Artificial degradable polymer (PGA) and oxidized regenerated cellulose (ORC), an absorbable hemostatic, are used in respiratory surgery. We investigated the in vivo and in vitro biodegradation behaviors of these materials. In the in vitro study, the pH of the buffer solutions in the PGA group tended to gradually become more acidic, while that of buffer solutions in the ORC group rapidly became acidic before stabilizing. In the rat air leak sealing model, adhesion with the chest wall was observed in all immunosuppressed rats (NDrat) in the PGA group and in half of NDrat rats in the ORC group. While residual fibers and inflammation were observed in the PGA group, the ORC group tended to exhibit mild adhesion. Prolonged inflammation and oozing caused by localized acidification associated with the degradation and absorption of PGA were thought to be responsible for the difference in adhesion between the materials.

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The aim of this study was to examine the effects of the postoperative low-dose infusion of landiolol for the prevention of tachyarrhythmia after surgery in patients with primary lung cancer meeting one of the following criteria: age ≥70 years old, concomitant heart disease, bilobectomy or more extended lung resection, lung resection with bronchoplasty or angioplasty, and lung resection with combined resection of the surrounding organs. In the treated group, patients were administered 0.005 mg/kg/min of landiolol hydrochloride for 3 days postoperatively. No patients with postoperative tachyarrhythmia were noted in the treated group, being significantly lower than in the non-treated group (13.8%; p = 0.0266). No side effects were observed. Therefore, landiolol hydrochloride was a safe and effective drug for the prevention of tachyarrhythmia after primary lung cancer surgery.

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We developed a Clinical Pathway (CP) for patients who were to undergo an operation for spontaneous pneumothorax from May 2008. We have subsequently reviewed the efficacy of the CP. The patients were divided into two groups, Non-Path and Path. The Path group was subsequently divided into two groups, Path-DPC and Path+DPC, being with and without Diagnosis Procedure Combination (DPC), respectively. The patients in the Non-Path and Path groups were not significantly different in terms of their mean age, gender, affected body side, and preoperative time in hospital, and all underwent similar surgical approaches and procedures. Patients in the Path group had fewer chest radiographs (1.2 vs. 2.5, respectively), a shorter postoperative duration of drainage (2.2 vs. 3.7 days, respectively), and a shorter postoperative hospital stay (3.6 vs. 5.8 days, respectively). On the other hand, no significant differences were found between Non-Path and Path patients in terms of the recurrence rate and subsequent hospitalization within 30 days. The hospital charges were significantly lower for patients in the Path group (Path-DPC: 84,000 points vs. Non-Path: 91,000), with all patients coming under the same national insurance system.
We conclude that implementation of the CP was effective with regards to both the patients' health benefits and expense.

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Objective: The aim of this study was to evaluate the significance of postoperative CEA levels in non-small cell lung cancer (NSCLC) patients with normal preoperative CEA values. Subjects and Methods: From January 2003 to October 2007, 40 NSCLC patients with normal preoperative CEA values who had undergone radical surgery were retrospectively studied. The changes in CEA values were investigated from the early (1 to 6 months after surgery) to late (6 to 24 months after surgery) postoperative period. Results: CEA elevation was noted in 9 cases. The elevated CEA group of 9 cases showed a significantly shorter relapse-free survival time compared with the stable CEA group of 31 cases (p<0. 0001). Multivariate analysis showed that CEA elevation was an independent predictive factor for relapse (p=0. 0014). Even in 5 cases of CEA elevation within the normal range, 3 cases relapsed. Conclusion: The elevation of CEA levels was a predictive factor for relapse even in patients with normal preoperative values.

