Minimally invasive surgery is being widely performed for the management of lung cancers owing to rapid technological advances in surgical devices and techniques. In recent times, because chemotherapy and radiotherapy have both become less invasive treatment strategies, therapeutic opportunities for the use of multimodality therapy have been increasing. Minimally invasive surgery is an important component that requires additional improvements to derive the complete benefit of multimodality therapy. We have been actively performing video-assisted thoracic surgery(VATS) for the management of advanced lung cancers, as well as early lung cancers to reduce surgical stress in our patients, thereby enhancing the scope of multimodality therapy. Although some reports have demonstrated the efficacy of VATS for the management of early lung cancers, only a limited number of reports have discussed the advantage of VATS for the management of advanced lung cancers. In this report, we reviewed patients with advanced lung cancer (pathological stageⅡ or Ⅲ) in whom complete resection was performed between January 2011 and December 2016, and we examined the role of VATS as a component of multimodality therapy.

With the advent of molecular targeted therapeutic agents and immunity checkpoint inhibitors, lung cancer drug therapy has advanced. We cannot expect to improve the performance of surgical treatment without drug therapy. The problem of improving the performance of surgical treatment for lung cancer is:① the role of surgery in multidisciplinary treatment for c-stageⅢ N2 lung cancer, ② post-operative adjuvant therapy, ③ multidisciplinary treatment of post-operative recurrence, ④ salvage surgery, and ⑤ sublobar resection in high risk cases. We will describe each of these with reference to our own experiences and literature considerations.

Clinical N2-stageⅢA non-small cell lung cancer(NSCLC) is known to be quite heterogeneous. Many clinical trials proved the effect of postoperative adjuvant chemotherapy for locally advanced NSCLC, which is recommended as grade C1 by Clinical Guideline for Lung Cancer, however, induction treatment for clinical N2-stageⅢA remains still controversial. We showed retrospective data of concurrent chemoradiotherapy using S-1 and cisplatin followed by surgery, which may provide a better prognosis for locally advanced NSCLC patients. In addition, we summarized the findings of prospective clinical trials for treatment of clinical N2-stageⅢA NSCLC patients.

Intravenous leiomyomatosis is a rare neoplastic condition characterized by the benign intravascular proliferation of smooth muscle cells originating from either the uterine venous wall or a uterine leiomyoma. In the present report, we describe the case of a 36-year-old woman, who was referred to our institution due to abdominal pain. Computed tomography indicated the presence of a giant intravenous leiomyoma originating from the uterus and extending to the right ventricle with complex pathways. The patient was successfully treated by tumor resection under circulatory arrest in two-stage operations in conjunction with gonadotrophin-releasing hormone agonists therapy. She continued to recover and did not exhibit any recurrence at the 8-month follow-up.

An estimated 2~16% of primary lung cancers form cavities with cases that form thin-walled cavities being comparatively rare. We treated a patient with squamous cell carcinoma of the lung with a small cystic shadow that showed no changes for 3 years. The cyst then suddenly grew larger, after which the cyst wall thickened over time and a thin-walled cavity was seen. Here we report this important case showing the development process of lung cancer that formed a thin-walled cavity, together with a discussion of the literature.

A 69-year-old female with left atrial tumor was refered to our hospital for surgical treatment. The tumor was attached to the interatrial septum and resected completely. Histopathological analysis confirmed a myxoma with ossification(mature bone). These findings may support the hypothesis that the undifferentiated mesenchymal cells are the origin of cardiac myxoma.

A 49-year-old man was admitted to our hospital for an abnormal chest shadow. Computed tomography showed a pulmonary nodular shadow in the right upper lobe and swelling of the right hilar, mediastinal and supraclavicular lymph nodes. A positron emission tomography(PET) scan showed fluorodeoxyglucose accumulation in the tumor and swollen lymph nodes. He was diagnosed with stage cT1aN3M0 (ⅢB) pulmonary adenocarcinoma and was treated with a combination of cisplatin and paclitaxel. After 6 cycles of chemotherapy, serum carcinoembryonic antigen (CEA) level was markedly decreased. A PET scan showed fluorodeoxyglucose accumulation only in the primary site. He was diagnosed with stage ycT1aN0M0(ⅠA) disease, and the salvage surgery was scheduled. As chemotherapy had resulted in severe fibrosis of the lung hilum, he underwent a partial resection. After partial resection of the right upper lobe, he has been alive without recurrence for 8 years.

