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Background It is presumed that tracheobronchomalacia in adults is caused by airway pressure-induced injury due to chronic cough related to pulmonary emphysema or chronic bronchitis. Commonly, a posterolateral approach using stabilizing materials is the surgical technique of choice for treating tracheobronchomalacia. We report a case in which thoracoscopic plication of the membranous portion was performed instead of airway stent placement for tracheobronchomalacia in an elderly individual. Case presentation An 87-year-old man who had been treated for bronchial asthma, pulmonary emphysema, and tracheobronchomalacia was admitted to our hospital with acute exacerbation of dyspnea. The patient underwent tracheal intubation, which was followed by tracheostomy 16 days later. Insertion of the tip of the adjustable-length tracheostomy tube to the end of the stenotic lesion enabled him to breathe spontaneously. However, conservative management failed due to recurrent pneumonia caused by the tracheobronchomalacia. Crescent-type tracheobronchomalacia (Johnson’s classification grade III) was diagnosed, and the main narrowed area of the trachea was assumed to be approximately 3–10 cm from the tracheal bifurcation. A thoracoscopic approach was selected because a posterolateral approach was considered too invasive considering the patient’s age and general condition. We placed eight stitches on the tracheal membranous portion and four stitches on the membranous portion of the right main bronchus, using the horizontal mattress suture technique. The use of foreign materials was avoided because meropenem-resistant Pseudomonas aeruginosa was cultured in a tracheal specimen. Immediately after the operation, the expiratory airway stenosis improved, and subsequently, spontaneous ventilation was possible using a normal type of tracheostomy tube instead of an adjustable-length tracheostomy tube. Conclusions Tracheobronchomalacia is not a rare condition in patients with chronic obstructive pulmonary disease. The thoracoscopic approach is less invasive than the posterolateral approach and is suitable in cases that are otherwise refractory to medical treatment. We believe that thoracoscopy may be a useful treatment option in cases where conservative treatment is not appropriate.

Background To report the follow up data and clinical outcomes of the JME study (UMIN 000008177), a prospective, multicenter, molecular epidemiology examination of 876 surgically resected non‐small‐cell lung cancer (NSCLC) cases, and the impact of somatic mutations (72 cancer‐associated genes) on recurrence‐free survival (RFS) and overall survival (OS). Methods Patients were enrolled between July 2012 and December 2013, with follow up to 30th November 2017. A Cox proportional hazards model was used to assess the impact of gene mutations on RFS and OS, considering sex, smoking history, age, stage, histology, EGFR, KRAS, TP53, and number of coexisting mutations. Results Of 876 patients, 172 had ≥2 somatic mutations. Median follow‐up was 48.4 months. On multivariate analysis, number of coexisting mutations (≥2 vs 0 or 1, HR = 2.012, 95% CI: 1.488‐2.695), age (≥70 vs, A prospective, multi‐center, molecular epidemiology study of 876 surgically resected non‐small cell lung cancer cases, and the impact of somatic mutations (72 cancer‐associated genes) on recurrence‐free survival and overall survival (OS). A smaller number of co‐existing mutations, earlier stage, and younger age were associated with longer recurrence free survival and OS, while epidermal growth factor receptor mutations were significantly associated with improved OS.

Purpose This study was designed to evaluate the feasibility of concurrent induction chemoradiotherapy (CRT) using S-1, an oral fluoropyrimidine derivative, plus cisplatin followed by surgery in locally advanced non-small cell lung cancer (NSCLC). Patients and methods We defined locally advanced NSCLC as pathologically proven chest wall invasion or hilar and/or mediastinal lymph node metastases by endobronchial ultrasound-guided transbronchial needle aspiration. Twenty-three patients were enrolled in this study from May 2011 to April 2014. The patients received S-1 40mg/m 2 orally twice daily on days 1 through 14 and 29 through 42, and cisplatin 60mg/m 2 was injected intravenously on days 8 and 36. The patients also underwent radiotherapy and received a total dose of 40Gy in 20 fractions beginning on day 1. Surgical resection was performed from 4 to 6 weeks after completion of the induction treatment. Results Of the 23 eligible patients, 18 had stage IIIA and 5 had stage IIB NSCLC. Twenty patients (87.0%) completed induction CRT and underwent surgical resection. Representative grade 3 adverse reactions were neutropenia (21.7%) and leukocytopenia (8.7%); no grade 4 adverse reactions were observed. Radiologically, 7 (30.4%) of the 23 patients achieved partial response and were therefore radiologically downstaged. Twenty patients were curatively resected. Six (26.1%) complete responses were identified and 12 cases (52.2%) were histopathologically downstaged by induction CRT. Conclusion Concurrent induction CRT using S-1 plus cisplatin is a feasible and promising new treatment modality for locally advanced NSCLC. Evaluation of histopathological downstaging revealed sufficient anti-cancer effects for preoperative treatment. MicroAbstract Because chemoradiotherapy (CRT) using cisplatin and S-1, an oral fluoropyrimidine, is effective for unresectable non-small cell lung cancer, the feasibility of this therapy in a neoadjuvant setting was evaluated in a multicenter phase II study. Toxicities were very mild and 87.0% of the 23 patients completed induction CRT. This protocol seems feasible and is considered an option among preoperative therapies.

The operative morbidity rate in elderly patients with lung cancer is high in comparison to nonelderly patients, probably because of the increase in comorbidities that occurs with aging. However, previous reports were retrospective and were performed at single institutions; thus, the preoperative comorbidities and operative morbidity could not be fully assessed. We conducted a multi-institutional prospective observational study of elderly patients (>75 years of age) with a completely resected non–small cell lung cancer. From March 2014 to April 2015, 264 patients from 22 hospitals affiliated with the National Hospital Organization in Japan were prospectively registered in the present study. The primary end point was operative morbidity (National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0). The secondary end points were operative mortality and the risk factors for operative morbidity. Preoperative comorbidities were assessed according to the Adult Comorbidity Evaluation-27 index. The mean age at the time of surgery was 79.3 years (range 75-90 years). Forty-one percent of the patients were >80 years of age. Twenty-six percent underwent sublobar resection. The incidence of morbidities of any grade was 43.2% (90% confidence interval: 38.2%-48.2%). Respiratory system-related morbidity (19.3%), followed by cardiovascular system-related morbidity (10.2%), was the most common morbidity. The in-hospital mortality rate was 1.1% (3 of 264 patients). A multivariate analysis of the risk factors for operative morbidity showed that both Adult Comorbidity Evaluation-27 grade and the blood loss volume were significant factors. The results of the present prospective multi-institutional study should be used as a reference in the surgical treatment of elderly patients with lung cancer.

