The most important end point in the evaluation of lung cancer surgery is “survival”. However, there is no uniform and acceptable definition of “death from other diseases” in Japan in the calculation of survival rates.
An investigation of cases we treated indicated that more than half the deaths attributable to other diseases occurred within 2 years of surgery, that mortality by other diseases was significantly higher in those who underwent multiple organ resection and in those in stage Mb. Furthermore, respiratory diseases which are not ranked highas a cause of death in Japanese people accounted for a much higher proportion in those whose cause of death was assessed as attributable to other diseases. Those results suggest that the primary disease and subsequent surgery are somewhat related to “death from other diseases”. When death from other diseases is included in the calculation of survival rate of those who underwent surgery, there was a significant difference in the result. Accordingly, for a reliable assessment of the lung cancer surgery as well as for an objective comparison of results with those of other reports, it is considered necessary to calculate survival rates with reference to all deaths including surgery-related deaths and deaths from other diseases.

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Nine resected cases of primary benign bone tumors and tumor-like lesions of the rib (3 fibrous dysplasia, 2 non-ossifying fibroma, 1 eosinophilic granuloma, 1 osteoid osteoma, 1 solitary bone cyst, 1 osteochondroma) were reported. Seven cases were males and 2 females, and the average age of the patients was 35.8 years, higher than that of usual benign bone tumor. Stamp cytology and frozen section did not lead to a correct diagnosis, but a plain roentgeno-gram was likely to be useful for the differential diagnosis instead. All cases were treated by simple partial resection of the affected ribs and had no recurrence.

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Between January 1980 and April 1995, 1141 patients with primary lung cancer underwent surgical resection of the lung in our institution. In this study, we retrospectibely reviewed 106 patients among them with primary lung cancer of the right or left upper lobe, who had complete mediastinal dissection (R2a or R2b) and were diagnosed to have pN2-stage IIIA. The primary lesion was located in the right lung in 54 patients, and left in 52 patients. The nodal involvement at various lymph node sites was evaluated. The involvement of #4 and #3 node was observed more on the right side, while #5 and #6 nodal involvement was observed more on the left side. #7-#9 nodal involvement was rare, and it occurred in 16 cases (15.1%) in the site #7, 2 cases (1.8%) in #8, and 1 case (0.9%) in #9. We classified the 106 patients into the two groups, 16 with #7, #8 or#9 node positive cases, and 90 with #7. #8 and #9 node negative cases, and compared the clinical profile and prognosis of the groups. The five year survial rates of patients with pN2-STAGE IIIA upper lobe primary lung cancer were 12.7% in #7-#9 node positive cases and 37.1% in #7-#9 node negative cases, respectibely. The survival rate of #7-#9 node positive patients was significantly poorer than that of #7-#9 node negative patients. We conclude that subcarinal and inferior mediastibnal lymph node dissection is not necessary to improve the prognosis in patients with pN2-stage IIIA upper lobe primary lung cancer, but is essential in evaluating the accurate staging of the disease.

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To investigate the effectiveness of interpleural analgesia (IPA) in the management of post-thoracotomy pain, we compared the epidural anesthetic group with the epidural anesthetic and IPA combination group. We divided 33 post-thoracotomy patients into two groups. Epidural anesthetic was administered to one group of the patients (Epi group), and epidural anesthetic and IPA were combined in the other group (IPA group). Buprenorphine hydrochloride was used as the epidural anesthetic agent. A double lumen chest tube was used as an indwelling drainage tube, and 20 ml of 0.25% bupivacaine was injected into the pleural cavity through the double lumen chest tube in the IPA group. Pain was assessed by visual analog scale (VAS) and the Prince Henry pain score (PH). The concentration of plasma bupivacaine was measured before and after Epi/IPA administration.
The severity of pain was significantly milder in the IPA group than the Epi group. The concentration of plasma bupivacaine started to increase soon after IPA administration, after reaching a maximum in one hour (0.95 ± 0.21, μ/ml), it gradually decreased, and did not reach a toxic level.
These findings suggested that epidural anesthetic and IPA combination was an easy and effective way to manage of post-thoracotomy pain.

