We evaluated mediastinal lymph node metastasis and prognostic factors in ninety pN2 non-small cell lung cancers. The most frequent location of node metastasis associated with tumor affecting the upper lobe was the superior mediastinum (from rt. upper lobe ; 97.0 %, lt. upper lobe ; 63.2 %). The most common location of node metastasis associated with tumor affecting the lower lobe was subcarinal lymph node (from rt. lower lobe ; 75.9 %, lt. lower lobe ; 62.5 %). However, superior mediastinal metastasis was often found with tumor affecting the lower lobe (from rt. lower lobe ; 65.5 %, lt. lower lobe ; 50.0 %), and subcarinal lymph node metastasis was also found with tumor affecting the upper lobe (from rt. upper lobe ; 18.2 %, it. upper lobe ; 36.8 %) (distant node metastasis). The 5-year survival rate of all subjects except patients underwent absolute non-curative operation was 19.8 %. Because the distant node metastasis is found with considerable frequency, complete mediastinal dissection should be recommended as curative resection for non-small cell lung cancer. This study revealed that the presence of 5 or more metastatic mediastinal lymph nodes, cN2, pT3 and pT4 were the poor prognostic factors in the patients with pN2 lung cancer. Especially pN2 patients with pT4 or who concurrently have two or more poor prognostic factors should be excluded from the indication for curative operation.

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Using an ETA kit (ED046), we measured the changes in serum KL-6 levels in the early post-operative phase in 16 patients with or without lung resection.
In those with lung resection, serum KL-6 levels in the early post-operative phase decreased to 70% of the pre-operative values. Serum KL-6 levels of 9 patients with lung resection were signficantly lower than those of 7 patients without lung resection on the 7th post-operative day. These findings show that in patients with lung resection, the serum KL-6 level decreases.

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Twenty-nine patients with non-malignant neoplastic middle lobe syndrome were reviewed. There were 11 males and 18 females ranging from 23 to 85 years (mean, 59.6 years). The right middle lobe was involved in 27 patients and the lingula in 2 patients. Sixteen patients underwent surgical resection and 13 conservative therapies (resection ratio : 55 %). This disease was most common in patients aged between 50 and 60 years (66 %). All the patients between the ages of 40 and 50 underwent surgery, in contrast to none of the patients between 70 and 80. None of the patients without symptoms underwent surgery. The predominant bronchoscopic abnormalities, such as mucosal inflammation, edema, granulomatous change, and irregular narrowing, were found in 83 % of the patients. Seventeen percent of the patients had normal bronchoscopic findings. Each one case had the lesion originating from tuberculosis and extrinsic bronchial compression. The reasons why surgical procedures avoided included effective medical treatments (antibiotics for pneumonia in 10, bronchial artery embolization for hemoptysis in 2), high age and low pulmonary function in 5, and other similar lesion besides middle lobe in 2 patients. Surgical indication should be determined carefully according to the presenting symptoms and clinical course. Bronchial stenting and thoracoscopic approach should be considered.

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Twenty-eight men and two women, aged 47 to 84 years (mean age, 66.1 years), with roentgenographically occult lung cancer were identified by means of sputum cytology over the past 12 years. All patients had a significant history of smoking. All but one of the patients were diagnosed with squamous cell carcinoma by means of fiberoptic bronchoscopic procedures with biopsies. Surgical treatment was provided in 27 patients : 18 lobectomies, 7 sleeve lobectomies, one lobectomy + segmentectomy and one segmentectomy. Pathological TNM classification of these 27 patients was TisN₀M₀ in 7 patients, TiNoMo in 14 patients, T₁N₁M₀ in 3 patients, T₂ N₀M₀ in one and T₃N₀M₀ in one, T₃N₁M₀ in one. Four patients (13 %) developed a second airway cancer three lung cancers and one laryngeal cancer. Overall 5 year survival rate was 76.9% in all 30 patients and it was 94.1 % in 25 patients treated surgically excluding other death.
We conclude that sputum cytology should be used as a case-finding tool in heavy smokers and that operation is a reliable treatment for occult lung cancer.

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We compared patients undergoing video-assisted thoracoscopic surgery (VATS) and thoracotomy (OPEN) for spontaneous pneumothorax. (1) Surgical stress : Postoperative CPK, CRP, and WBC in the blood of VATS group were significantly lower than OPEN group, but plasma IL-6 levels in the two groups were equal. (2) Postoperative course : Duration of postoperative chest drainage and postoperative hospital stay of VATS group were significantly shorter than OPEN group. (3) Recurrence : The rate of postoperative recurrence of pneumothorax in VATS group was higher than in OPEN group. Collectively, VATS was almost equal to thoracotomy in surgical stress and was better than thoracotomy in the hospital stay and cosmesis, although VATS had a higher recurrence rate. These observations suggest that the indications for VATS do not apply to the aged pneumothorax patient and that new ways must be devised to reduce the recurrence rate.

