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A 54-year-old man with hereditary hemorrhagic telangiectasia and severe hypoxemia was referred for lung transplantation. Embolization had not been performed because of numerous bilateral small pulmonary arteriovenous malformations. Although he appeared to be qualified for lung transplantation, we instead performed bilateral thoracoscopic multiple wide wedge resections because of his age, lifestyle as a farmer, and relatively clustered distribution of arteriovenous malformations. Intermittent bilateral ventilation was needed because of poor oxygenation in the early stages of the operation, but his oxygenation improved as the resection progressed. His postoperative oxygenation improved significantly, and lung transplantation was avoided.

This report describes the case of a patient who underwent bilateral lung transplantation for idiopathic pulmonary arterial hypertension with coexisting partial anomalous pulmonary venous return and tracheal bronchus. The hypoplastic and low-positioned left atrial orifice caused by abnormal reflux of the right upper pulmonary vein and high-positioned right upper lobe bronchus made right anastomosis challenging. To prevent excessive tension on left atrial anastomosis, the donor's right main bronchus was anastomosed to the recipient's bronchus intermedius, a maneuver that resulted in successful anastomosis and an uneventful postoperative course.

Patients with lung cancer with a history of treatment often undergo curative surgical resection. However, the impact of previous cancer treatment on the outcome of lung cancer remains unclear.We conducted a retrospective study of patients who underwent curative resection for non-small cell lung cancer between 1998 and 2011. We collected clinicopathologic data and patients were divided into groups by previous history of cancer treatment. Comparisons between groups, estimation of survival rates, and multivariate analyses were performed. Propensity score matching was used to create cohorts with reduced bias.Of 878 patients, 196 (22.3%) had previous extrathoracic malignancies, and stage I lung cancer was more frequent in this group (P.001). In multivariate analysis of the whole cohort, older patients, men, non-adenocarcinoma histologic type, more advanced pathologic stage of lung cancer, interstitial pneumonia, and previous extrathoracic malignancies were associated with appreciably worse prognosis. When propensity score matched cohorts were compared, prognosis was significantly worse in patients with previous extrathoracic malignancies than patients without (5-year survival rates, 75.3% vs 82.7%; P = .009), although recurrence was not frequently seen (5-year recurrence-free rates, 78.7% vs 83.0%; P = .491).Because treatment history of extrathoracic malignancy was not associated with postsurgical lung cancer recurrence, proposing curative resection could be justifiable if the previous cancer is deemed cured or controlled. However, the results showing that patients with previous cancer history have a worse survival rate than patients without should be taken into account when curative surgery is considered.

Single-lung transplantation (LTx) is an option for lung injury after bone marrow transplantation. We report a patient who underwent right single LTx for obliterative bronchiolitis after bone marrow transplantation and suffered post-LTx hypoxemia because of a marked ventilation-perfusion mismatch in his native lung. Pulmonary artery banding at 78 days after LTx decreased pulmonary arterial flow to the native lung and successfully resolved the hypoxemia. When we encounter hypoxemia after single LTx, ventilation-perfusion mismatch in the native lung should be considered as a possible diagnosis and surgical pulmonary artery banding is a feasible option.

We report a case of atypical type A thymoma variant manifesting polymyalgia rheumatica. A 68-year-old man underwent extended thymectomy with concomitant resection of the pericardium and right lung for an anterior mediastinal tumor. He was diagnosed with atypical type A thymoma variant with pericardial invasion. He developed pain in his extremities 1 year and 2 months after surgery. Detailed examinations resulted in a diagnosis of polymyalgia rheumatica and bone metastasis of thymoma. He was treated with oral prednisolone for polymyalgia rheumatica. His symptoms and bone lesion have been stable up to the present time of 3.5 years post-surgery.

