The objective of this study was to evaluate risk factors which extend the operative time of VATS right upper lobectomy. We retrospectively analyzed videos of 30 patients with lung cancer who received VATS right upper lobectomy and lymphadenectomy. We measured the time necessary for right upper lobectomy and lymphadenectomy of the upper mediastinum. The average time for right upper lobectomy was 91 minutes (37-87 minutes), and the average time for lymphadenectomy of the upper mediastinum was 26 minutes (13-65 minutes). On univariate analysis, risk factors leading to a longer operative time for right upper lobectomy were an incomplete fissure between upper and middle lobes (p=0.001), an incomplete fissure between upper and middle lobes (p=0.007), and less extensive experience of the surgeon (p=0.002). On multivariate analysis, a risk factor leading to a longer operative time for right upper lobectomy was an incomplete fissure between upper and middle lobes (p=0.02). On univariate analysis, risk factors leading to a longer operative time for lymphadenectomy of the upper mediastinum were a younger age (p=0.01), a greater vital capacity (p=0.007), and less extensive experience of the surgeon (p=0.05). On multivariate analysis, risk factors leading to a longer operative time for lymphadenectomy of the upper mediastinum were a younger age (p=0.04) and less extensive experience of the surgeon (p=0.02). It is considered that the improvement of approach techniques for patients with an incomplete fissure between upper and middle lobes and skills training for surgeons can reduce the operative time for VATS right upper lobectomy and lymphadenectomy.

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Pleomorphic carcinoma is a rare histologic subset of lung cancer, first proposed by the World Health Organization and revised in 1999. While pleomorphic carcinoma presents various pathologic findings, its associated prognosis is generally very poor. We retrospectively investigated the outcome of surgery for pleomorphic carcinoma patients regarding the clinical characteristics and behavior. Methods: Data were retrospectively examined for 12 consecutive patients who underwent surgical resection for pleomorphic carcinoma in a single institute between November 2010 and October 2014. Results: The patient population consisted of 10 men and 2 women between the ages of 42 and 72 years (mean, 62.8 years). Eleven patients (91.7%) were smokers. Overall, 10 lesions were in the right upper lobe. The median tumor doubling time in seven cases, the tumor diameter of which could be measured over time on preoperative CT, was 81 days. Surgical procedures included 2 pneumonectomies and 10 lobectomies. As for lymph node dissection, an ND1a was performed in one case, an ND2a-1 was performed in five cases, and an ND2a-2 was performed in 6 cases. Extended resections were required in 6 cases because of invasion to surrounding structures, and concurrent resection of distant metastasis was required in 1 case. While 6 patients including 4 with adjuvant chemotherapy currently show relapse-free survival, 5 died of lung cancer. Overall, the 3-year survival rate was 43.0%.

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We report the case of a 60-year-old man undergoing right middle-lower lobectomy and lymph node dissection for a small lung nodule and swelling of the right hilar lymph node. Pathologic analysis of the lung specimen showed a papillary component with psammoma bodies, nuclear grooves, and ground glass nuclear and solid components with necrosis. He had a history of thyroid lobectomy for thyroid carcinoma 43 years ago. The specimen of thyroid carcinoma was preserved and the pathological diagnosis was pulmonary metastasis of poorly differentiated thyroid carcinoma. Poorly differentiated thyroid carcinomas have a variety of biological behaviors. We must keep in mind that a patient with a history of thyroid carcinoma has a possibility of delayed lung metastasis even after a long disease-free period.

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Background: Lung metastases of gastrointestinal stromal tumors (GIST) are rarely treated surgically; hence, resection of lung metastases of GIST has not been studied in depth. Case Report: A 66-year-old woman presented with GIST recurrence in the form of lung metastasis after resection of the primary tumor in the stomach. She was allergic to imatinib and refused any other molecularly targeted drugs; therefore, she underwent surgery for the lung metastasis. Although the lung metastasis of GIST recurred after lung surgery, the patient has been alive for 7 years and 3 months after resection of the primary tumor in the stomach (4 years and 3 months after the appearance of the first metastasis). Results: While molecularly targeted therapy could not be used in this patient, resection of the lung metastasis of GIST may have inhibited disease progression and facilitated an improved prognosis. Conclusion: Surgery is not indicted for lung metastases of GIST because of the lack of clinical evidence for a sufficiently improved prognosis. However, surgical treatment in carefully selected cases of lung metastasis of GIST might improve the prognosis when the administration of molecularly targeted therapy is difficult.

