The present study was carried out to investigate the expression of MHC antigens using immunohistochemical staining on transplanted lungs and recipient's spleens of three single lung allo-transplanted Japanese monkeys during the subchronic period after operation.
The immunosuppressant FK506 was given during postoperative period, but no steroid.
Regarding the immunohistochemical study, ABC-GO method using anti-human HLA-A, B, C (class 1) and HLA-DR, HLA-DP and HLA-DQ (class 11) antibodies was applied for the staining. To determine the enhanced expression on the transplanted monkey cells, the specimens of a normal monkey were used as a control.
Among these human antibodies, HLA-A, B, C and HLA-DR antibodies have cross-reacted with Japanese monkey cells, but not antibodies including HLA-DP and HLA-DQ.
Expression of MHC class 1 antigen was consistently increased on alveolar and bronchial epithelia of the transplanted lungs in contrast to a variable expression on the normal lung or on the recipient's lung.
MHC class 11 antigen was expressed more intensely on alveolar, bronchial epithelia and vascular endothelia of the transplanted lung than those on the normal monkey.
There was no significant difference in staining intensity between the trasplanted lung and the recipient's lung.
In the recipient's spleen, expression of MHC class 1 and class 11 antigens were always increased, especially expression of MHC class 11 antigen was more conspicuous.
From these results, it was concluded that there was the enhanced expression of MHC antigens on epithelial and endothelial cells of the transplanted lung and on the recipient's spleen cells during the subchronic period after lung allo-transplantation. These phenomena suggest a sustaining stimulated immune response during the subchronic period after lung allotransplantation even if an immunosuppressant was given after transplantation.

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A study was done of the postoperative courses of 16 patients with lung cancer whose predicted postoperative forced expiratory volume in one second (FEV 1.0) calculated from perfusion or ventilation scans of the lung were less than 700ml/m². Postoperative complications were encountered in 6 of the 16 patients. The 6 complications consisted of 2 atelectases, 1 respiratory failure, 1 cerebral embolism, 1 acute heart failure and 1 postoperative hemothorax. Two of the 3 patients with respiratory complications died of the complication.
The preoperative FEV 1.0% of the 3 patients with postoperative respiratory complications was less thas 70%. Moreover, computed tomographic analysis of the 3 patients showed severe emphysematous changes in the lungs. In conclusion, (1) The safety limit of resectability of lung cancer can be settled as over 700m l/m² of the predicted postoperative FEV 1.0. (2) When severe emphysematous changes can not be detected by CT, the safety limit can be reduced under 700ml/m² of predicted postoperative FEV 1.0.

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For curative resection of lung cancer, the primary lobe must be resected completely without residual cancer cells being left in the hilar or mediastinal lymph nodes or the adjacent organs. Patients with Ti or T2 lesions (without invasion of a main bronchus), which are pathologically ranked Nla and M0 (but not “pm1”) are potential candidates for curative surgery with video-assisted lobectomy. In our series of 63 candidates the maximum tumor size was 35mm for adenocarcinomas and 45mm for squamous cell carcinomas. In order to confirm that the cancer is pNla or less, at least #3, #4, and #7 lymph node areas for cance of the right lung, and #4, #5, #6, and #7 for cancer of the left lung in addition to the hilar lymph node areas must be examined thoroughly by thoracoscopy or mediastinoscopy, based on our pathological findings of lymphnodes. There were no “pm2” lesions in any of our patients who were graded pN1a or less. In conclusion, curative resection is possible in primary lung cancer under video-assisted surger, when the diameter of the primary lesion is less than 35mm and 45mm for adenocar-cinomas and for squamous cell carcinomas, respectively. In such cases, sampling of medias-tinal lymph nodes is absolutely necessary to confirm N la cases, otherwise standard mediastinal lymph node dissection must be performed.

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The problems of decreased immunity in the elderly and the significance of immunity activation in the surgical treatment of lung cancer were examined in 353 patients with primary carcinoma of the lung. The number those with delayed type cutaneous hypersensitivity reactions to PPD, Candida and SK/SD decreased with age and a significant difference was observed in the reaction to SK/SD antigen between those under 60 years of age and those 60 to 69 years of age and especially those 70 years old or older.
Respiratory system complications were significantly more common in patients over 70 years old with negative SK/SD reactions. A negative SK/SD delayed cutaneous hypersensitivity reaction is a useful predictor of postoperative respiratory system complications in the elderly patients with lung cancer. It is also related to a lower survival rate of older patients with stage III lung cancer. Treatment with transfer factor raised their survival rate significantly.
In conclusion, improvement of the results of surgical treatment can be achieved by restoring or activating the immune state not only preoperatively but also postoperatively in aged patients with lung cancer.

