Congenital cystic lung disease (CCLD), which is often diagnosed prenatally, is increasing. Surgical resection is the standard of care for symptomatic CCLD. However, the management of asymptomatic cases remains controversial. We retrospectively reviewed the records of 8 patients with CCLD who were under 5 years old. Five were prenatally diagnosed by ultrasonography, and 2 of these required fetal therapy. Three were diagnosed after infection. A total of 7 underwent thoracotomy; 2 receiving fetal therapy required emergent operations (5 and 16 days). All postoperative courses were favorable without respiratory after-effects, relapse of lesions, or malignant disease. Surgery for the patient with CCLD under 5 was considered to be feasible. We recommend early resection for symptomatic and asymptomatic cases without reduction of the lesion. Patients with fetal therapy need to be managed, including emergent operations, shortly after birth.

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Myasthenia gravis (MG) is an autoimmune disease characterized by weakness and fatigue of the skeletal muscles, and is caused by anti-AChR antibody. Patients with MG often have thymoma or hyperplasia of the thymus, and thymectomy can improve the symptoms of MG. At birth, 10~20% of infants born to mothers with MG have transient neonatal myasthenia gravis (TNMG) caused by anti-AChR antibody of the mother transferred to the baby through the placenta. We measured anti-AChR antibody in the umbilical cord blood of 8 infants born to 6 mothers with MG in this study. Of all 8 infants, anti-AChR antibody in the umbilical cord blood was positive (1,7~180 nmol/l, mean: 34.9 nmol/l), and showed a positive correlation with anti-AChR antibody of the mothers before delivery. Clinical TNMG was not observed in any of the babies. Anti-AChR antibody of the mothers showed a steady decline during pregnancy and an increase after delivery in all cases studied.

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At present, lobectomy is the standard surgery for patients with resectable non-small cell lung cancer (NSCLC). However, for high-risk patients, limited resection may be an alternative option. The objective of this study was to evaluate limited resection for high-risk patients and to compare segmentectomy with wedge resection.
From 1992 to 2004 (median follow-up of more than 5 years), we treated 102 patients with cT1N0M0 NSCLC who were not able to tolerate a lobectomy with limited resection (segmentectomy: 49, wedge resection: 53). Neither the 5-year overall survival nor disease-free survival (DFS) differed significantly between the segmentectomy group (5-year survival: 79.6%, DFS: 70.3%) and wedge resection group (5-year survival: 69.8%, DFS: 72.5%). The difference in the incidence of postoperative tumor recurrence was not significant. Limited resection should be considered as an alternative for stage IA NSCLCs in high-risk patients. Then, if it is anatomically possible, wedge resection may be a promising procedure.

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Recently, the number of non-tuberculous Mycobacterium (NTM) infection cases has been increasing. Among those infections, the Mycobacterium avium-intracellulare complex (MAC) is the major cause. As such, it is sometimes difficult to treat NTM cases. We evaluated the clinical courses and surgical outcomes of NTM patients (eight of the patients were male, 12 were female, and their median age was 48 years old) who underwent pulmonary resection. The surgical procedures included 18 lobectomies, 1 segmentectomy, and 1 wedge resection. There was no surgical mortality. Ten patients had positive preoperative sputum cultures, and 8 of those patients (80%) attained a sputum-negative status after surgery. Three patients (15%) showed relapse after surgery, and all cases improved after antibiotic therapy. Initial surgery was indicated in six cases with localized NTM; such a treatment strategy may be an option in the treatment of early-phase NTM.

