Because of the low incidence of brain metastasis after complete resection of pathological stage I non-small cell lung cancer (NSCLC), periodic brain magnetic resonance imaging is not recommended for all patients. To establish criteria for the selection of patients who should undergo strict screening for brain metastasis, we performed a retrospective review of 218 patients with pathological stage I NSCLC who underwent surgery at our hospital between January 1999 and December 2008. The brain was the initial site of recurrence in 8 patients, and these patients were compared with 177 patients without brain metastasis. Thirty-three recurrence-free patients with a follow-up period of <4 years were excluded from this analysis. We observed that the risk of brain metastasis increased in patients with T1b or T2a disease, moderately or poorly differentiated non-squamous cell carcinoma, or undifferentiated carcinoma, and the right upper lobe was the site of origin. We noted a disease-free interval of >3 years in 2 patients. High-risk patients require careful long-term screening for brain metastasis.

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The apical pleural adhesion band may be life-threatening in cases of pneumothorax. We analyzed 154 consecutive pneumothorax cases at the initial onset using computed tomography (CT) to assess whether these bands are detectable. CT depicted the band in 31 out of 154 cases, while 4 cases were overlooked, confirmed by subsequent VATS. The apical pleural adhesion band was finally revealed in a total of 35 cases, meaning that 31 out of 35 cases, 88.6% sensitivity, were detected by CT. This favorable sensitivity supports the routine use of CT for pneumothorax cases, suggesting that cases showing the band should be indicated for VATS regardless of whether or not it is the first onset.

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The standard treatment for thymoma patients with postoperative recurrence has not been established, and the results of intervention remain unclear. We herein performed a retrospective analysis to clarify the outcome. Out of 190 thymoma patients who underwent surgical resection in our institute between 1991 and 2008, 25 patients (13.2%) with postoperative recurrence were investigated. According to WHO classification 2004, 2 cases were pathologically diagnosed as type AB, 2 cases as type B1, 9 cases as type B2, and 12 cases as type B3. Clinically, 3 cases were classified as stage I, 2 cases as stage II, 9 cases as stage III, 8 cases as stage IVA, and 3 cases as stage IVB according to Masaoka's staging system. The median disease-free interval was 26.2 months. Initial sites of recurrence were pleural dissemination in 17 cases, local relapse in 6 cases, and pulmonary metastasis in 2 cases. The treatment for recurrent thymoma included 14 cases with surgical resection (20 pleurectomy, 2 local repeat resection, 1 pulmonary metastasectomy, 1 lymph node dissection), 10 cases with systemic chemotherapy, and 4 cases with irradiation. The 3- and 5-year overall survival rates were 86 and 79%, respectively. The 3-year survival rates were 100 and 68% in patients with surgical and non-surgical treatment, respectively (p=0.06). In conclusion, pleural dissemination was a major relapse pattern following thymoma resection, and prolonged survival could be expected in patients with operative indications.

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The optimal treatment strategy for pulmonary aspergillosis (PA) remains controversial. Surgical resection is considered the most effective for aspergilloma. However, surgical resection is associated with marked mortality and morbidity. We investigated whether combining postoperative antifungal pharmacotherapy with surgical resection could yield a better outcome than surgery alone in patients with PA. Thirteen patients with pulmonary aspergillosis treated surgically at our hospital were retrospectively reviewed for clinical characteristics, preoperative treatment, operative methods, adjuvant antifungal treatment, and outcomes. All cases had an underlying disease, with respiratory disease in 11 patients. Five patients were treated with antifungal agents preoperatively. Non-antifungal pharmacotherapy as adjuvant therapy was performed in 10 cases. The average postoperative observation period was 879 days, with no recurrence in any of the cases.
We believe that antifungal pharmacotherapy may be unnecessary for cases of definitive mycetoma removal in PA patients with non-adjuvant antifungal therapy in whom there is no recurrence.

