We examined clinically and morphologically two primary and two metastatic (from the parotic gland and the lower leg) malignant fibrous histiocytomas (MFH) of the lung. One patient with primary MFH of the lung has survived. The diagnosis was made preoperatively by percutaneous lung biopsy in only one patient. The difinitive diagnosis of MFH is considered to be difficult with a small biopsy specimen because of the diverse histopathology of the tumor.
The histological appearance of primary MFH of the lung differed from that of metastatic MFH; a striform pattern was dominant in the former, while a pleomorphic pattern was dominant in the latter. Metastatic or recurrent lesion were treated with irradiation in three patients, and there was marked shrinking of the lesions in all three. This is because of the histological characteristics of the pleomorphic tumor, and radiotherapy rather than surgery should be considered first for metastatic or recurrent lesions of MFH.
No marked difference was observed in the microstructure of fibroblast-like and histiocyte-like tumor cells. Since the number of the former cells increased with growth of the tumor, MFH is considered to be derived from the histiocyte series.

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Distribution of Langerhans cells in thymic tissues and thymomas were examined by immunohistochemical analysis, using anti-S-100 antibody. Langerhans cells were demonstrated in 18 of 28 (64.3%) thymic tissues and in 31 of 37 (83.3%) thymomas. In thymic tissues, Langerhans cells were present mostly in the medulla. In thymomas, they were equally numerous in the cortical, medullary, and mixed types. In both thymic tissues and thymomas, Langerhans cells were more numerous in patients with myasthenia gravis (MG) than in those without, but the difference was not significant. Langerhans cells were more common in noninvasive than in invasive thymomas, but the difference was not significant.

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Respiratory function and the state of repair of the respiratory tract were followed for 1 to 11 years (mean 5 years) after surgery in 10 patients with tracheobronchial injuries. In four patients, who had been operated on in the acute phase, the results were satisfactory. In six patients treated 4 to 9 months after injury, pneumothorax and subcutaneous or mediastinal emphysema were noted immediately after injury, suggesting that an early diagnosis might have been possible. In one patient presenting with atelectasis of the middle and lower lobes and in two patients with a history of pneumonia, the pulmonary scintigram showed low ventilation distribution in the affected lung (affected side : normal side = 43 : 57, 41 : 59, 45 : 55). One patient, treated with Barclay's operation for carinal stenosis, developed obstructive ventilatory disorder due to tracheobronchial malacia at the anastomotic region.
Our results suggest that early diagnosis and surgical treatment are important to improve the longterm results of traumatic airway injuries.

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During the five-year period between January 1, 1983 and December 31, 1987, 712 patients were operated upon for thoracic and cardiovascular diseases. Median sternotomy was used for cardiovascular surgery, and 294 thoracotomies were performed for lung cancer, esophageal cancer, etc. Of these 294 patients, 33 (11.2%) remained in our Intensive Care Unit (ICU) for 10 or more days postoperatively. The incidence of postoperative pneumoniae was 52%. The pathogenic organisms were mainly Pseudomonas aeruginosa, Klebsiella pneumoniae and Staphylococcus aureus. Nine of those 33 patients (27%) died in the ICU; four of them had lung cancer, three had esophageal cancer and two had other diagnoses. Preoperative risk factors in these patients were cigarette smoking, respiratory hypofunction, low A/G ratio, low performance status, hypertension and diabetes mellitus. We conclude that it is very important to determine preoperative risk factor as well as to provide postoperative intensive care.

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The results and problems of tracheoplastic procedures for various tracheal diseases are reviewed.
Thirty patients underwent tracheoplasties in our department between 1957 and 1987. The tracheal lesions operated upon were thyroid cancer in 9 cases, primary tracheal tumor in 7 (adenoid cystic carcinoma 4, squamous cell carcinoma 2, chondrosarcoma 1), post-tracheostomy stenosis in 4, esophageal cancer in 3, traumatic rupture in 3, post-tuberculous stenosis in 2, post-radiation tracheal stenosis in 1, and congenital tacheal stenosis in 1. The tracheoplastic procedures performed were sleeve resection and end-to end anastomosis in 15 (50%), terminal tracheostomy in the anterior mediastinum in 6, suture closure of traumatic tracheal rupture in 3, patch closure or dilatation in 2, carinal reconstruction in 2, and other procedures in 2. These procedures were chosen according to the etiology, location and length of the lesions in each patient.
The post-operative death rate within 30 days after operation was 20%, many of these patients had extensive tracheal resections. The post-operative complication rates were also high, and the most common complications were anastomotic dehiscence and anastomotic stenosis.
At present, 14 patients are alive from one to 21 years after operation. The main cause of death was recurrence of malignant tumors.