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A 51-year-old man was referred to our hospital because of an abnormal chest shadow on a chest radiograph. Computed tomographic imaging demonstrated a mass measuring 6 cm in diameter adjacent to the bulla with fluid retention in the right upper lobe. Laboratory examination showed a WBC of 21,050/mm³ and high serum levels of CRP. We suspected lung cancer associated with an infective pulmonary bulla. Preoperative transbronchial brushing cytology of the mass revealed non-small cell carcinoma, and a right upper lobectomy was performed. Pathological examination of the resected specimen showed that the tumor developed from the lung parenchyma and progressed into the adjacent bulla. The tumor cells resided in the bulla. General bacteria and acid-fast bacillus tests were negative in a cultivation survey, and histopathological examination demonstrated giant cell carcinoma of the lung. Although preoperative levels of serum granulocyte-colony stimulating factor (G-CSF) were high, they returned to normal after the operation. An immunohistochemical analysis demonstrated that the tumor cells were positive for G-CSF, indicating that the tumor was a G-CSF-producing lung cancer. Our patient had leukocytosis in association with paraneoplastic syndrome of G-CSF-producing lung cancer, and fluid retention in the bulla with invasion of the tumor, and we suspected this to be related to the giant cell carcinoma with extensive necrosis.

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The patient was a 78-year-old female. She had previously undergone surgical resection of pancreatic carcinoma. In 2010, a lung nodule was detected on follow-up CT. A chest CT scan demonstrated an isolated nodule with a diameter of 2.0 cm in the right S9-10. FDG-PET scans demonstrated abnormal accumulation corresponding to the nodule. Since lung cancer was suspected, we performed a right basal segmentectomy. Histologically, the tumor demonstrated adenocarcinoma. Immunohistochemical staining for CK7 and CA19-9 were positive, but that for TTF-1 was negative in both the lung tumor and pancreatic carcinoma. These findings suggest that the pulmonary nodule was metastasis of adenocarcinoma of the pancreas. On 1-year postoperative follow-up, the patient showed no other signs of recurrence.

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A 59-year-old man was referred to our hospital due to an abnormal chest shadow in the left lung field detected on a medical examination. A computed-tomography scan of the chest revealed a round mass of 13 mm in diameter in the left S⁴. Bronchial brushing cytology showed class II cells. On positron emission tomography, the tumor showed the accumulation of fluorodeoxyglucose. Lung cancer was suspected from these examinations, so wedge resection of the left upper lobe was performed. On intraoperative consultation, we could not come to a definitive diagnosis. Immunostaining revealed lymphoepithelioma-like carcinoma (LELC). We recommended left upper lobectomy and lymph node dissection to the patient, but he did not consent to another operation. Eight months after surgery, a tumor of the left hilum and mediastinal and left subclavian lymph node swelling was recognized. We performed 1 course of CDDP/VNR combined chemotherapy and 2 courses of CBDCA/PTX chemotherapy with concurrent radiotherapy. However, the tumor progressed and he died 13 months after surgery.
LELC of the lung is a rare tumor in Japan. A review of the literature showed that LELC has a good prognosis, but we should treat LELC as carefully as common lung cancer.

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A 57-year-old man underwent thoracoscopic right lower lobectomy for primary lung cancer. Three months later, chest radiography showed an enlarged cardiac silhouette, and chest computed tomography showed a large pericardial effusion. Pericardiocentesis yielded 660 ml of milky fluid, confirming the diagnosis of chylopericardium. Lymphangiography revealed no injury to the thoracic duct. The patient was successfully treated with a thoracoscopic pericardial window. Chylopericardium following an operation for lung cancer is extremely rare. There are only 9 reported cases, including ours. Chylopericardium occurred after more than 20 days following right thoracotomy in 8 of the cases. Only one case occurred after left thoracotomy in the early postoperative period. We discuss and report this rare complication, along with a literature review.

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A 59-year-old man was admitted to our hospital because of persistent bilateral swelling in the trachelopanus. Neck-chest CT showed swelling of the bilateral submandibular and mediastinal lymph nodes (#4R).We performed a submandibular biopsy and an open biopsy of the mediastinal lymph nodes, and noted inflammation, but no malignancy. An increased number of IgG4-positive plasma cells were detected by immunostaining. Mikulicz's disease was diagnosed based on the elevated serum IgG4 level.Conclusion: It is important to be aware of Mikulicz's disease in the differential diagnosis of bilateral submandibular and mediastinal lymph nodes.

