From January 1, 1981 to June 30, 1991, 238 patients were admitted to our hospital with spontaneous pneumothorax, 26 of them with bilateral pneumothorax. The age range was 15-76 years (average 30.3); all these patients were male. Of the 26 patients, 6 had bilateral synchronous pneumothorax and 20 had metachronous pneumothorax. The incidence of bilateral synchronous pneumothorax was 2.5% and that of metachronous pneumothorax was 8.4%. The age range of those with synchronous pneumothorax was 15-66 years (average 32) at onset, and 5 of the 6 had concomitant diseases, such as bronchial asthma. The interval between the first and the synchronous contralateral pneumothorax was 1-48 months (average 17.6). The age range of those with bilateral metachronous pneumothorax was 15-76 years (average 26.9). Of the 20 with metachronous pneumothorax, 8 were in their teens and 7 in their twenties. The interval between the first and the contralateral pneumothorax was 0.7-204 months (average 32.2). The interval for those in their teens was 0.7-37 months (average 10.6). Of the 26 cases, 17 were treated with a one-stage operation through a bilateral axillary incision, one was treated with a one-stage operation through a median sternotomy and 5 were treated with a two-stage operation through a bilateral posterolateral incision. We conclude that a one-stage operation through a bilateral axillary incision is indicated for unilateral spontaneus pneumothorax in teen-aged patients.

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We evaluated the severity of chest wall deformity in 47 patients with funnel chest (40 males and 7 females ; age range, 4-28 years) using three indices derived from computed tomogram (CT) findings, and analyzed the correlations between these indices and lung function determined by spirometry. Indices were right-left ratio, which reflects the extent of asymmetry, depression ratio, which reflect the extent of chest wall depression, and deformity ratio, which reflects the overall severity of chest wall deformity.
The mean values of vital capacity as percentage of predicted (%VC), forced expiratory volume in one second as percentage of predicted (FEV_1.0%), the ratio of residual volume to total lung capacity (RV/TLC) were all within normal limits. %VC was decreased in those with high deformity ratio, but not in those with high right-left or depression ratios. FEV, 0% did not decrease with increase of any of these indices, nor was any clear correlation between RV% and any of these indices observed.

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From 1975 through 1990, 621 patients were operated on for primary lung cancer. Postoperative pulmonary complications appeared more often in the patients with preoperative FEV_1.0 less than 1 l/m². Passive limited resection is applied to those patients with preoperative FEV, _1.t less than 0.7 l/m², and for those with preoperative FEV_1.0 0.7-1 l/m², the type of resection is determined taking other factors into consideration.
When limited resection is applied for patients with primary lung cancer, there is a probability of leaving cancer tissue in lymph node or pulmonary metastase in the same lobe. Postoperative pathological studies of the 164 cases of c-NO peripheral type non-small cell lung cancer showed that when limited resection is perfomed, the risk of leaving cancer tissue unresected was 28.7%.

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An experimental study of the immunosuppressive effects of a new immunosuppressant, FK-506, in 23 canine lung allotranplantation is described. FK-506 was intramuscularly injected daily in a dose of 0.10 mg/kg after allotransplantation. One recipient dog died of lung rejection, but twenty two survived from 7 to 86 days until sacrifice. Microscopic examination showed a normal lung in 10, mild rejection in 8, moderate rejection in 2, and severe rejection in 3 dogs. No dog died of FK-506 toxicity, but 87% had appetite loss, 78% had diarrhea, and 9% had bloody stool during FK-506 treatment. Weight loss averaged 2.1 kg (18.9%) 3 weeks after transplant surgery. Mild rejection of the grafted lungs could not be detected on chest roentgenograms, but moderate rejection showed perihilar infiltration. Bronchofiberscopy showed no bronchial anastomotic stenosis, and the suture line was covered by normal mucosa 3 weeks after transplantaotion. The L/C ratio (bronchial mucosal blood flow at the second carina of the graft/blood flow at the carina of the recipient) was 1.05±0.24 (n=11) in normal lungs of control dogs. The L/C ratio decreased to 0.57 ± 0.09 (n=11) after transplantation, but recovered to 1.03 ± 0.10 (n=7) by 3 weeks after surgery. The inflammatory response score (IRS) was 8 (n=2), 4.3 ± 1.0 (n=4), and 2.0 ± 1.2 (n=7), 1, 2, and 3 weeks after transplantation, respectively. We have demonstrated that FK-506 is an effective immunosuppressant for canine lung allografts and that it does not interfere with the reconstruction of bronchial mucosal blood flow or the bronchial healing process. We conclude that FK-506 is a useful immunosuppressant for lung allotransplantation.