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We reviewed reoperation for postoperative intrathoracic recurrence of lung cancer. From January 1980 through December 1988, a total of 267 patients had primary operations for lung cancer, and nine had reoperations for recurrence of the tumor. The median interval between the operations was 24.1 months. Three patients underwent contralateral wedge resection after an initial lobectomy. In three patients, ipsilateral wedge resection was done after initial lobectomy or wedge resection. In the three remaining cases, an ipsilateral lobectomy was performed after primary lobectomy or wedge resection. Three patients died with recurrent disease within 15 months of the reoperation. One patient died of postoperative complication. Five patients are still alive and four are tumor-free. These results indicate that for patients with a recurrent lung cancer, reoperation especially wedge resection, offers acceptable survival rates with minimal risk of death and respiratory failure.

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Closure of bronchial anastomotic dehiscence was accomplished by applying bibrin glue through a flexible bronchoscope in a patient who had had right lower sleeve lobectomy for bronchogenic carcinoma.
A 65-year-old man had a right lower sleeve lobectomy for lung cancer. End-to-end anastomosis between the right intermedium bronchus and the middle bronchus with 4-0 Dexon was performed. The patient's postoperative course was uneventful until the 10th postoperative day when he had bloody sputum, and his chest X-ray showed pneumothorax with volume loss of the right middle lobe. Bronchial anastomotic dehiscence was suspected. A chest tube was inserted and continuous suction was started which revealed a continuous air leak. Bronchoscopy showed dehiscence involving one third of the anastomotic circumference. There was slight inflammation but no purulent secretion in the anastomotic area. Fibrin glue was applied through the bronchoscopic channel by silastic tubes. Chest tube suction was discontinued for 5 minutes after instillation of the fibrin glue. The patient tolerated the procedure well, the air leak through the chest tube stopped, and bloody sputum ceased after the procedure. The chest tube was removed 5 days later. The patient has made a full recovery.

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Left pneumonectomy with R2a lymphnode dissection was performed on a patient with lung cancer originating in the left upper lobe. The postoperative course was uneventful until the 21th POD. Then his chest roentgenogram showed decreased niveau and pleural effusion. His clinical condition and laboratory data were normal, but a tiny fistula of the bronchial stump was detected by bronchofiberscopy (BFS). Therefore, emergency pleurocentesis and reoperation were performed. Fortunately empyema was not present, so only omentopexy with fibrin glue was done. Postoperatively, BFS showed that the bronchial stump had progressively broken down and definite evidence of healing was observed 3 weeks after operation. The BFS finding indicated that it would take at least 1 week for empyema to develop after the formation of a tiny fistula. Early detection at this time would be very important for successful treatment of bronchopleural fistula.

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We performed surgical treatment for the plasmacytoma of the sternum associated with Takatsuki's disease (POEMS syndrome or Crow-Fukase syndorome).
A 48-year-old man was admitted to our hospital with complaints of abdominal distention and progressive edema and numbness of the lower extremities. On physical examination, hyperpigmentation, gynecomastia, generalized lymphadenopathy, hepatosplenomegaly, and an osteosclerotic lesion of the sternum were observed. Laboratory data revealed IgA-λ type M-component, elevated LH and FSH, low testosterone, low T3 and elevated TSH in the serum, and elevated urinary estrogens.
We resected the solitary myeloma of rht sternum in conjunction with steroid therapy. The sternal body with the sclerotic lesion was resected from the second through the fifth costal cartilages. The defect was repaired with Dexon mesh and Marlex mesh to prevent paradoxical respiration. No postoperative complications were observed. Histopathological diagnosis was IgA-λ type plasmacytoma.
The remarkable effect of removal of the plasmacytoma on the course of the disease was not immediately observed but the patient is in remission.

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A 66-year-old man was admitted to our hospital with cancer of the left lung. Left pneumonectomy was performed, and the postpneumonectomy space was managed with SF6. The patient died of heart failure 10 months later. The autopsy showed that the postpneumonectomy pleural surface was entirely covered with a fibrous membrane and that the thoracic wall and the mediastinum maintained moderate elasticity.

