The aim of this study was to perform a retrospective analysis of the tumor diameter range (in mm) determined by preoperative diagnostic imaging that yields an improved prognosis, and to discuss the indications for limited resection of such lesions. The subjects were 145 surgical cases of cNO lung cancer with lesions 20 mm or less in diameter on radiographs. Twelve patients with radiographically-visualized lesions measuring 10 mm or less in diameter and 44 patients with lesions 11-15 mm in diameter had comparable prognoses (5-year survival rates of 88% and 91%). The combined 5-year survival rate for the 56 patients with lesions 15 mm or less in diameter was 89%, a significantly better outcome (p=0.04) than that for 89 patients with lesions 16-20 mm in diameter (68%). However, 3 patients (7%) with lesions 15 mm or less in diameter were lymph node-positive. When the group was restricted to cases of bronchiolo-alveolar carcinoma, the prognosis was extremely good, even including those undergoing limited resection. Thus, cN0 lung cancer measuring 15 mm or less in diameter on radiographs has an excellent prognosis. If the disease is not bronchiolo-alveolar carcinoma, however, it is difficult to claim that limited resection is indicated

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Pleural lavage cytology at thoracotomy was performed in 352 patients with primary lung cancer who underwent curative resection between 1987 through 1997. Twenty-four patients (7.4%) had positive cytology. The frequency of positive cytology was significantly related to cell type, pleural invasion and lymphatic invasion. The 5-year survival of the positive cytology group was 30.2%, while it was 61.4% (p<0.001) in the negative cytology group.rPleural lavage cytology seems to be an important prognostic factor in lung cancer. Systemic recurrence was more common in the positive cytology group, while pleural recurrence was noted in only 2 of 17 cases. These results suggested that the positive cytology of pleural lavage can be regarded as microscopic metastasis with local treatment not effective in the positive cytology group.

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A patient with an abnormal shadow on a routine X-ray film was admitted to our hospital. She showed no clinical symptoms of myasthenia gravis (MG) but serologic test revealed positive result of anti-acetylcholine receptor antibody (anti-AchR Ab). From June 1992, we experienced 64 cases of extended thymectomy for MG with/without thymoma. During the same period, we also experienced 7 cases of thymus related tumors without clinical symptoms of MG. Five of them revealed positive results of anti-AchR Ab. These cases may represent subclinical MG, so operative procedures should take into consideration the possible onset of post-operative MG.

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A case of Schwannoma arising asynchronously in the right second intercostal nerve and right brachial plexus is presented. A 44-year-old man who had received surgery of Schwannoma of the right second intercostal nerve 9 years earlier was found to have an semi-round shadow of the right apex on a chest X-ray. Exploratory thoracotomy revealed a Schwannoma arising in the right brachial plexus. Tumorectomy was performed with additional supraclavicular approach. Postoperative neurological deficit improved in 7 months.

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Case 1: A 28-year-old man who was a bicycle racer sustained blunt chest trauma after being thrown from his bicycle. He complained of chest pain and small amounts of hemoptysis. The chest X-ray showed slight consolidation of the right lung without rib fractures. The CT scan of the chest demonstrated a cavity with an air-fluid level in the right lower lobe. The cavitary lesion decreased gradually in size on the follow-up CT scan of the chest.
Case 2: A 20-year-old man sustained multiple injuries in a motor vehicle accident. An initial chest X-ray revealed a right hemopneumothorax and extensive consolidation of the right lung. The right chest tube drained about 600 ml serosanguineous fluid, and a continuous severe air leak was noted. The CT scan of the chest revealed multiple cavitary lesions in the right lower lobe. The decision was made to perform an emergency operation because of severe air leak. The postoperative course was uneventful, and the cavitary lesions decreased in size on the follow-up CT scan like in Case 1.
Our two patients were treated and recovered uneventfully. It is important to detect traumatic pulmonary pseudocyst as early as possible. Earlier use of the chest CT scan might have led to a more timely diagnosis and alterations in the therapeutic strategy.

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A 77-year-old man underwent a left lower lobectomy and partial resection of the left upper lobe with mediastinal lymphadenectomy for a primary lung cancer, located in the left S⁶ segment. The pathological diagnosis was moderately differentiated squamous cell carcinoma and the pathological stage was IIB (T2N1M0). Body temperature rose to above 38°C on the 21st postoperative day, and bronchoscopic examination revealed bronchial necrosis mainly over the membranous portion from the second crescent cartilage of the left main bronchus to the orifice of the upper lobar bronchus. Then tube drainage was performed. Air leakage was not found at first, but was eventually recognized. A reoperation was performed on the 30th postoperative day. A segment of the gastric wall with omentum supplied by the right gastroepi-ploic vessels was mobilized from the greater curvature. Then the necrotic bronchus was resected and bronchial reconstruction was performed with the pedicled gastric seromuscular and omental flap.rClinical course after the reoperation was good and bronchoscopic examination performed on the 169th postoperative day revealed good healing. We could avoid a completion pneumonectomy by bronchial reconstruction with a pedicled gastric seromuscular and omental flap.