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From 1971 to December 1992, 33 patients underwent surgical treatment for emphysematous giant bullae in Nagasaki University Hospital. Naclerio-Langer's pneumorraphy method and partial resection of the lung followed by autosuturing were performed. In 8 patients with bilateral giant bullae, simultaneous bilateral surgery was performed through mid sternal incision. Video-assisted thoracic surgery was used in two recently treated patients with bilateral lesions. Symptomatic relief was good in 78% of those with Hugh-Jones II-V dyspnea. After surgery, FEV1.0% improved greatly. In 69% of the patients whose FEV1.0% was over 50%, postoperative lung function remained good during the follow-up period. Patients with severe obstructive lung disease experienced short-term improvement of dyspnea, but then their condition deteriorated gradually. On the basis of these findings, we discuss the indications for surgery.

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We evaluated the effect of cadaver cooling and pulmonary flushing on lungs transplanted from dogs with non beating hearts. Donors were killed with a KCl injection without hepariniza-tion and the lungs were inflated with 100% O₂. They were divided into the following three groups of 6 dogs each. Group I donors were kept at room temperature for 4 hours (warm ischemic time : WIT). Group II donors were cooled by crushed ice for 4 hours (cold ischemic time : CIT). Group III donors were kept at room temperature for 1 hour, and the lungs were then flushed with low potassium dextran glucose solution and preserved in the same solution for 3 or more hours. After left lung transplantation, the function of the transplanted lung, arterial blood gas analysis and pulmonary hemodynamics were assessed for 6 hours after ligation of the right pulmonary artery of the recipient animals. The lungs in group III had significantly better PaO₂ and PaCO₂ than did those in groups I and II. Pulmonary hemodynamics did not differ among the three groups. The wet/dry ratio of thetransplanted lungs after 6 hours of single lung perfusion was significantly lower in group III than in groups I and II : 4.99 ± 0.23 in group III, 6.20 ± 0.26 in group I and 5.77 ± 0.55 in group II (p <0.05). These results indicated that (1) cadaver cooling with crushed ice dose not provide significant protection for cadaver lungs and (2) for successful lung transplantation from donors with non beating hearts, it is necessary to flush the lungs with an appropriate solution soon (about 1 hour) after cardiac arrest.

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Bronchiectasis was treated by pulmonary resection in a total of 25 patients from January 1979 through December 1991. Sixteen lobectomies, 2 bilobectomies, 6 pneumonectomies and one segmentectomy were performed. Following complete resection of the lesion, improvement was recorded in 100% of the patients (86% were asymptomatic). All patients with bilateral bronchiectasis in whom one ectatic subsegment remained showed postoperative improvement ; 86% of two ectatic subsegments remained improved symptoms, but all patients in whom three ectatic subsegments remained complained of symptoms. It is concluded that in patients whose disease progresses despite medical treatment and the ectatic lesion is local, surgical resection is indicated. For bilateral bronchiectasis, if the number of postoperative residual ectatic subsegments is one or two, surgical treatment is recommended.

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A 68-year-old male underwent left upper lobectomy and wedge resection of the main bronchus for squamous cell carcinoma. The patient received postoperative rediation therapy in a total dose of 50 Gy. Two months later, he developed radiation pneumonia. Fifteen months after the surgery, the patient experienced an increased sensation of dyspnea during exercise. Bronchoscopy revealed a pin-hole like stenosis at the orifice of the left lower bronchus. We performed ballon dilatation of the stenosis. After that procedure, the sensation of dyspnea during exercise disappeared, and the pulmonary function improved. Fourteen months after the balloon dilatation, bronchial restenosis has not been found, and the patient's quality of life has improved. Thus, balloon dilatation may be the first choice in the treatment of post-lobectomy bronchial stenosis.

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A 6-year-old boy with Morquio's syndrome was referred from the department of pediatrics in our hospital for a sterno-turnover operation to repair his funnel chest.
In Morquio's syndrome, also termed mucopolysaccharidosis IV, there are many skeletal abnormalities and growth retardation because of acid sulfatase deficiency. This syndrome, however, has no neurological abnormalities. Instrumental repair of the skeletal deformities is not effective and even results in the suppression of cardiopulmonary functions or in mental depression. Therefore, the sterno-turnover operation seems to be the best therapy for funnel chest in patients with Morquio's syndrome.

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A 36-year-old male visited a local physician because of a cough. A chest X-ray film showed an abnormal shadow in the left superior mediastinum, and the patient was referred to our hospital. CT of the chest showed a dumbbell-shaped tumor of the posterior mediastinum developing in the vertebral canal through a spinal foramen. The tumor was very clearly seen by MRI as well as CT after myelography. MRI was thought to be useful in the diagnosis of dumbbell type tumors. Operation was performed first with a longitudinal skin incision of the back and laminectomy in the prone position followed by left axillary thoracotomy in the right lateral position. The dumbbell type tumor was removed completely. The pathological diagnosis was schwannoma. The postoperative course was good. This one-stage operation with position change is useful for dumbbell type tumor of the posterior mediastinum.

