There were 2, 632 lung cancer patients who underwent pulmonary resection during the period from 1953 to 1995. In the patients, 578 (22%) underwent non-curative resection (relatively non-curative 221, absolutely non-curative 357). Of the 578 patients, we examined clinico-pathological features of 56 patients (9.7%) who survived for over 5 years after operation (Group A), and compared the patients with all the 578 patients who underwent non-curative resection (Group B).
In the 56 patients (Group A), diagnostic criteria of 18 patients who underwent absolutely non-curative resection were residual carcinoma on bronchial stump in 9 patients, malignant pleural effusion in 5, pleural dissemination in 2 and residual carcinoma on surgical margin in 2 patients. Diagnostic criteria of 38 patients who underwent relatively non-curative resection were lobectomy and R1 dissection in 9 patients, partial resection·segmentectomy·lobectomy and RO dissection in 21, R2b dissection and metastasis to the 2b level lymph nodes in 8 patients. Combined resected organs were pericardium, chest wall, left atrium, or parietal pleura, and there was no case whose tumor invaded large vessels, diaphragm and esophagus. There were significantly lower ratio of T3·T4 disease, and significantly lower ratio of N2 disease in Group A compared with in Group B. Most of the long-term survivals in Group A were at relatively earlier stage in Group B. Some of patients who underwent relatively non-curative resection were cases whose tumor were resected completely by partial resection·segmentectomy or R0 ·RI dissection.

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T1-201 scintigraphy and Ga-67 scintigraphy were performed in 130 cases of lung cancer and 31 cases of benign lung tumor preoperatively.
Sensitivity of T1-201 scintigraphy was 66.9% for lung cancer, although sensitivity of Ga-67 scintigraphy was 56.2%.
Specificity of T1-201 scintigraphy was 83.9% for lung cancer, although specificity of Ga-67 scintigraphy was 80.6% for lung cancer.
T1-201 scintigraphy is considered to be a more useful preoperative examination for lung cancer than Ga-67 scintigraphy.
But we must be careful to consider false positives in the case of benign inflammable large tumor.

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To treat lung cancer in patients with idiopathic interstitial pneumonia (IIP), special consideration is required to avoid the occurrence of postoperative exacerbation of IIP. We investigated the clinicopathological features and problems of intraoperative and postoperative management. Eight patients with primary lung cancer complicated with idiopathic interstitial pneumonia underwent surgical resection. Seven cases were males and one case was female. Ages ranged from 63 to 77 years. First case died due to acute exacerbation of IIP on the 39th postsurgery day. After the second case, we tried to keep the PaO₂ about 80100 mmHg during or after surgery, and 5 cases were alleviated with low-dose steroid during or after surgery, with these cases not developing exacerbation of IIP. After discharge from the hospital, 3 cases developed acute exacerbation of IIP within two months, with these cases finally dying of respiratory failure within 6 months postoperatively. Recently 3 cases administered oral erythromycin after the operation, did not develop exacerbation after discharge from the hospital.
From these results, it was suggested that low-dose O₂ and steroid administration during or after surgery for 3 days, erythromycin before the operation and continued after the surgery were very effective to avoid postoperative exacerbation of IIP.

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The aim of this study was to determine whether a 2-day antibiotic prophylaxis regimen with a second-generation cephalosporin was effective in pulmonary operations for malignancies. We enrolled 61 consecutive patients who underwent elective thoracic surgery for lung cancer (n = 55) or metastatic lung tumors (n= 6). All the patients were given flomoxef (1.0 gm intravenously) at the time of anesthetic induction. Patients in group 1 (n= 31) were given flomoxef intravenously every 8 hours for a total of 8 times for 3 days immediately after ICU arrival. Patients in group 2 (n=30) were given flomoxef intravenously every 8 hours for a total of 5 times for 2 days immediately after ICU arrival. Thirteen of 31 patients received 3-day antibiotic prophylaxis in group 1 and 29 of 30 patients received 2-day antibiotic prophylaxis in group 2. Antibiotics were altered in 1 patient in each group and the duration of antibiotic administration became longer than the planned duration in the same patients. No significant difference was seen in duration of fever more than 38°C after surgery between the two groups. Wound infection was seen in 1 patient in each group. Empyema, death within 30 days after operation, and hospital death were not seen in either group. On day 7 and day 14 after operation, white blood cell counts and plasma CRP levels showed no significant differences between the two groups. These results suggest that 2-day antibiotic prophylaxis with a second-generation cephalosporin is of benefit for wound and other infections in pulmonary operations for malignancies.

