We retrospectively studied the treatment for spontaneous hemopneumothorax . Of 1045 cases of spontaneous pneumothorax treated in our hospital from January 1978 to May 2001, 15 cases of hemopneumothorax were included in this study (1.4%). The mean age was 35.7 years, ranging from 18 to 56 years, and the male-female ratio was 13 males, 2 females. There was no difference in the incidence between the left and right side. 93% patients had no history of pneumothorax. All patients initially complained of severe chest pain . Of all cases, 20% had hemorrhage shock. The mean total blood loss was 1459ml, ranging from 400 to 7100ml. We performed open thoracotomy for patients with incomplete drainage between 1978 and 1992 before using video-assisted thoracoscopic surgery (VATS). We successfully treated 4 cases using VATS since 1992 . The results of VATS were better than those of open thoracotomy with respect to surgical dulation, postoperative stay, time until operation, intraoperative bleeding and dulation of drainage . We conclude that early surgical repair for spontaneous hemopneumothorax should be performed and that VATS may be the first choice for treatment.

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Background Fibrin sealant is used in many kinds of surgical procedures. Though pasteurization is insufficient to remove human parvovirus (HPV) B19 from this plasma-derived product, the frequency of HPV B19 infection transmitted by its use has never been clarified. Moreover, it has never been clinically proved that fibrin sealant does not transmit hepatitis virus infection.
Methods Blood samples of 85 patients over 20 years of age, who underwent pulmonary resection with fibrin sealant, were obtained before and at least at 2 points of 2, 12, 24 and 48 weeks after surgery. Anti HPV B19 antibody IgG (HPV B19 IgG) and HPV B19 DNA were measured for the detection of HPV B19. HBsAg, HBsAb, and HBcAb were measured for the detection of hepatitis type B virus (HBV). Hepatitis type C virus (HCV) infection was detected with anti HCVAb.
Results In 56 (65.9%) of 85 patients, blood samples obtained before operation were positive for HPV B19 IgG. In these 56 patients blood samples obtained 12 to 48 weeks after surgery were all negative for HPV B19 DNA by PCR. In 6 (20.7%) of 29 patients, whose blood samples were negative for HPV B19 IgG before surgery, blood samples obtained 12 to 48 weeks after surgery were positive for HPV B19 DNA by PCR and also positive for HPV B19 IgG. In 5 of these 6 patients reticulocyte counts were decreased to 1 to 2‰ 10 to 20 days after surgery. In 29 of 85 patients, blood samples obtained before surgery were positive for HBsAb and HBcAb. In 56 patients without HBV infection before surgery, the blood samples obtained 12 to 48 weeks after surgery were all negative for HBsAg, HBsAb, and HBcAb. In 85 patients with HCVAb negative blood samples obtained before surgery, the blood samples obtained after surgery were also all negative.
Conclusions Epidemiological evidence suggests that over 20% of HPV B19 uninfected persons were infected with HPV B19 by use of fibrin sealant during surgery, while neither HBV nor HCV infection was induced by use of fibrin glue.

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Six cases treated for thymic cancer (mean age 53.8 years, three males and three females) were reviewed clinically. The histologic subtypes of the thymic cancer were squamous cell carcinoma in five, and poorly differentiated carcinoma in the other. There were two Stage II, and four Stage IVb cases. One stage IVb case was preoperatively diagnosed as thymic cancer by needle biopsy, and received induction chemoradiotherapy with excellent response (Ef.3). All cases underwent extended thymectomy and four also underwent resection of invading organs. All cases underwent postoperative adjuvant therapy: three with radiotherapy, two with chemoradiotherapy, and one with chemotherapy. We have three recurrent cases, two cases of which survived more than 5 years with the multimodal-therapy such as chemotherapy, radiation, PEIT (percutaneous ethanol injection therapy), and resection of the local recurrent lesion in the chest wall or pleural. However, the role of chemotherapy in thymic cancer is less well-defined. We report one recurrent case of pulmonary metastasis well-controlled by chemotherapy using Gemcitabine and Docetaxel.

