We experienced four cases of diffuse malignant mesothelioma in 1998. These four patients underwent extrapleural pneumonectomy. In order to perform safe and rational resection, we devised two points of operative technique.
First, the modified postero-lateral incisional line was prolonged along the anterior costal arch and by transecting the costal arch at the point of 6^thand 7^thcostal cartilages, a wide and clear operative field was gained. Especially diaphragm was resected easily and completely through the good operative field.
Second, the grand dorsal muscle pedicle flap was sewn onto the place where the pericardium and right hemi-diaphragm were removed. The benefit of using the grand dorsal muscle pedicle flap is not only to avoid prosthesis but to cover easily the bronchial stump or unexpectedly injured organ such as esophageal adventitia.
Results of this rational extrapleural pneumonectomy were as follows ; the average operation time was 6 hs. 25 min., the average volume of bleeding was 1, 260 ml. These results show that our method is safe and less invasive compared with conventional extrapleural pneumonectomy via postero-lateral approach.
We are going to add further improvement of this method and expand the indication of operation on diffuse malignant mesothelioma.

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The prognoses of 39 consecutive thymoma patients treated by surgery from 1977 to 1998 were retrospectively analyzed, with special reference to their preoperative diagnoses, preoperative therapies, and prognostic factors. A pathological diagnosis could be obtained in 26 of 32 patients (81.3%) before surgery by a percutaneous needle biopsy or aspiration cytological examination. Preoperative chemotherapy or irradiation was administered to 10 patients with an unresectable invasive lesion by diagnostic imaging, and the response rate was 80%. There were 13 patients with Masaoka's stage I, 7 with stage II, 15 with stage III, and 4 with stage IVa. The 10-year survival rate was 80% overall, 100% for stage I and II, and 72.7% for stage III patients. The 10-year survival rate for those patients who underwent complete and incomplete resections was 90.7% and 33.3%, respectively (p<0.0001) The 10-year probability of survival for those patients treated by preoperative therapy was 66.7%.Stage (p=0.0059) and the completeness of resection (p=0.0014) were the prognostic factors by univariate analysis. These results suggest that preoperative therapy for an invasive thymoma is effective and multimodality therapy with surgery might improve the prognosis. Masaoka's stage and completeness of resection were the prognostic factors in thymoma cases treated by surgery.

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Completion pnrumonectomy (CP) after initial operation for primary lung cancer was performed in 11 patients (5 with metastatic lung cancer, 3 with secondary primary lung carcinoma, 3 with lung abscess: two aspergillosis, one MRSA). All patients underwent radical lobectomy at the first operation. Among the 11 patients, there were no operative or hospital death, and also no major complications during the hospital stay. When CP is required, its radicality and the need to preserve residual respiratory function and cardiac function (FEV1.0 more than 450ml/m² and %VC more than 35%, total pulmonary vascular resistance at the unilateral pulmonary artery occlusion test less than 600 dyne.sec.cm^-5/m²) must be considered in making the decision to undergo CP. In cases where residual lung and the hilar structures showed severe adhesion, it is often prudent to consider the median sternotomy for CP. By using this approach, the pulmonary vessels are easily ligated intrapericardially, the bronchus can be transected as close to the trachea bifurcation as possible, and the stump often was reinforced with viable tissue such as pleura or percardial fat. The five-year survival rate after CP for 11 patients was 37.5% according to the Kaplan-Meier method.

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Two cases in which long-term survival was achieved by multidisciplinary treatment for primary mediastinal malignant lymphoma are described. In both patients, chest X-rays showed an abnormal shadow, and CT scans showed a giant tumor in the anterior mediastinum. A needle biopsy performed after admission led to a diagnosis of diffuse large B-cell lymphoma with sclerosis. Both patients were treated with chemotherapy mainly consisting of CHOP, followed by 50 Gy (Co⁶⁰) irradiation, which resulted in marked tumor regression. Surgery of the residual tumor was performed with the intent of deciding the subsequent therapeutic strategy. In both cases, the tumor was completely removed. Postoperative histopathological examination revealed no evidence of viable tumor cells within the residual tumor, revealing a pathological complete response. The patients are alive with no evidence of tumor recurrence as of 8 and 4 years after surgery. Finally, rare primary mediastinal diffuse large B-cell lymphoma with sclerosis, as seen in our patients, should be accurately diagnosed histologically, and treated by chemoradiotherapy, followed by removal of the residual tumor as soon as it responds to the chemoradiotherapy.

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A 68-year-old male was admitted to a nearby hospital with diabetic nephropathy to undergo chronic hemodialysis. Chest X-ray film and CT on admission demonstrated left pleural effusion, but a definite diagnosis could not be obtained by thoracocentesis and other examinations. The patient noted sudden onset of high fever seven months later, at which time massive pleural effusion was observed in his left thorax. When the chest drainage tube was inserted into the pleural cavity, cryptococci were isolated from purulent fluid. Because the patient's condition was not improved after treatment with fluconazole, decortication and muscle plombage were performed. The postoperative course was uneventful by precise hemodialysis. At present, 9 months after operation, he is alive without recurrence of empyema.

