Search

Solitary pulmonary hematoma is a rare consequence of blunt chest trauma. Moreover, there has been no reported case of solitary pulmonary hematoma radiographically diagnosed as a posterior mediastinal tumor. We present the case of a 63-year-old man who was referred for an oval-shaped opacity at the left paraspinal area on a chest X-ray. Chest computed tomography showed a well-circumscribed posterior mediastinal tumor on the left paraspinal lesion with extrapleural sign and callus formation on the left ribs posteriorly (7th to 11th ribs). The tumor was thoracoscopically confirmed to be a subpleural pulmonary tumor of the left lower lobe, and wedge resection was performed. Histological examination confirmed the diagnosis of pulmonary hematoma. On reviewing the callus formation of the ribs, which was suggestive of rib fractures, the pulmonary hematoma was determined to be traumatic in origin. The postoperative course was uneventful. We reviewed a rare case of pathologically proven traumatic solitary pulmonary hematoma. The rarity of this case is enhanced because the hematoma initially appeared to be a posterior mediastinal tumor.

There are few data available on the outcomes of postoperative recurrent thymic carcinoma (TC) and thymic neuroendocrine carcinoma (TNEC). The aim of this study is to evaluate the treatment and survival in patients with recurrent TC and TNEC after undergoing surgical resection. A retrospective chart review was performed using our multicenter database to identify patients with a postoperative recurrence of TC and TNEC from 1995 to 2018. The clinicopathological factors were reviewed and the survival outcomes were analyzed. Sixty patients were identified among 152 patients who underwent resection of TC and TNEC. The median follow-up period from the first recurrence was 14.8 months (range 0–144). The 5-year post-recurrence survival was 23% for the whole cohort. According to a univariable analysis, advanced stage [hazard ratio (HR) 2.81, 95% confidence interval (CI) 1.09–9.54], interval between primary surgery and recurrence (HR 0.97, 95% CI 0.95–0.99), any treatment for recurrence (HR: 0.27, 95% CI 0.13–0.58) and chemotherapy for recurrence (HR: 0.46, 95% CI 0.22–0.95) were significant factors related to post-recurrence survival. Chemotherapy rather than surgery appears to be the mainstay treatment for managing patients with postoperative recurrent TC and TNEC and it may also be considered in multidisciplinary management. Further studies with a larger sample size are required to confirm our findings.

Highlights • Congenital partial pericardial defects are rare but can cause cardiac herniation. • Pneumopericardium combined with pneumothorax suggests pericardial defect. • Pneumothorax may worsen the heart protruding through the pericardial defect. • VATS should be considered in the patients with a pericardial defect., Introduction Congenital pericardial defects are rare but can cause fatal complications. Most cases are asymptomatic and incidentally detected during a thoracic surgery or autopsy. We report a case of a partial pericardial defect confirmed based on spontaneous pneumothorax. Presentation of case A 16-year-old boy with left spontaneous pneumothorax showed pneumopericardium on chest X-ray. Chest computed tomography revealed a partial pericardial defect. Video-assisted thoracoscopic surgery was performed, and a small pericardial defect was confirmed at the level of the upper pulmonary hilum. We did not reconstruct the defect because of the improbability of cardiac herniation. Discussion Pneumopericardium combined with pneumothorax suggests the existence of a pericardial foramen. Partial pericardial defects could cause cardiac herniation or strangulation, and pneumothorax may worsen the protruding of the heart. Video-assisted thoracic surgery is an effective method to prevent the recurrence of pneumothorax and determine whether reconstruction of the defect is required. Conclusion Video-assisted thoracic surgery should be performed in the case of a pericardial defect combined with pneumothorax.

Highlights • Solitary pulmonary capillary hemangioma (SPCH) is a rare benign lung tumor. • SPCH presents with a ground glass opacity on CT scan. • Preoperative definitive diagnosis as SPCH is a real challenge. • Immunohistochemical staining is essential for diagnosis as SPCH., Introduction Solitary pulmonary capillary hemangioma (SPCH) is a rare benign lung tumor that clinically resembles early lung cancer and precancerous pulmonary lesions that present with similar imaging manifestations. Presentation of case The patient was a 54-year-old Japanese man who was referred to Nagara Medical Center with a ground glass opacity (GGO) lesion within the right upper lung that was incidentally detected on computed tomography. After 8 months of follow-up, video-assisted thoracoscopic segmental resection of the right upper lobe was performed with diagnostic and therapeutic intent. Pathologic examination of the resected specimen demonstrated thickening of the alveolar septum caused by the proliferation of capillary vessels. This lesion was positive for CD31 and CD34 and negative for thyroid transcription factor-1 and cytokeratin on immunohistochemical staining. The tumor was diagnosed as SPCH pathologically. Discussion When radiological examination demonstrates a GGO in the lung, SPCH must be considered as one of the differential diagnoses. For a definitive diagnosis, pathological examination of a surgically resected specimen must be conducted. Conclusion This study describes a case of SPCH and a review of the literature.

Background The aim of this multicenter, randomized phase II study was to analyze the feasibility and safety of alternate-day S-1, an oral fluoropyrimidine, for adjuvant chemotherapy in patients with completely resected pathological stage I (tumor diameter > 2 cm) non-small cell lung cancer (NSCLC). Methods Patients were randomly assigned to receive adjuvant chemotherapy for 1 year comprising either alternate-day oral administration of S-1 (80 mg/m2/day) for 4 days a week (Group A) or a 2-week oral administration of S-1 (80 mg/m2/day) followed by 1 week of rest (Group B). The primary endpoint was feasibility, which was defined as the proportion of patients who completed the allocated intervention for 6 months with a relative dose intensity (RDI) of 70% or more. Results Ninety-three patients were enrolled of whom 90 patients received S-1 treatment. Median follow-up was 66.9 months. The treatment completion rate based on an RDI of 70% or more for 6 months was 84.4% (95%CI; 70.5–93.5%) in group A and 64.4% (95%CI; 48.8–78.1%) in group B. There were no grade 4 adverse events in either group. Moderate or severe adverse events (grade 2 or grade 3) were significantly more frequent in group B (67%) compared with group A (29%, P = 0.001). The 5-year relapse-free survival rate was 87.0 and 80.9% for group A and B, respectively (P = 0.451). The 5-year overall survival rate for all patients (n = 93) was 100 and 89.4% for group A and B, respectively (P = 0.136). Conclusion Alternate-day oral administration of S-1 for 1 year as adjuvant chemotherapy was demonstrated to be feasible with low toxicity in completely resected stage I (tumor diameter > 2 cm) NSCLC. Trial registration Trial registration number: UMIN000011994. Date of registration: 10/8/2013.

