We examined the clinical characteristics of and treatment results for patients with multiple lung cancer based on our experience. The study population consisted of 16 patients with multiple lung cancers, in whom the second lung cancer was treated after surgery for the first cancer between January 2007 and December 2014. Surgical resection of the second lung cancer was performed in 8 cases, and radiation therapy was chosen for the remaining 8 cases. Development of a third lung cancer was found in 8 cases. The surgical procedures selected for the first lung cancer in the 16 cases were lobectomy in 12 cases, partial resection in 3 cases, and segmentectomy in one case. Procedures for the second lung cancer (8 cases) were partial resection in 5 cases, segmentectomy in 2 cases, and lobectomy in one case. During a mean follow-up period of 83.6 months after the first lung cancer had been treated, the 5-year survival rate was 100% and there was no death due to recurrence. The results suggest that the outcome of treatment for multiple lung cancers might be good if the timing of treatment for the second lung cancer after complete resection of the first lung cancer is appropriate.

We assessed the safety and efficacy of thoracoscopic surgery (TS) for lung cancer in patients with chronic obstructive pulmonary disease (COPD). Male patients (n=268) with c-stage I non-small cell lung cancer (NSCLC) who had been treated with TS in our hospital between 2006 and 2013 were retrospectively analyzed. Patients with COPD (n=119, C group) were compared with those without COPD (n=149, N group). There was no significant difference between the two groups in the duration of surgery (both 278; p=0.9845). The rate of conversion to open thoracotomy was significantly higher in the N compared with C group (6.7 and 1.7%, respectively; p=0.0479), whereas postoperative complications were significantly more frequent in the C compared with N group (23.5 and 12.8%, respectively; p=0.0210). There was no significant difference between the two groups in the postoperative hospital stay (N and C groups: 6 and 7 days, respectively; p=0.0545). Thirteen patients with COPD (11.0%) and five patients without COPD (3.4%) died of other diseases. Although the 5-year overall survival rate was higher in the C compared with N group (67.4 and 85.7%, respectively; p=0.0066), there was no significant difference in the 5-year disease-specific survival rates (85.4% and 90.2%, respectively; p=0.2042). These results demonstrate the safety and efficacy of TS for c-stage I NSCLC in patients with COPD.

We retrospectively evaluated the outcomes of surgical resection of thymic carcinoma. This study included 14 patients treated at our hospital from 2006 to 2015, comprising 9 men and 5 women with a mean age of 61.9 years. The histological types were squamous cell carcinoma in 11 patients and adenocarcinoma, typical carcinoid, and large-cell neuroendocrine carcinoma in 1 patient each. Two of the 14 patients had stage I cancer, 3 had stage II, 5 had stage III, 1 had stage IVa, and 3 had stage IVb. Twelve of the 14 patients underwent complete resection, and 9 (64.3%) required extended resection. There were seven operative morbidities; however, there were no operative mortalities. Adjuvant radiotherapy or chemoradiotherapy was performed in 7 of the 14 patients. The 3-year disease-free survival (DFS) rate was 38.3% and 3-year overall survival (OS) rate was 61.4%. The operative time and intraoperative bleeding for Masaoka-Koga stage I/II cancer were significantly shorter and less compared with those for stage III/IV cancer (p=0.016 and p=0.006, respectively). The DFS for Masaoka-Koga stage I/II cancer tended to be better than that for stage III/IV cancer (p=0.053). We suggest that patients with Masaoka-Koga stage III/IV thymic carcinoma can survive for longer periods of time with future multimodal therapy.

We describe a 51-year-old woman in whom a persistent tracheocutaneous fistula after tracheostomy was closed using costal cartilage. The patient developed spontaneous bilateral chylothorax. She could not cough up chyle, and underwent tracheostomy. The secretions decreased after five years, and we decided to repair the tracheal defect with her consent. The defective tracheal cartilage was relatively large (3×1.2 cm), and so we planned to close the trans-cutaneous tissue defect using transplanted costal cartilage because direct suture was difficult. We harvested the seventh costal cartilage and created a graft that was slightly larger than the defect by trimming. We placed the graft on the tracheocutaneous fistula, keeping the divided face aligned at the tracheal lumen, and fixed it to the tracheal defect with 4-0 polydioxanone and interrupted sutures. She fasted and her speech was restricted for three days postoperatively to stabilize the implanted region, and she was discharged on postoperative day 7. Bronchoscopy at one and six months after surgery showed that the graft had survived and transitioned smoothly into the tracheal mucosa.