Although follow-up surveillance after resection for lung cancer is commonly performed in clinical practice, there is no standard follow-up program. We attempted to establish follow-up examination schedules that we considered would be acceptable to the majority of doctors, and would like to propose them as standard postoperative follow-up pathways.We carried out a retrospective analysis of patients' data and reviewed the time of detection of recurrence and the site of recurrence after resection. Published papers were also reviewed. The postoperative follow-up pathways were established based on these data.The follow-up period was set at as 5 years after resection, and physical examinations, chest radiography, chest CT and blood examination are recommended. Two follow-up pathways were proposed taking the risk of recurrence into consideration: the Risk of recurrence-based pathway and the Comprehensive pathway. In the Risk of recurrence-based pathway, the follow-up examination schedule is modified according to the risk of recurrence. In the Comprehensive pathway, a single universal examination schedule is recommended for all patients. The choice between these two pathways is left to the discretion of the attending doctor.We proposed two follow-up pathways, based on retrospective analysis of patients' data and a review of published papers, which we considered would be acceptable to the majority of doctors and would be suited to the current medical environment in Japan. A prospective study to evaluate the efficacy of the follow-up pathways is ongoing.

Objectives: Chest tube insertion seems to be one important factor leading to intercostal nerve impairment. The purpose of this prospective study was to objectively evaluate intercostal nerve damage using current perception threshold testing in association with chest tube insertion. Methods: Sixteen patients were enrolled in this study. Intercostal nerve function was assessed with a series of 2000-Hz (Aβ fiber), 250-Hz (Aδ fiber), and 5-Hz (C fiber) stimuli using current perception threshold testing (Neurometer CPT/C R). Current perception threshold values at chest tube insertion were measured before surgery, during chest tube insertion and after removal of the chest tube. Intensities of ongoing pain were also assessed using a numeric rating scale (0-10). Results: Current perception thresholds at each frequency after surgery were significantly higher than before surgery. Numeric rating scale scores for pain were significantly reduced from 3.3 to 1.9 after removal of the chest tube (p = 0.004). The correlation between current perception threshold value at 2000 Hz and intensity of ongoing pain was marginally significant (p = 0.058). Conclusions: This is the first study to objectively evaluate intercostal nerve damage at chest tube insertion. The results confirmed that chest tube insertion has clearly deleterious effects on intercostal nerve function., General Thoracic and Cardiovascular Surgery, 62(1), pp.58-63; 2014

A rare case of a patient with primary adenocarcinoma of the middle lobe bronchus that was successfully treated with rigid bronchoscopy followed by middle sleeve lobectomy is reported. The patient was a 75-year-old man who presented with low-grade fever and cough. Chest computed tomography showed obstructive pneumonia of the lower lobe and a polypoid lesion in the truncus intermedius. Middle sleeve lobectomy and mediastinal lymphadenectomy were performed following recovery of respiratory function after partial resection of the tumor with rigid bronchoscopy. There was no sign of tumor recurrence and metastasis over 32 months of follow-up. We should be aware of tracheal or bronchial tumor in patients with prolonged asthma-like symptoms. Palliative resection with rigid bronchoscopy was useful to make the correct diagnosis, evaluate the extent of the tumor, and protect the right lower lobe.

Background: Lung transplantation cases have immunosuppression maintained using a calcineurin inhibitor, anti-metabolites, and steroid. Case Report: We report 2 clinical cases in which anti-metabolites (mycophenolate mofetil) were successfully withdrawn after living donor lobar lung transplantation by monitoring immune function using the ImmuKnow® assay. In the first case, a 43-year-old woman underwent living donor lobar lung transplantation for pulmonary alveolar proteinosis. Two healthy relatives donated a lower lobe each. Immunosuppression was maintained using tacrolimus, mycophenolate mofetil, and steroid. Six months posttransplantation, she developed invasive pulmonary aspergillosis. During anti-fungal treatment, we withdrew mycophenolate mofetil and tacrolimus trough levels were kept around 8 ng/mL. Despite the resulting low-level immunosuppression, the ImmuKnow assay showed immune function to be in the moderate range with tacrolimus and steroid alone, encouraging us to maintain this strategy to avoid recurrence of invasive pulmonary aspergillosis. In the second case, a 24-year-old man underwent living donor lobar lung transplantation for cystic fibrosis. Two healthy relatives donated a lower lobe each. Immunosuppression was maintained using tacrolimus, mycophenolate mofetil, and steroid. Five months posttransplantation, he developed persistent Pseudomonas aeruginosa pneumonia derived from the paranasal sinuses. Under ImmuKnow assay monitoring, mycophenolate mofetil was withdrawn, but immune function was maintained within the moderate range using tacrolimus and steroid alone. Discussion: Respiratory function in both cases was maintained; no findings of bronchiolitis obliterans syndrome were noted during this period. To the best of our knowledge, no reports have described successful anti-metabolite withdrawal in lung transplantation with ImmuKnow monitoring. Immune evaluation by ImmuKnow could offer a useful method to monitor and control immune status, particularly among recipients susceptible to infection, revealing that moderate immune function could be maintained using tacrolimus and steroid in living donor lobar lung transplantation., Transplantation Proceedings, 45(1), pp.356-359; 2013

Purpose Oncogenic driver mutations are critical for lung cancer development and serve as therapeutic targets. However, their associations with environmental factors are not fully understood. We aimed to elucidate the relationship between tumor developmental biology and exposure to environmental factors. Patients and Methods This was a prospective, multicenter, molecular epidemiology study. Eligible patients were those with newly diagnosed stages I to IIIB non–small-cell lung cancer (NSCLC) who underwent surgery. The tumors were examined for somatic mutations in 72 cancer-associated genes by targeted deep sequencing, estrogen receptor β (ERβ) expression using immunohistochemical staining, and infection with any of 37 types of human papillomavirus (HPV) using a polymerase chain reaction–based microarray system. Detailed information on patient demographics and environmental factors was obtained from a comprehensive questionnaire. Results From July 2012 to December 2013, 957 patients were enrolled, and molecular analyses were performed on 876 samples (from 441 ever- and 435 never-smokers). Oncogenic driver mutations in P53 and KRAS increased proportionally with smoking status, whereas mutations in EGFR and SMAD4 decreased. KRAS mutations in smokers and SMAD4 mutations were observed more frequently in proportion to body mass index. TP53 and NFE2L2 mutations were observed more frequently in advanced NSCLC stages. As for never-smokers, no environmental factors were significantly associated with mutational changes. EGFR mutations and TP53 mutations were observed more frequently in women and in men, respectively. Mutations in these two genes were also potentially associated with ERβ expression. Only three patients (0.3%) were HPV positive. Conclusion The mutational spectrum is associated with smoking, body mass index, and other environmental factors, as well as with ERβ expression. Little association was observed between HPV and NSCLC.