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We introduce the method and feasibility of percutaneous radioisotope injection for identification of senti nel lymph node in lung cancer . Six consecutive patients with clinical N0 lung cancers were eligible for this clinical trial. Patients first underwent body surface marking under CT guidance . Then, 99mTc-tin colloid was injected percutaneously in the RI examination room. RI labeled lymph nodes were detected at thoracotomy and at the completion of entire lymph node dissection by a handheld gamma probe . RI injection accounted for minor morbidities consisting of slight pneumothorax and slight hemoptysis not requiring any therapy . In vivo identification of RI labeled lymph node was disturbed due to airway seeding of radioisotope . Ex vivo sentinel lymph node was identified in 5 of 6 patients . Localization of sentinel node were level 12 in 2 cases, level 11 in one case and level 5 in one case. All the patients showed pathological N0 disease . According to this preliminary study, utility as well as some problems were proposed . Further study will be required to verify the value of sentinel lymph node biopsy in lung cancer.

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Carcinoids are rare in the thoracic surgery field and can be generally divided into primary pulmonary and primary thymic carcinoids. Although they are considered low-grade malignant tumors, occasionally they show a poor prognosis, especially in patients with atypical carcinoids . In this study, 28 patients with pulmonary carcinoids and 11 thymic carcinoids underwent operations at our department and were analyzed comparatively using clinical factors.
The 28 pulmonary carcinoids account for 0.83% of all 3371 resected lung cancers in our department, while the 11 thymic carcinoids account for 1.67% of all 662 mediastinal tumors resected.
There were no significant differences in sex or age distributions . About 60% of the patients were asympomatic and they were discovered by chest radiographs in population-based mass screening . The rate of correct pre-operative diagnosis for pulmonary carcinoids is 64.3% (18/28), while that for thymic carcinoids is 40% (2/5). Invasions to adjacent organs were found in cases of thymic carcinoids (27.3%, 3/11). Nodal involvement was observed in 5 of 15 atypical pulmonary carcinoid patients . The five-year survival rate of patients with thymic carcinoids was 38.9%, which was significantly worse than that of patients with pulmonary carcinoids (90.4%).
In patients with thymic carcinoids, local recurrences were frequently observed.
Based on these findings, it is now recommended that systematic nodal dissection should be done for atypical carcinoid patients, and that an adequate surgical margin should be left for thymic carcinoids.

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A 29-year-old man had chest pain and was found to have an anterior mediastinal tumor. A needle biopsy using computed tomographic imaging revealed a germ cell tumor composed of embryonal carcinoma and teratoma. The serum concentration of alpha-fetoprotein (AFP) was elevated at 9600 ng/ml, but all other tumor markers including beta-human chorionic gonadotropin were in the normal ranges. On December 16, 2000, combined chemotherapy (PEB regimen: cisplatin+etoposide+bleomycin) was administered twice, and high-dose chemotherapy (ICE regimen: carboplatin+etoposide+ifosfamide) followed by peripheral blood stem cell transplantation was also performed twice. After chemotherapy, the serum concentration of AFP decreased to 44.3 ng/ml, but was still high. Surgical resection followed by chemotherapy (PE regimen: cisplatin+etoposide) was performed, and the serum concentration of AFP decreased to a normal level 28 days after surgery. Histological examination of resected specimen revealed an immature teratoma. At present six months after surgery, the serum concentration of AFP is at a normal level and there are no signs of recurrence.

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We report successful surgery for chronic hemorrhagic empyema accompanied by a silent bronchial fistula detected after resection of the empyema cavity. A 68-year-old man with a history of tuberculous pleurisy was admitted because of progressive anemia, right heart insufficiency and penetration of expanding empyema cavity beyond the thoracic wall. After repetitive transcatheter embolization of the bronchial artery and internal thoracic artery, we performed curettage and resection of the empyema cavity. Then a bronchial fistula was detected at the membranous part within the right intermediate bronchus. Because of intraoperative cardiac dysfunction, we covered the bronchial fistula with intercostal muscle flap and fenestrated following omentopexy at postoperative day 13. The postoperative course was satisfactory and patient is in good health with no recurrence seven months post operatively. We speculate that the bronchial fistula was due to ischemia of the bronchial wall caused by repetitive transcatheter embolization and oppression with empyema cavity. Formerly, panpleuropneumonectomy was considered to be a radical surgical procedure for chronic hemorrhagic empyema, however, a less invasive method, curettage and resection of the empyema cavity, is also a useful technique for patients with this disease.