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We studied postoperative changes in atrial natriuretic peptide (ANP), renin-angiotensinaldosterone system and angiotensin converting enzyme (ACE) activity after pulmonary resection for lung cancer. ANP increased significantly immediately after operation. Also plasma renin activity (PRA) and angiotensin I (ANG I) increased significantly after operation, but angiotensin II (ANG II) did not increase. Aldosterone (ALD) increased transitorily immediately after operation but thereafter decreased. ACE activity decreased significantly due to reduction of pulmonary vascular bed by lung resection. We estimated that it was the cause of decrease of ALD. After pulmonary resection two contrary endocrine environments existed : ANP increased due to atrial loading whereas PRA increased too. Therefore body fluid should be managed under the dry side and use of catecholamine for support of cardiac function and maintaining renal perfusion should be considered after pulmonary resection.

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Empyema with destroyed lung requires pleuropneumonectomy. This procedure has, however, been reported to be associated with high mortality. We herein report four patients receiving pleuropneumonectomy for tuberculous empyema between January 1992 and December 1996. All patients received antituberculosis chemotherapy before surgery. Operating time was between 469 and 648 minutes and intraoperative hemorrhage was between 1492 and 3446 ml. One patient underwent re-exploration for chylothorax on the 25th postoperative day. Vital capacity and forced expiratory volume in one second tended to decrease from 1.76±0.5 to 1.35±0.2l and from 1.31±0.4 to 1.02±0.29 l, respectively. However, there were no significant differences in arterial blood gases between preoperative values (PaO² 75.9±7.0 Torr, PaCO² 45.3±7.9 Torr) and postoperative values (PaO² 79.4±11.3 Torr, PaCO² 43.5±5.8 Torr). Neither hospital death nor recurrence of empyema has been detected so far. We conclude that pleuropneumonectomy is an effective and safe surgical procedure for properly selected patients with tuberculous empyema and destroyed lung.

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The expression of the carbohydrate antigens, SLX and CA19-9, in resected pulmonary metastases and their primary colorectal cancers was examined immunohistochemically in 20 cases. The antigens were expressed similarly in pulmonary metastatic lesions and in primary colorectal lesions. Patients with expressed SLX had a significantly lower cumulative survival rate than those without SLX expression. The intensity of CA19-9 expression correlated with the number of pulmonary metastatic nodules. Patients with 4 or less metastatic nodules showed a sigingficantly better cumulative survival rate than those with 5 or more metastatic nodules. At the primary site, all cases of colon cancer and 60% of rectal cencer ceses expressed either SLX or CA19-9, or both. These results suggest that the expression of carbohydrate antigens correlates with the pulmonary metastases of colorectal cancers and patient prognosis.

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7 cases with primary pulmonary malignant fibrous histiocytoma were treated in the past 11 years. The patient were 4 males and 3 females, with a mean age of 57.1 years. 6 patients complained of cough and hemoptysis and 1 patient complained of fever. Chest X-ray films showed left total atelectasis in one case, intrapulmonary masses shadow in six cases. Bronchoscopy revealed a mass in left main bronchus in one case and lumen stricture in left lower lobe in another case. Results of biopsy and cytology were both negative. Altogether 7 cases were diagnosed as pulmonary malignant disease for surgical treatment and underwent lobectomy and dissection of mediastinal lymph nodes, including 2 cases of resection of right upper and middle lobes, one case of resection of right upper lobe, one case of resection of right lower lobe, one case of resection of right lower lobe with partial diaphragm and partial liver, one case of left pneumonectomy, and one case of resection of left lower lobe along with part of pericardium. 6 cases died in the interval of 3 to 18 months postoperatively, one patient recurred in the tenth month after right lower lobectomy. Radiotherapy was very helpful for the treatment. The patient has no evidence of recurrence and metastasis. and is still alive.

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We report a 47-year-old female with a 3-year history of hyperthyroidism who was hospitalized with pneumonia. CT scan on admission revealed a solid mass in the anterior mediastinum. We performed complete resection of the tumor including adjacent adipose tissue through a median sternotomy. Histopathological examinaiton showed thymolipoma. Thymolipoma associated with hyperthyroidism is very rare and only 3 cases have been reported in the literature. The first case was reported by Corning Benton in 1966. The second and third cases were associated with myasthenia gravis as well as hyperthyroidism. Our report, therefore, is the second case of the tumor with Graves' disease only. The patient's condition improved transiently after removal of the tumor. This explains the coincidence of thymolipoma and Graves' disease in the present case.

