Lung abscesses pose diagnostic and management challenges, particularly when they are associated with underlying causes, such as lymphoma. We report the case of a previously healthy adolescent with a lung abscess and lymphadenopathy. Despite antibiotics, improvement was minimal, and biopsy results were inconclusive. Surgery revealed an enlarged, adherent lymph node. Pathologic examination confirmed classic Hodgkin lymphoma invading the hilum and causing bronchial and vascular obstruction and secondary abscesses. This case highlights the importance of including lymphoma in the differential diagnosis of persistent lung infections and the surgical challenges arising from lymphoma-related lymph nodes with irregular enlargement and firm adhesion to surrounding tissues.

Cotton-core/polypyrrole (PPy)-sheath fibers (cotton/PPy fibers) were synthesized by aqueous chemical oxidative seeded polymerization and were utilized as precursors for nitrogen-containing carbon (NCC) tubes. Irradiation of the cotton/PPy fibers with a near-infrared (NIR) laser heated them to approximately 300 °C due to light-to-heat photothermal conversion by the PPy, and the cotton core was thermally decomposed and vaporized. Scanning electron microscopy studies revealed the formation of tubes with monodispersed diameters, and elemental microanalysis, Fourier transform infrared spectroscopy, and Raman spectroscopy confirmed that the PPy sheath was converted into NCC. Furthermore, sunlight also worked as the light source in fabricating the NCC tubes. The thicknesses of the tubes were controlled between 410 nm and 2.30 μm by tuning the PPy sheath thickness. The method developed in this study can be extended to other polymeric fibers, including acrylic and wool fibers. The shapes of the cross sections and surface nanomorphologies of the NCC tubes can be reflected in those of the polymer/PPy fibers.

Abstract Schwannomas are classified as neurogenic tumors and are the most frequent nerve sheath tumors in the paravertebral mediastinum. Recently, the addition of endobronchial ultrasound‐guided intranodal forceps biopsy (EBUS‐IFB) using standard‐sized biopsy forceps (SBFs) to endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) for metastatic lymph nodes in lung cancer patients reportedly improved the quality and quantity of the obtained specimens without significant complications. However, reports on the usefulness of this technique for benign diseases remain scarce. Here we report a case of schwannoma in the middle mediastinum, which was diagnosed by EBUS‐IFB using SBFs, despite inadequate specimens obtained via EBUS‐TBNA. An 80‐year‐old woman presented with dyspnea and a 5‐cm sized middle mediastinal tumor. EBUS‐TBNA and EBUS‐IFB using SBFs were performed for histological diagnosis. No complications were associated with the bronchoscopy procedure, and schwannoma was solely diagnosed using the EBUS‐IFB specimens. EBUS‐IFB using SBFs is potentially useful for diagnosing benign diseases, including schwannomas, which are often difficult to diagnose with EBUS‐TBNA.

Vascular endothelial growth factor (VEGF) inhibitors are widely used in chemotherapy for non-small lung cancer (NSCLC). The purpose of the current study was to examine the impact of background cardiovascular risk factors on VEGF inhibitor-related adverse vascular events (VEGF-related AVEs) in patients with NSCLC who also had comorbidities. We conducted a retrospective study of 118 NSCLC patients treated with bevacizumab or ramucirumab from April 2010 to December 2022. We compared baseline cardiovascular risk factors with VEGF-related AVEs. VEGF-related AVEs and discontinuation due to VEGF-related AVEs were reported in 54 patients and 21 patients, respectively. VEGF-related AVEs were significantly more common with male sex, smoking history, history of hypertension, dyslipidemia, diabetes mellitus, or cardiovascular disease. Discontinuation due to VEGF-related AVEs was significantly more common in patients with history of hypertension or chronic kidney disease. VEGF-related AVEs were significantly more common in patients with ≥ 3 cardiovascular risk factors than patients with < 3. Discontinuation due to VEGF-related AVEs was significantly more common in patients with ≥ 4 cardiovascular risk factors than patients with < 4. Multivariate analysis demonstrated that male sex, hypertension, and ≥ 6 cycles of VEGF inhibitors were each associated with VEGF-related AVEs and hypertension was associated with discontinuation due to VEGF-related AVEs. Our study demonstrated that history of hypertension was independently associated with increased risk of both VEGF-related AVEs and discontinuation due to VEGF-related AVEs. In conclusion, we need to be aware of VEGF-related AVEs when using VEGF inhibitors for patients with ≥ 3 cardiovascular risk factors.