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A 74-year-old female underwent partial resection of the right lower lobe for lung adenocarcinoma 11 years ago. She was referred to our hospital because of cough. Chest CT showed multiple lung nodules, and lymph node swelling in the bilateral hilum of the lung, mediastinum, and right supraclavicular lesion. She started the oral administration of gefitinib. Gefitinib led to a favorable response, and chest CT showed a nodule in the right lower lobe only. However, the size of the nodule increased, suggesting acquired resistance to gefitinib. We performed a right lower lobectomy. Exon 20 T790M, which is known to be associated with gefitinib resistance, was found in the lung tumor. Four months after the operation, chest CT showed recurrent nodules. She then restarted the oral administration of gefitinib. After 1 month, recurrent nodules were not detected on chest CT.

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A 66-year-old man undergoing a preoperative work-up for Lumbar-spinal-canal stenosis showed a 26-mm nodular shadow in the right lower lung field on a chest radiograph. Chest computed tomography showed a tumor arising from the right 6th rib. Magnetic resonance imaging showed a low-intensity mass in the T1WI image and a high-intensity mass in the T2WI image. Under the suspicion of a chondroma or chondrosarcoma, wide resection was performed.
After intraoperative pathological analysis, the tumor was diagnosed as a low-grade chondrosarcoma or chondroma.
Since there is no effective treatment except for surgical resection, wide resection was performed and the chest wall was rebuilt using Marlex mesh.

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A woman in her 30s was incidentally found to have a mass in the lower lung field on a lumbar radiography when she visited a neighborhood clinic for back pain, and was referred to the Department of Respiratory Surgery of our hospital. Chest radiography revealed a well-defined, round mass of approximately 9 cm in diameter in the left lower lung field. Chest CT and MRI demonstrated a dumbbell-shaped tumor, destroying the vertebral body at the ninth intervertebral foramen and extending to the spinal canal. The tumor had not reached the spinal dura mater and was, thus, thought to be a neurilemmoma originating from the proximal intercostal nerve. Single-stage surgery was performed via a simultaneous posterior plus anterior approach. After the nerve root had been treated via the posterior approach, thoracoscopy-assisted thoracotomy with a 10-cm incision was performed through the fifth rib bed. However, one more thoracotomy incision was required because intra-thoracic manipulation was difficult due to the large diameter of the mass and its extensive adhesion, and the thoracoscope was used only as a supplementary approach. The patient's back pain resolved postoperatively. Although thoracoscopy-assisted surgery with an anterior approach is recommended for dumbbell-shaped tumors because it is minimally invasive and safe, we believe that thoracoscopy should be limited to supplementary use.

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A 61-year-old male was referred to our hospital for cStage IIIA (cT4N0M0) adenocarcinoma of the right lung. Computed tomography (CT) revealed a large nodule, 61 mm in diameter, in the right upper lobe, with multiple nodules in the right upper and middle lobes. He received six courses of a combination of Carboplatin, Pemetrexed, and Bevacizumab as preoperative chemotherapy, and showed no serious adverse events. CT after preoperative chemotherapy revealed a major radiographic response. He underwent right upper lobectomy and wedge resection of the right middle lobe with partial resection of the 2^nd-5^th ribs. Histopathological examination revealed just a small viable part of the adenocarcinoma, 2 mm in diameter, in the right upper lobe, and that most of the tumor showed coagulation necrosis. The effect of preoperative chemotherapy was Ef.2. Preoperative chemotherapy with Carboplatin, Pemetrexed, and Bevacizumab may be useful for the treatment of locally advanced non-squamous non-small cell lung cancer.

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A 37-year-old woman was referred to our hospital because of pulmonary sequestration complicated by nontuberculous mycobacterial infection. When she was 35 years old, persistent cough developed and an abnormal shadow was detected in the right lower lung field on a chest radiograph. An enhanced CT scan showed an abnormal blood vessel extending from the descending aorta to the right lower lung and infiltration of the same lobe. Because Mycobacterium avium was isolated from sputum, she was diagnosed with intrapulmonary sequestration complicated by nontuberculous mycobacterial infection. She received CAM+RFP+EB therapy for twenty months. After chemotherapy, a right lower lung lobectomy was performed. Pathological examination revealed caseous necrosis and epithelioid cell granulomas. Cases of pulmonary sequestration complicated by nontuberculous mycobacterial infection are rare. In addition to the present case, we reviewed 9 previous reports of similar cases.

