Ten patients with thymic carcioma were studied clinically : 6 had squamous cell carcioma, one had spindle cell carcinoma, one had undifferentiated carcinoma, one had adenosquamous cell carcinoma, and one had small cell carcinoma. Most of the lesions were dvanced according to Masaoka's classification. The clinical stage was II in one patient, III in one, and IVb in 8. Lymphnode metastases were found in the mediastinum in 8 patients, in the neck in 4, in the abdomen in 2, and in the axilla in one ; hematogenous metastases were present in one patient. In spite of these metastases, 5 patients including 4 with squamous cell carcinoma, could be operated on, and the results were good : mean survival time 23 months, compared with 15.5 months in non-operated patients, in whom local invasion was the main cause of death. Chemotherapy and irradiation showed minimal effects. These data suggest that local control should be the main goal for thymic carcinomas. Wide resection with lymphnode dissection may yield favorable results, especially in squamous cell carcinoma patients.

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We studied the modes of extension in 11 patients with malignant mesothelioma of the pleura. Four of them had lymphatic extension only, and four had both lymphatic and blood-borne extension. None had only blood-borne metastasis. Dissemination along aspiration tract and operative wound were observed in two cases. Pneumothorax was observed in four. This may have been caused by invasion of the visceral pleura by tumor cells. Histological examination in the three patients tested revealed nodal involvement of the pulmonary hilum. Complete removal of gross tumor was performed in four patients, but three of them had local recurrence within six months. To improve the prognosis in cases of malignant mesothelioma, systematic lymphatic dissection of the pulmonary hilum, mediastinum and parasternal region are essential. Lavage of the operative field and changes of instruments and apparel are also recommended. More attention should be paid to pneumothorax in elderly patients because it is sometimes due to underlying mesothelioma.

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The prognosis of surgical treatment for p-N2 non-small cell lung cancer was analyzed and the mediastinal lymph system was minutely dissected. Forty nine patients underwent relatively curative pulmonary resection for N2 right non-small cell lung cancer at Nakano National Chest Hospital from 1979 to 1992. They were classified into two groups, high level N2 Group (H) : patients with metastases to superior mediastinal, paratracheal or pretracheal lymph nodes, and low level N2 Group (L) : patients without metastasis to superior mediastinal, paratracheal or pretracheal lymph nodes. The 5-year survival rate of 27 % for. group H was significantly less than that of 64 % for group L. Patients in group H were divided into two groups, Hi : patients who had only paratracheal or pretracheal lymph nodes metastases without other mediastinal lymph nodes metastases, and H2 : patients with superior mediastinal lymph nodes metastases or multiple mediastinal lymph nodes metastases. The 5-year survival rate of 19 % for group H1 was lower than that of 30 % for group H2.
The mediastinal lymph system of 7 cadavers were dissected minutely. The last mediastinal lymph nodes connecting directly with the venous angle or the cervical lymph nodes were identified. The superior mediastinal lymph nodes of all cases, the pretracheal lymph nodes of 6 cases and the para-aortic lymph nodes of 4 cases were the last mediastinal lymph nodes. The poor prognosis of group H seems to be due to the fact that not only the superior mediastinal lymph nodes but also the pretracheal lymph nodes connect directly with the venous angle or the cervical lymph nodes.

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The management of bronchial fistula after radiation therapy remains a problem area in the field of thoracic surgiry.
A 60-year-old female underwent rigth radical mastectomy and radiation therapy for right breast cancer 28 years ago. Ten years after operation, she developed a bronchial fistula in the anterior chest. Several surgeons in other hospitals failed to close the bronchial fistula.
We performrd an omental pedicle flap closure with a rectus abdominis myocutaneous flap for the bronchial fistula on 21 August in 1991.
Postoperarive complications were abscess in abdominal wall and in part of the transplanted flap, peritonitis, and pneumonia.
But the operative wound healed, and the bronchial fistula closed successfully 2 months later.
Omental pedicle flap closure with rectus abdominis myocutaneous flap should be effective for intractable bronchial fistula after radiation.

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The first patient, an 8-year-old female, was admitted with the diagnosis of right pneumothorax. She had the obvious skeletal and cardiovascular characteristics of Marfan syndrome. Her family history revealed that her father had had surgery for dissection of the thoracic aorta and had skeletal malformations. The second patient, a 17-year-old female, was the older sister of the first, and the third patient, a 15-year-old male, was her older brother. They were admitted with left pneumothorax, and they had the same skeletal and cardiovascular manifestations as the first case.
In all three, the lenses were normal, but a diagnosis of Marfan syndrome was established on the basis of their characteristic skeletal and cardiovascular manifestations and family historyHLA typing showed the A2-BW61 halotype

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A 60-year-old woman had been followed for middle lobe syndrome for 6 years. Atelectasis of the right middle lobe gradually increased for 6 months. Transbronchial lung biopsy (TBLB) showed probable malignant lymphoma. Direct invasion of the right upper lobe was suggested by computed tomography. The patient underwent upper and middle lobectomy and partial resection of the right lower lobe (S7) with radical dissection of hilar and mediastinal lymphnodes. Histological examination revealed diffuse small cell type malignant lymphoma (B cell origin) without lymphnode metastasis. The postoperative course was uneventful.
A 5-year survival rate of more then 70% can be expected in patients with complete surgical resection prior to chemotherapy.

