The evaluation of mediastinal nodal metastasis is important in the assessment of the operative indications and prognosis in patients with lung cancer. Various procedures are used to determine nodal metastasis preoperatively, but the level of accuracy is not satisfactory.
In this study, transesophageal endoscopic ultrasonography (E-EUS) was used to assess N-factors, especially mediastinal nodal metastasis, in 32 patients who had had resections of cancers of the left lung. The usefulness of E-EUS was evaluated. An ultrasonic probe with a 5 MHz linear array transducer, 12 mm in diameter and 40 mm in length, was attached to the tip of an esophagofiberscope for this study. Mediastinal and hilar lymph nodes were identified with the use of images of the heart and great vessels as landmarks. The outline of lymph nodes was clearly and continuously visible on E-EUS. so the long and short dimensions of a node could be measured easily on the image in which it was largest.
Nodes in which the average of the two dimensions was 10 mm or more were considered to have metastases. In E-EUS, the visual field was greatly restricted by various obstructing factors, such as air tracheal or bronchial cartilages and calcifications. Generally, only #5 (subaortic) and #7 (subcarinal) nodes could be demonstrated. There we investigated primarily these two portions in this study.
The reliability of E-EUS diagnosis of metastasis to #5 or #7 nodes was as follows. In #5 node, the sensitivity, specificity, and accuracy were 85.7%, 80.0% and 81.3%, respectively; these results are superior to those of CT scans. In #7 node, they were 100%, 93.1% and 93.8%, respectively, almost the same as with the CT scan.
We conclude that E-EUS is more useful in the assessment of mediastinal #5 nodal metastasis than CT scans in spite of its restricted visual field. Employing the average of the long and short dimensions of 10 mm as the cut-off point for determining the presence of metastases seems appropriate, but it was difficult to demonstrate the presence of nodal metastasis from the characteristics of the nodal ultrasonographic findings themselves.

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From June, 1987 to February, 1988, 100 patients with primary lung cancer, who were admitted to the National Cancer Center Hospital for surgical treatment, underwent neck ultrasound examination for preoperative evaluation of cervical lymph node metastases.
Lymph nodes were visualized in 24 patients by this examination. The characteristic ultrasonographic finding of metastatic lymph nodes was well defined, thickened, fused, lobulated and hypoechoic. Nineteen of the 100 patients had ultrasonographically suspected cervical lymph node metastases. Eight (9.6%) of 83 patients for whom thoracotomy was planned had ultrasonographically suspected cervical lymph node metastases and in 4 of these 8 metastases were found in the lymph nodes. Of the 98 patients without palpable cervical lymph nodes 17 had ultrasonographically suspected cervical lymph node metastases.
These results show that about 10% of thoracotomies might not be indicated. If Daniels' biopsy is employed for patients in whom ultrasound examination shows possible cervical lymph node metastases, the staging of lung cancer in those without palpable cervical lymph nodes is more efficient and accurate.

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From June, 1987 to February, 1988, 74 patients with primary lung cancer, who were admitted to the National Cancer Center Hospital for surgical treatment, underwent transesophageal endoscopic ultrasound examination (EUS) for preoperative evaluation of mediastinal lymph node metastases.
Although right superior mediastinal lymph nodes were not sufficiently observable, the detectability of lymph nodes by EUS was excellent in the other mediastinal sites. Furthermore, the shape, contour and interior of the lymph nodes were clearly visible by EUS. Therefore, it seemed that EUS was a very good diagnostic tool.
The diagnostic accuracy by EUS was shown to be excellent with 51.9% sensitivity and 98.1% specificity, while the positive predictive accuracy was 82.4% and the negative predictive accuracy was 92.2% with an overall accuracy of 91.3% when the right superior mediastinal lymph nodes, which are in the dead angle of EUS, are excluded, the sensitivity is 84.0%. Diagnostic examinations for mediastinal lymph node metastases were also conducted by computed tomography (CT) in the same 74 patients and compared with the results of EUS. The diagnostic accuracy of EUS was better. The evaluation of mediastinal lymph node metastases is even better when EUS and CT are used together.
EUS cannot differentiate adenocarcinoma from squamous cell carcinoma or demonstrate micrometastases in lymph nodes.