Purpose To better determine suitable resection lines for sublobar lung resection, especially to obtain sufficient resection depth, a novel technique of virtual-assisted lung mapping (VAL-MAP) 2.0 was developed by combining multispot dye marks (conventional VAL-MAP) and a deeply placed microcoil. Description With the patient under local anesthesia and sedation, multiple dye marks were bronchoscopically made on the lung surface. Microcoils were then bronchoscopically placed centrally to the tumor to indicate deep resection margins. Postmapping computed tomography confirmed the marking locations. Evaluation Six patients underwent VAL-MAP 2.0: 5 for wedge resection and 1 for segmentectomy. The mean diameter and depth of the targeted lesions were 10.0 ± 4.1 and 12.6 ± 10.3 mm, respectively. In total, 18 dye marks and 9 microcoils were placed without major complications. The microcoils were successfully identified with intraoperative fluoroscopy, effectively assisting the surgeons' decision regarding the deep resection lines. Conclusions This study confirmed the safety and feasibility of VAL-MAP 2.0. This technique effectively assisted surgeons to obtain sufficient resection margins in sublobar lung resection, even when removing deeply located lesions.

Background Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multi-spot dye-marking technique, which can be combined with bronchoscopic placement of a microcoil (VAL-MAP 2.0). VAL-MAP can identify unpalpable pulmonary lesions; however, the markings are occasionally deemed invisible intraoperatively. We investigated preoperative risk factors for invisible markings after VAL-MAP. Methods We prospectively performed preoperative VAL-MAP in patients at the University of Tokyo between January 2014 and June 2020. Data of 219 patients (257 lesions) and 857 markings were retrospectively reviewed. Dye markings were categorized as Grade 0 (invisible) or 1–5 (visible). The risk factors for Grade 0 markings were assessed using multiple logistic regression analysis. Subsegments of the bronchus showing Grade 0 markings were also evaluated for 133 lesions and 504 markings without missing data for the target segment. Results Sixty-one of the 257 lesions (24%) displayed > 1 Grade 0 markings. Seventy-six (8.9%) of the 857 markings were Grade 0 intraoperatively. VAL-MAP 1.0 was performed for 202 (79%) and 25 lesions (10%) without and with electromagnetic navigation bronchoscopy, and VAL-MAP 2.0 with a microcoil was performed for 30 lesions (11%). Upper lobe markings were associated with a significantly increased risk of invisible markings. There was no significant difference in the frequency of Grade 0 markings among the VAL-MAP methods. Among all bronchi subsegments, left B1+2c exhibited the highest rate of Grade 0 markings. Conclusions Markings placed using VAL-MAP are more likely to be invisible for upper lobe pulmonary lesions. Injecting markings for lesions in the left S1+2c thus require caution.

Living-donor lobar lung transplantation is often indicated for acute exacerbation of idiopathic interstitial pneumonia because of the long waiting time for cadaveric lung transplantation in Japan. Donors without major underlying diseases are selected after medical screening. A 44-year-old man donated his right lower lobe to his sibling with idiopathic interstitial pneumonia. Although he was free of any major medical problems before transplantation, fibrotic changes appeared in both the donated lung and the donor's remaining lungs in a case of familial interstitial pneumonia. For living-donor lobar lung transplantation for idiopathic interstitial pneumonia, donor candidates should be informed of the potential issue of a familial disease.

An 81-year-old woman with a 2-year history of dysphagia detected a cervical mass. Computed tomography showed a thyroid tumor extending through the superior and anterior mediastinum. Analysis of an incisional biopsy specimen revealed a thymoma. Total resection of the thyroid and mediastinal tumor was performed. The thymoma invaded the anterior tracheal wall and left brachiocephalic vein. Pathologic examination revealed thymoma type B1 concomitant with B2 and B3 (World Health Organization classification), Masaoka IVb, and T3 N2 M0-IVb, with cervical lymph node metastasis. Clinicians must be cautious during radical operations for invasive ectopic thymomas.

