We performed video-assisted thoracic surgery (VATS) for 13 confirmed or suspected spontaneous hemopneumothorax patients as early as possible. All 13 patients underwent VATS within 5 hours after initial treatment (range, 2-5 hours; mean, 2.5 hours). During the operation, we could detect the bleeding point at the torn adhesion between the parietal and visceral pleura on the cupula, and control bleeding for all patients. The amount of blood drained preoperatively was 50-1,850 mL (mean, 483 mL). Total blood loss during the clinical course was 160-3,150 mL (mean, 1,315 mL). There was only 1 patient whose total blood loss was less than 400 mL. The length of the postoperative drainage period was 1-3 days (mean, 1.9 days). Their postoperative courses were uneventful, and the hospital stay was 3-10 days (mean, 4.4 days). Early VATS for spontaneous hemopneumothorax is considered feasible.

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We present the clinical and pathologic features of primary malignant pericardial mesothelioma. To better understand the clinical, radiographic, and pathologic features of this entity, we reviewed 13 cases with data stored at national Rousai Hospitals from 2004 through August 2013. Findings of the review included a Male: Female ratio of 1 : 1, an age range of 47 to 85 years old (mean, 69), and documented asbestos exposure in 9 patients (70%). Symptoms are often unspecific. Commonly used imaging studies do not show marked sensitivity: diffuse thickness of pericardium detected in 11 cases, and a pericardial mass in 2 cases by computed tomography. A diagnosis was provided by biopsy 8 cases, and post-operatively 1 case. Cytological examination of pericardial fluid is seldom conclusive (malignant cells demonstrated in 4 cases). Pathologic findings revealed a diffuse growth pattern in 10 cases, together with epithelioid findings in 46%. Chemotherapy was performed in 4 cases, and resection and chemotherapy in 1 case. Regarding the prognosis, the median survival of 13 cases was 6.0 months. To assess the prognosis, we compared the group receiving treatments with that receiving no treatments; the latter shows a prognosis as poor as the former group. In conclusion, with or without therapy, the prognosis was uniformly poor, since 12 of the patients died of the disease.

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Air leakage is a common complication after complete video-assisted thoracic surgery (cVATS) lobectomy. This study evaluated the efficacy of an autologous blood patch to prevent air leaks after cVATS lobectomy, especially on postoperative days (POD) 0 and 1. Forty-one patients who underwent cVATS lobectomy for lung cancer and who developed air leaks on POD 0 were investigated and assigned to 2 groups. Group A received autologous blood patch pleurodesis (blood patch) for air leak on POD 0 and 1, whereas group B (n=25) received no treatment. We analyzed the effects and complications of blood patch use retrospectively. Air leak size (evaluated in four grades) was larger in group A. In groups A and B, 56 and 20% of the patients showed air leak stoppage on POD 2, respectively (p=0.04). One patient developed empyema and one developed surgical site infection in group B. No patient from group A had any infectious complications. We therefore suggest that using autologous blood to treat air leaks on POD 0 or 1 after cVATS lobectomy is safe and effective.

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Female pneumothorax, especially premenopausal female pneumothorax, has been considered to be a more complicated pathology than male pneumothorax or menopausal female pneumothorax. We evaluated the clinical characteristics of 15 of 195 (7.7%) surgical cases of female pneumothorax during the past 5 years in our institution. The average age of the patients was 25.7 years (range, 14-41 years). There were nine cases of initial pneumothorax and eight cases of recurrence. The Brinkmann index in the recurrent cases was significantly higher than that in the initial cases. According to the body mass index, affected patients tended to be of slight build, similar to juvenile male pneumothorax cases. Only one patient was diagnosed with catamenial pneumothorax, while the others were diagnosed with spontaneous pneumothorax. All patients underwent bullectomy, plication, or ablation for bullae or blebbing under video-assisted thoracic surgery. The serum CA125 level in the pleural effusion was high in eight patients (normal value, <35 U/ml), whereas that in six patients without primary endometriosis or catamenial pneumothorax was within normal limits. The serum and pleural CA125 levels in patients with right-sided pneumothorax were higher than those in patients with left-sided pneumothorax. The drainage period after surgery was 2-5 days (average, 2.7 days). Postoperative complications comprised two cases of air leakage and one case of subcutaneous emphysema, none of which required treatment. To date, there have been no recurrences since surgery.