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From April, 1990 to March, 1991, granulocyte elastase and other parameters were examined after operations for lung cancer. Four patients died, and nine survived. Five patients with pneumothorax served as controls. Leukocytes, granulocytes, granulocyte elastase, elastase/ granulocyte ratio, AT-III, TAT, α-PI and the respiratory index were measured on the day before operation and on the first, third and fifth days after operation. In the control group, granulocyte elastase remained within normal limits (21-165 μg/l). The survival group had transient increases of elastase on the day after operation, but normal levels by the fifthdays. In the patients who died, elastase levels were above 500 μg/l on the day after operation, and they continued to increase. High elastase levels cause a hypercoagulable state and respiratory disturbances. It is useful to predict DIC and respiratory complications after operations for lung cancer.

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The course of healing of tracheal autografts treated with omentopexy was studied histopathologically in 15 dogs. In Group 1 (n=6) tracheal autografts were implanted in the greater omentum for 5, 10, and 28 days. The omentum alone could restore the totally ischemic tracheal autografts irrespective of their length. The epithelium of the grafts originated from the donor and a layer of reepithelialization was seen in their membranous portion and between the tracheal rings where revascularization seemed to be quite rapid. There was hardly any damage to the cartilage. In Group 2 (n=9) the trachea of less than 4 cm in length were excised and reimplanted as autografts with omentopexy. Inflammation and damage to the epithelium and tracheal glands remained for a long time. The healing of the tracheal autografts was closely associated with the restoration of epithelium and subepithelial tissues. Histopathological healing of tracheal grafts required more than 2 months.

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The DNA content was determined by flow cytometry in fine needle aspiration samples and fresh tumor samples of 24 resected lung cancers.
The aspiration was carried out with 21 gauge needles once or three times at the same point of the tumor. Each tumor was sampled with two fine needle aspirations (3 times or 1 time) and one fresh tumor sample.
The coefficient of variation showed no statistically significant difference between fine needle aspiration samples and fresh tumor samples.
The DNA indices in fine needle aspiration samples of 24 lung cancers correlated closely with those in fresh tumor samples : 0.84 and 0.98, respectively.
There was a good correlation between the percentage of cells in the S-phase in the fine needle aspiration samples and in the fresh tumor samples from the same tumor.
Flow cytometrically determined DNA content in fine needle aspiration samples should be useful in the evaluation of lung cancer.

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We treated seven patients with a spontaneous pneumothorax by Nd : YAG laser through thoracoscope. The patients were all male and the average age was 25.6 years. Four patients had recurrent pneumothorax, and in three it was the first episode which had not been cured by continuous suction therapy. The main role of Nd : YAG laser in pneumothorax was to cause coagulation by a photothermal reaction on the ruptured blebs. The power level used in the treatment ranged from 6 to 10 watts, irradiated by continuous waves for 1-3 seconds. We use surgery for localized blebs, but suggest that this laser therapy be used for multiple emphysematous blebs and/or giant bullae, and also for patients with poor respiratory function in whom thoracotomy is contraindicated.

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A 39-year-old man was admitted with the chief complaint of cough. Chest X-ray and CT scan showed a large mass in right hilum, and bronchoscopy showed complete obstruction of the truncus intermedius by an intrabronchial tumor. He underwent 60Co irradiation (20 Gy × 20) and bronchial arterial infusion. Forty days after the second infusion, he developed a bronchoesophageal fistula. Right sleeve pneumonectomy and subtotal esophagectomy were performed. The esophagus was repaired with a stomach roll with omentum. Bronchial and esophageal anastomose were wrapped with an omental pedicle flap. Both anastomose were healed well. However, he died 67 days after operation from a brain metastasis which was not evident before operation. Treatment for malignant bronchoesophageal fistula is still difficult. This report describes one-stage surgical repair of a bronchoesophageal fistula.