We herein report an unusual case of invasive thymoma with venous intraluminal extension. The thymoma extended into the superior vena cava, the left brachiocephalic vein, and the proximal portion of the left jugular and subclavian veins intraluminally. It was suggested that the tumor had a discrete intravascular growth via the thymic vein into the left brachiocephalic vein and extended into the proximal portion of the left jugular and subclavian veins in the opposite direction of the venous stream.

Background: Oral adjuvant chemotherapy without hospitalization might reduce the physiological and psychological burden on patients if effectiveness could be guaranteed. We conducted a multicenter feasibility study using S-1, an oral derivative of 5-fluorouracil, as postoperative adjuvant chemotherapy in patients with curatively resected pathologically stage IB-IIIA non-small-cell lung cancer. Patients and Methods: Adjuvant chemotherapy comprised 8 courses (4-week administration, 2-week withdrawal) of S-1 at 80-120 mg per day. Fifty-one patients from 7 institutions were enrolled in this pilot study, from June 2005 to March 2007. The primary end point was the completion rate of scheduled adjuvant chemotherapy. Secondary end points were the incidence and grade of adverse reactions. Results: Fifty patients were eligible. The completion rate for the planned 8 courses of S-1 administration was 72.0% (36 patients). Total percentage administration amount was 71.1%. Grade 3 adverse reactions such as neutropenia (4.0%), anorexia (4.0%), thrombopenia (2.0%), anemia (2.0%), elevated total bilirubin (2.0%), hypokalemia (2.0%), nausea (2.0%), and diarrhea (2.0%) were observed, but no grade 4 adverse effects were encountered. Overall and relapse-free survival rates at 3 years were 87.7% and 69.4%, respectively. Conclusions: Postoperative 1-year administration of S-1 seems feasible as oral adjuvant chemotherapy for lung cancer. The oral formulation and low incidence of adverse reactions permit treatment on an outpatient basis. The present study would be reasonable to follow up with a properly powered phase III trial., Clinical Lung Cancer, 13(6), pp.464-469; 2012

Objective: Chronic pain is a common complication after thoracic surgery. The most important factor appears to be intercostal nerve damage. The purpose of this prospective study was to objectively evaluate intercostal nerve damage associated with post-thoracotomy pain after three surgical procedures using current perception threshold testing. Methods: The 32 patients were classified into three groups: the video-assisted thoracic surgery group (n=7), the video-assisted minithoracotomy with metal retractors group (n=15), and the conventional thoracotomy group (n=10). Intercostal nerve function was assessed by a series of 2000-Hz (Aβ fiber), 250-Hz (Aδ fiber), and 5-Hz (C fiber) stimuli using current perception threshold testing (Neurometer CPT/C(®)). The current perception threshold values were measured before and 1, 2, 4, 12, and 24 weeks after surgery. The intensities of ongoing pain were also assessed using a numeric rating scale (0-10). Results: The video-assisted thoracic surgery group showed no changes in any current perception threshold values and no residual pain more than 12 weeks after surgery. The video-assisted minithoracotomy with metal retractors group and the conventional thoracotomy group showed significantly higher current perception threshold values at 2000Hz 1 week after surgery (p=0.0013, p=0.0012, respectively), with pain in approximately 70% of patients 12 weeks after surgery. The correlation between current perception threshold values at 2000Hz and the intensities of ongoing pain 4 and 12 weeks after surgery was significant (p=0.03, p=0.04, respectively). Conclusions: This is the first study that objectively evaluated pain after video-assisted thoracic surgery. The results suggest that the Aβ and Aδ fibers play a significant role in the development of intercostal nerve damage. The current perception threshold values clearly demonstrated that video-assisted thoracic surgery is a less-invasive procedure resulting in less post-thoracotomy pain and, they have some possibilities to objectively evaluate the ongoing pain after surgery., European journal of cardio-thoracic surgery, 39(6), pp.1033-1039; 2011

The aim of this study was to evaluate the clinical outcomes of chest wall reconstruction using a new, expanded polytetrafluoroethylene prosthesis, 'DualMesh'. Between December 2005 and March 2010, chest wall reconstruction using 2-mm DualMesh was performed in 11 patients. The indication for resection was primary lung cancer in six patients, malignant mesothelioma in one patient, recurrent lung cancer in one patient, recurrent invasive thymoma in one patient, postirradiated osteomyelitis in one patient, and chondro-hamartoma in one patient. The mean observation period was 23 months, and four cases were observed for more than three years. There were no operative deaths and no wound infections. There were two postoperative complications: prolonged air leakage occurred in a patient with pulmonary emphysema who underwent right lower lobectomy, and slight paradoxical respiration occurred in the patient who underwent resection of the entire sternal body for osteomyelitis. Follow-up chest computed tomography was performed routinely. No dehiscence occurred in any cases. Chest wall reconstruction using DualMesh demonstrated acceptable durability and biocompatibility, even after long-term follow-up. DualMesh has the potential to become an ideal prosthesis for the bony chest wall as an alternative to conventional polytetrafluoroethylene or polypropylene grafts.

The purpose of this study was to evaluate the clinical significance of multiple focal pure ground-glass opacities (GGOs) on high-resolution CT images of patients with lung cancer.The cases of 23 patients with proven lung cancer and associated multiple focal pure GGOs on high-resolution CT images were retrospectively reviewed. The number, size, distribution, and morphologic characteristics of focal pure GGOs were evaluated. Serial changes in focal pure GGOs that were not surgically resected were analyzed at follow-up high-resolution CT.The number of focal pure GGOs was 196 in total. The size of the opacities ranged from 2 to 30 mm in largest diameter. Lung cancer and focal pure GGOs were seen in the same lobe and/or in the other lobes. One hundred seventy-one of the lesions (87%) had a well-defined border or round shape. Histologic findings were obtained for 15 lesions representing 74 focal pure GGOs that were surgically resected: 11 atypical adenomatous hyperplasia lesions, three bronchioloalveolar carcinomas, and one lesion of focal fibrosis. In 110 of the cases of focal pure GGOs, all of which were followed up with HRCT for a median duration of 1,351 days, the size of 105 lesions (95%) did not change, the size of one decreased, and four lesions disappeared.The size of most focal pure GGOs associated with lung cancer did not change during the follow-up period. Most of the small number of lesions histologically diagnosed were atypical adenomatous hyperplasia or bronchioloalveolar carcinoma. These data justify the therapeutic strategy of resecting the primary tumor without therapeutic intervention in the remaining focal pure GGOs.

8549Background: We previously reported molecular profiling as a primary endpoint in a prospective multicenter molecular epidemiology study, collecting 876 surgically resected NSCLC and examining 72...