Empyema with bronchopleural fistula is a challenging condition that often requires open-window thoracostomy. Bronchial occlusion with Endobronchial Watanabe Spigot is an effective and less invasive procedure to close the fistula; however, delivering a spigot into the target bronchus requires high technical skills. Herein, we report a case of bronchopleural fistula occluded with a spigot using a new ‘traction method’ in which the spigot is tied as an anchor to a guidewire and pulled into the target bronchus. Our method allows selective and steady placement of the spigot for patients who undergo open-window thoracostomy for the treatment of bronchopleural fistula.

Minimally invasive surgery (MIS) has occasionally been used for selected patients with thymoma, but there is little information on the MIS approach for thymic carcinoma. The aim of this study was to evaluate survival outcomes after MIS for early-stage (Masaoka stage I-II) thymic carcinoma and thymic neuroendocrine carcinoma. A retrospective chart review of the cases recorded in our multi-institutional database was performed to identify patients who underwent resection for thymic carcinoma between 1995 and 2017. MIS thymectomy was performed in 17 cases (VATS, n = 14; RATS, n = 3. male, 41%; median age, 72 years). The median follow-up period was 32.7 (range 7.4-106) months. The five-year overall survival and relapse-free survival rates were 84.4% and 77.8%, respectively. The present study demonstrated encouraging preliminary results regarding MIS for the treatment of early-stage thymic carcinoma and thymic neuroendocrine carcinoma. Further studies with a larger sample size are required to evaluate the indications for this surgery.

Objectives Previous studies have suggested that a second malignancy often develops after resection of thymoma; however, it remains unknown whether this is applicable to thymic carcinoma. Methods A retrospective chart review was performed based on our multi-institutional database of resected thymic epithelial tumours between 1991 and 2016. A second malignancy was defined as newly diagnosed after thymic tumour resection. The cumulative incidence of and related death from a second malignancy after thymic and neuroendocrine carcinoma resections were estimated using a competing risk model and were compared to those of patients undergoing a thymoma resection. Results Two hundred and thirty-eight patients were identified (thymic carcinoma 59; thymoma 179). A second malignancy developed in 1 patient (1.7%) with thymic carcinoma and in 17 patients (9.5%) with thymoma. Deaths from second malignancies were noted in 7 patients with thymoma. There was a tendency towards a lower cumulative incidence of and a lower cumulative death from a second malignancy after thymic carcinoma resection (P = 0.139 and P = 0.20, respectively) than after thymoma resection. The cumulative incidence of a second malignancy in patients with thymic carcinoma was 2.8% at 5 years and at 10 years (8.0% at 5 years and 11.8% at 10 years in patients with thymoma). Conclusions After resection of thymic and thymic neuroendocrine carcinoma, the probability of developing a second malignancy, as well as mortality from a second malignancy, is very low. A prospective study with a larger sample size is required to validate our results.

Characteristics of pneumothorax associated with nontuberculous mycobacterium (NTM) infection are rarely reported, especially in terms of surgical treatments. Our objectives were to show the tendency and clinical courses of pneumothorax due to NTM and discuss the way of therapy in our hospital. We retrospectively analyzed 557 patients with NTM infection over a period of 5 years at the Nagara Medical Center. A total of 12 out of the 557 patients (2.2%) suffered from pneumothorax caused by NTM infection without other pulmonary diseases. The diagnosis of all NTM cases was mycobacterium avium complex. Of these 12 patients, three required observation only (25%), five required drainage only (42%), and four required surgery after drainage (33%). The four surgically treated patients suffered from empyema as well as pneumothorax. They were in worse nutritional condition than non-surgically treated patients. For the patients requiring surgery, we selected reasonable surgical methods; we sutured the fistula of lung in all cases and covered it with muscle or omentum or polyglycolic acid sheets without a case in which endobronchial embolization was performed in advance before surgery. Finally, all pneumothorax healed. Thereafter, three of these four patients took unfavorable courses: progressing malnutrition, complications worsening or contralateral pneumothorax. We should select an appropriate treatment including surgery against NTM-associated pneumothorax without losing an opportunity because of its intractability and exhausting effect.

Pulmonary sclerosing pneumocytoma (PSP) arising from the hilar lesion is extremely rare. We report an asymptomatic 70-year-old female with a thoracic tumor of unknown origin. Contrast-enhanced chest tomography showed a poorly and heterogeneously enhanced 40-mm tumor compressing the left upper lobe, bronchus, and pulmonary arteries. Positron-emission tomography did not detect abnormal integration in the tumor. Surgical resection was planned to confirm diagnosis and avoid further compression on the structures. Intraoperative findings revealed a dark red-colored tumor, projecting from the left upper lobe in the hilar lesion. Left upper lobectomy was performed through video-assisted thoracoscopic surgery to achieve complete resection and avoid contact bleeding. Immunohistochemical examination revealed the presence of PSP.

Dubin–Johnson syndrome is a form of constitutional jaundice induced by a mutated ATP-binding cassette-C2 (ABCC2) gene. The ABCC2 gene is involved in the excretion of drugs. We recently treated a patient with malignant pleural mesothelioma complicated with Dubin–Johnson syndrome with cisplatin/pemetrexed combination therapy. One-third of the dose compared to the standard dose of pemetrexed was administered during the first course. We increased the dose of pemetrexed in stages after evaluating the patient for adverse effects. Cisplatin was combined beginning in the fourth course. The adverse effects of cisplatin/pemetrexed combination therapy were slight, and the patient exhibited a partial response. We measured the blood concentration and analyzed the pharmacokinetics of pemetrexed. As a result, the excretion of pemetrexed was found to be good, and no delay of excretion was observed compared to that in normal patients. It was previously reported that the ABCC2 gene is expressed in the kidneys. However, it appears that ABCC2 might not be related to the excretion of pemetrexed. These results suggest that standard dose cisplatin/pemetrexed combination therapy could be conducted for patient with malignant pleural mesothelioma complicated with Dubin–Johnson syndrome from the first course.