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Primary lung cancer rarely shows a cystic pattern, but we treated large cell carcinoma that showed a cystic and solid pattern on chset CT. A 45-year-female was admitted to our hospital, complaining of hemosputum. Her chest X-rays showed a homogenous mass shadow which was well-defined and 50×45 mm in size in the left lower lobe. Her chest CT showed a cystic and solid pattern in the left S¹⁰. The specimen, which was taken by transbronchial biospy, showed necrosis. Aspiration biopsy cytology of the mass during the exploratory thoracotomy revealed largel cell carcinoma, and left lower lobectomy was performed. Resected specimen showed cavity formation which consisted of viable cancer cell at solid part of the mass with massive necrosis.
Histological examination suggested that the cystic and solid mass shown on chest CT was produced by occlusion of the bronchus involved by the tumor and tumor necrosis.

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A 72-year-old woman was admitted to our hospital for further examination of abnormal shadow on chest X-ray. Chest CT showed a mediastinal cyst with tumorous portion. Venography showed that the left brachiocephalic vein was coursed around the cyst and into the lower part of superior vena cava. Thallium scintigraphy showed a positive sign on the tumorous portion. The tumor was resected and was found to be composed thymic cyst with thymic cancer. This case suggests that malignant tumor can arise from a benign thymic cyst.

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We report a case of lung cryptococcosis in a post-renal transplant patient. Thoracoscopic operation was very beneficial for making a diagnosis and treatment in this case.
A 49-year-old man, who had received a renal transplant two years previously and was being given immunosuppressive agents, was admitted to our hospital because of a chest abnormal shadow. No remarkable physical findings were found except for the abdominal operaion scar of the renal transplant. The values of laboratory data were unremarkable. Chest rentogenogram showed a well-defined nodular shadow in the right middle lung field. CT scan demonstrated a well-defined mass, about 3 cm in diameter, in the peripheral region of rt. S². The definite diagnosis could not be obtained by fiberoptic bronchoscopy and other examinations. The immunosuppressive agents were administered just before the operation. Thoracoscopic tumor resection was performed and we made a diagnosis of cryptococcosis by its frozen section. After operation he was administered fiuconazole. The postoperative course was uneventful, with a hospital discharge on day 10. The blood cyclosporine level varied within the therapeutic range. Pathologically the surgical specimen showed the tumor consisting of necrotic tissue surrounding with infiltration of lymphocytes, and numerous capules appearing as an unstained halo. Many capsules were seen as a clear space with the Grocott's staining.
It was very beneficial for immunocompromised patients after renal transplantation to undergo thoracoscopic operation for diagnosis and treatment of lung nodular shadows.

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A 72-year-old man who underwent thoracoscopic volume reduction surgery for pulmonary emphysema developed severe irreversible pulmonary hypertension after surgery. The patient's preoperative pulmonary function tests revealed a forced expiratory volume in 1 second of 480 ml (50.0% of predicted). The forced expiratory volume was 960 ml (45.4% of predicted). Total lung capacity was 5600 mL and the residual volume was 4350 mL. The patient's partial pressure of oxygen (PO₂) in the arterial blood was 67 mmHg on 2L/min of nasal oxygen. The partial pressure of carbon dioxide pressure (PCO₂) was 38 mmHg. Cardiac catheterization revealed a cardiac output of 4.32 L/min. The pulmonary arterial pressure was 57/32 (38) mmHg, and the pulmonary vascular resistance was 429 dynes·sec/cm^-5m². The pulmonary arterial pressure and resistance increased postoperatively to 71/27 (50) mmHg 520 dynes·sec/ cm^-5m², respectively. The pulmonary hypertension persisted until the patient's death, despite administration of dobutamine, alprostadil, and amrinone. We conclude that the presence of moderate pulmonary hypertension in a patient with pulmonary emphysema is a contraindication for volume reduction surgery.