Cystic fibrosis (CF) is rare in Japan. We encountered a CF case with drug-resistant Pseudomonas aeruginosa infection and successfully performed lung transplant from living related donors. A combination of betalactams and aminoglycosides for drug-resistant P. aeruginosa infection was administered before lung transplantation. Intravenous colistin was also used immediately before and after transplant surgery. Gram staining of respiratory specimens was performed every day after surgery and it was useful in monitoring infection status. Strict monitoring of infections by the Gram staining and culture of respiratory specimens is considered to be effective in preventing lower respiratory infection in lung transplantation., Internal Medicine, 49(21), pp.2353-2358; 2010

60歳男性．胸部単純写真で左下肺野に腫瘤影を指摘された．CTでは左下葉に径15cmの巨大腫瘤を認め，肺門・縦隔リンパ節腫大も認めた．CTガイド下肺生検にて肺多形癌と診断された．cT3N2M0 Stage III Aで，腫瘍の急速な増大と血痰を繰り返すため，手術を施行した．巨大な腫瘍により下葉の可動性はなく肺静脈処理を先行させることは困難であり，葉間肺動脈，下葉気管支，舌区気管支，舌区静脈の順に処理し，最後に下肺静脈をステープラで切離した．その後，右橈骨動脈ラインの圧波形が平底化し，触知不能，冷感が出現し，塞栓閉塞を疑った．術後血管造影で上腕動脈の閉塞を認め，緊急塞栓除去術を施行した．血管内腔は腫瘍栓で閉塞しており，病理診断でも腫瘍塞栓であった．肺切除術に伴う腫瘍塞栓はまれであるが，肺静脈に浸潤が疑われる症例では，術前の評価方法や術中の操作に考慮すべき点がある．

背景．HIV感染者に発症する肺癌は海外において近年増加傾向にあるが，本邦における手術報告例は少ない．症例．57歳男性．肺炎を契機にHIV陽性と診断され，HAART（highly active antiretroviral therapy）内服開始となった．HIV感染診断5年後の胸部単純写真で左上肺野に結節影を指摘された．胸部CTでは左S1+2に21 mm大の結節を認め，PETでも同部と肺門リンパ節に集積が見られた．気管支鏡下擦過細胞診で診断は得られなかったが肺癌を強く疑った（cT1N1M0，stage IIA）．血液曝露を少なくする目的もあり胸腔鏡下左上葉切除術を施行した．最終病理診断は腺癌で，進行度はpT1N2M0，stage IIIAであった．経過は良好で術後9日目に退院した．周術期を通じて職業感染対策のため血液曝露の機会を極力少なくするなど工夫を行った．結論．HIV感染合併肺癌でもHIV感染が良好に制御されていて全身状態が良好であれば通常と同様に手術が可能である．胸腔鏡下手術は血液汚染が少なく，感染防止に有用であった．

Distant metastasis of benign pleomorphic adenoma of salivary glands rarely occurs, and these neoplasms have been termed metastasizing pleomorphic adenoma. We present a rare case of metastasizing pleomorphic adenoma of the submandibular gland with lung and bone metastases obtained MR images and pathological findings. On MRI, the lesions were depicted as an area of high signal intensity on T2-weighted images (WI), reflecting myxoid or/and chondroid matrices. Metastasizing pleomorphic adenoma should be considered as a differential diagnosis when a pulmonary lesion shows high signal intensity on T2-WI and the patient has a medical history of salivary pleomorphic adenoma., European Journal of Radiology Extra, 72(2), pp.e69-e72; 2009

BACKGROUND: The present study aimed to elucidate the relationship between microvessel count (MVC) according to CD34 expression and prognosis in intrahepatic cholangiocarcinoma (ICC) patients who underwent hepatectomy based on our preliminary study. METHODS: Relationships between MVC and clinicopathological factors were examined in 37 ICC patients. CD34 expression was analyzed using immunohistochemical methods. RESULTS: Median MVC for ICC patients was 140/mm(2), which was applied as a cutoff value. Lower MVC was significantly associated with larger tumor size, periductal infiltrating type, and advanced Japanese tumor-node-metastasis stage (p < 0.05). Univariate survival analysis identified higher carcinoembryonic antigen level, periductal infiltrating type, poor histological differentiation, and lower MVC as significantly associated with lower 5-year survival rates. The 5-year survival rate in the higher-MVC group was significantly greater than that in the lower-MVC group (44% vs. 7%, p = 0.048). According to Cox multivariate survival analysis, only periductal infiltrating type on macroscopic examination was identified as a significant independent risk factor for poor survival after hepatectomy (risk ratio 4.8; p = 0.006), not MVC (1.1; p = 0.82). CONCLUSION: Tumor MVC might offer a useful prognostic marker of ICC patient survival after hepatectomy and further investigation in a larger series is warranted., Annals of Surgical Oncology, 16(8), pp.2123-2129; 2009

A 68-year-old Japanese man with Sjögren's syndrome was pointed out to have a nodular shadow in the anterior mediastinum. The tumor was resected under video-assisted thoracoscopy and it was pathologically diagnosed to be thymic mucosa-associated lymphoid tissue (MALT) lymphoma. There has been no recurrence for 17 months after surgery. Mucosa-associated lymphoid tissue lymphoma of the thymus is rare, and its pathological diagnosis requires sufficient knowledge and experience. Since thymic MALT lymphoma is distinct from MALT lymphoma of other sites in several ways, including gene abnormalities and geographic distribution, an alternative oncogenic pathway and the influence of racial and/or environmental factors must be considered to be involved. However, since the number of reported thymic MALT lymphomas is limited, these issues are still unclear. The accumulation of further similar cases will help to elucidate various issues concerning thymic MALT lymphoma associated with Sjögren's syndrome.

PURPOSE The treatment strategy for patients with non–small-cell lung cancer (NSCLC) involving ipsilateral mediastinal lymph nodes is still controversial. We performed a phase II feasibility study of induction chemotherapy followed by surgery for patients with pathologic N2 NSCLC. PATIENTS AND METHODS Patients with mediastinoscopy- positive stage IIIA N2 NSCLC received 2 cycles of cisplatin 80 mg/m2, vinorelbine 25 mg/m2, and mitomycin-C 8 mg/m2. Patients without progressive disease underwent thoracotomy and lobectomy with lymph node dissections 2-4 weeks later. RESULTS From January 2000 to July 2004, 24 eligible patients (15 men, 9 women) were enrolled. Induction chemotherapy was completed as planned in 23 patients (95.8%). Hematological toxicity was the primary grade 3/4 toxicity. Twelve (50%) patients achieved a partial response. Twenty-three patients underwent surgical resection, and complete resection was achieved in 22 patients (95.7%). There were no surgery-related deaths. Pathologic complete response in metastatic lymph nodes was achieved in 5 patients. With a median follow-up of 5.4 years (range, 2.88-7.7 years), the estimated 5-year survival was 51.8% (95% CI, 41.3-62.3) and progression-free survival was 46.6% (95% CI, 36–57.2). CONCLUSION Induction chemotherapy followed by surgery for patients with pathologic N2 NSCLC was feasible and associated with high response to lymph node metastasis and good survival.

