Four hundred and fifty-seven patients underwent operation for primary lung cancer in our hospital and five patients (1.1 %) had synchronous bilateral lung cancer treated by simultaneous resection. Four of 5 patients underwent simultaneous resection via a median sternotomy that was added to an anterolateral thoracotomy on one side, and one patient was resected by only median sternotomy. Bilateral lobectomy was performed in one case and lobectomy on one side with wedge resection on another side was performed in four cases. Bilateral mediastinal and hilar lymph node dissection were performed in four of these 5 cases and all were p-stage I on the pathological examination. These cases were free of severe complications irrespective of the extent of the resection ; they are still alive 5 to 78 months after surgery without any evidence of recurrence and their current performance status is very good. In the last one case lymph node dissection was not performed due to arrhythmia at the time of the operation, and the died of aspiration pnemonia associated with mediastinal lymph node metastasis 4 months after surgey.
This experience suggests that this approach is advantageous from the point of view of curability of operation in the treatment of resectable synchronous bilateral lung cancer and it is necessary to have careful management of the intraoperative and postoperative courses.

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Effects of epidural anesthesia (EA) on expectoration disturbance (atelectases) after lung resection were studied on 197 patients who underwent lobectomies. Atelectases were observed in 48 of 197 patients. In a group received EA during the early postoperative phase, atelectasis developed in 3 of 39 patients (7.7 %). This occurrence rate was significantly lower than that (28.5 %, 45 of 158 patients) in a group without EA. In 128 patients with severe obstructive lung disease (predicted FEV_1.0 <800 ml/m²), 31 patients received EA during the early postoperative phase and atelectasis developed in 1 patient (3.2 %). This occurrence rate was significantly lower than that (34.0 %, 33 of 97 patients) in a group without EA. In conclusion, EA during the early postoperative phase may be useful in the prevention of atelectasis.

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From 1985 to 1995, 58 patients with non-small cell lung cancer and bulky mediastinal lymph nodes on chest CT scans received induction therapy consisting of cisplatin (80 mg/m²) and vindesine (3 mg/m²) prior to their operations. Of these 58 patients, 37 with pathological N2 NSCLC were studied to assess the effect of the induction therapy. Of the 37 patients, 10 received one cycle of chemotherapy during 1985 to 1989 and the remaining 27 had 2 or more cycles of the same regimen plus irradiation after 1990 ; nineteen of the 27 patients received 2 to 3 cycles of concurrent chemoradiotherapy which consisted of cisplatin, vindesine and concomitant irradiation (20 Gy) as one cycle. Complete resection was carried out in 21 of the 37 patients with bulky pN2 cases. Complete sterilization of bulky mediastinal nodes was observed histologically in 10 of them. Of these 10 patients with a histologic complete response (CR) of the mediastinal lymph nodes, nine had received concurrent chemoradiotherapy (CCRT) and one had received 4 cycles of chemotherapy alone. Judgment of the effect was focused on the mediastinal lymph nodes rather than the main tumor. The 5-year survival rate was 38.9 % in patients with histologic CR for bulky N2 nodes and this was significantly superior to the result of 9.1 % in patients with partial or minimal response. One cycle of chemotherapy resulted in a poor histologic response and was of no survival benefit. There were 4 major complications postoperatively. Three of 4 were CCRT atients and 2 deaths were related to the induction therapy but the onset of complications was after their discharge, 4 months postoperatively. One patient died at 23 months postoperatively of massive hemoptysis caused by empyema developing from a pulmonary fistula and the other died at 16 months of respiratory failure caused by interstitial pneumonitis.
We conclude that (1) survial was improved in patients with complete resection after histologic sterilization of bulky N2 nodes, (2) two cycles of concurrent chemoradiotherapy produced an excellent response of N2 nodes and the primary tumors, (3) critical postoperative complications often had a late onset after discharge.

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We evaluated the prognosis of non-small cell lung cancer cases in a total of 980 cases resected from 1976-1993, including 36 cases with ipsilateral intrapulmonary metastasis (pm) and 72 cases with metastasis in other organs (M1). The survival rate in the pm group (5-year survival 26.3 %) was significantly better than that in the Ml group (5-year survival 10.9 %).
In the pm cases, cases of adenocarcinoma (n=24) were most frequent (67 %). There were five T2, seven T3 and 24 T4 cases. Significant differences in the survival curves were demonstrated between cases with T2 and T4 disease and between NO and N3 disease. Multivariate analysis using a Cox proportional hazards model showed that the dominant factors in survival are pathological T factor and metastatic site.
These data supported the suitability of the criteria proposed by The Japan Lung Cancer Society (The 4th Edition) in 1995 for ipsilateral intrapulmonary metastasis.

