Methods: Between February 2009 and March 2015, we prospectively analyzed the postoperative and long-term acute exacerbation (AE) and prognosis of lung cancer patients with idiopathic pulmonary fibrosis (IPF) following surgery in the Niigata Chest Surgery Study Group.

Results: Of the 48 eligible patients, 47 were male and 1 was female. The average age was 70 years old. The incidence of postoperative AE was 6% (3 of 48 patients). One of 3 patients died due to recurrence of AE, and 2 of 3 patients died due to re-recurrence of AE. By univariate analysis, there was no prognostic factor for postoperative AE, and postoperative AE was identified as a significant predictor of long-term AE. Fourteen patients (29%) developed long-term AE, at an average of 16 months, and 8 patients died of long-term AE. The 3-year overall survival rates were 0 and 70.6% for patients with or without postoperative AE, respectively (p < 0.001). The 3-year overall survival rates were 35.7 and 80.3% for patients with or without long-term AE, respectively (p = 0.001).

Conclusion: Only the presence of postoperative AE was identified as a predictor of long-term AE. Careful follow-up with awareness of long-term AE is needed.

An 82-year-old man was referred to our hospital because a nodule was incidentally detected in his left lung on performing chest CT. Follow-up CT showed that the nodule had enlarged. ¹⁸F-fluorodeoxy glucose-positron emission tomography (FDG-PET) showed high uptake, and the serum SCC antigen level was elevated. Transbronchial lung biopsy did not aid in determining the diagnosis. He was operated by VATS. Intraoperative biopsy could not exclude a tumor with low grade malignancy. Left lower lobectomy was performed. The tumor was histologically diagnosed as solitary mixed squamous and glandular papilloma. No malignancy or Human papilloma virus infection was recognized. No recurrence was observed over the next 5 years. We also reviewed 78 Japanese case reports on papilloma subtypes. Solitary papillomas are difficult to distinguish from lung cancer, but complete resection appears to be curative.

Chest computed tomography showed an abnormal chest shadow in a 64-year-old man during a health checkup.

Squamous cell carcinoma stage T3 (pm) N1M0 stage IIIA was diagnosed by transbronchial lung biopsy. Right middle lower lobe lobectomy and lymph node dissection were performed. Pathological examination revealed adenocarcinoma and squamous cell carcinoma. Genetic analysis detected EGFR mutations, L858R and T790M, in both tumors. The adenocarcinoma had a P53 gene mutation, but the squamous cell carcinoma did not. We diagnosed these synchronous multiple lung cancers as squamous cell carcinoma cT2N0M0 stage IIA, and adenocarcinoma cT1cN1M0 stage IIB. The tumors recurred recurrence as brain metastasis and pulmonary metastasis 6 months after the operation, and he was treated with osimertinib.

He survived for 1 year and 10 months thereafter. T790M mutation is almost always an acquired mutation; de novo T790M mutations are rare.

A 72-year-old man exhibited an abnormal shadow on chest roentgenogram during the follow-up of another disease. Chest CT showed a mass measuring 90 mm in the anterior mediastinum. The mass without calcification and fat contained some low density area.

On FDG-PET, the maximal standardized uptake value of the mass was 2.69. The values of serum tumor markers and anti-acetylcholine receptor antibody were not remarkable. Therefore, the preoperative diagnosis favored stage I thymoma. At surgery, a thymectomy with the removal of a part of the right lung and pericardium was performed via a median sternotomy. Histopathologically, the tumor consisted of cystic and solid regions. In a solid region, there were mucus secreting cells, well differentiated squamous epitheliums and intermediated cells. The pathological diagnosis was low grade mucoepidermoid carcinoma and stage II disease. We tried to detect a fusion gene, the so called mammalian mastermind-like gene 2 (MAML2), but the result was negative. The prognosis of a mucoepidermoid carcinoma is reported to depend on the tumor stage and histologic grade. Although this case was stage II disease, a good prognosis is expected due to the complete resection and pathologically low grade.