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A 43-year-old woman was referred to our hospital for evaluation of a mediastinal mass in the left cardiophrenic angle which had been discovered on a routine chest roentgenogram. CT and MRI demonstrated a solitary mass with smooth contour in the left cardiophrenic angle. Angiography revealed the vascular supply to be from a well-developed left internal mammary artery. At thoracotomy, a well-encapsulated mass approximately 7 cm in diameter was found to be adherent to the pericardium, anterior chest wall and diaphragm. It was resected completely. Histological examination showed lymphoid tissue containing numerous lymphoid follicles, some of which were transfixed by one or more vessels with thick walls surrounded by concentric cuffs of lymphocytes. The interfollicular areas showed extensive vascular proliferation and numerous lymphocytes. These findings lead to the diagnosis of the hyaline-vascular type of Castleman's disease. She recovered uneventfully and remains asymptomatic with a normal chest roentgenogram 10 months after operation.
Castleman's disease in the cardiophrenic angle is extremely rare. Although lymph nodes are constantly present in this place, they are not usually seen on chest roentgenograms because of their small size and their investment with fat and connective tissue adjacent to the pleura. Enlargement of diaphragmatic lymph nodes, as in Castleman's disease, should be considered in the differential diagnosis of masses in the cardiophrenic angle.

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We treated two patients with complete rupture of the cervical trachea and incomplete rupture of the intrathoracic trachea following blunt trauma.
In the diagnosis and management of tracheal injury caused by blunt trauma,
1) Neck and chest CT scans as well as bronchoscopy are essential to confirm the diagnosis and to determine the extent of tracheal injury.
2) Adequate surgical approach and early surgical repair of tracheal rupture are necessary.

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A 67-year-old woman had fallen on a needle which penetrated her chest wall. It caused pain. She left the needle in place because no pain. Pneumothorax developed suddenly three years later. Chest x-rays revealed the needle piercing both the lung and the chest wall. With the video-assisted thoracoscopy, we succeeded in removing the intrapulmonary needle and curing the pneumothorax. We think that thoracoscopic surgery is better than conventional surgery because of its minimal invasiveness and pain.

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A 19-year-old male was admitted with an abnormal shadow in his chest roentgenogram, which appeared to be a mediastinal mass. CT scan, endoscopic ultrasonography and MRI showed a cystic lesion surrounding the aorta and azygos vein. Other laboratory data were within normal limits.
Thoracotomy was performed without a preoperative diagnosis. The cyst, 8 × 5 × 11cm in size, was located in the posterior mediastinum. The thoracic duct and cyst were in contact, and there was a pin-hole communication between them. The fluid in the cyst was bloody and chylous. So, the diagnosis was thoracic duct cyst. Twenty-five thoracic duct cysts in the mediastinum have been reported. However, none surrounded the thoracic aorta and azygos vein, as it did in this case.

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A 39-year-old woman presented with dyspnea and chest pain. A chest roentgenogram and CT scan showed a large mass extending from the mediastinum to the left thoracic cavity. Needle biopsy of the tumor showed “mature teratoma, no malignancy”, but we suspected a malignant component because the serum levels of AFP, CA19-9 and CAl2-5 were high. One course of preoperative chemotherapy (cisplatin, etoposide, bleomycin) was administered, but the serum tumor markers increased and the tumor did not shrink. An operation was performed through median sternotomy and 4th. intercostal space anterolateral thoracotomy. The tumor, which involved the left upper lobe but not the great vessels, was completely removed along with the entire left upper lobe. The serum levels of tumor markers returned to normal by one month after surgery. The pathological diagnosis was immature teratoma. Immunohistochemical studies of the tumor showed AFP, CA19-9 and CAl2-5 in the immature tissue. The patient is alive and well 14 months after surgery, and the serum levels of tumor markers have remained normal.

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In 1945 a fragment of incendiary shell penetrated the right anterior chest wall of a 17-year-old female and a piece lodged within the right middle lobe. She did not experience any chest disorders during the next 46 years, but hemoptysis occurred March, 1991 when she was 63 years old. In April, 1991, she was admitted to our hospital, and the foreign body was removed surgically. Metallic foreign bodies in the lung can cause clinical symptoms and in some cases have been linked to carcinogenesis. The authors believe that even if there are no symptom, such foreign bodies should be removed surgically when diagnosed.

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A 48-year-old male was admitted to our hospital with Pancoast symdrome. Chest X-ray, CT and MRI revealed a tumor located widely from the anterior to the posterior portion of the left apical thorax. After preoperative irradiation with 5250cGy, the tumor was resected through a median sternotomy and wide neck incision, consisting of two collar incisions and a vertical incision between them.
The invaded structures were resected : the chest wall (the first rib and vertebral bodies of C6, C7, Ti), the brachial plexus (C7, C8, and Ti) and the vessels (the brachial, jugular, and subclavian veins and subclavian artery). The resected clavicle was implanted in the defect of the vertebral bodies, and the subclavian artery was replaced with a ringed e-PTFE graft 8mm in diameter. Left upper lobectomy and wide dissections of hilar, mediastinal and neck lymph nodes were added as for primary lung cancer. However, because neither tumor cells nor scar formations were recognized in the left upper lobe and lymph nodes, the tumor was finally diagnosed as poorly differentiated adenocarcinoma of unknown primary site.
The anterior thoracic approach associated with wide neck incision provides an excellent operative exposure for surgery of invading apical cancer.

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