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A 21-year-old female was found to have a well-difined shadow in the right lung.
We could not distinguish the tumor from mediastinal tumor by chest X-ray or chest CT scan. Bronchial arteriography revealed that the tumor was in the lung. She underwent segmentectomy of right S7. Histological examination showed sclerosing hemangioma of the lung.

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A giant mediastinal teratoma, asymptomatic for 19 years, was dignosed in a 31-year-old female admitted to our hospital because of an abnormal shadow on routine chest X-ray. Respiratory function tests showed restrictive pulmonary dysfunction. Laboratory studies revealed increased CA19-9 in serum. Plication of the diaphragma was done because the phrenic nerve wan cut during operation. The histological diagnosis was mature teratoma associated with aberrant adenomatous adrenals. CA19-9 revealed that adrenals was a only tissue that had CA19-9 activity.

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We treated three patients with intrathoracic needles. In two patients the needles were located in the lung and were removed under thoracotomy. The other needle was in the pleural space, and it was removed with thoracoscopy. Intrapulmonary two needles were a sewing needle and an injection needle, and intrapleural one was an acupuncture needle. The injection needle was thought have broken off accidentally during an intravenous injection and reached the lung via the heart. The other two needles were thought to have been inserted into the lung or pleural space through the thoracic wall.

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We have recently treated three patients with carcinoma of the thymus. A 63-year-old man complained of hoarseness, dry cough and mild dysphagia. The tumor had markedly invaded the trachea, esophagus and surrounding structures and required palliative resection. Histologecally, the tumor was squamous cell carcinoma. The second patient was a 60-year-old man who complained of pain and dullness of the right upper arm and a right supra clavicular nodule. The tumor was at the junction of the right superior and posterior mediastinum and the neck. Partial resection of the tumor was performed because marked invasion of the mediastinum was evident. Clear cell carcinoma of the thymus was noted histologically. The third patient was a 44-year-old man with no complaints. An encapsulated tumor was located anterior to the carina but posterior to the SVC. The tumor was completely resected at operation. The histological diagnosis was undifferentiated carcinoma of the thymus. A review of previously reported cases indicates that carcinomas of the thymus frequently invade surrounding strctures and that they show various morphological features. Therefore, in many cases diagnosis and selection of therapy are difficult. Our hope is that discussion of this subject will increase, enabling physicians to acquire a clearer concept of the diagnosis and therapy of carcinomas of the thymus.

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Diagnostic imaging showed a mass shadow involving bronchi and blood vessels in the right lower pulmonary hilum of a 71-year-old male. Poorly-defined confluent opacifications were also present in the peripheral lung field, but they shrank with time into spotty shadows. Right lower lobectomy was performed, and pathological examination revealed moderately differentiated adenocarcinoma (p-T3N2M0, stage IIIA). Two reduced lesions in the peripheral lung field had convex margins and were diagnosed pathologically as pulmonary infarctions. No intravascular tumor thrombus was noted. Lung cancer with extensive central invasion is sometimes accompanied by pulmonary infarction, and it is necessary to rule out pulmonary metastasis when there is rapid resolution of infarction.

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We describe the successful management of superior vena cava syndrome (SVCS) associated with metastatic lung tumor expanding into the mediastinum. We used a self-expandable metallic stent, Gianturco type.
A 19-year-old man underwent partial resection of the left femur for osteosarcoma. Chemotherapy was administrated. Two years later, metastatic tumors were found in the right lung. A few partial resections were performed. After 1 year, facial edema occurred and extended to his neck and arms, causing marked discomfort. We inserted a Gianturco self-expandable metallic stent into the SVC. Edema of face and upper extremities was relieved. With this stent it was very easy to treat SVCS. It is recommended for the palliative treatment of endstage metastatic lung tumor.