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Elastofibroma dorsi (EFD) is a relatively rare, benign, slow-growing, fibroproliferative tumor, which is often localized in the subscapular region on the chest wall. EFD is often asymptomatic and incidentally discovered by patients with the development of a mass in the subscapular region. Surgical excision is recommended when EFD causes functional disability or symptoms. A 61-year-old man presented with increasing discomfort in the right posterior chest wall. Computed tomography (CT) revealed a 7.6×2.3-cm heterogeneous soft-tissue mass in the infrascapular region. T1- and T2- weighted magnetic imaging (MRI) showed a soft-tissue mass that was isointense to skeletal muscle groups interlaced with hyperintense fatty areas between the corpus of the right scapula and chest wall. The tumor was diagnosed as EFD. Surgery was indicated due to his symptom and the tumor size, and the lesion was composed of a mixture of coarse elastic fibers and collagenous tissue with scattered fibroblasts, associated with entrapped mature fat cells. There are some reports of EFD by orthopedic and plastic surgeons. MRI can be the most reliable and noninvasive technique for the conclusive diagonosis of EFD. Asymptomatic patients with typical imaging characteristics may not require biopsy or excision. We conclude that EFD should be kept in mind by chest surgeons.

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Although mucoepidermoid carcinoma of the lung is a rare tumor, we report 3 cases. The first case was a 51-year-old female. She presented to the hospital with cough, sputum, and an abnormal shadow on a chest radiograph. One and a half years after right pneumonectomy, she died of multiple lung metastases. The histological type of the tumor was a high-grade mucoepidermoid carcinoma. The second case was a 16-year-old female with no symptoms. A chest radiograph revealed an abnormal shadow in the right middle lung field. We performed right lower lobectomy. The histological type of the tumor was a low-grade mucoepidermoidcarcinoma. The third case was a 54-year-old female with no symptoms. A chest radiograph revealed an abnormal shadow in the right lower lung field. We performed right lower lobectomy. The histological type of the tumor was a low-grade mucoepidermoid carcinoma. In addition, we reviewed the clinical features of 30 cases reported in Japan, and compared them with those of the present three cases.

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A 40-year-old man called the emergency medical services (EMS) because of aggravated severe dyspnea at rest. When EMS arrived, he was alert and complaining of severe dyspnea, but he lost consciousness and entered cardio-pulmonary arrest during emergent transportation. On arrival at our hospital, he was still in cardio-pulmonary arrest. While we performed cardio-pulmonary resuscitation, a chest radiograph showed bilateral tension pneumothorax. We immediately performed bilateral thoracic drainage and, ten minutes later, spontaneous circulation returned. He was admitted to the intensive care unit for management. As his mental and performance status gradually improved, we performed surgery for bilateral pneumothorax on the 26th day of illness. His condition was favorable during the postoperative period, and he was transferred to another hospital for rehabilitation on the 73rd day of illness.
Bilateral tension pneumothorax is relatively rare, and there are few reports of successful resuscitation after cardio-pulmonary arrest. As demonstrated by our case, rapid and appropriate medical treatment is necessary for survival.

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We describe a 75-year-old male patient in whom an abnormal chest shadow was pointed out during a medical check-up in 2002. This was judged to be inflammatory change, and was not followed up. A further medical checkup in 2011 again demonstrated the abnormal chest shadow, which showed very slightly increased enhancement on CT examination. Although a bronchoscopic inspection was conducted, no definitive diagnosis could be made. Therefore, the patient was referred to our department for exploratory surgery aimed at diagnosis and treatment. We performed thoracoscopic partial resection of the left lung, and pathological examination of the excised specimen yielded a diagnosis of Noguchi C-type mixed mucinous and non-mucinous lung adenocarcinoma. The tumor doubling time was 1,631 days, and, thus, growth was very slow. Immunohistochemistry was performed to distinguish mucus- and non-mucus-producing parts of the tumor. P53 protein was negative, and the Ki-67 index was less than 5%. The grade of malignancy of both parts of the tumor was very low. The present case of lung adenocarcinoma that manifested as a solid shadow showed a low grade of malignancy and very slow growth.