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【Introduction】The incidence of postoperative complications is high in elderly patients with lung cancer, but there is no method to assess the surgical risk. 【Methods】From January 2005 to September 2013, 191 surgical operations for lung cancer were performed in 75-year-old or older patients in our hospital. The patients were divided into 2 groups depending on the presence or absence of postoperative complications. Univariate analysis was performed to compare the background, nutritional condition, respiratory function, and surgical factors between the 2 groups. Using significant factors identified in the univariate analysis, we performed multivariate analysis to detect risk factors for postoperative complications. The patients were divided into 5 groups depending on the presence or absence of risk factors which were significant in multivariate analysis. We compared the postoperative complication rate among 5 groups (from groups 0 to 4). 【Results】The mean age of all patients was 78.4 years. Postoperative complications occurred in 47 patients (24.6%) and hospital deaths occurred in 2 patients (1.1%). Regarding the results of multivariate analysis, a male sex (P=0.00253), FEV1.0%≤70% (P=0.00381), segmentectomy or lobectomy (P=0.00293), and CONUT score≥2 (P=0.0175) were significant. The postoperative complication rate of group 3 was significantly higher than in groups 0, 1, and 2 (P=0.0144, P<0.001, and P=0.0124, respectively), and that of group 4 was significantly higher than in groups 0, 1, and 2 (P=0.0013, P<0.001, and P=0.0017, respectively). 【Conclusions】It is important to preoperatively assess not only the surgical procedure and respiratory functions, but also the nutritional condition and sex when conducting surgery for lung cancer in elderly patients in order to reduce the incidence of postoperative complications.

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A 41-year-old woman visited a local physician with the complaint of a headache. A prescription analgesic was not effective and, 2 days later, the patient visited the Department of Neurosurgery with a visual field defect. Computed tomography (CT) of the brain revealed the presence of a 35×27-mm brain abscess and surrounding brain edema. Contrast-enhanced CT of the chest on admission demonstrated a 50×36-mm tumor, feeding artery, and draining vein in the left S⁹ segment. Based on these findings, the patient was diagnosed with pulmonary arteriovenous fistula. Emergent cranial drainage was performed and antibiotic therapy was infused continuously for approximately 6 weeks. After the resolution of the brain abscess and edema was confirmed on a brain CT, surgical treatment for pulmonary arteriovenous fistula was performed and a 5-cm white and purple tumor was found protruding from the pulmonary surface of the left lower lobe. First, the inferior pulmonary vein was stapled in order to avoid iatrogenic air embolism or thrombosis embolism during the surgery. Next, the artery and bronchus were stapled and the lower lobe removed. Recently, trans-catheter arterial embolization has been widely used for the treatment of pulmonary arteriovenous fistula. Surgical treatment can be one of the effective treatment options, depending on the size and location of the tumor, and the diameters of the feeding and draining blood vessels.

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A 65-year-old male was referred to our hospital because of dyspnea on effort. An abnormal mass shadow in the right lung field and right pleural effusion were noted on chest radiograph. Chest computed tomography revealed a round mass measuring 5 cm with a smooth margin and heterogeneous inner structure in the right chest wall. For diagnostic and therapeutic purposes, surgery was performed for the total removal of the tumor together with resection of the intercostal muscle and partial resection of the right upper lobe. Histopathologic examination revealed a 50-mm tumor located within the parietal pleura, and the final diagnosis was a biphasic type of LMM with multicystic formation in the pedunculated pleural mass based on immunohistochemical studies. The tumor recurred in the right chest wall 2 years and 6 months after the operation, chemotherapy was conducted, and he has survived for 3 years. The relapsed disease was considered to be a dissemination and different from DMM. Further pathological study and the establishment of treatment for DMM are warranted.

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A 40-year-old man was admitted to hospital complaining of bloody sputum. Chest computed tomography demonstrated a tumor of 3.5 cm in diameter in the upper lobe of the lung. On bronchoscopic examination, a lung carcinoma was diagnosed, and a right upper lobectomy was performed. Histological examination revealed a large cell carcinoma with rhabdoid phenotype (LCCRP), which is classified as a variant of large cell carcinoma according to the 1999 WHO classification. This histological type of disease is usually aggressive and leads to a poor prognosis. At the time of writing, our case had remained relapse-free for 55 months after surgical resection. This is one of only five reported cases in Japan where the patient survived for more than 36 months.