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A 67-year-old man was referred to our hospital because of cough and hemosputum. Chest CT showed inflammatory changes with bronchiectasis at S⁶ of the left lung. Blood serum analysis revealed elevations of beta-D-glucan and aspergillus antigen. He had had pulmonary tuberculosis and two attacks of pneumonia in his infancy. Our diagnosis at this time was bronchiectasis with aspergillosis after old pulmonary tuberculosis. He was treated with an antifungal drug. Three years later, he showed repeat hemosputum and the affected lung area extended. We repeatedly took his medical history in detail. Thirty five years ago, he received a diagnosis of esophageal fistula based on esophagoscopy, and has sometimes coughed after meals. We made a definitive diagnosis of congenital esophagobronchial fistula by esophagography. He underwent excision of the fistula and left lower lobectomy. Detailed medical history taking may help identify congenital esophagobronchial fistula in adults, and esophagography was shown to be a useful method to make a definitive diagnosis.

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Systemic arterio-pulmonary venous fistula is a very rare disorder. This report describes a case of systemic arterio-pulmonary venous fistula, that presented with hemoptysis, with a concomitant proximal anastomotic pseudoaneurysm after surgery for a descending thoracic aortic aneurysm. Chest computed tomography showed a subpleural nodule in the lower lobe of the left lung with a dilated pulmonary vein. A left inferior phrenic arteriograph demonstrated the dilated artery with a fistula flowing into the pulmonary vein. The patient underwent a left lower lobectomy, and was discharged after an uneventful postoperative course.

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We report a resected case of solitary lung metastasis from gastric cancer. A 69-year-old man had undergone total gastrectomy for gastric cancer. A follow-up chest CT scan revealed a mass lesion in the lower lobe of the right lung. A right lower lobectomy was performed 11 months after the gastrectomy. Pathological examination of the resected specimen showed a well-differentiated adenocarcinoma, which was thought to be metastasis from gastric cancer. The postoperative course was uneventful, but CT revealed multiple liver metastases one month after the operation. Postoperative chemotherapy was ineffective. Surgical resection for such cases should be indicated carefully.

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The patient was a 32-year-old female with a chief complaint of mastodynia. A computed tomography (CT) scan incidentally presented a homogeneously enhanced tumor, 3.1 cm in diameter, in the posterior mediastinum. Venography by the right brachial vein showed retrograde flow from the superior vena cava to azygos vein in the early phase. In the delayed phase, pooling of contrast medium in the tumor was observed. Based on the above findings, the tumor was diagnosed as an azygos vein aneurysm. She underwent aneurysm resection under video-assisted thoracic surgery (VATS) due to the risk of pulmonary thrombosis and rupture of the aneurysm. Initially, the proximal end of the azygos vein was resected due to the risk of pulmonary embolism, and, then, three intercostal veins and the distal end of the azygos vein were resected. Finally, after complete blockage of the azygos vein, the aneurysm was resected. The patient followed an uneventful postoperative course, and was discharged on the 10th postoperative day without complication.

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A 66-year-old woman with complete situs inversus received a diagnosis of primary malignant melanoma of the esophagus (PMME) four years previously. She underwent esophagectomy and received adjuvant therapy (DAC-tam). During the postoperative follow-up, hilar lymph node enlargement of the left lung was detected by chest CT. PET-CT also showed an abnormal accumulation in the same lesion. We suspected the lymph node enlargement to be PMME recurrence, and performed lymphadenectomy for diagnosis and treatment. Regarding intraoperative findings, the structure of the pulmonary vasculature of the left lung was the same as of the right lung because of complete situs inversus. The enlarged lymph node was fixed to V1, V3, and A3. Therefore, we ligated and divided them to resect the lesion completely. The lymph node was diagnosed as metastasis of PMME, and she received adjuvant therapy (DTIC) after surgery. Now, ten months after surgery, she is alive and without any evidence of recurrence. This is the first reported case of resection to isolate lymph node recurrence of PMME.

