We report that pleurodesis using 50% glucose was successfully performed in patients with pulmonary air leakage after lobectomy and those with pneumothorax who wanted to avoid surgery. We injected 200 ml of 50% glucose and 10 ml of 1% xylocaine into the chest cavity. We treated 11 patients from April to July 2012, and treatment was successful in 9 of them, but unsuccessful in the other 2 cases resulting in changing to pleurodesis with OK-432 to remove the pulmonary air leakage. In the 2 cases, the patients had severe emphysema, and the amounts of pulmonary air leakage were especially large. Although the efficiency of pleurodesis with this method may be weaker in comparison with OK-432, there were few adverse reactions such as chest pain or fever, and it could be safely used in 2 cases with interstitial pneumonia as well. In conclusion, this is easy-to-use, safe, and efficient treatment method and can be applied first as a pleurodesis agent.

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Fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) for the preoperative diagnosis of lung cancer has been reported to be more accurate than computed tomography. It is useful for the differentiation between benign and malignant tumors and for locating lymph node or distant metastasis. As a result, FDG-PET is being used increasingly frequently for the diagnosis of recurrent lesions. However, FDG-PET can also yield false-positives and-negatives, posing problems in diagnosis. We reviewed six cases in which a positive FDG-PET finding revealed non-recurrent lesions. Of the six cases, three involved infectious disease, all of which were treated with chemotherapy. In one case thoracotomy revealed suspected intercostal and subcutaneous tumor dissemination, but the final diagnosis was inflammatory granulation tissue. Based on these six cases, false-positive FDG-PET findings can be useful in the detection of infectious foci or additional tumors, leading to a definite diagnosis by thoracotomy or video-assisted thoracoscopic surgery.

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It has been reported that video-assisted thoracic surgery (VATS) is a useful treatment for acute empyema. Recently, the number of cases of acute empyema with a poor performance status and severe complications is increasing. We retrospectively evaluated the preclinical characteristics of twenty-two consecutive cases of acute empyema, who underwent curettage under VATS, by dividing them into a favorable and poor PS group, and we also evaluated the current status and some problems of VATS for acute empyema by examining the postoperative complications, drainage period, and hospital stay according to the performance status (PS). The postoperative drainage period was 17.8 days in the favorable PS group, but 28.4 days in the poor PS group (p=0.0107). The postoperative hospital stay was 26.4 days in the favorable PS group and 46.9 days in the poor PS group (p=0.002). The number of postoperative complications including aspiration pneumonia was significantly higher in the poor PS group (p=0.0132), and these complications were correlated with prolongation of the postoperative hospital stay. We need to closely monitor the patient's condition after surgery to avoid postoperative complications. There have been no hospital deaths or recurrence cases since surgery, indicating that VATS is a safe and useful procedure for acute empyema even in poor PS cases.

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Descending necrotizing mediastinitis (DNM) refers to a serious condition in which infection involves the mediastinum. Since 2000, we have encountered 6 patients with this disorder. They consisted of 4 males and 2 females, with a mean age of 56.8 years. Causative diseases were odontogenic and pharyngolaryngeal infection in 3 patients each. There was no underlying disease that may cause infection. Concerning drainage, cure was achieved by a cervical approach alone in one patient. In the other patients, drainage with a cervical approach and thoracoscopic surgery (VATS) was performed, achieving cure in all patients. Additional surgery was required in 1 patient. In 4 recently treated patients, after examining intrathoracic inflammation using a thoracoscope, a port was added, if necessary, and intrathoracic lavage/drainage were conducted. In DNM patients, mediastinal and thoracic drainage by VATS is useful due to its non-invasiveness and a favorable visual field.

