Bronchial fistula is one of the major complications after lung surgery, and remains a serious disorder associated with high mortality. Recently it is reported that some types of the neoadjuvant chemotherapy or concurrent chemoradiotherapy are effective for advanced lung cancer using G-CSF agents. Such patients, however, have a high incidence of bronchial fistula after surgery. Usually surgical operation is performed for treatment of the bronchial fistula only when the patient is considered able to tolerate general anesthesia. We report here that coil occlusion method through bronchoscopy effectively treated bronchial fistula without surgical stress. This suggests that coil occlusion method could be of therapeutic benefit in life-threatening bronchial fistula especially in poor risk patients.

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Cartilage is an important component of the trachea. Its stiffness was examined physically and biochemically in 29 rabbits aged from 1 to 118 weeks. Calcification was found biochemically and histologically in the cartilage. Calcification started from 15 weeks, and increased with age. At about 29 weeks, the increase of calcification reached the plateau phase. Based on the age-related changes in calcium content and morphometrical findings, the development of tracheal cartilage was divided into three phases : precalcified phase (pre-phase), progressive phase (pro-phase) and plateau phase (p1-phase). The physical properties of the cartilage were assayed by analogizing with the ductile fracture test using a Creepmeter. The yield point stress (S) and energy absorption (EA) were taken as the measures of stiffness. Both S and EA were found to be increased significantly (p <0.001) during the pre-phase and pro-phase with aging. However, the increase stopped from the p1-phase. The Ca content was found to be positively correlated with S and EA (p < 0.05 and 0.0001, respectively), while the glycosaminoglycan representing the tissue proteoglycan, hydroxyproline representing the tissue collagen and the water content were inversely correlated with S and EA (p <0.050.001). In conclusion, during development, the tracheal cartilage showed age-related changes in composition and stiffness. A good consistency among the changes in biochemical parameters and S and EA was also found. Therefore, S and EA may be good parameters for reflecting the physical properties of tracheal cartilage.

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To evaluate the new TNM classification for lung cancer, we investigated surgical results and the significance of pleural lavage cytology.
The 5-year survival rate was calculated for 364 consecutive, previously untreated patients who had undergone complete resections more than 5 years previously for non-small cell lung cancer : 75.8% in stage IA, 64.6% in IB (IA versus IB, p= 0.0314), 63.3% in IIIA, 54.1% in IIIB, 25.3% in IIIA and 16.7% in IIIB. Especially for patients in stage IA, there was a significant positive correlation between a tumor size less than 2 cm and survival. The 48.0% 5 year survival rate for pT3N0M0 patients was significantly better than that for stage IIIA and the prognosis of those with satellite tumor (s) within the primary-tumor lobe of the lung depended on the N-category.
Pleural lavage cytology was investigated immediately after thoracotomy in 313 consecutive patients with adenocarcinoma who did not show pleural fluid on their preoperative CT scans : 46 patients (14.7%) had positive results including 8 patients with NO, M0, D0 and pm0, carrying poor prognoses.
We concluded that the revised stage grouping was significant only for dividing stage I into A and B categories and placing T3N0M0 in stage II. In future revisions, it would be more meaningful to define Ti as a tumor ≤ 2 cm in its greatest dimension. We could not agree that the results of pleural lavage cytology should stay out of the TNM classification and it would remain unclear how to deal with patients dying of non-cancerous diseases or unknown causes.

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In the present study, the effect of anticancerdrug, CDDP, on tracheal cartilage in rabbits was examined. We measured the stress (S) at the yieldpoint as a physical index in compressive fracture test and quantified the chemical composition, % H₂O, calcium content (Ca), hydroxyproline (Hyp), glycosaminoglycan (GAG) as a mucopolysaccharide, glucosamine (Glc) as an oligosaccharide composed of GAG, valine (Val) as an aminoacid related to composition of tracheal cartilage.
We performed a preliminary experiment with 29 rabbits from 1 to 118 weeks in age and confirmed the stability phase as the 3rd phase which was over 27.5 weeks. Therefore, we used only 29 weeks rabbits in the actual experiment. S was significantly lower in experimental group 4 (1.6-2.2 mg/kg) that is effective dose in cancer therapy than control group (p < 0.05). S value showed the dose dependency and an indirect significant correlation was found between the CDDP dose (X) and stress (Y) (Y =-0.123X +1.96, p <0.03). A significant correlation was not found between % H₂O, GAG, Hyp, Ca and the CDDP dose, but a direct significant correlation was found between Glc, Val (Y) and CDDP dose (X) (Y =0.037X +0.248, p<0.03, Y = 0.124X +1.29, p <0.01). An indirect significant correlation was found between S (Y) and Glc, Val (X) (Y = e^-1.55x + 1.33, p<0.01, Y=-0.32X + 2.40, p<0.05).
We conclude that CDDP therapy may change the composition of the cartilage matrix and reduce the tension of the cartilage.