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We treated a patient with myasthenia gravis who developed invasive thymoma. The intrathoracic dissemination of thymoma was found 6 and 13 years after the initial surgery, and resection was repeated. During thoracotomy for recurrent thymoma, no dissemination was detected in the mediastinal pleura which had been irradiated previously. The dissemination was found primarily around the costodiaphragmatic recess, which was outside the field of irradiation. These findings suggest that radiation therapy is useful for invasive thymoma. We believe that it is necessary to pursue more aggressively surgical therapy combined with radiotherapy in the treatment of invasive thymoma.

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A 64-year-old man with an abnormal shadow on chest X-ray films was admitted for further examination. Physical and biochemical examinations revealed no significant abnormalities except for mild hyperlipidemia. The chest X-ray films and chest CT scan showed a round mass, 18 × 17 mm in diameter, in the left S⁵.
Wedge resection of the tumor was carried out, and it was found to be a multilocular cystic tumor containing mucinous fluid. The pathological diagnosis was mucinous cystadenoma with high columnar epithelium which stained positively with PAS, CEA, CA 19-9, and EMA.
The postoperative course was uneventful, and the patient has done well for the past 2 years and 6 months since the operation.
Only 3 cases have been reported in the literature to date, so as many data as possible should be made available on this disease.

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The patient is a 66-year-old woman, whose chest roentgenogram revealed a coin lesion in the right lower lung field. Partial resection of the right lung was performed for metastatic lung tumor. The resected tumor was presumed to be leiomyosarcoma, but the diagnosis was uncertain. Six months later, a chest roentgenogram revealed a similar coin lesion in the left lower lung field. Left S6 segmental resection was performed. Histological examination revealed black pigmentation with the Fontana Masson silver stain in spindle-shaped cells in the resected tumor, so malignant melanoma was diagnosed. The previous metastatic tumor of the right lung was reexamined and finally diagnosed as malignant melanoma. There was no evidence of malignant melanoma in the skin, eyes or genital region. Therefore, a soft palate tumor which had been resected six years ago was considered to have been the primary lesion.

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Primary malignant fibrous histiocytoma (MFH) of the lung is very rare. As far as we know, only 15 cases have been reported in the literature in Japan. A 74-year-old female was admitted because of bloody sputum. Her chest X-ray showed a round tumor shadow (40×37 mm) in the left lung field. Since the tumor increased size, left upper lobectomy was performed. The specimens showed the typical storiform pattern of fibroblast-like cells and histiocyte-like cells with scattered giant cells. The serum ferritin level was slightly increased and the serum α1-antitrypsin level was within the normal range. No abnormal finding was detected by Gascintigraphy after the operation. Therefore the tumor was diagnosed as the primary MFH of the lung. The increased serum ferritin level might be a marker for MFH.

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A 13 year-old girl had a mediastinal lipoma which was curatively removed and histologically diagnosed as a myxolipoma on the basis of the presence of atypical vacuolated cells and the absence of infiltration and lipoblasts in the lesion, differentiating it from liposarcoma. The patient is alive and disease-free two years later.

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A-70-year old female with lung cancer was treated with left upper lobectomy and resection of the posterior chest wall, including the 2nd, 3rd, 4th, and 5th ribs. Postoperatively, the left arm was immobile because the lower half of the scapula collapsed into the chest wall defect. Reconstruction of the chest wall was performed 3.5 months after the original surgery. A silicone block 15 mm thick was pressed until it was 8×12 cm in area. With marlex meshes it was applied in a sandwich-like manner as supplementary material to reconstruct the defective site of the chest wall. To prevent contact of the material with the scapula, the reconstructed region was covered by a latissimus dorsi muscle flap. For the prevention of flail chest after resection of the chest wall, a support stronger than that of the conventional method was necessary in this reconstruction. Postoperatively, the patient was able to raise her arm, and no local complications were found at the reconstructed site. This method was therefore considered to be useful for reconstruction of the chest wall.

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