Purpose Analgesia following thoracotomy is routinely accomplished using epidural blockage performed by anesthesiologists. More effective pain control can be achieved with continuous paravertebral blockage performed by thoracic surgeons. We aimed to retrospectively analyze the efficacy of paravertebral blockage for managing post-thoracotomy pain. Methods The study included 125 patients who underwent continuous paravertebral blockage for the following types of thoracic surgery: video-assisted thoracoscopic surgery(n = 87), anterior axillary thoracotomy (n = 21), posterolateral thoracotomy (n = 16), and median sternotomy with additional left thoracotomy (n = 1). We retrospectively evaluated the analgesic effects of continuous paravertebral blockage by assessing whether a good cough effort could be performed and whether an additional painkiller was given as a rescue medication. Results About 115 patients could perform a good cough effort to expectorate sputum immediately after extubation in the operating room. Six patients tolerated postoperative pain well without any oral or rectal non-steroidal anti-inflammatory drugs (NSAIDs). For97 patients postoperative NSAIDs could control thoracotomy pain well. Twenty-two patients were given an additional painkiller stronger than NSAIDs. Three patients complained of nausea postoperatively. Conclusion Adequate post-thoracotomy pain control was accomplished by continuous paravertebral blockage, with few complications.

Summary Warm ischemia-reperfusion injury related to donation after cardiac death donors is a crucial and inevitable issue. As surfactant function is known to deteriorate during warm ischemia, we hypothesized that surfactant inhalation during warm ischemia would mitigate warm ischemia-reperfusion injury. We used an isolated rat lung perfusion model. The rats were divided into three groups: sham, control, and surfactant. In the control and surfactant groups, cardiac arrest was induced by ventricular fibrillation. Ventilation was restarted 110 min later; subsequently, the lungs were flushed, and heart and lung block was recovered. In the surfactant group, a natural bovine surfactant Surfacten® was inhaled for 3 min at the end of warm ischemia. Then, the lungs were reperfused for 80 min. Surfactant inhalation significantly improved graft functions, effectively increased lung tissue ATP levels, and significantly decreased mRNA levels of IL-6 and IL-6/IL-10 ratio at the end of reperfusion. Histologically, lungs in the surfactant group showed fewer signs of interstitial edema and hemorrhage, and significantly less neutrophilic infiltration than those in the control group. Our results indicated that surfactant inhalation in the last phase of warm ischemia maintained lung tissue energy levels and prevented cytokine production, resulting in the alleviation of warm ischemia-reperfusion injury.

Summary Successful living-donor lobar lung transplantation (LDLLT) largely depends on donor outcome. We reviewed our experiences with LDLLT and focused on preoperative computed tomographic evaluations of donors. Twenty-five LDLLTs were performed in Kyoto University. As a routine preoperative assessment, high-resolution chest computed tomography (CT), and three-dimensional (3D)-CT angiography were performed. Preoperative evaluations, surgical procedures, and early postoperative outcomes were reviewed in 43 consecutive LDLLT donors. All donors were discharged home after the donor lobectomies. Severely incomplete fissures were intraoperatively identified in two donors, whose interlobar fissures were mostly not identified by high resolution CT preoperatively. Preoperative 3D-CT angiography was effective for the identification of the branches of the pulmonary artery and vein. Pulmonary arterioplasties were performed with auto pericardial patches in three left donors. The bilateral donors had to be exchanged because of an anomaly of the pulmonary veins in one donor. Small pulmonary arterial branches to the remaining lobes were to be sacrificed in 23 donors (53%). Early postoperative complications were ascertained in seven donors, and five of them presented air leak-related complications. Living donor lobectomies were safely performed with low morbidities in our institution. Preoperative computer tomographic evaluations might be useful in donor lobectomies.

Summary Successful living-donor lobar lung transplantation (LDLLT) largely depends on donor outcome; however, there are few studies that have assessed outcomes of LDLLT donors, particularly pulmonary function. We investigated the outcomes and pulmonary function after donor lobectomy in LDLLT donors. Retrospective evaluation of consecutive 33 LDLLT donors was performed. Preoperative characteristics and perioperative and postoperative variables were investigated. Evaluation of pulmonary function 3, 6 and 12 months after donor lobectomy was performed prospectively. All donors were well alive after donor lobectomies. Morbidity was found in five donors (15%). Postoperative complications consisted of re-accumulation of pleural effusion requiring readmission in three donors and prolonged air leakage in two donors. Sacrifice of pulmonary arteries was performed in 20 donors (61%) with 1.4 ± 0.6 branches. Forced vital capacity was 77.8 ± 6.1%, 84.8 ± 6.0% and 89.4 ± 6.6% of the preoperative value 3, 6 and 12 months after donor lobectomy, respectively. Forced expiratory volume in 1 s was 80.5 ± 7.8%, 85.6 ± 8.9% and 89.3 ± 8.7% of the preoperative value 3, 6, and 12 months postoperatively. Living-donor lobectomy was performed with low morbidity. Pulmonary function even after lobectomy was better preserved than expected.

A 6-year-old girl with idiopathic interstitial pneumonia successfully underwent living-donor right single-lobe lung transplantation from her mother. Her mother's right lower lobe was 207% bigger than her right chest cavity, and attempting chest closure caused significant compression and narrowing of the right pulmonary vein anastomosis, as assessed by transesophageal echocardiogram. Her chest was temporarily closed without rib approximation. The following day, her chest could be completely closed. The pulmonary vein anastomosis, confirmed by transesophageal echocardiogram, was now patent. Currently, 7 months after the transplantation, she is well without limitations.

[Background.] One method of countering chronic lung donor shortages is the practice of donation after cardiac death (DCD). However, this technique inevitably leads to pulmonary dysfunction related to warm ischemia. One promising method of alleviating this problem is ventilation. However, it can rarely be initiated from the onset of cardiac arrest, particularly in uncontrolled DCD donors. We investigated the protective effect of the last 60 min of ventilation during a 240-min warm ischemic time. [Methods.] We rendered donor dogs cardiac dead and left them at room temperature. Six dogs received ventilation with 100% oxygen for 60 min starting at 180 min after cardiac arrest (ventilation group). Eight dogs received no ventilation. Lungs were harvested 240 min after cardiac arrest, then transplanted into recipient dogs. At 60 min after reperfusion, the right pulmonary artery was ligated, and the function of the left transplanted lung was evaluated. [Results.] In the ventilation group, all six animals survived for 240 min after reperfusion, whereas in the nonventilation group, only four of eight survived. The ventilation group demonstrated significantly better pulmonary oxygenation, shunt fraction, and wet-to-dry weight ratio. Furthermore, the ventilation group revealed significantly higher levels of high-energy phosphates in the lung tissues, fewer apoptotic cells, lower levels of tumor necrosis factor-α and interleukin-8 messenger RNA in the lung tissues, and lower levels of interleukin-6 messenger RNA in the serum. [Conclusion.] Our results suggest that ventilation during the late phase of the preprocurement period may ameliorate ischemia-reperfusion injury in DCD donors.