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The patient was a 73-year-old male who had been treated for lung cancer located in the left lower lobe (S9-10), evaluated as cT2aN2M0. He received chemoradiotherapy, which involved combination chemotherapy with carboplatin and paclitaxel, and radiotherapy of 50.0 Gy for the primary lesion. Diffuse radiation pneumonitis and fibrosis were seen in his left lower lobe, 3 months after the therapy. In addition, left pneumothorax was recognized a month after that. Because conservative therapy using chemical pleurodesis for this secondary pneumothorax ended in failure, surgical intervention was performed. A pulmonary fistula of about 1 cm in diameter was present in part of the primary lung cancer. Due to lung parenchyma hardening and its fragile visceral pleura, we performed the intra-fistula filling method using fibrin glue and PGA felt, which was followed by direct suturing and reinforcement of the visceral pleura. This reinforcement outside visceral pleura was achieved using a fascia patch and the combination of PGA felt and frictional spraying of fibrin glue. This intra-fistula filling method using fibrin glue and PGA felt can be effective when a standard surgical procedure for pneumothorax using an autosuturing device cannot be performed.

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A 59-year-old woman had undergone a Miles operation for rectal cancer in June 2002. In June 2004, she had undergone wedge resection of the right S³ and S¹⁰ for metastatic lung cancers from rectal cancer. A chest CT scan detected a nodule in the right S¹⁰ 5 years after the operation, and the size of the nodule increased during follow-up. SUV of the nodule was 1.9 on FDG-PET. We performed a wedge resection of the nodule for a diagnosis in August 2010. The pathologic diagnosis of the nodule was a foreign body granuloma. No bacterium, fungus, nor mycobacterium was detected on the culture of the nodule. The nodule seemed to have occurred due to disturbance of the ventilation and blood supply or the foreign body reactions.

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We encountered a rare case of extrapleural hematoma which developed into late-onset pleural effusion. The patient was a 52-year-old male. On admission to our hospital, we diagnosed him with traumatic hemothorax, and conducted chest tube drainage. The amount of drainage decreased rapidly (50 ml/day), and so the patient was extubated and discharged from the hospital. After one week, the patient presented with a noticeable increase of pleural effusion, for which we conducted chest tube drainage again.
To identify the cause of the recurrent pleural effusion, we conducted VATS (video-assisted thoracoscopic surgery). We noted that a part of the parietal pleura was torn and a dark red liquid was flowing into the thoracic cavity from the tear. It was thought that a hematoma had formed outside the parietal pleura, and hemolysate from the hematoma flowed into the thoracic cavity, causing recurrent pleural effusion. The current case suggests that VATS may be a useful option in diagnosing and treating patients with extrapleural hematomas.

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A 68-year-old man had a cough and hemosputum. He was strongly suspected of having pulmonary actinomycosis based on bronchoscopy by his primary physician. Antibiotics were started. His major complaints improved. However, the mass on chest CT showed no shrinkage. Thus, we strongly suspected lung cancer. We decided to perform surgery without a definite diagnosis. The operative procedure was a right upper lobectomy and lymph node dissection. The postoperative diagnosis was pulmonary adenocarcinoma (p-T3N1M0 stage IIIA). Actinomyces was not noted in surgical specimens. Although cases of lung cancer with pulmonary actinomycosis are very rare, an increase is anticipated due to the super-graying of society. Consideration of the coexistence of lung cancer should be given without delay when opaque pulmonary actinomycosis on antibiotic administration persists.

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The patient was an 81-year-old woman. Right pleural effusion was noted in March 2010 when she received treatment for hepatitis C infection and hepatic cirrhosis, for which paracentesis and aspiration were regularly performed on an outpatient basis. Fluid accumulation became frequent and was associated with respiratory discomfort; thus, she was referred to our department. In spite of thoracic cavity drainage and pleurodesis performed after admittance, effusion control was difficult and thoracoscopic surgery was performed. The entire diaphragm was covered with bioabsorbable prostheses made from polyglycolic acid (PGA felt), as no diaphragmatic defects were noted via thoracoscopy. Pleural effusion accumulation disappeared 2 weeks after surgery and has not recurred. In the present case, we speculated that the diaphragmatic defects were likely closed, as the entire diaphragm and bottom surface of the lung were fully adhered, while no defects were found on the diaphragm. There have been a variety of reports of treatment for intractable hepatic hydrothorax. We consider that the present approach is a simplified method of thoracoscopic pleurodesis.

