We received replies of a questionnaire on thymic epithelial tumors from 115 institutes which were recognized as a certificate by The Japan Association for Chest Surgery . We compiled 1, 320 patients with thymic epithelial tumor who were treated from 1990 to 1994. Review of these patients revealed 1, 082 thymomas (82.0%), 11 atypical thymoma (well differentiated thymic carcinoma) (0.8%), 186 thymic carcinomas (14.1%), and 41 thymic carcinoids (3 .1%). Thymoma was a predilection for female. In thymic carcinoma and carcinoid males were more affected than females. The patients of thymic carcinoma were elder than those of thymoma . About 70% of patients with thymoma were Stage I or II, whereas the majority (90%) with thymic carcinoma were Stage III or IV. First choice of treatment for most of thymic epithelial tumors is surgery. In some tumors not only surgery but also radiation therapy and chemother apy are performed. Resectability rate; thymoma stage I: 100%, II: 100%, III: 84 .2%, IVa: 40%, IVb: 45.2%, thymic carcinoma: 50.5%, thymic carcinoid: 87.5%. Recurrence rate; thymoma stage I: 0.9%, II: 3.7%, III: 27.3%, IV: 33 .3%, thymic carcinoma. 51.2%, thymic carcinoid: 64.3%. Overall 5-year survival rate; all thymoma: 94 .8%, thymic carcinoma: 50.5 %, thymic carcinoid: 84.8%, thymoma stage I: 100%, II: 98.3%, III: 89 .2%, IVa: 73.1%, IVb: 63.5%.

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Catamenial pneumothorax is a rare syndrome of pneumothorax which occurs at the time of menstruation. The therapy for this disease has not been established. We operated on 5 cases of catamenial pneumothorax (3 cases via thoracotomy; 2 cases via video-assisted thoracic surgery using minithoracotomy). Affected females were in the third or fourth decade. All had right-sided pneumothorax. Operative findings showed that only 1 case had bulla and all cases had defect, attenuation or, brown spot in their diaphragms. Partial resections of the lung were undertaken in 4 cases, and partial resections of the diaphragm in all cases . Postoperatively, pnuemothorax recurred in 2 cases, and contralateral pnuemothorax occurred in 1 case. Hormonal therapy was not indicated because of patient refusal.
Catamenial pnuemothorax should not be overlooked as a cause of pnuemothorax in woman . We should carefully decide the therapeutic strategy because relapses sometimes occur even after operation.

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The Social Health Insurance System (SHIS) in Japan was updated in April 2000 and here we review 60 cases to estimate the cost of endostaplers used in Video-Assited Thoracoscopic Surgery (VATS) lobectomy. The overall cost of endostaplers in VATS lobectomy was \140, 067 (5.1 staples), or 24.1% of the operation charge. The length of postoperative hospital stay in the VATS lobectomy group was about 10 days shorter than that in the conventional lobectomy group.rMoreover, the hospitalization fee for 7 days was equal to the difference in operation costs between VATS lobectomy and conventional lobectomy. Thus, we consider the changes in the SHIS were improvements in terms of hospital costs. However, since the basic operating charge for a VATS lobectomy includes the cost for a VATS biopsy, it also incurs a heavy loss for hospitals under SHIS. Therefore, there is still some room for reconsideration regarding the current system.

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A 67-year-old male was admitted to our hospital for further examination of abnormal shadow in the left hilar region on chest X-ray . Computed tomography guided biopsy and bronchoscopic lung biopsy failed to make a diagnosis, and the patient was followed as silent lung abscess. During the follow-up, the tumor became enlarged and repeated series of examinations were performed. However, a definite diagnosis could not be obtained . Thor acotomy was performed because of the possibility of malignancy . The tumor was located in the anterior segment of the left upper lobe and extensively adhered to the anterior mediastinal fat. Segmentectomy of the left upper division combined with resection of mediastinal fat was performed. Microscopic examination of the resected specimen revealed a mature intrapul monary teratoma occupying the bronchial tree and no communication to the mediastinum.

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Recently clinical investigations have reported an improvement of survival in localized advanced non small cell lung cancer (NSCLC) after induction chemotherapy by using various combinations of anticancer drugs. A trial of inducton chemotherapy with cisplatin (CDDP) plus vinorelbine (VNB), a new anticancer drug, was conducted in our hospital. Four patients with localized advanced NSCLC received two to three cycles of CDDP plus VNB chemother apy. Two had a Partial Response, and the others had a Minor Response. Three were performed surgical procedures after chemotherapy, and all of them underwent complete resection. One showed pathological complete response in the resected specimens . They all have been alive without recurrence until now. Chemotherapy complication: Grade 3 eutropenia occurred in all. Severe anemia requiring blood transfusion occurred in only one. Grade 3 nausea-vomiting occurred also in only one. The toxicity of the induction chemother apy with CDDP plus VNB was tolerable. Further study is planned to investigate the efficacy of this regimen.