This paper presents an approach to improve the surface wettability of polytetrafluoroethylene (PTFE) using an atmospheric-pressure plasma of argon gas with water-ethanol vapor. Plasma is generated by the dielectric barrier discharge of argon gas bubbled into a water-ethanol solution. Quadrupole mass analysis revealed that the plasma promoted the decomposition of ethanol and production of H-2, CH4, and CO, which saturated at low ethanol concentrations. The modified PTFE surface was strongly influenced by the ethanol concentration in the solution and treatment time. Plasma treatment with 3%, 5% and 9% ethanol resulted in a significant reduction in the water contact angle from 115 degrees to 16.5 +/- 2.8 degrees after 10 s of treatment. X-ray photoelectron spectroscopy showed that oxygen-containing functional groups (hydroxyl, carbonyl, and carboxyl groups) formed on the plasma-treated PTFE surface, reflecting the hydrophilization of PTFE. At the beginning of the plasma treatment, the water vapor induced the breaking of the CF2 chain, and the additional ethanol vapor generated oxygen-containing polar groups on the PTFE surface. In addition to the modification of the PTFE surface itself, a low-molecular-weight oxidized material layer was deposited over the surface, which prevented further surface modification, and the deposited layer exhibited excellent wettability. The deposited low-molecular-weight oxidized material layer was easily removed by immersion in deionized water, and the exposed modified PTFE surface exhibited stable wettability with water contact angle of 52.7 +/- 3.5 degrees.

malignant lymphoma, slow growing, pulmonary adenocarcinoma, solid nodule, metachronous double malignancy A 71-year-old woman was found to have an abnormal shadow on a chest radiograph during a medical checkup. Chest computed tomography (CT) showed a solid nodule in the right S 4 a segment. The nodule was 1.0 × 0.9 cm in diameter. She treated by chemotherapy for malignant lymphoma at age 49 and achieved complete remission at age 66. Looking back at her previous chest CT performed during the treatment of malignant lymphoma, the solid nodular shadow had been increasing slowly over the last 13 years. Therefore, she was referred to our department for more de-tailed examination and treatment. Although percutaneous CT-guided transthoracic needle biopsy (CTNB) was performed for diagnostic purposes, a definitive diagnosis was not made. From the chest CT findings and clinical course, in-flammatory disease was suspected. However, decided to perform surgery due to the high risk of carcinogenesis after treatment for malignant lymphoma. We performed right middle wedge resection, and the intraoperative rapid pathological middle with nodal dissection. From the findings, the tumor was suggested to be secondary malignancy due to chemotherapy for malignant lymphoma. It is extremely rare because it showed a solid nodular shadow from the time of tumor appearance, and there are no reports of slow growing lung adenocarcinoma suggesting secondary malignancies.

