This retrospective study aimed to review the clinical features of 62 patients who underwent computed tomography (CT) -guided marking followed by surgical resection of peripheral lung nodules. We assessed the usefulness of CT-guided marking by direct vision. The mean size of the lesions was 1.10 cm and the mean distance from the pleura was 5.60 mm. Histologic examination of the resected specimens revealed malignant tumors in 55 patients (89%). Forty-eight resected lung nodules showed ground-glass opacity (GGO) using CT preoperatively and the mean size of the GGO nodule was 1.18 cm, while the mean distance from the pleura was 4.88 mm. Seven patients (14.6%) had visible GGO nodules. In total, 10 nodules (16.1%) were visible, all in contact with the pleura. Visibility was poor in patients with pure GGO nodules in contact with the pleura. For small GGO nodules of approximately 1.0 cm in diameter in contact with the pleura, markings are needed. However, a CT finding of pleural change may be beneficial to assess the visibility of small lung nodules. For patients with GGO nodules in contact with the pleura and pleural change, it may not be necessary.

A 71-year-old woman was found to have a large mass in the left inferior lobe on chest computed tomography. She was eventually diagnosed with pulmonary adenocarcinoma (cT2aN3M1b, Stage IV) involving brain metastasis. After stereotactic radiotherapy for brain metastases, systemic chemotherapy was performed. The disease was controlled, but she had drug-refractory chronic cough and bloody sputum due to a growing tumor in the lower left lobe. She received chemoradiotherapy involving an immune checkpoint inhibitor (nivolumab) and palliative irradiation (30 Gy/10 Fr) for the tumor in the lower left lobe. However, nivolumab was discontinued after two courses owing to the development of erythroblastosis, and her symptoms gradually worsened. Because of the symptoms of drug-refractory cough and bloody sputum, she had difficulty talking, and was referred to our hospital for surgery for the relief of symptoms. She underwent thoracoscopic left lower lobectomy and it was completed uneventfully. The postoperative course was good, and there were no postoperative complications. The chronic cough and bloody sputum markedly improved after surgery, and treatment for lung cancer could be continued. Thoracoscopic surgery was considered effective in this case as the symptoms greatly improved.

A 64-year-old man with a 45-mm tumor in the right upper lung presented with invasion of the body of the T3 vertebra and adjacent rib, which was observed on chest computed tomography (CT). The patient was diagnosed with clinical stage IIIA non-small cell lung cancer (T4N0M0), and en bloc resection was planned. Preoperatively, embolization of both Th2-4 intercostal arteries was performed to decrease blood loss from the resected vertebra and prevent pulmonary congestion of the resected lung. For the tumor, video-assisted thoracic surgery (VATS) was performed for the hilar structure of the right upper lobe, and the T3 vertebra was released through a posterior midline incision. We tried to remove the resected specimen using a dorsal incision. However, it could not be removed because of severe pulmonary congestion. Therefore, posterior spine stabilization was achieved and the patient was placed in the left decubitus position to remove the resected specimen through a posterolateral thoracotomy. After resection of the tumor block, vertebral body reconstruction was performed by placing an expandable cage. The pathological diagnosis was squamous cell carcinoma (pathological stage: IIIA T4N0M0) and microscopic complete tumor resection (R0) was performed. The patient was treated with adjuvant chemotherapy (CDDP+VNR 4 courses). Thirteen months after surgery, the patient was healthy without tumor relapse.

A 30-year-old man was transported to our hospital emergently after receiving a crush injury to his left chest. CT showed a left hemopneumothorax with multiple rib fractures. In addition, CT revealed intraperitoneal free-air and the transverse colon herniating into the left thoracic cavity. After the insertion of a chest tube, his condition rapidly deteriorated into shock, with large amounts of blood draining from the chest tube. We made a decision to perform emergency thoracotomy followed by laparotomy. The intraoperative findings were slight bleeding from the chest wall and herniation of the colon through the ruptured diaphragm. We cauterized the bleeding sites on the chest wall, repaired the diaphragm, and then closed the thoracic cavity. A laparotomy was initiated in a supine position. Upon entry into the peritoneal cavity, blood spouted out, and the patient deteriorated further into severe hemorrhagic shock. The left renal artery had been completely transected. First, we extirpated the left kidney and sutured the proximal stump of the renal artery. After that, we resected the transverse and descending colon given the presence of ischemic changes and fashioned a colostomy. The postoperative course was uneventful. Blunt diaphragmatic injury complicated by complete transection of the renal artery is extremely rare. In the present case, we emphasize that the renal artery injury caused the massive hemothorax through the ruptured diaphragm. When a hemothorax accompanied by diaphragmatic injury is observed, we should bear in mind that intraperitoneal organ injury can cause the hemothorax, and devise a strategy for surgical intervention.

