Although arrhythmias are important complications occurring after general thoracic surgery, there have so far been few reports concerning the relationship between postoperative arrhythmias and the value of brain natriuretic peptide (BNP), which is thought to be an indicator of heart failure. We herein examine the perioperative BNP values and postoperative arrhythmias in general thoracic surgery.From January 2008 to May 2010, 63 patients (40 lobectomies, 15 wedge resections of the lung, 5 pneumonectomies, 3 mediastinal tumor resections) underwent general thoracic surgery at our hospital, and both the pre- and postoperative BNP levels were measured. Thereafter, the relationships among the BNP values, preoperative comorbidities, and postoperative arrhythmias were analyzed.Regarding the preoperative comorbidities, heart failure, ischemic heart disease, arrhythmia, and renal failure were all associated with increased preoperative BNP values. The BNP values in the patients with normal preoperative BNP values increased on postoperative day 1 and then decreased to normal levels for about one week. However, the BNP values in the patients with high preoperative BNP values decreased at a slower rate. In the 54 patients with preoperative BNP values below 100 pg/ml, the difference between the postoperative (day 1) and preoperative BNP values in patients who suffered from postoperative arrhythmias were significantly larger than that of the patients who did not experience postoperative arrhythmias, thus suggesting that the difference in the post- and preoperative BNP values may be an indicator of postoperative arrhythmia.

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Background: Most cases of secondary pneumothorax in patients with interstitial pneumonia are refractory to all forms of treatment. It is sometimes difficult to select the operative procedure because of postoperative complications. We evaluated the effect and safety of surgery. Methods: A retrospective review of 14 secondary pneumothorax patients with interstitial pneumonia who were surgically treated were considered for this analysis. We analyzed the background of these patients, results of surgery, clinical characteristics, and surgical methods of recurrent pneumothorax cases, and postoperative morbidity and mortality. Results: In all cases, air leaks were successfully treated. The recurrence rate of pneumothorax was 35.7% (5/14 cases). All patients with recurrent pneumothorax received steroids, and the lesion was characterized as interstitial pneumonia with changes in the lung structure. Operative mortality was noted in 7.1% (1/14 cases) of the cases. This case showed a worsening of interstitial pneumonia. Postoperative complications were noted in 14.3% (2/14 cases) of the cases. One involved empyema and the other showed worsening of interstitial pneumonia. Conclusions: Surgery for secondary pneumothorax in patients with interstitial pneumonia was effective. It is necessary to pay attention to the characteristics of recurrent cases and acute exacerbation in cases of interstitial pneumonia.

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Intrapleural fibrinolytic therapy has been considered to be effective in the treatment of fibrinopurulent empyema. However, its efficacy in elderly patients with a high surgical risk has not yet been fully defined. Between 2008 and 2012, 8 elderly patients with performance status (PS) 2 or 3 were treated with the intracavitary instillation of urokinase because of ineffective chest drainage. The mean age was 76 years old, and 7 men and 1 woman were included. Six patients had mental disorders. The etiology of empyema was aspiration pneumonia in 5 patients, community-acquired pneumonia in 2 patients, and an aspirated foreign body in 1 patient. One patient was cured by intrapleural fibrinolytic therapy, and all the other 7 patients who failed to respond to that therapy were cured by subsequent surgical treatment; 4 patients were treated with surgery and 3 patients were treated with percutaneous abscess drainage. Acute empyema in elderly patients with PS 2 or 3 is most often associated with mis-swallowing. We concluded that insufficient evidence exists to support intrapleural fibrinolytic therapy for those patients.

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Using the multidetector 3D-CT system, rare anomalous segmental veins passing dorsally to the main stem or intermediate bronchus were depicted clearly in 3 cases requiring upper and lower lobectomy. These veins seemed to be V2 terminalis having no or very little the communication with the central vein and ramified from the left atrium close to the upper pulmonary vein (UPI) or UPI itself. These exceptional segmental veins would cause unexpected bleeding during upper bronchial dissection and subcarinal lymphadenectomy. The successful dissection of those veins in advance enabled us to perform safe lobectomies with or without subcarinal lymphadenectomy. The multidetector 3D-CT system facilitated safe lobectomy in some exceptional cases.

