Recurrent rupture of intercostal artery aneurysms in neurofibromatosis type 1.

Vasculopathy associated with neurofibromatosis type 1 (NF-1) can cause a spontaneous hemothorax, which is an uncommon but life-threatening complication of the disease. We report a case of recurrent rupture of intercostal artery aneurysms in an NF-1 patient. A 40-year-old man with NF-1 suffered from a right spontaneous hemothorax. The bleeding source was not identified by dynamic contrast-enhanced computed tomography (CT), so he was initially treated by conservative therapy. However, repeated contrast CT revealed aneurysms of the right 10th intercostal artery. They were successfully occluded by transcatheter arterial embolization (TAE). Seven months afterward, he presented with sudden lower back pain and was diagnosed with a contralateral spontaneous hemothorax due to a ruptured aneurysm of the left 12th intercostal artery. TAE was successfully performed.

Video-assisted thoracic resection for intralobar pulmonary sequestration.

We present a case in which video-assisted thoracic resection for intralobar pulmonary sequestration (ILPS) was successfully performed. A 36-year-old woman had repeated pneumonia. Chest computed tomography (CT) showed a round mass in the right lower lobe of the lung. Subsequent three-dimensional CT revealed that a large anomalous artery arising from the descending thoracic aorta was distributing to the posterior basal segment containing the lesion and was draining into the inferior pulmonary vein. The patient was diagnosed with ILPS and underwent surgery. The anomalous artery was divided, and the sequestered segment was completely resected by video-assisted thoracic surgery (VATS). We think that VATS resection for ILPS is feasible and is a major therapeutic option as noninvasive surgery.

Bronchial and cardiac ruptures due to blunt trauma.

Tracheobronchial and cardiac injuries following blunt thoracic trauma are uncommon but can be life-threatening. We report a case in which the patient with bronchial and right atrial ruptures due to blunt trauma survived after emergent repairs. An 18-year-old female driver was transported to our hospital after a traffic accident and was hemodynamically stable on arrival. Chest computed tomography revealed cervicomediastinal emphysema and hemopericardium, and fiberoptic bronchoscopy showed a tear in the right main bronchus. She was intubated with a double-lumen endotracheal tube guided by bronchoscopy. A median sternotomy was undertaken, and a laceration of the right atrium was oversewn without the use of cardiopulmonary bypass. After that, right-sided thoracotomy was performed. The tear in the membranous portion of the right main bronchus was repaired with interrupted sutures, and the suture lines were wrapped with a pedicled flap of intercostal muscle.

Primary lung cancer arising from the wall of a giant bulla in which positron emission tomography was useful for preoperative diagnosis.

We report a case of lung cancer arising from the wall of a giant bulla. A 58-year-old man consulted a physician because of bloody sputum. Chest computed tomography (CT) revealed a left upper giant bulla with partial thickness of the wall. Cytology of both sputum and transbronchial brushing was negative at that time. After 6 months follow-up CT scans showed more thickness of the wall, and positron emission tomography (PET) revealed high accumulation of fluorodeoxyglucose in the thickened wall. Because lung cancer was highly suspected, we performed an operation without a definitive diagnosis. The postoperative pathological diagnosis was large cell carcinoma arising from the wall of a giant bulla. Because a preoperative diagnosis is difficult in the case of lung carcinoma associated with bullous disease due to the lack of a characteristic radiological appearance and the difficulty of pathological examination, we emphasize that PET is a useful diagnostic tool.

Localized extraosseous Ewing's sarcoma of the chest wall resected by video-assisted thoracoscopic surgery.

Extraosseous Ewing's sarcoma (ES) is a small round cell tumor arising in soft tissue that was undifferentiated histologically from classic ES of bone. It frequently affects children and adolescents, with an unfavorable prognosis. Herein, we report a case of localized extraosseous ES of the chest wall resected by video-assisted thoracoscopic surgery (VATS). An asymptomatic 40-year-old man presented with an abnormal shadow on chest radiography. Chest computed tomography showed a 1.5-cm solid tumor on the chest wall. VATS was undertaken for the undiagnosed tumor. Thoracoscopic findings showed a hemispheric tumor with a smooth surface on the chest wall. The tumor was diagnosed with an extraosseous ES by pathological and cytogenetic examinations. As adjuvant therapy, the patient was treated with radiotherapy, followed by multiagent chemotherapy. There have been few reported cases in which VATS was used for extraosseous ES of chest wall, so our case was thought to be very rare.

Successful thoracoscopic lobectomy for lung cancer in a patient with anatomic variation of the left inferior pulmonary vein.

We present a case of primary lung cancer with a rare distribution pattern of left inferior pulmonary vein (PV), encountered in the thoracoscopic left lower lobectomy. Thoracoscopic observation revealed 2 trunks of inferior PV (ventral and dorsal branch) at the stem level. The ventral trunk consisted of a branch of vein (V(5)) from the lingular segment and venous ramifications (V(8)a, V(9) and V(10)a) from the basal segment. On the other hand, a branch of vein (V(6)) from the superior segment in the lower lobe and other veins (V(8)b and V(10)b + c) from the basal segment emptied together into the dorsal trunk. We successfully carried out a thoracoscopic left lower lobectomy without excision of the aberrant vein (V(5)). Retrospective review of the preoperative chest CT demonstrates the double trunk inferior PV and the aberrant lingular branch emptying with V(8)a into the ventral trunk. Knowledge of the branching variations of PV from preoperative evaluations leads to appropriate thoracoscopic procedures for lung cancer.

