En bloc stapling of the pulmonary artery and bronchus, combined, is an optional procedure during anatomical lung resection for patients with silicotic lymphadenitis. We performed simultaneous stapling of the pulmonary artery and bronchus in 5 of 160 patients who underwent major lung resection for cancer during a recent 3-year period. All five were women with a primary lesion in the right lower lobe and pathological stage I disease, with histologically confirmed adenocarcinoma. Although all operations were started thoracoscopically, three were converted to open surgery for anatomical assessment of the hilar region via direct vision. Despite this, the pulmonary arteries and bronchus could not be isolated. Although preoperative computed tomography (CT) suggested no lymphadenopathy, positron-emission tomographic (PET) -CT showed the diverse non-specific accumulation of FDG in the hilar and mediastinal lymph nodes, probably indicative of chronic lymphadenitis. All patients recovered uneventfully. There are no negative reports of en bloc stapling, but no one has recommended this procedure. Further attempts should be made to evaluate its long-term outcomes in more patients, and, at present, en bloc stapling should be considered as a last resort.

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Robotic surgery for general thoracic surgery is still basic. We performed 25 cases of robotic surgery using the da Vinci S robotic system (Intuitive Surgical Inc., CA, USA), and obtained favorable results in our hospital for a year from January 2011. Operative procedures for 14 cases of primary lung cancer comprised 5 right upper lobectomies, including: 1 wedge bronchoplasty, 3 right middle lobectomies including 1 combined partial resection of the upper lobe, 2 right lower lobectomies, 3 left upper lobectomies, and 1 left basal segmentectomy. The mean operative time was 323.1 minutes (console time: 245.7 minutes) and the amount of bleeding was 92.1 ml. There were two postoperative complications: atrial fibrillation and acute cholecystitis. Eleven thymectomies were performed. There were 5 cases of myasthenia gravis (2 with thymoma), 2 of thymoma, 2 of Castleman disease, 1 of teratoma, and 1 thymic cyst. The mean operative time was 207.4 minutes (console time: 148.5 minutes), and the amount of bleeding was 9.8 ml. Postoperatively, one chylothorax occurred in a case of extended thymectomy for myasthenia gravis with invasive thymoma. The advantages of robotic surgery were excellent visualization using the three-dimensional scope and accurate manipulation by robotic forceps with articulation. The early establishment of robotic surgery as an optional technique for general thoracic surgery is expected.

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We reviewed 167 cases of rib fracture following blunt chest trauma between January 2009 and December 2011. The age of patients ranged from 18 to 97 years, with an average age of 60.1, and they were predominantly male. The major causes of blunt chest trauma were traffic accidents in 66 cases (39.6%), falls in 43 cases (25.7%), and falling down in 43 cases (25.7%). The average number of fractured ribs was 3.3. Multiple rib fractures were observed in 72.3%of patients, and bilateral ones in 7.8%. Injuries other than rib fractures were involved in all patients who suffered over 7 rib fractures. There were 9 death cases. Excluding one patient who died of pneumonia 62 days after trauma, 8 patients died within 48 hours: 7 in a shock state and 1 in cardiac pulmonary arrest on arrival. More than half of the patients with rib fractures were hospitalized. As over 60%of them suffered extrathoracic injuries, treatments by other department doctors were needed as well as by thoracic surgeons. For the better establishment of an emergency system, closer communication is essential between people involved, such as doctors, nurses, and paramedics.

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The patient was a 34-year-old man. Chest CT revealed a small nodule with ground-glass opacity (15 mm) in the right S3 segment of the upper lobe. As the nodule was suspected to be lung cancer, video-assisted thoracoscopic surgery (VATS) was carried out for the purpose of diagnosis and treatment. The lesion site showed thickening of the alveolar septa and proliferation of the capillary vessels. The histopathological diagnosis was solitary capillary hemangioma of the lung. There have been no signs of recurrence after six postoperative years. Pulmonary solitary capillary hemangioma is a very rare disease. Therefore, We report this case with a bibliographic review.

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The case was a 55-year-old man. He was hospitalized with pneumonia of the left lower lobe in another hospital in January 2010, and, after one week, showed a pneumonia shadow and the relief of inflammatory symptoms, and was discharged. The infiltrative shadow remained after three months, and so he was introduced to this hospital for close inspection in April. Bronchoscopy showed Papanicolaou examination class V from the left B8a. We performed left lower resection and lymph node dissection in June. The postoperative diagnosis was bronchioloalveolar carcinoma (pT3N0M0 IIB). When a shadow remains after treatment for pneumonia, in pneumonia cases that are not obstructive pneumonitis, neoplastic disease should be considered.

