Primary mediastinal germ cell tumor (PMGCT) is rare, and its non-seminomatous subtype (NSGCT) is highly malignant. The mainstay of treatment for PMGCT is systemic chemotherapy, and surgery for a residual tumor is considered in patients with normalized tumor markers. The survival benefit of salvage surgery for persistent positive-marker patients remains unclear. Our purpose was to clarify the role of residual lesion resection in these patients.

A total of 7 patients undergoing surgery for NSGCT in our institution from August 2008 to February 2013 were reviewed. Surgical outcomes of these patients were retrospectively analyzed.

All patients were men and the median age was 25 (range, 18-36) years. The serum alpha-fetoprotein (AFP) level was initially elevated in all patients. All patients received primary chemotherapy consisting of bleomycin, etoposide, and cisplatin with a median cycle number of 4. Four patients additionally received 2^nd (n=2), 3^rd (n=1), or 4^th (n=1) line chemotherapy. The AFP levels did not normalize in 3 patients but decreased to less than 0.5% of the prechemotherapy levels. Complete R0 resection was achieved and AFP levels normalized in all patients.

A pathological complete response was observed in 3 patients. The median 3-year recurrence-free and overall survival rates for all 7 patients were both 86%. The 4 patients with preoperatively normalized AFP levels were alive without recurrence, with a median follow-up period of 56 (range, 26-74) months. Of the 3 persistent AFP-positive patients, 2 were alive without recurrence at 24 and 33 months after surgery.

This study suggests that salvage surgery might be beneficial even for persistent positive-marker patients if the post chemotherapy maker level markedly decreases.

We reviewed 4 patients aged 80 or older with acute empyema treated by surgery. They were 3 men and one woman. The average preoperative treatment period was 3.5 days, and the mean operative time was 57 min. The postoperative drainage period was 11 days. Three patients could eat and walk on or the next day of operation. Two patients left our hospital on foot, one patient died of pneumonia after intervention of arteriosclerosis obliterans (ASO), and one died of senile infirmity two months after the operation. In elderly patients with acute empyema, postoperative management in addition to early surgery is also important. Video-assisted thoracic surgery (VATS) was a safe and less-invasive method for those patients.

Thoracoscopic partial pulmonary resection for small peripheral nodules not using a stapler has been introduced to our hospital. After partial resection was performed with electrocautery, two different methods of surface sealing were used: coagulation method (C method) with SOFT COAG alone, and coagulation-suturing method (CS method) with SOFT COAG combined with continuous suturing. The clinical outcomes using the two methods were retrospectively compared in this study. The C method was performed in 19 lesions of 18 cases, and the CS method was performed in 20 lesions of 19 cases. Primary lung cancer was the most frequent, comprising 22 lesions of 21 cases. There was no difference between the two groups in the size or depth of the lesions. The operative time was longer with the CS method than C method. Postoperative air leakage was a complication in 4 cases with the C method, and one of them required re-do surgery, whereas only one case with the CS method had temporary air leakage. Postoperative computed tomography revealed cavitation in 3 cases of the C method and 5 cases of the CS method, all without related symptoms. There was no local recurrence at resected sites. In conclusion, the C method was technically easy to perform, but air leakage may be prolonged after surgery. The CS method may have the advantage of causing less air leakage than the C method, but learning the technical skill is important to shorten the opearative time.

We encountered a case of delayed cardiac tamponade after blunt thoracic injury. Furthermore, the patient developed pericarditis due to postpericardiotomy syndrome.

A 34-year-old man fell from a height of 80 cm during work. He was diagnosed with multiple rib fractures and mild hemopneumothorax, and chest drainage was performed. When we removed the drain on day 4 after injury, cardiac tamponade developed. We performed urgent open heart surgery. We diagnosed injuries of the cardiac sac and epicardium caused by the fractured ribs, and repaired them.