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A 57-year-old male who presented with a feeling of chest tightness was diagnosed with a giant tumor in the right thoracic cavity and anterior mediastinum. Based on radiological findings, we suspected the tumor to be a lipoma or well-differentiated liposarcoma. Complete resection of the tumor was performed through a median sternotomy. The excised tumor measured 36 × 20 × 13 cm and weighed 2,900 g. The postoperative pathology confirmed the diagnosis of a well-differentiated liposarcoma. At follow-up, two years and eight months after surgery, the patient was well without any adjuvant therapy. Mediastinal liposarcoma is a rare disease often identified as a giant tumor. A favorable prognosis can be expected following complete resection; however, careful follow-up is necessary as local recurrences are often seen with this form of tumor.

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The patient was a 61-year-old man. He was admitted to our department due to hemosputum. CT showed thyroid goiter extending to the tracheal bifurcation through the left anterior mediastinum. Adenomatous goiter was diagnosed by fine needle aspiration cytology under an echogram. The tumor was resected with a median sternotomy, in addition to collar-shaped incision in the left neck. The tumor was 15.5×7.5 cm, and it forked to span the bifurcation of the trachea. Considering the accuracy of the preoperative evaluation, the resection of goiter without complications of bleeding or recurrent laryngeal nerve paralysis was performed with a median sternotomy. We reviewed and discussed these core reports of intrathoracic goiter.

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Mature mediastinal teratomas account for about 10% of mediastinal tumors. In many cases, teratomas are discovered in chest radiograph films, and remain asymptomatic. Sometimes, teratomas are found because of such symptoms as pyrexia and chest pain. We report the thoracoscopic resection of a mature mediastinal teratoma in a patient with abnormally high blood levels of CA19-9.

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A 66-year-old woman presented with two nodules in the upper lobe of the left lung on screening computed tomography (CT) scans. These nodules measured 13×8 and 10×5 mm, respectively, and exhibited a homogeneous density and regular margin. Chest CT scans performed 7 years previously demonstrated that these nodules existed in the same sites but were much smaller. We suspected them to be malignant tumors and, thus, performed video-assisted thoracic surgery to resect them. During surgery, the nodules showed cystic lesions filled with clear yellow fluid on the surface of the upper division of the left lung. Pathological findings of the resected specimens revealed no malignant findings in the cyst wall. Immunohistochemistry showed that the lining cells of the cyst were positive for factor- VIII related antigen, CD31, and CD34, and negative for D2-40. These findings suggested that the lining cells originated from the vascular endothelium. However, the tumors were diagnosed as intrapulmonary cystic lymphangiomas on the basis of the morphological and cytological findings. Intrapulmonary cystic lymphangioma is quite rare, and a few cases have been reported. We considered that the present case is atypical of lymphangiomas, and the tumors may have been derived from the premature endothelium which would differentiate into lymphatic vessels.

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The patient was a 29-year-old-female. She had undergone seven operations between 1989 and 2006 for pheochromocytoma or paraganglioma. Although she had been medicated with several anti- hypertensive agents, her blood pressure had remained high. Computed tomography showed tumors on the left side of the Th2 vertebra and on both sides of Th5. Endocrine examinations showed elevated levels of noradrenaline in both the serum and urine. Multiple mediastinal pheochromocytoma was suggested as treatment for the tumors. Video-assisted thoracic surgery (VATS) was carried out. The right tumor was removed, and the left tumors were removed after changing the patient's position. The postoperative blood pressure was stable within normal limits, and she was discharged from the hospital on the 12^th postoperative day.

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This report describes two cases of multiple schwannomas of the chest wall treated by surgical resection. Two 61-year-old women demonstrated abnormal shadows on chest radiographs. Chest CT scans showed chest wall lesions suspected of being multiple benign tumors. The tumors were resected by thoracoscopic surgery and diagnosed as multiple schwannomas. One case had a long history of chest wall tumors presenting very slow-growth over a nineteen-year period. Both cases showed multiple schwannomas originating from the same intercostal nerve.
Intrathoracic schwannoma is usually found in the para-vertebral area, and its location on the chest wall is uncommon. However, there are some case reports of plural schwannomas found on the chest wall close to each other. It is considered that careful inspection of the thoracic cavity is necessary in patients with chest wall schwannoma. Thoracoscopic surgery may be useful to prevent the overlooking of residual lesions.

