Many cases of outpatient drainage therapy for pneumothorax using Thoracic Egg^® (TE: Sumitomo Bakelite Company Limited, Tokyo, Japan) have been reported. Compared with a larger catheter, TE causes less pain and is easier to manage. In the case of a thick pleura, particularly in a young patient, however, a splitting procedure is necessary, which causes marked pain and, therefore, decreases the ADL. For the purpose of reducing the pain, we devised a new method using a modified central venous catheter (CV-TE). The CV-TE was applied to patients who had moderate to severe pneumothorax without pleural effusion. We studied a total of 69 patients with pneumothorax who received CV-TE treatment in Aizawa Hospital between September 2010 and August 2012. They were 58 males and 11 females, with an age ranging from 16 to 89 years (mean: 47). Thirty-three patients had spontaneous pneumothorax, 26 secondary pneumothorax (COPD), 6 traumatic pneumothorax, 2 iatrogenic pneumothorax, 1 postoperative air leakage, and 1 hemopneumothorax (this patient underwent unplanned treatment). In 56 cases (81 percent), use of the modified central venous catheter was successful for drainage; the remaining 13 cases required replacement with a larger-bore catheter because of insufficient drainage due to obstruction of the catheter, or for the purpose of additional pleurodesis. The CV-TE method proved to be useful for treating pneumothorax, reducing pain, and preventing a decrease in ADL.

View full abstract

We performed video-assisted thoracoscopic surgery (VATS) for five patients with spontaneous hemopneumothorax (SHP) in our hospital. In many reports, this disease is noted as hemothorax which requires an emergency operation. We compared five cases of SHP with eighty-five cases of primary spontaneous pneumothorax (PSP). SHP and PSP patients were enrolled in this study from 2009. In four cases of SHP, the aberrant vessel was identified near the bulla. On comparing the two groups, the backgrounds were similar. However, the operative results for SHP and PSP groups were as follows: operation time (94.2±24.0 vs. 73.1±30.5 min, NS), blood loss (896.0±466.3 vs. 5.7±11.2 ml, P<0.05), duration of postoperative drainage (2.0±1.7 vs. 1.5±1.7 days, NS), and postoperative hospital stay (6.2±2.9 vs. 4.0±2.6 days, P<0.05), respectively. The postoperative course was uneventful in all cases. Although the recurrence rate of pneumothorax in both groups was not significant based on the Kaplan-Meier method, SHP patients had a lower recurrence rate than PSP patients (0 vs. 12.1%, respectively). In conclusion, we suggest that SHP is associated with a lower recurrence rate of pneumothorax than PSP.

View full abstract

Secondary pneumothorax with advanced lung cancer is an intractable and serious pathosis, which directly aggravates patients' Quality of Life (QOL) and prognosis. We first select the intrapleural administration of fibrin glue for secondary pneumothorax with advanvced lung cancer. From April 2009 to May 2012, we encountered 5 patients who developed secondary pneumothorax during treatment for advanced lung cancer. Their average age was 60.8 years old, and 4 of them had squamous cell carcinoma, 1 had adenocarcinoma, and all had unresectable advanced lung cancer. In 4 of them, the point of air leakage could be detected by pleurography, and leakage could be stopped by the intrapleural administration of fibrin glue. All of them could receive chemotherapy or radiotherapy after treatment for secondary pneumothorax. The intrapleural administration of fibrin glue may be an effective and valid treatment for intractable secondary pneumothorax with advanced lung cancer.

View full abstract

A 71-year-old woman who complained of difficulty in walking and speech was admitted to our hospital. She was diagnosed with cerebellar dysfunction. However, brain MRI showed no abnormal lesions. Paraneoplastic cerebellar degeneration was suspected. Fluorodeoxyglucose-positron emission tomography (PET)/CT showed abnormal accumulation in the subaortic region. Mediastinal lymph node metastasis was suspected. She underwent resection of an enlarged mediastinal lymph node. Histological examination revealed that the lymph node consisted of small cell carcinoma. After surgery, walking and speech functions improved. She showed no sign of cancer recurrence.