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We report the case of a 61-year-old female patient with breast cancer who developed recurrent organizing pneumonia outside the radiation field after radiation therapy for postoperative breast cancer. The patient had received tangential radiation therapy and aromatase inhibitors for postoperative breast cancer. Chest computed tomography confirmed an irregular nodule and ground-glass opacities in the left lower lobe outside the radiation field 10 months after radiation therapy. The nodule demonstrated high uptake on 18F-fluorodeoxyglucose positron emission tomography; therefore, lung cancer could not be ruled out. We performed partial resection of the lung, and a diagnosis of organized pneumonia was made on histopathological examination of the resected specimen. Three days after surgery, a chest radiograph revealed an abnormal shadow in the right lower field. The possibility of organizing pneumonia was considered when pulmonary infiltrate did not respond to conventional antibiotic therapy and the patient recovered completely after treatment with steroids. Furthermore, chest CT performed 4 months after surgery revealed consolidation in the right lower lobe. Again, the patient recovered completely with steroid treatment, indicating the possibility of recurrent organizing pneumonia. The number of such reported cases has increased in recent years; however, the etiology remains unclear. In the case presented, aromatase inhibitor therapy combined with radiation therapy may have been the cause of the organizing pneumonia.

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A 60-year-old man complaining of fever, cough, and body weight loss was referred to our hospital for further examinations of an abnormal shadow of the right lung field on a chest radiograph. Chest CT showed the mass lesion obstructing the bronchus intermedius, atelectasis of the right middle and lower lobe, and right pleural effusion. The specimens obtained from transbronchial biopsy revealed slightly atypical cells. We suspected that the pathological findings showed a malignant tumor, but a definitive diagnosis could not be made before the operation. We had suspected cT2aN0M0 squamous cell carcinoma, and performed a right middle and lower lobectomy of the lung for definitive diagnosis and treatment. Pathologically, the tumor was composed of spindle and polygonal cells with atypia. Immunochemical findings showed that the tumor cells were positive for SM-actin and Calponin. The operation led to a definitive diagnosis of primary pulmonary leiomyosarcoma. The postoperative course was uneventful, and the patient left our hospital on the 9th postoperative day. At present, 9 months after the resection, the patient remains free of the disease. Lung carcinoma is the most common pulmonary malignant tumor, but primary pulmonary sarcoma is rare. In this study, we report an operative case of primary pulmonary leiomyosarcoma that developed in the bronchus.

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We report the case of a 71-year-old woman who underwent pneumonectomy for nontuberculous mycobacterial infection after chemoradiation therapy for small cell lung carcinoma. She was diagnosed with small cell lung carcinoma in 1993. She was treated with chemoradiation, and there has been no recurrence up to the present. In 2009, she presented with hemoptysis, and was diagnosed with nontuberculous mycobacterial infection. We immediately started chemotherapy (CAM, RFP, and EB). Chest radiograph showed a 58×55-mm mass with a cavity in the right upper lung field. The mass size increased and there was no sign of the therapeutic efficacy of chemotherapy, so we decided to perform right pneumonectomy. Although lobectomy is the standard surgical procedure for nontuberculous mycobacterial infection, this patient had damage in the middle and lower lobe from chemoradiotherapy performed for small cell lung carcinoma in the past, and a possible focus for infection as well, which led us to perform right pneumonectomy. The surgery was successful without any complications such as bronchopleural fistula, which is a considerable risk in right pneumonectomy. Postoperative chemotherapy was not selected as she had previously experienced severe side effects. There was no recurrence within the 8-month observation period. Surgical therapeutic strategies for nontuberculous mycobacterial infection remain to be established. We would like to state the importance of seeking a strategy with further studies.

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We report a 55-year-old male patient with a left pneumothorax followed by ARDS, who had a history of pulmonary emphysema. On admission to our hospital, after the diagnosis of left pneumothorax, tube drainage of the left thorax was performed. He suffered severe hypoxemia, and a CT scan of the lung revealed consolidation and a honey comb pattern in the left lung. He was diagnosed with ARDS, and started treatment with corticosteroids and sivelestat sodium hydrate. He received conservative treatment, but the left pneumothorax did not improve. On the 19th day after admission, he underwent video-assisted thoracic surgery. The surface of the left lung became hard and thick like the liver, and large and small bullae were detected. A bulla of the left upper lobe was resected and air-leaking sites were sealed by bioabsorbable PGA sheets and fibrin glue. Histological examination revealed the proliferation of myofibroblasts and hyperplasia of type II pneumocytes, which were consistent with the diagnosis of the proliferative stage of ARDS.

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A 39-year-old man showed an abnormality on a chest radiograph, but had not consulted a doctor. He presented with bloody sputa. Chest computed tomography at our hospital revealed consolidation in the left lower lobe. Based on the detection of an anomalous arterial supply to the basal segment in the left lower lobe originating from the thoracic aorta on chest magnetic resonance angiography, a diagnosis of intralobar pulmonary sequestration was made. Wedge resection of the sequestered lung in the left lower lobe with division of the anomalous artery was performed. Although the diameter of the aberrant artery was 8 mm at the orifice, it was dilated as aneurysmal change up to 25 mm in the affected lung. There have been some case reports of intrapulmonary sequestration accompanied by aneurysmal change of the aberrant artery. In such cases early surgical intervention is recommended as rupture of the aneurysm can be fatal considering the fragile nature of the aberrant artery.