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It has been reported that anastomotic complications of carino plasty occur at a high rate. In this study we aimed to prevent the complications, avoiding excessive tension and deformation of the anastomotic site.
The carino plasty by Grill's procedure often has separation or stenosis of the bronchial anastomosis to the side of the trachea. Then a continuous suture was employed instead of interrupted sutures so as not to induce excessive tension at a few sutures.
On the wedge carinal resection, when the membranous trachea is folded to compensate for disparity of the lumen, complications of anastomosis often developed.
Therefore the cartilaginous portion of the trachea was cut as a wedge-shaped piece to reduce the opening diameter.
In addition, telescopic anastomosis was carried out between the trachea and bronchus in both cases.
Anastomotic problems, such as granulation, stenosis and separation were not observed with bronchofiberscope after operation.

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A 63-year-old man had a right pneumonectomy for bronchogenic carcinoma. His pathological stage was T₁N₂M₀, Stage III A, squamous cell carcinoma.
Empyema with bronchial fistula developed on the 81st POD.
After 70 days of tube drainage, he underwent thoracoplastic surgery (modified operation of Wilms) and omentopexy. From the 60 th day after reoperation, the empyema cavity disappeared on computed-tomography of the chest, and the bronchial stump has been covered with normal bronchial mucosa bronchoscopically.
But he suddenly died of perforation of the ascending aorta on the 110 th day after the reoperation. We thought that the cause of perforation was injury by costal edge.
When using the modified operation of Wilms, we think that muscle covering of costal edge is necessary to avoid injury to the mediastinal organs by ribs.

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A 40-year-old woman was admitted to our hospital with an abnormal shadow on the chest X-ray film. Chest CT scan revealed four mass shadows in the right lung. The differential diagnosis could not be made by bronchoscopy, and therefore a surgical procedure was performed. There were two tumors each in right middle and lower lobes, and they were enuclated. The pathological findings were consistent with salivary gland pleomorphic adenoma. The tumors were considered to be lung metastasis of the pleomorphic adenoma, originating in salivary gland which was resected 25 years ago.

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The patient was a sixty-year-old man with lung cancer who underwent extended lymphadenectomy and lobectomy through a median sternotomy. The operation proceeded uneventfully. When lymphadenectomy along the left main bronchus was being performed, he suddenly developed bradycardia and hypotension. Soon cardiac arrest occurred. Fortunately he was resuscitated about 5 minutes after cardiac massage was started. Post-operatively, according to coronary angiography significant coronary artery stenosis was not found. However coronary artery showed severe stenosis after ergonovine injection. We suspect spastic angina to have been the primary cause of cardiac arrest.

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A-49-year old woman was referred due to dyspnea on exertion and wheezing. An irregular endobronchial tumor was noted in the membranous portion of the trachea. A chest CT showed no extratracheal tumor invasion and no mediastinal lymph node metastasis. We urgently employed Nd-YAG laser irradition, afterwhich operation was done. Circumferential resection of the 7 tracheal rings and end-to-end reconstruction were successfully performed. She is alive and well without recurrence 2 years later. Empey's index was decreased after the operation.

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Recurrent liposarcoma of the anterior mediastinum is very rare. We report here a case of recurrent liposarcoma arising in the anterior mediastinum. A 58-year-old woman was admitted to our hospital because of asymptomatic abnormal shadow on a chest X-ray. Radiographical examinations such as CT suggested a mediastinal tumor, and a procedure similar to extendedthymothymectomy was performed. The tumor weighed 340 g, and the histopathological diagnosis was thymolipoma. The patient was followed up for 3 years and 9 months, when an abnormal shadow was noted on a chest X-ray. CT and MRI revealed a recurrent mass in the anterior mediastinum. Wide resection was performed and the tumor was completely resected. The weight of the tumor was 600 g, and its histological diagnosis was liposarcoma, well-differentiated type. The general principle for treatment of primary liposarcoma is complete resection, and this should remain true for recurrent liposarcoma as long as resection is possible as in our case. Close follow-up by radiographic examination is also important.

