We present a case of intralobar pulmonary sequestration (IPS) and pulmonary aspergillosis (PA) in a 32-year-old Japanese man. Immunological examination indicated an initial diagnosis of PA and an antifungal agent was administered. Since an abnormal chest shadow persisted, another causative lung disease was suspected to exist. Further inspection revealed the presence of IPS and surgical resection was performed. The symptoms of IPS are usually secondary to pyogenic infection; nevertheless, Aspergillus is a possible causative microorganism.

In this report, we describe a case of a thymic carcinoma that developed in a thymic cyst, which was resected by video-assisted thoracic surgery (VATS). Chest radiography of a 68-year-old Japanese woman revealed an abnormal shadow. She was asymptomatic with normal physical examination findings. Chest computed tomography demonstrated a well-confined cystic mass that measured 4 cm in diameter occupying the anterior mediastinum. Based on these findings, a thymic cyst was suspected. It was completely resected by VATS. The excised cyst was multiloculated with a partially thick wall. Microscopic examination revealed that the nodular excrescence of the wall to be limited to papillary adenocarcinoma and the cyst wall to be lined by cuboidal cells. On the basis of this diagnosis, we performed multidrug adjuvant chemotherapy. The patient was alive without any sign of recurrence 15 months after the operation.

Purpose. Owing to advances in cardiovascular surgery, patients with cardiovascular disease require improvement of health-related quality of life (QOL) than before. We measured the QOL of patients undergoing cardiovascular surgery using the eight-item Short Form (SF-8) and assessed its usefulness.Methods. This was a prospective repeated-measures observational study. The SF-8 questionnaire was completed through interviews with 117 consecutive adult patients undergoing cardiovascular surgery at a single center (Nagara Medical Center, Japan) from April 2006 to March 2008. The SF-8 was evaluated before surgery and at 7 days, 1 month, and 6 months after surgery. The physical and mental scores over time were assessed.Results. Regarding physical status, compared with the normal population, the patients' scores were worse preoperatively and had deteriorated 7 days postoperatively; they gradually got closer to preoperative status a month after the procedure. At 6 months after surgery, all physical scores were higher than before surgery. The mental scores, including a mental component summary score, were inferior to those of the normal population until 1 month postoperatively, and they reached those of the normal population at 6 months.Conclusion. The SF-8 changed with the postoperative time course. It was a useful tool for analyzing the physical and mental QOL of patients who underwent cardiovascular surgery.

With synovial sarcoma (SS) of the thorax, being exceptionally rare, its definite diagnosis is difficult, and the optimal therapy has not yet been established. An examination of our patient, a 64-year-old man with SS using a chest roentgenogram showed a large mass with homogeneous density in the lower two-thirds of the left hemithorax. A computed tomographic image of the chest revealed a large, heterogeneous, enhanced mass in the left hemithorax. Histologic examination of the resected tumor tissues suggested monophasic fibrous SS. A fragment of the SYT-SSX1 fusion transcript, which was smaller than the control, was amplified with reverse transcriptase polymerase chain reaction. Direct sequence analyses revealed the fusion between exon 9 of SYT and exon 5 of SSX1 instead of fusion between exon 10 of SYT and exon 6 of SSX1, which is found in most cases. Although the biological and clinical significance of this rare variant is not yet known, our data present another example of the usefulness of molecular analyses for making a definite diagnosis of SS in unusual sites. (Ann Thorac Surg 2009; 88: 297-300) (C) 2009 by The Society of Thoracic Surgeons

A carinal tumor was detected in a 65-year-old male patient by preoperative bronchoscopic examination but was not diagnosed on simultaneous transbronchial biopsy. Also, a right lower bronchial tumor was diagnosed as squamous cell carcinoma. Resection of the carinal tumor and right lower lobectomy were performed simultaneously. We performed a modified one-stomatype carinal reconstruction and flap bronchoplasty to prevent complications on anastomosis. This case report illustrates that these procedures represent useful options for carinal-bronchial reconstruction.