The patient was a 50-year-old woman with a history of contrast medium allergy. A nodule shadow in the left lung was pointed out on a chest radiograph obtained in a health examination. Chest CT showed a nodular lesion of 37 mm that contacted the distal part of the aortic arch and S1+2 segment of the left lung. PET-CT showed the high-level accumulation of FDG (SUV-max: 6.05) in the nodule lesion, suggesting lung cancer or angiosarcoma. Chest MRI showed thoracic aortic dissection. After discussing treatment strategies with cardiovascular surgeons, we decided to perform stent-graft insertion (TEVAR) for thoracic aortic dissection and simultaneous thoracoscopic biopsy. However, hemoptysis occurred suddenly before the operation, the lesion expanded rapidly, and pulmonary hemorrhage was observed. Thus, emergent TEVAR was performed. Bronchoscopy was conducted postoperatively, but a definite diagnosis was not obtained. Fortunately, follow-up chest CT showed a decreased in the nodular lesion showed a decrease in the size, and the nodular lesion was judged as thoracic dissociative aortitis due to dissection of the thoracic aorta. The patient had a history of contrast medium allergy, and it is extremely difficult to make an accurate diagnosis of thoracic dissociative aortitis without the use of contrast medium on CT. It was fortunate for us not to perform trans-bronchoscopic biopsy, because the risk of bleeding would be high in thoracic dissociative aortitis. Thoracoscopic biopsy is the most useful method for distinguishing malignant tumors such as lung cancer from benign tumors. However, in the present patient, this was difficult to perform due to the coexistence of thoracic aortic dissection.

Nodular lymphoid hyperplasia (NLH) is a rare tumor classified as a lymphoproliferative disorder. A 71-year-old man with a history of chronic bronchitis had a cough. He had a past history of epilepsy and Hashimoto's disease. Chest computed tomography showed a 17-mm nodule in the left upper lobe. Fluorodeoxyglucose (FDG) -positron emission tomography showed an abnormal uptake of FDG, with a maximum standardized uptake value of 1.42 in the nodule. Although he was diagnosed with chronic inflammation by bronchoscopy, the nodule gradually grew and he was referred to our department. He underwent partial resection of the left upper lobe under thoracoscopy. Histochemical and immunohistochemical examinations confirmed the resected tumor to be NLH. We report a surgical case of NLH requiring differentiation from lung cancer.

The case was a 36-year-old man. An abnormal shadow was pointed out on a chest radiograph at his medical examination. Chest CT revealed centrilobular granular shadows predominantly in the lower lobes. The diagnosis was not confirmed by bronchoscopy, and so thoracoscopic lung biopsy was performed. Histopathological findings showed calcifications of 0.5 mm in diameter and bone tissues with fatty medulla, that were bifurcated forms along the alveolar wall septum. We diagnosed it as dendriform pulmonary ossification. This disease is extremely rare and causes ectopic ossification in lung tissues. This is usually found at autopsy due to the nature subjective of the symptoms, however the prognosis is unclear because there are few reports on long-term follow up. The patient has been alive for 4 years since the operation without any changes on imaging.

We herein report the case of a patient with chylothorax following the resection of a giant schwannoma of the right chest wall. A 66-year-old female with abnormal chest radiograph findings on medical examination was referred to our hospital. Chest computed tomography revealed a 12-cm mass in the right chest cavity. On magnetic resonance imaging, the mass exhibited a high signal intensity in T1-weighted images and low signal intensity in T2-weighted images, consistent with a cystic tumor. The patient underwent open thoracotomy and tumor resection. The pathological diagnosis was schwannoma. Chylous pleural effusion was observed in the chest tube after a meal on the day after surgery. Despite conservative therapy with drainage and fasting, the amount of daily drainage was persistently more than 1000 mL. On postoperative day 7, she underwent thoracoscopic surgery. There was no damage to the thoracic duct, but chyle leak from the chest wall was observed. The thoracic duct and site of the chyle leak were closed with clipping, which led to a reduction in the chylous drainage to 200 mL/day. The pleural effusion completely resolved following pleurodesis with 10KE of OK432, 14 days after the re-operation.