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Lung torsion is rare, and only a few cases have been reported in the medical literature. We describe a patient in whom lung torsion occurred following right upper lobectomy.
Our patient was a 58-year-old man who had a right upper lobectomy for bronchogenic carcinoma. On the first postoperative day, his chest radiograph showed atelectasis of the right middle lobe. Bronchoscopy revealed only an inflammatory change in the orifice of the right middle lobe. A plain chest radiograph, showed that the atelectatic lobe had not improved and position of the right lower lobe was abnormal. On the eight postoperative day, a reexplorative thoracotomy was performed. Adhesion of the mid mediastinum was present at S⁶, to be causing the residual lobes were twisted. The middle lobe was heavy and boggy with a blue-black hemorrhagic appearance. V⁴⁺⁵ was obstructed by thrombi, but A⁴⁺⁵ was patent. Middle lobectomy was performed and his postoperative course was good.

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A 36-year-old female was admitted because of recurrent spontaneous pneumothorax after tube drainage. Neither chest X-ray nor chest CT scan showed any abnormal findings. Surgical operation combined with pleurodesis revealed the presence of multiple bullae and granular nodules were incidentally found in the lung. A biopsy specimen revealed typical pulmonary lymphangiomyomatosis. She has had no episode of pneumothorax and has been asymptomatic since the thoracotomy one year ago. This patient had early stage pulmonary lymphangiomyomatosis. Even if no symptoms are present and X-rays are negative, in cases of repeated pneumothorax in females, histological studies need to be performed for diagnostic confirmation.

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A 71-year-old male with a history of ethanol abuse for 50 years and chronic pancreatitis for 15 years had had hemoptysis for more than one year. Chest radiographs on admission demonstrated infiltration in the left lower lung field with on pleural effusion. Fiberoptic bronchoscopy revealed small hemorrhages from the left B¹⁰.Neither malignant cells nor acid fast bacilli were detected in brushing materials of washing fluid obtained from left B¹⁰. To clarify the cause of hemoptysis, open thoracotomy was performed on July 16, 1992. Pancreatic fistulas were seen penetrating the diaphragm, which were continuous with the pleura at the base of the left lower lobe. The lower lobe was resected, and pathological examination showed that pancreatic fistulas perforated the diaphragm and reached the bronchial tree. The clinicaopathological and radiological findings are described in this rare care of chronic pancreatitis causing hemoptysis.

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A 74-year-old female had left upper lobectomy for lung cancer. Torsion of the lower lobe occurred 24 hours later. The diagnosis was made from chest x-ray films and bronchofiberscopic findings. Chest x-ray films showed an opaque shadow in the left lower lobe which increased gradually in density and finally developed into atelectasis. Bronchofiberscopy showed narrowing of the lower lobe bronchus and 90-degree clockwise torsion of the B6 bronchus. Complete occlusion was noted 48 hours after surgery. Since her condition was good, conservative treatment was chosen instead of a seconed thoracotomy.
After 14 days, the torsion had improved ; the patient is now well 30 months after surgery. According to the literature, spontaneous improvement of pulmonary torsion is very rare. The prognosis seems to depend on the degree of torsion. When it is less than 180 degrees, improvement may occur without thoracotomy.
Therefore bronchofiberscopical procedure is important to determine the degree of torsion.

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Lung cancer combined with empyema is uncommon. A 66-year-old man had a right pneumonectomy for lung cancer with partial empyema. The bronchial stump was reinforced and wrapped with a 5th intercostal muscle flap to prevent postoperative infection. On the 22nd postoperative day, a bronchopleural fistula developed. The distal part of the muscle flap was still alive, but it had degenerated and disappeared only around the fistula. The bronchial stump was so short that the fistula was directly resutured and wrapped with an omental pedicle flap. The patient is doing well 11 months after operation.
Reinforcement by muscle flap was not effective to protect the bronchial stump against infection. We consider that a prophylactic omental flap might be better to avoid bronchopleural fistula due to infection.

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An 18-year-old male underwent complete resection of mediastinal and cervical lymphangioma. There have been six reported cases of mediastinal and cervical lymphangiomas in Japan. We discuss the clinical features and pathogenesis of this disease.

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Although artificial pneumothorax therapy for pulmonary tuberculosis was very popular and showed good results before the age of chemotherapy, it was sometimes followed by such complications as chronic thoracic empyema, chronic hemorrhagic pleuritis, malignant lymphoma arising from the empyema wall, etc, several decades after treatment. The author treated a 49-year-old man, whose chief complaints were DOE and left chest pain. He had chronic expanding left hemothorax, which had gradually developed in a long-standing residual cavity from previous artificial pneumothorax. It finally occupied the whole left hemithorax and compressed the mediastinum to the contralateral side.
“Pulmonary detachment procedure”, which consists of mobilization of the lung from the adjacent tissue and visceral decortication of the pleural peel, was carried out to allow lung reexpansion and to diminish the hemothorax cavity.
He still has a small intrathoracic dead space, but he has been enjoying better quality of life for over five years after operation with no evidence of relapse of the disease. This operation can be judged to have been successful.

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