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A 71-year-old man presented to our hospital with hemosputum, and was diagnosed with primary tracheal cancer. He had received a right upper lobectomy (ND2a) for primary lung cancer five years previously. As severe adhesion was anticipated in the right pleural cavity or around the trachea, we adopted a median sternotomy for tracheal resection. We completely resected the tumor along with 5 rings of the tracheal wall, and then administered adjuvant radiotherapy. The pathological diagnosis was primary tracheal adenocarcinoma. He was free of recurrence as of 12 months.

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We report a surgically treated patient with lung cancer pathologically diagnosed as clear cell carcinoma. A 62-year-old man was referred to our hospital for further examination of a mass shadow detected on chest radiograph. Lung cancer was suspected preoperatively with a clinical stage of T2aN0M0, and an operation was performed. The tumor was diagnosed as a carcinoma by needle-biopsy during surgery. The patient underwent right upper lobectomy with systematic lymph node dissection. The postoperative pathological diagnosis was clear cell carcinoma. Screening of the abdomen performed pre- and post-operatively revealed no suspected primary lesion in the kidney, and the tumor was diagnosed as clear cell carcinoma of the lung. The post-operative course was uneventful, and there was no recurrence as of 9 months after surgery.

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Background: Pulmonary sarcoma is a rare type of tumor. Radiotherapy and chemotherapy are usually not effective for its treatment, and surgical resection may be opted for. We surgically treated pulmonary sarcoma of the lung; the sarcoma protruded into the tracheal lumen and was accompanied by symptoms of suffocation.
Case: A 21-year-old man with transient suffocation symptoms induced by sputum was referred to our hospital. He was found to have a polypoid tumor arising from the right main bronchus, which extended centrally and almost entirely obstructed the lower trachea. The patient underwent an emergency rigid bronchoscopy-guided core-out procedure. The tumor, extending from the upper right lobe of the bronchus, was extirpated as much as possible. The core-out procedure resolved the right atelectasis and improved the patient's general condition. Since histological examination of the resected tissue suggested spindle cell sarcoma of the lung, right-sleeve pneumonectomy was performed after 40 days. The tumor originating from the upper right lobe had invaded the right tracheal wall. The trachea was resected from the 5^th cartilaginous ring up to the bifurcation and then anastomosed with the left main bronchus. Anastomotic stricture occurred during the operation, and, thus, a Dumon stent was inserted at the anastomotic site. Although local recurrence was noted 4 months later, a favorable partial response was obtained by chemotherapy consisting of doxorubicin and ifosfamide. Chemotherapy became ineffective after the 11^th course. The patient died 26 months after the operation.
Conclusions: Rigid bronchoscopy-guided core-out was successful in improving the general condition of the patient with primary sarcoma of the lung. It also provided information to make a diagnosis and determine the therapeutic strategy, thus allowing two-step tumor resection. The duration between the two-step surgery should be considered in the presence of rapid growth of the tumor. Dumon stent placement was useful for controlling the occurrence of anastomotic stricture during the operation.

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We report a case of two aberrant mediastinal goiters that were resected by video-assisted thoracoscopic surgery (VATS) with a purely thoracoscpoic view. A 55-year-old male was admitted to our hospital for the treatment of a mediastinal tumor. Chest CT revealed a mass behind the trachea and to the left of the esophagus. MRI demonstrated a mass consisting of two tumors positioned one above the other. The extirpation of these tumors was performed employing VATS with a purely thoracoscpoic view. Pathologically, these tumors were diagnosed as adenoma. Aberrant mediastinal goiter separate from the thyroid gland is a rare disease. VATS with a purely thoracoscpoic view is feasible in cases of upper mediastinal tumor.