View full abstract

A 50-year-old male with adenocarcinoma of the left lung underwent left upper lobectomy and lymph node dissection, and a diagnosis of mixed subtype adenocarcinoma, pT1aN0M0 Stage IA was made. Subsequently, there were no signs of recurrence. However, left thoracodorsal pain developed over 6 and a half years later. Radiography showed no clear abnormalities, but the pain gradually increased. Chest CT performed 7 and a half years after surgery revealed a tumor (major axis, 5 cm) centering on the dorsal side of the left 4^th intercostal space. As a result of CT-guided percutaneous needle biopsy, a diagnosis of lung adenocarcinoma recurrence was made. The recurrence site corresponded to the site of CT-guided biopsy performed before surgery for lung cancer, and no other metastases were observed. Therefore, recurrence was thought to be due to tumor implantation by the biopsy needle, and the chest wall containing the 3^rd-5^th ribs was resected. There was neither pleural dissemination nor pulmonary invasion. The resection margin of the chest wall was negative, and his postoperative course was favorable. We report this case since recurrence within the biopsy needle track after CT-guided percutaneous needle biopsy is rarely observed.

View full abstract

We describe a case of pulmonary hyalinizing granuloma with extrapulmonary protrusion. A 59-year-old man was admitted to our hospital because of an abnormal shadow in the right apical portion on a chest radiograph. Computed tomography revealed a mass of about 3 cm in diameter arising smoothly from the right fourth rib, showing an extrapleural sign. From the findings, it was considered to be a pleural tumor prior to surgery. Thoracoscopic findings revealed a white mushroom-shaped mass that protruded from the visceral pleura of the right upper lobe of the lung. The tumor was resected with pulmonary parenchyma. Histopathologically, the tumor mainly consisted of collagen bands accompanied by lymphocytic infiltrate. It was finally diagnosed as pulmonary hyalinizing granuloma.

View full abstract

A 60-year-old male presented with a left lung nodule (Lt., S6, nodule with necrosis and cavitation, 27×27×29 mm) detected by screening. Although it was difficult to diagnose based on the preoperative transbronchial lung biopsy of the nodule, it showed malignant findings, and was suspected to be a large cell neuroendocrine carcinoma or poorly differentiated squamous cell carcinoma. The clinical stage was T1bN0M0 stage IA. We performed left lower lobectomy and lymphadenectomy (2a-1) under hybrid video-assisted thoracic surgery. The resected specimen showed rapid growth (35×30×35 mm, estimated doubling time: 41 days), and the patient was eventually diagnosed with a pulmonary basaloid carcinoma based on immunohistochemical results of being positive for 34βE12 and negative for Chromogranin A, Synaptophysin, CD56, and Thyroid Transcription Factor-1. He was diagnosed with T2aN0M0 pathological stage IB. The patient was informed that pulmonary basaloid carcinoma is an uncommon variant of large cell carcinoma, and he chose follow-up without additional therapy. Neither local recurrence nor distant metastasis was noted at the seventh postoperative month. It may be difficult to diagnose pulmonary basaloid carcinoma by small or crushed tissue samples from transbronchial biopsies. Thus, surgical resection, or autopsy in same cases, and detailed immunohistochemical examination should be performed.

View full abstract

A 52-year-old woman was admitted to our hospital with a 2-cm mass surrounded by spiculation in the middle lobe of her right lung that was positive upon 18F-FDG positron emission tomography/computed tomography (PET-CT). Although cytology under bronchoscopy revealed a class I lesion, a right middle lobectomy and lymph node dissection were performed by video-assisted thoracic surgery owing to the possibility of lung cancer. However, the mass mainly consisted of small or medium-sized plasma cells that were IgG4-positive. Her left submandibular gland was also positive upon PET-CT, and yielded the same pathological findings. Her serum IgG4 level was very high. Therefore, we diagnosed her with IgG4-related lung disease.