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A 40-year-old man presented to our hospital with right chest and back pain and dyspnea on effort. Chest computed tomography revealed an anterior mediastinal tumor, of about 14 cm in diameter, and massive effusion in the right pleural cavity. Laboratory data showed an elevated serum level of alpha-fetoprotein (AFP), which was 699.2 ng/mL. Bloody effusions were evacuated from the right pleural cavity. It was diagnosed as mediastinal germ cell tumor with right hemothorax. Because there was progression of anemia, continuous intrathoracic hemorrhage was suspected. An emergency operation was performed and the tumor was resected. Pathological evaluation revealed a mixed germ cell tumor which consisted of a yolk sac tumor and immature teratoma. Microscopically, the causes and locations of bleeding and the findings of the tumor rupture were unclear. The tumor did not invade the neighboring organs, and complete resection of the tumor was performed. Postoperatively, the patient has been observed without adjuvant chemotherapy and no recurrent findings have been noted. Mediastinal germ cell tumors are rare, and few cases with hemorrhage have been reported. Because surgery after chemotherapy is generally recommended and the outcome of surgery alone is not clear, it requires strict observation.

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A 55-year-old woman, who had been treated for nephrotic syndrome, was referred to our department due to an asymptomatic nodule at the anterior mediastinum. She had a past history of intestinal tuberculosis. The anterior mediastinal nodule was 2 cm in diameter, adhering to the left upper lobe of the lung, as revealed by computed tomography. FDG-PET scan showed a strong accumulation of FDG in the mediastinal nodule (SUVmax: 6.93), and weak accumulation of FDG was also noted in the supraclavicular, mediastinal, and hilar lymph nodes. As a diagnostic and therapeutic procedure, surgical resection using video-assisted thoracic surgery (VATS) was performed, with combined resection of the left upper lobe of the lung. The tumor was filled with pus that was positive for Mycobacterium tuberculosis on by PCR examination. Pathological examination identified epithelioid granuloma with caseous necrosis in the thymic tissue. Although thymic tuberculosis is a rare disease, the possibility of it should be kept in mind when treating a patient with an anterior mediastinal nodule irrespective of the past history of tuberculosis.

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We report a case of thymoma that showed repeated growth and regression within a short period of time. A 28-year-old man visited our hospital with fever and chest pain. A heterogeneous 35-mm shadow was detected in the anterior mediastinum on computed tomography (CT), and the inflammatory response was elevated. Symptoms and inflammation improved without treatment, and the mass regressed in size to 29 mm on CT performed 1 month later. After another 3 months, the patient visited our hospital again for fever and chest pain. The mass had grown to 48 mm, and the inflammatory response was again elevated. Symptoms and inflammation improved without treatment, and the mass had regressed to 25 mm on CT performed 2 months later. Nonetheless, surgery was carried out due to the suspicion of a mediastinal tumor. The histological diagnosis was thymoma. Intratumoral hemorrhage, fibrosis, and a mixture of old and new inflammation were also observed, consistent with the history of repeated growth and regression. Although spontaneous regression of thymoma is occasionally reported in Japan, a case of two repetitions of growth and regression in a short period is extremely rare. This case of a rare thymoma is reported herein.

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A 77-year-old woman complained of chronic cough and was suspected to have left lung cancer. Intrapericardial left pneumonectomy was performed because of hilar lymph node swelling, and postoperative phrenic palsy was noted. On postoperative day 4, anorexia and vomiting appeared and the chest radiograph revealed an elevated left diaphragm and gastric dilation. Conservative medical treatment was performed but the symptom did not improve, and esophageal dilation was confirmed on a chest radiograph on postoperative day 9. Gastrointestinal fiberscopy and a contrast radiograph of the upper gastrointestinal tract with gastrograffin revealed that flexion of the esophagogastric junction due to marked diaphragmatic eventration caused esophageal obstruction. Emergent diaphragm plication via a 6th thoracotomy was performed to treat the paralyzed hemi-diaphragm; the diaphragm was relaxed but showed no injury. The diaphragm was recovered to a normal position and both symptoms were resolved after the operation.