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The timing of recanalization of the bronchial artery interrupted by esophagectomy was investigated by microangiography in dogs and effectiveness of omental wrapping on healing of the bronchial anastomosis was evaluated.
After combined esophagectomy and pulmonary resection, healing of the bronchial anastomosis is apt to be poor, especially in terms of recanalization of the interrupted bronchial artery. Omentopexy was found to be of great benefit in promoting regeneration of the interrupted bronchial artery following bronchoplasty.

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Bronchial carcinoids were found in eight of 620 patients with primary lung tumors (1.3%), and thymic carcinoids in three of 75 patients with tumors of the thymus (4%). Five of the bronchial carcinoids were in central sites and three were in peripheral sites.
Seven of the bronchial carcinoids were removed by lobectomy and one by partial resection. There were no recurrences or metastases, but it was sometimes very difficult to distinguish between carcinoid and small cell lung cancer. The diagnosis was made by immunohistochemical staining using monoclonal antibodies derived from non-small cell lung cancer.
It was difficult to differentiate between thymic carcinoid and invasive thymoma by chest X-ray or other imaging methods. Two thymic carcinoids could be resected only partially and one completely, but all three patients had recurrences or metastases.

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Neoadjuvant therapy is a new modality treatment for primary lung cancer. This paper analyzes the complications after 30 adjuvant operations in our institution from Jan. 1984 to Dec. 1987. Thirty patients were treated with preoperative chemotherapy (two or more courses) in a randomized controlled study. The protocol was as follows : 1) CPA+ADM +VCR or CDDP+VP-16 therapy in 13 patients with small cell lung cancer. 2) CDDP+VDS or CDDP+VDS+MMC therapy in 17 patients with non-small cell lung cancer. The postoperative complication rate was 73.3% (22 of 30). The major complication rate was 16.7% (5 of 30). The overall operative and hospital mortality rate was 6.7% (2 of 30). Many patients with small cell lung cancer had side effects from preoperative radiotherapy or cardiac toxicity induced by Adriamycin. Many patients with non-small cell lung cancer had complications following resection for advanced disease (Stage III) or renal toxicity induced by CDDP.
All patients had prolonged water retention, and some had late postoperative complications.

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Sixty patients with primary mediastinal tumors and two with extra-mediastinal thymomas have been treated in our clinic since 1956. Their clinical signs and symptoms were correlated with their prognosis. The primary tumors included thymomas (35%), teratomas (13%), neurogenic tumors (11%), lymphomas (10%) and miscellaneous other tumors. Malignant tumors were diagnosed histologically in 22 patients (45%). The incidence of malignancy was 72% in thymomas, 15% in teratomas, 14% in neurogenic tumors and 100% in lymphomas. No symptoms were present in 27% of the patients and most of these had benign tumors. The absence of symptoms, however, does not necessorily indicate benignity, and primary mediastinal tumors should be extirpated in any case. It is emphasized that one should aim to resect the tumor totally, even if adjacent tissues and organs should be resected simultaneously. It may improve the prognosis of the patient with an invasive mediastinal tumor.

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Thymomas, especially epithelial component were cultured, and differentiation between invasive and noninvasive thymoma was attempted.
Materials were obtained at operations and were immediately minced. A portion was digested with 500-1000 u/mlof dispase, 0.25% trypsin or 0.05% collagenase and the remainder was placed in plastic tissue culture dishes, some of which were coated with type I collagen. Culture media were Dulbecco's modified MEM, Ham's F12 or Medium 199. These were supplemented with 10-20% fetal bovine serum, and some as the following additives were tested : 0.5 mg of ATP, 5ug/ml of dibutyryl cyclic AMP, 5 half-maximal units of IL-2, 0.05 u/ml of Insulin, 5 ng/ml of EGF, 10 ng/ml of phorbol 12-myristate 13-acetate, 10^-9 M of chorela toxin, 2.5 mg/ml of methylprednisolone, autologous peripheral blood lymphocytes.
Tissues were obtained from 9 patients with invasive and 7 with noninvasive thymoma. None of them was established and no additives promoted cell proliferation under the conditions described in this paper. Primary cultures from the invasive thymomas grew well and many epithelial cells were easily obtained. Tumor cells were dissociated easily by proteases or by physical forces. On the contrary, few or no tumor cells were obtained in the noninvasive cases. The growth of mesenchymal cells was always more dense in the noninvasive than in the invasive cases. Microscopic findings in the invasive cases were : dense cytoplasm and thick margin of nucleus, large nucleus, 1 or 2 clearly visible large nucleoli, sharply defined cell borders.
Although we cannot necessarily distinguish between invasive and noninvasive thymoma from these results alone, this method may become a useful tool in the diagnosis of thymoma.