According to the tumor, node, metastasis (TNM) classification of the Union for International Cancer Control (UICC) and the International Association for the Study of Lung Cancer (IASLC), N factor is defined by the anatomic extent of the metastatic lymph nodes, but is not related to the metastatic pattern. N1 is defined as "metastasis in ipsilateral peribronchial and/or ipsilateral hilar lymph nodes and intrapulmonary nodes, including involvement by direct extension". Lymph node involvement is one of the most important prognosistic factors in non-small cell lung cancer patients. Squamous cell carcinoma (SCC) arises in the central airway and directly invades adjacent lymph nodes more frequently compared to the other histologic types. We retrospectively evaluated the prognostic impact of lymph node involvement patterns in pulmonary pN1 squamous cell carcinoma (SCC) patients. The clinical records of 23 patients with pN1 SCC who underwent complete resection and systematic lymph node dissection at our institute were retrospectively reviewed. We classified the patient into 2 N1 groups based on the nodal involvement pattern:metastatic N1 nodes involved directly by the main tumor (direct group) and metastatic N1 nodes not directly involved by the main tumor (separate group). The direct group consisted of 10 patients, and the separate group comprised 13 patients. There were no significant difference in the gender, tumor size, surgical procedure, and number of metastatic lymph nodes. Overall survival and disease-free survival curves were plotted using the Kaplan-Meier method, and the statistical differences between both groups was determined by the log-rank test. P values <0.05 were considered statistically significant. The direct group had a much better 5-year overall survival rate of 100.0% compared with 55.9% for the separate group (p=0.037). The N factors in TNM classification are defined only by anatomical location. However, our results suggest that the mode of nodal involvement in pulmonary pN1 SCC might be a prognostic factor. Accordingly, it is likely that biological behaviors are different between direct metastasis and separate metastasis. Since there are some limitations in this study:its retrospective design and small sample size, the clinical implication of direct extension to N1 lymph nodes needs to be confirmed by a large scale prospective study in the future.

Intravenous leiomyomatosis (IVL) is a condition in which leiomyoma originating from uterine myoma or intrauterine venous walls develops intravenously. A single-stage operation was planned by the departments of gynecology and cardiovascular surgery for a patient in which the IVL was extended across the tricuspid valve. It was possible to safely perform perioperative care with continued evaluation of the tumor position and intravascular volume through the use of transesophageal echocardiography (TEE). TEE can be useful in the intraoperative care of patients with intracardiac tumor extension as in this case.

We report a patient with seminoma which recurred as late relapse at the pelvis with elevated alphafetoprotein (AFP) levels. A 40-year-old man presented with a left testicular tumor and subsequently underwent high orchiectomy in 2006. Pathological findings showed that the tumor was a seminoma with invasion into the tunica albuginea (pT2N0M0). Seven years after surgery, computed tomography showed a 12×8.7 mm, well-circumscribed, pelvic cystic tumor, and AFP and human chorionic gonadotropin levels were elevated. He was clinically diagnosed with recurrent testicular cancer. Despite the fact that the patient had four courses of bleomycin, etoposide, and cisplatin (BEP), the tumor enlarged and AFP levels were still elevated. Therefore, we performed open excision of the pelvic tumor. Judging from the pathological report, we made the final diagnosis of mature cystic teratoma. The patient was free of recurrence or metastasis within 48 months of follow-up.

A 62-year-old man presented to our hospital with the chief complaint of continuous penile pain and swelling for 4 months. Computed tomography and magnetic resonance imaging showed an invasive bladder tumor with penile, bone, and lymph node metastases. Needle biopsies of the bladder and penile lesions were obtained, and histological evaluation of these specimens revealed urothelial carcinoma, findings which are consistent with invasive bladder cancer with penile metastasis. After several therapeutic options were discussed with the patient, he decided toundergogeneral chemotherapy. However, the patient died about 16 days after admission without treatment because of his poor general condition.

