The clinical usefulness of lymph node dissection was assessed prospectively in 477 of 596 consecutive lung cancer patients. One hundred fifty two patients with N2 non small cell disease were classified into the following three groups : 1) 29 with False negative N2 disease, which could not be detected macroscopically at the time of dissection, 2) 52 with true-positive N2 disease, and 3) 72 with obvious N2 disease. The 81 patients in groups 1) and 2) represented 17 % of the 477 eligible patients. They were compared with 325 patients with N0 and Ni disease, 68% in whom the efforts only resulted in staging. Of these 81 patients, 63 had Ti, 2 or 3 M0 disease ; 28% of them survived for 5 years or longer. Skip metastasis, defined as metastasis to the upper mediastinum without involvement of the carinal, hilar, or intrapulmonary nodes, was found in 28 patients, or 18% of the 152 with N2 disease. A part from one patient with a large bronchioloalveolar carcinoma, none of them had lower lobe disease. Of 152 N2 patients, only 11 of the 58 (19%) undergoing upper lobectomy had positive carinal nodes, while 53 patients of 94 remainders (56%) of those undergoing other operations had positive carinal nodes. Ten of 11 other patients had N2 nodes in the upper mediastinum, and one had an Ni hilar node and chest wall invasion. This means that carinal node involvement can easily be predicted before the dissection of carinal node.
We conclude that upper mediastinal dissection is not required for lower lobe tumors with negative intrapulmonary, hilar and carinal nodes, especially squamous cell carcinoma, but is required for upper lobe tumors. In upper lobe tumor, carinal node dissection can be omitted when the nodes in both the upper mediastinum and the upper lobe are intact.

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We analyzed the diagnostic procedures, treatment and postoperative complication in three patients treated for pulmonary aspergillosis between 1976 and 1993. Fungus balls were found in two patients and a localized mass with pneumonia-like infiltration in the chest X-ray of the third patient. Hyphae were found preoperatively in two patients, an air meniscus sign was seen in the chest X-ray of the third, so we suspected pulmonary aspergillosis. Two patients with pulmonary aspergilloma did well without postoperative complications. One patient developed a postoperative bronchopleural fistula which responded to conservative treatment, but pulmonary aspergillosis recurred after 19 months later. We concluded that lobectomy is a reasonable operative procedure rather than segmentectomy for pulmonary aspergilloma, on the basis of pathohistological findings, if the function of the residual lung is adequate.

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During the past 45 years at our institute, we have surgically treated 108 children 15 yr of age or younger with primary mediastinal tumor. Then age distribution of patients with neurogenic tumors was such that 12 (86%) of 14 patients with malignant tumors were 3 yr or younger and 31 (91%) of 34 patients with benign tumors were over 3 yr of age. There was no sex difference in any kind of mediastinal tumor. All benign tumors were completely resected, and except for one child with von Recklinghousen's disease, all survived. A follow-up of patients with malignant tumors showed that 4 (18%) of 11 patients with neuroblastoma and all 3 patients with ganglioneuroblastoma survived for 22 years after surgical resection. One of 3 patients with invasive thymoma and the patient with carcinoid have been alive for 15 years since surgical resection. Treatment for malignant lymphoma included chemotherapy and radiotherapy. Only 2 (14%) of 14 patients with malignant lymphoma survived for 9 years ; their disease was limited to the mediastinal lymph nodes ; Stage 1, and 12 (86%) died within 2 years. The treatment of choice for mediastinal tumors was mainly surgery with adjuvant chemotherapy and radiotherapy.

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A 73-year-old man was referred to our hospital with bilateral foot edema and severe gonalgia. His chest X-ray film showed an abnormal shadow in the right lower lobe. The histological diagnosis of tissue obtained by bronchoscopy was large cell carcinoma. Bone scintigraphy showed abnormal linear accumulation along the cortical margin of the femur. His fingers and toes were clubbed and his nails were thickened and white. Those scrapings showed trichophiton. His serum level of FSH was slightly high but LH, PTH, estrogen and calcitonin were normal. Foot edema disappeared within a week after lobectomy, and gonalgia was greatly reduced. Tinea unguium improved steadily. This is the first case of hypertrophic pulmonary osteoarthropathy to be reported in which tinea unguium was spontaneously cured after resection of lung cancer with no use of antifungal agents.