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The incidence of lymph node metastases, recurrence rate and prognosis, depending on the surgical mode of intervention were examined in patients with peripheral non-small cell lung cancer of less than 2 cm in diameter. Patients and methods : Eighty-four patients with peripheral non-small cell lung cancer (< 2 cm in diameter), were divided into two groups depending on the surgical mode : lobectomy plus group (64 patients), lobectomy combined with hilar and mediastinal lymph node dissection performed through an open thoracotomy, and simple lobectomy group (20 patients), simple lobectomy without lymph node dissection performed through an open thoracotomy. Squamous cell carcinoma (7 patients) was significantly less common than adenocarcinoma (77 patients). There were significantly more patients with well-differentiated cancer in the lobectomy plus group than in the simple lobectomy group. Significantly more patients received adjuvant chemotherapy in the simple lobectomy group than in the lobectomy plus group. The incidence of lymph node metastases was examined in the lobectomy plus group, and the recurrence rate and prognosis were compared between the two groups. Results Seventeen percent of patients in the lobectomy plus group had lymph node-positive disease. Cancer in the right middle lobe or left lingual division metastasized to lymph nodes more frequently than cancers in other locations. There were no significant differences in recurrence rates between the two groups. The recurrence rate of cancer in the right middle lobe or left lingual division was higher than that in other locations. There were no significant differences in prognosis between the two groups. There were no differences in recurrence rates or prognosis with regard to histologic type, tumor grade, or postoperative adjuvant chemotherapy. Conclusion : We conclude that there were no necessity of hilar and mediastinal lymph node dissection in patients with peripheral non-small cell lung cancer less than 2 cm in diameter because of the lack of difference in recurrence rates and prognosis between the two groups.

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Cytological examination of pleural effusions is important in patients with primary lung cancer in order to determine the treatment schedule and estimate the prognosis. We report here on patients with pleural lavage positive cytology but little or no pleural effusion.
Group A : From June 1985 to November 1987, cytological examinations of pleural lavage fluid (intra-operative diagnosis) were conducted in 107 primary lung cancer patients in whom no pleural effusion could be detected macroscopically at the time of thoracotomy. In five patients (4.6 %) the fluid ware cytologically positive. All five had adenocarcinoma (9 % of the 56 with adenocarcinoma). One case was free from P and PM factors, although others were complicated with those factors. All five died recurrence within 5 years, including one patient without lymph node metastasis.
Group B : From July 1984 to May 1992, of the 522 primary lung cancer patients who underwent thoracotomy, 78 had very little pleural fluid and cytological examination of pleural lavage was done. Fourteen had positive cytology.
In the j patients in group A, the 3-year survival rate was 40.0 %, and the 5-year survival rate was 0 %. In the 14 positive patients of Group B, it was 30.5 % and 0 % respectively. The difference in survival between the two groups was not signifiant. These survival rates are significantly lower than those of patients with stage I or II primary lung cancer (p<0.005), but are similar to those of patients with stage III or IV cancer. Thus, cytological positivity is associated with a worse prognosis irrespective of the presence of pleural effusion. The above findings should be considered in the planning of the staging and treatment of primary lung cancer.

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In recent years, the number of surgically treated patients with advanced lung cancer who require pre-and postoperative adjuvant therapy has been increasing, accompanied by an increase in the risk of postoperative bronchial fistula. Fistulas forming in the stump of the main bronchus after pneumonectomy are often fatal.
Since October 1991, we have attempted to prevent postoperative bronchial fistula by wrapping the stump with a pedicled pericardial flap containing the pericardiacophrenic artery (PCA), instead of using the conventional covering method. The usefulness of this method was analyzed, primarily in patients whose data after surgery were available.
Of the 17 patients in whom the bronchial stump was covered with a PCA-preserved pedicled flap, 16 were free of bronchial fistula. Minor leakage was observed at the bronchial stump in one patient 5 months after the operation.
These results indicate that fistula formation in the bronchial stump after pneumonectomy can be effectively prevented by overing the bronchial stump with a PCA-preserved pericardial flap, and that this method is particularly useful in high-risk patients who undergo surgery after induction therapy.