57歳，男性．主訴は発熱．繰り返す肺炎の既往あり．肺炎と診断され抗生物質の投与を受けたが胸部X線上異常陰影は消失しなかった．胸部CT上左肺下葉には最大径6cmの腫瘤影と下行大動脈より分岐し腫瘤影へ注ぐ異常血管が認められた．大動脈造影検査では大動脈より肺底区へ流入する拡張した異常血管がみられたが，還流静脈を同定することは出来なかった．以上の検査結果より肺底動脈体動脈起始症と診断し手術を施行した．手術所見では正常肺と異常肺の境界が不明瞭なため，胸部下行大動脈より左肺下葉へ流入している異常動脈を切離し左肺下葉切除術を行った．切除標本の所見は肺内で約6cmまで拡大し血栓を伴った異常血管が左肺底区へ流入していた．繰り返す肺炎や改善しない胸部異常陰影がある症例では本疾患の可能性も考慮した精査と診断がつけば検査結果を考慮した術式での手術が必要と考えられた．

症例は，69歳男性．主訴は呼吸困難．CTで右肺上葉結節影，気管分岐部下腫瘤影（径6cm）が認められ，FDG-PETでそれぞれ集積あり，右肺上葉原発肺癌・縦隔リンパ節転移を疑った．気管分岐部下腫瘤に対し縦隔鏡・胸腔鏡検査を施行し，悪性所見はなかった．引き続き開胸にて，右肺上葉結節はadenocarcinomaと診断され，右肺上葉切除及び気管分岐部下腫瘤摘出を含むND2aリンパ節郭清術を施行した．右肺上葉結節は肺癌（pT2N1M0），気管分岐部下腫瘤はCastleman病と診断された．Castleman病はPET検査陽性で，肺癌縦隔リンパ節転移と鑑別困難である．このような縦隔リンパ節病変を合併した肺癌では病期診断に注意を要する．

症例は72歳男性．19歳時結核性胸膜炎の既往あり．61歳時に右胸部異常陰影を指摘され，前医にて経過観察されていた．陰影が徐々に増大し，6ヵ月前から労作時呼吸困難を自覚するようになった．病変は最大径19cmで右胸腔内より縦隔を圧迫するように存在していた．病変内部の経皮生検では陳旧性の凝血塊を認めた．総合的な判断よりChronic expanding hematomaと診断し血腫摘出手術を施行した．血腫を被膜の外側で剥離し，炎症性癒着の強固な中下葉および横隔膜を合併切除した．横隔膜はポリプロピレンメッシュを用いて再建した．術後経過良好で労作時呼吸困難は軽減し，呼吸機能は術前より改善した．

症例は73歳男性. 胃潰瘍にて近医通院中, 胸部写真にて右上縦隔の腫瘤影を指摘された. 胸部CT, MRI上, 右上縦隔に腕頭動静脈に接する辺縁整な腫瘤影が認められた. 上縦隔に発生した良性腫瘍の診断で摘出術が施行された. 頚部襟状切開および胸骨正中切開にて, 右鎖骨下動脈前面の反回神経分枝前の迷走神経の走行上に5×3×3.5cmの卵形の腫瘍が認められ, 迷走神経を切断して摘出した. 腫瘤は繊維性の被膜に包まれた, 弾性軟の充実性腫瘍で, 病理組織学的に, 神経鞘腫であった. 第4病日より嗄声が認められたが, その他の経過は良好であった.

1998年10月～2004年5月に, 集学的治療を行った悪性胸膜中皮腫は7例で, 男性7例, 年齢50～72歳 (平均60.6±7.0歳), 病側は左4例, 右3例であった. 治療内容は, 胸膜肺全摘術, 術後化学療法 (ADM 60mg/m2, CPA 600mg/m2, CDDP 70mg/m2) および放射線療法 (術側全胸壁に54～60Gy) とした. 組織亜型は, epithelial type 5例, sarcomatous type 2例で, International Mesothelioma Interest Group (IMIG) による臨床病期はIII期5例, IV期2例であった. 病巣は全例肉眼的には完全切除された. 術後合併症は, 心不全3例で軽快した. 化学療法によるGrade 4の毒性は5例にみられ, 好中球減少が5例, 貧血が1例, 血小板減少が1例, 食欲不振が1例であった. 5例は治療を完遂したが, 1例はPSの低下のため化学療法・放射線療法を途中で中止し, 1例は化学療法により全身状態不良となり中止した. 全症例の2年生存率, 5年生存率はそれぞれ68.6%, 45.7%であり, 中間生存期間は29.0ヵ月であった. 悪性胸膜中皮腫に対する集学的治療は, 長期生存を期待できる.