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Soft tissue tumors of the mediastinum are rare among mediastinal tumors. We report a case of middle mediastinal spindle cell sarcoma resected after chemotherapy. The patient was a 59-year-old male in good health. He was referred to his family physician with an abnormal chest nodule pointed out on a chest radiograph as part of a health check-up. He was diagnosed with a middle mediastinal tumor, and was referred to our department. A neurogenic tumor was suspected based on the results of an EUS-guided fine-needle biopsy. We decided that curative resection was difficult, and performed systemic chemotherapy. After the chemotherapy and embolization of the feeding artery, he underwent resection of the tumor with combined resection of the right middle and lower lobe of the lung and a part of the muscular layer of the esophagus. The postoperative course was uneventful. He is presently in good health without any signs of recurrence.

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We report a case of pulmonary nontuberculous mycobacterial disease with abnormal ¹⁸F-fluorodeoxyglucose (¹⁸FDG) accumulation and an elevated serum CA19-9 level. A 61-year-old woman showed an elevated serum CA19-9 (299.7 U/ml) level during follow-up after surgery and chemotherapy for a uterine sarcoma (leiomyosarcoma) and its pulmonary metastasis. Chest CT revealed a solitary mass shadow measuring 30 × 44 mm in the remaining left lower lobe. Whole-body ¹⁸FDG-positron emission tomography (PET) showed abnormal accumulation in the left pulmonary mass (maximum standardized uptake value (SUV) = 4.5). These data suggested recurrent pulmonary metastasis. Partial pulmonary resection was performed. Pathological findings of the resected specimen were aggregated epithelioid granulomas with multinucleated giant cells including partial caseous necrosis. There were acid-fast-positive bacilli around the caseous necrosis. Bacterial culture of the resected tissue revealed Mycobacterium avium. The pulmonary mass was diagnosed as pulmonary nontuberculous mycobacterial disease. The postoperative serum CA19-9 value returned to normal. There were many bronchoepithelial cells positive for CA19-9 immunostaining in the resected specimen.

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A 25-year-old woman complaining of a cough showed abnormal shadows on a chest radiograph. Chest and abdominal CT scans revealed multiple, calcified, round-shaped tumors of the right upper lobe and a submucosal tumor in the stomach. Right upper and middle lobectomy of the lung and partial gastrectomy were performed. Pathologically, the lesions of the lung were pulmonary chondromas, and the lesion of the stomach was a gastrointestinal stromal tumor (GIST). Carney's triad is a rare syndrome and characteristically includes multifocal pulmonary chondroma, gastric stromal sarcoma, and extra-adrenal paraganglioma. Patients are diagnosed by having at least two out of Carney's triad. We describe a case of incomplete Carney's triad with reference to the literature.

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Solitary plasmacytoma is a rare tumor. We report a resected case of this tumor arising from the rib. A 57-year-old man was pointed out as having an abnormal shadow on chest radiograph. Chest CT showed a tumor in the right 5th rib, the cortex of which was compressed and destroyed. On PET-CT, ¹⁸F-FDG accumulation with an SUV_max of 58.0 was seen in this tumor. No other lesions were detected. Right 5th rib resection was performed. This tumor was diagnosed as a plasmacytoma. Bone marrow biopsy showed no abnormal findings. Finally, we diagnosed this tumor as a solitary plasmacytoma arising from the right 5th rib. After resection, adjuvant therapy was not performed. At present, 32 months after the resection, the patient remains free of the disease.