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We have treated 3 patients with Castleman's disease during the past 15 years. All three patients were asymptomatic, and the tumors were discovered during routine chest radiographic examination. The noninvasive tumors, which originated from the mediastinum near the hilus were removed without difficulty. The histopathological diagnosis was Castleman's disease, hyaline vascular type. The postoperative course has been uneventful, and there have been no recurrences of the tumor 15, 12 and 0.5 years after the operations. Complete removal of the tumor with extensive dissection of lymph nodes is necessary to prevent recurrence and/or malignant change of the tumor. Close follow-up examinations are important.

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A 62-year-old asymptomatic man was admitted to the hospital with an abnormal shadow on chest X-ray films, which was suspected to be a mediastinal mass. CT scan and MRI showed a cystic tumor at the left pulmonary hilum adjoining the aortic wall. A bronchogenic cyst was suspected, and the video assisted thoracoscopic surgery was performed. The cyst, 6x6x6 cm in size, was located at the left pulmonary hilum and was connected to the thoracic duct. It was easily removed by ligation and division of the thoracic duct. The fluid in the cyst was chylus. So the diagnosis was thoracic duct cyst. His postoperative course was uneventful.

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A 42-year-old female had been admitted to an other hospital because of pneumonia in 1984. An abnormal shadow had been pointed out on chest X ray film since 1988. Tumor size and pneumatic space on chest X ray film had enlarged every year. She was admitted to our hospital in July, 1995 and diagnosed with mediastinal teratoma perforating into the lung. Mediastinal tumor resection combined with left upper lobectomy was performed. The histological diagnosis was mature teratoma with pancreatic tissue. In the literature, mediastinal teratoma, perforating into an adjacent organ and observed for a long period, was mostly perforated into the lung or bronchus. We considered that mediastinal teratom a perforating into the lung or bronchus, was observed for a prolonged period because of moderate symptoms due to a good drainage of tumor content.

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A medical examination of a 52-year-old man revealed an abnormal shadow in the right upper lung field. He was thus admitted to our hospital. Chest CT scan revealed a solitary mass lesion (2 cm in size) in the S2 area with no contractile change or lymph node swelling. TV-brushing cytology showed no abnormal findings, and video-assisted partial resection of the right upper lobe was performed.
Histologically, the lesion was confirmed as cryptococcosis of the lung.
This case had no associated immuno-suppressive disorder (such as a malignant or a collagen disease) and no history of being a bird fancier. However, because he is a veterinarian, he was suspected of having had occupational exposure.
The postoperative course was smooth, and there has been no sign of recurrence even though no adjuvant chemotherapy was administered.

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A 72-year-old male was admitted to our hospital complaining of left back pain. The clinical diagnosis was primary lung cancer (cT4N1M0) in the left upper lobe. The cancer extended into the distal aortic arch. The patient underwent resection of the left upper lobe combined with en bloc resections of the left subclavian artery and distal aortic arch using a percutaneous cardiopulmonary support system (PCPS). The partial extracorporeal circulation was performed through the right femoral vein and artery with the blood flow rate 1.5-2.0 L/min. An ACT was controlled around 200 sec using PCPS circulation. The aortic clamp was placed between the distal side of the left carotid artery and descending aorta. The defect of the aortic wall was repaired with a Gelseal ® graft patch. The volume of bleeding during operation was about 2000 ml. The patients is doing well at 2 years postoperatively.
We conclude that PCPS is a safe and useful aid in pulmonary surgery with combined resection of the aorta.

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A case of catamenial pneumothorax with “blue berry spots” and perforation on the diaphragm is presented. A 46-year-old, married woman twice experienced right pneumothorax during the period from June to December on 1995. Each episode was apparently related to the onset of menstruation suggesting catamenial pneumothorax. Right thoracoscopy revealed the presence of multiple “blue berry spots” and several pinhole like perforations in the central tendon of the diaphragm and a small bulla on the right lower lobe. Partial resection of the diaphragm including these lesions and bullectomy were performed under VATS. The patient has been asymptomatic for 6 months after operation. Surgeons should be aware of the importance of carefully inspecting the diaphragm during operation.

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A 63-year-old man was admitted because of blunt chest trauma caused by being trapped between moving parts of a large machine. On admission, he complained of chest pain, but no dyspnea. A chest x-ray film showed meiastinal emphysema. A chest CT scan showed mediastinal emphysema and disruption of the mediatinal trachea. Disruption of the membranous portion of the trachea just above the carina was confirmed by bronchofiberscopy. Through a right thoracotomy, the tear (3.5 cm in length) was repaired with interrupted 5-0 polyglyconate monofilament sutures 3 days after the injury.
He had an uneventful postoperative course and was discharged on the 40th postoperative day. There is no tracheal stenosis 2 years after pepair.