症例は75歳男性. 結核性膿胸に対する肺剥皮術後1年経過し, 食思不振及び咳嗽を来した. 胸部X線写真上左胸腔内にair fluid levelを認め, 胸部CTにて左肺尖部空洞内にアスペルギローマを認めた. 胸水よりアスペルギルスを検出した. 開窓術を施行し胸腔内の菌の陰性化は得られたが気道内の菌の陰性化は得られず, 左肺尖部の空洞切開を行い, 菌塊を摘出した. 菌の陰性化を得たのち, 左肺全摘・大網充填術を施行した. 術後経過を良好である. 肺アスペルギローマとアスペルギルス膿胸を合併した症例に対し開窓術後, 空洞切開術を行い, 肺全摘術を行ったという報告はみられず, この方法により難治性の再発膿胸を治癒し得た.

症例は72歳女性. 53年前, 左肺結核に対し人工気胸術をうけた. 3ヵ月前から左側胸壁が腫脹し, 皮膚瘻を生じた. 画像上, 病変は左下胸腔内に充満, 横隔膜を圧排し胸壁外に突出していた. 結核性膿胸, 悪性腫瘍が疑われたが, 菌培養, 経皮生検とも陰性であった. 慢性出血性膿胸の診断にて開胸術を行うと, 長径24cm, 3000gの繊維性被膜を伴う充実性腫瘤が横隔膜を越え後腹膜腔内に達していた. 横隔膜とともに被膜ごと血腫を摘出し, ポリプロピレンメッシュにて横隔膜を再建して閉胸した. 術後の再発は認められていない.