Background We previously proposed calculating forced vital capacity (FVC) by the number of segments for size matching in living-donor lobar lung transplantation (LDLLT). The primary purpose of this study was to compare spirometry-obtained calculations of lower lobe volumes with three-dimensional (3D) computed tomography (CT) volumetric images. Our second goal was to compare the data of pulmonary function tests with CT volumetry in living lung donors. Methods Pulmonary function test, including FVC and total lung capacity (TLC), and 3D CT volumetry were performed pre-operatively in 21 healthy donor candidates for LDLLT. The relationship of 3D CT volumetric data and calculated volume of lower lobes by the number of segments was investigated. Also studied were 3D CT volumetric data in relation to FVC and TLC. Various pre-operative variables were analyzed retrospectively. Results According to 3D CT volumetry, the right and left lower lobe volume was 26.3% ± 2.9% and 22.6% ± 3.1% of the total lung volume, respectively. We found a significant, strong correlation between each lower lobe volume and the total lung volume. Because the calculated volumes of right and left lower lobes by the number of segments were 26.3% and 21.1%, respectively, our results implied that the volume of both lower lobes was accurately described by the number of segments. FVC was significantly associated with TLC and the total lung volume. Conclusions We confirmed that it would be justified to estimate graft FVC by the number of segments according to the CT volumetric data in LDLLT.

症例は76歳男性．原発性肺癌に対して，胸腔鏡下左上葉切除術を施行された．周術期に肺塞栓症予防対策を施行し，術後回復良好，16日目に退院した．同日に呼吸苦が出現したが我慢した．20日目に受診し，脱水症状や血液検査で軽度の炎症所見が存在した．しかし，補液などの対症的な治療によってすぐに呼吸困難を含めた全身状態の改善を認めた．原因究明のための精査をすすめたところ，術後26日目の胸部造影CT，下肢血管エコーにて肺塞栓症と深部静脈血栓症の確定診断が得られた．抗凝固治療とIVCフィルター留置を行った．3週間後に，肺血管内血栓は消失したが，下肢血栓の改善を認めず，IVCフィルター留置のまま退院となった．本症例においては，肺血栓塞栓症の診断に，はからずも入院後約1週間を要した．呼吸器外科術後に，呼吸苦などの非特異的な臨床所見を呈した場合，常に肺塞栓症を念頭に置き，より積極的に精査を行う必要があると考える．

BACKGROUND: For patients with a thoracic malignancy whose peripheral veins are not suitable for blood access for chemotherapy, we evaluated a totally implantable central venous access port, in which the port is implanted in the ulnar side of the arm and the catheter is introduced via the basilic vein into the superior vena cava (TIAP-BV). METHODS: Twenty-five patients (21 with lung cancer, 2 with malignant pleural mesothelioma, and 2 with thymoma) receiving TIAP-BV were included. Indications, surgical complications, and long-term complications were analyzed. RESULTS: Indications for TIAP-BV were: chemotherapy (17 patients) and chemotherapy with parenteral nutrition (8 patients). The following surgical complications occurred: arrhythmia due to misplacement of the tip of catheter (1 patient); intraoperative conversion from the left to right arm (2 patients); and hematoma at the implantation site (1 patient). Short-term problems were: death 1 week after implantation without the use of TIAP-BV (2 patients). Long-term complications were: skin ulcer at the port site (1 patient); early removal of TIAP-BV because of port site infection (1 patient); catheter occlusion (1 patient); and venous thrombosis of basilic vein (2 patients). In the 22 patients who did not die early or have the device withdrawn early, the median duration of TIAP-BV use was 7 months (range, 1 to 20 months) without any break to the port system, leakage of drugs, or catheter-related infections. CONCLUSION: TIAP-BV can be employed for long-term use for chemotherapy and parenteral nutrition. However, a patient's expected prognosis and infectious disease status at the time of implantation surgery should be considered before the surgery proceeds.

Thioredoxin is a ubiquitous protein with anti-oxidative, anti-apoptotic, and anti-inflammatory effects. It was reported [Fukuse T, Hirata T, Yokomise H et al. Attenuation of ischaemia reperfusion injury by human thioredoxin. Thorax 1995; 50: 387-391] that rhTRX protected lungs from ischemia-reperfusion injury as a radical scavenger; however, the mechanism was not elucidated. Therefore, we investigated the effect of perfusion and inhalation of rhTRX, and the associated mechanisms, by analyzing the concentrations and molecular states of the perfused rhTRX.Perfusion and inhalation studies of rhTRX were conducted with an isolated rat-lung perfusion model. The heart-lung block was perfused for 15 min and subsequently exposed to a 55-min ischemia followed by a 120-min reperfusion. Pulmonary artery pressure, weight gain, dynamic airway resistance, pulmonary compliance, and tidal volume were measured continuously. The concentrations and molecular states of the perfused rhTRX were measured.A 350-microg/ml perfusion of rhTRX decreased post-ischemic pulmonary artery pressure (P0.05), while a 200-microg/ml perfusion did not. Throughout the experiment, the rhTRX concentrations were constant, and the rhTRX molecules were mostly dimeric. The inhalation of rhTRX showed adverse effects on the pulmonary function compared with the control group (P0.05).A 350-microg/ml perfusion, but not inhalation, of rhTRX protected rat lungs from ischemia-reperfusion injury. rhTRX was effective in dimeric form without transit to the lung tissue. rhTRX may be effective by some mechanism other than radical scavenging.

Introduction: Management of pulmonary metastasis of non-small cell lung cancer (NSCLC) remains controversial. We reviewed our surgical treatment for pulmonary metastasis of NSCLC. Methods: Seventy-six patients with pulmonary metastasis of NSCLC underwent pulmonary resections in two institutes during the past 10 years. Eighteen patients with simultaneous same lobe metastasis as the primary lesion underwent mostly lobectomies. Sixteen patients with simultaneous different lobe metastasis underwent combined margin-free resections. Forty-nine pulmonary metastasectomies were performed in 42 patients with recurrent lung cancer. Overall survival and disease-free survival in each group were examined, and factors affecting survivals were investigated. Results: In the patients with the same lobe metastasis 5-year survival was 79.6%, and median and 5-year disease-free survivals were 39.1 months and 41.3%. In the patients with simultaneous different lobe metastasis median survival and 5-year survival were 37.7 months and 30.7%, and median and 5-year disease-free survivals were 13.3 months and 12.5%, respectively. Multiple pulmonary metastasis and mediastinal node metastasis were identified as significant factors affecting survivals. In the patients with recurrent pulmonary metastasis median survival and 5-year survival were 40.0 months and 34.8%, and median and 5-year disease-free survivals were 23.7 months and 14.4%, respectively. Node metastasis, higher age, and shorter interval from the prior resection were identified as significant factors affecting survivals. Conclusions: These findings suggest that the simultaneous same lobe metastasis is under the same indication for the primary lesion, and that the simultaneous different lobe metastasis and recurrent pulmonary metastasis should be removed in selected patients.