Patients with thymomas are at high risk of developing extrathymic malignancies. We investigated the impact of extrathymic malignancies on the prognosis of patients with thymoma who underwent surgery and the risk factors for postoperative extrathymic malignancies.A multicenter retrospective review of 252 patients who underwent surgical resection of thymomas from January 1977 to March 2016 was conducted. The exclusion criteria were recurrent thymoma, rare types of thymoma, and missing data. The overall number and incidence of extrathymic malignancies were calculated. Potential predictors of extrathymic malignancies were also evaluated.Two hundred twenty-eight patients were analyzed. Fifty-five extrathymic malignancies were observed (23 postoperative, 8 synchronous, and 24 preoperative). Among the overall cohort, the incidence of extrathymic malignancies significantly increased the patients' risk of death (hazard ratio [HR], 4.02; 95% confidence interval [CI], 1.72 to 9.40; p0.01). Among patients aged less than 70 years, the incidence of extrathymic malignancies was an independent risk factor for death. The incidence of postoperative extrathymic malignancies was significantly higher in patients with indolent forms of thymoma (type A/AB/B1) than aggressive forms (type B2/B3) (p = 0.02). In the multivariate analysis, indolent forms of thymoma (type A/AB/B1) (HR, 4.03; 95% CI, 1.12 to 14.6, p = 0.03) and a history of ever having smoked (HR, 5.29; 95% CI, 1.30 to 21.6; p = 0.02) were significant risk factors for the cumulative incidence of postoperative extrathymic malignancies.Extrathymic malignancies increased the risk of death in patients with thymomas. Indolent forms of thymoma and a history of ever having smoked were risk factors for postoperative extrathymic malignancies.

A patient with pleuroparenchymal fibroelastosis (PPFE) was successfully treated with living-donor lobar lung transplantation. A 27-year-old woman with a 3-month history of dyspnea received a diagnosis of PPFE. Her chest wall was extremely flattened over time, and her respiratory condition progressively deteriorated. She underwent semielective bilateral living-donor lobar lung transplantation. Her chest wall rigidity, which was secondary to PPFE, required intensive pulmonary rehabilitation postoperatively. By 6 months after transplantation, the flattening of her chest wall was reversed. Living-donor lobar lung transplantation was a life-saving procedure for this patient and improved the chest wall deformity of PPFE.

Background Systemic chemotherapy remains the standard treatment for metastatic transitional cell carcinoma (TCC) of the urinary tract. For pulmonary metastases of several malignancies, surgical therapy for selected patients has become a treatment of choice to achieve cure. However, data on pulmonary metastasectomy for urinary TCC remain limited. Methods From 1990 to 2005, 2,288 patients who underwent pulmonary metastasectomy for all types of malignancy were registered in the Metastatic Lung Tumor Study Group of Japan. Of these, we extracted 32 patients with TCC who underwent pulmonary metastasectomy with a curative intent from the database. We investigated the surgical outcomes of the patients, focusing on long-term progression-free survival (PFS) and modified PFS as a parameter for achieving a cure. In modified PFS, when the disease-free status had continued for longer than two years after repeated resection at the last follow-up, the first recurrence was not considered as an event. Results The five-year overall survival and PFS rates were 50% and 26%, respectively. Including 3 patients who underwent a second pulmonary metastasectomy for recurrence, 9 patients survived without recurrence for more than 5 years, resulting in a modified five-year PFS rate of 40%. Multivariate analysis revealed that a pulmonary metastasis greater than 3 cm was a significantly poor prognostic factor. The modified five-year PFS rate for patients with a pulmonary metastasis smaller than 3 cm in diameter was 65%. Conclusions Pulmonary metastasectomy may have a curative role in the treatment of metastatic TCC in appropriately selected patients, especially those with a small solitary pulmonary metastasis.