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A 21-year-old female underwent extended thymectomy through a median sternotomy for myasthenia gravis (Osserman I) in July 1998. Postoperative chest X-ray showed atelectasis of the right upper lobe and pneumothorax, and consequent bronchoscopy showed abnormal bronchus of the right upper lobe arising from the right tracheal wall the orifice of which was filled with sputum. Bronchial toilet and thoracic drainage improved the respiratory condition of this case.
Although bronchial anomalies are rare, they must be taken into consideration as a cause of postoperative atelectasis of the lung.

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We report here a rare operative case of liposarcoma in the mediastinum, with resection and reconstruction of the chest wall.
A 79-year-old man was admitted to our hospital because of asymptomatic abnormal shadow in the right hilum on a chest X-ray. As a benign mediastinal tumor like teratoma was suspected, extirpation of the mediastinal tumor and partial resection of the sternum and ribs were performed. The defect of chest wall was reconstructed by the Marlex-resin sandwich. Eleven months after the operation, he died of multiple metastase and local recurrence.

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Thymic cyst with thymoma is a rare disease with only ten cases thus far reported in Japan. We report an additional case here.
A 28-year-old man was admitted to our hospital with an abnormal shadow on screening chest radiograph. Chest radiograph showed that a mass shadow whose contour was smooth, was present on the left side of the cardiac shadow. Chest CT revealed a cystic anterior mediastinal mass with a solid part on the wall. The tumor was resected by median sternotomy. It consisted of a multilocular cyst and a whitish mass on the wall.
Histopathologic examination revealed that a multilocular thymic cyst whose walls were lined by a monolayer of flat epithelial cells, with thymoma which consisted of spindle shaped tumor cells and lymphocytes.

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Thymic hyperplasia is commonly associated with hyperthyroidism. A radiologically visible thymic mass, however, is rare. We experienced a thymic hyperplasia associated with hyperthyroidism. The patient was a 34-year old female who complained of palpitation and loss of body weight. She was diagnosed with hyperthyroidism and diabetes mellitus. Her thyroid function test showed a serum-free T4 of >9.5pg/ml (normal range is 0.9-1.8), a serum-free T3 of>24pg/ml (normal range is 2.4-4.3), and a serum-TSH of <0.1μIU/ml (normal range is 0.6-4.9).
A chest roentgenogram showed a left hilar enlargement. A chest CT scan showed a diffusely enlarged thymus. The patient was treated with MMI 45mg/day for one month, and her thyroid function was gradually normalized. The size of the anterior mediastinal mass on a follow-up chest CT scan was slightly increased, which was suggestive of thymic tumor.
Median sternotomy and total thymectomy and subtotal thyroidectomy were performed on July 14, 1998. Histological examination showed thymic hyperplasia. The thymus weighed 69.5g and the right lobe was 9×5cm in size and the left lobe 12×8cm. Her postoperative course was uneventful.
At preoperative study, this mass showed a high signal intensity on T1 weighted MRI and a lower signal intensity on the chemical shift system. This phenomenon supprts containing of minimal fat in the tissue. MRI image on the chemical shift system may be able to distinguish thymic hyperplasia and thymoma, because the former contains fat and the latter does not. Treatment for hyperthyroidism with anti thyroid drugs may cause a decrease in size of the enlarged thymus. Recognition of the association of thymic hyperplasia with hyperthyroidism is important and would prevent further invasive procedures. New technique of MRI (the method of change phase) may be useful to diagnose thymic hyperplasia preoperatively.

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A 71-year-old woman was referred to a university hospital with an abnormal shadow on chest X-ray. A CT scan and MRI scan showed an unhomogeneous lobulated solid mass in the anterior mediastinum. A pre-operative diagnosis of thymoma was made, and thymomectomy & extended thymectomy was performed. Pathological diagnosis was also thymoma of Masaoka stage II at that time, so the patient was discharged after radiation therapy in good health. Ten months after the operation, the chest X-ray showed a right pleural effusion and pleural dissemination was suspected on chest CT. The tumor markers of the serum were normal, but the NSE in pleural effusion showed 40 ng/ml (>10). The exfoliative cytology of the effusion revealed a cluster of atypical cells, with all cells having irregular nuclei and hyperchromatin. So thymic carcinoma was suspected. Therefore the operation specimen was looked over immunohistochemically and was positive for NSE, negative for chromogranin A, and partly positive for cytokeratin. The H&E sample was re-examined and individual cell necrosis, coagulation necrosis and frequent mitotic figures were seen. The tumor was diagnosed as a thymic small cell carcinoma.