View full abstract

A 20-year-old female was referred to a local doctor due to an abnormal shadow in the right lower lung field on a chest radiograph obtained during a medical examination. She consulted our hospital for evaluation of multiple suspected pleural tumors on chest computed tomography. Follow-up CT performed after one month revealed growth of the masses. However, FDG-PET imaging showed a very low standardized uptake value, and chest magnetic resonance imaging suggested that the lesions were benign, such as fibrous tumors. Making a differential diagnosis based on preoperative imaging was difficult; therefore, surgery was performed for diagnosis and treatment. The intraoperative thoracoscopic view revealed a pedunculated mass in the parietal pleura and a sessile mass in the visceral pleura. Microscopically, the masses consisted of dense fibrous tissue containing mildly pleomorphic spindle cells with inflammatory infiltrates and psammoma calcification. Immunohistochemically, the masses were positive for vimentin and negative for other markers. Therefore, the masses were diagnosed as calcifying fibrous tumors (CFTs). CFT of the pleura should be taken into consideration in the differential diagnosis of intrathoracic tumors.

View full abstract

A 58-year-old female was admitted for an abnormal shadow on a chest radiograph. Chest CT showed a 30-mm-diameter, round mass adjacent to the superior vena cava. We suspected a neurogenic tumor originating from the right phrenic nerve. We performed video-assisted thoracoscopic surgery (VATS). Based on macroscopic findings, we diagnosed it as a neurogenic tumor originating from the right phrenic nerve, and resected it along with the right phrenic nerve. The right phrenic nerve was immediately reconstructed by VATS. The right phrenic nerve was temporarily paralyzed, but it fully recovered 3 months after the operation. The postoperative pathological diagnosis was schwannoma. Schwannoma of the phrenic nerve is a rare lesion, and 27 cases have previously been reported in the Japanese literature. To our knowledge, this report is the first to indicate the feasibility of immediate phrenic nerve reconstruction after resection of a phrenic nerve schwannoma.

View full abstract

Basaloid variant of squamous cell carcinoma (SCC) of the lung is rare and mostly observed in the proximal bronchi. We report a patient with a peripheral lung basaloid variant of SCC who underwent lobectomy. A 77-year-old woman with a history of smoking presented to our department with a two-year history of a growing lung tumor in the left lower lobe. FDG-PET/CT scan was positive. She underwent thoracoscopic lung wedge resection, followed by lobectomy. Frozen sectioning revealed a poorly differentiated carcinoma. The final pathological diagnosis was a stage IA basaloid variant of SCC. She was alive without evidence of recurrence at 31 months. In this case, basaloid variant of SCC of the lung was diagnosed both morphologically and immunohistochemically, excluding large cell neuroendocrine carcinoma, small cell carcinoma, and poorly differentiated squamous cell carcinoma.

View full abstract

We report a rare case of single synchronous lung metastasis from intrahepatic cholangiocarcinoma. An 81-year-old man was referred to our hospital with an abnormal shadow on a chest radiograph, and given a preoperative diagnosis of triple primary lung, liver, and ampulla of Vater carcinomas. These tumors were removed by two-stage surgery consisting of hepatopancreatoduodenectomy and subsequent left upper lobectomy performed with an interval of 37 days. The patient's postoperative course was uneventful. Pathological examination of the resected specimens revealed the lung tumor to be a metastasis from the intrahepatic cholangiocarcinoma. In this patient, the tumor recurred in the lung 11 months after the operation, and he died 11 months after recurrence.

View full abstract

A 47-year-old woman was admitted due to a right pneumothorax. Chest CT showed a large cystic lesion in the middle lobe of the right lung. Because of prolonged air leakage, surgery was performed. The cyst occupied almost all of the middle lobe, and right middle lobe resection was performed. Pathologically, the inner surface of the cyst was covered with ciliated epithelium, and components of cartilage and smooth muscle were found in the cyst wall. Thus, it was diagnosed as mesenchymal cystic hamartoma. Mesenchymal cystic hamartoma of the lung is rare, but it should be considered as a differential diagnosis of cystic lung disease.

View full abstract

A 77-year-old woman underwent mediastinal drainage for descending necrotizing mediastinitis combined with a cervical abscess after tracheostomy and drainage for the cervical abscess. The procedure consisted of drainage for the left upper mediastinal abscess superior to the aortic arch and the middle mediastinal abscess inferior to the tracheal bifurcation under video-assisted thoracoscopic surgery. On postoperative day 5, postoperative chylothorax was recognized. The amount of chest tube drainage remained at more than 1,000 ml per day in spite of oral intake cessation and total parenteral nutrition. On postoperative day 12, reoperation was performed resulting in the decrease of pleural fluid. However, during the night of the following day, the pleural effusion increased up to 1,000 ml per day again. Two days after the reoperation, she was administered subcutaneous octreotide at 300 μg per day. The pleural effusion decreased soon afterward, and the chylothorax did not recur. In surgery for descending necrotizing mediastinitis, abscess drainage by sufficient dissection of the mediastinum is mandatory. Thus, we should note that chylothorax is a possible postoperative complication. Octoreotide was effective in the present case.