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We examined the rate and clinical features of recurrence following video-assisted thoracoscopic surgery for spontaneous pneumothorax and its prevention. From March 1992 to March 1997, we treated 140 patients with spontaneous pneumothorax by video-assisted thoracoscopic surgery. Nine patients suffered recurrence of pneumothorax. Six of these nine underwent reoperation. The previous staple line was on the bulla in three of the six patients. This suggested that incomplete wedge resection of the bulla was the cause of recurrence. In two patients, an overlooked bulla or new bulla was the cause of recurrence. The recurrence rate was 15% in the first period, but decreased to 3 % in the second period. The rate of postoperative air leakage was lower in the second than in the first period, indicating operative learning effects, and the recurrence rate was lower in patients without postoperative air leakage. We conclude that postoperative recurrence can be decreased by adequate learning of operative methods. In addition, the recurrence rate was lower for patients treated by pleural abrasion, suggesting that this method is useful for the prevention of recurrence of pneumothorax.

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We examined 308 Japanese patients with lung cancer for mutations at codon 12 and 13 of the K-ras gene by a polymerase chain reaction-sequence specific oligonucleotide probe hybridization assay. Twenty-five (8.1%) had mutations of the K-ras gene and all of them were smokers or ex-smokers. There were no significant differences between wild type cases and mutant type cases of histological differentiation, TNM classification or pathological stage. The most frequently identified mutational spectrum was G to T transversion (22/25, 88%) resulting in the substitution of the amino acid glycine for cysteine. It was considered that mutation in the K-ras gene in lung cancer patients is associated with smoking.

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Investigation of the late complications correlated with the utilization of pledgets and nonabsorbable sutures was performed in lung cancer patients who underwent surgical resection. To reinforce the mechanical closure of bronchial stumps, teflon pledgets or absorbable pledgets were applied in 61 and 82 cases, respectively. Among those patients, 18 developed postoperative symptoms and was considered to be the indication for bronchofiber examination. Of examined eleven cases with teflon pledgets, migration of them into the bronchial lumen was observed in 4 patients, and bronchial stump aspergillosis (BSA) was found in 2. Of the other seven cases with absorbable pledgets, a pledget was temporarily appeared endobronchially in one case.
From these results, a combination of pledgets and non-absorbable sutures should not be employed to close the bronchial stump because the endobronchial pledgets cause late complications such as BSA and hemosputa.

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We experienced a rare case of squamous cell carcinoma (SCC) arising in chronic empyema cavity. The patient was a 55-year-old male who had the long interval of 19 years between development of empyema and onset of carcinoma with draining cutaneous fistula. The origin of SCC was supposed to be mesothelial metaplasia of empyema cavity, and the type of tumor findings was scattered foci.
In a review of the literature, we found 14 cases of SCC arising in chronic empyema cavity in Japan and concluded the following. 1) The mean age was 63 years, ranging between 42 and 84, and 13 of the 14 cases were male. 2) The mean period between first appearance of empyema and detection of malignancy was 31 years (from 8 to 57 years) and 10 of the 14 had bronchial and/or cutaneous fistula. 3) Two types of tumor findings (mass formation and scattered foci) were observed in 6 cases each.