He showed postpericardiotomy syndrome on day 23 after the primary operation. Thus, we performed fenestration of the cardiac sac. Inflammation was improved when we administered an antiphlogistic analgetic postoperatively.

We report this case, which followed an interesting course after blunt chest trauma.

We report a rare case of primary inflammatory myofibroblastic tumor with bronchial obstruction. A 75-year-old man was admitted with productive cough and exertional dyspnea, and was diagnosed with pneumonia. He was referred to our hospital after antibiotic treatment was ineffective. Based on bronchoscopic biopsy, we diagnosed him with lung cancer T3N0M0 stage IIB.

We performed thoracotomy left pneumonectomy, and the postoperative histopathologial diagnosis was an inflammatory myofibroblastic tumor. The postoperative course was uneventful, and he has been relapse-free for 1 year.

Solitary capillary hemangioma of the lung (SCHL) is a very rare benign tumor that must be distinguished from early lung cancer. Here, we report a case of SCHL that was suspected to be lung cancer, based on chest CT findings. The patient was a 51-year-old woman. A small nodular shadow was incidentally identified in the right lower lobe (S10) during a comprehensive medical checkup. Video-assisted thoracic surgery was performed for definitive diagnosis and treatment. On pathological examination, the lesion was a blackish-brown, solid, borderless tumor, measuring 8×7 mm. The lesion site showed thickening of the alveolar septa and the proliferation of capillary vessels. Many dilated capillary vessels were growing densely in the tumor, and no malignancy was apparent. After the operation, immunohistochemical staining of a paraffin section revealed that the thickened alveolar septa had resulted from the proliferation of capillary vessels, which were positive for CD31 and CD34 and negative for D2-40. The histopathological diagnosis was SCHL. The postoperative course was uneventful, and there have been no signs of recurrence.

We herein report the cases of 2 patients whose thymomas spontaneously regressed. The first patient was a 71-year-old woman who was admitted to a nearby hospital due to the sudden onset of chest pain. Chest computed tomography (CT) showed an anterior mediastinal mass of 8×10 cm with pleural and pericardial effusion. She was scheduled to undergo tumor extirpation or thymectomy at our hospital. A chest CT examination carried out just before the surgery revealed tumor regression to 6.5×7.5 cm and the disappearance of the pleural and pericardial effusion a month after the first presentation. The second patient was a 59-year-old woman who was admitted to a nearby hospital due to a cough. Chest CT showed an anterior mediastinal mass of 6×2 cm. She was scheduled to undergo tumor extirpation or thymectomy at our hospital. A chest CT examination carried out just before the surgery revealed tumor regression to 5×1 cm 6 months after the first presentation. The pathological diagnosis of each case was a thymoma, and microscopic findings showed a necrotic area in the central part of the resected tumor.

We encountered a case of lymphoepithelioma-like carcinoma (LELC) of the lung. A 71-year-old male had been followed up after low anterior resection due to sigmoid colon cancer in the surgical department of our hospital. Five years after the operation, a round tumor shadow, of about 1 cm in diameter, was pointed out in his right lower lung field on chest CT. Therefore, he was referred to our department. Metastasis or primary lung cancer was strongly suspected. However, the tumor was too small and too close to the PA to perform biopsy, and so we selected right lower lobectomy.

The pathological diagnosis was LELC of the lung. LELC is thought to be a rare disease in Japan. This tumor is believed to involve Epstein Barr (EB) virus infection in its etiology.

Our patient did not demonstrate EB virus on EBER-1 in situ hybridization, but antibodies of VCA and EBNA were both positive. These findings suggest that the patient had a past history of EB virus infection.