Bronchoscopic lung volume reduction (BLVR) for severe emphysema is less invasive than lung volume reduction surgery. Fibroblast growth factor-2 (FGF-2) has been reported to enhance fibrogenesis and angiogenesis. The aim of this study was to investigate the feasibility of BLVR with the FGF-2, and ability to reduce lung volume and promote recovery of lung function. The BLVR based on FGF-2 is less invasive than surgical procedures, and can be performed repeatedly if the effectiveness of volume reduction is inadequate. This simple bronchoscopic approach allows selective reduction in the volume of the emphysematous parenchyma, and intratracheal administration of FGF-2 induces an increase in pulmonary blood flow, thus allowing recovery of pulmonary function.

肺に穿破した縦隔成熟型奇形腫の2症例を経験し，その病因，臨床像について文献的考察を加え報告する．症例1は19歳女性．前胸部痛で来院，胸部CTで径3cmの前縦隔腫瘍を指摘され成熟型奇形腫の診断で手術を行った．手術所見では腫瘍は右肺上葉と強固に癒着しており，上葉部分切除および心膜合併切除を伴う腫瘍切除術を行った．組織学的には腫瘍は豊富な膵組織を有する成熟型奇形腫で，肺実質内に穿破していた．症例2は35歳女性．右胸部痛と血痰で来院，胸部X線で右中肺野に腫瘤影を指摘され，胸部CT，MRIで前縦隔奇形腫が疑われた．術中所見では腫瘍は右肺に穿破しており中葉切除を伴う腫瘍切除術を施行した．組織学的診断で成熟型奇形腫の肺内穿破と診断した．本疾患は多彩な臨床症状を呈し，確定診断に苦慮することも多いが今回MRIが有用であった．

症例は31歳，男性．生来健康であった．嚥下時の違和感が出現し持続するため近医受診した．胸部単純写真にて気管の右方偏位，CTにて上縦隔腫瘍を指摘され，精査加療目的に当科紹介となった．術前に確定診断を得ることができず，手術を施行したところ微小甲状腺癌の縦隔リンパ節転移であり，甲状腺左葉切除，左頚部郭清，縦隔腫瘍切除，左反回神経切除と再建，気管8リング合併切除再建を行った．術後経過は良好で，気管縫合不全や狭窄などの合併症はなく軽快退院した．現在術後12ヵ月経過したが，明らかな再発を認めず外来にて経過観察中である．縦隔腫瘍の鑑別疾患として，甲状腺癌の縦隔リンパ節転移も念頭においた精査が必要であると思われた．

Background: Postoperative 1-year administration of S-1, an oral derivative of 5-fluorouracil (5-FU), was shown to be feasible in lung cancer. The 5-year survival rates of postoperative patients treated with S-1 adjuvant chemotherapy and the prognostic impact of clinicopathological factors were examined. Methods: The data of 50 patients with curatively resected pathological stage IB to IIIA non-small cell lung cancer, who were treated with S-1 postoperatively, were analyzed. The prognostic impacts of 22 clinicopathological factors including expressions of the 5-FU pathway enzymes were evaluated. A single-nucleotide polymorphism (SNP), i.e. 538G>A (rs17822931), of ABCC11/MRP8, which encodes a 5-FU excretion enzyme that is known as an earwax type determinant, was also evaluated. Results: The 5-year overall and relapse-free survival rates were 72.5 and 67.5%, respectively. A performance status ≥1, lymphatic vessel invasion, blood vessel invasion, and the A/A type of SNP538, which is responsible for the dry earwax type, were significantly associated with shorter relapse-free survivals. In 34 patients who showed a relative performance of 70% or more for chemotherapy, multivariate survival analysis indicated significant hazard ratios only for the A/A type of SNP538 (p = 0.007). Conclusions: S-1 has sufficient power as adjuvant chemotherapy. However, its effect might be small in the dry earwax type patient group in an adjuvant setting.

Objective:Althoughacuteinterstitialpneumonia is a life-threatening complication followingsurgery forlungcancer, thecauseand riskfactors for acute interstitial pneumonia remain unknown. We conducted this study to determine the characteristics of acute interstitial pneumonia after pulmonary resection and to identify the risk factors for this disease. Methods: We experienced 16 (2.0%) cases of acute interstitial pneumonia among 822 patients who underwent pulmonary resection for primary lung cancer over a period of 12 years. We performed a retrospective analysis of these patients, comprising the patients’ background, the operative procedure, the radiographic characteristics and the prognosis. Results: In all patients, the shadow appeared within 1 week after the operation. Twelve patients required mechanical ventilatory support due to the development of respiratory failure. The site of the tumor (right side), preoperative radiation or chemotherapy, pneumonectomy, blood transfusion, and intraoperative complication were independent risk factors for the incidence of acute interstitial pneumonia (P = 0.001, 0.0484, 0.0012, 0.0002, 0.0003, respectively) in the multivariate analysis. Nine of the 16 patients died due to respiratory failure, resulting in a mortality rate of 56.3%. The maximum amount of lactate dehydrogenase (LDH) in the operative death patients was significantly higher than that in the survivors (472 138 IU/l vs 257 79 IU/l, respectively, P = 0.0031). Conclusions: We concluded that in order to reduce the incidence of acute interstitial pneumonia, it is necessary to perform careful postoperative management for patients who are male, have right lung disease, have undergone preoperative chemo or radiation therapy, or have undergone pneumonectomy.

OBJECTIVE: We compared the results of bronchoplasty and bronchoplasty with pulmonary angioplasty (broncho-angioplasty). Multivariate analysis was done to determine potential prognostic factors for both procedures based on our 20-year single-center experience. METHODS: Between January 1985 and December 2004, 163 bronchoplastic procedures were done in 1405 patients who underwent lung resections for lung cancer at Nagasaki University Hospital. After excluding 16 carino-plasty patients, 147 patients (118 bronchoplasty and 29 broncho-angioplasty) were included. RESULTS: In the bronchoplasty group, the postoperative morbidity was 22.9% (27/118) and the 90-day postoperative mortality was 5.9% (7/118), while in the broncho-angioplasty group the postoperative morbidity was 27.6% (8/29) and the postoperative mortality was 17.2% (5/29). The 5-year survival for all patients was 56.0%. Among patients with stage I or II, the 5-year survival was 76.2% in the bronchoplasty group and 51.9% in the broncho-angioplasty group (p=0.1791). On the other hand, among patients with stage III or IV, 5-year survival was 43.5% in the bronchoplasty group and 7.9% in the broncho-angioplasty group (p=0.0192). Multivariate analysis indicated that the type of operation, postoperative complications, histologic type, and pN status were significant factors affecting survival. CONCLUSIONS: Both bronchoplasty and broncho-angioplasty are useful for the treatment of patients with lung cancer and should be performed in stage I or II. However, careful patient selection is mandatory in patients with advanced tumor stages and in those with nonsquamous cell carcinoma, especially if broncho-angioplasty is being considered.