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Malignant thoracic tumor occasionally invades the superior vena cava (SVC), and this is the main reason of incomplete resection or unresectability. Reconstructing the SVC with prosthetic graft, we could perform complete tumor resection in patients with malignant thoracic tumor extending to the mediastinal structures.
From December 1991 to October 1997, eight patients with malignant thoracic tumor underwent surgical resection combined with reconstruction of the SVC. There were four mediastinal germ cell tumors (two yolk sac tumors, one seminoma, and one embyonal cell carcinoma). Two cases were invasive thymomas and another two were primary lung adenocarcinomas. Four patients had associated SVC syndrome and in all cases the tumor extended to the SVC wall or to the SVC lumen histopathologically.
In seven cases the operation was performed with median sternotomy. After making a permanent bypass from the left brachiocephalic vein to the right atrial appendage using a 10 mm wide ringed expanded polytetrafluoroethylene (EPTFE) graft, the SVC was resected with the entire tumor. A 10 mm wide ringed EPTFE graft was also interposed between the right brachiocephalic vein and the inflow tract of the right atrium.
In another case of lung carcinoma, the operation was done through posterolateral thoracotomy, a 10 mm wide ringed EPTFE graft was interposed between the junction of left and right brachiocephalic vein and the right atrial appendage while the azygos vein was maintained patent. After performing the anastomosis of the graft, the SVC and the whole right lung were resected followed by the azygos vein ligation.
In seven cases two grafts were interposed and in one case only one graft. In all cases the intraoperative hemodynamic state was stable, and the operation was safely done. All patients received anticoagulant therapy for 3 to 6 months after the operation.
Among the 15 prosthetic grafts in eight patients, eleven grafts were patent and four grafts had been obstructed at the time of study, but all patients had no trouble in their venous return. All patients received adjuvant treatments. Chemotherapy was administered to seven patients and radiotherapy to five patients. There was no operative mortality, but one hospital death caused by systemic metastasis. Six patients died of recurrent malignant tumor 2 to 59 months after the operation. In these patients, all but one of the grafts were patent and the graft patency had no relation to the cause of death. Two patients are alive free of tumor. The overall cumulative survival rate is 63% at one year, 31% at three years, and 16% at five years.
The combined resection of the SVC was safely done with simple crossclamping after making a permanent bypass from the left brachiocephalic vein to the right atrial appendage with EPTFE graft in a case of surgical resection of malignant thoracic tumor. There was no trouble in venous return or local recurrence in any case.

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A 51-year-old male complained of paralysis in the right forearm. Chest X-ray and CT demonstrated a mass in the right apex of the lung, involving the first rib. Primary lung cancer of the right apical region with direct invasion to the first rib was suspected. En bloc resection of the tumor and the first rib was scheduled. First, partial resection of the first rib was performed through a transverse axillary incision. Then right upper lobectomy with mediastinal lymph node dissection was performed through a posterolateral thoracotomy. After subsequent radiotherapy, the patient had been well and free from the recurrence for six months.
In conclusion, the transverse axillary approach, which had been applied to the resection of the first rib for the thoracic outlet syndrome or other benign lesions, can be also beneficial for resection of apical cancer directly invading the chest wall.

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We describe a case of a 15-year--old female a giant emphysematous pulmonary cyst. From infancy, she had experienced shortness of breath during walking. Her chest X-ray films and CT showed a right giant emphysematous pulmonary cyst and a deviation of the mediastinum to the left. Arteriogram of the chest showed a deviation of the right pulmonary arteries and the pulmonary ventilation and perfusion scintigram showed little function in the right lung. Operation was done on June 28, 1997. We could see that the right lung was highly collapsed with multiple bullae present in the right upper and middle lobes. The giant emphysematous pulmonary cyst was located in the right upper lobe. We performed right pneumonectomy because the right lung function was impaired. We speculate after pathological examination that there had been a emphysematous pulmonary disease in this case from infancy.