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Increasing attention has recently been given to sleep apnea syndrome (SAS), but the diagnosis is difficult if there are no subjective symptoms before surgery. Two patients with SAS because of middle lobe atelectasis after lobectomy are presented. Both patients (metastatic lung cancer in case 1 and right lower lung cancer in case 2) underwent right lower lobectomy. Chest radiographs showed increased pleural effusions, and chest CT showed middle lobe atelectasis, on postoperative day POD1 in case 1 and on POD6 in case 2. They showed somnolence and apnea after sleeping, with a decreasing oxyhemoglobin saturation. SAS was suspected, and continuous positive airway pressure mask treatment was started. The radiographs on the next day showed the improvement of atelectasis. On polysomnography, the apnea hypopnea index of case 1 was 89.6, and that of case 2 was 45.8. SAS should be considered as a cause if atelectasis occurs after lobectomy.

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A 74-year-old woman presented with an abnormal shadow on a chest radiograph. Enhanced chest computed tomography showed a heterogeneous mass, 54 mm in diameter, in the anterior mediastinum. Positron emission tomography showed a slightly high fluorodeoxyglucose accumulation (maximum standardized uptake value 2.0). The preoperative diagnosis based on these findings was non-invasive thymoma, and we performed anterior mediastinal tumor resection with a median sternotomy. The cut surface of the resected tumor was grayish white and solid. Histopathologically, the tumor cells formed lobules and whorls, which showed immunopositivity for the epithelial membrane antigen, claudin-1, and vimentin. We diagnosed the tumor as an ectopic meningioma. Primary ectopic meningiomas are exceedingly rare. Only a few cases of mediastinal ectopic meningioma have been reported. We present a case of primary mediastinal meningioma that was treated by surgical resection.

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We report on a rare case of pulmonary sclerosing hemangioma with lymph node metastases. A 38-year-old male was referred to another hospital because of an abnormal chest shadow that was detected during a routine health check-up in 2010 and 2014. Chest computed tomography revealed a 2.6 × 2.0 × 3.5-cm tumor in the left upper lobe. Transbronchial biopsy and percutaneous needle biopsy guided by computed tomography were performed, revealing that the tumor was not malignant. Subsequently, the patient was referred to our hospital. Enucleation of the tumor was performed to determine a diagnosis. Adenocarcinoma of the lung was diagnosed intraoperatively, and we performed a left upper lobectomy and lymph node dissection. Based on the results of the pathological examination, pulmonary sclerosing hemangioma with lymph node metastases was diagnosed postoperatively. Although pulmonary sclerosing hemangioma with lymph node metastases is rare, we consider that it is necessary to examine the regional lymph nodes during surgery and continually monitor the patient's condition for metastasis to the lymph nodes.

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A 46-year-old woman was diagnosed with pneumothorax and followed up. After that, she experienced chest pain during the menstrual period. The clinical course suggested catamenial pneumothorax. We performed an operation during the luteal phase owing to the patient's social background. The operation was carried out under thoracoscopy. A thinning cyst was observed on the middle lobe, and multiple holes were observed around the central tendon of the diaphragm, with blueberry-spots surrounding the area. The specimens showed stromal cells with positive staining for estrogen receptor, progesterone receptor, and CD10. The patient was therefore diagnosed with catamenial pneumothorax. The patient underwent hormone therapy and remains free of recurrence. Although we were unable to identify endometriosis lesions, immumnostaining served as a diagnostic tool.

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A 37-year-old man underwent a health examination, and a coin lesion was detected in his rt. lung field on chest radiograph. Chest CT showed a pulmonary vein aneurysm localized in the rt. V7+10. This pulmonary vein aneurysm enlarged without mitral valve disease over a period of three years. We performed segmentectomy of the rt. S9+10 to avoid the risk of thrombus formation in the pulmonary vein aneurysm and its rupture. The strategy for pulmonary vein aneurysm is controversial. In cases with the increasing size of an aneurysm without heart disease, surgical indication would be considered.