Objectives We evaluate the efficacy and safety of the modified intrapleural cisplatin treatment for lung cancer patients with positive pleural lavage cytology or malignant effusion. Methods The treatment was performed for seven patients with malignant effusion and 18 patents with positive pleural lavage cytology. After pulmonary resection, the pleural cavity was filled with cisplatin with a normal saline solution for 30 min. Complications and survival of the patients were evaluated. Results The chest tube duration were significantly prolonged in the treatment (CDDP) group (5.7 ± 3.6 vs. 2.8 ± 2.6 days). We had one operative death that developed a bronchial fistula; however, the other complications were not severe. The mortality rate was 4% and the morbidity rate was 60%. We experienced two carcinomatous pleuritis in the CDDP group. The median survival time of the CDDP group was 47.0 ± 11.1 months and the 3- and 5-year survival rate was 52.6% and 11.3%, respectively. Conclusions We were able to perform this treatment for these advanced lung cancer patients, which had the preventive effect of carcinomatous pleuritis. This therapy shows the possibility of a treatment that might lead to an improvement in the prognosis of these patients, without causing severe complications. J. Surg. Oncol. 2006;93: 323–329. © 2006 Wiley-Liss, Inc.

Background and Objectives Recently, the use of the potassium-titanyl-phosphate (KTP) laser with a wavelength of 532 nm, which is half the wavelength of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, has been expanding in many fields, since this laser offers hemostasis and vaporization with minimal coagulation of the underlying structures. The purpose of this study was to determine the usefulness of the KTP laser in limited lung resection done for pulmonary nodular lesions. Study Design/Patients and Methods We used the KTP laser to manage 10 partial resections (Group 1) and 16 segmentectomies (Group 2). The variables that were used to compare the two methods of resection included intra-operative blood loss, mean drainage time, and post-operative morbidity. Results The mean intra-operative blood loss was smaller in Group 1 (152.8 ± 65.0 cc, P = 0.002) than in Group 2 (341.9 ± 178.6 cc). Mean drainage time was shorter in Group 1 (1.8 ± 1.0 days, P = 0.0141) than in Group 2 (3.6 ± 2.9 days). The results of both groups with respect to hemostatic and healing effects were satisfactory. On histopathologic evaluation, the KTP laser-irradiated field tissue alteration consisted of two layers with a depth up to 2 mm. Conclusions The results of this study suggest that the KTP laser has the potential to become a useful and reliable tool for limited lung resection. Lasers Surg. Med. 38:290–295, 2006. © 2006 Wiley-Liss, Inc.

We conducted this study in order to determine how we should perform the surgical treatment for clinical stage I non-small cell lung cancer (NSCLC) in octogenarians. Thirty-three octogenarians with clinical stage I NSCLC participated in this study. They were retrospectively divided into two groups: one group of 11 patients who underwent a lymph node dissection (ND group), and one group of 22 patients who did not undergo this procedure (ND0 group). We analyzed the surgical invasiveness, morbidity, mortality, and survival in both groups. The morbidity rate in the ND group (45%) was higher than that in the ND0 group (23%); however, the difference was no statistically significant (P = 0.1805). There was no significant difference in the overall survival rates of the two groups (P = 0.1647), and the median survival time of the ND0 group (76 months) was slightly longer than that of the ND group (26 months). There was no significant difference in local recurrence rate between the two groups (9.1% vs 4.5%, P = 0.6059). We thus conclude that a limited operation without lymph node dissection might be the best surgical treatment for carefully selected octogenarians with clinical stage I NSCLC.

Objective Multiple gene transfer might permit modulation of concurrent biochemical pathways involved in acute lung graft rejection. We investigated whether gene cotransfection into the recipient reduces acute lung graft rejection. Methods Brown Norway rats were used as donors, and F344 rats were used as recipients. Recipient animals were injected with saline (groups I/VI) or 1 × 10 10 pfu of adenovirus encoding β-galactosidase (groups II/VII), transforming growth factor β1 (groups III/VIII), interleukin 10 (groups IV/IX), or both transforming growth factor β1 and interleukin 10 (groups V/X) into both leg muscles 2 days before transplantation (groups I-V) or at the time of harvest (groups VI-X). The Kruskal-Wallis test for rejection score and 1-way analysis of variance were used to compare groups. Results Oxygenation was significantly improved in the cotransfected groups treated 2 days before transplantation and at the time of harvest. Rejection scores were also reduced in the cotransfected groups. In group V cotransfection suppressed endogenous interleukin 2 but not interferon γ and tumor necrosis factor α. Conclusion Recipient intramuscular cotransfection of transforming growth factor β1 and interleukin 10 suppressed interleukin 2 expression and provided a synergistic effect that reduced acute lung graft rejection. This approach might be applied to the clinical setting because transplant recipients could be treated at the time of implantation.

目的. 多発肺癌に対する外科治療成績を検討し, 手術適応と術式選択につき検討する. 対象と方法. 臨床病理学的に多発肺癌と診断した64例を対象とした. 結果. 平均年齢64.3歳, 男女比49:15, 同時性27, 異時性37例. 組織型は共に腺癌27, 共に扁平上皮癌14, 腺癌―扁平上皮癌11例で, 病期は共にI期35, I・II期14例. 同時性では一期的手術14例, 二期的手術11例で, 複数回手術43例の初回手術は肺葉切除 (27例) が多く, 2回目は縮小手術が多かった (28例). 4例に両側肺葉切除, 3例に残存肺全摘術を行った. 術死および重篤な術後合併症は認めなかった. 予後は異時性が術後5年生存率 (5生率) 74.9%, 同時性は63.9%であった. 異時性で二次癌がIA期では5生率85.1%, IB期で66.7%, II期以上は有意に予後不良であった. 組織型では共に腺癌 (81.5%) が最も良好であった. 結論. 多発肺癌に対する外科治療は合併症も少なく安全に施行できた. 二次癌に対しても, 残存肺機能やperformance statusがよい症例には, 両側肺葉切除や残存肺全摘術も可能である. 特にI期症例では予後も期待でき, 積極的に外科治療を行うべきである.

