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Background Granulosa cell tumors (GCTs) are uncommon sex cord-stromal ovarian neoplasms. We report a case of GCT presenting in the chest, 18 years after oophorectomy for ovarian cystadenocarcinoma. Case presentation A 63-year-old female was admitted to our hospital for evaluation of a right hilar lesion. Subsequent abdominal and pelvic computed tomography and brain magnetic resonance imaging were unremarkable. Eighteen years earlier, the patient had undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy at another institution for a uterine myoma, with the pathological findings indicating a uterine myoma, dermoid cyst of the right ovary, and serous cystadenocarcinoma and endometrioid adenoacanthofibroma around hemorrhagic cyst of the left ovary. No indication of a granulosa cell tumor (GCT) was present in either ovary. As such, diagnostic video-assisted thoracoscopic surgery was performed, revealing a well encapsulated tumor located next to the inferior pulmonary vein and small, disseminated lesions on the chest wall and diaphragm. Thereafter, we performed resection of the main tumor in its entirety and the disseminated lesions to the extent possible. Pathological examination of the resected specimens revealed a neoplasm characterized by sheets and islands of closely packed tumor cells exhibiting small follicles (Call-Exner bodies) surrounded by cells with pale, uniform nuclei, typically observed in the microfollicular pattern of adult GCT. Although the etiology of occurrence of intrathoracic granulosa cell tumor is unknown, we assumed that the neoplasm oriented from radiologically undetectable peritoneal seeding at the time of her previous surgery, with subsequent migration through the diaphragm. Over the next 10 years, she received chemotherapy with cyclophosphamide, adriamycin, and cisplatin; other combination chemotherapy; single-agent chemotherapy; and palliative radiotherapy. She died from malignant pleuritis and peritonitis 10 years after thoracoscopic surgery. Conclusions We have reported a case of a 63-year-old female with a history of ovarian cystadenocarcinoma who underwent resection of a pleural neoplasm, which turned out to be a granulosa cell tumor. This possibility resulted from dissemination of a previous abdominal lesion.

Objectives The first surge in severe acute respiratory syndrome coronavirus 2 infection had a significant impact on health care institutions. Understanding how the pandemic affected general thoracic surgery would provide valuable data for establishing a health care protocol for upcoming surges. Methods A questionnaire survey on coronavirus disease-related patient statistics and health care was conducted between February 2020 and June 2020 across 14 facilities affiliated with the Kanagawa General Thoracic Surgery Study Group. Results The average number of newly referred patients from February to June 2020 was 65% of that during the same period in 2019. Six facilities placed restrictions on medical care services, among which four restricted surgeries. At all institutions and those placed on surgical restriction, the total number of surgeries under general anesthesia was 92% and 78%, the total number of primary lung cancers was 94% and 86%, and the total number of surgeries for pneumothorax was 71% and 77% of that in the preceding year, respectively. Infection control and insufficient resources of the medical material were the most influential factors impacting the medical institutions’ decision to restrict the services provided. Conclusions Restrictions on surgery had a significant impact on the care provided by general thoracic surgery departments. To avoid patient inconvenience, establishing a collaborative system that refers patients to operational medical institutions in case of medical treatment restrictions may be useful. Supplementary Information The online version contains supplementary material available at 10.1007/s11748-021-01724-z.

Tracheobronchial injurie( TBI) is rare but potentially life threatening. Blunt trauma of the chest and post-intubation injury are the most common cause of TBI. Clinical findings of TBI are subcutaneous emphysema, pneumomediastinum, and pneumothorax. Chest computed tomography (CT) and bronchoscopy are important examination for TBI to evaluate of injured site and condition. Most traumatic or iatrogenic TBIs occurred within 2.5 cm of the carina and/or main bronchus. Early diagnosis and early treatment are important to improve the long-term results of TBI. In principle, blunt traumatic TBI excluded membranous minor laceration should be operated immediately, if possible. Surgical procedures are usually selected single closure or end to end anastomosis with or without débridement. Right thoracotomy is often suitable for repair of carina or main bronchus in closed trauma. Recently transcervical repair of iatrogenic distal membranous tracheal laceration is reported. Conservative treatment of iatrogenic TBI cause by single lumen tube may be a save option in patients with stable spontaneous breathing, no other injury( such as esophagus), and small to moderate rupture. Left main bronchial rupture caused by double lumen tube during right thoracic surgery is critical situation. Throughout the operation expert cooperation between surgeon and anesthetist is important.