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Recently, small pulmonary nodules have been frequently detected owing to the development of computed tomography (CT). Needle markers are often used because identifying such lesions during surgery is sometimes difficult. However, some cases of air embolism associated with this procedure have been reported. In our institution, CT-guided needle marking has been performed in 139 patients, and two cases of air embolism have occurred until now. We report these two cases of air embolism and discuss CT-guided marking. The first case, a 71-year-old woman, was admitted to the hospital for biopsy of a diffuse bilateral pulmonary reticulo-nodular shadow. CT-guided needle marking was performed to ensure the biopsy location. Soon after the marking, she lost consciousness, and cerebral air embolism was diagnosed by CT. The second case, a 72-year-old man, had a small pulmonary nodule in the right middle lobe of the lung along with a tumor-like shadow in the right lower lobe of the lung. CT-guided needle marking was performed for the detection of the small nodule. Immediately after marking, he suddenly complained of chest oppression, and a coronary artery air embolism was diagnosed by CT. The shadow of the air bubble was diminished on observation and resolved without any symptom in both cases. Air embolism may cause serious conditions, so the indication of CT-guided marking needs to be carefully decided upon.

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A 59-year-old man was admitted to our hospital with a 50×45-mm right apical segment tumor diagnosed by CT after a chest radiograph. After bronchoscopic cytologic diagnosis showed the adenocarcinoma, a right upper lobectomy and mediastinal lymph node dissection were performed. Histological examination showed the tumor to be well-circumscribed, containing more than 90% clear cells, and composed of solid nests and focal gland structures. A Periodic-acid Schiff (PAS) stain and a PAS with diastase pre-digestion (d-PAS) stain revealed intracellular glycogen and mucin in the glands. On immunohistochemical analysis, the tumor cells were positive for keratin (AE1/AE3), and only the surface of the lumina of the tumor glands was positive for CD10, but the tumor cells were negative for TTF-1, HMB-45, and vimentin. As other organs had no tumors, our final diagnosis was clear cell adenocarcinoma of the lung. Tegafur-uracil (UFT) was administered orally for 24 months as adjuvant chemotherapy, and the patient has survived for 6 years and 3 months since the surgical resection. We herein report a rare case of clear cell adenocarcinoma of the lung, and review the literature.

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We report 2 cases of congenital cystic adenomatoid malformation (CCAM). Case 1. A 1-year-old boy was admitted to our hospital because he suffered from respiratory infection three times in over 4 months. Chest computed tomography (CT) showed multiple cysts in the right lower lobe, and lobectomy was performed. The cyst was histologically diagnosed as type I CCAM. Case 2. A 9-year-old girl who suffered from pulmonary abscess 2 times in 2 years was admitted to our hospital. Chest CT showed a large cyst in her right S⁸. Partial resection of the right S⁸ was performed. It was histologically diagnosed as type I CCAM with mucinous bronchioloalveolar carcinoma. Because optimal management of CCAM remains controversial, an appropriate surgical procedure should be selected.

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Fetal adenocarcinoma is a rare type of malignant lung tumor resembling fetal lung tissue, and is estimated to account for only 0.1% of all pulmonary malignant neoplasms. We report a resected case of well-differentiated fetal adenocarcinoma. A 21-year old man was found to have a tumor shadow in the right lower field of a chest radiograph as part of a medical examination. Chest computed tomography showed a 45×30-mm cavity-forming mass in the right lower lobe, and transbronchial biopsy revealed adenocarcinoma. A right lower lobectomy was performed via video-assisted thoracoscopy. The post-operative pathological diagnosis was well-differentiated fetal adenocarcinoma, Stage IB (pT2aN0M0). The patient was treated with postoperative adjuvant chemotherapy, and there had been no evidence of recurrence as of 30 months postoperatively.

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We report a case of lung cancer with a thin-walled cavity detected concurrently with angiosarcoma of the scalp. A 51-year-old man, who suffered from angiosarcoma of the scalp, presented with a mass of 6×8 mm, mainly containing a thin-walled cavity in the left lower lobe at the same time. After complete resection of the angiosarcoma of the scalp, we followed up the pulmonary lesion by administering Teceleukin, genetically recombinant IL-2, since we considered the pulmonary mass to most probably be metastasis of the angiosarcoma. During the treatment for six years after the surgery, although there was no apparent recurrent episode of angiosarcoma, the lung lesion gradually increased in size. Then, for diagnosis and treatment, we performed resection, and the lesion was diagnosed as a pulmonary adenocarcinoma. A cavitary lesion in the lung has the possibility of involving a wide variety of lung diseases. When a pulmonary cavitary lesion is detected concurrently with a disease which can metastasize to the lung and form a cavitary lesion in the lung, careful follow-up should be mandatory. In addition, if the lesion shows a clinical course inconsistent with a metastatic tumor, surgical biopsy should be performed without hesitation.