Myasthenia gravis occasionally develops in a postthymectomy patient with no preoperative history of this disease.We retrospectively assessed the clinical course, history, and findings of myasthenia gravis, and examined the serum titers of antiacetylcholine receptor-binding antibody in patients who had undergone thymectomy.We enrolled 67 patients with thymoma and 11 with other thymic tumors, all of whom underwent thymectomy. Twelve thymoma patients had had myasthenia gravis preoperatively, and their serum titers were all positive for antiacetylcholine receptor-binding antibody. Thirteen of 55 patients (24%) who had had no preoperative myasthenia gravis, but none with other thymic tumors (p0.0001), had a similar positive reaction. Five of the 55 thymoma patients without preoperative myasthenia gravis presented with the disease 3 to 46 months after thymectomy. These 5 patients showed no significant clinical or pathologic features, and in only 1 did the tumor recur. However, they all, including 2 patients who had shown negative antiacetylcholine receptor-binding antibody titers preoperatively, showed the presence of antiacetylcholine receptor antibody after onset. No postoperative elevation of the antiacetylcholine receptor binding antibody titer was observed in any postthymectomy patient who had no myasthenia gravis.We found that patients in whom postthymectomy myasthenia gravis developed showed high titers of antiacetylcholine receptor-binding antibody at the onset of the myasthenia gravis. We suggest that a positive preoperative antiacetylcholine receptor antibody level may be a risk factor for postthymectomy myasthenia gravis.

Background The use of thoracoscopic techniques for pulmonary metastasectomy is controversial because small metastatic foci might be missed without thorough finger palpation of the lung. Methods We retrospectively examined preoperative findings of helical computed tomography and pathologic findings of pulmonary nodules obtained by open thoracotomy, including median sternotomy or thoracoscopy, in patients thought to have pulmonary metastasis from colorectal cancer. Results We performed 122 pulmonary metastasectomies (43 thoracotomies and 79 thoracoscopies) in 102 patients from 1999 to 2005. Repeat metastasectomies were excluded. Preoperative evaluation revealed 219 pulmonary nodules suspicious for pulmonary metastasis, and 250 nodules were resected; however, pathologic examination revealed that 47 (18.8%) of 250 nodules were not metastases. When the diameters of the pulmonary nodules were small, the rates of metastasis were also significantly lower. Finally, 4 thoracotomy (9.3%) and 5 thoracoscopy patients (6.3%) were found to have additional pulmonary metastases at operation. Recurrent pulmonary metastases were found at the ipsilateral side of the metastasectomy in 27 (34.2%) of 79 thoracoscopies and 27 (62.8%) of 43 open thoracotomies (p = 0.0023) within 2 years after the pulmonary surgery. These metastatic foci might have been missed at the time of pulmonary metastasectomy. Conclusions The ability to detect pulmonary metastases in patients with colorectal cancer is limited by preoperative evaluation with computed tomography and surgical techniques, including open thoracotomy with bimanual palpation. Pulmonary metastasectomy by open thoracotomy or thoracoscopy may be a suboptimal intervention to remove metastatic foci in the lungs.

Background The optimal mode of resection for thymoma in nonmyasthenic patients remains unclear. The aim of this study was to explore whether or not thymomectomy alone is a relevant option for patients with stage I (T1N0M0) thymoma in the proposed TNM classification. Methods We investigated 2,835 patients with thymic epithelial tumors treated at 32 institutions participating in the Japanese Association for Research on the Thymus (JART). A total of 1286 patients with thymomectomy: resection of thymoma with partial thymectomy (n = 289) or thymothymomectomy: resection of thymoma with total thymectomy (n = 997) for stage I thymoma were included. Surgical and oncologic outcomes were compared between the 2 groups. Results Patients who underwent thymomectomy were older (61.1 versus 57.0 years; p = 0.000) and had smaller tumors (4.77 versus 5.99 cm; p = 0.000) than those who underwent thymothymomectomy. There was a significant difference in the distribution of histologic subtype ( p = 0.007). After propensity-score matching, the matched cohort consisted of 276 patients in each group. Postoperative complications were seen more frequently in the thymothymomectomy group than in the thymomectomy group (8.3% versus 4.3%; p = 0.0397). The 5-year overall survival rate was 97.3% in the thymomectomy group and 96.9% in the thymothymomectomy group ( p = 0.487). Patients who underwent thymomectomy tended to have local recurrence more frequently than did those who underwent thymothymomectomy (2.2% versus 0.4%; p = 0.0613). Conclusions Thymomectomy alone is acceptable for stage I thymoma in regard to postoperative complications and prognosis. Further studies are needed to evaluate long-term outcomes.