A 58-year-old man was admitted to our hospital for examination of right chest back pain persisting for 4 months and a tumor shadow noted in the upper right lung field on a chest radiograph. A tumor shadow of 42 mm was observed in contact with the upper right lobe chest wall on a chest CT and the peripheral rib margin in the vicinity was irregular and chest wall invasion was suspected. Confirmation of the diagnosis by bronchoscopy was not obtained but primary lung cancer (cT3N0M0 cStage IIB) was strongly suspected. Right upper lobectomy with resection of the chest wall including the 3rd-5th intercostal muscles and lymph node dissection (ND2a) was performed with posterior lateral incision. Intraoperative fine needle aspiration (FNA) revealed poorly differentiated cancer and the postoperative pathologic diagnosis was lung primary pleomorphic carcinoma (pT3N0M0 stage IIB). Bone metastasis to the 7th thoracic vertebrate body was noted on MRI taken 1 month after surgery. We performed combined chemoradiotherapy (Chemotherapy: Carboplatin (CBDCA) +weekly Paclitaxel (PTX) 4 Cool Radiotherapy: 30 Gy). The FDG accumulation in the 7th thoracic vertebrae disappeared after treatment, and the patient has survived without recurrence for nine years and two months until the present.

A 78-year-old woman who had undergone radical surgery for papillary thyroid cancer at the age of 60 years was followed up regularly with computed tomography (CT). CT performed 10 years after surgery revealed a 1.3-mm nodular shadow located in S10 of the right lung. Annual follow-up CT showed that the nodule had a tendency to grow slowly. CT performed at 8 years of follow-up revealed that the tumor shadow had increased to 10 mm. Lung metastasis of thyroid cancer or a low-grade lung malignancy was suspected, and the patient underwent thoracoscopic partial pulmonary resection. The pathological diagnosis was pulmonary hamartoma. The doubling time of the tumor was 319 days. In the literature, few previous studies described the long-term clinical course of a newly developed pulmonary hamartoma and measured the tumor doubling time.

We report two resected cases of Mullerian cyst in the posterior mediastinum. Case 1: A 50-year-old woman was referred to us with a posterior mediastinal cystic tumor found during a systemic examination of a renal nodule. Magnetic resonance imaging revealed a 30 × 20-mm smooth-surfaced cyst with high-intensity signals in T2-weighted images on the left side of the Th7 vertebra. We diagnosed it as a neurogenic tumor and resected it by thoracosopic surgery. Histopathological examination revealed that the cyst had a thin fibrous wall covered with a single layer of cilliated columnar epithelium. Immunohistochemical staining was positive for estrogen and progesterone receptors in the epithelia. Finally, we diagnosed it as a Mullerian cyst. Case 2: A 36-year-old woman was referred to us with a nodule on the left side of the vertebra and cranial side of the aortic arch found on a chest radiograph during a medical check-up. Chest computed tomography revealed a 30 × 18-mm homogenous cystic lesion on the left side of the Th4 vetebra. We diagnosed it as a neurogenic tumor and resected it by thoracoscopic surgery. Histopathological examination revealed that the inner side of the cyst wall was lined with pseudostratified cilliated epithelium and we diagnosed it as a bronchogenic cyst. After encountering case 1, we additionally performed immunohistochemical staining. It was positive for estrogen and progesterone receptors in the epithelia. We corrected the diagnosis to a Mullerian cyst.

Immunoglobulin G4 (IgG4)-related disease (RD) is a multi-organ disease with tumorous or hypertrophic lesions associated with IgG4-positive plasma cells. Here, we show a case of IgG4-RD in the anterior mediastinum mimicking the recurrence of lung cancer. A female patient underwent left upper lobectomy and apical segmentectomy of the left lower lobe with nodal dissection for synchronous multiple primary lung adenocarcinoma 4 years earlier. The pathological stage was IA2 for the upper lobe lung carcinoma and pTisN0 for the lower lobe carcinoma. Four years after the operation, periodic follow-up CT revealed a tumor-like lesion in the anterior mediastinum. FDG-PET showed significant uptake in the lesion. Since malignancy, including recurrence of lung cancer, could not be excluded, incisional biopsy was performed. Pathological findings indicated the anterior mediastinal lesion as IgG4-RD. A blood test revealed that the serum IgG4 level was elevated to 264 mg/dL. From these findings, we concluded the anterior mediastinal lesion to be IgG4-RD. Oral glucocorticoid administration was started after the diagnosis. The serum IgG4 was normalized and the anterior mediastinal lesion was improved three months after starting the treatment.