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A 76-year-old male sought medical attention after complaining of pain in the right shoulder. Further examination revealed squamous cell lung carcinoma in the right upper lobe associated with the right aortic arch, corresponding to type I as classified by Stewart and Edwards. In terms of pathology, the tumor was identified as T3N0M0 (p-stage IIB), having invaded the chest wall directly and being devoid of detectable metastases in lymph nodes or distant organs. There was no indication of cardiac anomalies in the present case, and we performed a right upper lobectomy with combined chest wall resection and lymph node dissection. The right recurrent laryngeal nerve had branched upward from the right vagal nerve, encircling the right aortic arch, and great care was taken to conserve the nerve during mediastinal lymph node dissection. No postoperative complications such as hoarseness were present. The case above demonstrates the need for careful attention to the recurrent laryngeal nerve pathway and associated malformations during preoperative evaluation to avoid perioperative complications that accompany surgery for lung carcinoma associated with the right aortic arch. Further research into the range of lymph node dissection based on the lymph flow, through an examination of additional cases associated with the right aortic arch, will likely be necessary.

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Large cell neuroendocrine carcinoma (LCNEC) of the thymus is rare. In this report, we present a case of combined thymic epithelial tumor containing a component of large cell neuroendocrine carcinoma. A 60-year-old woman presented with an anterior mediastinal nodule in the thymus with calcification, which was detected on a computed tomography (CT) scan for close investigation of chest pain. The patient received thymo-thymomectomy using a video-assisted thoracoscopic surgery (VATS) approach with a pre-operative diagnosis of a mediastinal tumor, with a suspicion of Masaoka stage I thymoma. Postoperative histological examination revealed Masaoka stage I, combined thymic epithelial tumors (adenocarcinoma+squamous cell carcinoma+LCNEC). After the surgery, positron emission tomography (PET)/CT showed no significant FDG-accumulation. Therefore, the patient did not receive postoperative chemotherapy and radiotherapy. No recurrence was detected during the 24 months after the surgery.The patient had neither relapse nor metastasis at the 24-month follow-up. Neuroendocrine carcinoma of the thymus has a poor prognosis, and, thus, patients with this type of tumor require a long-term follow-up. It is necessary to document and study cases of this tumor to understand its pathology and recommend suitable treatment.

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We report a case we encountered concerning the occurrence of multiple lymphocysts on the diaphragm. The case was a 45-year-old female. She was receiving outpatient treatment for chronic articular rheumatism. In 2010, during a physical examination, kidney cysts were noted on the left side, and, in a precision CT examination, a shadow of multiple tumor masses with a maximum diameter of 3 cm was noted on the right diaphragm. In a follow-up CT one year later, enlargement of the shadow was observed, and surgery was performed. The tumor masses were five cystic lesions with consecutive capsules that were pedunculated from the diaphragm pleura, and, internally, they contained a white suspension believed to be a chyle constituent and a white substance that appeared to be necrosed. The tumor masses were excised under a thoracoscope. Moreover, a small amount of chyle pleural effusion was observed. Histologically, cyst walls were lined with lymphatic endothelial cells that were positive on D2-40 immunostaining, leading to a diagnosis of multiple lymphocysts occurring in the subserosa of the diaphragm pleura.

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A 84-year-old man underwent left upper lobectomy for primary lung adenocarcinoma. As demonstrated in the preoperative CT-scan, the branch of the mediastinal type from the left main pulmonary artery was recognized. The branch descended anteriorly to the left upper bronchus, and ran mainly into the left lower lobe as A⁸_b, adjacent anteriorly to the left lower lobe bronchus. A⁵ was bifurcated in the middle portion of the branch, adjacent anteriorly to the lingular lobe bronchus. A⁵ was ligated and cut on the peripheral side of the bifurcation so as to preserve A⁸_b. This is a very rare case of abnormal branching of A⁵ and A⁸_b as a common trunk from the left main pulmonary artery.

