We have performed first video-assisted thoracoscopic surgery (VATS) for 135 patients with primary spontaneous pneumothorax (PSP) in our hospital since 2009. We compared 20 patients who underwent VATS due to persistent air leakage after chest tube drainage and 115 patients who underwent VATS for other reasons. On comparing the two groups regarding their backgrounds, the Leak group had a higher initial pneumothorax rate than the Non-Leak group (75.0 vs. 40.0%, respectively, P<0.01). As the operative results, the Leak group had a lower postoperative recurrence rate than the Non-Leak group (0.0 vs. 13.0%, respectively, P=0.02). On univariate analysis of the risk factors affecting the postoperative recurrence rate, the Non-Leak group and age <25 years old were significant factors. In conclusion, we suggest that the Leak group is associated with a lower recurrence rate of pneumothorax than the Non-Leak group.

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A 65-year-old woman without cardiac or coagulation disorder consulted our hospital for an abnormal shadow noted on chest CT. Chest CT showed a ground glass opacity in the left S³, and we performed surgery. Based on an intraoperative pathological study, we diagnosed her with lung cancer and performed left upper lobectomy with lymph node dissection. On the 4th postoperative day, she developed paralysis and a cold sense. We diagnosed her with acute occlusion of the right axillary artery by enhanced CT, and performed anticoagulation therapy after surgery. Although the thrombus was not found on the enhanced CT or echocardiography, this case was thought to be caused by a thrombus in the pulmonary vein stump. It is important to consider the possibility of arterial occlusion after lung surgery.

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We report a case of cardiac tamponade developing the day after a pulmonary lobectomy. A 53-year-old man underwent left upper lobectomy and lymph node dissection for lung cancer. On the 1st postoperative day, he suddenly developed prostration, hypotension, and a decline in arterial oxygen saturation. Chest computed tomography and echocardiography confirmed a diagnosis of cardiac tamponade. Emergent pericardial drainage was performed. Immediately after 280 mL of bloody fluid was discharged, the cardiac function of the patient recovered. After the drainage, he was uneventfully discharged on the 8th postoperative day. By reviewing the intraoperative video, we speculated that the auto-suturing device used on the left upper pulmonary vein ruptured the pericardium which led to pericardial hemorrhage.

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A 54-year-old man was admitted with a massive hemothorax. A chest tube was inserted and continuous suction drainage was started. Three preoperative cytodiagnosis tests were negative. Since drainage was inadequate and hemothorax began to aggravate, hematoma elimination was performed twice by VATS, but the procedures were unsuccessful. Then, the massive hemothorax recurred, we had to perform a third operation. We extracted the hematoma with 9,000 mL of bleeding. The pathological findings indicated small cell lung cancer. The patient died of an increase of the hematoma and a tumor on the 21st day after the operation.

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We report a case of bronchial artery aneurysm resected by thoracoscopic surgery. A 46-year-old woman was found to have an abnormal shadow on a chest radiograph. Computed tomography revealed a bronchial artery aneurysm of 11-mm in diameter in the right hilum and an aneurysm of 16-mm in diameter between the middle and lower lobes. Aneurysmectomy was performed because embolization of the bronchial arteries was difficult. A thoracoscopic approach was used. An initial incision into the pleura was made under the tracheal bifurcation, and the 11-mm aneurysm was excised. The 15-mm aneurysm was then separated from the middle and lower lobes and excised. The patient remained in a favorable condition and was discharged 5 days after the surgery.

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Excessive hemorrhage from a pulmonary arteriobronchial fistula after lobectomy of the lung is a life-threatening complication. A 64-year-old male underwent a right lower lobectomy for lung carcinoma (cT2N0M0, stage IB, squamous cell carcinoma); five weeks after the surgery, he developed sudden excessive hemoptysis with shock. Chest CT demonstrated an expansion of the right pulmonary arterial stump. Pulmonary artery aneurysm and bronchial stump fistula were diagnosed. The hemorrhage was caused by a rupture of the pulmonary arterial aneurysm. We performed excision of the aneurysm and bronchial stump. We encountered a life-threatening case of hemorrhage from a pulmonary arterial aneurysm saved by surgical treatment.

