnosis was intramuscular hemangioma. In addition, the chest and abdominal wall tumors had the same origin. It is rare for hemangioma to develop in deep soft tissue. Furthermore, a large hemangioma involving the chest and abdominal walls is even more rare. Considering the frequency of this condition and radiographic findings, we hypothesize that this hemangioma grew in the inferior intercostal muscle and developed into the abdomen.
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  • Hiroshi Iwabuchi, Yoshitaka Nagatsuka, Tatsuya Inoue, Norio Uchimura
    2011 Volume 25 Issue 4 Pages 388-391
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    We experienced an extremely rare case of lung metastasis from breast cancer 30 years after mastectomy. A 71-year-old woman underwent radical mastectomy at the age of 41 for cancer of the left breast. Five years after the operation, she stopped attending the hospital for review and follow-up was subsequently not performed. She presented to our hospital because of a productive cough. Chest CT scans revealed a mass of 24 mm in diameter in the right lower lung field (S10). CT-guided needle aspiration cytology was performed, and the results strongly suggested malignancy. Partial resection of the right lower lobe was performed, revealing a lung metastasis from breast cancer. It has been reported that metastasis occurs in about 20-25% of all patients who undergo the resection of breast cancer, but most metastases are found within 5 years of surgery. In our patient, lung metastasis was found 30 years after mastectomy, and few cases of such late metastasis have been reported. The patient should be carefully followed up with hormonal therapy.
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  • Soichi Oka, Sosuke Yamada, Hidetaka Uramoto, Mitsuhiro Takenoyama, Tak ...
    2011 Volume 25 Issue 4 Pages 392-396
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    Tracheo-bronchial leiomyoma is a rare disease. We herein describe the case of a 57-year-old female patient who presented with a carinal leiomyoma. The patient complained of progressive dyspnea and paroxysmal cough. She had previously been treated for bronchial asthma. Because her symptoms worsened, further examinations were performed. Both computed tomography and bronchoscopic examinations revealed a lobulated carinal tumor measuring 1.5×1.0 cm. The tumor obstructed 80-90% of the orifice of the left main bronchus. Because the lesion was suspected to be a malignant tumor based on a bronchoscopic biopsy, carinal resection and reconstruction were performed. The pathological examination revealed leiomyoma. The patient's postoperative course was uneventful, and no finding of recurrence has been observed for 6 years after surgery. In this report, we discuss the appropriate surgical treatment for this condition.
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  • Masaki Hashimoto, Seiji Matsumoto, Nobuyuki Kondo, Fumihiro Tanaka, Se ...
    2011 Volume 25 Issue 4 Pages 397-400
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    We present the case of a 41-year-old male with a 3-cm mass in the left costophrenic angle. Based on chest radiograph and chest CT, a posterior mediastinal tumor was suspected preoperatively. Thoracoscopic surgery revealed that the mass was located in the left pleural cavity and connected to the left costophrenic angle with a thin stalk, but no direct connection to the left lung was observed. Histological analysis revealed that the mass contained immature structures of lung parenchyma, bronchi, and aberrant vessels. The final diagnosis of the present case was extralobar pulmonary sequestration. Extralobar pulmonary sequestration in adults is rare, but should be considered when diagnosing posterior mediastinal tumor.
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  • Yoshimasa Tokunaga, Takeshi Konndo, Hiroyuki Cho, Tatsuo Nakagawa, Tor ...
    2011 Volume 25 Issue 4 Pages 401-405
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 71-year-old woman being treated for oral lichen planus with hypogammaglobulinemia showed mass lesions in the anterior mediastinum. On chest CT, an independent tumor in each lobe of the thymus was detected. The left-sided lesion was pathologically diagnosed as a thymoma by CT-guided needle biopsy, and thymothymectomy revealed the two tumors to be type A and AB multiple thymoma. She has experienced no recurrence of the thymoma, and the oral pain due to lichen planus had partially resolved while her hypogammaglobulinemia had not improved at 13 months after surgery.
