Resection of the chest wall accompanied with lobectomy is described with special reference to the three branches of the aortic arch or the nerves and the 1st or 2nd rib. The thorax was divided into four areas according to main arteries running : A, the area supplied by the left common carotid and left subclavian arteries ; B, contralateral to A; C, the midclavicular area just below the clavicle ; D, the lateral thorax beneath the axilla.
A region A case is presented, in which a left upper lobectomy with combined resection of the left clavicle and the 1st rib was performed through a median sternotomy. In a region B case, surgery was performed through a posterolateral thoracotomy, since resection at the hilum preceding removal of the lesion in region B provided better exposure to the affected vessels and the right recurrent nerve. This helps to make the decision easier as to whether an anterior approach is needed. In regions C and D with peripheral lesions, the 1st rib might not be involved, but the axillary vessels and brachial plexus appear easily in the operating field by pulling the affected lung, which is adherent to the soft tissues of this region, towards the operator. Therefore the surgeon cannot ignore these structures even when the lesion is below the first rib.
An enhanced CT, showing the subclavian vein on the affected side provides valuable information as to how close the tumor is to the critical point and is superior to MRI or angiography.

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Patients with a history of artificial pneumothorax or tuberculous pleurisy sometimes develop massive non-purulent collections of semi-solid exudate, necrotic material, or hematomas. During the past 10 year 104 patients with a diagnosis of chronic empyema were treated in our hospital, and five of them (4.8%) were found to have no pus.
Their symptoms differed from those of patients with chronic empyema only in that they had more hemosputum. The fluid obtained by thoracentesis was bloodtinged usually, but occasionally pure blood was withdrawn. No organisms could be cultured.
Chest X-ray showed non-homogeneous clouding of the lower 1/3 to 2/3 of the hemithorax without any fluid level. CT scans resembled those of chronic empyema with patchy calcification in the pleural cavity, but no pleural thickening or fluid.
Four of the five patients were treated successfully two with pleuropneumonectomy, one with decortication, one with extra-periosteal air plombage. The fifth patient died of fungal infection of the thoracic cavity after open drainage.
Histological examination showed capillary hemangiomas with or without signs of inflammation in the thickened pleura. We conclude that exudative non-purulent pleurisy is the result of chronic bleeding from hemangiomas on the pleura.
As the disease progresses infection eventually develops. The damaged pleura should be removed early, since surgery for the late stage of this disease is extremely difficult.

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We have treated eight lung cancer patients with a history of chromate exposure for eight to 31 years. The primary site of lung cancer was peripheral in two patients and hilar in six. Metachronous double or triple lung cancers were detected in three of eight patients during the postoperative follow-up. Early squamous cell lung cancers were found in five of 13 foci, including those with metachronous cancers.
It is important to detect lung cancer early in chromate workers a typical high risk group. Lung cancer patients with chromate exposure should be examined with due regard to the possibility of synchronous or metachronous cancer.

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The changes in small cell carcinoma of the lung (SCLC) in response to chemotherapy and/or radiotherapy were examined immunohistochemically. Epithelial and neuroendocrine markers were analyzed in eight patients with SCLCs who had preoperative adjuvant therapy and in 18 who did not have preoperative therapy. In the former group, five patients had chemotherapy only, two had radiotherapy only, and one had both radiotherapy and chemotherapy. Keratin and secretory component (SC) were used as markers of epithelial cells, and gastrin releasing peptide (GRP), neuron specific enolase (NSE), and Leu 7 were used as markers of neuroendocrine cells. There were no differences in percentages of positive staining for keratin, SC, NSE, and Leu 7 between the two groups. On the other hand, fewer patients who had received preoperative adjuvant therapy showed positive staining for GRP than those without preoperative therapy. It appears that the neuroendocrine nature expressed by GRP was decreased in SCLC by chemotherapy and/or radiotherapy.

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Ninety-four patients with T1NOMO peripheral lung cancer were operated upon in our hospital from 1970 through 1985.
The 5-year survival rates were 76.3% for the entire group, 75.5% for the adenocarcinoma group, and 78.6% for the epidermoid carcinoma group.
For the curative operation group, the 5-year survival rate was 83.2% and significantly better than that for the non-curative operation group. Patients with tumors less than 15 mm in diameter all received curative operations and had a 5-year survival rate of 100% which was significantly better than that for patients with tumors more than 16 mm in diameter. Patients over 70 years old had a low survival rate of 48.9%. However, in the curative operation group, no significant difference was noted in survival rates between the older and younger groups.
Recurrences were noted in 20 patients during the follow-up period of 7-79 months, in 6 cases of adenocarcinoma later than 60 months postoperatively.

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A 29-year-old male patient was referred to our hospital because of bilateral chylothorax. He was first treated with bilateral closed pleural drainage and intravenous hyperalimentation. He lost 2000-2500 cc of chyle every day. One month later, when the right pleural effusion had decreased in volume, a left pleuroperitoneal shunt was placed, which controlled the effusion on the left thereafter. As serous effusion accumulated in the right pleural space again, transthoracic supradiaphragmatic thoracic duct ligation was performed, but the chylous leak continued undiminished. Two months later, the right pleural effusion decreased spontaneously, and ascites appeared. A peritoneo-venous shunt was interposed to control the ascites without loss of fluid. It was appropriate to use a double-valved shunt tube to prevent occlusion. Chyle was returned to the vein, and the normal physiological route was restored. His nutritional state returned to normal. He was discharged on a low fat diet and is doing well.