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An 80-year-old female was admitted to the hospital complaining of left chest pain. At the age of 38, she had undergone total hysterectomy because of a uterine myoma. Chest computed tomography showed a well-circumscribed mass in the left upper lobe. Left upper lobectomy was performed under a diagnosis of pulmonary adenocarcinoma by transthoracic needle lung biopsy. Histologically, the resected tumor specimen revealed complex branching glands consisting of columnar tumor cells, sporadically forming morules in the tubules. Morphological and immunopathological findings were not those of typical lung adenocarcinoma but resembled those of endometrioid adenocarcinoma. Because positive staining for PAX8 and no primary neoplastic lesions were found in any organ examined, we judged metastatic uterine endometrioid adenocarcinoma to be the most likely diagnosis. There has been no report on such a tumor recurring so late after hysterectomy. The patient was well without signs of recurrence four years after surgery.

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A 69-year-old woman was referred to our department due to abnormal shadows on a chest radiograph. Chest CT revealed a mass shadow with a cavity in the right upper lobe and a mass shadow with calcification in the right lower lobe. Bronchoscopy was performed, but a definitive diagnosis could not be obtained. The diagnosis based on CT-guided percutaneous lung biopsy for the right lower mass was carcinoma. A histological diagnosis for the right upper lobe was not obtained, but we suspected that it was a malignancy according to the imaging studies. We perfomed video-assisted thoracoscopic pneumonectomy on the suspicion of synchronous multiple lung cancers or lower lobe lung cancer with a metastasizing nodule in the ipsilateral upper lobe. Pathology revealed the tumors in the upper lobe and lower lobe to be moderately differentiated squamous cell lung cancer and small cell lung cancer, respectively. These were diagnosed as synchronous multiple lung cancers. The cancers had not spread to the lymph nodes, so we could perform complete resection. Synchronous multiple cancers including small cell lung cancer and squamous cell lung cancer without lymph node metastasis are extremely rare. We report a rare case of synchronous multiple lung cancers including small cell lung cancer and squamous cell lung cancer which were resected completely by right pneumonectomy.

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A 76-year-old man was referred to our hospital because of an abnormal shadow in the mediastinum. Chest computed tomography showed a 5-cm-diameter mass in the right middle mediastinum. Magnetic resonance imaging showed a mass with a homogeneous component. T1- and T2-weighted images showed a higher signal intensity than that of skeletal muscle. Video-assisted thoracoscopic surgery was performed to resect the tumor. The histopathological diagnosis was a MALT lymphoma. We report a rare case of a MALT lymphoma arising from the middle mediastinum.

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A 50-year-old man was admitted to our emergency room due to sudden-onset chest pain. Enhanced CT revealed left-sided pleural effusion, indentified as hemothorax by thoracentesis, showing a 7×5-cm mass-like lesion with extravasation of contrast media in the anterior mediastinum and isodense regions around the lesion. Because of the suspicion of a ruptured mediastinal tumor, we performed a median sternotomy. The thymic parenchyma was distended due to the hemorrhage. A total of 2,170 grams of clotted blood was evacuated from the anterior mediastinum and left pleural cavity. We performed thymectomy. Both gross pathological and histological findings revealed a swollen hematomatous thymus without a neoplastic lesion. There were no abnormal findings on a chest radiograph obtained 2 months before the operation. Therefore, we diagnosed him with spontaneous thymic hemorrhage. To our knowledge, only three adult cases have been reported.