View full abstract

A 46-year-old man was pointed out as showing a slow-growing cavitary lesion in the left upper lung field in an annual chest radiograph for the screening of pneumoconiosis. Chest CT showed a cavitary nodule in the left upper lobe. A definitive diagnosis could not be made by bronchoscopic examination. We performed thoracoscopic partial resection of the left upper lobe for the differential diagnosis. The histopathological findings of the resected specimen showed pulmonary siderosis. There was no evidence of malignancy. Considering the patient's occupation, we finally established a diagnosis of welder's lung. Welder's lung is a benign disease sometimes requiring a differential diagnosis from lung cancer.

View full abstract

A 48-year-old man was admitted to our hospital with left back pain and dyspnea in February 2011. He was diagnosed with left pneumothorax. He was treated by suction drainage in an outpatient clinic, and cured. However, the pneumothorax relapsed again. Chest computed tomography (CT) revealed multiple bullae in the apex of the left lung, and there was a small nodule near these bullae. Partial resection of the left lung was performed during video-assisted thoracoscopic surgery to treat the pneumothorax and investigate the nodule. Based on a rapid histological examination during the operation, the nodule was diagnosed as lung cancer, and he additionally received left upper lobectomy and lymph node dissection. Finally, a large cell neuroendocrine carcinoma combined with adenocarcinoma (pT1aN0M0, Stage IA) was diagnosed. He received 2 cycles of adjuvant chemotherapy (CDDP+CPT-11). He was alive without recurrence 21 months after surgery.

View full abstract

A 51-year-old woman was admitted to our hospital with bilateral pleural effusion. She underwent thoracentesis, and was diagnosed with bilateral chylothorax. Owing to the absence of an apparent causative disease, she was diagnosed with bilateral idiopathic chylothorax. She was treated conservatively with low-fat-diet therapy and continuous chest tube drainage, but the pleural effusion again increased after three months. Then, ligation of the thoracic duct was performed. Left chylous pleural effusion increased on the evening of the day after surgery and drained at about 800 ml/day on the third postoperative day. Therefore, octreotide and low-fat-diet therapy were started. Chylous effusion decreased and the patient was discharged after the administration of octreotide for two weeks. No recurrence was observed in the follow-up after over a year. Idiopathic chylothorax is a rare disease, and optimal treatment has not yet been established. Furthermore, additional treatments are often needed after surgery because of incomplete healing. We believe that octreotide is useful for patients with idiopathic chylothorax who do not improve upon ligation of the thoracic duct.

View full abstract

A 54-year-old woman complaining of a subscapular tumor was referred to our hospital. The tumor was located in the right subscapular area, and it was 3 cm in diameter, hard, and unmovable from the chest wall. CT revealed an ill-defined soft-tissue tumor. The tumor was iso-intense on T1-weighted MR imaging, with a low intensity inside and high intensity outside. We could not obtain a preoperative histological diagnosis, but suspected the tumor to be an elastofibroma because of its location. After resection of the tumor, it was diagnosed as a desmoplastic fibroblastoma, one of the rare histological types of soft tissue tumors.

View full abstract

A 50-year-old woman was admitted to our hospital for cough and dyspnea. Chest radiography and computed tomography showed a large mass opacity in the left lower lobe, stenosis of the left bronchus, mediastinal enlargement, and pleural effusion. Bronchoscopic examination showed a polypoid tumor in the left bronchus, and the pathological diagnosis of the biopsy specimen was malignant melanoma. Systemic staging studies revealed metastases of the parietal skin. We diagnosed this patient with primary malignant melanoma of the lung because the pulmonary lesion was large and solitary and no other primary organ was affected. We carried out a left lower lobectomy, chemotherapy, and radiation therapy, and this patient is still alive. Primary malignant melanoma of the lung is extremely rare, and so we report this case.