A 63-year-old woman was emergently admitted because of left lower limb myoclonus and gait deficiency. Brain MRI demonstrated diffuse T2 high-intensity foci in the cortex and sub-cortex of the cerebrum, and these enlarged within a 10-day period. Chest CT revealed a mediastinal mass suggestive of thymoma, and the serum level of anti-acetylcholine receptor antibody was elevated. Despite the administration of prednisolone pulse therapy followed by tapering, the neurogenic symptoms and signs of brain dysfunction such as aphasia, muscle weakness, and dementia progressed rapidly. Because the patient had remained immobile in bed, venous thrombosis of the lower limbs occurred. Paraneoplastic neurological syndrome was suspected, and therefore extended thymo-thymectomy was performed on day 31 after admission. The tumor was diagnosed as a type AB thymoma and the WHO pathological staging was pT1N0M0 stage I or Masaoka classification stage I. The neurogenic symptoms and brain dysfunction improved markedly thereafter, and the patient was discharged ambulatory 32 days after surgery following rehabilitation for improvement of the muscle strength.

Paraneoplastic neurological syndrome with a relatively acute onset is considered to be due to an auto-immune reaction against both neurogenic protein and a tumor such as thymoma. Active early treatment of the tumor despite exacerbation of the performance status (PS) is necessary in order to prevent worsening of the neurogenic symptoms.

A 32-year-old woman presented with cough and fever.

Computed tomography showed multiple cysts with fluid and consolidation in the right upper lobe. She had been on antibiotic therapy for the previous two months, but the treatment was not effective. Therefore, a right upper lobectomy was performed to control the infection. The right upper lobe was firmly adhered to the parietal pleura and mediastinum, so we divided the vessels from the fissure to the hilum, and finally performed adhesiotomy. The cystic lesion was pathologically diagnosed as a type I congenital pulmonary airway malformation. Most patients diagnosed with congenital pulmonary airway malformations in adulthood have a history of lung infection; other cases are detected incidentally because of abnormal shadows on chest radiographs. Repeated lung infections cause intrathoracic adhesions that may complicate the operation. Furthermore, the spread of infections makes them more difficult to control using only antibiotics. Therefore, lobectomy should be performed as soon as possible in patients with a suspected diagnosis of congenital pulmonary airway malformation.

Cholesterol granulomas are found most commonly in the paranasal sinuses or middle ear, and those in other areas have rarely been reported. We report a rare case of cholesterol granuloma in the thymus of a 68-year-old female. Positron emission tomography computed tomography showed 18F-fluorodeoxyglucose uptake with a maximum standardized uptake value of 4.12. Extended thymectomy was performed and histological findings indicated cholesterol granuloma. This is an important disease, as a PET-CT-positive benign tumor of the thymus.

A 42-year-old man visited our hospital with the chief complaint of chest pain. Chest CT showed bone destruction of the thoracic vertebra, which was adjacent to a lung nodule under the right lung, S6 pleura, that appeared to be lung cancer with spinal invasion. Thoracoscopic needle biopsy of the lung nodule was performed, but it did not lead to a diagnosis of lung cancer and a definitive diagnosis was not possible. We considered that more biopsy specimens were necessary, and removed the pulmonary nodule and paraspinal column organization, which adhered to each other, en bloc during posterolateral open thoracotomy. The histopathological diagnosis was not lung cancer but abscess formation by Staphylococcus aureus due to pyogenic spondylitis. When we doubt lung cancer with spinal invasion, pyogenic spondylitis should always be considered as an important disease as part of the differential diagnosis.

Growing teratoma syndrome (GTS) is a rare condition among patients with non-seminomatous germ cell tumors who present with enlarging masses during appropriate systemic chemotherapy in spite of normalized serum makers. We encountered a case of mediastinal GTS in which a metastatic tumor appeared on the chest wall after the resection of primary GTS. Histopathological examination of the resected chest wall tumor showed a sarcoma with spindle cells, suggesting the malignant transformation of the sarcomatoid tissue component of the primary GTS. Primary mediastinal GTS is extremely rare, and so we report this case including a discussion based on the literature.