超高速,超低遅延,多数同時接続を実現する次世代移動体 通信システムである 5G(第 5世代)は,わが国では 2020 年 から商用サービスが開始されている。5Gではこれまで 4G で利用されてきた 700 MHz~3.5 GHzの通信周波数帯に代わ り,より高周波側へと移行し,日本で 5Gに割り当てられて いる周波数は,3.7,4.5,28 GHz帯となっている。さらに 2030 年ごろの商用化に向けた Beyond 5Gでは,よりミリ波 側の高周波数帯(300 GHz帯)の利用が想定されている。この ような高周波数帯での高速通信,とりわけ自動運転や遠隔操 作など精度が高く安全性が必要な技術を確実に実施するため には「超低遅延」を実現する高速伝送通信の確立が不可欠と なってきており,次世代高速通信用配線板の材料・プロセス・ デバイス設計開発が盛んにおこなわれている 。 電気信号の高周波化が進むと導体や絶縁体に由来する伝送 損失の影響が大きくなり,新たな材料開発やプロセス開発が 必要となる 。電気信号の伝送損失は,誘電損失と導体損失 の和で表される。誘電損失は絶縁材料の特性に起因する損失 で,周波数 f,絶縁材料の比誘電率εの平方根,および誘電正 接 tanδの積で表されることから,損失の低減には絶縁基板の 誘電率と誘電正接の小さい材料を選択する必要がある。これ まではエポキシ樹脂やポリイミドなど比誘電率 4.0~5.0,誘 電正接 0.0200 以上のものが使用されてきたが,次世代対応 の基板材料としては比誘電率が 3.0 以下,誘電正接が 0.0200 以下の材料が検討されている。具体的な材料としては,PPE 樹脂(Polyphenylenether)系,液晶ポリマー(Liquid Crystalline Polymer:LCP)系,フッ素樹脂(Polytetrafluoroehylene:PTFE) 系などが候補として挙げられる。 フッ素樹脂は,構成分子にフッ素原子を含む結晶性の熱可 塑性樹脂の総称であり,骨格を形成する C-F結合のエネル ギーが大きい(460~502 kJ/mol)ことから,化学的に高い安定 性を有する。このため,フッ素樹脂は耐熱性,耐薬品性,耐 候性に優れ,さらには樹脂表面に近密に存在するフッ素原子 に由来する低い表面自由エネルギーのため,高い撥水・撥油 性,低摩擦特性,非粘着性を発揮し,近年エレクトロニクス 分野や医療分野など利用範囲が拡大している。中でも Cと F のみから構成される PTFEは C-F結合中の電子の安定性から 外部電場による影響を受けにくく,樹脂の中でも最も低い誘 電特性(誘電率 2.1,比誘電率 0.0002)を示す。これらの観点 から特にフッ素樹脂は超低遅延の実現に向けた低伝送損失基 板材料として期待されている。一方で,フッ素樹脂に限らず, 低誘電特性を示す材料は,樹脂成分中に存在する極性基が少 ないこともあり,概して銅回路との密着性に乏しいことが課 題となる。このため,低誘電特性の樹脂基板と銅回路の密着 性を確保するためには,界面の凹凸に由来するアンカー効果 や接着剤を使用する必要があるのが現状である。 しかしながら,伝送信号が高周波化するにつれて信号の大 部分が導体の表面を流れる表皮効果の影響が無視できなく なってくる。その結果,導体表面の凹凸が大きいと配線抵抗 が高くなり,信号伝搬速度の遅延につながる。表皮深さは導 体材料の電気抵抗率と透磁率に依存し,銅の場合,周波数 100 GHzでは約 0.2 μmとなる。従来のプリント配線板では 樹脂と銅箔または銅めっき膜との界面の密着性をサブ μm~ 数 μm程度のアンカー効果により確保しており,次世代のプ リント配線板としては対応できない。これらの観点から,低 誘電樹脂基板と銅回路界面の粗化を伴わない新たな接着プロ セスの開発が望まれている。 最近著者らのグループでは,樹脂層と金属層の界面粗さを 極力低下させるとともに層間に密着促進層を介在させない直 接接着技術を開発し,めっき法あるいは熱圧着法により従来 困難であったフッ素樹脂と金属の直接接着を実現してきた 。 本解説では,プラズマ表面改質によるフッ素樹脂と金属銅の 直接接着技術について紹介する。