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A 22-year-old woman presented with an abnormal chest shadow during a medical examination two months ago. A tumor of 6 cm in diameter was detected on her right diaphragm by computed tomography (CT), and she was referred to our hospital for surgical treatment. A few days before admission, fever and right chest pain developed. A chest radiograph and CT indicated pleural effusion and rapid tumor growth. Therefore, tumor rupture and hemorrhage were suspected. In order to select an appropriate treatment strategy, CT-guided biopsy was performed, and a histopathological examination demonstrated a spindle cell tumor. Thus, we judged that there was no necessity for preoperative treatment, and performed emergency surgery for diagnostic and treatment purposes. The tumor originated from the diaphragm and had infiltrated the pericardium and middle and lower lobes of the right lung. Part of the tumor exhibited hemorrhaging and necrosis. Tumor resection, lower lobe lobectomy, partial resection of the middle lobe, and reconstruction of the diaphragm and pericardium were performed. Histopathological and immunostaining examinations revealed invasive growth by spindle cells that exhibited nuclear atypia and positive reactions to epithelial markers (cytokeratin AE1/AE3 and epithelial membrane antigen). Furthermore, the SYT-SSX chimera gene was also detected in the tumor cells. We finally diagnosed the patient with synovial sarcoma of the diaphragm, monophasic type. As additional treatment, four-cycle adjuvant chemotherapy (Adriamycin+Ifosfamide) was performed. She is now alive with no evidence of recurrence 10 months postoperatively. In the case of sarcoma, selection of the initial treatment method is generally important. However, in these patients, who must be treated immediately and cannot be diagnosed definitively, determination of the treatment strategy based on the cell form of the tumor is useful.

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In patients undergoing surgery for primary lung cancer in Japan, the proportion of those receiving bronchoplasty is reportedly 1.7%. In this article, we report a relatively rare technique, flap bronchoplasty. The patient was an 11-year-old girl. A tumorous lesion was detected on investigating repeated pneumonia, occupying the bronchus intermedius. Initially, a diagnosis of benign papilloma was made based on bronchoscopy-guided biopsy findings. Rigid bronchoscope-guided core-out tumorectomy was performed. Finally, pathological findings suggested a low-grade mucoepidermoid carcinoma. Bronchoscopy revealed residual tumor cells at the tumor base on the B⁶ side of the bifurcation between the B⁶ area and bronchus basalis. Based on these findings, additional resection was considered necessary. S⁶ segmentectomy with wedge resection of the bifurcation between the B⁶ area and bronchus basalis was performed. Reconstruction with a B⁶ bronchial flap for an inferior-lobe bronchial defect was conducted. Due to ①the tumor base being located on the bifurcation between the B⁶ area and bronchus basalis, and ②preopearative pathological findings suggesting a low-grade mucoepidermoid carcinoma, reconstruction with a B⁶ bronchial flap (S⁶ segmentectomy) was performed as limited surgery.

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We report the case of a 74-year-old female who had undergone total thyroidectomy for papillary thyroid carcinoma in 1998. In March 2014, she was admitted to our hospital for surgery because a nodule in the right upper lobe, disclosed by chest computed tomography (CT) in June 2011, had enlarged. We performed a partial resection of the right upper lobe. Because the nodule was suspected of being primary lung cancer based on intraoperative rapid diagnosis, we performed right upper lobectomy with lymph node dissecsion (ND2a-1). Also, we conducted a partial resection of the right lower lobe due to the new appearance of a nodule in the right lower lobe on preoperative CT, and the nodule was diagnosed as inflammatory granuloma by intraoperative rapid diagnosis. At the time of postoperative pathological examination, the nodule of the right upper lobe was diagnosed as metastatic lung tumor from thyroid carcinoma, and the nodule of the right lower lobe was diagnosed as epithelioid cell granuloma. Incidentally, minimal pulmonary metastasis was recognized in the vicinity of the epithelioid cell granuloma. We report the interesting case of pulmonary metastatic lesions which proliferated at markedly different speeds.

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We encountered two surgical cases of spontaneous pneumothorax that developed during pregnancy, which are reported as follows. Case 1 was a 28-year-old female. Left pneumothorax developed six months prior to natural conception and at the eighth week of pregnancy, both of which were resolved by thoracic drainage. Left pneumothorax recurred for the third time at the 11th week of pregnancy and persistent pulmonary fistula was noted for four weeks or longer; therefore, video-assisted thoracoscopic surgery (VATS) was performed at the 16th week of pregnancy. The postoperative course was favorable, and a healthy baby was born at full term. Case 2 was a 21-year-old female. Right pneumothorax was diagnosed at the 20th week of pregnancy, which improved with thoracic drainage. Right pneumothorax recurred at the 24th week of pregnancy. Thoracic drainage was performed again; however, she was admitted for surgery since the air leak persisted. The Department of Obstetrics and Gynecology cooperated with the Department of Anesthesiology during the perioperative period, and VATS was performed at the 25th week of pregnancy. The postoperative course was favorable, and a healthy baby was born at full term. Although pneumothorax during pregnancy is rare, recurrence is common once it has developed, due to factors involving ventilation; therefore, regular VATS may be possible based on surgical indications in consideration of the gestational age.