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We report a case of non-nodule-forming malignant lymphoma developing in the pyothoracic wall following artificial pneumothorax. A 69-year-old man, who had undergone an artificial pneumothorax for pulmonary tuberculosis 48 years earlier, was admitted to our hospital for left chest pain. The chest radiograph and CT scan showed a thickened and calcified pyothoracic wall, but no definite tumor mass was revealed in the wall. Pulmonary decortication was performed. Although no discrete tumor tissue was found macroscopically surround the resect ed pyothoracic wall, histological examination revealed that anaplastic large cell lymphoma cells proliferated diffusely in the pyothoracic wall. Immunohistochemical examination of the tumor cells indicated null cell characteristics. Epstein-Barr virus mRNA was found in the tumor tissue specimens by in situ hybridization. Considering that according to previously reported cases of pyothorax-associated lymphoma, the most common presenting symptoms were unrelenting chest pain and a rapidly growing mass, the present case showed a rare growth pattern. Malignant lymphoma should be considered when there is chronic empyema following artificial pneumothorax even if nodular growth was not found in radiological examinations.

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A 16-year-old boy was admitted to our hospital due to chest pain and an abnormal shadow on chest roentgenogram. Chest CT scan showed a sclerosing change in the left fourth rib, and MRI revealed a low intensity tumor. There were no malignant cells seen on needle biopsy . Incisional biopsy under video-assisted thoracoscopic surgery showed a small round cell tumor, and total resection of the mass with combined excision of the third, fourth and fifth ribs was performed on April 2000. The defect in the chest wall was reconstructed with Marlex mesh. The tumor measured 8×3.8×2.2cm and had invaded the fourth rib with destructive change. Histological examination revealed small round cells, containing oval or short spindle nuclei, hyperchromic nuclei, scanty cytoplasm and a Homer-Wright rosette pattern . Immunohisto chemistry showed that the tumor cells were positive for MIC2 gene product. The diagnosis was primitive neuroectodermal tumor of the thoracic wall (also known as Askin tumor). The patient was administered systemic chemotherapy and irradiation to the thoracic wall, and postoperative recovery was uneventful. He has remained free from local recurrence and metastasis for 11 months postoperatively.

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We report here a 36-year old man with a mediastinal mass shown on chest X-ray film. Chest CT and MRI revealed an anterior mediastinal tumor. Although ultrasonic percutaneous biopsy was attempted, a definite diagnosis could not be made, and since a mesenchymal tumor or teratoma was suspected, extirpation of the anterior mediastinal tumor was performed. Pathological findings were malignant teratoma with sarcomatous components (angiosarcoma, osteosarcoma, leiomyosarcoma). This is a rare case of malignant teratoma in the medias tinum.

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The lobar emphysema or intrapulmonary bronchogenic cyst with bulla were incidentally detected in the left lung by chest CT, when a 13-year old boy was admitted for spontaneous pneumothorax. The findings of the abnormal shadow by chest CT scan suggested lobar emphysema or intrapulmonary bronchogenic cyst . Video-assisted upper division seg mentectomy was performed to resect the abnormal shadow completely . Histopathologic examination revealed an intrapulmonary bronchogenic cyst . The preoperative chest CT scan was useful to diagnose intrapulmonary disease and determine the surgical procedure . Surgical treatment would be recommended for an asymptomatic patient with intrapulmonary bron chogenic cyst.

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A 66-year-old woman was admitted due to productive cough, and diagnosed with pneumonia for the first time in her life. After admission, whenever she took food orally, she developed pneumonia repeatedly. A fistula penetrating between the left main bronchus and middle esophagus was observed by esophagography, gastroenteroscopy and bronchofiberscopy, leading to a diagnosis of broncho-esophageal fistula. Resection of the fistula and wrapping of the suture line with an intercostal muscle flap were performed followed by a left thoracotomy. Intraoperatively, a severe inflammatory adhesion was observed around the fistula at the pulmonary hilum. Postoperatively, histopathological examination showed no malignant cells around the fistula. We concluded this case to be an acquired broncho-esophageal fistula based on the clinical course and intraoperative findings.

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Pulmonary Langerhans'cell histiocytosis (PLH) is a granulomatous disorder characterized by Langerhans'cell proliferation mainly confined to the lung. The radiographic features of the disease are usually bilateral and diffuse abnormalities. Localized pulmonary lesions have been reported rarely. We report a case of a symptomless 73-year-old man with PLH presenting as a solitary pulmonary nodule. The patient had a previous history of resection of colon cancer 3 years earlier, and was admitted to our hospital because a nodular lesion had been detected on chest CT performed as part of a routine check up.rThe lesion was 0.5cm in diameter located in the right upper lobe. Because a diagnosis of metastatic tumor was suggested, the patient underwent wedge resection of the nodule. Histological examination of the pulmonary nodule revealed PLH.