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Zirconium oxide (ZrOx) films were successfully prepared on a transparent conducting substrate (fluorine-doped tin oxide) by galvanostatic cathodic electrolysis of a solution containing ammonium hexafluorozirconate (AFZ) and ammonium nitrate at 323 K. The morphology of the film evidently changed based on the initial concentration of AFZ in the solutions. The film prepared at comparably higher AFZ concentration exhibited aggregates of sword-type leaf-like units tens of micrometers in size in the longitudinal direction, radially growing and dividing into secondary structure. On the other hand, normal planar films of a micrometer order were deposited at a lower concentration of the AFZ solution. The films were classified as zirconium oxyfluorides (Zr-O-F) from the atomic concentration ratios of Zr, O, and F determined by X-ray fluorescent spectrometry analysis. Regardless of the initial AFZ concentrations, the crystallographic structures of the films were converted to monoclinic crystalline ZrO2(baddeleyite) by the calcination at 773 K. The leaf shape of the film obtained in the solution of higher AFZ concentration was maintained following the calcination process, indicating the development of a 3D ZrO(2)film. The present work evaluated the chemical character of the films and gave deeper insight into the growth mechanism of these remarkable materials.

Iron-based nanoparticles show unique magnetic properties, and their syntheses from metal complex solution by pulsed lasers have been widely studied; however, the aggregation of nanoparticles is unavoidable in homogeneous solution. We report the production of water-dispersible iron-based nanoparticles in a mixture of water and ferrocene n-hexane solution by femtosecond laser irradiation without using any additive agents. The mean diameter of iron-based nanoparticles (ca. 7 nm) is independent on the concentration of ferrocene and laser irradiation time. We propose that hexane microdroplets dispersed in water act as reaction vessels and reduce the opportunity of aggregation of primary nanoparticles.

C-F 結合中の電子の安定性から外 部電場による影響を受けにくく，高い電気絶縁性や高周波振 動に対して誘電分極が起こりにくいという特長を有しており， 通信ケーブル等の電線被覆材料や基地局アンテナの絶縁材料 として重用されている。 例として 3 種類のフッ素樹脂をピックアップし，それらの 分子構造と主な物性を表 1 にまとめた 1) -3) 。PTFE(Polytetrafluoroethylene) は，完全に対称な線状高分子であり，結晶性 が高い。融点 (327 ℃) 以上においても溶融粘度が高過ぎるた めに溶融押出しや射出成形などは適用できず，粉末を常温で 圧縮成形してから融点以上で加熱焼成するという特殊な方法 で成形される。従って，成形品やコーティングなどの用途が 主流であり，シートやフィルム状の製品は成形ブロックを削 り出す工法により生産されるのが一般的である。 FEP(Tetrafluoroethylene-hexafluoropropylene copolymer) はテ トラフルオロエチレンとヘキサフルオロプロピレンの共重合 体であり，分子構造は PTFE

A 74-year-old man with lung adenocarcinoma recurrence was admitted to our hospital because of dyspnea 7 days after receiving initial immunotherapy with nivolumab. Electrocardiography revealed ST-segment elevation in V1-6 and echocardiography showed a markedly reduced left ventricular ejection fraction of 9% and akinesis of the anteroseptal wall and apex. He died from acute heart failure 3 days after admission. Microscopically, multiple small foci of myocardial necrosis with few inflammatory cells were scattered in both ventricles. Obstruction of the coronary artery was not identified. We believed that the cause of death was acute heart failure possibly due to nivolumab-induced myocardial necrosis.