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Birt-Hogg-Dube (BHD) syndrome is a rare autosomal and predominantly inherited disorder which has three characteristics: multiple lung cysts associated with pneumothorax; skin fibrofolliculomas; and renal neoplasms. We herein report a case of BHD syndrome. A 39-year-old man was admitted to our hospital due to spontaneous pneumothorax. Five family members had experienced episodes of pneumothorax. A chest CT showed multiple lung cysts, which are unusual findings of spontaneous pneumothorax. He underwent pulmonary wedge resection, ligation of blebs, and covering of the visceral pleura. He had skin eruptions on the nose, and BHD syndrome was suggested clinically. On genetic analysis, the BHD gene mutation was identified. For multiple-cystic disease of the lung with an unknown etiology or atypical spontaneous pneumothorax, it is necessary to consider the possibility of BHD syndrome.

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A 65-year-old female with an abnormal shadow on a chest radiograph was referred to the hospital. Chest CT and MRI showed a large foliaceous and heterogeneous mass in the left thoracic cavity. The tumor had a smooth surface and clear border and was mixed with a fat component, suggesting a liposarcoma. Although a definitive diagnosis was not facilitated by percutaneous neddle biopsy, we performed an operation with the suspicion of a mesenchymal tumor. The tumor was encapsulated with the mediastinal and visceral pleura and invaded the lung parenchyma around the pulmonary vein without invasion to adjacent organs such as the chest wall or diaphragm. The tumor and left lower lobe of the lung were resected through a left thoracotomy. The tumor was 1,580 g in weight. The postoperative pathological diagnosis was mediastinal liposarcoma, of the well-differentiated type. She followed a favorable course without adjuvant therapy after surgery. Liposarcomas usually arise in the extremities or the retroperitoneum. Primary liposarcoma of the mediastinum is very rare. We report a rare case of posterior mediastinal liposarcoma.

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A 63-year-old male with multiple ground-glass nodules (GGNs) in both lung fields detected on CT was followed up over five years. CT indicated that a section of the GGNs was growing. Therefore, left upper lobectomy was performed under a video-assisted thoracoscope to remove three GGNs. The final histological diagnosis for each GGN was inflammatory changes. Limited resection is often adopted for such cases because slow-growing GGNs usually have a low-grade malignant potential even if they are cancerous. However, it is sometimes difficult to obtain a diagnosis and decide on treatment strategies in cases whose multiple GGNs exist inside the lung parenchyma. Furthermore, in some case reports of growing GGNs, pathological findings were not malignant even though radiological images suggested lung cancer. Considering these observations, it is necessary to treat each case individually. In addition, the frequency of growing GGN cases should be clarified throughout Japan.

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A 64-year-old man was referred to our institution because of an abnormal shadow of the mediastinum on a chest radiograph. Chest CT demonstrated a 50 mm mass in the middle mediastinum. The mediastinal mass showed high-level accumulation of FDG. Based on diagnostic imaging, we suspected a mediastinal tumor. We performed extirpation of the mediastinal tumor under thoracoscopic surgery. The specimen was confirmed as adenocarcinoma. Immunohistochemical staining suggested pulmonary adenocarcinoma to be positive for CK7, negative for CK 20, positive for thyroid transcription factor-1, and positive for napsin A. Pathological examination showed the adenocarcinoma to be of lung origin. Although whole-body examination failed to detect the primary site of the adenocarcinoma, this suggested the mediastinal lymph node carcinoma to be of unknown primary origin. Fourteen months later, brain metastasis occurred. We performed brain tumor resection. The patient was given platinum-based chemotherapy as adjuvant therapy. We encountered a surgical case of a rare mediastinal lymph node carcinoma of unknown primary origin.