Background To investigate the clinical characteristics and therapeutic outcomes of patients who underwent surgery for stage III thymoma in Japan. Methods Using the Japanese nationwide database, which contains the records of 2,835 patients with thymic epithelial tumors who underwent treatment between 1991 and 2010, we extracted and analyzed the records of those who underwent surgery for stage III thymoma. Results A total of 310 patients (170 males, 140 females; median age, 58 years) were analyzed. Involved sites were the lung in 194 (62.6%), the pericardium in 151 (48.7%), the great vessels in 126 (40.6%), the phrenic nerve in 84 (27.1%), and the chest wall in 7 (2.3%). Complete resection (R0) was achieved in 247 (79.7%) cases. Induction therapies were administered to 42 (13.5%) patients, and postoperative therapies were administered to 147 (47.4%). In R0 cases, 68 (27.5%) experienced recurrence. The pleural space was the most frequent site of recurrence (46; 18.6%). The 10-year overall and disease-free (in R0) survival rates were 80.2% and 51.6%, respectively. Multivariate analyses revealed that age ( p = 0.002), male sex ( p = 0.017), induction therapy ( p p = 0.037) were independent adverse predictors for overall survival. Chest wall invasion was the only independent adverse predictor for disease-free survival, although the factor analysis was marginal for overall survival. Conclusions The outcomes of surgery for patients with stage III thymoma were favorable unless chest wall invasion was present; however, the role of complete resection and appropriate multimodal treatment plan require further investigation.

Background . The hemodynamic effects of carbon dioxide insufflation under single-lung ventilation were studied in 22 consecutive thoracoscopic harvests of the left internal mammary artery, which was used for minimally invasive coronary artery bypass grafting. Methods . An electrocardiograph, arterial catheter, Swan-Ganz catheter, and transesophageal echocardiograph were used to monitor seven hemodynamic variables. Baseline data were obtained during ventilation of both lungs and the measurements were repeated after the left lung was collapsed and at 5 and 30 minutes after hemithorax insufflation with low-flow (2 to 3 L/minute) carbon dioxide gas was begun. The intrapleural pressure was maintained at 8 to 10 mm Hg. Results . Thoracoscopic harvest of the internal mammary artery was completed in all cases with a mean insufflation time of 44 ± 12 minutes. There were no significant changes in the mean arterial pressure, heart rate, cardiac index, and left ventricular ejection fraction throughout the procedure, whereas the central venous pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure ( p Conclusions . Low-flow carbon dioxide insufflation into the left hemithorax with an intrapleural pressure of 8 to 10 mm Hg under selective right-lung ventilation does not compromise the human heart with normal to moderately depressed function and can be an efficacious adjunct in specific thoracoscopic procedures.

Background. Recently, intrapulmonary metastases in non-small cell lung cancer have been considered to have less influence on prognosis than extrapulmonary metastases. We report a subgroup found among patients with intrapulmonary metastases showing a good prognosis. Methods. A retrospective study was performed on 236 consecutive patients with non-small cell lung cancer who underwent surgical resection of their tumors. Intrapulmonary metastases were found histopathologically in 50 of them, and their clinicopathologic features were investigated. Results. Analysis of postsurgical results revealed a subgroup of patients showing excellent prognosis (n = 15). They had well-differentiated adenocarcinomas with bronchioloalveolar spread and pT1–2 N0, without vascular or lymphangitic invasion. Their actuarial 5-year survival rate was 100%, with a mean survival interval to date of 28 months. However, none of the other 35 patients survived for 5 years, with a mean survival interval to date of 11 months. Conclusions. We have clarified that patients with histopathologically diagnosed intrapulmonary metastases from non-small cell lung cancer do not constitute a homogeneous group. Pulmonary metastases with good prognosis, which are considered to be hematogenous metastases, may be benign lesions such as adenomatous or atypical adenomatous hyperplasias mimicking malignant tumors.