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Pulmonary lymphangioleiomyomatosis (LAM) is a rare disease of atypical smooth muscle proliferation that affects women of childbearing age. We diagnosed 3 cases of LAM by lung biopsy with video-assisted thoracoscopic surgery (VATS). The first case was treated with VATS for recurrent pneumothorax, but two years later symptoms of the disorder developed. In the other two cases, VATS was used for the diagnosis. All cases had distinctive findings from chest CT scan and pathological study. In one case of immunohistochemical stain for estrogen receptor was positive. This one case has received progesterone therapy. We conclude that VATS is useful for the diagnosis of LAM and lung biopsy with VATS is necessary for recurrent pneumothorax of childbearing aged woman.

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We present a 70-year-old man with squamous cell carcinoma, receiving operation of left pneumonectomy with concomitant resection of the aortic wall. Chest magnetic resonance imaging (MRI) indicated invasion of the tumor into the wall of the descending aorta unlikely findings showed by chest computed tomogram (CT). Partial resection of the aortic wall, 6×4cm, in size, which enabled complete resection of the lung cancer, was repaired with patch of prosthesis, under a partial cardiopulmonary bypass with heparin coating circuit. MRI provide a key for diagnosis of invasion to the aorta and cardiopulmonary bypass with a heparin coating circuit for the aortic resection avoided high dose heparin during the operation for a lung cancer.

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Recurrent desmoid tumor was recognized in the left thoracoabdominal wall of a 44-year-old male by physical examination. The CT scan demonstrated that the desmoid tumor was clearly demarcated from subcutaneous fat but not from adjacent muscles. The desmoid tumor was slightly hyperintense on T2-weighted MRI to the adjacent muscles and thus, sharply demarcated from muscles. The coronal and sagittal views of MRI clearly showed the cranial and caudal extension of the tumor. The tumor was completely resected with a 5 cm surgical margin and reconstructed with the right rectus abdominal muscle-skin flap. The patient is doing well without recurrence 27 months after the third operation.
MRI is a useful method for preoperative evaluation of the local invasion of desmoid tumor.

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A 73-year-old woman underwent a left lower lobectomy with R2b lymph node dissection for left lung cancer. Early postoperative course was uneventful, however she developed chest discomfort with tachycardia on the 6th day after operation. Pulmonary embolism was suspected by an electrocardiogram. Emergent lung perfusion scintigraphy confirmed the diagnosis of pulmonary embolism. Anticoagulant therapy of urokinase was immediately administered and the patient symptom was temporarily improved, although the attacks of pulmonary embolism recurred two times. On the 12th day after the lung operation, we inserted a vena caval filter into the inferior vena cava just below the renal vein for the prevention of pulmonary embolus. The clinical course after the insertion of the filter was uneventful during one year without any recurrence of pulmonary embolism.

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A 41-year-old man complained of cough, back pain, and fever. Chest X-ray and computed tomographic (CT) scan showed enlargement of mediastinal shadow, bilateral pleural effusions, and pericardial effusion. He was diagnosed with mediastinitis and referred to our department. Then, through a right thoracotomy, debridement and drainage were performed. After operation, in spite of drainage and administration of antibiotics, fever continued. On hospital day 10, therefore, we started mediastinal lavage. After lavage, culture of the drain fluid became negative, and he was discharged on hospital day 63. Descending necrotizing mediastinitis is a rare and lethal disease. CT scan is useful for early diagnosis, and aggressive and adequate drainage is required. In our experience, aggressive mediastinal drainage by a thoracotomy approach and mediastinal lavage are recommended.