The removal of the whole regional lymphatic system together with primary tumor is one of the important rules in oncological surgery. According to the study of regional lymphatic drainage, we considered reasonable lymphadenectomy contributes the post-operative survival of the Left lung cancer patients with mediastinal lymph node metastasis. Due to anatomical limitations imposed by arch of aorta, it is difficult to perform complete dissection of upper zone mediastinal lymph nodes through the left thoracotomy in the left lung cancer. We had devised Systematic extended bilateral mediastinal dissection through a median sternotomy (ND3 operation) for patient with NSCLC of the left lung. This report aimed to introduce procedure of our operation and investigate the prognostic impact of Upper zone lymph node dissection for left upper lobe NSCLC. The our operative procedure is as follows. In the supine position, made a median sternotomy. We dissect the meidastinal nodes before pulmonary resection. The dissection is started on the highest area. Tape the right and left recurrent laryngeal nerve and dissect the highest paratracheal lymph nodes in the thoracic inlet. After making the pericardiotomy, the ascending aorta is retracted to the left. Remove the whole upper zone tissue lying in front of the trachea. And dissect the pre and paratracheal nodes, together with bilateral highest nodes. Then, dissect the subcarinal nodes. Tie off the blood vessels (arteries and veins) and airways leading to the affected lobe, and then remove the lobe. We retrospectively studied 213 patients [157 male and 61 female, mean ages 60.4 years (range, 29-75)], underwent ND3 operation due to NSCLC of the left upper lobe, from January 1990 till December 2017. The patients with NSCLC who are estimated to be able to conventional radical operation and aged 75 year-old or less becomes the adaptation of our operation. Overall 5-year survival rate in the 218 patients of left upper lung primary was 65.1%. Operative mortality in 218 patients was 2.8%. Lymph node metastasis to the mediastinum was confirmed in 70 (32.1%) patients (pN2 was 43, pN3α was 18, pN3γ was 9). According to pathological stages, five-year survival rate was 92.7% in stage IA ,80.1% in stage IB, 53.8% in stage IIA, 66.7% in stageIIB, 51.7% in stageIIIA, 38.4% in stageIIIB. And it was 52.1% in pN2 cases, and 55.0% in pN3α cases. Five-year disease free survival rate was was 85.6% in p-stage IA ,74.0% in p-stage IB,49.7% in p-stage IIA, 49.4% in p-stageIIB, 33.3% in p-stageIIIA, 19.4% in p-stageIIIB, 32.6% in pN2 cases, and 27.8% in pN3α cases. In this nonrandomized comrarision, the post-operative survival of patients with pN2 and pN3α NSCLC of the left upper lung primary would be remarkably improved by our Systematic Bilateral Mediastinal Dissection. And better local tumor control by our operation does not increase mortality. When faced with a patient with resectable mediastinal lymph node metastasis, we should consider Extended bilateral mediastinal lymph node dissection through a median sternotomy. To improve survival rate, it is important to perform curative operation with upper zone mediastinal dissection.

Background Arrhythmias are known as one of the complications of lung cancer surgery, and most of them are not lethal. Life-threatening arrhythmias have been reported in the literature but in reality very rare. Case presentation A 67-year-old Japanese man with a history of hypertension was diagnosed with squamous cell carcinoma in left lower lobe underwent a left lower lobectomy and bilateral mediastinal lymph node dissection through a median sternotomy. During lymph node dissection along the right vagus nerve, the patient’s heart rate and blood pressure dropped suddenly and an electrocardiogram monitor showed ST elevation. These abnormalities returned to normal soon after cardiac massage was performed and a coronary vasodilator was given. A temporary pacing wire was inserted at the end of the surgery. The postoperative course was uneventful and the patient was discharged on postoperative day 11 without a need for permanent pacemaker. Conclusions We present a patient who was complicated with lethal arrhythmias during lung cancer surgery for the purpose of elucidating, from anatomical viewpoint, the relationship between arrhythmias and the involvement of cardiac plexus during lymph node dissection. The result showed that arrhythmia was inadvertently elicited by cardiac plexus stimulation during lymph nodes dissection around the vagus nerve. It is important to be familiar not only with the course of phrenic, vagus, and recurrent laryngeal nerve but also the anatomy of cardiac plexus to prevent arrhythmic complications in lung cancer surgery.

Nickel-nanoparticle-containing polyimide composite films were prepared by liquid-phase reduction of Ni2+ ions with potassium borohydride (KBH4). The nanoparticles were amorphous with diameters of approximately 10-20 nm, depending on the KBH4 concentration and reduction temperature. At high KBH4 concentrations, the nanoparticles appeared to contain various nickel boride species. The number of nanoparticles and Ni content both increased upon repeated adsorption/reduction of Ni2+ ions, where the particle growth was inhibited by the rigid polymer chain and the formation of smaller particles was favored.