It is important to distinguish tumour recurrence from other conditions that could show high accumulation on 18F‐fluorodeoxyglucose‐positron emission tomography (FDG‐PET). We describe the case of a 78‐year‐old woman who underwent partial resection of the left lower lung lobe for carcinoid treatment 20 years previously. Five years earlier, chest radiography revealed an abnormal shadow, and chest computed tomography (CT) showed partial atelectasis in the left S8. Periodical CT showed that the atelectasis had developed into a mass. The patient was referred to our hospital. A mass of 45 mm diameter was detected on CT and it had a maximum standardized uptake value of 8.91 on FDG‐PET. We suspected recurrence and performed surgery. Pathological examination revealed epithelioid cell granuloma (maximum diameter, 25 mm) with necrosis. Tissue culture showed no evidence of Mycobacterium tuberculosis. However, serum anti‐MAC antibody level was elevated, suggesting epithelioid cell granuloma caused by non‐tuberculous Mycobacterium infection., It seems crucial to differentiate tumour recurrence from other conditions that could show high accumulation on 18F‐fluorodeoxyglucose‐positron emission tomography. We present a case of epithelioid cell granulomas arising at the margin of lung resection for carcinoid treatment 20 years previously.

We aimed to investigate if Computed tomography (CT) attenuation values can help improve the identification of age-related changes in the thymus. We assessed CT images of 405 patients aged 0 to 80 years. We measured the area of the anterior mediastinum at the level of the carina and its average CT attenuation value. We evaluated the thymic area, the ratio of the thymus area to the total thoracic area, and the CT attenuation value. Additionally, we evaluated changes in the thymus area in the 0 to 13-year age group. The area of the thymus decreased from birth to the middle 20s. After the middle 20s, the area tended to increase and plateau till after 50 years of age. The ratio of the thymic area to the thoracic area decreased from age 0 to 20 years, but remained stable after 20 years of age. The CT attenuation values were stable from birth to puberty, decreased after puberty, and were stable again in the late 50s and beyond. The thymus of children showed mass formation, but the shape changed with age. No significant differences in the CT attenuation value were found across underlying conditions for the 0 to 13-year age group. The decrease in the CT attenuation values, observed with advancing age, reflects adipose degeneration of the thymus, indicating that by the late 50s, thymic tissue is replaced completely by adipose tissue. Our data suggest that adipose degeneration of the thymus begins after puberty and advances with age.

Background Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a rare lung disease that manifests as parenchymal fibrosis of the upper lung lobe and pleura. There have been no reports of IPPFE complicating pregnancy. Here, we report a case of IPPFE that deteriorated rapidly during pregnancy. Case presentation A 29-year-old woman presented with dyspnea and dry cough at 19 weeks of gestation. IPPFE with acute exacerbation was suspected on chest computed tomography (CT). Despite steroid treatment, her condition progressed. A cesarean section was performed at 28 weeks of gestation. On postoperative day 26, she underwent living-donor lung transplantation. She was discharged a year after transplantation. Conclusion Our experience suggested that when pregnancy is complicated by PPFE, the disease may deteriorate rapidly. In this case, even though IPPFE with acute exacerbation was diagnosed during pregnancy, live birth was achieved, and the mother survived after lung transplantation. Lung transplantation should be considered in these patients because, once advanced, pulmonary lesions may be irreversible.