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A 51-year-old man had a 0.8 × 1.0 cm coin lesion in the right lower lung field on a chest X-ray film. Antituberculousis therapy with INH, RFP and EB was initiated, but the size of the coin lesion did not change. Lung cancer was suspected and open lung biopsy was performed.
Macroscopically, the tumor was a well-circumscribed light grey mass filled with necrotic debris. Microscopically, parasites were seen in a small pulmonary artery and were diagnosed as Dirofilaria immitis.
Human dirofilariasis of the lung is a rare disease, but case reports are increasing. This disease should be included in the differential diagnosis of pulmonary coin lesions.

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Benign localized pleural mesothelioma was diagnosed in a 42-year-old asymptomatic woman with no complaints. Chest X-ray revealed a mass in the right lower lung field. A preoperative diagnosis of benign visceral pleural tumor was made by bronchography and computed tomography of the chest, etc. The patient underwent partial resection of the right lower lobe. The tumor was solid, encapsulated and pedunculated. Histological examination showed spindle cell & collagen fibers. The presence of desmosome connections and microvilli formation was highly suggestive of an epithelial origin. Light and electron microscopy established the diagnosis : benign localized pleural mesothelioma. In resecting the so called “benign” localized pleural mesothelioma, we do not recommend simple enucleation, since our speciman was not clearly separated from the surrounding lung parenchyma, and there are reports of local recurrences after resection of these tumors.

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Recently we experienced nine patients of surgical treatment using a pedicled omentum for management or prevention of serious complications in thoracic surgery. In five it was used to prevent anastomotic leakage and infection, in three to treat bronchial fistula with pyothorax after pulmonary resection, in one to treat pneumothorax with pyothorax. There were no abdominal complications, although one patient complained of abdominal distension after omentopexy. Though leucocytosis persisted for a relatively long period after surgery in most cases, there were no clinical problems. In all the patients treated preventively the use of the pedicled omentum was successful. In those with complications would healing was achieved in three, but one patient had a recurrence of bronchial fistula and died. In failed case we did not use additional procedures such as muscle transposition or thoracoplasty. Omentopexy plus additional treatment may be advisable for the achievement of healing.

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Pulmonary dirofilariasis was diagnosed in a 68-year-old male farmer who hd a dog. The Patient had resection of a mucoepidermoid carcinoma of a parotid gland and postoperatively was found to have a coin lesion about 1 cm in diameter in the right lower lung field. This lesion grew larger for two months, so partial resection of the right lung was performed because metastatic lung cancer was suspected. A 12 × 11 × 10 mm tumor was found in the right S⁶. It was elastic, hard, light yellow and covered with a white semitransparent membrane. A male dirofilaria immitis worm occluded a pulmonary artery. ELISA and Ouchterlony's tests carried out postoperatively were both positive, and cross reactions were observed. Recently, this disease has been reported more often, and should be considered in the differential diagnosis of coin lesions. The improvement of sensitivity and specificity in immunological tests and the elucidation of biological behavior are considered to be necessary for the improvement of diagnostic accuracy.

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Aggresive fibromatosis is disease in which benign but invasive fibrous tissue proliferates within the deep soft tissue of the trunk or extremities.
A 22-year-old female with a hard tumor of the chest wall was admitted to our hospital. Preoperative examinations, chest tomography, chest CT scan, MRI-CT, bone scintigraphy, etc. led to a presumptive diagnosis of aggressive fibromatosis arising from the deep soft tissue of the chest wall. The tumor was resected with the third, fourth and fifth ribs in a bloc 9 × 10 cm. Reconstruction of the chest wall defect was done with layers of Marlex-mesh. The post-operative course has been uneventful, now 12 months since surgery.

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A 37-year-old female, with a history of three previous episodes of right pneumothorax, visited our hospital with the chief complaint of a feeling of oppression of the right chest. Her chest X-ray film on admission revealed mild right pneumothorax. During the most recent previous episode, thoracoscopy at another hospital had shown no evidence of bullae or blebs, so pleurodesis was performed. Recurring right pneumothorax had been strongly suspected of being associated with menstruation in all of episodes. So cat menial pneumothorax was diagnosed. A large amount of air (about 500 ml) was insufflated through the uterus and Fallopian tubes, and two hours later her chest X-ray film showed free air below both diaphragms and aggravation of the right pneumothorax. Therefore, we performed surgery with confidence in our diagnosis. Since many small holes were observed in the center of the diaphragm, the region was resected and the defect sutured. The resected specimen showed no pathological evidence of endometriosis. At present, four months after the operation, no recurrence of pneumothorax can be seen.
In comparison with the conventional technique, pneumoperitoneum, transhysterosalpingial insufflation is a non-surgical, simple and very useful diagnostic method. Our technique confirmed the theoretical basis of this disease and demonstrated its pathogenesis.

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