Thoracoscopic debridement of the cavity and closure of the fistula to prevent empyema are minimally invasive and useful. However, if the fistula cannot be controlled after surgery, open-window thoracostomy is often required. We used an Endobronchial Watanabe Spigot (EWS) for thoracoscopic surgery in 3 cases of empyema with fistula at the same time and tried to control the fistula. In 2 cases, the postoperative fistula was controlled, and they were discharged on the 17th and 28th postoperative days.

One patient had recurrence of postoperative empyema and underwent open-window thoracostomy, but since the fistula was controlled by EWS, the thoracostomy could be closed one month later. The use of EWS in thoracoscopic surgery prevents transition to open-window thoracostomy, and even if a shift to thoracostomy is necessary, the fistula is controlled and it is possible to close the thoracostomy early. Thoracoscopic surgery with EWS is considered to be an effective treatment against empyema with fistula.

There is no consensus regarding limited surgery for small lung cancer, and clinical trials are currently ongoing. Adenocarcinoma in situ (AIS) has been reported to be associated with a good prognosis, with a 100% 5-year survival rate. The present case involved a patient in whom CT showed a ground glass opacity (GGO) lesion in right S1 of 10 mm. The lesion grew gradually each year, forming a partly solid nodule by year 3 and a solid nodule of 16 mm after 5 years; the patient was then referred to our hospital. We performed limited surgery for this patient. The pathological diagnosis was AIS, and now at 7 years since the surgery, recurrence has not been detected. We observed changes in the GGO lesion with time over 5 years, and suggest that AIS may appear as solid nodules on computed tomography and that limited resection is a possible treatment.

A 65-year-old man was hospitalized urgently for respiratory failure with CO₂ narcosis. He was diagnosed with Swyer-James syndrome with increased radiolucency of the right upper lung field on a chest radiograph over 20 years ago. Ventilator management failed to adequately improve his respiratory status. Deterioration of the respiratory status was caused by the progression of hyperinflation of the right upper lobe and compression of the left lung field; therefore, we performed right upper lobectomy. After the operation, his respiratory status gradually improved and he was finally discharged without the need for home oxygen therapy. Most cases of Swyer-James syndrome have been followed by conservative therapy. However, here we report a case of Swyer-James syndrome with respiratory failure that was successfully treated with surgical therapy.

A 69-year-old woman was referred to our hospital because of an abnormal shadow detected on chest computed tomography (CT), which showed a partially solid nodule in the left S¹⁺² segment. In addition, a displaced anomalous B¹⁺²⁺⁶ bronchus arising from the left main bronchus was found behind the main pulmonary artery. Hyperlobulation between the S¹⁺²⁺⁶ segment and S³⁻⁵ and B⁸⁻¹⁰ segments was also noted on preoperative CT. The S¹⁺²⁺⁶ segment was independent of the other segments, and we performed left S¹⁺²⁺⁶ segmentectomy. There was no lymphadenopathy, and the lesion mainly showed a partially solid nodule on high-resolution CT. We therefore omitted subcarinal lymph-node dissection. We performed the operation safely by ascertaining the structure on 3-dimensional CT (3D-CT). We report the rare case of a displaced anomalous B¹⁺²⁺⁶ bronchus arising from the left main bronchus.

We report a case of traumatic pneumatocele due to a fall. A male in his 60s fell from a stepladder during work and struck his right chest. He presented to our hospital with right chest pain. Initial chest radiograph and computed tomography (CT) showed multiple right rib fractures, consolidation with a cavitary lesion, and pulmonary hematoma in the right lower lobe. A traumatic pneumatocele was diagnosed. As the systemic and respiratory status was stable, conservative treatment was provided instead of surgery. Follow-up CT showed gradual resolution of the right lung abnormalities. Six months after the injury, the CT findings had nearly disappeared, leaving only a linear shadow. A traumatic pneumatocele can be seen in a pulmonary contusion following blunt chest injury but is relatively rare. A pneumatocele often heals in the short term without special treatment. Patients' conditions following consolidation injury vary. It is important to promptly detect a traumatic pneumatocele and evaluate the extent of pulmonary contusion to determine appropriate treatment. Chest CT was useful for early diagnosis and monitoring the course over time.