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Thoracoscopic surgery for anterior mediastinal tumors is difficult because the sternum can be a great obstacle to surgical maneuvers and impedes adequate thoracoscopic vision compared to that provided by median sternotomy. We performed mediastinoscopic and thoracoscopic resection by lifting the inferior portion of the sternum with a Laparolift in a 31-year-old female with mature cystic teratoma localized under the left brachiocephalic vein. Intraoperative bleeding was noted at a site of the thymic vein, and 850 ml of blood was lost due to the delayed thoracoscopic approach. Although thoracoscopic and mediastinoscopic resection of benign anterior mediastinal tumors through a xiphoid approach is useful due to the absence of postoperative pain that allows early discharge from the hospital, the operative bleeding may occur unexpectedly, which requires adequate measures such as rapid surgical treatment.

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A quite rare case of metastatic tumor in the diaphragm is reported. A 55-year-old woman who had received resection of endometrial carcinoma 5 years previously was referred to our hospital for bloody-stained sputa. Chest X-ray films and CT showed a large mass in the right lower field of the lung. Compared with the past chest X-ray films, the tumor was growing gradually with positive extrapleural sign toward the lung. MRI showed the tumor mainly well defined with lung and liver but partially ill defined with lung. Right middle and lower lobectomies with mediastinal lymph node dissection and partial resection of diaphragm and liver were performed. Histological examination revealed metastasis in the diaphragm from endometrial carcinoma.

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A 60-year-old woman receiving steroids therapy for collagen diseases and membranous nephropathy was admitted to our hospital because of productive cough, fever, chest pain and dyspnea. She had cardiac failure, orthopnea and cyanosis. A chest roentgenogram and computed tomography revealed a giant bulla which occupied 2/3 of the right hemithorax, with pleural effusion and atelectasis. Laboratory examination revealed a high level of serum C-reactive protein and hypoxia. Chest tubes were inserted percutaneously under local anesthesia into the giant bulla and pleural cavity to drain the air and pleural effusion. Although the size of the giant bulla was unchanged, dyspnea and infection improved. Then, the giant bulla was resected using knifeless GIA. The residual lung expansion was sufficient and a good postoperative course was obtained without complications.

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A 41-year-old woman was admitted to our hospital because of back pain and dyspnea on exertion. Chest X-ray and chest CT scan showed a giant tumor in the left pleural space. Selective angiography showed that the 6 th intercostal artery fed the tumor strongly. Operation was done through a left 6 th intercostal thoracotomy. The surface of the tumor was bled easily during the operation and was strongly fixed to the 6 th rib. Tumor resection was performed smoothly after resecting the tumor from the 6 th rib. The left lower lobe that was compressed by the tumor, recovered enough during the ventilation. The postoperative course was uneventful. The pathological diagnosis was a benign ancient neurilemmoma (Schwannoma) of the chest wall.

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Hemangioma is one of the most uncommon tumors in the mediastinum. We experienced a 12-year-old girl who had a mediastinal mass shadow on screening chest X-ray examination. Physical examination revealed no abnormal findings. Routine blood examinations were all within normal limits. Plain chest X-ray film showed a mass shadow in the left upper mediastinum. Plain chest CT scans showed that homogeneous-density tumor developed from the left thymus toward the anterior portion of aortic arch. Left internal thoracic arteriograms showed pooling and cotton wool like staining with contrast medium in the tumor. The tumor was completely resected through a median sternotomy on Dec. 13, 1984. Histological examination showed that the tumor was a benign cavernous hemangioma extending to surrounding fatty tissue, which suggested the possibility of future recurrence. Thirteen years follow up at the outpatient clinic, however, has shown no evidence of recurrence so far.

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A 71-year-old female was admitted because of abnormal chest shadows. She was diagnosed as having multiple congenital pulmonary arteriovenous fistulas in right S⁶ and S⁹ by chest tomography, pulmonary arteriography and helical CT. An operation was performed under VATS. The feeding artery and the drainage vein were stapled respectively in double lines with an ENDO-TA30TM. VATS is an effective treatment for congenital pulmonary arteriovenous fistula.