Objective Tumor necrosis factor is an important mediator of lung transplant ischemia-reperfusion injury, and soluble type I tumor necrosis factor receptor binds to tumor necrosis factor and works as a tumor necrosis factor inhibitor. The objectives of this study were to demonstrate that gene transfer of type I tumor necrosis factor receptor–IgG fusion protein reduces lung isograft ischemia-reperfusion injury and to compare donor endobronchial versus recipient intramuscular transfection strategies. Methods Three donor groups of Fischer rats (n = 6/group) underwent endobronchial transfection with either saline, 2 × 10 7 plaque-forming units of control adenovirus encoding β-galactosidase, or 2 × 10 7 plaque-forming units of adenovirus encoding type I tumor necrosis factor receptor–IgG fusion protein. Left lungs were harvested 24 hours later. Two recipient groups (n = 6/group) underwent intramuscular transfection with 2 × 10 7 plaque-forming units or 1 × 10 10 plaque-forming units of adenovirus encoding type I tumor necrosis factor receptor–IgG fusion protein 24 hours before transplantation. All donor lung grafts were stored for 18 hours before orthotopic lung transplantation. Graft function was assessed 24 hours after reperfusion. Transgene expression was evaluated by means of enzyme-linked immunosorbent assay and immunohistochemistry of type I tumor necrosis factor receptor. Results Endobronchial transfection of donor lung grafts with 2 × 10 7 plaque-forming units of adenovirus encoding type I tumor necrosis factor receptor–IgG fusion protein significantly improved arterial oxygenation compared with the saline and β-galactosidase donor groups (366.6 ± 137.9 vs 138.8 ± 159.9 and 140.6 ± 131.4 mm Hg, P = .009 and .010, respectively). Recipient intramuscular transfection with 1 × 10 10 plaque-forming units of adenovirus encoding type I tumor necrosis factor receptor–IgG fusion protein improved lung graft oxygenation compared with that seen in the low-dose intramuscular group (2 × 10 7 ; 320.3 ± 188.6 vs 143.6 ± 20.2 mm Hg, P = .038). Type I tumor necrosis factor receptor–IgG fusion protein was expressed in endobronchial transfected grafts. In addition, intramuscular type I tumor necrosis factor receptor–IgG fusion protein expression was dose dependent. Conclusions Donor endobronchial and recipient intramuscular adenovirus-mediated gene transfer of type I tumor necrosis factor receptor–IgG fusion protein improved experimental lung graft oxygenation after prolonged ischemia. However, donor endobronchial transfection required 500-fold less vector. Furthermore, at low vector doses, it does not create significant graft inflammation.

胸腔鏡下に手術を施行した縦隔腫瘍41例について, 臨床的に検討した.対象は男性16例, 女性25例, 平均年齢50.4歳, 疾患別には胸腺腫6例, 胸腺嚢腫6例, 神経原性腫瘍12例, 気管支嚢腫7例, 心膜嚢腫2例, 奇形腫2例, その他6例で, 腫瘍の部位は前縦隔17例, 中縦隔8例, 後縦隔13例, 上縦隔3例で腫瘍径は平均4.6cmであった.術式は胸腔鏡のみによる摘出が20例, 小開胸併用16例, 通常開胸への移行例3例, 生検2例であった.ポート数は平均3.1ヵ所, 手術時間は175±78分であった.出血量 (83±160g), 胸腔ドレーン留置期間 (1.1±0.7日), 術後入院期間 (7.7±4.3日) は同時期の胸骨正中切開症例と比較し有意に少なかった.術後合併症は3例 (7.3%) に認めたが, 術死や在院死はなかった.縦隔腫瘍に対する胸腔鏡下手術は低侵襲で安全な手術であり, 小開胸の併用や適切なポートの追加によりどの部位の縦隔腫瘍に対してもアプローチ可能であると考えられた.

69歳, 女性.慢性肺気腫による低酸素血症のため在宅酸素療法導入後に, 1期肺癌を疑う径1.2cmの腫瘤が発見された.肺機能的には一秒率26.6%, 一秒量410mlと高度閉塞性肺障害を有し, 肺切除術の危険性は極めて大きかったが, 肺気腫として臨床的に肺容量減少手術の適応を有し, 腫瘤がそのtarget areaに存在していたため肺切除可能と判断した.胸腔鏡補助下に小開胸併用で左下葉の約30%を切除した.病理学的には肺腺癌で, 肉眼的にリンパ節転移や切除断端の遺残を認めず, IA期と考えられた.術後肺機能の低下はほとんどなく, 日常生活では在宅酸素療法を離脱して良好なQOLが得られている.高度閉塞性肺障害を有する肺癌患者でも, 慎重に手術適応を検討することにより, 安全に外科切除が可能であると考えられた.

Objective: Gene transfer to experimental lung grafts has been shown to reduce ischemia-reperfusion injury and acute rejection. The optimal delivery route should produce high lung expression with no inflammation and minimal systemic expression. The goal of this study was to determine the optimal gene transfer route for use in experimental lung transplantation. Methods: F344 rats were injected with 2.9 × 1010 plaque-forming units of adenovirus vector encoding β-galactosidase through intratracheal, intravenous, intraperitoneal, or intramuscular delivery routes and killed 48 hours later. Gene expression was measured by means of enzyme-linked immunosorbent assay. Results: Intratracheal delivery produces significantly greater gene expression in the lung (75,350 ± 47,288 pg/100 μg of protein, P

Objective: Multiple gene transfer might permit modulation of concurrent biochemical pathways involved in lung graft ischemia-reperfusion injury. In this study we analyzed whether recipient intramuscular naked plasmid cotransfection of transforming growth factor β1 and interleukin 10 would result in amelioration of lung graft ischemia-reperfusion injury. Methods: Forty-eight hours before transplantation, 6 groups (n = 6) of F344 rats received intramuscular injection of naked plasmid encoding chloramphenicol acetyltransferase, chloramphenicol acetyltransferase plus β-galactosidase, transforming growth factor β1, interleukin 10, or transforming growth factor β1 plus interleukin 10 or were not treated. Donor lungs were flushed and stored for 18 hours at 4°C before transplantation. Twenty-four hours later, grafts were assessed immediately before the animals were killed. Arterial oxygenation, wet/dry ratio, myeloperoxidase, and proinflammatory cytokines (interleukin 1, tumor necrosis factor α, interferon γ, and interleukin 2) were measured, and immunohistochemistry was performed. Results: For lung graft function, the arterial oxygenation was considerably higher in the cotransfected group receiving transforming growth factor β1 plus interleukin 10 compared with that in all other groups (P ≤.03). The wet/dry ratio, reflecting lung edema, was reduced in the cotransfected group compared with that in control animals (nontreated, P