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We report two cases of catamenial pneumothorax treated by video-assisted thoracoscopic surgery. The first case was a 36-year-old woman who developed right pneumothorax and came to our hospital. Thoracoscopic surgery was performed in the menstrual period, and revealed multiple perforations of the diaphragm, so we performed the diaphragm reefing procedure. Postoperative hormone therapy was initiated and amenorrhea was maintained, but she developed recurrence of pneumothorax 6 months after surgery. There was continuous air leakage after thoracic drainage, so we performed re-operation. Thoracoscopy showed a bulla in the middle lobe of the right lung that was not seen during the first surgery, and we performed resection. The second case was a 40-year-old woman who developed right pneumothorax in the menstrual period, and came to our hospital. There was continuous air leakage after thoracic drainage. We performed thoracoscopic surgery, which revealed multiple perforations of the diaphragm and a bulla in the middle lobe of the right lung. We performed partial resection of the diaphragm in the perforated area and bulla resection. In both cases, we could not histologically identify endometrial tissue in the resected specimen. Although no clear criterion have been established about the timing of surgery for catamenial pneumothorax, when we encounter a case of catamenial pneumothorax with prolonged air leakage, an operation should performed immediately without persisting with a histological diagnosis because there is a possibility of an emphysemal lesion or rupture.

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Acute mediastinitis as a complication of acute pancreatitis or acute exacerbation of chronic pancreatitis is rare. This report presents a surgical case of acute mediastinitis secondary to acute exacerbation of pancreatitis. A 43-year-old male with a history of chronic alcoholic pancreatitis was referred to our hospital due to back pain and heartburn. Further examination revealed the acute exacerbation of pancreatitis and acute mediastinitis, and emergency thoracoscopic transthoracic mediastinal abscess drainage was performed. High levels of Elastase I in the abscess fluid led to a diagnosis of acute mediastinitis secondary to the acute exacerbation of pancreatitis. In the event that a patient with a history of pancreatitis presents complaining of heartburn or other chest discomfort, we recommend attempts at an early diagnosis which are guided by the possibility of severe intrathoracic complications. When acute mediastinitis is confirmed, surgical drainage should be performed.

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A 63-year-old man showed an abnormal shadow on a chest radiograph. CT and MRI revealed a tumor in the right posterior mediastinum. The tumor had grown into the Th2/3 intervertebral foramen and destroyed the vertebra. The tumor had infiltrated the ribs. Surgery was performed. In a prone position, we exfoliated the vertebral body and ribs, removed the costal head, and separated the root nerve with a backward approach. We resected the tumor with a right thoracotomy. The tumor was revealed pathologically as sarcomatous malignant mesothelioma. Postoperative chemo-radiotherapy was performed, but he died 15 months after surgery. We herein report a rare case of localized malignant mesothelioma in the posterior mediastinum which grew into the intervertebral foramen.

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We report a case of mediastinitis with iliopsoas abscess. The patient was a 45-year-old male with well controlled diabetes mellitus. He complained of lumbago, and, three days later, a high-grade fever and anterior chest pain developed. Although the patient was treated with antibiotics, his symptoms and inflammatory status deteriorated. Computed tomography showed an anterior mediastinal mass with ring enhancement, pleural effusion, and a low-density area of the left iliopsoas. From his general condition and findings on medical examinations, he was diagnosed with acute mediastinitis complicated with empyema and iliopsoas abscess. The patient received antibacterial medication and underwent emergency surgery for mediastinitis and empyema. After those treatments, his general condition and laboratory and radiological findings immediately improved. When idiopathic mediastinitis is diagnosed even in a healthy patient, the possibility of additional abscesses in other organs should be investgated.

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A neurogenic tumor in the cervico-thoracic region is rare. To remove such a tumor, a supraclavicular approach, mini-sternotomy, video-assisted thoracic surgery, or a combination of these procedures is performed in consideration of minimally invasive surgery. A 25-year-old male was pointed out by others as showing a left cervical swelling 6 months previously. He was diagnosed with a cervico-thoracic tumor of 5.5×4.5 cm by chest computed-tomographic scanning, originating from the vagus nerve and passing to the level of the aortic arch. Physical examination showed café-au-lait macules, Lisch nodules, and scoliosis, and the patient was diagnosed with neurofibromatosis type 1 (NF-1). We incised the skin from the left cervical region to median anterior thorax. A figure-L unilateral mini-sternotomy at the left first intercostal space was performed. The tumor originating from the vagus nerve was resected by 22 cm in its longitudinal length, and pathological examination showed neurofibroma. A type I thyroplasty for hoarseness from the left recurrent nerve palsy was performed. A combination of the figure-L unilateral mini-sternotomy and supraclavicular approach is considered an effective and useful minimally invasive approach for a cervico-thoracic tumor.

