[Intractable Myasthenia Gravis Accompanied with Thymoma;Report of a Case].

A 46-year-old female visited a hospital due to pelvic inflammatory disease (PID) and then her chest computed tomography revealed an abnormal shadow in the upper mediastinum. Four months later,she complained muscle weakness with her limbs, dysphagia, and ptosis of her eyelids. Total thymectomy was performed through a median sternotomy for mass lesion, which was pathologically proven to be type B1 thymoma. Postoperative myasthenia gravis (MG) crisis, which led to respiratory failure requiring intubation and mechanical ventilation, developed and laboratory tests showed elevated serum anti-AChR Ab(130 nmol/l), antinuclear antibody( ×640 serum dilution, speckled pattern) and anti-RNP Ab(129.2 U/ml). For MG crisis, steroid pulse therapy, immunosuppressive therapy and immuno absorption were performed, and she successfully weaned from mechanical ventilaton on 41 post operative day (POD). Some factors such as inapparent mixed connective tissue disease (MCTD) and Anti RNP antibody were thought to be a cause for having any difficulty in MG treatment in the present case.

[Pneumothorax Secondary to Pulmonary Metastasis of Angiosarcoma of the Scalp;Report of a Case].

Angiosarcoma has been reported as a rare case, having high potential of hematogeneous lung metastasis and then developing to pneumothorax with ease. The patient was a 74-year-old man afflicted with a malignant hemangio endothelioma (MHE) of the scalp. His MHE of the scalp was resected and skin grafting was made, then, he was administered docetaxel hydrate intravenously as adjuvant setting. Three years after, he complainted left chest pain and dyspnea, so his chest Xp was checked up and showed left pneumothorax. Chest computed tomography revealed multiple thin walled cavities of right and left lung and bullae with slightly thick walled cavity at apex legion of the left lung. We resected bullae with tumor of the left apex legion under video assisted thoracic surgery. After operation, He was administerd ricombinant interleukin-2 intravenously in order to control lung metastasis of the scalp, but his condition deteriorated and 6 months after pneumothorax he died. The average survival time from the 1st pneumothorax episode was only 4.7 months. He kept a good activities of daily living without reccurrence of pneumothorax by operation, so we thought that the operaion for pneumothorax with MHE was one option for therapy.

[Thoracic and abdominal and limb wounds by gun shot].

In Japan, we are permitted to own fire arms only for hunting and clay pigeon shooting, but gunshot wound victims have neen rarely seen due to the strict laws against owing guns, and the lack of related crimes. Therefore, surgeons should be familiar with ballistics, practical gunshot wound management, and the possibility of delayed lead poisoning ssociated with bullet residue. A 69-year-old man was brought to our hospital because he was accidentally shot by his companion's shotgun during hunting. On admission, although he had stable vital sign and multiple gunshot wounds on his right forearm and femur, chest X-ray and computed tomography (CT) revealed a few of bullets and its flagments on his back, into spleen and pericardium. Following local debridment after removal of the bullets in his right forearm and femur at an emergency room, broken heart muscle and diaphragm were repaired and hematoma in the anterior mediastinum was removed at the operating room. The patient was discharged on the 25th post-operative day and his post-operative course was uneventful. In case of gunshot injuries, in addition to prompt diagnosis and evaluation of organ injuries, careful follow up for possible delayed lead poisoning is important.

[Castleman's Disease of the Chest Wall Successfully Resected by Thoracoscopic Surgery；Report of a Case].

A 61-year-old woman without a significant past medical history was pointed out the abnormal shadow on the annual medical checkup. Chest computed tomography (CT) revealed a well-defined paravertebral chest wall tumor of 20 mm in maxmum size. Furthermore, diffusion weighted image on magnetic resonance imaging (MRI) showed high intensity, and standardized uptake value (SUV) max on positron emission tomography/computed tomography (PET/CT) was 13.4. Schwanoma, solitary fibrous tumor (SFT) or malignant lymphoma was suggested. Complete resection was performed with thoracoscopic surgery. The histological diagnosis was Castleman's disease with hyalineized type.

[Diaphragmatic lipoma needed to distinguish from Bochdalek hernia; report of a case].

A 69-year-old woman had been followed up for an abnormal shadow on the left diaphragm at a nearby hospital, which showed gradual increase in size and she was referred to our hospital for treatment. Chest computed tomography(CT) showed a dome-shaped and homogeneous mass with smooth surface on the left diaphragm. CT showed 50×60 mm hypodense mass and partly interrupted diaphragm. Magnetic resonance imaging( MRI) revealed fat signal intensity on both T1 and T2 weighted image and fat suppressed T1 image. Bochdalek hernia or diaphragm lipoma was suggested and surgery was done. Yellowish round tumor on the diaphragm was resected. The omentum was easily separated from the tumor. Histopathological finding revealed the lipoma cell invading into striated muscle of diaphragm, and the tumor was diagnosed as a mature lipoma originated from diaphragm.

A case of cervical schwannoma with upper tracheal stenosis followed up as asthma for 4 years.

Cases of upper tracheal stenosis due to cervical schwannoma are fairly rare; therefore, no treatment has been determined. In this case, our patient had been treated for asthma for 4 years and was admitted to our hospital because of exacerbation. Computed tomography showed a tracheal stenosis lesion just below the vocal cords, and a biopsy revealed schwannoma. Conservative therapy was preferred rather than tumour resection by surgery. Follow-up for 5 years showed no changes on imaging. Conservative treatment is considered as an option if the extratracheal tumour does not grow.

Predictors of indocyanine green visualization during fluorescence imaging for segmental plane formation in thoracoscopic anatomical segmentectomy.

BACKGROUND: To determine factors predicting indocyanine green (ICG) visualization during fluorescence imaging for segmental plane formation in thoracoscopic anatomical segmentectomy. METHODS: Intraoperatively, the intravenous ICG fluorescence imaging system during thoracoscopic anatomical segmentectomy obtained fluorescence emitted images of its surfaces during lung segmental plane formation after the administration of 5 mg/body weight of ICG. The subtraction of regularization scale for calculating the exciting peaks of ICG between the planned segments to resect and to remain was defined as ΔIntensity (ΔI). Variables such as the ratio of forced expiratory volume in 1 s to forced vital capacity (%FEV1.0), smoking index (SI), body mass index (BMI), and low attenuation area (LAA) on computed tomography (CT) took a leading part. RESULTS: The formation of the segmental plane was successfully accomplished in 98.6% segments and/or subsegments. SI and LAA significantly affected ΔI levels. The area under the receiver operating characteristic curve for the %FEV1.0, SI, and LAA was 0.56, 0.70, and 0.74, respectively. SI >800 and LAA >1.0% were strong predictors of unfavorable ICG visibility (P=0.04 and 0.01, respectively). CONCLUSIONS: Fluorescence imaging with ICG was a safe and effective method for segmental plane formation during thoracoscopic anatomical segmentectomy. In spite of its high success rate, unfavorable visibility may potentially occur in patients who are heavy smokers or those with a LAA (>1.0%) on CT.