The most common etiology of young adult pneumothorax is primary spontaneous pneumothorax. Bullae in the apex are often the cause of pneumothorax. However, it is uncommon for multiple cysts and emphysematous changes to be localized in one segment. In such cases, pulmonary cysts are usually secondary to some underlying disease, such as bronchial atresia.

A 30-year-old man with a history of left spontaneous pneumothorax visited our hospital presenting with a chief complaint of dyspnea. A chest radiograph showed recurrence of the left spontaneous pneumothorax. Computed tomography (CT) showed multiple pulmonary cysts and peripheral hyperinflation localized in the left superior segment. No emphysematous change was detected in other lung areas. A thoracoscopic bullectomy was performed, and no cyst was observed in the left lower lobe. A subsequent pathological examination revealed an emphysematous change and multiple cyst formation without evidence of an inflammatory response. The alveolar epithelium of the cysts was almost decidualized. Thoracoscopic surgery was performed again due to prolonged air leakage and postoperative empyema. The clinical course after the second operation was uneventful and the patient remains asymptomatic.

Although we did not reach a definitive diagnosis in the present case, we suggest that bronchial atresia may be responsible for the localized cyst formation. CT did not show an atretic bronchus or mucoceles. Hyperinflation was seen in the peripheral region of the superior segment, but not in the entire segment. These negative CT findings suggest that congenital bronchial atresia (CBA) is not a probable diagnosis. These findings can be explained in adult cases of acquired bronchial atresia by well-developed collateral ventilation pathways such as the pores of Kohn, bronchioalveolar channels of Lambert, and interbronchiolar channels. These collateral pathways reduce air-trapping, which causes mild hyperinflation and drainage of mucoid materials, resulting in an absence of mucoceles. Other differential diagnoses include congenital pulmonary airway malformations (CPAM) and Birt-Hogg-Dubé (BHD) syndrome. However, the CT findings in our case do not support the diagnosis of CPAM, and the past medical history and family history rule out the diagnosis of BHD syndrome.

In conclusion, we encountered a case of spontaneous pneumothorax due to cystic lesions and hyperinflation localized in the left upper lobe. Transient bronchial atresia is the most probable mechanism of localized cyst formation in the present case; however, we lack pathological evidence for a conclusive diagnosis. There might be other such inconclusive cases with radiologic findings similar to our case. We believe that our case should be reported as it makes a significant contribution to the existing literature.

Background: We report a case of desmoid-type fibromatosis (DTF) in the surgical wound of a patient who had undergone lung cancer surgery, and analyzed cases of DTF of the chest wall reported over the past 50 years. Case presentation: The patient was a 76-year-old man who underwent surgery for lung cancer of the right upper lobe. Chest computed tomography (CT) showed a growing mass lesion in the right 7^th intercostal space. Because CT-guided fine-needle biopsy could not confirm the diagnosis, surgical intervention for the lesion was performed. The lesion and right 7^th and 8^th ribs were resected and the lesion was diagnosed as DTF.

Discussion: Regarding the characteristics of DTF of the chest wall, it has been reported that the occurrence rate does not differ between the sexes, 30% of the cases were related to surgical procedures, 30% developed postoperative recurrence, and DTF related to surgical intervention occurred in older patients.

Conclusion: It is important to consider that lesions requiring surgical intervention may be DTF.

A 68-year-old woman was referred to our hospital because of an abnormal chest shadow. A thoracic duct cyst was suspected because a cystic tumor was found along the course of the thoracic duct on magnetic resonance imaging, and surgery was performed. As preparation to identify the thoracic duct, the patient ingested fatty foods 3 hours before the induction of general anesthesia. During the procedure, the thoracic ducts communicating with the tumor could be easily identified, and these were ligated and dissected. Chylothorax was not noted after the operation. Although thoracic duct cyst is a rare disease, it is essential to treat the thoracic duct communicating with the tumor properly. Our preparation in surgery for thoracic duct cyst is considered a simple and safe method to identify the thoracic duct.

Metaplastic thymoma, adopted in the World Health Organization (WHO) classification in 2004, exhibits a biphasic architecture consisting of polygonal epithelial and spindle cells. Only about 30 cases have been reported so far. We report two rare cases of metaplastic thymoma. The first case was a 44-year-old woman presenting with bilateral ptosis, swallowing difficulty, severe fatigue, and a positive result for anti-acetylcholine receptor antibody (78.6 nmol/L). Computed tomography showed a well-circumscribed mass measuring 3.1 cm in maximum diameter in the anterior mediastinum. She was diagnosed with thymoma-associated myasthenia gravis, and underwent extended thymectomy through a median sternotomy. The second case was a 55-year-old man treated for prostate cancer. He underwent computed tomography for further examination. A well-circumscribed low-density mass was located in the anterior mediastinum. The anti-acetylcholine receptor antibody level was below 0.3 nmol/L. With a diagnosis of thymoma, he underwent thymectomy through a median sternotomy. In both cases, histology demonstrated the biphasic architecture of epithelial and spindle cells. The postoperative pathological diagnosis of both cases was metaplastic thymoma, pT1aN0M0 pStage I.