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A 56-year-old man underwent aortic valve replacement through a right anterolateral thoracotomy at another hospital. He became aware of a lump in his chest and chest pain two years after the operation. Dynamic CT images with a Valsalva maneuver showed lung herniation from the 3^rd intercostal space. We performed radical surgery using an expanded polytetrafluoroethylene (ePTFE) patch. No recurrence was detected one year after the operation.

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Synovial sarcoma is a malignant soft tissue tumor which most frequently affects the periarticular regions of the upper and lower extremities in young adults. We report a case of synovial sarcoma in the mediastinum, a rare location for the disease. A 73-year-old man was brought to our hospital with a complaint of chest and back pain. Chest computed tomography revealed a 62×52-mm cystic lesion at the aortopulmonary window, and surgical treatment was performed. The mass was located close to the aortic arch and pulmonary artery, and was incompletely resected due to severe adhesion. Apparent malignant findings could not be detected on intraoperative pathological examination. However, postoperative pathological examination demonstrated that the tumor consisted of biphasic elements of epithelial and spindle-shaped cells, and an abnormality of the SYT gene was detected on FISH, which confirmed the diagnosis of synovial sarcoma. Four cycles of adjuvant chemotherapy with ifosfamide were performed, and the remaining tumor was stable 17 months after surgery.

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The current report presents a surgical case of lung cancer in the left upper lobe with a displaced anomalous left B¹⁺² bronchus accompanied by an anomalous V¹⁺² pulmonary vein. An 83-year-old male was referred to our hospital because of an abnormal shadow measuring about 3 cm in diameter in the left middle lung field noted on a chest radiograph. Further examination revealed squamous cell lung carcinoma in the left upper lobe with a displaced anomalous left B¹⁺² bronchus accompanied by an anomalous V¹⁺² pulmonary vein. Both the displaced anomalous left B¹⁺² bronchus and anomalous V¹⁺² pulmonary vein were located behind the left pulmonary artery. A left upper lobectomy was performed in which first the displaced anomalous left B¹⁺² bronchus and anomalous V¹⁺² pulmonary vein, then other pulmonary vessels and bronchi, and finally the incompletely lobulated fissure were divided. We suggest that particular attention be paid to anomalous blood vessels, and recommend planning the operative procedure beforehand in cases of lung cancer with a displaced anomalous bronchus and anomalous pulmonary vessel.

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We herein report a rare surgical case of quadruple cancer including synchronous multiple primary lung cancers, colon cancer, and cholangiocarcinoma. To our knowledge, this is the first report in Japan. A 76-year-old man, with a history of endoscopic resection of colon cancer, was incidentally diagnosed with lung neoplasms. Chest computed tomography revealed two nodules in the right upper lung. No other extrapulmonary metastatic lesions were present. With a diagnosis of lung cancer after transbronchial lung biopsy, we performed right upper lobectomy with lymph node dissection. The nodules were pathologically diagnosed as synchronous multiple primary lung cancers that had different histological types: adenocarcinoma and squamous cell carcinoma. Seven months later, he developed jaundice and was diagnosed with bile duct stricture due to cholangiocarcinoma with endoscopic retrograde cholangiopancreatography. After the endoscopic procedure, acute pancreatitis occurred, and he died one month later. The prognosis of patients with multiple cancers is basically poor, so it is important to perform close follow-up before and after surgery with collaboration among specialists in other fields.

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A 46-year old woman was found to have a tumor shadow in the left middle field on a chest radiograph as part of a medical examination. Chest computed tomography showed a 18×16-mm nodule located at the bifurcation of the superior division and the lingular bronchus in the left upper lobe (S⁴). Although the tumor was deep in the parenchyma near the hilar parts, three-dimensional computed tomography (3D-CT) detected a mediastinal type in the lingular artery. Enucleation of the tumor with an interlobar approach by complete video-assisted thoracic surgery was successfully performed without the resection of normal lung tissue. The tumor was a hamartoma of the lung.