A 53-year-old man was referred to our hospital with chest and back pain and dyspnea. We performed an emergency right upper lobectomy to stop the bleeding by hemoptysis and hemothorax. Multiple organ failure followed and he died 5 hours after surgery. Pseudomonas aeruginosa was detected in sputum and blood cultures. Pathological examination of the resected specimens led to a diagnosis of hemorrhagic pneumonia caused by Pseudomonas aeruginosa pneumonia. Community-acquired pneumonia caused by Pseudomonas aeruginosa is extremely rare. Respiratory failure progresses rapidly and the mortality rate is high, but there has been no report of Pseudomonas aeruginosa pneumonia causing hemorrhagic shock due to hemorrhagic pneumonia. We report the use of surgery to stop the bleeding due to hemoptysis and hemothorax caused by Pseudomonas aeruginosa community-acquired pneumonia.

Dermatomyositis is associated with lung cancer. We report two resected cases of lung cancer complicated by dermatomyositis with different onsets and clinical courses. Case 1. A 74-year-old female was referred to our hospital because of a nodule in the left S⁴⁺⁵ on chest computed tomography (CT). A biopsy specimen of the nodule by bronchofiberscopy revealed squamous cell carcinoma. She complained of fever and worsening muscle pain 10 days after the bronchofiberscopy, and was diagnosed with dermatomyositis. The symptoms improved a few days after surgery. Case 2. A 74-year-old man was referred to our hospital because of a nodule in the left S³ and S⁸ on chest CT. He underwent left upper lobectomy and wedge resection of the left lower lobe. Erythema on the face and upper arms and a low-grade fever appeared 5 months after the operation. Dermatomyositis was diagnosed based on clinical and laboratory findings. At that time, CT and laboratory data revealed no findings suggesting the recurrence of lung cancer. The dermatomyositis was treated with corticosteroid (predonisolone) and the symptom promptly improved. Metastases of the mediastinal lymph node became evident on chest CT 4 months after the onset of dermatomyositis.

An 80-year-old man was transferred to our hospital because of a 4.0×2.0-cm mass in the anterior mediastinum and multiple nodules in both lungs that were detected on chest CT. A percutaneous fine needle biopsy of the mass revealed the proliferation of inflammatory cells and fibrous matrix without malignancy. The mediastinal mass was minimally changed in size; however, the size of the pulmonary nodules increased, and a PET/CT showed radiotracer uptake in both the mediastinal mass and pulmonary nodules. Thus, we performed thoracoscopic biopsies of the mediastinal mass and one of the pulmonary nodules. Histological examination revealed an increased amount of fibrous matrix with the infiltration of plasma cells and lymphocytes. The tumor was composed of IgG4-positive plasma cells in both tissue specimens, therefore, IgG4-related inflammatory pseudotumor was diagnosed. The mass in the anterior mediastinum and all pulmonary nodules disappeared one year after the initiation of oral steroid therapy.

A 71-year-old female underwent left upper lobectomy for lung cancer. On postoperative day 23, enhanced computed tomography revealed thrombus formation in the stump of the left superior pulmonary vein. Anticoagulant therapy with rivaroxaban was initiated and the thrombus almost disappeared. In recent years, thrombus formation in the pulmonary vein stump has become a common complication after lobectomy, especially after left upper lobectomy. However, treatments have not been established.

We report a case of anticoagulant therapy with rivaroxaban for pulmonary vein stump thrombosis, together with a review of the literature.

Most cases of acute mediastinitis are descending necrotizing mediastinitis caused by oropharyngeal abscess. There are few reports on mediastinitis associated with cancer. These cases are caused by the penetration of esophageal cancer or endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Acute mediastinitis due to necrotizing lymph node carcinoma metastasis is rare. We encountered a case of acute mediastinitis because of necrotizing lymph node metastasis of rectal cancer. It is considered to be a rare oncologic emergency case for chest surgeons. When we encounter acute mediastinitis of unknown origin, it is important to systematically examine the patient and review the medical history thoroughly.