BACKGROUND: Although platinum-based chemotherapy is accepted as adjuvant chemotherapy for resectable advanced non-small cell lung cancer (NSCLC), its completion rate is low due to severe adverse events. S-1 plus cisplatin is associated with relatively low toxicity and an unimpaired quality of life, and has been used for unresectable advanced lung cancer. We investigated the acceptability and feasibility of combination therapy with S-1 plus cisplatin as postoperative adjuvant chemotherapy following complete resection of pathological stage II-IIIA NSCLC. METHODS: Enrolled patients received oral S-1 at a dose depending on their body weight twice daily for 21 days with intravenous cisplatin 60 mg/m(2) on day 8, with 1 cycle comprising 5 weeks and 4 cycles. Patients received standard precautions against adverse events and received standard treatment when adverse events occurred. The primary endpoint was completion rate; secondary endpoints included safety, status of drug administration, disease-free survival (DFS), and overall survival (OS). RESULTS: A total of 19 patients [14 men, 5 women; mean age, 59.1 years; mean body surface area, 1.688 m(2); 17 with an Eastern Cooperative Oncology Group performance status (PS) of 0 and 2 with a PS of 1; 7 (36.8%) with stage II disease and 12 (63.2%) with stage IIIA disease] were enrolled. The rate of completion of 4 cycles was 68.4%. Grade 3 adverse events that occurred in ≥10% of patients included neutropenia (21.1%), nausea (21.1%), and anorexia (15.8%). No grade 4 adverse events, febrile neutropenia, or treatment-related deaths occurred. The mean relative dose intensity (RDI) was 79% for S-1 and 80% for cisplatin. The 2-year DFS rate was 42.1%, and 2-year OS rate was 83.3%. CONCLUSIONS: This study demonstrated the acceptability and feasibility of using S-1 plus cisplatin as adjuvant chemotherapy. TRIAL REGISTRATION: This study was registered on the UMIN clinical study registration site (protocol ID: UMIN000016191) on December 1, 2015.

Aims Mutation or promoter methylation of the phosphatase tensin homologue deleted on chromosome 10 tumour suppressor gene ( PTEN ) promotes some cancers. Moreover, PTENP1 ( PTEN pseudogene) transcript regulates PTEN expression and is thought to be associated with tumourigenesis in some cancers. Here, we investigated PTEN expression in thymic epithelium and thymic epithelial tumours. Methods Immunohistochemical analysis of PTEN was performed on two non-tumourous thymus (NT) samples, 33 thymomas (three type A, eight type AB, 11 type B1, six type B2, and five type B3), and four thymic carcinomas (TCs). In 16 cases (two NT, three A, five B1, two B2, one B3 and three TC), analyses of mutations, promoter methylation and comparisons of PTEN mRNA and PTENP1 transcripts were undertaken using PCR-direct sequencing, methylation-specific PCR, and reverse-transcription real-time PCR after target cell collection with laser microdissection. Results PTEN protein was not immunohistochemically detected in NT epithelium or types B1 or B2 thymoma cells, but was expressed in type A thymoma and carcinoma cells. Neither PTEN mutations nor promoter methylation were detected in any samples. Statistical analysis revealed that PTEN mRNA expression was highest in NT epithelium and lowest in type A thymoma cells. PTENP1 transcript expression did not significantly differ among NT, thymoma and TC samples. Conclusions We speculated that NT epithelium and types B1/B2 thymoma cells have a mechanism of PTEN translation repression and/or acceleration of protein degradation, whereas type A thymoma cells exhibit transcriptional repression of PTEN mRNA and accelerated translation and/or protein accumulation.

Purpose: We performed a retrospective analysis to evaluate the usefulness of positron-emission tomography/computed tomography (PET/CT) findings in the classification and management of anterior mediastinal tumors. Methods: Between 2006 and 2015, 105 patients with anterior mediastinal tumor received PET/CT. 18F-fluorodeoxyglucose (18F-FDG)-PET images were obtained 60 minutes after the injection of 18F-FDG. Results: The histological classifications were as follows: thymoma (n = 49), thymic carcinoma (TC) (n = 19), malignant lymphoma (ML) (n = 8), teratoma (n = 7), thymic cyst (n = 14), and others (n = 8). Upon visual inspection (SUV max: >2.0), all of the malignant tumors showed 18F-FDG accumulation (with the exception of one type A thymoma). Two of the 14 thymic cysts and three of the seven teratomas showed slight 18F-FDG accumulation. The SUV max values of the low-grade thymomas, high-grade thymomas, TCs and MLs were 3.14 ± 0.73, 4.34 ± 1.49, 8.59 ± 3.05, and 10.08 ± 2.53, respectively, with significant differences between the low- and high-grade thymomas, and between TCs and MLs. The sensitivity, specificity and accuracy of 18F-FDG in the detection of low-grade thymomas and thymomas with a maximum diameter of ≤50 mm and an SUV max of ≤3.4 were 85%, 48%, and 60%, respectively. Conclusion: FDG-PET/CT is an objective and useful modality in the differential diagnosis and management of anterior mediastinal tumors.