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A 40-year-old woman had an abnormal shadow on a chest radiograph.
A computed tomography scan showed a well-circumscribed anterior mediastinal tumor with heterogeneous enhancement with a longitudinal diameter of 59 mm, and fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal accumulation. The tumor was diagnosed as type A or type B thymoma by needle biopsy.
The patient underwent resection via a median sternotomy. Pathological examination revealed a characteristic biphasic architecture consisting of islands of epithelioid cells and surrounding bundles of spindle cells. Immunohistochemical staining showed that while the epithelial cells were strongly positive for cytokeratin, the spindle cells were weakly positive. The final diagnosis of the patient's condition was metaplastic thymoma.
We report a rare case of metaplastic thymoma.

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We report a rare case of chest wall neurinoma with bone destruction that was initially suspected as a malignant tumor. A 72-year-old female was referred to our hospital because of an abnormal chest shadow. Chest CT scan demonstrated a posterior chest wall mass with bone destruction of the left 4th and 5th ribs and part of the 4th thoracic vertebra (transverse process). FDG-PET showed abnormal accumulation in the lesion and no other lesion was present. We diagnosed her with a primary malignant chest wall tumor and performed surgical complete resection with hemi laminectomy and rib resection. The pathological diagnosis was chest wall neurinoma with bone destruction of ribs and a vertebra. No finding of recurrence has been observed for 3 years since surgery.

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We report a rare case of a large malignant SFTP with synchronous metastasis to the right thoracic cavity. The patient was a 39-year-old woman, who presented with a left chest wall mass and left chest pain. Chest computed tomography (CT) showed a 90×58-mm tumor in the left chest wall and a 41×28-mm tumor in the right thoracic cavity. A biopsy specimen was taken from the tumor of the left chest wall, and the tumor was diagnosed as a malignant SFTP. We suspected that the tumor of the right cavity arose because of metastasis from the tumor of the left chest wall. During the first operation, the tumor of the left chest wall was completely resected with the chest wall, pericardium, diaphragm, and left lower lung. However, the right tumor grew rapidly for a few months, and we were unable to resect it during the second operation because of dissemination. The histopathological diagnosis of the tumor in the right thoracic cavity was metastatic malignant SFTP. The patient died because of recurrence and metastasis, 12 months after the first operation.

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An abnormal shadow was detected on the chest radiograph of a 53-year-old male during a medical check-up. Chest computed tomography showed a mass at his left lower mediastinum in which 18F-fluorodeoxyglucose accumulated, with a maximum standardized uptake value of 3.37. Thoracoscopic mediastinum tumor resection was performed, and frozen sectioning showed lymphoid infiltrations without malignancy. The final pathological diagnosis was Castleman's disease, hyaline vascular type. The postoperative course was uneventful, and the patient still remains disease-free. We report Castleman's disease of the posterior mediastinum showing accumulation on positron-emission tomography and computed tomography.

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An 80-year-old man was found to have an abnormal shadow in the right lung on follow-up chest computed tomography (CT) performed 2 years after left lung cancer resection. Wedge resection of the right lower lobe of the lung was performed. The resected specimen was diagnosed as squamous cell carcinoma; however, it was difficult to distinguish between primary and metastatic cancer. The clinical course between postoperative days 1 and 5 was good except for prolonged air leak after pulmonary resection. On postoperative day 8, the patient complained of general fatigue and subsequently developed syncope. Severe hyponatremia was observed, and he was consequently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Serum sodium levels normalized following water restriction (1,000 ml/day) and correction of electrolyte abnormalities and the patient's symptoms resolved. We speculate that the cause of SIADH in this case was postoperative intra-pleural inflammation and surgical stress after pulmonary resection.

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A female in her fifties with solitary pulmonary metastasis of breast cancer 26 years after initial surgical treatment is reported. At 35 years old, she underwent surgical treatment for breast cancer. Twenty-six years later, she complained of hoarseness and was pointed out to have a solitary mass of the left lung lower lobe on a chest radiograph. Under a diagnosis of non-small cell lung cancer with clinical-T4N2M0, she successfully received neoadjuvant chemotherapy, after which she underwent left pneumonectomy. The pathological diagnosis based on hematoxylin and eosin sections was pulmonary adenocarcinoma with lymph node metastases at the subcarinal lymph node. Four years after left pneumonectomy, a solitary brain tumor appeared, which was surgically removed. The pathological findings were compatible with a lung tumor; however, the immunohistological findings showed a positive result for estrogen receptor, progesterone receptor, human epidermal growth factor receptor type 2, and mammaglobin 1, and a negative result for thyroid transcription factor 1 and surfactant protein A, resulting in a final diagnosis of metastasis for both the pulmonary and brain tumors from breast cancer. While solitary pulmonary metastasis of breast cancer over 25 years after the initial treatment is uncommon, it should be kept in mind that lung adenocarcinoma with a past history of breast cancer should be examined based on multiple immunohistochemical stainings.

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