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Endometrial stromal sarcoma (ESS) is a rare uterine neoplasm. We report a case of mediastinal metastasis from ESS 20 years after hysterectomy. The patient, a 64-year-old female, was referred to our hospital because of a mediastinal mass. We diagnosed it as a mediastinal neoplasm, and carried out a total resection of the tumor, which was diagnosed pathologically as metastasis from low-grade ESS, by review of the primary uterine ESS. Three months after the thoracic operation, a huge recurrent mediastinal tumor was detected on chest CT. The patient died shortly after. We describe the first reported case of ESS metastasis to the mediastinum.

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A 77-year old female, who had left pneumothorax, left 7^th-9^th rib fractures, and left femur fracture caused by a traffic accident, was admitted to our hospital. She was treated with thoracic drainage, but we found increasing bloody drainage fluid during the night-time on the 2nd and 3rd day after injury. We performed an emergency thoracotomy, and found a descending aortic injury caused by the sharp projecting edge of a fractured rib. We used TachoComb^® and fibrin glue for hemostasis, and trimmed the edge of the fractured ribs. The postoperative course was uneventful, and an operation for the femur fracture was performed on the 8th day after the chest surgery. Careful observation is required in patients with fractured ribs adjacent to the aorta after chest trauma because of the possible delayed presentation of massive hemothorax.

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A 78-year-old woman was referred to our hospital complaining of a tumor in the right chest wall. She had undergone a right pneumonectomy for tuberculous empyema about 30 years earlier. Chest CT revealed a tumor shadow in the right chest wall. It was diagnosed as adenocarcinoma by fine needle aspiration biopsy. Initially, radiation therapy was conducted, and the tumor was then resected. Histopathologically, however, this tumor was diagnosed as angiosarcoma. Even though re-operation and radiotherapy were administered for recurrent angiosarcoma, she died of tumor bleeding and infection 3 months postoperatively. It is necessary to consider the development of angiosarcoma after treatment for thoracic empyema.

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A 46-year-old woman presented with a right hilar tumor on a chest radiograph. Chest computed tomography revealed a 10-cm well-circumscribed tumor in the anterior mediastinum. On chest magnetic resonance imaging, the tumor had some cystic lesions. The signal intensity of the cystic lesions was slightly lower than that of skeletal muscle on T1-weighted images and higher on T2-weighted images. The tumor was suspected of being a cystic thymoma, and she underwent thymothymectomy. The tumor was diagnosed as mucinous adenocarcinoma of the thymus based on histopathological findings.

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A 62-year old man was admitted to our hospital for the further investigation of abnormal chest shadows. Chest CT revealed multiple granular shadows in the right lower field and a nodule in the superior segment (S⁶) of the right lower lobe. Bronchoscopy confirmed an endobronchial tumor in the superior branch (B⁶) of the lower bronchus protruding into a lower lobe bronchus. No definitive histological diagnosis was obtained preoperatively. Because the location of the tumor stalk was not confirmed bronchoscopically, we planned an operation. To preserve the middle lobe and basal segment, we decided to perform S⁶ segmentectomy with flap bronchoplasty. In the operation, we preserved the superior wall of B⁶ as a flap and, following S⁶ segmentectomy, the defect of the lower lobe bronchus was closed using the flap. The postoperative course was uneventful, and brochoscopic findings revealed favorable healing of the suture line and no stenosis.

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We report a case of a 78-year-old woman presenting with an anterior mediastinal tumor that gradually enlarged and invaded the superior vena cava. In the operation, temporary bypass grafting was performed between the innominate vein and right atrial appendage; however, clamping the superior vena cava resulted in bradycardia and hypotension. Therefore, resection of the anterior mediastinal tumor along with reconstruction of the superior vena cava should be performed under cardiopulmonary bypass. Postoperative histopathologic examination showed that this tumor was a thymic squamous cell carcinoma, and that the vessel stumps showed no evidence of invasion. Reduction of arterial blood flow to the sinus node was thought to have caused the reversible bradycardia observed after clamping of the superior vena cava. In case clamping needs to be performed near the base of the superior vena cava, devices such as a temporary pacemaker or a cardiopulmonary bypass should be available in case bradycardia occurs, followed by circulatory disturbance.