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Castleman's disease in the chest wall is relatively rare. A forty-two-year-old woman visited our hospital with a complaint of bloody sputum. Chest X-ray film and bronchofiberscopy were normal. However, chest CT scan showed a right precordial tumor and dynamic CT scan showed enhancement of the tumor in early phase. Chest magnetic resonance imaging showed a low intense tumor near the chest wall in the precordia (T1-weighted MRI). Further, in T2-weighted MRI, the tumor showed a high intensity similar to that found in fatty tissues. We performed a thoracoscopic resection. A hard tumor covered by the parietal pleura was discovered protruding into the thoracic cavity. We believed the tumor originated from the chest wall because it was located outside the right internal thoracic artery. Microscopic findings of the tumor revealed hyperplasia of lymphatic follicles and growth of vessels in and between the follicles. Histopathologically, the tumor was diagnosed as the hyaline vascular type of Castleman's disease. The patient recovered uneventfully and was discharged 6 days after surgery.

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Two cases of mediastinal parathyroid cyst were described. Case 1.-A 32-year-old woman was admitted to our hospital for a right upper mediastinal shadow on the chest X ray film. The serum calcium level was high on her admission. A CT scan of the chest revealed a homogenous water density mass in the superior mediastinum. As a thymic cyst was suspected, the cyst was removed through a median sternotomy, together with the thymus. It was connected with the thymus, but there was no connection with the thyroid gland. Histological diagnosis was the cystic degeneration of the aberrant parathyroid adenoma of the thymus. Both serum calcium and PTH levels after operation returned to normal limits. It was considered a functional aberrant parathyroid cyst. Case 2.-A 62-year-old woman complained of facial edema. As the cyst was palpable at the lower anterior neck, a percutaneous cyst aspiration by a fine needle was performed. As PTH level in the content fluid was high, we could diagnose this case as parathyroid cyst preoperatively. The cyst was removed by transcervical approach and the parathyroid gland was histologically recognized in the cyst wall. It was considered a nonfunctional parathyroid cyst.

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This patient is a 39-year-old woman. She had complaints of a slight fever and cough, and an abnormal shadow was detected on chest X-ray by her home doctor. So, she was admitted to our hospital.
CT scan and MRI revealed tumor shadow about 2 cm in diameter involving the right intermediate bronchial trunk and atelectasis of middle and lower lobes due to this tumor, but it was difficult to diagnose by bronchoscopic finding and biopsy.
Right middle and lower lobectomy was performed for a diagnosis of intrabronchial tumor. Macroscopic finding revealed a smooth, yellow-white colored tumor originating from the right middle lobe bronchus, and this tumor was protruded into the right intermediate bronchial trunk. The tumor was diagnosed pathologically as bronchial mucous gland adenoma, and this patient is alive one and a half years after surgery without any evidence of recurrence.

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We describe a case of Pancoast tumor which was treated with initial chemotherapy followed by surgical resection. A 68-year-old man presented with a lung tumor at the apex of right lung. Initially, the patient was treated with two courses of chemotherapy including docetaxel and cisplatin. However, the tumor of the apex remained the same size after the chemotherapy. Hence, we performed right upper and middle lobectomy combined with chest wall resection. The postoperative course was satisfactory. We assayed for CEA mRNA by RT-PCR in the peripheral blood taken before and again 15 days after surgery from the patient to evaluate whether circulating tumor cells are present. CEA mRNA was detected in both blood samples.

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A 60-year-old man was admitted to our hospital with chest pain and fever. The chest roentgenogram revealed left-sided pleural effusion and suggested pulmonary empyema. He was treated with intravenous administration of cefozopran hydrochloride, tube drainage and deterging with povidone iodine. After three weeks the improvement of these symptoms allowed cessation of antibiotics. Tube drainage and deterging were continued to decrease the remaining space of the empyema cavity. But seven weeks after admission he developed multiple brain abscesses with headache, epilepsy and consciousness disturbance. Methicillin-resistant staphylococcus aureus (MRSA) was detected in both sputum and impetigo under the drain fixing tape. Under the diagnosis of acute MRSA empyema and resultant brain abscess, vancomycin hydrochloride was administered intravenously. Then he recovered from epilepsy with improvement of the brain abscesses. And the disappearance empyema cavity made it possible to remove the thoracic drain. Careful treatment is necessary for empyema because of the high possibility of microbial substitution including MRSA infection.

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