A 52-year-old man was referred to our hospital because of a cough and radiographic abnormality. Chest CT revealed a tumor of 53 mm in diameter in the anterior mediastinum. His preoperative serum squamous cell carcinoma antigen (SCCA) levels were markedly high (77.6 ng/mL) and serum anti-acetylcholine receptor (AchR) antibody levels were also slightly high (0.4 nmol/L). However, no autoimmune diseases including myasthenia gravis were identified. FDG-PET revealed abnormal accumulation at the mediastinal tumor (SUVmax: 3.4). The tumor was suspected to be thymic cancer and he underwent extended thymothymomectomy. Pathological findings showed a type B1 thymoma in WHO's histological classification and stage I in Masaoka's classification. Postoperative systemic evaluation showed no abnormalities including in the head and neck, dermatological, gastrointesitinal, and rectoproctal regions. Current serum SCCA levels are decreasing moderately 2 years and 6 months after surgery. Several reports showed discrepancies in laboratory data between immunoassays such as the chemiluminescent immunoassay (CLIA) method and fluorescence enzyme immunoassay (FEIA) method used to evaluate serum SCCA levels. The results in our case showed a marked difference (approximately ten-fold) between them. Here, we describe the clinical course of this patient and also discuss the mechanism of this difference, because this discrepancy might affect the dignosis of the tumor type.

We herein report a case of thoracoscopic surgery using high-frequency jet ventilation (HFJV) for left acute empyema after total right pneumonectomy. A 71-year-old man had undergone right pneumonectomy at 64 years old for squamous cell carcinoma of the right lung. At his recent presentation, the patient complained of left chest pain. He was treated with antibiotics for pleurisy, but left pleural effusion and dyspnea worsened. Chest drainage was performed. Cloudy pleural effusion was observed, and the patient was referred to our department for acute empyema. As computed tomography revealed pleural effusion in multiple cavities, we decided to perform decortication by means of video-assisted thoracic surgery. Surgery was performed thoracoscopically with the left lung ventilated with HFJV and started in the right lateral position. Although the lungs were slightly inflated by HFJV, we were able to secure a visual field and working space by excluding them. The postoperative course was uneventful, and the patient was discharged on the sixth postoperative day.

A 71-year-old woman had been diagnosed with autoimmune pulmonary alveolar proteinosis 4 years prior to presentation at our department. Chest computed tomography (CT) showed a lung nodule with cavitation in the right upper lobe, with typical CT findings of pulmonary alveolar proteinosis disappearing gradually. We suspected that the nodule was lung cancer and decided to perform surgery. The operative procedure was right upper lobectomy and lymph node dissection via complete video-assisted thoracic surgery (VATS). The pathological diagnosis was pT1cN0M0, pStage IA3, adenosquamous carcinoma. The pulmonary alveolar proteinosis was not exacerbated during the perioperative period. Pulmonary alveolar proteinosis is a rare pulmonary disease characterized by excessive alveolar accumulation of surfactant due to defective alveolar clearance by macrophages. Patients positive for anti-granulocyte-macrophage colony-stimulating factor antibody are categorized as having autoimmune pulmonary alveolar proteinosis. There are only a few published case reports of autoimmune pulmonary alveolar proteinosis occurring in association with lung cancer. To our knowledge, this is the first case report of autoimmune pulmonary alveolar proteinosis associated with lung adenosquamous carcinoma. Autoimmune pulmonary alveolar proteinosis may be involved in lung cancer development and mycobacterial infection.