Pulmonary metastasectomy for colorectal carcinoma is a well-accepted procedure; however, reports on indications and prognostic factors are inconsistent. This study was designed to clarify a role for resection of pulmonary metastases for such tumors and to define the patients who benefit from pulmonary metastasectomy.Between 1990 and 2007, 84 patients with pulmonary metastases from colorectal carcinomas underwent curative pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm a role for metastasectomy and to analyze prognostic factors for overall survival and disease-free survival after metastasectomy.Overall survival rate after metastasectomy was 60.5% and 48.4% at 5 and 10 years, respectively. Disease-free survival rate was 34.4% and 30.6% at 5 and 10 years after pulmonary resection, respectively. On multivariate analysis, patients with unilateral pulmonary metastasis presented a significantly favorable overall survival (P = 0.045). In contrast, there was no significant prognostic factor for disease-free survival.Current practice of pulmonary metastasectomy for colorectal carcinoma in our institution was well justified. Our study confirmed that unilateral pulmonary metastasis was significantly relevant to a better prognosis.

Objective A method to compensate for the donor shortage may be the utilization of donation after cardiac death. The control of lung injury against warm ischemia is crucial in manipulating donors after cardiac death. Nebulization is a simple and feasible drug delivery route after cardiac death. Herein we have examined the potential effect of nebulized milrinone, a phosphodiesterase III inhibitor, on pulmonary warm ischemia. Materials and Methods Deeply anesthetized rats were euthanized by exsanguination. Lungs were exposed to warm ischemia with ventilation up to 2 hours. Milrinone was nebulized for 10 minutes at the beginning of warm ischemia (n = 5). In the control group (n = 5), normal saline was nebulized for the same time. At given intervals, the lungs were partially resected to measure adenine nucleotide and cyclic adenosine monophosphate levels. Results In both groups, lung tissue cyclic adenosine monophosphate levels decreased significantly at 2 hours after warm ischemia; however, there was no significant difference between the groups. Lung tissue adenosine triphosphate levels significantly decreased at 2 hours after ischemia in the control group, while they did not drop up to 2 hours in the milrinone group. Further, lung tissue adenosine triphosphate levels at 2 hours after ischemia were higher in the milrinone group than the control group. Conclusions Our results confirmed that milrinone nebulization during warm ischemia maintained lung tissue adenosine triphosphate levels. Therefore, milrinone nebulization may have potential for lung protection against warm ischemia.

Outcome for highly immunogenic lung transplantation remains unsatisfactory despite the development of potent immunosuppressants. The poor outcome may be the result of a lack of minimally invasive methods to detect early rejection. There is emerging clinical evidence that, paradoxically, expression of forkhead box P3 (FOXP3, a specific marker for the regulatory T cells) is upregulated within rejecting grafts.Orthotopic lung transplantation was performed using miniature swine without immunosuppression. Rejection was monitored by chest radiography and open lung biopsy. Expressions levels of FOXP3, perforin, Fas-L and IP-10 mRNA were quantified in the peripheral blood. In addition, rescue immunosuppressive therapy (steroid plus tacrolimus) was administered on post-operative day (POD) 4 or 6.Early rejection was detected by open lung biopsy, but misdiagnosed by chest radiography on POD 4. Expression of FOXP3 in the peripheral blood reached its highest value as early as POD 4, followed by a decline. Such an increase of FOXP3 was not observed in recipients given high-dose tacrolimus. Neither perforin, Fas-L or IP-10 in the peripheral blood exhibited significant fluctuations in the early phase of rejection. Rescue immunosuppressive therapy from POD 4, when peak FOXP3 was seen, prolonged graft survival (27.2 days, versus 9.1 days without immunosuppression, p0.001), in contrast to POD 6, when rejection was suspected by chest radiography (11.5 days, p = not statistically significant [NS]).In a miniature swine lung transplantation model, the FOXP3 mRNA level in the peripheral blood was upregulated at an early phase of rejection. The clinical implication of this finding remains to be elucidated.

Pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs; however, few data have been available about lung metastasectomy for hepatocellular carcinoma. To confirm the role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience.Between 1993 and 2005, 12 patients with pulmonary metastases from hepatocellular carcinomas underwent complete pulmonary resection. All patients had undergone curative resection of their primary hepatocellular carcinomas and also had obtained or had obtainable locoregional control of their primaries. Various perioperative variables were investigated retrospectively to analyze the possible prognostic factors for overall survival and pulmonary metastases-free survival after pulmonary metastasectomy.Nine patients were male and three were female (median age, 53 (range, 43-80) years). Overall survival rate after metastasectomy was 80.8%, 57.7%, and 28.9% at 1, 2, and 5 years, respectively. Pulmonary metastases-free survival rate was 64.2%, 32.1%, and 21.4% at 1, 2, and 5 years, respectively. Five patients presented recurrences in the remaining liver before pulmonary metastases, but hepatic recurrences at this interval did not affect an overall survival after pulmonary metastasectomies. Two patients had undergone living-related liver transplantation. The maximum tumor size of the pulmonary metastasis3 cm was the only favorable prognostic factor for overall survival (P = 0.0006), whereas there was no significant prognostic factor for pulmonary metastases-free survival.Pulmonary metastasectomy for hepatocellular carcinoma in selected patients was well justified when the maximum tumor size was3 cm.

Pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs; however, little data have been available about lung metastasectomy for head and neck cancers. To confirm a role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience. Between 1991 and 2007, 20 patients with pulmonary metastases from head and neck cancers underwent complete pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary head and neck cancers. Various perioperative variables were investigated retrospectively to analyze the prognostic factors for overall survival and disease-free survival after metastasectomy. Of the 20 patients, 10 (50%) had squamous cell carcinoma, 7 (35%) had adenoid cystic carcinoma, and 3 had miscellaneous carcinomas. The median disease-free interval from the time of treatment of the head and neck primary cancers to the development of pulmonary metastases was 27 months. Overall survival rate after metastasectomy was 59.4% at 5 years and 47.5% at 10 years, respectively. Disease-free survival rate was 25.0% at 5 years after pulmonary resection. A disease-free interval equal to or longer than 12 months was a significantly favorable prognostic factor for both overall survival and disease-free survival (p = 0.02 and 0.01, respectively). Patients with squamous cell carcinoma and male sex showed a worse overall survival (p = 0.04 and 0.03, respectively). The current practice of pulmonary metastasectomy for head and neck cancers in our institution was well justified. A disease-free interval equal to or longer than 12 months, nonsquamous cell carcinoma, and female sex might be relevant to a better prognosis.

Objectives A method to compensate for donor shortages could be donation after cardiac death. In this study, we considered endothelial cell-specific molecules, claudin-5 and VE-cadherin, as possible biomarkers predicting lung injury against warm ischemia. We investigated how the expression of these molecules could change after cardiac arrest in a mouse lung, comparing other molecules presumably relating with ischemia. Methods At given intervals after cardiac arrest, the lungs were harvested. Quantitative analysis of mRNA expression of claudin-5, VE-cadherin, IL-1beta, IL-10, HIF-alpha, Egr-1, VEGF, Ang-1 and Ang-2 genes in lung tissues with several periods of warm ischemia was performed. Results Regarding endothelial cell-specific molecules, there were significant differences in both claudin-5 and VE-cadherin mRNA expression between 0 h and 4 h after cardiac arrest. IL-1beta mRNA expression 1 h, 2 h and 4 h after cardiac arrest increased significantly, compared with that at 0 h. There were no significant differences with the other genes. Conclusions We found that it took more time for claudin-5 and VE-cadherin mRNA expression to change significantly than IL-1beta mRNA expression; therefore, endothelial cell-specific molecules, claudin-5 and VE-cadherin, might be no better candidates for clinical use than IL-1beta.

移植後リンパ増殖性疾患（Posttransplant lymphoproliferative disorder，PTLD）は臓器移植後に発生する重篤な合併症であり，わが国における肺移植後のPTLDは稀である．今回，脳死肺移植後のPTLDに対しrituximabを用いた症例を経験したので報告する．症例は３０歳代の男性で，若年性肺気腫に対し脳死両肺移植が行われた．移植後４ヵ月後のCTで両肺に多発結節影を認め，FDG-PETにて集積を認めた．経皮生検にてpolymorphic PTLDと診断した．免疫抑制剤の減量，抗ウィルス剤は無効で，引き続き抗CD２０モノクローナル抗体であるrituximabを１コース投与した．結節は縮小し，FDG-PETにおける集積は消失した．治療後１年以上経過し，腫瘤はほぼ消失し，再発徴候を認めていない．

After lung transplantation, early detection of acute allograft rejection is important not only for timely and optimal treatment, but also for the prediction of chronic rejection which is a major cause of late death. Many biological and immunological approaches have been developed to detect acute rejection; however, it is not well known whether lung mechanics correlate with disease severity, especially with pathological rejection grade. In this study, we examined the relationship between lung mechanics and rejection grade development in a rat acute rejection model using the forced oscillation technique, which provides noninvasive assessment of lung function. To this end, we assessed lung resistance and elastance (RL and EL) from implanted left lung of these animals. The perivascular/interstitial component of rejection severity grade (A‐grade) was also quantified from histological images using tissue fraction (TF; tissue + cell infiltration area/total area). We found that TF, RL, and EL increased according to A‐grade. There was a strong positive correlation between EL at the lowest frequency (Elow; EL at 0.5 Hz) and TF (r2 = 0.930). Furthermore, the absolute difference between maximum value of EL (Emax) and Elow (Ehet; Emax − Elow) showed the strong relationship with standard deviation of TF (r2 = 0.709), and A‐grade (Spearman's correlation coefficients; rs = 0.964, P < 0.0001). Our results suggest that the dynamic elastance as well as its frequency dependence have the ability to predict A‐grade. These indexes should prove useful for noninvasive detection and monitoring the progression of disease in acute rejection., After lung transplantation, early detection of acute allograft rejection is important for both in timely treatment and prediction of chronic rejection which is a major cause of late death. We examined the relationship between lung mechanics and rejection grade development in a rat acute rejection model using the forced oscillation technique, which provides noninvasive assessment of lung function. Our results suggest that the dynamic elastance as well as its frequency dependence reflect the perivascular‐interstitial component of rejection severity grade (A‐grade), and this method should prove useful for noninvasive detection and monitoring the progression of disease in acute rejection.

Background The prevalence of comorbidities and functional impairment among elderly patients may enhance the risk of operation-related complications, but the importance of these conditions in elderly patients undergoing thoracic surgery remains unclear Methods One hundred twenty patients ≥ 60 years of age who underwent thoracic surgery were registered prospectively and examined. A comprehensive geriatric assessment (CGA) that evaluated such diverse areas as functional status (ie, performance status and activities of daily living [ADLs] using the Barthel index), comorbidity, nutrition (ie, body mass index, arm-muscle circumference, albumin level, transferrin level, lymphocyte count, and cholinesterase level), and cognitive function (ie, mini-mental state examination [MMSE] and negative emotions for operation) was performed in the 2 weeks before patients underwent the operation Results The diseases of the 120 patients were as follows: lung cancer, 85 patients; mediastinal tumor, 14 patients; bullas, 12 patients; and other diseases, 9 patients. Postoperative complications developed in 20 patients (16.7%). The patients with dependence for performing the ADLs, and dementia were more likely to develop postoperative complications (p = 0.041, and p=0.0065, respectively). The patients who experienced longer operation times (ie, ≥ 300 min; p=0.018) were more likely to have complications. The incidence of prolonged air leak in the patients with malnutrition increased seven-fold (p = 0.045) and that of postoperative infectious diseases in those patients with obesity increased 24-fold (p = 0.0013), while all patients who developed delirium had low scores in the MMSE preoperatively (p = 0.0003). Using multiple logistic regression, the best model was obtained with a combination of MMSE (p = 0.031) and the Barthel index (p = 0.04). When the operation variables were added to this model, the operation time had the strongest effect (p = 0.016) Conclusions Dependence for the performance of ADLs and impaired cognitive conditions are important predictors of postoperative complications, especially when the operation time is long. CGA is necessary in addition to the conventional cardiopulmonary functional assessment in elderly patients