We report a case of bronchial atresia. A 56-year-old woman with a long-lasting cough showed an infiltrative shadow in her left upper lung field on a chest radiograph. The patient was referred to our hospital for further examination and treatment. Chest CT showed atelectasis and mucoid impaction in segment¹⁺² of the left lung and B¹⁺² obstruction with calcification. Bronchofiberscopy showed the superior division bronchial obstruction and narrowing of the lingular-bronchus. The patient underwent left upper lobectomy with a diagnosis of bronchial atresia with repeated obstructive pneumonia. We could not clarify the definite cause of the bronchial obstruction. Despite being a benign disease, bronchial atresia with clinical symptoms should be treated surgically.

A 74-year-old woman was referred to our hospital for cough and an abnormal shadow on a chest radiograph. Contrast-enhanced chest computed tomography showed a mass of approximately 10 cm in diameter and a low-density right upper mediastinal shadow. MRI of the tumor showed iso-intensity of fat on T1WI and T2WI, and low-intensity on a fat suppression image. We diagnosed the tumor as a lipoma. However, there was a possibility that the tumor was a well-differentiated liposarcoma. We performed an operaton. Microscopic findings of the tumor showed highly differentiated fat cells and a thin fibrotic wall in the tumor. There were no findings suggesting sarcoma, so the tumor was diagnosed as a lipoma.

A 66-year-old man was found to have an 18-mm nodule in the right lower lobe S9 segment on computed tomography (CT) performed in the first postoperative year following surgery for sigmoid colon cancer, and underwent surgery with the diagnosis of right lower lobe lung cancer (c-T1aN0M0, Stage IA). An anomalous vein in the V2 segment, which ran posterior to the right main bronchus and flowed into the contralateral upper pulmonary vein root, was detected on preoperative 3-dimensional (3D)-CT. Lower right lobectomy and lymph node dissection were performed thoracoscopically. We performed subcarinal lymph node dissection after taping V2, with careful attention to the vasculature. An abnormality of V2 running posterior to the bronchus is relatively rare. We report the case of a safe surgery for a lung cancer patient with an anomalous V2 flowing into the contralateral upper pulmonary vein, supported by preoperative 3D-CT to identify the anatomical relationships between the blood vessel and bronchus.

We report a case of urgent lobectomy for massive hemoptysis after transbronchial lung biopsy of primary pulmonary mucoepidermoid carcinoma. Computed tomography (CT) revealed a mass in the upper lobe of the left lung of an 83-year-old man, and transbronchial lung biopsy was performed for the diagnosis of the mass. Six days after the biopsy, he coughed up large amounts of blood, and a chest radiograph revealed massive atelectasis throughout the entire left lung. Considering the possibility of hemorrhaging from the mass and the risk of airway obstruction, we immediately performed left upper lobectomy. During the intraoperative procedure, we resected the left upper bronchus, removed the clots in the lower bronchus, and closed the cut end. During the postoperative course, we performed tracheostomy to remove the remaining blood sputum, and the patient was discharged on postoperative day 31. The tumor was pathologically diagnosed as a primary pulmonary mucoepidermoid carcinoma (pT2aN0M0, pStage IB).

We report a case of pericardial tamponade that occurred after mediastinal lymph node dissection. A 67-year-old man underwent a left lower lobectomy with mediastinal lymph node dissection (ND2a-2) for primary lung cancer. Two years later, chest computed tomography (CT) showed enlargement of a paratracheal lymph node, and transbronchial needle aspiration of the lymph node established a diagnosis of recurrence of squamous cell lung cancer. The patient underwent a thoracoscopic right upper mediastinal node dissection. On postoperative day 1, the drainage fluid turned milky, and a diagnosis of chylothorax was made. He received pleurodesis with OK432 and the chylothorax disappeared. Two days after the removal of the chest drainage tube, his systolic blood pressure decreased suddenly in association with sinus tachycardia. Urgent echocardiography revealed a large pericardial effusion consistent with cardiac tamponade. A drainage tube was immediately inserted into the pericardial space, and thereafter a cloudy white effusion was discharged, leading to the diagnosis of chylopericardium. Because conservative treatments were not successful, the patient underwent an operation with ligation of the thoracic ducts and pericardial fenestration. Since the operation, he has experienced no recurrence of the chylothorax or chylopericardium. Although chylopericardium after non-cardiac surgery is extremely rare, cardiac tamponade resulting from chylopericardium might be life-threatening. Therefore, thoracic surgeons should consider the possibility of this complication after surgery.