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A 31-year-old Japanese woman, who had been treated for 8 years with steroids and azathioprine for systemic lupus erythematosus for 8 years, was referred to our hospital for surgical treatment of right spontaneous pneumothorax. Air leakage was massive despite chest tube drainage for more than 40 days. Bacteriological examination of the discharge through the chest tube revealed Pseudomonus maltophilia and β-Streptococcus.
Operation was performed on the 57th day after insertion of the chest tube. At operation several bullae were present mainly in the right upper lobe. Pneumothorax was due to rupture of one of them.
Bullectomies were performed. The patient was discharged on the 58th POD although wound infection had occurred postoperatively.
Microscopic examination of biopsied lung tissue revealed no typical parenchymal changes of SLE.

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A recurrent bronchopleural fistula in a 50-year-old diabetic male in whom resuturings of the leaking bronchus had failed twice was closed successfully with an omental pedicle flap. The original procedure was right lower lobectomy. The postoperative course was complicated by cough, high fever and large amounts of foul smelling sputum for 4 years. The empyema with a large bronchopleural fistula was completely healed without additional chest deformity or loss of pulmonary function. The advantage of the omental pedicle flap procedure are simplicity, absence of cosmetic defect, and suitability for right lower bronchopleural fisftula.

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A 72-year-old male with an abnormal shadow in the right lower lung field was admitted to the Showa University Hospital. The clinical diagnosis was primary lung cancer in the right lower lobe (S6). He underwent right middle and lower lobectomy with dissection of the mediastinal lymphnodes. Histologic examination showed multiple primary lung cancers, a welldifferentiated squamous cell carcinoma in S6 and a well-differentiated adenocarcinoma in S10. Lymphnode metastase were found (No. 7 and No. 11). His postoperative course was uneventfull except for air-leakage for about three weeks due to pleural fistula.

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Most granular cell tumors originate from the tongue, skin or breast.
Only 13 cases of granular cell tumors of the trachea, bronchi and lungs have been reported in Japan since 1970.
Our patient was a 16-year-old boy who had had a productive cough and fever for one month. His chest x-ray showed an abnormal shadow in the anterior segment of the right upper lobe.
Bronchoscopic examination revealed a white tumor of the r-B³, and biopsy confirmed the diagnosis of granular cell tumor. A right upper sleeve lobectomy was performed uneventfully. The tumor was localized within the wall of the right upper bronchus with no evidence of metastasis to the regional lymph nodes. He is well 21 months after operation.
Surgical resection is the treatment of choice if the tumor is large and causes symptoms.

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A 25-year-old male complaining of fever and cough was admitted to our hospital.
Bronchofiberscopy revealed a polypoid tumor nearly obstructing the right main bronchus. Biopsy of the tumor proved it to be a bronchial carcinoid. Endoscopic Nd-YAG laser treatment was done to identify the base of the polyp and the extent of tumor involvement before operation. After the laser delivery of 13276 Joules in three times the obstruction was relieved. To preserve pulmonary function, a bronchoplastic procedure was performed as follows : the truncus intermedius was cut just above the middle lobe bronchus, then the right main bronchus was cut below the upper lobe bronchus to remove the tumor. The resected edge proved to be tumor free by frozen section during the operation. Preoperative laser treatment for polypoid bronchial neoplasms may be useful in preserving pulmonary functions by effective bronchoplasty

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