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A 37 year-old female had bronchial asthma. She had dyspnea, and chest CT scanning showed a nodule of the right upper lobe and 68 mm cystic mass located just beneath the bifurcation of the trachea. CRP, WBC, and CA19-9 were high on a blood exam. FEV1.0% was 48.8% on spirometry. After she took antibacterial drugs, FEV1.0%, CRP, and WBC entered the normal range and the cyst size reduced. A month later, cyst resection and partial resection of the right upper lobe was perfomed by video-assisted thoracic surgery. The cyst resection was incomplete, but epithelial tissue of the cyst was fully resected. The cyst was a bronchogenic cyst, and the nodule of the right upper lobe was pulmonary infarct on pathological diagnosis. CA19-9 entered the normal range after surgery. We encountered a case of bronchogenic cyst with pulmonary infarct which was found due to dyspnea.

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A 69-year-old man underwent a left pneumonectomy for squamous cell carcinoma. The bronchial stump was wrapped with an intercostal muscle flap. On the 15th postoperative day, a chest roentgenogram showed an air-fluid level in the left thorax. A bronchopleural fistula was suspected, and a chest tube was inserted and antibiotics were administered. On the 29th postoperative day, he underwent thoracoscopic surgical debridement and irrigation of the pleural cavity. Eventually, he recovered favorably without further surgical treatment. Post-pneumonectomy empyema associated with bronchopleural fistula is a serious complication. Although open window thoracostomy followed by thoracoplasty or omentoplasty is a standard therapeutic procedure, appropriate antibiotic treatment and thoracoscopic surgical management may be effective in selected patients.

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Primary leiomyomas of the lung are rare benign tumors, which account for about 0.04% of pulmonary neoplasms. We report a case of primary leiomyoma of the lung treated with pulmonary resection. A 34-year-old man who had an abnormal shadow on a chest radiograph on a medical checkup was referred to our hospital. Chest computed tomography showed a pulmonary nodule located in the right middle lobe (S4) presenting an iceberg tumor growth pattern. Neither atelectasis nor pneumonia was detected on radiographic examinations. Bronchoscopy detected a nodule obstructing the lumen of B4a. Following bronchoscopic tumor biopsy, the tumor consisted of spindle cells, and was suspected to be a leiomyoma. We performed thoracoscopic right middle lobectomy. Pathological examination revealed the tumor to be a bronchial leiomyoma. Depending on the size and location, various treatments for primary leiomyoma of the lung have been reported. In this case, we performed thoracoscopic lobectomy. His postoperative course was uneventful, and subsequent follow-up examinations have shown no abnormal findings for 20 months after the pulmonary resection.

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A 17-year-old woman experienced sudden hemoptysis during menstruation 6 months after intrauterine curettage. She came to our hospital because of repeated catamenial hemoptysis during each menstruation period. Chest CT revealed infiltrative shadows around S9 of the right lung. Bronchoscopic examination revealed hemorrhage from the right B9. Thus, pulmonary endometriosis with the responsible lesion in S9 was suspected. Hormone therapy was effective to improve her hemoptysis. However, she desired to return to regular school life to improve future employment prospects,with withdrawal from hormonal agents. Thus, surgical therapy was performed for radical therapy resecting ectopic endometrial tissue. A lesion was identified as the hemorrhage site showing change under the visceral pleura via a thoracoscope. Although mild adhesion after inflammation was noted, right lower lobectomy appeared feasible and was completed in endosurgery. A lesion was diagnosed as pulmonary endometriosis by histological confirmation of an ectopic endometrial gland and endometrial stromal tissue in the resected lung. On immunohistochemical examination, endometrial gland cells stained positively for ER and PgR, whereas endometrial stromal cells stained positively for CD10, ER, and PgR. The postoperative course was uneventful. The patient has been asymptomatic for 3 years since surgery. Pulmonary endometriosis is rare, comprising one sixth of pleural endometriosis cases. Furthermore, histological confirmation like in this case is rare. The role of endosurgery is considered important in this disease.