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Primary pulmonary clear cell carcinoma is a histologically rare type of lung carcinoma. We report a case of primary pulmonary clear cell adenocarcinoma resected with thoracoscopic surgery. A 56-year-old man who underwent chemotherapy for malignant lymphoma was suspected of having two primary lung carcinomas in his left upper lobe. The tumors were diagnosed as adenocarcinoma of the lung with intraoperative histopathological diagnosis, so we performed thoracoscopic left upper lobectomy and node dissection. The postoperative histological/immunohistochemical diagnosis was primary pulmonary clear cell adenocarcinoma with mixed-type adenocarcinoma. A recurrence of the hilar lymph node was detected a month after surgery, and metastases of the brain, adrenal gland, and bone were detected five months after surgery. He has been undergoing chemotherapy.

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A 59-year-old man was admitted to our hospital with chest pain and a cough. Chest CT revealed abscesses in the left anterior mediastinum and left lower thoracic cavity. The inflammation did not improve in spite of prescribing antibiotics, and the thoracic drain was difficult to insert into the abscess, so we performed thoracoscopic drainage. The inflammation promptly resolved, and he was discharged on the 10th day after surgery.As Streptococcus constellatus (bacterium in the oral cavity) was detected from the pus and he had no other underlying disease but chronic periodontitis, we considered that his empyema with anterior mediastinal abscess arose from periodontitis. We should be aware of periodontitis as a cause of empyema and anterior mediastinal abscess.

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Generally, thoracotomy is an appropriate treatment for traumatic massive hemothorax.
However, under some selected conditions, VATS or TAE may be a superior procedure as they are less invasive therapy.
We report two cases of mainly penetrating injury of the internal thoracic artery. We selected VATS and TAE for each patient, and their clinical courses were uneventful.
It is difficult to determine the strict indication of these procedures, but, for hemodynamically stable patients with a massive hemothorax, VATS or TAE can be good options after deliberate judgment.

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Here, we report the case of a 63-year-old man who developed recurrent squamous cell carcinoma in the contralateral lung 5 years after successful chemotherapy and thoracic radiation for limited-stage small cell lung cancer (SCLC). Chest computed tomography performed at the current admission revealed a pulmonary nodule approximately 16 mm in diameter in the left lower lobe. Positron emission tomography revealed the uptake of fluorodeoxyglucose by the nodule. The serum progastrin-releasing peptide level was within the normal limits. We diagnosed the patient with non-SCLC, and performed left basal segmentectomy with hilar and mediastinal lymph node dissection. Histopathological examination of the resected specimen revealed squamous cell lung carcinoma. Two years after surgery, the patient was in good health with no episode of recurrence. Careful follow-up is necessary for patients with SCLC who survive for longer periods in order to detect recurrence.

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A 63-year-old man underwent unilateral nephrectomy for renal cell carcinoma in 2001. In 2007, chest CT scans revealed three small nodules in the same segment of the right lower lobe, and they were suspected of being metastatic lung cancer. They grew very slowly, and were resected in 2012. Pathologically, two of the three lesions were metastatic lung cancer from renal cell carcinoma, and one was hamartoma. All tumors were smooth, round-shaped, and well-defined, and there was no difference in their tumor doubling time. We report that there can be no evident difference in the growth speed between metastatic lung cancer from a slow-growing-type renal cell carcinoma and benign lung tumor.

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A 14-year-old boy was referred to our hospital with complaints of a high fever and cough. Computed tomography demonstrated two mediastinal tumors with the radiographic characteristics of mature teratoma, measuring 11 and 4.5 cm in diameter. With a high serum level of alpha fetoprotein, the lesions were diagnosed as mixed germ cell tumors including a non-seminomatous malignant component. As a large part of the tumors seemed to be a resectable mature teratoma, and infection in the tumor was suspected to be the origin of the high fever, we performed surgical resection. The resected specimen contained two mature teratomas which were the predominant component, a yolk-sac tumor of 2 cm in diameter, and seminoma in the thymic gland. Postoperatively, a tumor of 1 cm in diameter was detected in the right testis, which was suspected of being a seminoma. High inguinal orchiectomy was performed. Histological examination revealed a testicular epidermoid cyst. Two courses of postoperative chemotherapy with cisplatin and etoposide were performed. In the treatment of a malignant mediastinal germ cell tumor, surgical resection followed by chemotherapy might be a reasonable and effective treatment if the lesion seems to be resectable and infectious.