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A 66-year-old man was hospitalized with weakness in the right lower extremity. Chest X-ray and CT scan revealed a large mass on the left upper lobe, and a solitary metastatic tumor was concomitantly found on the left parietal lobe by cranial CT. Resection of the brain metastasis, showed choriocarcinoma histologically. The patient had no abnomarity in his testis. After two courses of chemotherapy, the level of human chorionic gonadotropin (βHCG) in his plasma and urine were decreased. Left upper lobectomy with lymph node disection and chest wall resection was performed. However, the patient died 6 months after surgery from spinal, brain and pulmonary metastases. Pulmonary choriocarcinoma in the male is a rare tumor and only 5 cases have been reported in the Japanese literature.

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A case of giant schwannoma with a low blood coagulation factor XIII activity was reported.
A 58 year-old-female was admitted to our hospital complaining of exertional dyspnea. Her blood coagulation factor XIII activity was less than 40% of standard plasma level. Chest roentogenogram and CT-scan demonstrated a chest wall tumor with pleural effusion in the right hemithorax. Thoracotomy was performed through the 5th intercostal space. Coagulation factor XIII concentrates were administrated intravenously for intrathoracic bleeding associated with a low coagulation factor XIII activity. Resected tumor was 19.5×14.5×13 cm in size and 1760 g in weight, and was microscopically diagnosed as a schwannoma originating from the intercostal nerve. Her blood coagulation factor XIII acitivity gradually increased after the operation.

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A 62-year-old man was referred to our hospital for evaluation of dysphagia. Bronchoscopy revealed squamous cell carcinoma bulging from the membranous portion of the upper trachea. Paralysis of the left vocal cord resulting from involvement of the recurrent laryngeal nerve was observed. Computed tomographic scan further showed its extention to esophagus and left lobe of thyroid. Subtotal resection of trachea combined with total laryngoesophagectomy and left lobectomy of the thyroid was performed. According to Grillo's procedure, anterior mediasinal tracheostomy at the 4th ring from the carina was made. To avoid massive hemorrhages from the aorta and/or superior vena cava, major pectral musclar and pedicled omental flap from the gastric tube were laid over the tracheal stoma. On the 24th post operative day, infection around the stoma caused its stricture. A silicone tube designed for the indivisual patient, therefore, has been applied to for maintain the patency of the stoma up to the present. The patient's quality of life was adequately compensated using an electronic artifical larynx.

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A case of eosinophilic granuloma that originated in the rib was treated by resection under video-assisted thoracic surgery. A 59-year-old man complained of chest pain on the right side. Osteolysis of the right fourth rib was seen in X-ray films, and chest computed tomograms showed a tumor with osteolysis of the rib. The diagnosis was a primary rib tumor. A posterolateral skin incision about half the usual length was enough to expose the tumor. Video monitoring through a thoracoscope of the pleural cavity was safe and helpful in resection of the tumor together with part of the chest wall, and the operation was less invasive than it would have been without such monitoring. The pathological diagnosis was eosinophilic granuloma, which rarely originates in the ribs. In the treatment of eosinophilic granuloma of the ribs, surgical resection is often undertaken, but careful follow-up is necessary for identification of new lesions in other organs.

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A 25-year-old male patient with a primary mediastinal non-seminomatous germ cell tumor producing α-fetoprotein (AFP) is described. The patient initially experienced chest pain. A chest x-ray film and chest CT revealed a large tumor in the anterior mediastinum and left lung field. Preoperatively three courses of cis-platin-based combination chemotherapy were administered. The serum α-fetoprotein level decreased rapidly to a normal level, and the tumor was completely resected after the patient's serum α-fetoprotein level fell within the normal range. Five days were required for weaning of the patient from a respirator. Thereafter, his clinical course was normal. Postoperatively a single course of cis-platin-based combination chemotherapy was administered. As the observation time has been only two years, we not make definitive conclusion regarding the treatment modality. However, we feel that an adjuvant surgery should be performed after the normalization of serum AFP level by chemotherapy.
He continues to be active in society two years after the surgery and no recurrence of the tumor has been detected.

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