A 64-year-old male patient with a history of pulmonary emphysema and aspergillosis was admitted to our hospital because of right pneumothorax. Although we performed chest drainage, air leakage did not improve. We performed surgery and found air leakage caused by a bulla in S6. Bullectomy was contraindicated due to severe emphysema and adhesion, so we placed a tissue-healing sheet over the lesions and performed pleurodesis using 4 g of sterile talc. On the 5th day after surgery, his respiratory condition worsened and bilateral interstitial shadows were found on CT. Because he was diagnosed with acute respiratory distress syndrome, we administered corticosteroids, oxygen, and antibiotics. Despite these treatments, his condition did not improve and he died on the 15th day after surgery. In addition to talc, several factors (i.e., history of pulmonary aspergillosis, emphysema, general anesthesia, and surgery) may contribute to the progression of ARDS. We should pay close attention when performing talc pleurodesis for patients with any respiratory diseases or a poor general condition.

A 16-year-old female with a huge intrathoracic mass was referred to our department. CT demonstrated a tumor with smooth surface measuring 14 cm in the maximum diameter that was located in the anterior mediastinum and extended to the right pleural cavity. Based on the histological diagnosis of thymolipoma established by percutaneous needle biopsy, the patient underwent surgery. The tumor was completely removed en bloc with the thymus through a right thoracotomy. Postoperative pathological examination confirmed that the resected specimen was a thymolipoma. This represents an unusual case of a huge benign mediastinal tumor that was incidentally found and indicated for surgery.

A 62-year-old woman presented with a diaphragmatic hernia in the right thoracic cavity. She had a history of left renal cancer. Chest computed tomography revealed a well-defined soft tissue mass, of 20 mm in diameter, located in the right lower lobe near the diaphragm. As the tumor was growing slowly, we suspected metastatic cancer of the lung. She underwent video-assisted thoracoscopic surgery for the tumor. The intraoperative findings revealed a liver herniation through one of the defect holes in the right diaphragm. Histological examination revealed normal liver tissue, so we diagnosed her with a diaphragmatic hernia. Although a diaphragmatic hernia without acquired factors, including a history of trauma, is rare, our experience revealed that we should take diaphragmatic hernia into account as a differential diagnosis of a lung tumor on the right diaphragm.

A 34-year-old female with a mediastinal tumor that had grown from 7.3 to 9.8 cm in 3 months was referred to our hospital. Chest CT and MRI showed a large heterogenous mass in the left thoracic cavity, suggesting a liposarcoma or other malignant soft tissue tumor. The tumor was adjacent to the pericardium, diaphragm, and inferior pulmonary vein. The patient underwent surgery under general anesthesia. The tumor was excised from the surrounding tissue and removed with a part of the left lower pulmonary lobe with video-assisted thoracic surgery. The specimen was successfully extracted through the trans-diaphragmatic route under the costal arch in order to avoid post-operative intercostal neuralgia. The pathologic diagnosis was dedifferentiated liposarcoma. We report a rare case of liposarcoma of the mediastinum.

Birt-Hogg-Dube (BHD) syndrome is a rare, autosomal dominant disorder characterized by the development of hair follicle tumors, renal tumors, and pulmonary cysts. Sometimes, the syndrome occurs with pulmonary cysts alone. A 24-year-old woman was referred to our hospital due to prolonged right-sided pneumothorax. She had suffered from left-sided spontaneous pneumothorax four years before and her father had experienced bilateral spontaneous pneumothorax. Chest computed tomography in this case showed a right-sided apical bulla and bilateral bullae in the mediastinum. Video-assisted thoracoscopic surgery was performed. The bullae were resected with automatic staplers and the bullae on the surface of the lung were covered with polyglycolic acid sheets. Since air leakage was noted after the operation, pleurodesis was performed, after which the leak was resolved. Following discharge, pneumothorax recurred two times in three weeks. Therefore, video-assisted thoracoscopic surgery was performed again. Air leakage was found near a different bulla from the site of the previous operation and pleural coverage was performed. Air leakage occurred after the surgery and pleurodesis was required. Due to the recurrent pneumothorax and the patient's family history, we suspected BHD syndrome. Genetic screening confirmed the diagnosis of BHD syndrome. Only pneumothorax developed in this case. Continuous observation for other characteristics of BHD syndrome is necessary.