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Mesenchymal cystic hamartoma is very rare. The patient was a 66-year-old woman admitted to our hospital because of a pulmonary cystic lesion, detected by chest computed tomography (CT). CT showed a cystic lesion with a septum and partial wall thickness. Based on these findings we suspected malignancy or aspergiloma. Video assisted thoracoscopic surgery was performed and the cystic lesion was resected from peripheral part of the right lower lobe. Pathologically, the tumor was composed of cartilage tissue and bronchial epithelium. From the pathological findings, the tumor was diagnosed as mesenchymal cystic hamartoma.

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Background: Localized malignant mesothelioma of the pleura (LMM) is an extremely rare tumor. Moreover, the biologic association between LMM and diffuse malignant mesothelioma of the pleura (DMM) remains unclear. Therefore, standard treatment for LMM has not been established. Case: A 65-year-old man who had a history of asbestos exposure was referred to our center because of cough and an abnormal mass shadow in the upper field of the left lung on plain chest radiograph. Computed tomography and magnetic resonance imaging revealed a mass about 7 cm in diameter with a smooth margin and heterogeneous inner structure in the left chest wall. Histologic examination after a fine needle biopsy of the tumor showed an epithelial type of mesothelioma. We considered it to be a localized tumor based on FDG-PET and thoracoscopic findings. Surgery was performed for total removal of the tumor, together with resection of the chest wall. The tumor relapsed at the left chest wall after the operation, and radio-chemotherapy was performed. Conclusion: We reported a case of LMM treated primarily by radical resection, which subsequently relapsed. The relapsed disease was considered to be an isolated dissemination, and different from DMM. According to previous reports, the prognosis of LMM is better than that of DMM. Further studies of the pathologic behavior and establishment of standard treatment are clearly warranted.

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A 71-year-old female was seen by a previous physician for gait disturbance that had worsened a month prior. Neurological examination led to a diagnosis of sensory ataxia due to peripheral neuropathy. The patient tested positive for anti-Hu antibodies, so nervous system paraneoplastic syndrome was suspected, and the patient was referred to this hospital. An FDG-PET scan revealed masses with clearly defined margins concentrated on the left side of the aortic arch and in the left supraclavicular fossa, so the patient was diagnosed with an anterior mediastinal tumor and nervous system paraneoplastic syndrome. The patient then underwent surgery. The surgical approach was a median sternotomy. Intraoperative frozen section diagnosis revealed a malignant epithelial tumor. Given the potential for thymic carcinoma, an extended thymectomy was performed and masses in the left supraclavicular fossa were removed. Small cell carcinoma was detected in permanent specimens, and the patient was diagnosed with cancer of unknown primary origin in mediastinal lymph nodes. The patient's postoperative course was satisfactory, and the patient began 4 courses of chemotherapy (CBDCA+VP16) a month later. Neurologic symptoms have disappeared, and the patient is now able to walk unassisted. Gait disturbance testing revealed cancer in the mediastinal lymph nodes that tested positive for anti-Hu antibodies, as reported here.

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A 49-year-old woman presented with an anterior mediastinal tumor. Based on the presence of hypogammaglobulinemia, Good syndrome was diagnosed. The patient was referred to our hospital to evaluate the possibility of surgical treatment. We planned surgical treatment with the perioperative supplementation of gammaglobulin to preventperioperative infectious complications. Extended thymo-thymomectomy was performed. Pathological examination revealed type AB thymoma. Indications for surgical treatment in patients with Good syndrome remain controversial. However, surgical treatment is feasible if careful perioperative evaluation and management is undertaken.

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The patient was an 80-year-old woman with dyspnea. She had repeatedly undergone radiofrequency ablation (RFA) and transcatheter arterial embolization for hepatocellular carcinoma (HCC) associated with type C cirrhosis in our hospital. Computed tomography revealed right pleural effusion and that the large intestine had herniated into the thoracic cavity through the defect of the diaphragm. Overswelled vessels in the abdominal wall due to portal hypertension and severe atrophy of the liver were also recognized. No signs of ileus were observed. Diaphragmatic hernia after RFA was suspected, and surgery was performed. Magnetic resonance imaging after RFA for an S6 lesion revealed that the diaphragm had been damaged by the heat of the ablation and was torn. That was considered to be the cause of the diaphragmatic hernia. Laparotomy would increase the risk of postoperative hepatic failure because it can reduce the hepatic blood flow and injure the abnormal vessels of the abdominal wall. Video-assisted thoracic surgery (VATS) was performed. The large intestine and greater omentum were repositioned into the abdomen, and the direct closure of the diaphragmatic defect of about 3 cm in size was carried out. VATS was a safe and effective approach in this case.

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