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A 50-year-old female was referred to us because of an abnormal mass at the right anterior mediastinum on X-ray film. Chest CT showed a mass 4 cm in diameter adjacent to the ascending aorta.
Operation was performed by median sternotomy. The tumor was a black and elastic hard mass, which was located in the lower portion of right lobe of the thymus, and pericardial invasion was noted.
The intraoperative histological diagnosis was malignant melanoma (MM) or malignant melanotic schwannoma (MMS).
Histological examination showed mainly spindle cells with heavy melanin pigmentation and partially epithelioid cells. The tumor was examined by light microscopy with immunohistochemistry (S-100 protein and HMB-45 antigen) and by electron microscopy, but no evidence was found to distinguish MM from MMS. Through the microscopic findings of the form of the tumor cells, and the frequency of the occurrence of each tumor, a diagnosis of MM was made. Both MM and MMS originate in neural crest and histologically similar, so the differential diagnosis between these two tumors is difficult.
Thymus was diagnosed as the primary site, since no primary lesions could be located except in the thymus at postoperative evaluation and microscopically the tumor was surrounded by thymic tissue.
This is the fourth reported case of MM originating in the thymus.

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We reported a case of chronic hemorrhagic empyema, which is a special type of pyothorax. A 64-year old man was referred to our hospital with a complaint of right back pain. Chest X -ray film showed a huge mass lesion in the right thorax, which is markedly larger than that in the X-ray film 2-years before. Right thoracotomy was performed, and the mass was proved to be filled with hematoma and fibrous tissue, not with pus. Histological study revealed hematoma and amorphous substances with dilated microcapillaries beneath a fibrous capsule. He was successfully cured by resection of the mass and decortication of the right lung, and showed improvement in pulmonary function tests.

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We studied assessment and perioperative management after pneumonectomy or completion pneumonectomy for unilateral destroyed lung due to frequent infection. The infections included Aspergillosis, Pseudomonas aeruginosa and Methicillin resistant staphylococcus aureus. Three had previous lung resection due to pulmonary tuberculosis or mycobacterial infection. The blood gas analysis was normal except one patient with over 50 mmHg of Paco2. The average pre-operative vital capacity and forced expiratory volume were 57.1% and 63.3% of the predicted value, respectively. Pre-operatively, all patients showed scintigram of the unilateral destroyed lung with less than 5% of perfusion and less than 10% of ventilation. The forced vital capacity decreased significantly from 1.84 liters preoperatively to 1.72 liters postoperatively : however Pao₂ was significantly improved from 77.9 to 86.1 mmHg. Two patients needed mini-tracheostomy due to retention of sputum and one had pleuro-cutaneous fistula, however there was no operative or hospital death. We concluded that contralateral lung should show normal function by blood gas analysis, pulmonary spirometry and scintigram and that perioperative management must prevent spread of infection to the contralateral normal lung.

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We report a case of a tracheal tumor on the carina treated by tracheobronchoplasty after radiotherapy.
A 48-year-old man was admitted for severe dyspnea due to carinal stenosis. Adenoid cystic carcinoma on the carina was revealed. The tumor extended from the lower 3rd tracheal ring to both main bronchi. Airway stenosis was treated by local injection of ethanol and cautery with Nd-YAG laser. A silicon stent was placed in the stenotic site and preoperative irradiation was performed (35 Gy).
After tumor regression, carinal reconstruction of the montage type (CRm) was performed. End to side anastomosis was performed with a telescopic running suture. The postoperative course was uneventful. The residual tumor of the trachea was well controlled with postoperative irradiation (35 Gy) and local injection of cisplatin, and the patient was discharged.
CRm demonstrates more complications at the anastomotic site than other types of tracheobronchoplasty. Based on our findings, common complications included dehiscence and stenosis of the end to side anastomotic site. Telescopic running suture was considered as a reliable procedure for this site.

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A 64-year-old woman was referred to our hospital complaining of a left posterior chest wall tumor. Chest CT scan revealed a giant soft tissue tumor of the left posterior chest wall. Operative findings revealed that the tumor was growing from the fifth intercostal muscle and tumorectomy was performed. It weighed 950g and measured 16×14×6cm. Pathological findings and various immunohistochemical properties of the specimen were morphologically compatible with solitary fibrous tumor. We added a chest wall resection with fifth and sixth ribs, but the pathological findings of the pleura were normal, so, this tumor was originating from soft tissue of the chest wall. The postoperative course was uneventful and the patient has not shown any complaints concerning our procedure.

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Peripheral pulmonary arterial aneurysm has rarely been reported and most cases have hemoptysis. A case of asymptomatic solitary peripheral pulmonary arterial aneurysm noted on medical examination is described. The patient was a 56-year-old woman with coin lesion, 4 cm in diameter, at the right hilar region on the chest X-ray film. It was strongly stained on enhanced computed tomography, and pulmonary angiography revealed a mass adjacent to the right A⁴. Operation was performed under the diagnosis of peripheral pulmonary arterial aneurysm. The postoperative course was good.

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