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A 54-year-old man was admitted to our hospital because of fever and a left apical abnormal shadow on chest X-ray. The original diagnosis was acute pneumonia, so antibiotics were started, but high fever persisted. His laboratory date revealed marked leukocytosis (>20, 000/μl), and a high erythrocyte sedimentation rate (>100 mm (1hr)) and CRP (>10 mg/dl) despite medical treatment. No malignant findings could be obtained in any cytological studies. Open thoracotomy was performed on the 54th hospital day. As the superior sulcus tumor invaded the chest wall, complete resection of the tumor was impossible. Immunohistochemical examination demonstrated that the tumor was poorly differentiated adenocarcinoma with cytoplasm positively stained by mouse anti-G-CSF monoclonal antibodies. Although 5 courses of anticancer chemotherapy and radiation therapy were undertaken, left adrenal metastasis and Pancoast's syndrome developed. He died one year after the thoracotomy. During the course of anticancer therapy, the ALP level changed in parallel with the white blood cell count.

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We treated a 58-year-old man with a large squamous cell lung carcinoma occupying S⁶. Bronchoscopy revealed a polypoid tumor protruding to the truncus intermedius and almost occluding the lower lobe bronchus. At operation we found that the volume of the middle lobe was as large as that of the upper lobe. Right lower sleeve lobectomy with anastomosis of the truncus intermedius to the middle lobe bronchus was performed. Postoperative bronchoscopy revealed good patency of the anastomotic site. Postoperative respiratory function tests showed a decrease of only 13% in both vital capacity and forced expiratory volume in one second.

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A 68-year-old man underwent radical left lower lobectomy for adenocarcinoma in segments S⁶ and S¹⁰. Aberrant ramification of the left pulmonary artery was recognized. This artery, running along the anterior aspect of the lower lobe bronchus, had two rami into the inferior lingular and the anterior basal segments (A⁵⁺⁸), and it branched off the root of the left main pulmonary artery. This may be an embryological variation of the pulmonary artery and left eparterial bronchus, a congenital abnormality.

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A 40-year-old female was admitted to our hospital because of left back pain and left hemothorax. Her chest X-ray showed a left hilar mass (7.5 × 7.5 cm) and large left pleural effusion. CT scan showed a huge, irregular mass in the left lower lobe. In an angiogram, the left pulmonary artery was seen to be greatly compressed by the tumor. Fiberoptic bronchoscopy, however, showed almost normal findings, and biopsy was not performed. Because primary lung sarcoma was the most likely tumor, the patient underwent left pneumonectomy. The surgical specimens showed the typical storiform pattern of fibroblast-like cells and histiocyte-like cells. Immunohistochemical examination with MAC 387 (marker for histiocytes) was positive. Systemic examinations revealed no other abnormality. Therefore the tumor was diagnosed as primary malignant fibrous histiocytoma of the lung. Postoperative adjuvant chemotherapy has been applied, and no relapse has been seen for 10 months following surgery.

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A 68-year-old woman underwent a lower anterior resection of the rectum for adenocarcinoma of the rectum in November, 1993. Postoperatively, an IVH catheter caused thrombophlebitis of the innominate vein and a transient SVC syndrome.
A routine chest X-ray photograph in April, 1994 revealed considerable pleural effusion which was found by thoracentesis to be chyle. Repeated thoracentesis and fasting therapy failed to relieve the chylothorax. Thoracoscopic surgery with stapling of the thoracic duct at the level of the diaphragm stopped the flow of chyle.

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A patient, 61-year-old male, had enlarged lymph nodes in the middle and lower lobe of the right lung, upper mediastinum, and left hilum, but the primary cancer could not be found. The right paratracheal?pretracheal lymph nodes were especially enlarged (8 cm in diameter). The lymph nodes were resected, and the histological diagnosis was metastatic adenocarcinoma in the mediastinal nodes. Right middle and lower lobectomy and R3b lymph node dissection were performed, but the lymph nodes from the other sites showed sarcoidosis, and we could find no malignant lesion in the lung. The mediastinal nodes contained clear cells, so we suspected that the tumor had metastasized from the kidney, but the kidneys were normal. It is now 14 months after the operation, a primary site has not been identified, tumor markers are in the normal range, and the patient is disease free.

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A 52-year-old female complained of bloody sputum. A chest X-ray film showed a mass in the left upper lung field. Bronchofiberscopy revealed an anomalous B¹⁺²a branching from the left main bronchus. A tumor was present in the area of this abnormal bronchus. Cytological examination of material obtained from the tumor revealed squamous cell carcinoma. A CT scan demonstrated ectatic bronchi in the left apex. The clinical staging was T2N2M0. A left pneumonectomy was performed. Pathological examination of the resected material revealed a moderately differentiated squamous cell carcinoma, infiltrating the epithelium of the ectatic bronchi leading to the primary lesion. An intrapulmonary metastasis was found in the left upper lobe, so the pathological staging was T2N2M1 (pm 1), stage IV. The clinical course has been smooth during the postoperative 10 months.