The role of cell cycle inhibitors in tumorigenesis has been proven in various neoplasms; however, their roles in thymic tumors are still unclear. We examined the expression of cell cycle inhibitors such as those of the Cip/Kip family (p21, p27, and p57) and the INK-4/ARF family (p16 and p14) in thymoma and thymic carcinoma. Samples from 41 thymoma and 14 thymic carcinoma patients, and 34 normal thymic tissue samples were prepared for the study. Immunohistochemical analysis using antibodies to p21, p27, p57, p16, and p14 was carried out, and the positivity for these inhibitors in each group was estimated in terms of their subcellular location and percentage of cells showing positive staining. Nuclear p27 showed a stepwise decrease (p

We present a surgical case of bronchial artery aneurysm (BAA) connecting pulmonary artery accompanied with racemose hemangioma. This is a third surgical case report of BAA directly connecting pulmonary artery in the English literature. A 63-year-old female was found a BAA, 2 cm in diameter, connecting right A4 pulmonary artery. The patient underwent two attempts for embolization. However, due to extensive collaterals, there was persistent flow in the aneurysm. Standard lateral thoracotomy was performed. A BAA was located between A4 and A5 PA. A small branch of A4 PA was separated, and the small vessel connecting to the BAA could be ligated. A5 PA was separated similarly, however BAA was ruptured not to identify the other small vessel connecting to the BAA. After a clamp of the BAA, middle lobe lobectomy was performed. We removed the aneurysm with dilated bronchial artery connecting to the aneurysm. The postoperative course was uneventful.

Objective Differentiation of atypical adenomatous hyperplasia (AAH), bronchioloalveolar carcinoma (BAC), and invasive carcinoma on computed tomography (CT) is useful for determining “follow-up or resection” strategies for lesions displaying ground-glass opacity (GGO). The purpose of this study is to evaluate one-dimensional quantitative CT values of GGO on high-resolution CT (HRCT) images using computer-aided diagnosis. Methods Between April 2001 and March 2010, a total of 44 nodules in 42 patients with pure or mixed GGOs ≤2 cm were retrospectively evaluated. Maximum diameter and one-dimensional mean CT (m-CT) value of the diameter were measured using a computer graphics support system (HOPE/DrABLE-EX, Fujitsu, Tokyo, Japan) that displays a CT density profile across the tumor. Results m-CT values were −682 ± 64 HU (range) for AAH lesions, −544 ± 179 (range) for Type A lesions, −496 ± 147 (range) for Type B lesions, and −371 ± 142 (range) for invasive lesions. AAH lesions had a significantly lower m-CT value than Type B lesions. AAH, Type A, and Type B lesions had significantly lower m-CT values than invasive lesions (p 1 cm and m-CT value >−600 HU were invasive lesions. Conclusion Observation may be indicated for GGO lesions with a maximum diameter ≤1 cm and m-CT value ≤−600 HU.

症例は59歳，男性．直腸癌に対し腹腔鏡下腹会陰式直腸切断術施行．手術数時間後より呼吸循環障害あり．胸腹部CTにて肝右葉，小腸が右胸腔内に脱出．脱出小腸は拡張，壁肥厚あり．右肺中下葉は圧排され無気肺となり，軽度気胸を伴っていた．以上の所見より，右横隔膜ヘルニア嵌頓と診断し緊急開胸手術施行．右横隔膜後外側にヘルニア門を認め，右側Bochdalek孔ヘルニアと診断．脱出小腸は拡張し軽度浮腫状ではあったが血流障害は認められず，切除再建を行わずに腹腔内へ還納．脱出していた肝右葉も腹腔内へ還納し，ポリプロピレンメッシュにて横隔膜欠損部を補填した．成人右側Bochdalek孔ヘルニアの報告例は非常に稀ではあるが，無症状で経過している症例が潜在的に数多く存在している可能性があるとも報告されている．本症例の発症契機は長時間の気腹操作であると考えられ，術後合併症の一つとして念頭に置くべき疾患であると思われた．