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In three tracheobronchoplasty operations, we used a special catheter with a cuff for high frequency positive pressure ventilation (HFPPV). Two patients had right sleeve upper lobectomy after left upper lobectomy and one had right sleeve pneumonectomy for primary squamous cell carcinomas of the lung. For the right sleeve upper lobectomies after left upper lobectomy, we performed HFPPV to the right middle and lower lobes combined with manual ventilation of left lower lobe, and for the right sleeve pneumonectomy, we performed HFPPV to the left lung only. There were no problems in pulmonary or systemic circulation, and we were able to achieve good access to the operative site with unimpaired visualization. HFPPV has some problems, such as the choice of catheter, contaminations of the operative field by the catheter and aspiration of blood through the opened bronchus. We used the Univent tracheal tube with open lumen blocker (Fuji systems corp.) with good results, because we could advance the special catheter into the operative field aseptically through the side lumen of the tube, inflate the anastomosed lung with good expansion and prevent the aspiration of blood.

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A 68-year-old man, who had undergone left upper sleeve lobectomy, had recurrence of lung cancer in the left main bronchus. We resected the left main bronchus and anastomosed the carinal left main bronchus to the left lower lobe bronchus. To expose the full length of the left main bronchus and carina, we mobilized and retracted downward the aortic arch after division of the four upper intercostal arteries. This retraction of the aortic arch permitted good exposure of the left main bronchus and surrounding tissues, where a lesion might be present. This approach also provided adequate exposure for the anastomosis between the carina and left lower lobe bronchus. The patient received 63Gy postoperatively and was discharged. Postoperative bronchoscopy revealed neither stenosis nor granuloma. An angiogram demonstrated no compression of the left pulmonary artery by the aorta. Tomograms showed a slight shift of the carina to the left, probably due to fixation of the left lower lobe bronchus by the aortic arch.

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Lobectomy was performed in two patients with lung cancer and a history of myocardial infarction.
One of them had experienced two attacks of myocardial infarction with 100% obstruction of the three coronary arteries : right coronary artery, left anterior descending artery, and circumflex artery.
The other patient had experienced myocardial infarction two months before lobectomy.
In both cases a thermo-dilution catheter with a V-pacing probe was introduced the day before the thoracic operation and the patient's hemodynamic condition was observed throughout the operative and postoperative periods.
Lobectomy was performed under phentanyl and pure oxygen anesthesia.
No attacks of ischemic heart disease were noted throughout the operative and postoperative periods.

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A 59-year-old man with squamous cell carcinoma of the lung was treated with left pneumonectomy and aortic wall resection. The invaded wall of the descending thoracic aorta was partially resected and repaired with a Dacron patch. He is in good condition 9 months after surgery. In this operation a heparinized tube was used satisfactorily for temporary bypass while the aorta was clamped.

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A-62-year old male with squamous cell carcinoma of the right lung underwent sleeve pneumonectomy and partial resection of the superior vena cava.
On the day of operation and on the seventh postoperative day, the patient developed sudden hypotension accompanied by cyanosis, facial edema and unconsciousness. At the time of the first episode, conservative treatment was successful, but after the second, the patient's condition continued to deteriorate. Thrombectomy of the superior vena cava was performed with saphenous vein patch grafting.
Prior to this operation, an external jugular-femoral vein bypass was placed with the use of a 16Fr. needle and hemodialysis system. During this procedure, the patient's condition improved immediately and r operation was performed safely.
We feel that this method is useful in the treatment of acute and progressive superior vena caval obstruction. The surgical indications and intervention for advanced pulmonary or mediastinal carcinoma with involvement of the superior vena cava must be considered carefully.

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A 27-year-old male patient with Recklinghausen's disease had a large intrathoracic neurofibroma. The tumor was diagnosed benign neurofibroma by percutaneous needle biopsy. We performed en bloc resection, because it had grown larger in 2 years, and malignancy could not be ruled out completely. The tumor originated from the right 3rd intercostal nerve. We found no malignant changes on post operative investigation.
It is reported that about 30% of neurofibromas associated with Recklinghausen's disease become sarcomas and that those found in patients older than 30 years must be resected because of the especially high possibility of malignant changes. Although in this case the tumor was benign fortunately, we will continue to choose surgical treatment for cases like this in the future.
This is the 6th intrathoracic neurofibroma with Recklinghausen's disease to be reported in the Japanese literature.

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A coin lesion in the left middle lung field on the X-ray film and a high CEA level were noted in July, 1982. A culture of scrapings from the lesion grew out tubercle bacilli. After antitubercular therapy, the size of the shadow decreased temporarily but increased again from about May, 1986. Adenocarcinoma cells were detected in smears obtained at bronchoscopy, and a diagnosis of pulmonary tuberculosis complicated by lung cancer was made. A left lower lobectomy was performed. Histopathological studies revealed that foci of adenocarcinoma were the main constituents of the mass which had infiltrated around the focus of tuberculosis.
Immunohistochemical staining for CEA in this specimen showed that CEA was localized in the cytoplasm of the adenocarcinoma cells.

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Two patients with flail chest due to chest trauma were treated.
Many authors have recommended a respiratory fixing method with the use of a ventilator. However the surgical fixation is most important both in simple chest trauma and in severe dislocation of fracture segments. This method shortens the respiratory fixing times. Prosthetic ribs made from alumina ceramics are thought to be excellent materials for rib fixing.

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