We report a resection of a posterior mediastinal metastasis of colon cancer. A 29-year-old man who had undergone a right hemicolectomy and liver resection for ascending colon cancer with liver metastasis was referred to our hospital with the diagnosis of a solitary posterior mediastinal metastasis. Tumor extirpation with descending aorta replacement was performed. Five months after the operation, local recurrence developed in the posterior mediastinum, which was also resected. He has been recurrence-free for 5 years since the second procedure. In this case, the metastases were believed to have occurred through the thoracic duct.

Background Solitary pulmonary lesion poses a diagnostic challenge, especially in patients with a history of malignancy. The purpose of this study was to evaluate the characteristics of solitary pulmonary lesions and the outcome of surgical resection. Methods We retrospectively analyzed 243 patients with a history of cancer who underwent surgery for new-found solitary pulmonary lesion between January 1998 and December 2007. Results The diagnosis was primary lung cancer in 92 patients, metastasis in 133, and benign lesions in 18. The 5-year survival rate was 67.9% in all patients, 74.6% in those with primary lung cancer, 62.8% in those with metastasis, and 79.9% in those with benign lesions ( p = 0.56). In metastasis patients, history of extrapulmonary recurrence and larger diameter lesion were risk factors for recurrence by multivariate analysis. History of cancers other than colorectal and bone and soft tissue sarcoma and shorter disease-free interval were indicators of poor prognosis. Pathologic stage was the only indicator of prognosis for primary lung cancer, and none of the factors concerning antecedent cancer influenced prognosis. Conclusions Surgical resection of solitary pulmonary lesion is essential in patients with a history of cancer because substantial numbers of benign lesions are included. In the case of malignancy, metastasectomy had a life-prolonging effect for selected patients, and prognosis of primary lung cancer was no worse than for the general population if treated appropriately. It is important not to hesitate to take a surgical approach for a diagnosis and to treat with standard therapy for primary lung cancer.

Background The lung is the major organ for distant metastasis from head and neck cancers, and pulmonary metastasectomy is indicated for selected cases. The efficacy of surgical treatment for pulmonary metastatic lesions from head and neck cancers has not been thoroughly examined. Methods The database developed by the Metastatic Lung Tumor Study Group of Japan was retrospectively reviewed. Between November 1980 and September 2006, 237 patients underwent resection of pulmonary metastases from primary head and neck cancers. After excluding nonsquamous cell carcinomas, 114 cases were analyzed, and the survival and prognostic factors for pulmonary metastasectomy for metastases from head and neck cancers were determined. Results The overall 5-year survival rate after pulmonary metastasectomy was 26.5%, and the median survival time was 26 months. As determined by univariate analysis, poor prognostic factors were oral cavity cancers, lymph node metastasis, a disease-free interval of 24 months or less, and incomplete resection. Multivariate analysis revealed that poor prognostic factors were being male, having oral cavity cancers, lymph node metastasis, and incomplete resection. When patients were divided into males with oral cavity cancers (n = 17) and all others (n = 97), the 5-year survival rates were 0% and 31.6%, respectively. Survival of male patients with oral cavity cancer that metastasized was significantly reduced (p Conclusions Male sex, oral cavity cancers, lymph node metastasis, and incomplete resection were poor prognostic factors for pulmonary metastases, but there is the potential for a good surgical outcome in carefully selected patients.

This communication describes our clinical experience with the hybrid method, a video-assisted anterior minithoracotomy approach developed for minimally invasive limited pericardiectomy to treat 8 patients with massive pericardial effusion. The average operating time was 37.2 minutes, and there was no procedure-related morbidity or mortality. The mean follow-up period was 5.6 months, and there have been no recurrences. The hybrid approach can be accomplished irrespective of pleural adhesions. It eliminates the need for hemipulmonary collapse, making it more advantageous than the totally port-access thoracoscopic approach.