縦隔悪性胚細胞性腫瘍（MGCT）の診断および治療アプローチを再確認するために，切除例の検討を行い，臨床上の問題点を明らかにした．対象は，1993～2006年に昭和大学関連3病院で切除したMGCT8例で，21～69歳，すべて男性．部位は前縦隔6例，中縦隔2例．AFP高値2例，HCG高値1例，両マーカーとも高値1例，上昇なし4例であった．組織検査は，CT下針生検4例，傍胸骨生検1例，縦隔鏡1例，未施行2例で，生検を行った6例中5例で，最終病理と一致した．初回治療は，化療4例（CR2例，PR2例），放治1例（NC），手術3例で，最終病理診断は，Seminoma3例，Yolk sac tumor1例，Adenocarcinoma with teratoma1例，Embryonal carcinoma1例，その他2例であった．MGCTの治療に際しては，化療の効果は良好であることからマーカー陽性例は速やかな抗癌剤治療が必要である．MGCTのなかに比較的高齢者，あるいは中縦隔発生例があることは留意すべき点である．

他疾患の精査中に前縦隔腫瘍が発見されることはしばしばあるが，ともに手術が必要な心臓疾患と前縦隔腫瘍の合併例の報告は比較的少ない．今回われわれは術中に心嚢内播種が確認された胸腺腫と大動脈弁置換術との同時手術例を経験したので報告する．症例は73歳男性．労作時呼吸困難を主訴に他院を受診．精査の結果大動脈弁閉鎖不全と診断され，また胸部CT上前縦隔腫瘍を指摘された．腫瘍はCTガイド針生検で胸腺腫と診断された．2003年5月手術を施行．腫瘍は心嚢，左腕頭静脈への浸潤を認め，血性心嚢液，心嚢内播種も確認された．腕頭静脈，心嚢を合併切除し腫瘍を摘出したが，不完全切除に終わった．続いて大動脈弁置換術を施行した．胸腺腫の病理はWHO分類Type B3であった．術後縦隔に60Gyの放射線照射を施行した．術後33ヵ月に肺炎呼吸不全で亡くなったが，遺残腫瘍の再増大は緩徐で，また心不全症状はなくQOLは良好であった．

Background In a number of human malignancies, tumor-associated macrophages (TAMs) are closely involved in tumor progression. On the other hand, dendritic cells (DCs) that infiltrate tumor tissues are involved in tumor suppression. However, there have been very few reports on the distribution profiles of TAMs and DCs in thymic epithelial tumors. We examined the difference in the distribution profiles between TAMs and DCs in thymoma and thymic carcinoma. Methods We examined 69 samples of surgically resected thymic epithelial tumors, namely, 16 thymic carcinomas and 53 thymomas, in which we immunohistochemically evaluated the presence of TAMs using CD68 and CD163 as markers and DCs using S100 as the marker in tumor tissue samples in comparison with normal thymic tissues. Results The percentage of samples with a large number of CD68+ TAMs was not significantly different between thymic carcinoma and thymoma (7/16 versus 16/53, p = 0.904). However, the percentage of sample with a large number of CD163+ TAMs was significantly higher in thymic carcinoma than in thymoma (15/16 versus 34/53, p = 0.024). In contrast, the percentage of samples with a large number of S100+ DCs was significantly lower in thymic carcinoma than in thymoma (2/16 versus 23/53, p = 0.021). Conclusions To the best of our knowledge, we are the first to show a high percentage of CD163+ TAMs and a low percentage of S100+ DCs in thymic carcinoma samples, and our findings may provide an idea for future targeted therapeutic strategies for thymic carcinoma using antibodies that inhibit monocyte differentiation to TAMs, thereby skewing TAMs differentiation toward DCs. Virtual Slides The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_215