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A 75-year-old woman was referred to our hospital for evaluation of abnormal shadows on a routine chest roentgenogram. Chest CT scans showed two separate anterior mediastinal masses the size and findings of which were the same.
After obtaining a diagnosis of thymoma with CT-guided needle biopsy, we resected both tumors combined with sorrounding thymic tissues via a median sternotomy. Those tumors were found, one in the right and the other in the left lobe of the thymus. Both tumors were encapsulated solid masses 4 cm in diameter.
Microscopically, the tumors were consistent with thymoma of the predominant lymphocytic type. Immunohistochemical study, using Leu7 and cytokeratin, showed similar characteristics between the tumors. However, because the tumors had the same size and non-invasive nature, we considered that their origin was multicentric development rather than intra-thymic metastasis.

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Case 1 was a 33-year-old female, who underwent left lower lobectomy without lymphnode dissection. Case 2 was a 62-year-old female, who underwent right lower lobectomy with mediastimal lymphnode dissection. Both patients died due to brain metastasis 6 months after operation. They had both the cancerous element of adenocarcinoma and the sarcomatous elements differentiated into leiomyosarcoma and chondrosarcoma. In both cases, resected lung tumors were diagnosed to be true carcinosarcoma by showing the non-epithelial elements demonstrated with electron microscopy and immunohistochemical studies.
We examined the p53 protein immunostaining, which showed positive staining in case 1 and negative staining of the epithelial and non-epithelial elements in case 2, and the bcl-2 protein immunostaining, which showed negative staining in both cases. The finding of p53 protein expression shows that the pulmonary carcinosarcoma come from monoclonal origin, and the negative expression of bcl-2 protein may suggest poor prognosis of the pulmonary carcinosarcoma.

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A 45-year-old man was admitted to our hospital for an abnormal shadow on chest X-ray film. A chest wall benign tumor arising from the parietal pleura was suggested by the chest X-ray and CT findings. The tumor was surgically removed by video assisted thoracoscopic surgery.
Histological examination revealed that the tumor consisted of highly hyalinized collagenous tissue and regularly shaped spindle cells. Pathological diagnosis was solitary fibrous tumor. The patient is doing well without recurrence 3 years and 1 month after the operation.

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The case was a 69-year-old female who was referred to this department because of a shadow on chest x-ray while receiving dialysis twice in a week for chronic renal failure. She had a quickly growing large mass at the posterior mediastinum observed by the simple chest x-ray film, CT and MRI before the operation. As a result of biopsy, the mass was found to be a mesenchymal tumor and diagnosed as sarcoma originating at the posterior mediastinum. Operation revealed continuity of the mass to the esophagus with ambiguous demarcation although there was only a slight adhesion involving a part of the lower lobe of the lung, aorta and diaphragm. Therefore, the mass was considered to be a leiomyosarcoma originating from the esophagus, and tumor enucleation was performed. The tumor size was 13.5×13.5×9.5cm, weighing 840 g with hemorrhagic and necrotic foci within the mass. The tumor was diagnosed as GIST (Gastro-Intestinal-Stromal-Tumor) of a mesenchymal tumor originating in the esophagus.
GIST originating in the esophagus is often difficult for the differential diagnosis from posterior mediastinal tumor for the mode of growth. Therefore, careful preoperative diagnosis is required.

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A 59-year-old male visited our hospital with a chief complaint of dry cough. Chest X-ray showed an atelectasis of the right middle and lower lobes. Chest CT revealed a polypoid lesion that completely obstructed the intermediate bronchus, expanding its lumen. Bronchoscopy revealed a grayish white endobronchial polypoid mass, and biopsy yielded a histological diagnosis of leiomyoma. A sleeve resection of the intermediate bronchus including the tumor and end-to-end anastomosis was performed successfully. Immunohistochemical staining for α-SMA was positive. DNA analysis of the tumor based on flow cytometry showed a diploid pattern. The patient showed a significant improvement on pulmonary function tests and is doing well without any evidence of tumor recurrence 3 years postoperatively.

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In each case of primary or metastatic lung cancer, chest CT reveals pulmonary nodules in addition to primary or metastatic lesions.
Case 1 demonstrated primary lung cancer at the left apex, and small nodule at right S9 is shown. Under CT guidance, video-assisted thoracoscopic surgery (VTS) was performed. The samll nodule was a lymph node histologically.
Case 2 was post colectomy and hepatectomy. Chest CT revealed a small nodule at the bilateral lung. VATS was performed. The small nodule at right S9 was microscopically lymph node with anthoracosis.
It is difficult to differetiate these small nodules from lung metastasis. We considery VATS surgery a very useful procedure for diagnosing and treating subpleural intrapulmonary lymph nodes.

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