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A 52-year-old man was referred to our hospital for further investigation and treatment of a tumor shadow noted on chest X-ray in January, 2000. The chest CT scan showed a large tumor shadow in the right upper lobe. Tumor markers (keratin, SLX, CYFRA and NSE) were elevated. On January 25, right upper lobectomy with regional lymph node dissection and partial resection of the third rib were performed . Pathological diagnosis was combined large cell neuroendocrine carcinoma (LCNEC) and squamous cell carcinoma, and histological staging grade was II B (T3N0M0). The postoperative course of the patient was good, but he had a local recurrence 10 months after discharge and then died.

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A 63-year-old male was admitted to our hospital in February 2001, because of abnormal findings on sputum cytology detected by a mass screening program. Chest X-ray film did not show any particular finding's (occult case), but the patient was diagnosed as having moderately differentiated squamous cell carcinoma at the orifice of the right B⁷ by transbronchial biopsy. Immediately after right S⁷ segmentectomy under thoracoscopic surgery, icterus and severe anemia appeared necessitating a blood transfusion. Postoperative hematological investigation revealed the presence of severe hemolytic anemia. Finally, he was found to have hereditary spherocytosis (HS) on microscopic findings of a blood smear and characteristic osmotic fragility. HS is the most common type of congenital hemolytic anemia, and is a genetically determined red blood cell membrane disorder resulting in hemolytic anemia. The patient was discharged on the 18th postoperative day and is doing well. A very rare case of lung cancer associated with HS was reported.

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We report a case of extrinsic empyema thoracis occurring as a complication of severe chest wound . A 22-year-old zookeeper was attacked by a lion. He underwent urgent surgery at another hospital to control right intrapleural hemorrhage from multiple rib fractures and torn lung parenchyma. The patient was referred to our hospital for treatment of postoperative empyema 4 days after the accident. The empyema was secondary to a large gangrenous area in the chest wall.Following extensive debridement and intrapleural irrigation during a second thoracotomy, the patient was successfully treated by 4 weeks of closed thoracic drainage and positive airway pressure ventilation.The patient was discharged 87 days after the second surgical intervention. In such cases, sufficient surgical debridement followed by positive airway pressure ventilation is necessary to control the infectious foci of extrinsic empyema.

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We reported two cases of locally advanced non-small cell lung cancer successfully treated with induction chemo-radiotherapy using weekly carboplatin and paclitaxel.
In case 1, a 71-year-old man had squamous cell carcinoma in the right upper lobe, and an undiagnosised tumor in the left S⁶ field. After weekly chemotherapy with carboplatin at AUC 1.25 and paclitaxel 70mg/m² for 6 weeks that achieved a partial response, radiation therapy was administered to the right tumor. Right upper lobectomy was performed followed by left S⁶ segmentectomy without operative complication.
In case 2, a 65-year-old woman with an adenocarcinoma in the left S⁶ was performed left pneumonectomy after induction concurrent chemo-radiotherapy with weekly carboplatin at AUC 1.25 plus paclitaxel 40mg/m² and radiation therapy that achieved a partial response without complication.
Induction chemo-radiotherapy with weekly combined carboplatin and paclitaxel may be effective for locally invasive non-small cell lung cancer.

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A 16-year old male, complaining of edema of the face and neck, was admitted to our hospital. Chest X-ray and chest CT scan revealed a huge mass at the anterior mediastinum. We recognized an oncologic emergency with superior vena cava syndrome and airway obstruction. With the core needle biopsy under local anesthesia we were unable to get a histological diagnosis. Therefore we performed open biopsy under general anesthesia and diagnosed seminoma accurately. Chemotherapy using cisplatin and etoposide was most effective.
For a massive anterior mediastinal tumor developing into an oncologic emergency, open biopsy under general anesthesia followed by the best protocol of chemotherapy was effective.

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We report a case of aberrant mediastinal goiter (AMG) that was resected in VATS. A 31-year-old woman presenting with abnormal chest shadow was admitted. Chest CT revealed a right upper mediastinal mass, that measured 48mm×40mm. The mass exhibited a clear margin and nonhomogeneous density. MRI demonstrated no communication between the mass and the thyroid gland; moreover, there were no major feeding arteries or veins detected. Thyroidal scintigraphy and thyroid function test showed a normal pattern. The mass was resected in VATS and diagnosed as adenomatous goiter on the basis of histological findings. AMG is a rare mediastinal tumor. Documentation indicates that AMG is characterized by a copious blood supply. However, mediastinal mass resection by VATS was performed uneventfully as a result of preoperative examination of the feeding vasculature. The relation of the main vasculature was examined by enhanced CT and MRI prior to surgery. We submit that VATS is beneficial in cases of mediastinal tumor.