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  • Naoki Hashizume, Takashi Anayama, Motohiko Kume
    2011 Volume 25 Issue 4 Pages 406-412
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    We report the case of a ruptured pulmonary arteriovenous malformation (PAVM) which caused hypovolemic shock. A 41-year-old woman developed back pain and dyspnea. Chest CT showed massive pleural effusion in the left hemithorax. Pulmonary angiography confirmed the diagnosis of PAVM in the left lung (A4, 5). The patient subsequently went into shock, and so an emergent operation was performed. An aneurysm of 3.0 cm in diameter was observed, with both the feeding arteries and draining veins dilated. Left lingulectomy was performed. Intrapleural rupture is a rare complication of PAVM. Most cases of PAVM are associated with hereditary hemorrhagic telangiectasia (HHT, also called Osler-Weber-Rendu syndrome). The present patient was suspected to have HHT.
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  • Satoshi Nagasaka, Hideyuki Ito, Hiromi Kuwata, Ayako Seike, Shinsuke K ...
    2011 Volume 25 Issue 4 Pages 413-417
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    Penetrating tracheobronchial injuries are very rare but life-threatening. The successful diagnosis and treatment of such injuries requires a high-level suspicion of tracheobronchial injury and early, appropriate surgical intervention. In this study, we describe our single surgical experience of such injury. A 76-year-old woman who stabbed her neck while attempting suicide was admitted to our hospital. The primary symptoms of the injury were dyspnea and subcutaneous emphysema. A thoracic tube was inserted into her right thoracic cavity because of right pneumothorax; she was intubated because of airway insufficiency. The patient underwent chest computed tomography, which did not reveal any stabbing-associated vascular or esophageal injury. She underwent otolaryngological surgery under local anesthesia for the cervical tracheal injury. A tracheobronchial injury was detected by bronchoscopic examination during surgery. The patient was referred to us for this injury. After consulting an anesthesiologist, we repaired the damage under spontaneous respiration, using the median full sternotomy approach. Thus, surgical repair was straightforward and did not require ventilation with a tube inserted beyond the injury, PCPS support, or tube insertion through the operative field. The patient was extubated the day after surgery. The postoperative course was excellent. She was discharged 7 days after surgery. It is generally recommended that right posterolateral thoracotomy at the fourth intercostal space be performed using mechanical ventilation with the tube positioned beyond the injury in cases of tracheobronchial injury. We have reported this case on the basis of bibliographical considerations.
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  • Saki Nishida, Makoto Oda, Isao Matsumoto, Masaya Tamura, Ryuichi Wased ...
    2011 Volume 25 Issue 4 Pages 418-423
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 59-year-old female was referred to our hospital for stage IV (cT3N2M1b) adenocarcinoma of the right lung. At the age of 56, at another hospital, she had undergone extended hysterectomy and resection of the sigmoid colon for suspected endometrial carcinoma and had received a diagnosis of lung adenocarcinoma based on pathological findings, a CT scan, and other examinations. A total of six regimens of chemotherapy and radiotherapy with a total dose of 100 Gy had been performed over 3 years, but it was resistant. Therefore, she was referred to our hospital to consider surgical treatment. We performed a right upper lobectomy because the tumor was localized and no other metastatic lesion was found. We ablated the tumor from the chest wall because it grew to the apical chest wall. In the hilum of the lung, individual ligation and closure of the pulmonary vessels and bronchus was found to be impossible because they tightly adhered to the peripheral tissue. Therefore, the hilar vessels and bronchus were clamped and cut in one mass. Their stumps were oversewn with 3-0 vicryl and covered with a pedicled pericardial flap. The post operative course was favorable, and the patient underwent adjuvant chemotherapy at the hospital that had originally referred her to us. She was free of clinically evident recurrence 9 months after treatment. We suggest that the mass closure of the hilar vessels and bronchus and covering the stumps with a pedicled pericardial flap are useful for cases in which it is difficult to individually close the vessels and bronchus due to ligneous scarring caused by radiation.
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  • Tetsuhiko Go, Noriyuki Misaki, Chihiro Yoshida, Sung Soo Chang, Shinya ...