View full abstract

Background: Lymphoepithelioma-like carcinoma (LELC) of the lung is a rare entity. It is classified as a variant of large cell carcinoma, and its development is believed to involve Epstein-Barr (EB) virus infection. Case 1: An abnormal chest shadow was seen on the chest radiograph of an 83-year-old woman during a medical checkup. A chest computed tomography (CT) scan revealed a 19×19-mm tumor in the right upper lobe of the lung. Bronchoscopic brushing cytology revealed a poorly differentiated adenocarcinoma. She underwent a right upper lobectomy involving video-assisted thoracoscopic surgery. She was diagnosed with LELC, and in-situ hybridization for EB virus small RNA 1 (EBER1) was weakly positive. She has been healthy without recurrence for 29 months since the surgery. Case 2: An abnormal chest shadow was seen on the chest radiograph of an 84-year-old man during a medical checkup. A chest CT scan revealed a 22×20-mm tumor in the left S6 segment. Bronchoscopic brushing cytology revealed a large cell carcinoma. He underwent left S6 segmentectomy, a limited surgery, because of a poor respiratory function. The histopathological diagnosis was LELC, and in-situ hybridization for EBER1 was negative. He has been healthy without recurrence for 4 months since the surgery. Conclusions: Only 17 cases of pulmonary LELC (including these 2 cases) have been reported in Japan. Previous reports have stated that the average age of patients with pulmonary LELC is lower than that of those with standard lung cancer, and that there were no patients aged over 80 years.

View full abstract

We report a case of primary lung cancer with marked bone formation. A 75-year-old woman presented with a tumor shadow with marked calcification in the left upper lobe, which was detected on computed tomography. The patient received left upper lobectomy for the tumor, which tended to increase on follow-up. Pathological examination revealed the tumor to be adenosquamous carcinoma with marked bone formation. Primary lung cancer with bone formation is very rare, and there have been only 13 cases reported, including the present case. Adenosquamous carcinoma involved only the present case. Histological findings vary by case, many questions have been pointed out, and the mechanism of bone formation has been suggested to involve transforming growth factor type-β (TGF-β) and bone morphogenetic protein 2 (BMP2). The accumulation of further cases, discussed from various aspects, such as the mechanism, characteristics, and prognosis, is expected in the future.

View full abstract

Intraosseous well-differentiated osteosarcoma is a rare subtype of osteosarcoma associated with a much better prognosis than conventional osteosarcoma. The tumor commonly originates in the extremities. We report a very rare case of intraosseous well-differentiated osteosarcoma occurring in the ribs of a 70-year-old female. The patient underwent resection of the left anterior part of the sixth rib for fibrous dysplasia at the age of 33. At the age of 45, the patient underwent a second resection for the subcutaneous recurrence of fibrous dysplasia. At the age of 67, a chest computed tomography (CT) scan showed a 1.5-cm nodule arising from the surgical margin of the left sixth rib. Because the nodule increased to 3 cm after 3 years of follow-up, we suspected the tumor was a recurrence of fibrous dysplasia. We subsequently performed chest wall resection with an adequate surgical margin. The pathological diagnosis was intraosseous well-differentiated osteosarcoma. The patient had no additional adjuvant chemotherapy nor radiation therapy postoperatively. Over a short follow-up period, the patient has shown no signs of recurrence.

View full abstract

A 78-year-old man with a posterior mediastinal tumor was referred to our clinic. Chest computed tomography showed a well-defined solid tumor in the left paravertebral space. In April 2011, complete resection (R0) was performed under video-assisted thoracic surgery. Immunostaining was positive for CD5 and bcl-2, and the pathological findings revealed thymic squamous cell carcinoma of Masaoka stage I. Currently, the patient is doing well, with no evidence of recurrence for two years. We concluded that the patient had a thymic tumor derived from an ectopic thymus, and a final diagnosis of carcinoma showing thymus-like differentiation (CASTLE) was made. CASTLE in the posterior mediastinum is extremely rare, and only reports of two cases have been published in Japan. We report a case of CASTLE which we diagnosed as resectable, and performed complete resection.

View full abstract