目的. WHO分類の悪性度の高い胸腺腫 (type B3) および胸腺癌 (type C) の共通点・相違点を臨床の面から明らかにすることを目的とした. 方法・対象. 過去14年間に入院した両疾患の手術例および非手術例を対象に遡及的手法で検討した. 全症例は23例でtype B3が11例, type Cが12例であった. type B3は男女それぞれ8例, 3例, type Cは同じく11例, 1例であった. 発見時の年齢の平均はそれぞれ51歳, 54歳で統計学的に有意の差がなかった. type B3の10例とtype Cの8例に手術を行った. 少ない症例であったが可能な限り統計学的推定を行った. 結果. type B3, type C両群症例を臨床病期からみると各病期をカテゴリー化した解析では両群問に有意の差はなかった. 全症例の予後は平均生存日数ではtype B3, type Cで1916日, 987日であり, 中央値はそれぞれ1673日, 466日であって, 両群の生存曲線に有意の差を認めた. 両群問で腫瘍の切除率に差はなかった. 切除症例の予後はtype B3, type Cの平均生存日数がそれぞれ2088日, 1410日であり, 中央値は1673日, 1425日であったが, 生存曲線で差がなかった. 重症筋無力症の合併はtype Cにはなく, type B3に有意に多かった. 結論. 両群は性差, 臨床病期, 切除率で共通の性格をもつ反面, 予後, 合併疾患の頻度の面で相違がみられた.

Thymic carcinoma associated with acute monocyte leukemia (AMoL) and a history of choriocarcinoma was diagnosed in a 58-year-old female. We found no other such case in a literature search. She was first treated with DCMP therapy: daunorubicin, cytosine arabinoside, 6MP-riboside, and prednisolone against AMoL. After induction chemotherapy, complete AMoL remission was attained. Chest CT scan after chemotherapy revealed regression of the mediastinal tumor. Resection of the tumor included the left upper lobe of the lung, phrenic nerve and pericardium. Pathological diagnosis showed poorly or moderately differentiated squamous cell carcinoma. Although the patient died of pneumonia during chemotherapy for relapsed AMoL, chest X-ray and CT revealed no recurrence of the mediastinal tumor after the original operation. Judging from this case and other successful cases of chemotherapy, we feel that intensive chemotherapy may be a beneficial strategy against thymic carcinoma.

Endoscopic transthoracic sympathectomy (ETS) is a minimally invasive method, causing only small injuries and few complications, and requires only a short period of hospitalization. Therefore, this method has been applied to patients with palmar hyperhidrosis to whom the conventional transthoracic sympathectomy, which is much more invasive, or thoracic sympathetic blockade, which often causes complications, cannot be applied. Conventional thoracoscopes, such as a resectoscope 8 mm in diameter for urological operations, or a thoracoscope 5 mm in diameter, were usually used for this purpose, but they cause operative injuries. We performed ETS using a thoracoscope 2 mm in diameter (MiniSite 2 mm 0 degrees, USSC171303). Its visual field and handling were not inferior to those of conventional thoracoscopes, and the operative injuries were only 2 mm in size. For the patient, a small scar of this size means virtually no scar.

高CA19-9血症を契機に発見された肺腺癌の1例を経験した.症例は80歳の男性.大腸癌術後の外来経過観察中に高CA19-9血症を指摘された.腹部検査の結果は異常はみられなかったが, 胸部CT検査で左S6のブラとその周囲の肥厚所見が認められた.同部の気管支鏡生検の結果, 腺癌と診断され, 平成7年5月左肺下葉切除を行った.術後病理は高分化腺癌で, 免疫染色の結果CA19-9産生肺癌と診断された.

Gorham's disease is a rare disorder characterized by a non-malignant proliferation of thin-walled lymphatic vessels that result in progressive bony destruction and often extend into the surrounding soft tissues. Chylothorax is a common complication in cases of mediastinal involvement. Here we report a case of a 22-year-old male with Gorham's syndrome complicated by chyloma of the chest wall, but without chylothorax. To our knowledge, this is the first report demonstrating an abnormality of the parietal pleura prior to the clinical development of the chylothorax.

Cardiac lipomas are very rare. We herein report a case of a 57-year-old woman who presented with intrapericardial extracavitary giant lipoma, and we also review the relevant literature. The patient had no symptoms except for a tendency to easily feel slightly fatigued. She underwent a resection of the lipoma through a clamshell thoracotomy. The lipoma weighed 1 700 g and had a cylindircal stalk measuring about 5 cm in diameter connected to the myocardium of the right ventricle.