Objective: This study was undertaken to determine whether low-dose endobronchial transfer to the donor of the gene for human interleukin 10 would decrease ischemia-reperfusion injury in lung transplantation. Methods: Experiments used male Fischer rats. Donor animals underwent right thoracotomy. A catheter was introduced into the left main bronchus, and vector was instilled. Group I (n = 6) received 2 × 10 7 plaque-forming units of adenovirus encoding human interleukin 10, group II (n = 6) received an adenovirus control encoding β-galactosidase, and group III (n = 6) received saline solution. After instillation the left main bronchus was clamped for 60 minutes. Lungs were removed 24 hours later and stored in low-potassium dextran glucose solution for 18 hours before left lung transplantation. Graft function was assessed at 24 hours immediately before the animals were killed. Ratio of wet to dry weight and tissue myeloperoxidase activity were measured. Transgenic expression of human interleukin 10 was evaluated by means of enzyme-linked immunosorbent assay and immunohistochemical assay. Results: Arterial oxygenation was significantly improved in group I relative to groups II and III (257.6 ± 59.7 mm Hg vs 114.6 ± 66.9 mm Hg and 118.6 ± 91.1 mm Hg, P =.008 and P =.007, respectively). Neutrophil sequestration, as measured by myeloperoxidase activity, was also significantly reduced in group I relative to groups II and III (0.141 ± 0.025 vs 0.304 ± 0.130 and 0.367 ± 0.153 Δ optical density units/[min · mg protein], P =.029 and P =.004, respectively). Enzyme-linked immunosorbent assay and immunohistochemical assay demonstrated the expression of human interleukin 10 in transfected lungs only. Conclusions: Low-dose endobronchial transfer to the donor of the gene for human interleukin 10 ameliorated ischemia-reperfusion injury in rodent lung transplantation by improving graft oxygenation and reducing neutrophil sequestration. Only 2 × 10 7 plaque-forming units of adenoviral vector were required for functional transgenic expression. Endobronchial gene transfer to lung grafts may be a useful delivery route even at low doses. J Thorac Cardiovasc Surg 2002;123:795-802

A 24-year-old man with cystic fibrosis underwent living-donor lobar lung transplantation (LDLLT) with grafts donated from his father, who had mild cirrhosis, and his uncle. The graft from his father failed, and retransplantation was required 44 h after LDLLT, using his sister's left lower lobe. The retransplantation was successful; 18 months postoperatively, the recipient and all three donors are doing well. The favorable outcome was achieved owing to the complete assessment of all potential donors in advance, and the appropriate decision to perform retransplantation in a timely manner. Whether this life-saving retransplant procedure for unexpected primary graft dysfunction after LDLLT can be justified requires further experience and a longer follow-up.

A 43-year-old woman with pulmonary alveolar proteinosis (PAP) was successfully treated with living-donor lobar lung transplantation (LDLLT). The patient's PAP had been diagnosed at age 35. She had been treated with repeated bronchoalveolar lavage and granulocyte-macrophage colony-stimulating factor (GM-CSF) inhalation therapy despite having no serum anti-GM-CSF autoantibodies. At age 42, her respiratory condition became critical and she underwent transplantation from two donors. While careful observation was needed for the recurrence of PAP in the transplanted lungs, she was functioning well without oxygen therapy 1 year after transplantation. This appears to be the first report of LDLLT for PAP in an adult.

A 59-year-old woman with a history of von Recklinghausen's disease (VRD) suffered sudden chest pain. Enhanced chest computed tomography showed massive hemothorax, but no evidence of tumors or an obvious bleeding point in the thorax. After we had ensured a stable hemodynamic condition, we performed video-assisted thoracic surgery to remove the hematoma. The bleeding point was in a branch of the right subclavian artery. We performed direct surgical ligation of the bleeding vessel with a fibrin tissue-adhesive collagen fleece. Recovery was uneventful, and the patient is now doing well with no evidence of re-bleeding, 12 months postoperatively. Spontaneous hemothorax in patients with von Recklinghausen's disease represents a critical event, and exploratory video-assisted thoracic surgery appears useful in the removal of clotted blood and reinforcement of fragile arteries for the prevention of re-bleeding. We should recognize this rare and critical condition in patients with von Recklinghausen's disease.

Recently, the prone position has been used for thoracoscopic oesophagectomy for oesophageal cancer because it is known to facilitate mediastinal dissection. We hypothesized that this advantage of the prone position could apply to video-assisted thoracoscopic surgery, which has been commonly performed with the patient in the lateral position.Forty-six patients with clinical stage I, right-sided, non-small cell lung cancer were enrolled in this study. They were classified into three groups: conventional thoracotomy using rib retractors (n = 17), and the lateral (n = 15) and semi-prone (n = 14) positions in video-assisted thoracoscopic surgery. Surgical parameters, such as operation time, the amount of blood loss, and the number of dissected lymph nodes, of each group of patients were compared.There were three (6.5 %) minor complications in this study, chylothorax and heart failure in the thoracotomy group and atelectasis with the video-assisted thoracoscopic surgery in the lateral position group. No complications were seen in the semi-prone group. The number of dissected lymph nodes was significantly higher in the video-assisted thoracoscopic surgery in the semi-prone position group than in the conventional thoracotomy group for inferior mediastinal nodes (subcarinal, paraeosophageal, and pulmonary ligament, average 8.9 and 5.9 lymph nodes, p = 0.04).To the best of our knowledge, this is the first report that has described video-assisted thoracoscopic lobectomy with the patient in the semi-prone position. Although the number of cases was limited, the results of this study show that the semi-prone position could be attempted especially for right lower lobe lung cancer.

A 46-year-old male was referred to our hospital due to abnormal opacities on chest X-rays. High-resolution CT disclosed focal ground glass attenuation counting up to more than one hundred throughout both lung fields. A wedge-shaped excision by a video-assisted thoracoscopic lung biopsy revealed numerous atypical adenomatous hyperplasia. Although not all the focal ground glass attenuation areas on high-resolution CT were identified as being adenomatous hyperplasia pathologically, so far, a case with adenomatous hyperplasia has not been previously reported., European Journal of Radiology Extra, 71(2), pp. e53-e55; 2009

We experienced a case of huge cholangiocellular carcinoma with an extrahepatic growth. An 89-year-old woman was admitted to the hospital because of an abdominal mass and abdominal discomfort. The tumor markers showed marked increases, CEA and CA 19-9 were 1.275ng/ml and 4.950U/ml, respectively. Abdominal echo visualized a huge tumor with a well defined margin, which was growing expansively from the right lobe of the liver. Abdominal CT revealed that the tumor was so huge as to reach to the pelvic cavity. Angiography showed that the tumor was fed from a 5 and a 6 arteries of the liver and no parasitic vessels were detected. Curative operation was performed with limited resection of segment 5 and 6 of liver. The excised tumor was 15×10×8cm in size, and 1, 300g in weight. Histopathologically, the tumor was diagnosed as well differentiated tubullar adenocarcinoma with some papillary proliferation. This case is very rare, since the huge cholangiocellular carcinoma with an extrahepatic growth have been reported in only two cases in Japan.