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Sclerosing hemangioma (SH) is a rare tumor considered to be benign or of low-grade malignancy. SH usually presents as a solitary, well-circumscribed nodule, rarely presenting as multiple lesions. Multiple SHs are difficult to distinguish from metastatic pulmonary nodules based on radiological findings. We report a case of multiple SHs with primary lung cancer. Case: A 55-year-old woman was referred to our hospital for the investigation of an abnormal shadow on a chest radiograph. Chest computed tomography revealed a 25-mm nodule with spiculation and pleural indentation in the right middle lobe and bilateral multiple pulmonary nodules (36 lesions) ranging from 2 to 6 mm in diameter. Video-assisted partial lung resection was performed to confirm the pathological diagnosis of the tumor in the right middle lobe and two of the multiple nodules in the right lower lobe. The intraoperative diagnosis of all lesions was adenocarcinoma. However, postoperative histological examination confirmed adenocarcinoma in the middle lobe and two SHs in the lower lobe. Consequently, we performed video-assisted completion right middle lobectomy and lymph node dissection. A new nodule appeared in the right S6 14 months after the lobectomy, while there were no changes in the size or shape of the multiple nodules recognized preoperatively. The new nodule was diagnosed as pulmonary metastasis of adenocarcinoma by surgical resection, and chemotherapy was added for recurrence. There have been no signs of cancer or enlargement of the multiple nodules for 3 years. Conclusion: SH rarely demonstrates multiple lesions and differentiation from pulmonary metastasis is important, especially when malignancy coexists. A pathological diagnosis of multiple lesions should be considered if possible.

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Pulmonary benign metastasizing leiomyoma (PBML) is a known but rare condition. It is also known that some cases of metastasis of uterine leiomyosarcoma stray into this category. We herein report 3 cases of lung metastasis of smooth muscle-derived uterine tumor and review the previous literature. Case 1. A 69-year-old woman was identified as having a single pulmonary nodule and uterine leiomyoma simultaneously during a medical checkup. Video-assisted thoracic surgery lobectomy was performed and the tumor was diagnosed as PBML. Immunohistochemical staining was positive for estrogen receptor (ER) and progesterone receptor (PgR). No new pulmonary lesion occurred during follow-up for 3 years. Case 2. A 48-year-old woman with a surgical history of uterine leiomyoma underwent a medical checkup and was identified as having multiple lung tumors. Partial resection of the lung revealed PBML with positive staining for ER and PgR. After follow-up for over 9 years, her general condition has not worsened. Case 3. A 77-year-old woman with a surgical history of uterine leiomyoma was identified as having multiple lung tumors during a preoperative examination for cataract. Partial resection of the lung revealed PBML, but immunohistochemical staining revealed that the tumor cells were negative for neither ER nor PgR. The remaining tumors grew slowly for years, but the lesion in the right upper lobe rapidly enlarged at 10 years after the surgery. She died 11 years after the surgery due to tumor progression.

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Thoracoscopic surgery is less invasive and more cosmetic than median sternotomy. However, it is difficult to control massive intraoperative bleeding. Minimally invasive cardiothoracic surgery (MICS) has grown in popularity for various cardiac diseases. A thoracoscopic approach in the MICS position provides a favorable surgical view the same as in a decubitus position and it is easy to convert to median sternotomy without changing the position in cases with massive bleeding from a large vessel injury. The MICS position is safe and effective for the resection of an anterior mediastinum tumor via a thoracoscopic approach.

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Thoracic surgeons often have to perform operations for patients without a confirmed diagnosis. Thus, frozen-section diagnosis is necessary to decide on the operative method. We opened a new division of thoracic surgery and built a telepathology system via the Internet and with virtual slides. Telepathology facilitates high-quality medicine and overcomes regional divides at hospitals without a full-time pathologist. The telepathology system requires a large initial investment and effective human resources for success.

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