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A case of surgical treatment for metastatic lung tumor from thymic carcinoid is reported.
A forty-five year old male underwent thymusthymonectomy combined with partial lung and phrenic nerve resection in August 1991. Pathological diagnosis was thymic atypical carcinoid. He received radiotherapy postoperatively. In August 1993 during the follow-up, a new nodular shadow in the right lung field was pointed out, 2.5×1.5 cm in size. A suspicion of metastatic lung tumor from thymic carcinoid and also positive bone scintigraphy prompted a trial of systemic chemotherapy rather than operation at that time. VP-16 was started by per os every two weeks (50 mg/day). No remarkable change in the nodular shadow was noted until November 1994. In February 1995, a new infiltrating shadow in the lower lung field was complicated. Enlargement of the mass shadow, 3.0×2.0 cm in size, and consolidation of segment 8 were shown in August 1995. He was admitted for further examination and proper treatment in October 1995. Brochofiberscopic findings on admission showed a polypoid lesion which obstructed the orifice of B8 b. Biopsy specimens were obtained under a brochofiberscope, however a pathological diagnosis could not be made because the tissues were necrotic. Right lower lobectomy and mediastinal node dissection were conducted on November 7 th. Pathological diagnosis was metastatic atypical carcinoid.

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Although it is rare to see mediastinal abscess today, because of the variety of effective chemotherapic agents available, mediastinal abscess is known to be mostly fatal when it occurs. Recently, we have treated seven patients with mediastinal abscess, five due to odontgenic or cervical infections and the other two following trauma. The success of the treatment depends on an accurate as well as prompt diagnosis of this condition. Chest CT-scan is the most useful method for early diagnosis as well as the exact distribution of mediastinal abscess. Continuous negative pressure drainage of the mediastinum should immediately be implemented as soon as the diagnosis is made. Postoperative course was uneventful, and all our patients were cured and discharged after one to four months of hospitalization.

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Extralobar sequestration located in the anterior mediastinum is a rare disease. Here we report a resected case of extralobar sequestration located in the anterior mediastinum.
A 16-year-old woman was admitted to our hospital with an abnormal shadow in the left middle lung field on chest X-ray film. Chest CT and MRI demonstrated a mass lesion in the left anterior mediastinum. Aortogram and pulmonary arteriogram showed no aberrant artery feeding the mass. Mediastinal tumor or pulmonary sequestration was suspected. Left thoracotomy was performed on August 15th, 1996. The mass exsisted between the anterior mediastinum and left upper lobe S3, and had a stalk connected to the hilum. The stalk contained branches of pulmonary artery, pulmonary vein, and bronchial artery. The resected mass consisted mainly of cystic lesions and had no connection with the bronchus, and was diagnosed pathologicaly as extralobar pulmonary sequestration.

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We report five rare cases of gastric cancer with resected pulmonary metastatic lesions. Their primary and metastatic lesions were compared for clinical pathological findings, and for immunohistochemical findings of expression of the carbohydrate antigens, SLX and CA19-9. Based on the mode of metastasis, three of the five cases were considered to be able to have further resection of recurrent pulmonary metastatic lesions. These three cases appeared to have a tendency to form metastatic nests preferentially in the lung, and shared common features such as pathologically differentiated (intestinal type) metastatic lesions and the positive expression of CA19-9. Of these three cases, one has survived for more than 5 years with weaker SLX expression in the metastatic site than in the primary. The present cases suggest the possibility that the carbohydrate antigens of gastric cancer may play a role in the formation of pulmonary nodular lesions due to metastasis of gastric cancer and in patient's prognosis.

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A 62-year-old man was treated for pulmonary tuberculosis. Chest X-ray showed a mass shadow in the left upper lung field and percutaneous lung biopsy revealed pulmonary carcinoma. Partial resection of the left upper lung was performed. Pathological examination of the resected lung showed pulmonary carcinoma accompanied by active pulmonary tuberculosis.
In general, elderly patients with pulmonary tuberculosis are more likely to have pulmonary carcinoma. Sputum test, chest X-ray, and chest CT examinations should be made periodically to detect any change in tuberculosis. In case of any suspected changes, an approach such as transbronchial or percutaneus lung biopsy should be adopted for early detection of pulmonary carcinoma.

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Two cases of pulmonary thromboembolism after lung resection were reported. In the first case, a third lung resection was performed upon a 56-year-old female for a metastatic pulmonary adenocarcinoma originating from breast cancer. On the third postoperative day, she suddenly developed syncope followed by dyspnea and low blood pressure (74 mmHg) after micturition. In the 2nd case, a right panpleuropneumonectomy was performed upon a 55-year-old female for a primary lung cancer with a pT4N2M0 adenocarcinoma. On the 5th postoperative day, she suddenly had a dyspnea and was in a state of shock. In both cases, acute pulmonary embolism was diagnosed by emergent pulmonary angiography. Afterward, tissue plasminogen activator (t-PA) was immediately injected into the pulmonary artery. Hemodynamics improved 4 hours later in case 2 and 5 days later in case 1. But low blood pressure caused by bleeding in the operated thorax developed 2 hours after injection of t-PA in case 1 and 4 hours in case 2.
Deep venous thrombosis in the lower limbs was comfirmed by venography in both cases. A Greenfield vena caval filter was placed in the 2nd patient, who received right panpleuropneumonectomy.

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