A thoracoscopically resected case of mediastinal parathyroid cyst.

A 67-year-old male visited his physician because of a 2-month history of cough and sputum. An abnormal shadow at the left upper mediastinum on chest x-ray film was detected, and the patient was referred to our department for further examination. Chest x-ray film revealed a round shadow at the left upper posterior mediastinum. Computed tomography(CT)revealed a uniform iso density mass about 4 cm in diameter, with a well-defined border. After the intravenous contrast administration, a slight peripheral enhancement was seen around the mass. On magnetic resonance imaging, the mass was hypointense in T1-weighting and hyperintense in T2-weighting. The contrast pattern was the same as that observed in the CT scan. On sagittal and coronal sections, the mass was adjacent to the aortic arch. Although a benign tumor was mostly suspected based on imaging findings, a malignant tumor was also possible. Accordingly, we resected this mass with video-assisted thoracoscopy. Findings at operation were a cystic mass. The pathological findings were compatible with benign parathyroid cyst, which was suspected to be the cystic degeneration of a parathyroid adenoma.

Effect of gravitation for detection of bronchioloalveolar carcinoma on computed tomography.

A 64-year-old female was found to have localized ground-glass opacity (GGO) in the middle lobe on a chest computed tomography (CT) for screening. Middle lobectomy with video-assisted thoracoscopic surgery (VATS) was undertaken, and pathological diagnosis was a bronchioloalveolar carcinoma (BAC) in stage IA. A follow-up CT a year following the surgery revealed localized GGO in area S6 of the left lung. However, it disappeared during the gravitation-dependent gradient in the observation period. The patient was scanned again under prone position to exclude the gravitational effect, resulting in definite detection of the GGO. Left extended S6 segmentectomy with VATS was performed, and pathological diagnosis was a BAC in stage IA. As GGO existing in a gravitation-dependent area may be masked by the gravitation-dependent density, a change of the scanning position may lead to a proper detection of the tumor for the diagnosis of BAC.

Mediastinal cyst with rim calcification.

A 58-year-old man who had been undergoing treatment for chronic pericarditis for 15 months was found to have a calcified mediastinal mass shadow on a chest X-ray and was referred to us for further study and treatment. Chest computed tomography and magnetic resonance imaging showed an anterior mediastinal multilocular tumor with rim calcification. Tumor markers were within normal limits. The patient was preoperatively diagnosed as having a calcified mediastinal cyst, and median sternotomy was performed to remove the cystic tumor and the surrounding thymic tissues. Histological examination revealed that the cyst wall consisted of dense fibrous tissue and calcification without epithelial cell lining on the inner surface. Thymic tissue was present around the cyst wall. Although we suspected a thymic cyst from the intraoperative findings, the final diagnosis was made as mediastinal cyst with rim calcification. We herein present a rare case of mediastinal cyst with rim calcification.

Primary thymic adenocarcinoma with production of carbohydrate antigen 19-9 and carcinoembryonic antigen.

A 59-year-old male, whose chest X-ray showed an abnormal shadow, visited us for further study. Laboratory examination showed the elevated level for both carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) in serum, and the chest X-ray and computed tomography showed an anterior mediastinal mass. Under a diagnosis of thymic malignancy, extended thymectomy with combined resection of the pleura and pericardium was performed. Histopathological findings showed a well-differentiated adenocarcinoma of the thymus, in which CA19-9 and CEA were positive immuno-histochemically. The level of serum CA19-9 and CEA returned to normal ranges postoperatively, however, the tumor recurred in local site with re-elevation of these tumor markers at the 20th month after surgery. He died at 4th month after the first recurrence despite the intensive chemotherapy. We report an extremely rare case of primary thymic adenocarcinoma with the production of CA19-9 and CEA.

Pulmonary inflammatory pseudotumor with rapid growth and serum carcinoembryonic antigen elevation.

Inflammatory pseudotumors consist of chronic inflammatory cells, predominantly plasma cells. We report a rare case of pulmonary inflammatory pseudotumor associated with rapid growth and elevated serum carcinoembryonic antigen (CEA). A 75-year-old man referred for bloody sputum was found in chest computed tomography (CT) to have a round circumscribed tumor with a cavity located in the periphery of the right lower pulmonary lobe. Cytological examination of a biopsy specimen obtained by CT-guided transthoracic fine needle aspiration showed no malignancy. Two months later, the tumor had noticeably grown, accompanied by a notable rise in serum CEA. We conducted right lower pulmonary lobectomy with regional lymph node dissection, since malignancy could not be ruled out by frozen-section examination. Histological examination of the resected specimen showed an inflammatory pseudotumor with CEA production.