Mediastinitis is a complication after median sternotomy. We report a rare case of mediastinitis and mycotic pseudoaneurysm of the brachiocephalic artery that occurred long after the resection of invasive thymoma and postoperative irradiation and was treated with extensive procedures. A 68-year-old woman was seen with skin ulceration and suppuration from the wound in the anterior chest wall. She had undergone resection of invasive thymoma through median sternotomy 65 months previously. This operative treatment included combined resection of pericardium, right lung, and superior vena cava, along with interposition of an artificial polytetrafluoroethylene graft between the brachiocephalic vein and the right atrium. The patient received adjuvant radiation therapy of 50 Gy to the mediastinum for pathologically diagnosed Masaoka stage III thymoma. Computed tomography of the chest showed a dilated branch of the aortic arch compressing the sternum posteriorly, an occluded artificial graft between the brachiocephalic vein and the right atrium, and low-density areas in the mediastinum (Figure 1). A culture of the suppuration grew Pseudomonas aeruginosa. Arteriography showed a sacral aneurysm of the brachiocephalic artery (Figure 2). The patient underwent excision of the aneurysm through median resternotomy and extended right collar incision for the diagnosis of mediastinitis and mycotic aneurysm of brachiocephalic artery. The implanted polytetrafluoroethylene graft was found to be filled with pus and was removed. After the sternum had been released from the aneurysm, the wall of which was found to be extremely thin, the aneurysm ruptured suddenly. Cardiopulmonary bypass was quickly instituted through the previously exposed cannulations of the femoral artery and vein, with the ruptured aneurysm compressed by the surgeon’s finger. Selective cerebral perfusion was established with additional cannulations of the right axillary artery and the right atrium. The aneurysm of the brachiocephalic artery was excised under conditions of circulatory arrest with profound hypothermia. A Dacron polyester fabric graft was anastomosed with the tailored aortic arch at the origin of the brachiocephalic artery proximally. The distal anastomosis was at the bifurcation of common carotid artery and subclavian artery, with cardiopulmonary bypass restarted without axillary artery perfusion. Circulatory arrest time was 22 minutes, and the duration of cardiopulmonary bypass was 224 minutes. After the patient was weaned from cardiopulmonary bypass, necrotic sternum was resected and the infected mediastinum was irrigated with povidone iodine. Pedicled omentum was then transposed to cover the mediastinum and the Dacron graft through the extended upper abdominal approach. The skin and subcutaneous tissues were resutured, with the defect in the sternum left. After the operation, the patient required mechanical ventilation for respiratory failure for 8 days. After endotracheal extubation, she recovered well. She has been doing well for 28 months after the operation.Figure 2Arteriography showing a sacral aneurysm of brachiocephalic artery.View Large Image Figure ViewerDownload (PPT) Pseudoaneurysm of the brachiocephalic artery has been reported from a variety of etiologies.1Kieffer E. Chieche L. Koskas F. Bahnini A. Aneurysms of the innominate artery surgical treatment of 27 patients.J Vasc Surg. 2001; 34: 222-228Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar Traumatic injuries are the most frequently reported cause of this pseudoaneurysm. Blunt or stabbing injury2de Jose Maria B. Gomar C. Mestres C. Sorribes V. Moral V. Sala X. Pseudoaneurysm of the brachiocephalic artery caused by blunt chest trauma.J Thorac Cardiovasc Surg. 1995; 110: 863-865Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 3Reddi A.A. Munasur M.M. Naidoo R.R. Steer D.D. Traumatic innominate artery aneurysm 26 years after stab injury.Ann Thorac Surg. 2005; 79: 1034-1036Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and medically introduced trauma,4Shield C.F. Richardson J.D. Buckley C.J. Hagood Jr, C.O. Pseudoaneurysm of the brachiocephalic arteries a complication of percutaneous internal jugular vein catheterization.Surgery. 1975; 78: 190-194PubMed Google Scholar such as catheterization, intravenous cannulation, and stenting, have occasionally been reported as causes. Infectious cause has infrequently been seen after cardiac surgery.5Katsumata T. Moorjani N. Vaccari G. Westaby S. Mediastinal false aneurysm after thoracic aortic surgery.Ann Thorac Surg. 2000; 70: 547-552Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar Cannulation sutures or artificial grafts have become the foci of mediastinitis and have caused mycotic pseudoaneurysm of adjacent arteries. Our patient showed mediastinitis and pseudoaneurysm of the brachiocephalic artery long after the surgical treatment for invasive thymoma. Because of the extent of the mediastinitis and the pus formation in the implanted graft, the pseudoaneurysm of the brachiocephalic artery appeared to be of infectious origin. The chronic mediastinitis was associated with previous median sternotomy and postoperative irradiation, although more than 5 years had passed since the resection of invasive thymoma. Adjuvant irradiation would have caused poor vascularization in the postoperative mediastinum, with consequent failure of protection against transsternal infection. Such a mycotic pseudoaneurysm of brachiocephalic artery after combined surgery and irradiation has seldom been reported in the literature. Extensive procedures—including removal of infective foci, necrotic sternum, and artificial graft; excision of the pseudoaneurysm; surgical irrigation; and omentum transposition—appear to have been successful in treating this extended mediastinal infection.

This report, emphasizing a possible complication of en bloc resections involving the vertebral bodies, especially after chemotherapy, radiotherapy, or both, might prompt the thoracic surgeon to evaluate a possible solution of continuity of the dura mater during extended lung resections. DiscussionChronic expanding hematoma of the thorax is a rare entity.Affected patients typically have a history of medical or surgical therapy for tuberculosis.Since Iuchi and associates 1 reported 5

Should heart transplantation be considered as a treatment option for patients aged 70 years and older?

胸部手術における有茎性大網充填術の有用性を検討した. 対象は1998～2001年に胸腔内へ大網充填を施行した23例 (男19, 女4, 平均65.1才) で, 膿胸気管支瘻19例 (慢性10, 術後6, 術後遠隔期気管支瘻3), 非感染性胸腔瘻2例 (肺1, 食道1), 気管支断端予防的被覆2例であった. 膿胸19例中有瘻16例で, 大網充填の時期は開窓後11例, ドレナージ感染制御後5例, 活動感染下3例であった. 膿胸19例中15例 (78.9%) で腔感染を制御できた. 失敗の主原因は大網の血行障害と感染の残存であった. 非感染性肺瘻症例及び予防的使用の2例は奏功, 食道瘻症例は失敗した. 腹部合併症は2/23例 (8.7%) で, 小腸穿孔1例, 拘扼性イレウス1例で腸切除を要した. 大網充填術は膿胸や瘻孔性疾患において有用であるが, 失敗や合併症も見逃せない. 大網虚血に留意した操作が必要で, 膿胸に対しては感染制御後に行うことが望ましい.