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A fifty-year-old man (case 1) and a forty-five-year-old woman (case 2) were admitted with coin lesions in the lung fields. Both cases were asymptomatic, but the preoperative findings did not lead to a definitive diagnosis, and lung cancer could not be excluded. They underwent partial resection of the lung, and postoperative pathological diagnosis was pulmonary dirofilariasis in each case. Currently, to distinguish pulmonary dirofilariasis from other diseases with pulmonary coin lesions is difficult, and establishment of a non-invasive diagnostic method is desired.

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A case of the left traumatic diaphragmatic hernia treated by video-assisted thoracic surgery was experienced. A 21-year-old male was admitted to our hospital due to the thoracic and abdominal blunt trauma sustained in a traffic accident. Chest X-rays on admission revealed only a slight degree of left pneumothorax and the left 5th and 9th rib fractures. On the tenth hospital day, he underwent a gastrointestinal fiberscopy due to a persistent upper abdominal dull pain, followed by an appearance of an abnormal shadow at the left cardiophrenic angle on chest X-ray. The diagnosis of the left traumatic diaphragmatic hernia was established by radiological examinations.
Video-assisted thoracic surgery was performed for the reposition of the hernia on the thirteenth hospital day. A slight degree of bloody effusion, a part of the transverse colon, the greater omentum, the stomach and the spleen were found in the thoracic cavity. No injury was seen on those organs. Left diaphragm was found to be ruptured sagittally for about 9 cm in length, up to the splenic hilum posteriorly. Although the reposition of these organs but the spleen was feasible under the thoracoscopy, the combined mini-thoracotomy for approximately 5 cm in length was necessary to replace the spleen safely. The lacerated diaphragm was repaired by direct suture. The postoperative course was uneventful, and he was discharged from our hospital on the tenth postoperative day.
It was suggested to be possible to treat the traumatic diaphragmatic hernia with a thoracoscopic surgery when the injury or adhesion of herniated organs are not likely to be present, although the combined mini-thoracotomy was recommended in the case with the splenic herniation.

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A 47-year-old man was admitted because of a tumor shadow on chest X-ray films. Transbronchial lung biopsy specimen showed papillary proliferation of atypical cells. As lung cancer was strongly suspected, a right lower lobecotmy was performed. The histological diagnosis was pulmonary acinomycosis. Actinomycosis is a chronic infectious disease usually caused by Actinomyces israelii. The frequency of pulmonary actinomycosis has been reported to be very low since this disease is often very similar to lung cancer on pathological and radiological findings. As it is also difficult to take biopsy materials by bronchoscopic biopsy, the exact diagnosis of this disease is not easy. In conclusion, proliferation of lymphocytes in pathological findings of pulmonary mass region is suggestive of pulmonary actinomycosis.

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A 65-year-old male was admitted to our hospital because of bloody sputum. A chest X-ray showed fibrosis with emphysematous change and without a clear mass shadow. A chest CT showed a tumor shadow in the left lower lobe. Adenocarcinoma was diagnosed from sputum and transbronchial washing cytology.
Left lower lobectomy and R2 lymphnode dissection were performed. The tumor was located at S10 of left lower lobe and measured 25 × 20 mm. It was accompanied by metastatic nodules in the same lobe. Pathological staging was Ma by P-T3N2M0. Histologically, the tumor was composed of carcinomatous (well differentiated adenocarcinoma) and sarcomatous (proliferated spindle cell) elements, so the diagnosis was so-called carcinosarcoma. Immunohistochemically, the sarcomatous component was positively stained by epithelial membrane antigen (EMA), suggesting sarcomatous transformation of the carcinomatous component

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A case of hemothorax in a 15-year-old girl secondary to injury to the diaphragm caused by a rib deformity is reported. The patient has multiple osteochondroma inherited as an autosomal dominant disease. She was admitted with left chest pain. Deformity was also found in the scapulas. Roentgenograms showed pleural effusion, and a pleural tap revealed a hemothorax. Pneumothorax was not found. Thoracic computed tomographic (CT) scan demonstrated no clear reason for the hemothorax, so thoracoscopic examination was performed. In the pleural cavity, about 900 ml of bloody effusion and spicula of some ribe were found. Bleeding was due to injury of the diaphragm by spicula of the 7th rib arising from the costochondral joint. This part of the rib was resected under mini-thoracotomy, and the injured part of the diaphragm was sutured under direct view. Rescted specimen and clinical findings led to a diagnosis of hereditary multiple exostoses. Thoracoscopic examination was useful for definite diagnosis of the cause of hemothorax and source of bleeding.

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