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A 57-year-old woman presented with an anterior chest wall tumor. She had undergone left partial mastectomy for breast cancer 13 years previously. Positron emission tomography/computed tomography (PET/CT) and dynamic enhanced magnetic resonance imaging (MRI) revealed a massive sternal tumor, another separated bone metastasis in the manubrium, and right parasternal lymph node metastasis. A recurrent sternal metastasis originating from breast cancer was diagnosed by fine needle aspiration biopsy. We performed subtotal sternectomy and reconstruction of the chest wall defect with a methylmethacrylate sandwich prosthesis. Thoracoscopic drainage for fluid collection under the prosthesis was required on the 19^th postoperative day. She was discharged on the 37^thpostoperative day.
Pathologically, the upper margin of the specimen was positive for cancer because of an insufficient surgical margin from the bone metastasis in the manubrium. An axillary lymph node metastasis was detected on PET/CT 2 years after the operation. She has been treated with chemotherapy and hormone therapy. Radical sternectomy for solitary sternal metastasis originating from breast cancer is feasible. Resection of the sternal tumor should be radical if including 3-cm margins macroscopically, and appropriate chest tube drainage around a prosthetic material should be performed for reconstruction with a sandwiched methylmethacrylate and Marlex mesh prosthesis.

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A 79-year-old man was referred to our hospital because of an abnormal shadow on a chest radiograph. Computed tomography (CT) showed a well-marginated mass lesion measuring 2.8×2.3 cm in the left inferior lobe. Dynamic CT demonstrated contrast enhancement. The clinical diagnosis was left lung cancer T1aN0M0. We performed left inferior lobe lobectmy and node dissection. He was diagnosed with basoloid carcinoma of the lung based on histopathological findings. Basaloid carcinoma is rare and associated with a poor prognosis. Therefore, it is very important to collect and record cases receiving certain chemotherapy regimens.

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We present a case of intrathoracic extramedullary hematopoiesis. The case was a 65-year-old man in whom bilateral posterior mediastinal masses were incidentally detected during treatment for gastric ulcer. The masses contained a fat component, and we considered the possibility of a malignant tumor, such as liposarcoma, so we performed a thoracotomy for the right-sided mass.
The mass was very fragile and bled easily. The pathological findings were intrathoracic extramedullary hematopoiesis. Since the left-sided mass was considered to be the same as on the right side, ¹¹¹In scintigraphy was performed for a diagnosis. ¹¹¹In scintigraphy showed an abnormal accumulation in the left-sided mass, also diagnosed as extramedullary hematopoiesis. We should avoid unnecessary surgery for a posterior mediastinal mass with a fat component, and ¹¹¹In scintigraphy is a helpful examination for extramedullary hematopoiesis.

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A 72-year-old man who was diagnosed with squamous cell carcinoma in the right lung underwent right upper lobectomy via video-assisted thoracoscopic surgery. The fused fissures were divided with staplers after the pulmonary veins, arteries, and bronchus were divided due to severe pulmonary emphysema and largely fused fissures. Two hours after the lobectomy, mechanical ventilation was started again because massive hemoptysis appeared. A diagnosis of pneumatocele at S⁷ which developed postoperatively was made based on the findings of chest computed tomography and thoracoscopy. Right S⁷⁺⁸ segmentectomy was performed 8 days after the lobectomy because hemosputum persisted. After segmentectomy, a two-staged thoracoscoplasty was performed for pneumonia and pyothorax, and he could leave the hospital 9 months after the lobectomy. We speculated that the cause of pneumatocele formation was excessive tensile force around the thick staple line because the emphysematous lung with largely fused fissures was divided with staplers. Additional staple line reinforcement by oversewing or ligation might be needed in cases of a brittle staple line. Furthermore, early surgical intervention should be considered in cases of persisting massive airway bleeding from the pneumatocele.