We report a case of left main bronchial mucoepidermoid carcinoma resected by anterior retraction of the aortic arch. The patient was a 22-year-old male who had spontaneous hemoptysis; he was referred to our hospital for further investigation. Enhanced chest computed tomography revealed a vascular-rich endobronchial tumor obstructing the orifice of the left main bronchus, which may have partially invaded the surrounding tissue. Bronchoscopy revealed that the tumor arising from the membrane portion easily bled. During the operation, anterior retraction of the aortic arch after the dissection of the two intercostal arteries provided adequate exposure of the proximal part of the left main bronchus and tracheal carina. The left main bronchus with the lesion was resected by deep wedge fashion; it was anastomosed with a good operative view.

The patient was a 54-year-old woman with a history of mastectomy for a phyllodes tumor of the left breast. Six years after the initial operation, she presented with rapidly worsening shortness of breath. Chest computed tomography (CT) showed a 16-cm mass in the left lung. Percutaneous needle biopsy revealed the mass to be a spindle cell tumor, and an operation was performed. The tumor was resected by left pneumonectomy with median sternotomy. The postoperative histological diagnosis was pulmonary metastasis from the phyllodes tumor of the left breast. We report a case of solitary pulmonary metastasis from a phyllodes tumor of the breast appearing six years after the initial surgery.

A 50-year-old woman with a large left posterior mediastinal tumor was admitted to our hospital for a persistent dry cough. She was diagnosed with a de-differentiated liposarcoma based on CT and MRI, which showed a lobulated heterogeneous hypointense mass including a few adipose parts. Since the de-differentiated part of the tumor tightly adhered to the pericardium, left lower lobe, and descending aorta, part of the pericardium and left lower lobe were rescected concomitantly. On the other hand, dissection of the esophagus and carina in contact with the differentiated part of the tumor was not problematic. The postoperative pathological diagnosis was de-differentiated liposarcoma, the same as the preoperative radiographical diagnosis. We consider that a precise radiographical diagnosis is necessary in order to perform appropriate surgery.

Automatic stapling devices are widely utilized for thoracic surgery to dissect or close tissues, such as the lung parenchyma, bronchi, and vessels. However, accidents associated with automatic stapling devices have also been reported. We have encountered postoperative bleeding due to the penetration of a staple at the bronchial stump to the adjacent pulmonary artery. We suggest that careful observation is required after the resection of a bronchus. In cases whereby the staple at the stump of a bronchus is close to or in contact with vessels, such as the pulmonary artery or vein, coverage of the bronchial stump using a tissue sealant patch, e.g., fibrin-glue-coated collagen fleece, or a tissue flap, e.g., a pericardial fat-pad, is recommended to prevent the damage of vessels.

A 32-year-old woman with lymph-angioleiomyomatosis and chylothorax was admitted to our hospital with empyema. Decortication was performed and the empyema improved gradually. However, after that she showed pneumonia-like symptoms, and a chest radiograph and CT demonstrated a reticulonodular shadow in both lung fields.

Exogenous lipoid pneumonia (ELP) was diagnosed based on microscopic analysis of her sputum, which revealed the presence of lipid-laden macrophages.

We concluded that ELP had been caused by the aspiration of chylous effusion through the minor leakage of visceral pleura. It is important to keep in mind the possibility of ELP when we perform thoracic surgery for a patient with chylothorax.

We herein report a case of spontaneous regression of thymic atypical carcinoid after abdominal surgery. A 68-year-old male was pointed out as showing an abnormal shadow in the anterior mediastinum before an operation for hepatocellular carcinoma. Chest CT revealed a solid and well-defined nodule measuring 31 mm in diameter in the anterior mediastinum. Five months after the operation, the nodule spontaneously reduced to 14 mm in diameter and a new lesion of 7 mm was confirmed within the thymus. We diagnosed the patient with multiple thymic epithelial tumors and decided to proceed with thymectomy. Histopathological examination of the resected specimen revealed that the two nodules were thymic atypical carcinoid and its metastatic lesion within the thymus. In this case, both spontaneous regression and tumor progression proceeded simultaneously in the thymus. The patient received adjuvant radiation to the mediastinum with a total dose of 50 Gy, and is currently disease-free at 14 months postoperatively.