We present a case of renal cell carcinoma growing into the renal pelvis with a fibrin cap in the ureter and bladder. A 66-year-old man presented to our hospital with anemia and gross hematuria. Computed tomography showed a large left renal tumor and space-occupying lesions in the left renal pelvis and ureter. Cystoscopy showed a 2 cm-restiform mass protruding from the left ureteral orifice. We performed open left nephroureterectomy, and there was a 3 cm white mass with a smooth surface in the bladder. Pathological examination of the resected mass revealed clear cell carcinoma with urinary collecting system invasion and fibrin cap in the ureter and bladder. As a result, it would have been difficult to make the diagnossis of renal cell carcinoma preoperatively if we had performed biopsy of the mass in the bladder or ureter. The patient was diagnosed as having lung metastases 5 months after surgery. Urinary collecting system invasion has been considered an independent prognostic factor in pT3 renal cell carcinoma.

Renal mucinous tubular and spindle cell carcinoma (MTSCC) is a rare, low-grade renal epithelial neoplasm. MTSCC has a lower malignant potential and shows relatively good prognosis, but can be difficult to distinguish from other renal cell carcinoma (RCC) subtypes. Here, we report two cases of metastatic and recurrent renal MTSCC diagnosed after long-term follow-up. Case 1 was a 79-year-old man with a history of macroscopic hematuria in whom a right kidney mass was detected and diagnosed as RCC (cT3bN0M0). After a radical nephrectomy, microscopic findings showed that the tumor consisted of spindle cells arranged in tubular patterns embedded in sarcomatoid tissues ; we diagnosed it as unclassified RCC with sarcomatoid differentiations (pT3aN0M0). Thereafter, metastases were twice detected and resected completely. The patient had no evidence of disease at his most recent follow-up, 10 years 1 month after the initial surgery. Case 2 was in a 72-year-old man in whom a right kidney mass, swollen lymph nodes, and a lung node were incidentally detected. This tumor was diagnosed as RCC (cT4N2M1), and radical nephrectomy and lymph node dissections were carried out. From the microscopic findings, we diagnosed papillary RCC type-2 (pT3aN2M1). After the surgery, pleural and bone metastases was detected. Despite sequential treatments with IFN-α and sunitinib, the patient suffered indolent-growing metastases and died at 5 years 6 months after operation. As these patients had relatively good prognoses despite assumed aggressive RCC subtypes, we reviewed their pathological findings. In both cases, tumor samples showed tubules lined by short cuboidal cells that were set within myxoid stromata and spindle cells ; we finally diagnosed these cases as renal MTSCC.

A 61-year-old man with a left renal mass, which was detected by ultrasound during a routine health examination, was referred to our department. The patient had a surgical history of two pneumothorax operations, and the patient's brother also had a history of pneumothorax surgery. A case of Birt-Hogg-Dubé (BHD) syndrome was suspected based on patient history. The pathological diagnosis of the resected tumor, which used robot-assisted laparoscopic partial nephrectomy, was determined to be chromophobe renal cell carcinoma (grade 2, pT1a). BHD syndrome was confirmed by genetic testing, where a nonsense mutation of exon 9 in the FOLLICULIN (FLCN) gene was detected. The patient is currently alive 10 months after surgery.

A 74-year-old man presented to our hospital with the swelling of penis in May 2016. Physical examination revealed a goose egg-sized lump at the tip of the penis under foreskin. After dorsal skin incision we confirmed the 7 cm tumor on the inner preputial skin and then resected the tumor with circumcision. Histopathological examination revealed sarcomatoid squamous cell carcinoma of the penis. Computed tomography (CT) revealed swelling of bilateral inguinal lymph nodes, and we performed partial penectomy with bilateral superficial inguinal lymph node dissection in July 2016. Because of the positive surgical margin 2 cm away from the tumor we performed a total penectomy 2 weeks after the previous operation. Histopathological examination revealed no residual tumor and negative inguinal lymph nodes. In about 3 months postoperatively, he presented with a complaint of dyspnea and a CT scan showed right, pleural effusion and multiple lung metastases. He died of cancer 4 months postoperatively.