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In thoracic surgery, we sometimes encounter vessel anomalies. If there is no information about such a vessel anomaly preoperatively, then such a phenomenon might result in major bleeding. A persistent left superior vena cava (PLSVC) is a relatively rare congenital venous anomaly of the thoracic systemic venous return, occurring in 0.3 to 0.5% of all individuals, and in up to 12% of individuals with congenital heart abnormalities. We herein report the findings of a female in her 60s who was admitted to our hospital in order to undergo an operation for the treatment of lung cancer. Before this admission, she had never been pointed out to have any comorbidities, such as heart disease. Preoperative chest CT showed PLSVC, normal RSVC, and the absence of a right brachiocephalic vein. Due to such vessel anomalies, the surgical view was markedly different from the typical one. However, we were nevertheless able to successfully perform a left lower lobectomy with no particular problems because the information obtained from the CT findings was sufficiently understood preoperatively. Therefore, chest surgeons must pay careful attention to the presence of any vessel anomalies based on the preoperative CT findings in order to safely perform the scheduled surgical procedures.

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A 60-year-old man presented with sudden right chest pain while sleeping. He had past medical histories of left pneumothorax, colon perforation, and 3 episodes of abdominal arterial rupture. Computed tomography (CT) revealed right intercostal arterial aneurysms, some of which had ruptured and created a large hematoma in the right chest wall. He gradually developed massive hemoptysis. We successfully controlled the active bleeding with transarterial embolization for intercostal arteries. However, minor bleeding in the right bronchus intermedius continued as oozing, caused by a fistula connected with the lung and airway with hematoma. We performed thoracotomy to relieve the hematoma, repair the fistula, and arrest the airway bleeding. Although we successfully controlled the airway bleeding, this patient died from cardiac failure on the 29th hospital day. We finally diagnosed the patient with vascular type Ehlers-Danlos syndrome postmortem. Ehlers-Danlos syndrome (EDS) is an uncommon inherited disorder of connective tissue. Vascular-type EDS results from mutations in the gene of type III procollagen and is the most serous type of EDS. Affected patients are at risk of rupture of the arteries, bowel, and uterus. When we encounter patients with arterial rupture, gastrointestinal perforation, and pneumothorax, we should be aware of the possible presentations of EDS and need to perform urgent and appropriate investigations and treatments.

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A 46-year-old woman was admitted to our hospital because of dyspnea. Left pleural effusion was noted on a chest radiograph. Chest computed tomography revealed two round masses with a smooth margin and heterogeneous inner structure in the left chest wall. For diagnostic and therapeutic purposes, surgery was performed for the total removal of the tumors. Histopathologic examination revealed 80- and 50-mm tumors comprising bone tissue with osteoid, and the final diagnosis was osteosarcoma that originated from the pleura. The tumor recurred in the left chest wall 2 weeks after the operation, chemotherapy was conducted, and we performed surgical resection for the remitted tumors.

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The patient, a woman in her 30s, exhibited gestational hypertension and hypercalcemia in her 33rd gestational week. She underwent detailed testing after giving birth in her 34th gestational week. High serum calcium and intact parathyroid hormone levels were observed, and a computed tomography scan showed a 13-mm mass in the anterior mediastinum. Tc-99 m methoxyisobutylisonitrile scintigraphy revealed an uptake consistent with the mass in the anterior mediastinum. The patient was diagnosed with ectopic parathyroid adenoma, and thoracoscopic surgery was performed. Immediately prior to surgery, methylene blue was administered in an intravenous drip and monitoring was conducted using near infrared spectroscopy. After administering methylene blue, oxygen saturation decreased to within the 80% range; however, there was no change in the regional saturation of oxygen. A blue-stained tumor was noted in the thymus and extracted. Histologically, no malignant findings were noted in the ectopic parathyroid adenoma. When administering methylene blue, we observed pseudohypoxemia, wherein a pulse oximeter showed decreased oxygen saturation despite a normal arterial oxygen pressure. In this case, surgery was performed safely using near infrared spectroscopy.