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A 57-year-old woman underwent hystero-oophorectomy for uterine leiomyosarcoma and adjuvant chemotherapy with radiation therapy 1 year previously. On positron emission tomography, the accumulation of fluorodeoxyglucose was seen in a pancreatic mass, suspected of being pancreatic cancer or a metastatic tumor. She underwent distal pancreatectomy. The pathological diagnosis was metastatic foci from uterine leiomyosarcoma. While receiving treatment for postoperative complications, she complained of dyspnea. Chest radiograph showed right pneumothorax. Chest CT showed a thin-walled cavitary nodule in the middle lobe and small solid nodules in the bilateral lower lobes. Chest drainage was performed, but it was not curative. She underwent thoracoscopic partial resection of the middle lobe and right lower lobe. The pathological diagnosis was pulmonary metastasis from uterine leiomyosarcoma. We report herein a case of secondary pneumothorax due to thin-walled cavitary pulmonary metastasis from uterine leiomyosarcoma, and review the literature.

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A 76-year-old man was hospitalized with a cough. Since chest radiograph showed an abnormal shadow, he was referred to our hospital. Chest CT showed a mass in the left lower lobe that was suspected of being lung cancer. Although it could not be definitively confirmed that the shadow was cancer, video-assisted surgery was performed. Initially, we obtained a specimen by needle biopsy, but could not detect cancer cells. Then, a left lung wedge resection was performed. The tumors were initially diagnosed as inflammation, but a second frozen section was diagnosed as a malignant tumor. Video-assisted left lower lobectomy+ND2a was performed. The mass was finally diagnosed as lymphoepithelioma-like carcinoma (LELC) of the lung. In this case, LELC was accompanied by lipoid pneumonia around the tumor, and we were unable to diagnose malignancy on the first frozen diagnosis. LELC is suggested to be related to Epstein Barr virus (EBV) infection. However, EBER-1 in situ hybridization of the tumor was negative, indicating the absence of EBV infection in this case.

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A 77-year-old man was admitted to our hospital because of a tumor shadow in the right middle lung field. CT scan revealed right lung, esophageal, and right renal tumors. Colonoscopy detected a rectal tumor. Right middle lobectomy, esophagectomy, and esophageal reconstruction of the gastric tube through the posterior mediastinum were performed. The pathological diagnosis was adenocarcinoma with mixed subtypes of the lung and moderately differentiated squamous cell carcinoma of the esophagus, respectively. Metastatic squamous cell carcinomas were detected in superior mediastinal and perigastric lymph nodes. Then, a right nephrectomy (pathologically, renal cell carcinoma) and endoscopic resection of the rectal tumor (pathologically, adenocarcinoma in adenoma) were performed. Our case indicates that radical resections were performed safely for synchronous quadruple cancer. He has been well, without any sign of recurrence, for 2 and half years after the right middle lobectomy and esophagectomy.

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A 70-year-old man was noted to have an abnormal shadow in the left lung during screening with chest radiography. A chest CT revealed an 8-mm nodule in S¹⁰ of the left lung. He was followed for one year, and was then admitted to our hospital for examination and treatment of the pulmonary nodule as it had not changed. We performed a partial resection of the left lung using a thoracoscopic surgical procedure. The intraoperative histopathological diagnosis did not show a malignant tumor. However, the final pathological diagnosis was mucinous (“colloid”) adenocarcinoma. We performed another operation (left lower lobectomy and lymph node dissection ND2a-2) using a totally thoracoscopic surgical procedure after obtaining informed consent. The pathological stage was pT1aN0M0-IA. Mucinous (“colloid”) adenocarcinoma is a rare histological type of lung cancer. The difficulty of diagnosing mucinous (“colloid”) adenocarcinoma should be taken into consideration.

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[in Japanese]

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