A 39-year-old man undergoing highly active antiretroviral therapy (HAART) for HIV was referred to our hospital for an abnormal shadow on a chest radiograph. Chest computed tomography (CT) revealed a huge mass in the right pleural cavity. As a result of CT-guided percutaneous needle biopsy, synovial sarcoma, spindle cell carcinoma, and malignant mesothelioma were considered as differential diagnoses. A tumor biopsy by video-assisted thoracic surgery (VATS) for cytogenetic diagnosis revealed the presence of a SYT-SSX1 fusion genes; therefore, he was finally diagnosed with primary pleuropulmonary synovial sarcoma. The patient received chemotherapy with ifosfamide and doxorubicin, but the tumor and pleural nodules were still increasing in size after the chemotherapy. His general status was good and the disease remained localized within the right pleural cavity; therefore, right EPP was performed. Chest CT at 7 months after the operation showed a recurrent lesion extending from the diaphragm to the retroperitoneal space and recurrent lesions in the right chest wall. We performed tumor resections by thoracolaparotomy. Unfortunately, multiple disseminations including pericardial disseminations were detected 2 months after the 2nd surgery. We performed chemotherapy with gemcitabine and docetaxel, but the pericardial disseminations markedly increased. Then, we changed to chemotherapy with pazopanib, and stable disease (SD) was maintained for 3 months. However, he died of cardiac tamponade caused by the tumors 17 months after the initial surgery.

A 59-year-old man was transferred to our hospital because of a 5.0×4.0-cm pulmonary nodule in the left lower lobe detected on a previous chest radiograph and computed tomography scan. Results of percutaneous fine needle biopsy of the nodule showed the proliferation of medium-sized lymphocytes, and they were CD20 (+), CD79 (+), CD10 (-), CD5 (-), cyclin D1 (-), CD23 (-), CD43 (+) and BCL-2 (+) on immunohistochemical staining. Findings generated by additional polymerase chain reaction analysis of the immunoglobulin H gene rearrangement from the paraffin-fixed sample showed monoclonal rearrangements in the VH (FR2) /JH and DH1-6/JH regions. No proliferation of the tumor cells was found in the bone marrow, and 18-fluorodeoxyglucose positron emission tomography showed no lesions, except for the pulmonary nodule. Thus, a stage I pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma was preoperatively diagnosed.

Although watchful waiting is indicated for a definitive diagnosis of MALT lymphoma, we performed left lower lobectomy because of the patient's age, surgical tolerability, resectability, and preference. The final pathological diagnosis was a MALT lymphoma without pleural invasion and a negative surgical margin. He has shown no evidence of recurrence without chemotherapy and radiotherapy for 8 months.

As a result of the recent spread of high- resolution CT (HRCT), reports of multiple lung cancers have been increasing. However, it is sometimes difficult to distinguish inflammatory from malignant lung nodules even with HRCT findings. We herein report a case of primary lung cancer coexisting with non-tuberculous mycobacteriosis (NTM) in the ipsilateral other lobe. A 69-year-old woman was referred to our hospital because of an abnormal shadow in the right middle lung field on lung cancer screening chest radiograph. Chest HRCT showed a solid nodule with a spicule and pleural indentation and surrounded by scattered shadows in the right upper lobe, and a part-solid ground glass nodule in the right lower lobe. Because we suspected multiple primary lung cancers, we decided to perform lung nodule biopsy via thoracoscopic surgery. The intraoperative pathological diagnosis based on the fresh frozen sections was as follows: the nodule in the right upper lobe was granuloma (suspected mycobacteriosis), and the nodule in the right lower lobe was adenocarcinoma. Therefore, we performed right lower lobectomy with lymph node dissection. Although we could not diagnose the two intrapulmonary nodules accurately before the operation, we could treat each nodule appropriately according to the intraoperative pathological diagnosis.

A 74-year-old man was admitted with a left anterior mediastinal tumor identified by chest computed tomography. We performed hemi-thymectomy because a thymic cyst was suspected, and confirmed a diagnosis of thymic basaloid carcinoma. Thymic basaloid carcinomas are characterized by the presence of mild, low-grade atypia. Because it is sometimes difficult to distinguish thymic basaloid carcinoma from other types of thymic cancer, it is necessary to evaluate them using immunohistochemistry.

Background: Mucoepidermoid carcinoma is rare, even among lung cancers, and discovery in the peripheral lung fields is especially rare. Patient: The patient was a 73-year-old man. Four years earlier, he had undergone an ileocecal resection for stage I cecal cancer. Three years previously, he had undergone chemoradiotherapy for stage I laryngeal cancer. One year earlier, he had undergone lateral segmentectomy for stage II alcohol-induced hepatocellular carcinoma. The patient was examined at the reporting hospital with the chief complaints of cough and sputum. A thoracic computed tomography scan revealed a 7-mm nodule in the periphery of S6 of the right lung. It was subsequently determined that the nodule had grown to 14 mm in size. Lung metastasis from any of the previous three cancers was suspected, and surgery was indicated. A thoracoscopic partial wedge resection of the lower lobe of the right lung was performed. The patient's postoperative progress was smooth, and he was discharged on postoperative day 11. Based on the results of the histopathological examination, we made a diagnosis of a highly malignant mucoepidermoid carcinoma (pT1aN0M0, stage IA). To date, 8 months post-surgery, the patient has had no recurrence and he is being monitored as an outpatient. Conclusion: The coexistence of mucoepidermoid lung carcinoma with other cancers has also been reported, so strict monitoring is required for the early detection of not only recurrence but also subsequent cancers.