The incidence of interstitial pneumonia caused by bleomycin is increasing, dependent on the total dose. Care should be taken in the treatment of a germ cell tumor requiring high-dose administration. If interstitial pneumonia occurs during treatment for a primary mediastinal malignant germ cell tumor, it may influence the subsequent surgical treatment. We report two surgical cases of interstitial pneumonia that occurred during BEP (bleomycin+etoposide+cisplatin) therapy for a primary mediastinal malignant germ cell tumor. Case 1 was a 19-year-old man and case 2 was a 24-year-old man. They both had an anterior mediastinal tumor of around 10 cm in diameter that was diagnosed as a yolk sac tumor by needle biopsy, and received BEP therapy. Interstitial pneumonia occurred at total bleomycin doses of 360 and 330 mg, respectively. They received steroid pulse treatment 103 and 109 days after starting therapy, respectively. Thereafter, they received steroid maintenance treatment by oral administration. Because they showed the improvement of interstitial pneumonia on imaging examinations, they received residual tumor resection and partial resection of the lung 17 and 26 days after starting steroid pulse treatment, respectively. Both post-operative courses were good, without the onset of respiratory failure.

The patient was a 69-year-old man who was admitted to our hospital with chief complaints of muscle weakness and weight loss. Chest computed tomography (CT) showed a polypoid nodule that protruded into the lumen of the pulmonary artery. Lambert-Eaton syndrome was suspected because of the neurological findings. Despite the absence of histological findings, we determined that the polypoid nodule was a malignancy complicated by a paraneoplastic syndrome; therefore, we performed left lower lobectomy and lymph node dissection. The postoperative pathology result was small cell lung cancer, pT1aN1M0 stage IIA. It is known as a progressive form of cancer: cancer cells grow and infiltrate the stroma, invade blood vessels and lymph vessels, leading to distant metastasis or lymph node metastasis via the bloodstream and lymph flow. In cases of progression into blood vessels, there are reports that the tumor grows into the vessel as a mass and occludes it. However, there are no published cases in which the main tumor progressed to a polypoid lesion only by a thin stalk in the vessel. We report a case of small cell lung cancer in the left lower lobe infiltrating the pulmonary artery (A6) and projecting into the lumen of the pulmonary artery as a polypoid lesion.

A male in his 60s with liver cirrhosis and ascites presented with a right-sided chylothorax. Chylous drainage was refractory to a 3-week fasting period and two attempts at pleurodesis. Ultrasound-guided intranodal lymphangiography demonstrated rupture of the thoracic duct and chyle leakage into the right chest at the level of the azygos vein. The thoracic duct was cannulated via a percutaneous transvenous retrograde approach, and embolization of the site of leakage was successfully performed using N-butyl-2-cyanoacrylate. Thoracic duct embolization is a minimally-invasive and useful treatment option for patients with chylothorax. Its application should be considered early in cases with non-traumatic as well as traumatic etiologies.

We developed an intraoperative histological procedure for improving the diagnosis of cases of small lung cancer that exhibit a ground glass with solid appearance on computed tomography and predicting minimally invasive adenocarcinoma. We punctured the center of a tumor lesion in a resected lung tissue specimen using a biopsy needle and microscopically examined the obtained tumor tissue during intraoperative evaluation. After surgery, a final pathological examination was performed using a complete (maximal diameter) tumor section, which was produced from the formalin-fixed resected surgical specimen without cutting through the tumor.

This technique is useful for checking whether resected lung tissue specimens contain cancerous tissue without having to cut the tumor during the intraoperative evaluation, which would make it difficult to evaluate pleural or stromal invasion during postoperative assessments of tumor aggressiveness based on the new World Health Organization classification.