We experienced two cases of postoperative mediastinal lymph nodes metastasis of colonic cancer which showed no evidence of pulmonary metastasis and carcinosis pleuritis radiologically. Both cases were detected to have para-aortic lymph nodes swelling, and compression of supra vena cava due to mediastinal lymph nodes swelling by postoperative follow up CT. First patient, a 54-year-old man, underwent para-aortic lymph nodes and mediastinal lymph nodes resection, and the other patient, a 68-year-old man, underwent mediastinal lymph nodes resection only. The lymphatics from the pelvis and abdomen drain into the thoracic duct. No direct communication between the anterior mediastinum and thoracic duct as it courses through the posterior mediastinum has been shown. Howerver, if incompetence or absence of valves controlling direction of flow exists, reflux of tumor emboli from the thoracic duct into the bronchomediastinal trunks will occur. McROUD assumed that the mechanism of mediastinal lymph node metastases from retroperitoneal nodes was retrograde flow into the bronchomediastinal trunks from thoracic duct. It was assumed that the mechanism of mediastinal lymph node metastases of the two cases in this report was same as above.

Hemophilia A is relatively rare and the number of patients with this disorder who undergo surgery is limited. We herein report a surgical case of bilateral pneumothorax accompanied by mild deficiency type of hemophilia A. Although this patient had undergone major surgery at another institution, a diagnosis of hemophilia A had not been made, nor had he noticed unusual bleeding in his daily life. Laboratory studies showed a slight prolongation of the activated partial thromboplastin time. A thoracoscopic operation was performed for bilateral pneumothorax in 1996. After the initial operation, the blood discharge from the right thoracic drainage tube continued. Despite two reoperations, oozing from the chest wall could not be controlled. Finally, the patient had achieved a stable condition with hemothorax encompassing the right thorax. After a diagnosis of hemophilia A was made, we removed any coagulated blood while administering a factor VIII preparation. Clinical and laboratory indications in daily life of mild deficiency type hemophilia A are not manifest in comparison with those of severe or moderate types. It is therefore necessary to consider this disorder in cases of abnormal bleeding at or after operation.

Thymic carcinoma is a rare mediastinal malignant tumor, and in many patients, the tumor is detected in an inoperable advanced stage. Even when chemotherapy is administered to such patients, the patients show a poor response. We investigated new biomarkers of therapeutic molecular targets.This study included 44 patients diagnosed and treated for primary thymic epithelial tumors at Showa University Northern Yokohama Hospital, Showa University Hospital, and Showa University Fujigaoka Hospital from 2003 to 2011. We investigated new biomarkers of therapeutic molecular targets, such as the peroxisome proliferator-activated receptor γ (PPARγ), insulin-like growth factor 1 receptor (IGF1R), epidermal growth factor receptor (EGFR), estrogen receptor (ER), progesterone receptor (PgR), androgen receptor (AR), human epidermal growth factor type 2 (HER2)/neu, CD44, and L-type amino acid transporter 1 (LAT1), in thymic tumors.Immunohistochemical analysis showed that the PPARγ positivity rate in thymic carcinoma was 32 %, which was significantly higher than that in thymoma (4 %). The IGF1R positivity rate in thymic carcinoma was 73 %, which was significantly higher than that in thymoma (27 %).Therefore, by examining the expressions of PPARγ and IGF1R, it would be possible to identify therapy-responsive patients and to improve results of thymic carcinoma treatment.

胸腺腫の上皮細胞に起きていると思われる腫瘍性変化を評価する目的で, 癌抑制遺伝子産物p53に対する抗体を用いて免疫組織学的検討を行った. さらにp53の発現と細胞増殖能との関連を検するために, proliferating cellnuclear antigen (PCNA) に対する抗体を用いた免疫組織化学的検討もあわせて行った. 胸腺腫症例のホルマリン固定標本のp53免疫染色結果は, 正岡の分類でI期の11例, II期の3例, III期の6例は全例陰性であったが, IVa期は4例中2例, IVb期の2例中に1例が陽性であった. また肺転移巣は2例中2例, 胸腔内播種巣は3例中2例がp53陽性であった. 新鮮凍結標本ではI期の3例は全例p53陰性であったが, III期の2例, IVa期の2例, IVb期の1例, 肺転移巣の1例, 胸腔内播種巣の2例は陽性であった. 一方PCNA免疫染色では, 胸腺腫のほとんど全ての上皮細胞およびリンパ球の一部に陽性細胞を認め, 陽性細胞数と胸腺腫の臨床病期とのあいだに相関を認めることができなかった. これらの結果から, 胸腺腫におけるp53の発現は, 腫瘍の悪性度を反映するマーカーとなりうることが示唆された.