Patients with Sjogren's syndrome frequently have pulmonary involvement, but the involvement of nodular pulmonary lesions, including pulmonary amyloidosis, is rare. Most cases of pulmonary amyloidosis involve multiple nodules; solitary pulmonary nodular amyloidosis, as an associated condition of Sjogren's syndrome, is very rare.In our report, we present the case of an 80-year-old female with Sjogren's syndrome who was incidentally found to have a small solitary pulmonary nodule. The nodule showed high fluorodeoxyglucose uptake and contained areas of calcification. Because the probability that the nodular lesion was malignant could not be excluded, the tumor was excised using a thoracoscopic procedure; the final diagnosis was pulmonary nodular amyloidosis. Although most cases of pulmonary amyloidosis involve multiple nodules, amyloidosis should be considered in the differential diagnosis for a solitary pulmonary nodule in patients with Sjogren's syndrome.

Tracheo-innominate artery fistula (TIF) is a surgical emergency with high mortality rates. Reported incidence is 0.1%-1.0% after tracheostomy with peak incidence 3 days to 6 weeks post procedure. TIF is usually fatal once it bleeds. For the successful management of TIF, treatment should be initiated immediately with the special considerations kept in mind. We describe two cases of TIF, and its clinical characteristics are reviewed in accordance with relevant literature.

Objective: To reveal the incidence and clinical significance of mediastinal nodal metastases without N1-station nodal metastases ('skip-N2 metastases') in non-small cell lung cancer (NSCLC). Methods: A total of 450 NSCLC patients who underwent tumor resection with a systemic mediastinal nodal dissection were retrospectively reviewed. p53 status and proliferative activity represented as proliferative index (PI) were also examined immunohistochemically. Results: Skip-N2 metastases were documented in 49 (13%) patients of all 450 patients; among 334 patients without N1-nodal involvement, 18% patients had skip-N2 metastases. The postoperative survival of skip-N2 patients was almost same as that for patients with metastases to both N 1 and N2 nodes. Skip-N2 metastases were significantly more frequent in male patients and squamous cell carcinoma patients. In addition, the mean PI for tumor with skip-N2 metastases was significantly higher than that for any other pathologic nodal (pN)-status diseases. Combined with histologic type and PI, the incidences of skip-N2 metastases for adenocarcinoma showing lower PI were only 5% (7/137) of all patients and 7% (7/94) of patients without Nl-nodal involvement. Conclusions: N1 nodal status is not a useful predictor of N2 nodal status in NSCLC, because skip-N2 metastases were documented in 18% patients showing no Nl-nodal involvement. However, N1 node-guided dissection might be performed in patients with adenocarcinoma showing lower PI, because the incidence of skip-N2 metastases was extremely low.

肺内穿孔をきたし緊急手術を行った縦隔奇形腫の1例を経験した.症例は18歳, 男性.2001年4月の検診にて右肺門部に腫瘤陰影を認め同月の胸部CTで前縦隔腫瘍と診断し手術予定で外来経過観察をしていたが, 2001年5月17日より胸痛, 血痰, 高熱が出現し, 同年5月20日右中下肺野に浸潤影を認めたため当科緊急入院した.エコーガイド下縦隔腫瘍穿刺吸引による腫瘍内溶液の性状はアミラーゼ0IU/l, リパーゼ4U/l, トリプシン19ng/lと低値であり, 腫瘍内溶液は黄色ブドウ球菌に感染していた.全身状態の悪化が著しいと考えたため, 2001年5月22日縦隔腫瘍摘出術及び右肺中葉切除術を行った.摘出標本の病理組織学的検査で縦隔奇形腫と診断された.術前に上昇していたSCC抗原, CA19-9, 可溶性IL-2レセプターは術後正常化しており嚢胞内産生が考えられた.

Recently, paravertebral block (PVB) has been reported to be an effective analgesic modality for post-thoracotomy pain, but there is no consensus on how thoracic PVB can be more effective. Our hypothesis that intact pleura has a significant impact on the analgesic effectiveness of thoracic PVB was evaluated.Data of patients who underwent general thoracic surgery [thoracotomy or video-assisted thoracic surgery (VATS)] and paravertebral catheterization at Nagara Medical Center between April 2010 and March 2013 were collected. To compare the frequency of non-steroidal anti-inflammatory drugs taken as well as the usage of rescue pain medications between patients with pleural disruption and those without, data were analysed after matching on propensity scores. Covariates for match estimation were age, sex, body mass index, American Society of Anesthesiologists score, diagnosis, operative details and local anaesthesia infused.There were 278 patients who underwent general thoracic surgery and paravertebral catheterization. The propensity score-matching process created 78 matched patients with pleural disruption and those without. Based on the propensity score matching, a significant increase in the frequency of non-steroidal anti-inflammatory drugs taken on postoperative day 1 and in the usage of rescue drugs was observed in patients with pleural disruption.According to our analysis, creating a sub-pleural space without pleural disruption is essential for quality thoracic PVB.

Adjuvant vinorelbine and cisplatin chemotherapy is recognized as a standard regimen for patients with completely resected stage II and III non-small cell lung cancer (NSCLC). However, efficacy of adjuvant chemotherapy in Japanese phase III trials with cisplatin-containing regimen has been controversial, and data are limited on the long-term outcome of adjuvant vinorelbine and cisplatin chemotherapy for NSCLC patients.This was a single-arm phase II study in patients with completely resected pathological stage II or III NSCLC, who had not received prior chemotherapy or radiotherapy. Patients received 4 cycles of vinorelbine [25 mg/m(2) of body surface area (BSA)] and cisplatin (40 mg/m(2) of BSA) on days 1 and 8, every 4 weeks. Primary end point was the 3-year relapse-free survival; secondary end points were overall survival and safety.Between December 2006 and January 2011, 60 patients (40 men and 20 women, median age 64 years) were enrolled; all patients were evaluable for survival and safety. Three-year relapse-free survival rate was 55.0 % (95 % confidence interval 42.4-67.6 %). Three- and five-year overall survival rates were 83.3 and 77.8 %, respectively. There were no chemotherapy-related deaths, and adverse effects were acceptable.Adjuvant vinorelbine and cisplatin chemotherapy was safe and showed a valid relapse-free survival rate. This regimen could be used as a standard regimen and deserves to be a control arm of trials on adjuvant chemotherapy in the Japanese NSCLC patient population.