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The patient was a 62-year-old woman. One year prior to presentation, she developed dyspnea and later showed repeated syncopal attacks. Contrast-enhanced chest computed tomography (CT) showed an 8-cm-diameter tumor in the middle mediastinum, which was accompanied by a contrast-filling defect in the right pulmonary artery. CT-guided biopsy showed the proliferation of tumor cells in a mucous-like matrix, leading to a diagnosis of myxofibrosarcoma. Invasion of the pulmonary artery trunk and heart was suspected, and, therefore, surgery was considered difficult. Because the patient had repeated syncopal attacks accompanied by interruptions of blood flow in the right pulmonary artery, irradiation at a dose of 46 Gy was performed 23 times as a semi-emergent treatment. Three months later, the tumor diameter had decreased to 3 cm, and blood flow in the right pulmonary artery had resumed. In addition, the subjective symptoms disappeared. Currently, after 2 years and 8 months of treatment, the patient is alive, showing no tumor regrowth. A myxofibrosarcoma that develops in the mediastinum is often difficult to resect completely; in such cases, radiation therapy may be effective.

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We report 2 cases of lung metastasectomies over 30 years after initial surgeries for their breast cancers. Case 1: A 75-year-old woman, who had undergone right mastectomy for breast cancer 31 years previously, showed a solitary pulmonary nodule in segment 6 of the right lung at a routine follow-up CT examination after an operation for aortic dissection. Video-assisted lung metastasectomy was performed and immunohistochemical analysis revealed a metastatic tumor from breast cancer. Case 2: A 72-year-old woman, who had undergone left mastectomy for breast cancer 38 years previously, showed a small pulmonary nodule in segment 1+2 of the left lung at a medical examination. Intraoperatively, multiple nodules on visceral and parietal pleura were detected, and immunohistochemical analysis revealed lung metastases and dissemination from breast cancer. Although the operations for both cases were performed with the suspicion of primary lung cancer based on the imaging diagnosis, both cases were diagnosed as lung metastases from breast cancer after an extremely long period following their initial mastectomies.

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A 68-year-old female was admitted to our hospital because of obstructive pneumonia with cough and fever. Chest CT showed right upper lobe atelectasis, and bronchoscopy showed complete obstruction of the right upper bronchus. Her serum CA19-9 and SLX levels were very high, and then a right upper lobectomy was performed under the preoperative diagnosis of lung carcinoma. Pathological examination of the resected lung revealed a granulomatous lesion and infiltration of lymphocytes without malignant findings. The levels of CA19-9 and SLX in the bronchial fluid were very high (2201,187 U/ml and 20,000 U/ml). A few colonies grew on a liquid medium, and were identified as Mycobacterium malmoense by PCR. Immunohistochemical staining of the bronchial epithelium and gland were positive for CA19-9. The increased serum CA19-9 and SLX levels normalized after the operation. This case suggests that CA19-9 and SLX are occasionally produced on a large scale in the lungs of patients without malignancy.

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A male patient in his 30's was referred to our hospital because of hemoptysis. Chest CT showed the left pulmonary artery supplying the S6 segment of the left lower lobe but not the basal segment, and an aberrant artery arising from the thoracic aorta and supplying the left basal segment. The bronchial tree was normal. We diagnosed this patient with an anomalous systemic arterial supply to the normal basal segment of the left lower lobe. During surgery, the left S6 segment looked almost normal, suggesting that the segment could be preserved. We performed a left basal segmentectomy and closure of the anomalous systemic artery completely by video-assisted thoracoscopic surgery (cVATS). The aberrant artery with a diameter of 8 mm was cut using a stapler alone. He had an uneventful postoperative course, and was discharged on postoperative day 10. At 5 months, he was in good health without hemoptysis. There have been some negative comments on cVATS for this anomaly from the aspect of safety, but, recently, some cases safely undergoing cVATS lobectomy or basal segmentectomy have been reported. We also performed cVATS left basal segmentectomy, with no safety problems.

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