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We report a case of a benign clear cell tumor of the lung. A 50-year-old woman was admitted to our hospital with an abnormal shadow on chest X ray film. Chest CT showed a round and well-marginated tumor (10 mm in dia-meter) in the right S⁵, which indicated a benign lung tumor or metastatic tumor. We performed partial resection of the lung. Pathologi cal diagnosis was “clear cell tumor”. The cells had an abundant clear cytoplasm containing glycogen and were immunoreactive for HMB45, but negative for keratin.

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A 74-year-old male was admitted to our hospital because of cough. The chest X-ray film and CT film showed an abnormal shadow in the right hilum and the upper lobe (S²). The tumor was diagnosed as squamous cell carcinoma by bronchoscopic lung biopsy in the orifice of the right B⁶, so middle and lower lobectomy with regional lymph node dissection was performed and partial resection of the right upper lobe was performed.
The histological diagnoses for each of the right B⁶, S², hilar and mediastinal lymph nodes (#7, #10, #11, #12) were squamous cell carcinoma (pT1N0M0 stageIA), well differentiated adenocarcinoma (pT2N0M2 stageIB), and small cell carcinoma (pT0N2M0 stageIIIA).
The postoperative course of the patient has been good with no evidence of recurrence 20 months after the operation.

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The standard operative approach for pleuropneumonectomy repair of chronic empynema even with a destroyed lung, is lateral position and posterolateral incision. The disadvantages of this approach include the aspiration of pus and necrotic tissue to the healthy lung, and the difficulty in debridement of diaphragmatic pleura. We report two cases with chronic empynema with fistula who were successfully treated by pleuropneumonectomy using supine position and anterior approach. Case 1 was a 72-year-old man with chronic empynema with internal fistula after left thoracoplasty for pulmonary tuberculosis. Because the empynema invaded into the retroperitoneal space, we decided to attempt this approach. Case 2 was a 63 -year-old woman with chronic empynema with internal and external fistula after right middle lobectomy for plumonary arterio-venous fistula. Because the pulmonary function was extreme ly poor, we decided to attempt this approach. In both cases, there were no aspiration problems and no difficulty in debridement of the diaphragmatic pleura. Safe and reliable pleurop neumonectomy, with chronic empynema, were applicable. In conclusion, in cases of chronic empynema, even with internal fistula, if pleuropneumonectomy is performed, we suggest the safe and reliable supine position and anterior approach for repair of empynema.

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Spontaneous pneumomediastinum is a rare disease. Most patients are treated only with bed rest and recover in a few days. Secondary pneumomediastinum should be ruled out.
A 12-year-old boy complained of chest pain and dyspnea when he was running during soccer, practice and consulted our hospital. Subcutaneous emphysema on his neck was palpable, and X-ray examination and CT scan showed pneumatosis in the mediastinum. He was diagnosed as having pneumomediastinum and admitted to our hospital. To rule out pneumomediastinum secondary to trauma or another disease, esophagoscopy and bronchoscopy were carried out, but no particular findings were disclosed. Then we made a diagnosis of spontaneous pneumomedis tinum and started conservative treatment consisting of bed rest and antibiotic administration. On the 4th hospital day, we could not observe any pneumatosis on a CT scan and he was discharged on the 5th hospital day. The disease has not recurred for these 6 months in spite of no limitation of sports training.

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We report two successful cases of thoracic duct ligation via a right thoracotomy for postoperative chylothorax. A 53-year-old man with left lung cancer who was admitted to our hospital after chemoradiotherapy underwent left pneumonectomy via a median sternotomy and left anterior thoracotomy. He developed chylothorax postoperatively, which was refractory to medical treatment and sealing with a dexon mesh and fibrin glue via a left thoracotomy . Subsequently, CT revealed chylomediastinum and a thoracic duct ligation via a right thor acotomy was performed. A 69-year-old man who had undergone coronary bypass surgery at other hospital was referred to our hospital because of left pleural effusion . On examination chylothorax was diagnosied, and thoracic duct ligation was performed because the chylothorax was refractory to treatment. Conventional thoracotomy was selected based on two reasons: evere adhesion in right thoracic space was suspected, and to avoid damaging the bypass graft, located in the left thoracic space. Both patients recovered well and were discharged with no sign of recurrence to date. We concluded that thoracic duct ligation via conventional thor acotomy is a useful method in patients with some limitations for thoracoscopic surgery.

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