The 300-nm-thick Cu6Sn5 microtube assemblies with a Cu inner layer and with a polyester fiber core were fabricated and their lithiation-delithiation performances as the anode of lithium ion batteries were evaluated. The Cu inner layer was obtained by electroless plating on nonwoven polyester fabrics. Cu was uniformly deposited on the fibers in a fabric treated with HNO3-O-3, by which stable hydroxy groups were formed on the fiber surface, and the Pd catalyst adsorption was enhanced. The Cu6Sn5 microtubes were fabricated by the contact immersion deposition process of Sn on the Cu-coated fibers. The deposited Sn formed a dense Cu6Sn5 layer without heat treatment, and its thickness agreed with the theoretical value estimated from the solid-state diffusion coefficient of Sn. Voltage profiles of the microtube assembly electrode during the lithiation-delithiation cycling show the typical features of Cu6Sn5. Capacities were stable during the initial 40 cycles and were paralleled with the Sn loadings. The capacities began to fade after 50 cycles without the removal of Sn, but with the morphological and compositional changes, that is, the trapping of Sn in the degradation products of electrolyte.

Recurrent cervical and mediastinal lymph node metastasis after the surgery of thyroid carcinoma is frequently reported. Generally, surgery is the best treatment but there is still no established standard surgical procedure. In our hospital, we perform the operation through median sternotomy. Surgical procedure for recurrent cervical and mediastinal lymph node metastasis after thyroid carcinoma varies throughout each institute. Recently, reports of the usage of VATs in these cases are increasing. We report 2 resected cases of cervical and mediastinal lymph node metastasis after thyroid cancer which underwent dissection through median sternotomy. A 68-year-old Japanese man underwent left thyroid lobectomy for poorly differentiated thyroid cancer in September 2009. The follow-up CT in 2014 showed a multiple mediastinal lymph node metastases. Therefore, the patient underwent mediastinal lymph node dissection through median sternotomy. Pathological findings showed metastasis in 24 of the 42 lymph nodes. During outpatient follow-up, CT revealed a recurrent mass lesion in the vincinity of the right subclavian artery and common carotid artery. Although I131 was administered, the mass did not respond. Therefore surgery therapy was required. The second operation was cervical incision. The pathological findings showed consistent recurrence. The patient was discharged from the hospital on postoperative day 4. The second patient was a 58-year-old Japanese man who had been treated by subtotal thyroidectomy in May 2008. The patient noticed a gradual increase of a mass near his right lower jaw from 2011. As a result of further examination, mediastinal lymph node metastasis was suspected. The patient underwent mediastinal lymph node dissection through median sternotomy and neck collar incision. Pathological findings showed metastasis in 9 of the 31 lymph nodes. Pathological findings revealed metastasis of papillary thyroid carcinoma. The patient was discharged from the hospital on postoperative day 13. Recent reports of recurrent cervical and mediastinal lymph node metastasis after thyroid carcinoma suggests using VATs, which may have less complications. In our hospital, the possibility of micrometastases is also considered in cases of post-operative lymph node recurrence. Therefore, we completely resect the mediastinal lymph nodes by median sternotomy approach. We have been promoting mediastinal lymph node dissection for lung cancer surgery at our center, but we would like to report the significance of mediastinal lymph node dissection for recurrence cases after thyroid carcinoma.