症例は2歳11ヵ月の男児.出生時特に異常所見はなかったが, 生後3ヵ月の胸部単純X線写真で右上縦隔の拡大を指摘された.その後右上葉無気肺, 肺炎等の呼吸器症状が出現し入退院を繰り返した.胸腺肥大の疑いでステ獄イド負荷療法を2回施行したが, いずれも無反応であった.2歳9ヵ月時, 胸腺腫の疑いで手術を施行した.び漫性に肥大した胸腺を認め胸腺全摘除術を施行した.摘出した胸腺は大きさ10×7×6cm, 重さ210gであった.病理組織は正常胸腺構造を呈し, 観察した範囲内に胚中心の形成はみられなかった.最終診断はTrue thymic hyperplasiaとした.

The indication for sleeve lobectomy of the middle lobe is limited, because the frequency of cancer occupying both the middle lobe and its bifurcation is low and the more commonly used middle and lower lobectomy is an alternate procedure. However, if a patient has accompanying cardiopulmonary restriction, lung preservation is paramount. We present a patient with hilar lung cancer (TisN0M0) associated with progressive cardiomyopathy, who underwent sleeve lobectomy of the middle lobe; the cancer took a favorable course.

A 38-year-old woman with metastatic choriocarcinoma of the lung had been treated for a hydatidiform mole nine years previously. During the interval she had conceived and given birth to a child. Following lobectomy she has been metastasis-free for five years.

During a 54-year-old woman's visit to a hot-spring resort, she suffered a fever and became dizzy and unable to speak clearly. She was admitted to our hospital due to serious pneumonia and respiratory failure type I. She was treated with antibiotics, but her condition became worse and developed into acute respiratory distress syndrome (ARDS). She was intubated and received artificial ventilation. Her blood pressure gradually decreased and she suffered septic shock probably due to endotoxin with gram negative coccus infection. Subsequently, she was treated with a direct hemoperfusion using a polymyxin B immobilized fiber column (PMX-DHP), which resulted in an improvement of oxygenation. However, her pneumonia led to the development of septic shock with gram negative coccus infection, and PMX-DHP treatment was resumed. After PMX-DHP re-treatment, she recovered gradually in intensive care including prone positioning ventilation.

Mediastinal lung herniation is a rare condition characterized by protrusion of 1 lower lung through behind the heart into the opposite side of the chest, usually from right to left. We present a case of mediastinal lung herniation associated with pulmonary sequestration, which was confirmed both surgically and pathologically in a 13-year-old girl initially admitted with a diagnosis of pneumonia. Contrast-enhanced computed tomographic images using a multidetector-row computed tomography clearly demonstrated the right lung herniation toward the left and 2 aberrant systemic arteries supplying the sequestered lung mass. These arteries run through the herniated lung from right to left. Additionally, on the basis of pleural anatomy, we discuss herein the difference between a mediastinal lung herniation and horseshoe lung.

A 33-year-old asymptomatic woman was referred to our hospital for evaluation of an abnormal shadow on a chest radiograph. A chest-computed tomogram revealed a cystic, partially solid tumor in the right inferior mediastinum. Following an initial diagnosis of cystic teratoma, surgery was performed. The tumor, a well-encapsulated, thin-walled cyst located within the right inferior lobe of the thymus, was extirpated by partial resection of the thymus. The cut surface revealed a unilocular cyst containing multiple grayish-white tumors on the inner cyst walls. Some tumors detached from the wall owing to loose connections. Microscopic findings revealed that the cyst was lined with squamous epithelium. The tumor on the cyst wall was diagnosed to be a type B1 thymoma. Based on these findings, we diagnosed this case as a thymoma originating from the wall of a thymic cyst, accompanied by intracystic dissemination from the tumor.