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Liposarcoma is one of the most common malignant soft tissue tumors, although it rarely occurs in the chest wall. A 58-year-old man was referred to our hospital for further evaluation of an abnormal shadow identified on a chest computed tomography (CT) scan in a medical examination. CT scan revealed a 3-cm, ill-defined mass with a low density in the left posterior chest wall. Magnetic resonance imaging confirmed a high signal intensity mass in the T1-weighted sequence. A bright part in the tumor on fat- suppressed images still existed. Surgical resection of the tumor including the seventh and eighth ribs with an approximately 3-cm margin was performed with a diagnosis of suspected primary liposarcoma of the chest wall. Histopathological examination showed the tumor to be a well-differentiated liposarcoma. Because the recurrence site of liposarcoma is usually local, wide resection of the primary lesion with an adequate surgical margin is essential for successful management.

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Careful manipulation is needed to avoid cardiac stress in lung cancer operations. However, we encountered three lung cancer cases that showed unexpected, severe bradycardia or cardiac arrest during surgery. All of these cases were left lung cancer patients, and bradycardia developed suddenly just when the hilum of the left lung was manipulated. Immediate cardiac massage and the injection of positive inotropic cardiac agents resuscitated patients from the bradycardia and cardiac arrest successfully, and then the operations were successfully completed in all cases.
We speculate that the cause of sudden bradycardia is a cardio-vagus reflex induced by stimulation of the pleura where the cardiac neural plexus is distributed. However, this remains uncertain. Nowadays, thoracoscopic surgery is available in respiratory surgery; however, there is anxiety over whether immediate direct cardiac massage is possible or not because the incision is too small to insert one's hand, consequently resulting in serious trouble.
We expect that our experience will help clarify the mechanism of sudden bradycardia, as well as prevent and treat it.

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A 57-year-old woman was referred to our hospital with a left upper mediastinal tumor detected by chest CT during follow-up after colorectal cancer surgery. Chest radiograph findings showed a 20-mm-diameter, smooth-surfaced tumor with a clear border in the mediastinum adjoining the aortic arch; MRI findings showed iso intensity on T1WI, a homogeneous high signal intensity on T2WI, and homogeneous enhancing effect with a contrast agent. Under the suspicion of non-invasive thymoma, the patient underwent surgery. The tumor showed no continuity with the thymus. It was smooth-surfaced, clear bordered, and adjoining the aortic arch. It was a blood-component-rich, dark-brown nodular lesion covered with a fibrous cap. Pathologically, various sized blood vessels multiplied markedly. As the insides of vessels were anti-CD34 antibody-positive endothelial cells, the tumor was diagnosed as a capillary hemangioma. In this study, we report an extremely rare case of the resection of a hemangioma that developed in the upper mediastinum.

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A 30-year-old man who had undergone resection of a femoral giant cell tumor in another hospital 2 months previously was referred to our hospital because of bilateral pneumothorax. Chest CT scan on admission revealed multiple nodules in both lungs and a bilateral pneumothorax, suggesting pulmonary metastases of the giant cell tumor of the bone. We surgically treated the pneumothorax and diagnosed the nodules as metastatic lesions. Intraoperative findings revealed that the tumors were located beneath the visceral pleura, with some accompanying pleural defects. Air leakages were observed from the pleural defects. We excised as many tumors as possible. They were pathologically diagnosed as metastatic giant cell tumors of the bone. Two months later, left pneumothorax recurred, followed by right pneumothorax the next day. Chest CT scan revealed that the remaining tumors had enlarged significantly after the initial surgery. Therefore, in the second surgery, we performed additional pleurodesis after excision of the metastatic lesions with air leakages. Recurrence of pneumothorax has not been noted after the second surgery. We report an extremely rare case of spontaneous bilateral pneumothorax caused by a metastatic giant cell tumor of the bone

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A 28-year-old man was admitted because of enlargement of the left fifth rib on a chest radiograph film. He had no symptoms and no past medical history nor traumatic injury. Computed tomography suggested a tumor of the left fifth rib. We observed that the tumor exhibited no tendency to invade adjacent organs by video monitoring through a thoracoscope. Resection was performed employing a small thoracotomy with thoracoscopic assistance. The fifth rib was resected with a margin of 3 cm to the tumor. Pathologic examination revealed fibrous dysplasia. Video-assisted thoracoscopic surgery is helpful to detect the location and the extent of tumor invasion.

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