Whether mediastinal lymph node dissection (MLND) improves survival is controversial. But, lymph node dissection plays important role in oncologic surgery. The removal of the whole regional lymphatic system together with primary tumor is one of the fundamental rules in oncological surgery. For left-side tumors, upper zone lymph nodes are considered inaccessible. Due to anatomical limitations imposed by arch of aorta, it is difficult to perform complete dissection upper zone mediastinal lymph nodes through the left thoracotomy. According to the study of regional lymphatic drainage, we considered reasonable lymphadenectomy contributes the post-operative survival of the NSCLC patients with mediastinal lymph node metastasis. And we had devised Systemic extended bilateral mediastinal dissection and lung resection through a median sternotomy (ND3 operation) for patient with NSCLC of the left lung. This study aimed to investigate the prognostic impact of Extended bilateral mediastinal lymph node dissection for left NSCLC. We retrospectively studied 314 patients [220 male and 94 female, mean ages 61.2 years (range, 37-75)], underwent ND3 operation due to NSCLC, from January 1990 till December 2017. The patients with NSCLC who are estimated to be able to conventional radical operation and aged 75 year-old or less becomes the adaptation of ND3 operation. Postoperative survival rates calculated with Kaplan-Meier method. Clinicalpathological data were compared according to the p stage. Overall 5-year survival rate in the 314 patients of left lung primary was 65.5%. Operative mortality in 314 patients was 2.8%. Lymph node metastasis to the mediastinum was confirmed in 95 (30.1%) patients (pN2 was 53 patients,pN3α was 23 patients, pN3β was 2 patients, pN3γ was 16 patients). According to pathological stages, five-year survival rate was 90.5% in stage IA ,75.8% in stage IB, 58.7% in stage IIA, 68.2% in stageIIB, 51.2% in stageIIIA, 38.9% in stageIIIB. And it was 51.5% in pN2 cases, and 53.6% in pN3α cases. Five-year disease free survival rate was was 84.3% in stage IA ,70.3% in stage IB,53.6% in stage IIA, 52.2% in stageIIB, 33.8% in stageIIIA, 15.6% in stageIIIB, 34.0% in pN2 cases, and 20.6% in pN3α cases. In this nonrandomized study, the post-operative survival of left side NSCLC patients with mediastinal lymph node metastasis would be remarkably improved. And better local tumor control by ND3 operation does not increase mortality. When faced with a patient with resectable mediastinal lymph node metastasis, we should consider Extended bilateral mediastinal lymph node dissection through a median sternotomy.

Arrhythmias are known as one of the complications after surgery, and most of them are not lethal. But life-threatening bradycardic arrhythmias, such as complete AV block and asystole, have been described in the literature, but in reality very rare. To consider the relationship between arrhythmias and the involvement of cardiac plexus during lymph node dissection from anatomical viewpoint by presenting two patients who were complicated with life-threatening arrhythmias during and after surgery. A 71 year-old Japanese woman had an abnormality in a chest X ray on the annual medical checkup. A CT scan and a bronchoscopic biopsy led to the diagnosis of adenocarcinoma in left lower lobe, cT2aN0M0 StageⅠB. A preoperative electrocardiogram showed a heart rate of 55 per minute with normal sinus rhythm, and the echocardiography was normal. The patient underwent a thoracoscope-assisted left lower lobectomy and lymph node dissection. Post-operatively the patient was noticed to have lower heart rates of 40s, and when the patient sat up on the next morning, the bradycardia progressed to asystole for 10 seconds. CPR was performed and sinus rhythm was resumed. Having a temporary then a permanent pacemaker been implanted, the patient was uneventfully discharged from hospital on postoperative day (POD) 22. The second patient was a 67 year old Japanese man who presented with bloody sputum. An X ray and a bronchoscopic biopsy led to the diagnosis of squamous cell carcinoma in left lower lobe, cT2bN0M0 StageⅡA. A preoperative electrocardiogram showed a heart rate of 73 per minute with normal sinus rhythm and the echocardiography was normal. The patient underwent a left lower lobectomy and bilateral mediastinal lymph node dissection through a median sternotomy. During lymph node dissection along the right vagus nerve, the patient’s heart rate and blood pressure dropped suddenly and an electrocardiogram monitor showed ST elevation. These abnormalities returned to normal soon after cardiac massage was performed and a coronary vasodilator was given. A temporary pacing wire was inserted at the end of the surgery. The postoperative course was uneventful and the patient was discharged on POD 11. The cause of arrythmias is probable that cardicac plexus was stimulated inadvertently during lymph nodes dissection around the vagus nerve, considering a role of cardicac plexus from the anatomical viewpoint. It is important to be familiar not only with the course of phrenic, vagus and recurrent laryngeal nerve but also the anatomy of cardiac plexus in lung cancer surgery.