We report a case of rapid mass development after lung surgery, and which was difficult to diagnose.

A 69-year-old man underwent surgery for rectal cancer 3 years prior. Follow-up computed tomography (CT) revealed a pulmonary nodule in the right lower lobe. A complete examination in our hospital led to the diagnosis of the nodule as rectal cancer metastasis. Thus, the patient underwent a right lower lobectomy and wedge resection of the right middle lobe. Although he received adjuvant chemotherapy for metastatic rectal cancer, the serum carcinoembryonic antigen (CEA) level increased 4 months later and CT revealed a pulmonary nodule on the stump of the staple line. Positron emission tomography (PET) demonstrated abnormal uptake by the nodule. Based on these findings, we diagnosed the nodule as a recurrence at the stump and planned to perform a right middle lobectomy or remnant pneumonectomy if the nodule was diagnosed as malignant intra-operatively. The nodule was diagnosed as a granuloma intra-operatively; we completed the operation after wedge resection of the mass. The final diagnosis of the pulmonary nodule was a granuloma. It is difficult to distinguish between benign and malignant lesions appearing on the surgical stump. When a tumor is noted on the surgical stump during non-anatomical resection, malignancy cannot be ruled out based on image and tumor markers. So, a histological diagnosis is necessary.

A 72-year-old female was referred to our hospital because of an abnormal shadow in the right upper lung field. Chest computed tomography showed a 2.7×2.0-cm solid nodule around ground glass attenuation (GGA) in the S¹ segment of the right upper lobe, and a 1.2×1.1-cm solid nodule around GGA in the S³ segment and a 1.0×0.8-cm area of pure GGA in the S¹⁺² segment of the left upper lobe. Therefore, simultaneous lung cancers were suspected. 3D-CT showed a displaced anomalous B² bronchus arising from the right middle lobe bronchus. Furthermore, 3D-CT angiography showed an anomalous A^2b pulmonary artery arising from A⁴⁺⁵ and anomalous A^1a and A^2a arising from A⁶. Thoracosocpic right S¹⁺³ segmentectomy was the treatment selected for the following reasons: the main tumor was in S¹; there was no metastasis to the lymph nodes; and it was the best method for preserving the pulmonary function after simultaneous left and right resections. We report a rare case of a displaced anomalous B² bronchus arising from the right middle lobe bronchus.

Tumors that originate in the sympathetic ganglia often extend with a craniocaudal orientation in paravertebral lesions. We report a case of posterior mediastinal ganglioneuroma that extended into the retrocrural space, and discuss the surgical modality to resect a neurogenic tumor located in a thoracoabdominal lesion. A 49-year-old female was referred to us with a mass, measuring 9×8×2 cm, that extended from TH9 to L1 levels in the paravertebral lesion and tapered into the retrocrural space. We made a preoperative diagnosis of a neurogenic tumor and conducted thoracoscopic surgery in the semi-prone position with an artificial pneumothorax to resect the tumor in the lowest position of the thorax. A favorable operating field in the posterior mediastinum facilitated meticulous dissection to resect the tumor with the affected sympathetic nerve and splanchnic nerve, and the involved azygos vein, while conserving the thoracic duct. The final pathology of the tumor revealed a ganglioneuroma, and she was discharged on postoperative day 5.

We report a case of tracheal reconstruction using high-frequency jet ventilation (HFJV) without operative field intubation. The patient was a 68-year-old woman with a raised mass (adenoid cystic carcinoma) in the cervical trachea, who was scheduled for tracheal reconstruction with curative intent. Initial airway management under anesthesia involved endotracheal intubation with a standard tracheal tube, and surgery was performed using a cervical approach. When tracheal detachment around the mass was finished, we exchanged the tracheal tube for an airway exchange catheter (Cook Medical Inc., Bloomington, IN, USA) and initiated HFJV via the catheter. We then resected the second to fourth tracheal cartilages followed by tracheal end-to-end anastomosis, and HFJV through the thin airway exchange catheter allowed us to avoid operative field intubation. Airway surgery using HFJV with a thin catheter is an acceptable method of airway management, and it provides a clear view of the surgical field.