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(case 1) A 73-year-old man was admitted because of an abnormal mass on a chest radiograph. Chest CT showed a tumor of 21 mm in the left S⁶ and left hilar lymph node enlargement. The patient underwent left lower lobectomy and mediastinal lymph node dissection. Histological examination revealed LCNEC with squamous cell carcinoma. (case 2) A 75-year-old man was admitted because of an abnormal mass on a chest radiograph. Chest CT revealed a tumor of 26 mm in the right S¹⁰ and right hilar lymph node enlargement. The patient underwent wedge resection of the right lower lobe. Histological examination revealed LCNEC with adenocarcinoma (micropapillary component). Combined LCNEC with a micropapillary component is an extremely rare tumor.

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A 42-year-old man with an intractable cough was referred to our hospital with a diagnosis of pulmonary sequestration. Enhanced chest CT revealed a cystic mass lesion in the left lower lung field (S10) which was supplied by an aberrant artery originating from the thoracic descending aorta. The patient was diagnosed with intralobar pulmonary sequestration. Thoracoscopic resection was performed, using one access window and two ports. Hyperlobulation between the normal lower lobe and the sequestration, which shared the visceral pleura of a normal pulmonary lobe, was noted during surgery. Firstly, the aberrant artery was proximally ligated with a silk suture and cut with a stapling device. Thereafter, the hyperlobulated area between the normal lower lobe and sequestration was cut with a stapling device, and only the sequestration was removed. Thoracoscopic sequestrectomy is feasible for hyperlobulated intralobar pulmonary sequestration.

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Lymphomatoid granulomatosis (LYG) is a rare disease that expands invasively into vessels to the bilateral lung field. We report a very rare case of LYG that was pointed out as an asymptomatic solitary nodule. An 85-year-old woman who had been followed up after an operation for left renal cancer consulted our department for further examination of a solitary pulmonary nodule. The 23-mm lung nodule was in the right middle lobe. Cytokeratin 19 fragment, pro-gastrin-releasing peptide, and neuron-specific enolase were slightly elevated. Abnormal uptake was shown on PET-CT. She was diagnosed with suspected stage IA lung cancer, and we performed a right middle lobectomy. Histopathologically, the tumor was grade 3 LYG. She is now being followed up carefully, and there has been no evidence of recurrence during the 13-month period without postoperative chemotherapy.

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A 44-year-old man with amyotrophic lateral sclerosis who had required mechanical ventilation because of his bulbar paralysis presented with dyspnea. A chest roentgenogram was obtained, and he was diagnosed with left tension pneumothorax. A chest drainage tube was inserted; however, the pneumothorax did not improve and there was an excessive and continuous air leak. Twelve days after onset, he underwent endobronchial occlusion with an Endobronchial Watanabe Spigot (EWS^®), and the air leak significantly decreased. Thirteen days after onset, pleurodesis with minocycline and 50% glucose solution was performed. Following the pleurodesis, the air leak was completely sealed. The chest drainage tube was removed 15 days after onset. At four months post-treatment, there was no recurrence of the pneumothorax. Combined therapy with endobronchial occlusion and pleurodesis might be a useful treatment modality for intractable pneumothorax.

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An intrathoracic aberrant needle is usually recognized incidentally as a foreign body that has penetrated from the outside accidentally. It should be surgically removed as soon as possible to avoid the risk of pneumothorax, pyothorax, or main vessel injury. A-63-year-old man under preoperative examination for lumbar disc herniation was referred to us with an abnormal needle-shaped shadow on a chest radiograph and computed tomography (CT) without any symptoms. He had the same shadow pointed out 25 years ago. However, he left it without any observation or treatment. CT demonstrated an aberrant needle in S3 of the right lung and the anterior mediastinum. We performed video-assisted thoracoscopic surgery (VATS) with fluoroscopy. We removed the needle with en-block resection of pulmonary partial resection and dissection of the mediastinal fat tissue. The needle was fragile due to rust in the lung and anterior mediastinal tissue. Fluoroscopy during the operation was useful to confirm the location of the foreign body and remove it without leaving a residual fragment.

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New simulated surgery has begun, owing to the progress and distribution of multi-detector computed tomography (MDCT), magnetic resonance imaging, and the three-dimensional (3D) printer. Reports of this method were applied to orthopedic, kidney, brain, liver, and facial deformity surgeries, but reports involving the chest are rare. Recently, we made original size lung and mediastinum models for clinical and educational purposes with a 3D printer using chest MDCT data. These models were constructed using real data of patients, and they are useful in understanding the 3D anatomy and structures for surgery.

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