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A 10-year-old boy was pointed out as showing a cardiac murmur in a school physical examination, and consulted a local doctor. A coin lesion, of 20 mm in diameter, in the right upper lung field was observed on a chest radiograph. Because the nodule increased to 26 mm after 8 months' follow-up, he was referred to our hospital for further examination. A chest computed tomography (CT) scan showed a nodule, of 26×24 mm in diameter, in the right upper lobe. A positron emission tomography scan showed the accumulation of FDG (SUV max: 8.7) in the nodule, while a leiomyoma was suspected based on pathologic examination with CT-guided needle biopsy. We suspected that the tumor was malignant, and, therefore, performed thoracoscopic right upper lobectomy and nodal dissection. The postoperative pathological diagnosis was low-grade leiomyosarcoma of the lung. This is the youngest male case of primary pulmonary leiomyosarcoma reported in Japan.

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A 32-year-old female underwent video-assisted thoracoscopic surgery (VATS) for recurrent spontaneous pneumothorax. She had undergone VATS wedge resection for a primary spontaneous pneumothorax 2 years earlier. At that time, the visceral pleura was covered with a regenerative oxidized cellulose membrane. Pleural coverage with a regenerative oxidized cellulose membrane was reported to thicken the visceral pleura without adhesion and prevent pneumothorax recurrence. In this operation, the site of the thickened pleura, over which the sheet had been placed during the previous operation, was free from the chest wall without adhesion. Aside from thickening of the pleura, a regenerated bulla was observed. We report a case of recurrent pneumothorax with intraoperative findings of visceral pleura thickening without adhesion, owing to the regenerative oxidized cellulose membrane.

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In some case reports, intrathoracic needle migration was reported as a pulmonary foreign body. We treated a case of lung cancer with a pulmonary foreign body in the same lobe resembling a stick of bamboo. Case: An 81-year-old man was admitted to our hospital because of a pulmonary nodule on a chest radiograph. Chest CT revealed a nodule of 1.6 cm and high-density linear opacity inside the pulmonary parenchyma of the left upper lobe neighboring the ascending aorta. Bronchoscopic biopsy of the nodule did not lead to a diagnosis of lung carcinoma. Two months later, the pulmonary nodule had grown to 2.2 cm in diameter based on chest CT, and was suspected to be a primary lung cancer. Left upper segmentectomy was performed for a definitive diagnosis of the pulmonary nodule and the removal of the bamboo stick-like structure. The pulmonary nodule was diagnosed as a squamous cell carcinoma. The hard stick-like structure was carbonized and histological examination showed many small chambers like a plant cell. We thought that the many small chambers were cell walls and that it was actually a bamboo fragment.

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We encountered a case of fibrosarcoma in which chest wall reconstruction was performed with titanium plates connecting the sternal head and xiphoid after chest wall resection including the sternal body, with an expanded polytetrafluoroethylene (ePTFE) patch covering the thoracic cage. A 61-year-old woman became aware of a chest wall mass with heat 1 year previously. She was diagnosed with fibrosarcoma and admitted to our hospital. Chest wall reconstruction after whole-layer chest wall resection was performed using a combination of titanium plates and ePTFE. Titanium plates were used vertically because her ribs could not tolerate plate fixation. There were no complications following surgical resection for 6 months.

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A chest radiograph revealed an abnormal shadow in a 50-year-old woman who presented for a routine physical examination. Chest computed tomography revealed a 50-mm cystic mass located in the middle mediastinum. Thoracoscopic resection of the cyst was performed, revealing a cystic mass with a smooth wall, located on the vertebral body and containing suspected chyle. A thoracic duct cyst was suspected, and clipping of the tubular structure was performed for apparent lymphatic leakage. The content of the mass was confirmed as chyle. Immunohistochemically, the cyst wall consisted of lymphatic endothelial cells, leading to a diagnosis of a thoracic duct cyst. Thoracic duct cyst is treated with surgical resection, with postoperative complications of chylothorax widely reported. The patient was discharged with no evidence of chylothorax.