    2011 Volume 25 Issue 4 Pages 424-428
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    We report a case in which octreotide (analog of somatostatin) had a favorable effect on postoperative chylothorax of lung cancer. The patient was a 61-year-old male. He underwent a right upper lobectomy and lymph node dissection through a complete VATS procedure. The pleural fluid became milky soon after the patient resumed oral intake. As chylothorax occurred on postoperative day 1, he received total parenteral nutrition support with the cessation of food intake. Meanwhile, the administration of octreotide was started subcutaneously at 100 μg twice a day. Four days after the start of its administration, we increased the dose to 3 times daily. The drainage volume markedly decreased 4 days later, followed by treatment for pleurodesis. The chylothorax disappeared, and no side effects of octreotide were noted. Octreotide should be considered an option for postoperative chylothorax treatment.
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  • Masaya Okuda, Shinichi Sumitomo, Kazuya Matsumoto, Takayuki Nakano, Sh ...
    2011 Volume 25 Issue 4 Pages 429-432
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    Fibroepithelial polyp is an especially rare tumor that occurs in the endobronchial/endotracheal area. We report a case of endobronchial fibroepithelial polyp involving a 52-year-old woman who presented with a 6-month history of prolonged dry cough, and was found to have an intraluminal tumor in the right bronchus intermedius. She was admitted to our hospital for diagnosis and treatment. Trans-bronchoscopic resection failed because the tumor's hardness made it difficult to mobilize and resect it. Therefore, sleeve resection of the basal bronchus was performed employing a thoracotomy.
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  • Satoru Okada, Motohiro Nishimura, Junichi Shimada
    2011 Volume 25 Issue 4 Pages 433-437
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 64-year-old female was referred to our hospital because of an abnormal shadow on a chest radiograph. Computed tomography (CT) displayed a well-marginated mass lesion measuring 5.0×3.5 cm adjacent to the left side of the aortic arch and left main pulmonary artery in the anterior mediastinum. Dynamic CT showed marked central and peripheral enhancement. Hemangioma, Castleman's disease, neurogenic tumor, or thymoma were suspected. The mediastinal tumor, which easily bled, was completely resected together with the left phrenic nerve involved with the tumor by video-assisted thoracoscopic surgery (VATS). The histopathological diagnosis was capillary hemangioma. Mediastinal hemangioma is rare, and rarely diagnosed correctly before surgery. We report a case of mediastinal tumor with an abundant blood supply which was resected under VATS and diagnosed as a mediastinal hemangioma.
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  • Masato Chiba, Satoshi Shiono, Masami Abiko, Toshimasa Okazaki, Hiroshi ...
    2011 Volume 25 Issue 4 Pages 438-441
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 58-year-old man with athymoma underwent an extended thymothymectomy. The pathological diagnosis was type AB thymoma according to the WHO histological classification, and stage II according to the Masaoka classification. One month after surgery, the patient received adjuvant radiation therapy. Three months after surgery, he developed generalized fatigue and anemia, and was diagnosed with pure red cell aplasia. The oral administration of predonisolone was started, but the anemia did not improve, and blood transfusions were required. After the initiation of oral cyclosporine, the anemia went into remission. It is well-known that thymoma is often associated with pure red cell aplasia; however, there have only been a few reports of post-thymectomy pure red cell aplasia. During patient follow-up after thymectomy, the possible development of pure red cell aplasia should be considered.
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  • Osamu Kawano, Motoki Yano, Hidefumi Sasaki, Satoru Moriyama, Yuu Hikos ...
    2011 Volume 25 Issue 4 Pages 442-446
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 52-year-old male was pointed out as showing a small nodule (12×12×7 mm) on CT examination. Primary lung cancer was suspected. Lymph node swelling (8 mm) was also pointed out in the right supraclavicular region. It showed FDG accumulation on PET examination. Supraclavicular lymph nodal biopsy and partial resection of the upper lobe of the lung (VATS) were performed. Both lesions were diagnosed as adenocarcinoma. As standard surgical treatment with lobectomy could not be recommended because of the pStage IIIB disease, chemotherapy (CBDCA+PTX) was selected. Eight months after the initial treatment, recurrence appeared in the residual right upper lobe and interlobar lesion. Complete pneumonectomy and postoperative adjuvant chemotherapy (CBDCA+GEM) were performed. Recurrence in the supraclavicular lymph node appeared 1 year and 3 months after the last operation, and radiotherapy was performed. The patient was placed on oral S-1 therapy thereafter. As small lung carcinoma with solitary skip metastasis of a unilateral supraclavicular lymph node is a rare condition, a standard strategy has not been established. We selected multiple modality therapy in the present case, and the patient has survived without recurrence for 4 years and 6 months since the initial treatment.