Chronic expanding hematoma was first described by Reid and colleagues in 19801Reid J.D. Kommareddi S. Lankerani M. Park M.C. Chronic expanding hematomas: a clinicopathologic entity.JAMA. 1980; 244: 2441-2442Crossref PubMed Scopus (191) Google Scholar and reported to occur in many locations. Although most hematomas resolve spontaneously, a few persist for long periods as slowly expanding, space-occupying masses. In the entity of chronic expanding hematoma of the thorax, the hematoma develops in the pleural space rather than in the pulmonary parenchyma. The hematomas are known to expand 30 years or more after medical or surgical treatment for tuberculosis. The patient usually showed mediastinal compression or chest wall protrusion. Although our patient presented with a sudden onset of hemoptysis, she had shown chest wall protrusion by the intrathoracic and also extrapulmonary hematoma for several months, which is essential for the diagnosis of this entity. In our patient, emergency bronchoscopy revealed contralateral spread of hemoptysis, which was shown in Figure 1, A.2Okubo K. Okamoto T. Isobe J. Ueno Y. Rupture of a chronic expanding hematoma of the thorax into lung parenchyma.J Thorac Cardiovasc Surg. 2004; 127: 1838-1840Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Because of the almost complete compression of the destroyed right lung by the hematoma, the patient required a pneumonectomy to survive. The surgical procedure was intentionally delayed for several days until the left-side spread of the hemoptysis decreased. Median sternotomy was the way to access the hilum directly without compressing the mediastinum through a massive hematoma. In the letter by Dr Sersar and associates, their experience of pulmonary hematoma was shown with some images. However, the chronic expanding hematoma of the thorax is quite different from intrapulmonary hematoma in both clinical course and presentation. Further comparative discussion of treatments does not make sense with different diseases. Rapidly accumulating spontaneous pulmonary hematomaThe Journal of Thoracic and Cardiovascular SurgeryVol. 129Issue 1PreviewWe read with the greatest interest the article entitled “Rupture of a Chronic Expanding Hematoma of the Thorax Into Lung Parenchyma.”1 We have the following comments. First of all, there is a delay in patient management. Why did the authors not do a diagnostic bronchoscopy, and why did they do a pneumonectomy and not a lobectomy? The chest radiograph A is a case suggestive of aspiration pneumonia. We wonder why they chose median sternotomy and not a thoracotomy. What was the pathology of the removed lung? We think that this was a case of spontaneous pulmonary hematoma caused by an arteriovenous malformation. Full-Text PDF

胸部手術における有茎性大網充填術の有用性を検討した. 対象は1998～2001年に胸腔内へ大網充填を施行した23例 (男19, 女4, 平均65.1才) で, 膿胸気管支瘻19例 (慢性10, 術後6, 術後遠隔期気管支瘻3), 非感染性胸腔瘻2例 (肺1, 食道1), 気管支断端予防的被覆2例であった. 膿胸19例中有瘻16例で, 大網充填の時期は開窓後11例, ドレナージ感染制御後5例, 活動感染下3例であった. 膿胸19例中15例 (78.9%) で腔感染を制御できた. 失敗の主原因は大網の血行障害と感染の残存であった. 非感染性肺瘻症例及び予防的使用の2例は奏功, 食道瘻症例は失敗した. 腹部合併症は2/23例 (8.7%) で, 小腸穿孔1例, 拘扼性イレウス1例で腸切除を要した. 大網充填術は膿胸や瘻孔性疾患において有用であるが, 失敗や合併症も見逃せない. 大網虚血に留意した操作が必要で, 膿胸に対しては感染制御後に行うことが望ましい.