A 70s man presented at a previous hospital with chronic cough. A chest radiograph showed a shadow of a large mass in the left upper lung. Chest computed tomography (CT) showed a large tumor in the left S¹⁺², with possible invasion of the third and fourth ribs, lower lobe (S⁶), and aorta. Subsequently, CT-guided lung biopsy was performed, and histological analysis suggested spindle cell sarcoma. He was referred to our hospital for surgical resection. We performed a left upper lobectomy with partial resection of the left lobe (S⁶) and third and fourth ribs. Histological examination revealed a primary pulmonary rhabdomyosarcoma (RMS). No lymph node metastases were found, and the resection margin was negative. The postoperative course was uneventful, and he was discharged 19 days after the operation. No recurrence was observed 24 months after the operation. Primary pulmonary sarcomas represent approximately 0.2-2.0% of all lung malignancies. Adult-onset primary pulmonary RMS is extremely rare. Complete surgical resection is the preferred and only potentially curative treatment. If the tumor is resectable, the surgeon should aim for complete resection, even if combined resection of adjacent organs is necessary.

We present the case of a 73-year-old male patient in whom posterior mediastinal masses were incidentally detected on abdominal CT during work-up for prostatic hypertrophy and urolithiasis. A posterior low-density mediastinal mass of 60 mm in diameter was detected on chest CT, and was mainly high-intense and partially low-intense on T1- and T2-weighted imaging, respectively, but the high-intensity area showed a low intensity on fat-suppressed T1-weighted imaging. Based on these findings, to rule out suspected liposarcoma, we performed video-assisted thoracoscopic surgery. The intraoperative findings showed that the tumor was yellowish, well-encapsulated, and very fragile, but it was completely resected with the surrounding capsule, and the final pathological diagnosis was posterior mediastinal myelolipoma. Follow-up examination showed no recurrence or hematologic abnormality 1 year after the operation. Myelolipoma is a benign tumor composed of mature adipocytes and normal myeloid cells, which often occurs mainly in the adrenal cortex, and mediastinal development is rare. Diagnostic imaging of mediastinal myelolipoma is not standardized and preoperative diagnosis is difficult. We reviewed 12 cases with CT and MRI findings over the last 10 years, and report them along with our case.

A 69-year-old man with cold symptoms was found to have a tumor in the right posterior mediastinum and was referred to our hospital. A chest radiograph and CT revealed a well-circumscribed mass with a smooth surface adjacent to the right side of the tenth thoracic vertebra. This tumor had not changed in size for five years and showed no activity on FDG-PET. Extirpation under video-assisted thoracoscopic surgery was performed for the preoperatively suspected neurogenic tumor. The soft, dark-red tumor was completely resected. Histopathologically, the tumor was composed of hematopoietic cells and mature adipocytes, and was diagnosed as myelolipoma. In this case, it was not easy to distinguish myelolipoma from extramedullary hematopoiesis because of the clinical aspects of anemia and splenomegaly. To make a confirmative diagnosis, postoperative bone marrow biopsy was performed to demonstrate normocellular marrow without any atypical cells.

Background: Most common thymic tumors are thymomas; however, thymic carcinoma is a rare disease. Because a large proportion of thymic carcinomas comprise squamous cell carcinomas, adenocarcinoma is extremely rare. Case: A 70-year-old woman was admitted to our hospital due to an anterior mediastinal tumor. Chest computed tomography (CT) showed an anterior mediastinal tumor. Chest CT showed a well-defined 12-mm cystic mass in the anterior mediastinum. The anterior mediastinal tumor was resected using video-assisted surgery. The histopathological diagnosis was non-papillary adenocarcinoma. Primary adenocarcinoma of the mediastinum is extremely rare; therefore, metastasis of other-organ cancers was suspected. CT and positron emission tomography (PET) revealed no obvious lesions, and so the patient was diagnosed with primary adenocarcinoma of the thymus (T1N0M0 stage I). She is alive without recurrence at 1 year after surgery. Conclusion: We encountered a patient with thymic adenocarcinoma showing a peculiar cystic growth pattern. Such an adenocarcinoma is rare in the mediastinum, and metastatic tumors should be excluded by differential diagnosis.

We report a multidisciplinary treatment for pyothorax caused by a traumatic reconstructed gastric-thoracic fistula after esophageal cancer surgery. To our knowledge, there has been no report of a thoracic fistula due to traumatic reconstructed gastric tube injury. A 72-year-old man with a history of falling 3 weeks earlier was diagnosed with acute respiratory failure due to multiple bilateral rib fractures and traumatic hemopneumothorax. After bilateral thoracic drainage and ventilator management, the respiratory status improved, but he showed right empyema. CT suggested a reconstructed gastric tube injury and gastrointestinal endoscopy confirmed the fistula. The fistula was directly closed with sutures, but it recurred. After fenestration and enterostomy, adequate nutritional management and hyperbaric oxygen therapy were performed, and the fistula was cured.