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A 67-year-old female was admitted to our hospital because of a chest pain. On chest roentgenography and CT, a hemispherical tumor that was protruding laterally and attaching to the descending aorta and chest wall was found in the hilum of left lung. The illness was diagnosed as left posterior mediastinal tumor preoperatively. Since schwannoma was suspected, thoracoscopic excision was performed. In this case, the lesion showed obscure boundary with the surrounding area, and was difficult to detach and easily hemorrhagic. It was diagnosed as hemangioma quickly during operation . The tumor was 2.5×2.5 cm in size and diagnosed as cavernous hemangioma after operation. Forty-five cases of mediastinal hemangioma have been reported to date, and the tumor was excised by thoracoscopy in 4 cases of them including the present case. Since hemangioma in the mediastinum is rare, we presented a case together with literature review

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We encountered a case of huge non-invasive thymoma incidentally discovered in a female patient during breast cancer surgery. The anterior mediastinal tumor was detected in a pre-operative examination for left mammary cancer excision at another hospital in 1984 when the patient was 72 years old . The clinical progress of the case was followed at regular intervals for 2 years postoperatively using thoracic CT. However, the patient was not examined at all after the transfer of the physician in charge to another hospital . From 1998, expectoration increased and exertional dyspnea appeared and in May 1999 pneumonia-like symptoms and hemoptysis also appeared. The patient was admitted to our department in July 1999, and on admission thoracic CT showed a 15-cm tumor on the left side of the anterior mediastinum and obstructive pneumonia in the lower lung. In August 1999, the tumor (15×10×10cm) was resected via a median sternotomy and left transversal thoracotomy. Pathological examination showed a spindle cell type thymoma with no capsular invasion and based on this finding diagnosed the stage as Masaoka's Clinical Stage I . No recurrence or symptoms have been noted in the 2 years since the operation . The clinical properties of non-invasive thymoma are discussed.

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We report a case of emergency operation due to perforation of an infected mediastinal teratoma into the right lung. An 18-year-old man had a mass shadow in the right hilar region on chest X-ray, and chest CT revealed an anterior mediastinal tumor. On May 17, 2001, he had severe chest pain and hemosputa accompanying high grade fever. Infiltration shadow in the right middle and lower lung field was pointed out on May 20, 2001. Ultrasonography guided needle aspiration revealed that the cyst content was infected by staphylococcus aureus, and the level of amylase, lipase, and trypsin was 0 IU/L, 4 U/L, and 19 ng/L, respectively. Because the general condition of the patient became worse during hospitalization, we performed urgent resection of the mediastinal tumor and the right middle lobe. The thoracotomy demonstrated that the mediastinal tumor perforated into the middle lobe causing severe inflammation. Histopathologically, the tumor was diagnosed as benign teratoma.

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A 55-year-old man had received home oxygen therapy for five years for progressive emphysema, and was admitted to our hospital with severe and progressive difficulty in breathing. Dynamic chest computed tomogra phy and bronchofiberscopy revealed 80 percent stricture from the trachea to the bilateral main bronchi. He was diagnosed with grade 3 tracheobronchomalacia using Johnson's classfication, and span plasty with a ringed PTFE was planned. We cut a ringed PTFE with a diameter of 12mm and length of 2.5cm. After dividing the prosthesis longitudinally, its curve was spread. The rings were cut in various portions to fit the membranous portion of the trachea and bronchi. We first sutured the reinforcement to the edge of the cartilaginous rings with 4-0 PSD-II. It was then sutured in a similar fashion at the proximal, distant and central points of the membranous portion. This process was repeated every 2 or 3 cm from the trachea at the apex down to the bilateral main bronchi. His symptoms were markedly improved postoperatively and he could leave the hospital. Postoperative dynamic chest computed tomography and bronchofiberscopy revealed good preservation of tracheal caliber throughout.

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