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An adult case of extralobar pulmonary sequestration is reported. A 41-year-old female was admitted to our hospital because of an asymptomatic abnormal shadow in the left lower lobe on chest X-ray film. The serum CA19-9 was elevated (81.9 U/ml). Chest CT showed a well circumscribed tumor which was contrasted heterogeneously. Chest MRI showed an aberrant artery arising from the descending aorta. Angiography confirmed the same artery and a vein draining into the hemiazygos vein. Under the diagnosis of pulmonary sequestration, thoracotomy was performed. Two aberrant arteries were feeding the sequestrated lung clearly demarcated from adjacent lung parenchyma. Sequestrated lung was resected. The operative specimen showed abnormal lung parenchyma with large, dilated bronchioles and alveolar ducts containing inflammatory changes and abscess. Aspergillus was detected in the culture. The histology was consistent with the diagnosis of pulmonary sequestration. Immunohistochemical staining for CA19-9 was positive in the bronchial epithelium. The postoperative course was uneventful, and she was discharged on the eleventh postoperative day. The serum CA19-9 was reduced to a normal level (10.8 U/ml) on the 46th postoperative day.

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A 20-year-old man (case 1) was admitted due to a traffic accident. Chest CT demonstrated subcutaneous and mediastinal emphysema. Emergent bronchoscopy suggested tracheal laceration, and an endotracheal tube was intubated beyond the tear. Conservative therapy was selected because subcutaneous emphysema and dyspnea became decreased. On the 3rd day, bronchoscopy was again performed and revealed perforation of the trachea, for which an operation was conducted. This tracheal defect was covered with an anterior cervical muscle flap.rAt this operation, we mistook the dislocation of the arytenoid cartilage. After operation, vocal cord was adhesive, and 5 months later, laryngoplasty was performed and a silicone implant was placed in the laryngeal space to prevent stenosis.
The second case was a 55-year-old man, who was admitted for hoarseness following blunt trauma by a rope while driving his motor bicycle. Laryngoscopy showed bilateral recurrent nerve palsy, but bronchoscopy was not carried out, and his tracheal injury could not be confirmed. On the seventh day after admission, his dyspnea gradually increased and tracheotomy was scheduled. At induction of anesthesia, the endotracheal tube damaged the trachea, and so tracheal reconstruction was performed. We misunderstood his tracheal injury until this operation.
Whenever we evaluate patients with blunt neck trauma, more careful examination of bronchoscopy is necessary to confirm the tracheobronchial and laryngeal disruptions. Early surgical treatment to maintain laryngeal functions is important to improve the quality of life.

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This paper describes 3 rare cases of rare double cancers of the lung and trachea, along with a review of the literature. All patients were male and heavy habitual smokers. The of double cancer histologies were of two squamous cell carcinomas in each patient. Two patients were treated by tracheal resection with primary end to end anastomosis, and one by laryngotracheal resection for tracheal cancer. One was treated with a right lower lobectomy, one with laser treatment and one with coagulation therapy for lung cancer. One patient has been alive without recurrence for 4.8 years after his operation for tracheal carcinoma. The other 2 patients died at 23 months and 9 months, respectively, after their operations.

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A 54-year-old female was admitted to our hospital because of an abnormal shadow on a chest roentgenogram. The chest roentgenogram showed a left upper mediastinal mass with tracheal deviation to the right. A computed tomography scan of the chest demonstrated a homogeneous posterior mediastinal mass connected to the left thyroid, which extended to the contralateral mediastinum and carinal area.
A radioiodide thyroid scan revealed uptake of isotope in the area of the mediastinal mass. The mass was removed using a collar incision of the neck and median sternotomy under preoperative diagnosis of mediastinal goiter. Its size was 12×7×7cm. A microscopic examination showed a benign adenomatous goiter. This paper described a rare case of huge posterior mediastinal goiter with contralateral mediastinal extention, with a review of the literature.

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We reported a case of traumatic diaphragmatic herniation which caused tension hemothorax due to splenic injury resulting from a stab wound of the back without intraabdominal bleeding. A 20-year-old male was admitted to our hospital for the treatment for left hemothorax resulting from stab wounds of the back. On admission, he was in a pre-shock state because of tension hemothorax, and we performed emergency operation. After left thoracotomy, we found about 3, 000ml blood in his left thoracic cavity. The source of bleeding was the spleen which herniated from a fissure of the diaphragmatic injury resulting from the stab wound by a piece of broken glass. No intraabdominal bleeding was found. We performed splenectomy and sutured the fissure of the diaphragmatic injury. His post-operative course was uneventful.