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A 15-year-old female was admitted to our hospital because of an abnormal shadow on a routine chest x-ray. Chest x-rays and chest CT scans revealed a well-defined tumor shadow in the left lower lobe. Serum CA19-9 and SLX were elevated. As we could not rule out malignancy, thoracotomy was performed. The pathological examination of the resected specimen showed plasma cell granuloma with policlonality. Postoperative CA19-9 and SLX did not return-to normal. Because the recurrence of this disease has been reported, although rarely, we must carefully follow this patient.

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This is the report of intradiaphragmatic mesothelial cyst with elevated CA19-9. A 72-year-old male was admitted to our hospital complaining of right flank pain. Three tumor markers were elevated in the peripheral blood ; CA19-9 2, 800 U/ml, SPAN-1 645 U/ml and CA-50 619 U/ml. Abdominal US, CT and MRI showed a cystic mass (10 × 8 cm in diameter) in the infradiaphragmatic, extrathoracic, extrahepatic space, Laparoscopy showed a large diaphragmatic mass covered with peritoneum. It was resected under thoracotomy and was macroscopically cystic. The diaphragm was sutured and closed. The three tumor markers were also elevated in the cyst fluid : CA19-9 2, 800, 000 U/ml, SPAN-1 703, 000 U/ml and CA-50 735, 000 U/ml. The peripheral blood levels decreased to the normal range after surgery. Pathological examination showed an intradiaphragmatic mesothelial cyst, the epithelium of which stained positively for CA19-9.

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A 67-year-old man was admitted to the hospital because of an abnormal shadow on chest X-ray. Chest X-rays showed a tumor shadow 40 × 35 mm with pleural indentation in S² of the rt-upper lobe. Simultaneously a fist-sized pulsating mass was noted in the middle abdomen. Abdominal CT showed an abdominal aortic aneurysm 69 × 58 mm in size. Preoperative bronchoscopy was not performed because of the risk of rupture of the aneurysm, but the tumor appeared to be lung cancer. We chosed to operate for lung cancer and abdominal aortic aneurysm in a one stage operation because of the progression of the lung cancer and the risk of rupture of the aneurysm in a two stage operation. With the patient supine an artificial graft was inserted to replace the aneurysm. Then the patient was turned to the lt-lateral decubitus position, and a needle biopsy of the tumor in the rt-S² was performed ; the tumor was adenocarcinoma, so rt-upper lobectomy was performed. The post operative course was uneventful, and he was discharge 27 days after surgery.

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Myasthenia gravis and pure red cell aplasia developed in a 44-year-old female three months after thymectomy for invasive thymoma. Her chest X-ray had demonstrated a mass on the left diaphragm. Preoperative examinations revealed neither myasthenia gravis nor anemia. Percutaneous biopsy indicated thymoma invading the thoracic cavity, and thymectomy as well as tumor extirpation was attempted through a median sternotomy. The thymoma had invaded the upper lobe of the lung, and there were many metastatic lesions 5 to 10 mm in diameter, mainly on the parietal pleura, and a fist-sized tumor adherent to the diaphragm. These tumors were resected along with the thymus and the parathymic adipose tissue. The tumor consisted predominantly of small lymphocytes and epithelial cells. The pathological diagonosis was invasive thymoma, stage IVa. To prevent recurrence, the patient received anticancer drugs intermittently through a subcutaneous implantable reservoir (PORT A CATH) bimonthly. About three months after the operation, the patient complained of general malaise and diplopia. These symptoms were attributed to myasthenia gravis and pure red cell aplasia. Her myasthenia and anemia were marked reduced by steroid therapy. She is now living and well with no evidence of recurrence of the diseases.

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Single-stage omentopexy for chronic empyema with bronchopleural fistula was performed on a 58-year-old male complaining of cough, purulent sputum and fever. He underwent a thoracoplasty for pulmonary tuberculosis 32 years ago. Chest X-ray films and other examinations demonstrated right chronic empyema complicated with bronchopleural fistula. Although the posterior portions of the ribs overlying the empyema space were resected subperiosteally, complete filling of the empyema cavity could not be obtained together with the transplanted omental pedicle. Nevertheless, cough and purulent sputum disappeared 6 months postoperatively.

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Intrathoracic goiter or substernal goiter is a tumor usually arising from a lower pole of the thyroid gland and extending to the anterior superior mediastinum. In our patient, the diagnosis of intrathoracic goiter was established with CT, MRI and arteriography. Transtracheal needle aspiration cytology suggested malignancy involving the tracheal wall, so median sternotomy was performed through a cervical collar incision for removal of the tumor. The tumor was found unexpectedly to be in the right lobe of the thyroid gland and was invading the tracheal wall. Right hemi-thyroidectomy with circular resection (4 rings) and reconstruction of the trachea was performed.
This experience showed that the thyroid gland may be located behind the sternum in a patient with a short neck and that cancer in such a thyroid may be misdiagnosed as intrathoracic goiter. Therefore, a cautious approach is required for the establishment of the correct diagnosis.

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