A 2-month-old girl was brought to the Department of Pediatrics at Wakayama Rosai Hospital because of poor feeding since 1 month of age. She was the third child of young healthy non-consanguineous parents whose first son was healthy but whose second son had died of 18 trisomy. Physical examination showed midfacial hypoplasia with coarse dysmorphic features, choanal stenosis, remarkable abdominal distention and bilateral talipes equivarus. Abdominal ultrasonography, computed tomography and drip infusion pyelogram showed left severe hydronephrosis and right moderate hydronephrosis. Having diagnosed Schinzel–Giedion syndrome, a left ureteroneocystostomy with tailoring was performed to preserve renal functions and to eliminate the urinary tract infection at the age of 3 months.

非常に稀な肺良性淡明細胞腫 (benign clear cell tumor) の1切除例を経験した.症例は50歳, 女性, 健診での胸部異常陰影で発見された.術前胸部CT検査で肺良性腫瘍が疑われたため1999年6月肺部分切除術を施行した.病理検査の結果, benign clear cell tumorと診断された.本邦では22例の報告があるのみである.

Transverse thoracosternotomy is the standard approach for bilateral lung transplantation (BLT), but all measures must be taken to prevent breakdown of the sternal wound. We report a case of sternal dehiscence with subcutaneous and peristernal air collections, which occurred 1 month after BLT, performed through a transverse thoracosternotomy, in a 38-year-old man. Surgical exploration revealed that the sternal wires had cut through the bone, causing air leakage of both lungs. We repaired the injured lungs and reapproximated the sternum; however, a pseudo-joint of the sternum developed postoperatively. We report the clinical course of this post-transplant patient to highlight the impact and management of sternal dehiscence.

OBJECTIVES: The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, adverse events (AEs) of stapling are occasionally experienced. The aim of this retrospective study was to analyse the AEs of stapling in pulmonary vascular surgery. METHODS: A retrospective multi-institutional review was conducted by the 29 institutions of the Central Japan Lung Cancer Surgery Study Group. All staplings of the pulmonary artery (PA) and vein in thoracic surgery were reviewed during the research period. RESULTS: Stapling of the PA and vein was performed 3393 times. The total number of AEs related to stapling was nine (0.27%). Eight events occurred intraoperatively and one occurred immediately after the operation. Intraoperative AE occurred more frequently than postoperative AE. AE in the PA occurred more frequently than in the pulmonary vein. The intraoperative AEs were oozing (n= 3), stapling failure (n= 2), laceration of the peripheral vasculature at compression (n= 2) and technical injury of the vasculature at insertion (n= 1). The causes of AEs were reported to be tissue fragility (n= 3), stapler rocking during stapling (n= 2), stapler-tissue thickness mismatch (n= 2) and technical failure (n= 1). The only postoperative AE was staple line rupture of the PV stump. No relationship was seen between the incidence of AE and cartridge colours, compression types of staplers or numbers of staple lines. CONCLUSIONS: Generally, stapling of the pulmonary vasculatures in recent thoracic surgery has been safe. Furthermore, the knowledge of the possible risks of pulmonary vascular stapling may help to decrease the AEs of stapling.

症例は, 56歳, 女性.10年来の発作的な上背部痛を自覚していた.初診時の胸部X線写真, 胸部CTにて左上縦隔に5.0×3.5cmの腫瘤を認め, 神経鞘腫を疑い後縦隔腫瘍摘出術を施行した.腫瘍は暗赤色で被膜に包まれ腫瘍内は血管に富んでいた.病理学的検査にて豊富な血管を取り巻く小型核を有するuniformな細胞がシート状に認められ, グロムス腫瘍と診断した.52歳時に摘出した左足部腫瘍組織と比較したところ同様の病理所見が認められ多発性グロムス腫瘍と考えられた.両部位とも摘出後に癖痛は消失した.後縦隔に発生したグロムス腫瘍は非常にまれであり, さらに長い経過で多発性に認められた稀有な症例を経験したので文献的考察を加えて報告した.

検診時腫瘤影にて発見された肺分画症の一例を報告する.症例は65歳女性で, 検診にて胸部異常陰影を指摘された.CTにて流入動脈を示唆する血管影を伴う, 嚢胞状の腫瘤影を認め, 肺分画症と診断した.術中, 胸部大動脈より左S10に流入する直径8rnmの異常動脈を認め, これを処理し, 左S10区域切除を施行した.分画肺は正常肺と胸膜の隔壁を持たず, 肺葉内型であり, 粘液で満たされた単嚢胞であった.

A combination of inspiratory and expiratory three-dimensional computed tomographic volumetry provides useful information on pulmonary function and lung volume. We previously reported an early outcome of a patient undergoing living-donor lobar lung transplantation with sparing of the bilateral native upper lobes. Long-term follow-up on such patients had not been reported, and therefore we herein, for the first time, reported the 2-year follow-up of the previously reported case. According to the inspiratory and expiratory three-dimensional computed tomographic volumetric data, we demonstrated that transplanted lower lobe grafts had been working efficiently and spared bilateral native upper lobes had not provided any adverse effects.

INTRODUCTIONThoracolithiasis is quite rare with only 18 cases reported in the literature.PRESENTATION OF CASEThe 65-year-old female was referred to us for the abnormality on the chest X-ray. The serial computed tomographic (CT) scans showed a mobile calcified nodule of about 10mm in diameter. Exploratory thoracoscopy was performed. A 15mm pearl-like pleural stone was removed with uneventful postoperative course.DISCUSSIONThoracolithiasis is very rare, and its etiology as well as its epidemiology still remains to be unclear. Preoperative diagnosis is always difficult. However, specific radiological findings could let us recognize the probability of that lesion and avoid unnecessary major operation.CONCLUSIONThoracolithiasis should never be overlooked as a differential diagnosis in a pulmonary calcified nodule.

Diffuse interstitial pneumonia (IP) associated with collagen disease is a rare indication for lung transplantation. The manifestations of collagen disease are variable and dermatomyositis (DM) is often considered a contraindication for lung transplantation because of active myositis and a high incidence of malignancy. Furthermore, clinically amyopathic dermatomyositis (C-ADM) is associated with rapidly progressive IP resulting in a poor prognosis. Bilateral living-donor lobar lung was transplanted in a 52-year-old female with rapidly progressive IP associated with C-ADM, and the postoperative course was uneventful. To our knowledge, this case represents the first living-donor lobar lung transplantation for a patient with rapidly progressive IP associated with C-ADM.