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We report herein a relatively rare case of a 33-year-old woman with a pericardial cyst in the right upper mediastinum. Thoracoscopic resection of the cyst was performed following cyst aspiration with a specially designed double balloon catheter to prevent spillage of the cyst contents into the thoracic cavity. This aspiration technique is safe and useful for thoracoscopic resection of mediastinal cysts.

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Surgical management of patients with concomitant resectable lung lesions and critical cardiac disease is controversial. We examined the usefulness of intra-aortic balloon pumping (IABP) for lung cancer patients with severe ischemic heart disease. They had difficulty being treated by coronary intervention. And these patients are mistimed the operation because of severe ischemic heart disease. In lung cancer patients who are surgically resected, left main trunk (LMT) disease, unstable angina and low ejection fraction (less than 30-40%) are indications for scheduled IABP. No complications were observed due to IABP in any patients of this group.rWe conclude that scheduled IABP is useful for lung cancer patients with severe ischemic heart disease.

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A 68-year-old woman was pointed out an abnormal shadow in the hilar region of the left lung on the routine chest X-ray at an annual check-up.rShe had no subjective symptoms. The tumor was slightly getting bigger and therefore operation was performed. A dark brown, hard and solid tumor was covered with a thin and fibrous membrane, but not with pulmonal or mediastinal pleura and did not invade surrounding tissue. The tumor was immunohistochemically diagnosed as epithelioid hemangioendothelioma on the basis of associated with immunoreactivity to factor-VIII related antigen. Epithelioid hemangioendothelioma is a rare tumor and has not been reported in the hilar region of the lung. Epithelioid hemangioendothelioma must be considered as a probable tumor on an abnormal shadow in the hilar region.

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An 85-year-old woman complained of dry cough. A mass was detected on chest X-ray which displaced the trachea to the left. Chest CT and MRI revealed a tumor in the right middle mediastinum, 4.5×4.5×7.0cm in size. Bronchoscopy revealed displacement of the trachea. Benign neurogenic tumor was suspected, and video-assisted thoracoscopic resection was done. The vagal nerve was partially involved and had to be resected. The tumor was histologically diagnosed as a neurinoma comprising mostly Antoni A type with some components of Antoni B type. She had no post-operative complications, and the post-operative course was uneventful.

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A 32-year-old woman with von Recklinghausen's disease was admitted for the treatment of metastatic lung tumor. She had undergone extended radical tumorectomy, radiotherapy, and chemotherapy for MPNST in right lower limb 33 months ago . Chest X-ray and CT showed a sharply demarcated solitary tumor in the right S⁶. Resection of the tumor under video-assisted thoracoscopic surgery was performed . The lung tumor was histologically diagnosed as a metastasis of MPNST.
Lung is the most common metastatic site of MPNST and MPNST with lung metastasis showing a very poor prognosis. The patient is well 21 months after the pulmonary resection without recurrence. Multidisciplinary therapy and careful follow up are important for MPNST.

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Thoracoscopic extended thymothymomectomy was performed using sternum lifting method effectively in two patients with stage II thymoma. Under general anesthesia, the patients were intubated with a double lumen tube with the neck and upper abdomen extended in the supine position. A six-centimeter skin incision was made at the site of the xyphoid process and the backside of the sternum was excoriated from the mediastinum . A five-centimeter collar incision was made and then the sternum was lifted using vessel loops through the backside of the sternum. After the bilateral upper poles of the thymus were ligated and divided from the thyroid, the left brachiocephalic vein was taped and the thymic veins were ligated and divided. Then the thymus was excoriated from the left brachiocephalic vein . The upper pole of the thymus was grasped and pulled to the caudal side with the forceps . The thymus was excoriated from the aorta, superior vena cava, pericardium and mediastinal pleura . As a result, the thymoma and thymus were removed from the site of the xyphoid process. The bilateral phrenic nerves were the resecting margin of the mediastinal pleura. The operating times were 199 and 271 minutes and the volumes of bleeding were 40 and 130g . Analgesics were given during the period of thoracic drainage for one patient, and both were discharged on the fifteenth postoper ative day. There were no complications from the operation and no recurrence has been observed for about two years.

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A 74-year-old man underwent an exploratory resection of an expanding and painful tumor on the right side in the chest wall. It was diagnosed as non-Hodgkin's lymphoma, diffuse large cell type, and radiation therapy was given postoperatively. About three and a half years later, on the left chest wall the same tumor as the right one appeared and was resected. It was diagnosed as recurrent non-Hodgkin's lymphoma from the pathological and clinical findings. Combination chemotherapy and radiation therapy were given. He is alive well, and free of recurrence four years after he was first treated. He had no history of empyema or tuberculosis. High titers of anti-VCA (IgG) antibody were found in his serum . Epstein-Barr virus was not found in tissue specimens by in situ hybridization. Malignant lymphomas in the chest wall mostly arise in cases of chronic tuberculous pyothorax or tuberculous pleuritis, but in the present case there was no preceding disease. We report a rare case of malignant lymphoma in the chest wall.

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