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  • Yasushi Mizukami, Hidenori Kawasaki, Noboru Higa, Tomofumi Yohena, Kiy ...
    2011 Volume 25 Issue 4 Pages 447-450
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    We encountered a rare case of a bronchogenic cyst that contained small stones. A 75-year-old man was found to have a mediastinal tumor on a visit to a private clinic 5 years previously. He was referred to our hospital for the evaluation of this tumor. Chest computed tomography revealed a well-defined tumor of 8 cm in diameter in the posterior portion of the mediastinum. The tumor exhibited a high intensity on T2-weighted MRI, suggesting a cystic lesion. Although we tried to completely remove the cyst through a right thoracotomy, we could not remove it completely due to adhesion to the left atrium, and so we opened the cyst during surgery, and detected 75 small stones within it. The remnant area of the cyst wall was ablated with an argon laser coagulator. Component analysis of the stones showed calcium oxalate. Pathological examination of the resected cyst led to the diagnosis of a bronchogenic cyst.
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  • Hitoshi Suzuki, Ryou Maeshiro, Kentaro Inoue, Chiaki Kondo
    2011 Volume 25 Issue 4 Pages 451-455
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 49-year-old male was admitted to a hospital with recurrent fever and back pain when he was 28 years old. Chest computed tomography (CT) revealed a cystic lesion in the upper mediastinum. However, he was discharged without surgery because the cystic lesion reduced in size within a short period. Subsequently, routine screening chest radiograph films demonstrated an abnormal shadow and he often experienced fever of unknown origin with back pain, but did not consult a hospital for a long time. More than 20 years later, he consulted our hospital with the same symptoms. CT revealed a round mass measuring 7 cm in the upper mediastinum. Resection of the cyst with the adhered S1+2 of the lung was performed as a diagnostic and therapeutic measure. Histopathological examination showed a bronchogenic cyst. Because complications such as infection and stricture of the bronchus have been reported, surgical resection may be recommendable for all symptomatic bronchogenic cysts.
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  • Minoru Yamaki, Toshio Noriyuki, Kiyomi Shimoda, Masaki Mukai, Shuuji Y ...
    2011 Volume 25 Issue 4 Pages 456-459
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 64-year-old male was referred to our hospital because of an abnormal shadow on a chest radiograph. Chest CT showed a well-defined mass, 35 mm in diameter, in the right hilum. FDG-PET showed high-level accumulation of fluorodeoxyglucose in the right hilum. We removed the hilar tumor. The pathological diagnosis was lymphoepithelioma-like carcinoma of the right hilar lymph node. We could not detect the primary site. We diagnosed the patient with hilar lymph node lymphoepithelioma-like carcinoma of unknown origin. We report this rare case.
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  • Takuma Tsukioka, Ryoji Yamamoto, Makoto Takahama, Ryu Nakajima, Hirohi ...
    2011 Volume 25 Issue 4 Pages 460-464
    Published: May 15, 2011
    Released: August 09, 2011
    JOURNALS FREE ACCESS
    A 62-year-old woman was referred to our hospital due to an abnormal shadow in left S1+2 on chest CT, which was performed for the preoperative examination of right breast cancer. Bronchoscopic examination showed that the left B1+2 diverted from the left main bronchus. A trans-bronchial biopsy was performed through the left B1+2a, and primary lung adenocarcinoma was diagnosed. Left upper lobectomy was performed. The left B1+2 was cut while separating the left upper lobe from the lower lobe using a stapling device. The left B1+2 diverged from the left main bronchus directly and rose to S1+2 behind the left pulmonary artery. Such anomalous divergence of the left B1+2 is rare. It is important to recognize that B1+2 might arise behind the left pulmonary artery when it diverges from the left main bronchus directly.
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