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A 73-year-old man showed an abnormal shadow on a chest radiograph. Chest computed tomography (CT) showed an anterior mediastinal tumor; additionally, the appearance of the right-and-left brachiocephalic vein and pericardium led to a suspicion of invasion. He underwent thoracotomy with a tentative diagnosis of an invasive thymoma.
We made an antero-lateral incision at the right 4th intercostal space and performed a median full sternotomy. A part of the tumor was submitted for frozen section biopsy, and thymoma was confirmed. Thymectomy and reconstruction were performed using cardiopulmonary bypass, and a horse pericardial patch was placed to reinforce the right atrium.
The right-and-left brachiocephalic vein to SVC reconstruction was performed using a ringed-ePTFE graft, which permitted extended thymectomy.
The postoperative course was favorable. The patient left the hospital after graft patency was verified by chest CT examination on postoperative day 18. The final pathological diagnosis was combined B2/B3 thymoma.
Two weeks after discharge, the patient revisited for outpatient consultation and reported feeling general fatigue. He showed marked pre-tibial edema, and a chest radiograph showed dull costophrenic angles on both sides. Blood test results confirmed acute renal failure. The patient was re-hospitalized immediately.
A renal biopsy showed minimal change nephrotic syndrome.
He was managed by the nephrology service. Despite positive results of treatment for renal failure, the patient died from aspiration pneumonia 9 months after the initial operation.

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We report a case of malignant solitary fibrous tumor (MSFT) arising in the thymus. A 68-year-old man was found to have an anterior mediastinal solid tumor measuring 41×26×53 mm on lung cancer screening with a CT scan. FDG-PET also showed abnormal accumulation (SUV max: 6.6) in the tumor.
Extended thymectomy was performed. Histology revealed MSFT arising in the thymus with marked vascular invasion. Five months after the operation, local recurrence and multiple systemic metastases were detected. Although he received chemoradiotherapy, he died 23 months after the operation.
We must establish more strategic adjuvant chemotherapies for MSFT as soon as possible.

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An 84-year-old male consulted our hospital because of an abnormal shadow pointed out on chest radiography during a medical check-up. CT showed a nodule in the left lower lobe measuring 1.5×1.2 cm. Under the suspicion of primary lung cancer, resection was planned 1.5 months later because coronary stenting had been performed 2 months earlier. Pre-operative CT performed 6 weeks after the initial CT revealed regression of the nodule, and it was diagnosed as an inflammatory nodule. However, as gradual regrowth was observed by CT at 4 and 9.5 months after the first consultation, video-assisted thoracic surgery was performed, and the nodule was diagnosed as small cell lung cancer pathologically. The patient is currently undergoing follow-up without any signs of recurrence 21 months after the operation. Even if a lung nodule decreases in size during follow-up, careful follow-up is necessary.

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A 55-year-old man was referred to our department because of mild swelling of his neck. Computed tomography (CT) revealed a large anterior mediastinal mass (80×60×40 mm). Although CT-guided biopsy confirmed that the mass was not malignant, the possibility of a cystic thymoma or other neoplasm could not be ruled out; therefore, surgery was performed. Intraoperative rapid diagnosis suggested benignancy. However, as complete resection was difficult, part of the cystic lesion was left in situ. A histological diagnosis of multilocular thymic cyst (MTC) was established. Over a follow-up period of 10 years, the size and contours of the lesion remained unaltered. Recently, it was reported that MTC shows a strong association with thymoma and thymic cancer, and so this long-term follow-up period was justified.

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We report a case of recurrent spontaneous pneumomediastinum followed by spontaneous pneumothorax. A 15-year-old boy, who caught a cold 2 days before onset, was admitted to our hospital because of chest pain and cough. A chest radiograph and computed tomography (CT) showed subcutaneous and mediastinal emphysema. He received a diagnosis of spontaneous pneumomediastinum (SPM). He was treated with bed rest and antibiotics. At the age of 17, he was readmitted to our hospital with cervical subcutaneous emphysema and a sore throat, without any precipitating factor. He received a diagnosis of recurrent SPM and was treated with bed rest and antibiotics. At the age of 18, he was admitted to our hospital again with left chest pain. He received a diagnosis of left spontaneous pneumothorax, and underwent video-assisted thoracoscopic surgery. He was well and free of SPM and spontaneous pneumothorax one year after surgery. Recurrent SPM is rare, and there are no reports of metachronous spontaneous pneumothorax following recurrent SPM. Spontaneous pneumothorax and SPM have similar etiologies. In this report, we reviewed the literature on the relationship between SPM and spontaneous pneumothorax.

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