A 59-year-old man presented with pain and swelling of the right scrotum. Magnetic resonance imaging revealed a mass withsignal intensity similar to background on an apparent diffusion coefficient (ADC)-map of the upper region of the right testis. Inflammation was considered, but a testicular tumor could not be ruled out. Right high orchidectomy and histopathological assessment revealed granulomatous orchitis. The cause, clinical course and treatment of rare granulomatous orchitis remain unknown. Granulomatous orchitis and testicular tumor are difficult to discriminate, and high orchidectomy is usually applied along with histopathological assessment to achieve a definitive diagnosis. On the other hand, some patients who were only medically treated for granulomatous orchitis have recovered. We recently found that diffusionweighted imaging and ADC values derived from magnetic resonance images can differentiate testicular tumor from orchitis. We suggest an algorithm for the diagnosis and treatment of granulomatous orchitis considering the present patient and previous reports.

Adenocarcinoma arising from the female urethral diverticulum is very rare, as only about 100 cases have been reported worldwide. An 82-year-old woman presented with asymptomatic macrohematuria. A transvaginal examination revealed a firm circular mass on the anterior vaginal wall. Cystourethroscopy showed a urethral tumor, which was determined to be clear cell adenocarcinoma after transurethral resection of the urethral tumor. However, we could not resect all of the tumor, so anterior pelvic exenteration and ileal conduit urinary diversion were performed. The final pathological diagnosis was clear cell adenocarcinoma arising from the urethral diverticulum. However multiple lymph node metastases appeared 10 months after surgery. The patient refused additional therapy and died 23 months after surgery.

A 70-year-old man was admitted with complaint of gross hematuria. Cystoscopy and computed tomography (CT) revealed a 2.5 cm nodular tumor in the urinary bladder. Pathological diagnosis after the transurethral resection of bladder tumor (TURBT) was invasive urothelial cancer with trophoblastic differentiation of pT1. The tumor was positively stained with human chorionic gonadotropin (HCG). The serum HCG level was 12.8 IU/l in the fourth week after TURBT, and it increased to 35.7 IU/l in the 20th week after TURBT. However, radiological examination at this point did not reveal tumor recurrence or metastases. Three months later, the patient coughed up bloody sputum. Lung metastases (up to 2.4 cm) were identified, and they were surgically removed. The pathological specimen consisted of syncytiotrophoblastic giant cells with hemorrhage and necrosis, but no urothelial cancer element. Because the lung and lymph node metastases developed soon after surgery, chemotherapy was planned. Because the patient had impaired renal function with a creatinine clearance of 33.7 ml/min, we selected combination chemotherapy with gemcitabine and oxaliplatin (GEMOX) rather than cisplatin -based chemotherapy. CT after two courses of GEMOX showed stable disease, but HCG levels markedly decreased from 1,240 IU/l to 7.9 IU/l. This marker of response continued through six courses of GEMOX. Then, the chemotherapy was discontinued due to grade 2 neuropathy. He died of cancer 12 months after development of metastases. Autopsy revealed only tumor cells with trophoblastic differentiation, but no urothelial carcinoma in multiple metastatic sites.

We report a case of successful treatment of recurrence of peritoneal dissemination with axitinib. A 55-year-old man presented at our hospital with the chief complaint of remarkable abdominal fullness 18 months after right radical nephrectomy, which had been performed at another hospital for the treatment of renal cell carcinoma. The pathological diagnosis was papillary renal cell carcinoma type 1, pT3aN0M0. A large amount of ascites was detected by computed tomography, and recurrence of peritoneal dissemination was diagnosed (ascites cytology : class V). Sunitinib was started as a first-line treatment, but 1 month later, this was discontinued because of an adverse event (hyponatremia) and a lack of efficacy. As a second line therapy, axitinib 10 mg/day p. o. was administered. The ascites markedly decreased, and the disease status has remained stable after 18 months of treatment. To our knowledge, this is the first study to demonstrate the efficacy of axitinib in treating peritoneal dissemination.

A case of solitary metastasis of renal cell carcinoma to the thyroid gland is presented. The patient was a 82-year-old man found to have an abnormal mass in his neck. He had a past history of renal clear cell carcinoma of the left kidney (pT1aN0M0, G1>2, alveolar type, clear cell subtype), which had been resected 12 years previously. Ultrasonography revealed a tumor mass in the right hemithyroid gland. This time fine needle biopsy of the thyroid tumor suggested metastatic thyroid carcinoma. Right hemithyroidectomy was performed last year. The histopathological findings were suggestive of clear cell carcinoma, thus metastatic renal carcinoma was diagnosed. This is the 26th case of thyroid solitary metastasis of clear cell renal cell carcinoma reported in Japan to date.