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We report a rare case of mucoepidermoid carcinoma of the thymus, together with a review of the literature. A 71-year-old female was pointed out as showing an abnormal shadow on a chest roentgenogram. Chest CT and MRI suggested that she had a stage I thymoma (Masaoka staging system). She was admitted to our hospital, and underwent surgical resection. The tumor had invaded the right mediastinal pleura and upper lobe of the right lung. From the pathological findings, the tumor was diagnosed as mucoepidermoid carcinoma of the thymus, high-grade. The postoperative course was uneventful. The patient was discharged from the hospital on the fourth postoperative day. Mucoepidermoid carcinoma of the thymus is so rare that only 37 cases of the disease including this case have been reported.

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We report a case of solitary fibrous tumor (SFT) of the pleura. A 77-year-old man with bladder cancer, who underwent SFT resection 25 years ago, was referred for the treatment of a lung tumor and mediastinal lymph node swelling. Although the mediastinal lymph nodes showed high-level accumulation of FDG, the lung tumor showed no accumulation. We resected the tumor in 2008, and it turned out to be nylon thread from the surgery that had been performed 25 years ago which had adhered to the tumor, and the tumor was diagnosed as SFT pathologically. Four years later, local relapse of the tumor was observed, and we resected the tumor again. The tumor relapsed after a long time, and the tumor doubling time before resection was one month. His pathological specimen rarely showed mitosis or malignant manifestations described in other papers. However, it showed high immunoreactivity for Ki-67, a tumor proliferation marker.

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A 76-year-old female was referred to our hospital because of an anterior mediastinal tumor identified by chest computed tomography (CT). Chest CT and MRI showed a mass shadow in the anterior mediastinum. The serum interleukin-2 receptor level was high, at 1,830 U/mL. We suspected that the tumor was a thymic lymphoma or thymoma. We attempted a thoracoscopic biopsy, but there was severe adhesion. So, we converted to tumor excision via a median sternotomy. The tumor was completely resected. Regarding pathological findings, the tumor was a thymic MALT lymphoma. Thymic MALT lymphoma is rare, so we reviewed surgical cases of thymic MALT lymphoma in the literature.

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We report a rare case of low-grade mucoepidermoid carcinoma (low-grade MEC) with lymph node metastasis. A 47-year-old female was referred to our hospital because of an abnormality on a chest radiograph and CT. Chest CT revealed a mass in the truncus of the left upper bronchus and atelectasis of the lingula. PET showed abnormal FDG accumulation in the left upper tumor but not in the regional lymph node or in a distant site. The tumor was diagnosed as low-grade MEC by bronchial biopsy (cT2aN0M0). We performed left upper sleeve lobectomy and mediastinal lymph node dissection because of hilar lymph node metastasis based on the intraoperative frozen pathology. The final pathological diagnosis was low-grade MEC (T2aN1M0). The postoperative course was uneventful. The patient was alive without recurrence 2.5 years after surgery.

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A 73-year-old woman was admitted for biopsy of a small mixed ground-glass opacity (GGO) in the right S3 area by video-assisted thoracoscopic surgery. Immediately after CT-guided marking with a hook wire, the patient lost consciousness. Multiple air embolisms were detected in the brain and ascending aorta on CT, for which various treatments were emergently performed. Thoracoscopic partial resection was performed 4 weeks after the patient had stabilized and started showing signs of improvement. However, 8 months after onset, weakness of the left side of the body remained. Although serious air embolism rarely occurs, the indications for CT-guided marking with a hook wire require careful consideration.

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Background: Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm that arises most commonly in the pleura. We report a patient with SFT originating from the orbit, which recurred in the bilateral lungs 20 years after the initial surgery. Case: The patient was a 63-year-old male who underwent the resection of an orbital tumor about 20 years ago. He was pointed out as showing a slowly growing nodule in his right lung on a chest roentgenogram. Chest CT revealed multiple well-defined nodules in the bilateral lungs. For diagnosis and treatment, he underwent resection of the tumor of the right lung, and was diagnosed with SFT. The other two tumors in the left lung were considered to be contralateral pulmonary metastases. There were no other metastases except for those in the left lung, and he received surgery for the left lung tumors. The pathological results were similar to those of the right lung. Thereafter, the initially resected orbital tumor was histopathologically reviewed, and was found to be consistent with SFT. Conclusion: It is rare for extrapleural SFT to arise at multiple sites. In the present patient, malignant SFT originating from the orbit recurred in the lungs 20 years after the initial surgery. Long-term follow-up after complete resection is necessary because SFT can recur after a long-term disease-free interval.

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