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The present patient was a 53-year-old male who had large cell lung cancer of c-T4N1M0. We administered multi-drug regimen including mitomycin C, vindesine and cisplatin (CDDP) because of cancer invasion into the great vessels seen on a chest CT. After 3 courses, the cancer showed no change in size. Therefore, we adopted chemotherapy of docetaxel (Taxotere: TXT) and CDDP. After 4 courses, the size of the mass had decreased (partial response). The only major toxic defect was grade 3 neutropenia. A good response to TXT and CDDP could lead to complete resection of lung cancer. It is suggested that TXT is effective in the treatment of large cell lung cancer.

118 patients with lung cancer who underwent treadmill exercise electrography (ECG) as part of their preoperative evaluation, were investigated for postoperative events. On the treadmill exercise ECG 27 patients were positive and 91 were negative. The more elderly patients tended to reveal ischemic findings in treadmill exercise ECG. Of the 71 patients with normal of result by ECG at rest, 15 patients (21.1%) had postoperative ischemic change on ECG. As a result, it was considered that this examination was insufficient to detect latent ischemic heart disease. The patients who had a discontinued at stage 2 or less of the Bruce protocol and had a negative result by treadmill exercise ECG, were classified as insufficient group and separated from the others. (27/118 patients). This group consisted of advanced age (p < 0.05) who tended to experience postoperative events. In the sufficient group, patients showed ischemic events predominantly on ECG at postoperative period (p < 0.01). We concluded that as preoperative screening of heart disease prior to lung cancer surgery ECG at rest was not adequate while treadmill exercise ECG was useful.

Clinical problems of pulmonary tuberculosis in the elderly patients were discussed. As for diagnosing tests, chest X ray sometimes shows atypical findings in patients with pre-existing pulmonary diseases (i.e. pulmonary emphysema, interstitial pneumonia and etc). It is most important to get bacteriologic evidence from suspected patients of pulmonary tuberculosis. Elderly patients have co-existing diseases except pulmonary tuberculosis. Controlling co-existing diseases is essential for treatment of pulmonary tuberculosis in the elderly patients. Treatment with standard chemotherapy leads to good result even in the elderly. However, we have to investigate the mechanism of rush cases, who dies in a few months in spite of adequate chemotherapy.

We evaluated the cause of death in patients with pulmonary tuberculosis who died within one year after diagnosing as tuberculosis. Of 325 bacillary patients during the past seven years, 43 (13.2%) died within one year. Twenty-three patients (53.5%) died directly of tuberculosis. In this group, 13 patients died in emaciation state. Most of them were aged and under a poor nutritional condition. Some patients died in spite of improvement of tuberculosis. The fact indicates the need to detect tuberculosis as early as possible in elderly persons, and treatment should be initiated immediately. Eight patients died of respiratory failure and their chest X-ray film showed wade-spread tuberculosis. Seven of the patients died in spite of initiating treatment within one month after the onset of symptoms. This fact suggests the importance of regular check up by chest X-ray to detect tuberculosis early. Two patients died of massive hemoptysis. They had an episode of bloody sputum and the laboratory examination showed anemia. On the other hand, 20 patients died due to coexisting diseases unrelated to tuberculosis. Ten patients died of malignant diseases and most of them were lung cancer. Two patients died of hepatic failure possibly caused by the adverse reaction of TB chemotherapy. The interval between the onset of the treatment and death was less than a month, and the fact suggests the need to observe carefully for adverse reactions especially in the early stage of treatment.

A 46-year old man was admitted to a hospital because of cough and dyspnea. He was diagnosed as interstitial pneumonia and was treated with prednisolone (PSL) and antibiotics. The symptoms improved temporarily but he soon developed acute respiratory failure and was transferred to our hospital. Chest X-ray and CT revealed ground-glass opacities in both lung fields. He was treated with methyl PSL, antibiotics, and antimycobacterial drugs but he died on the fourth hospital day. Retrospectively, hematologic laboratory examinations revealed that CD4+ cell count was 0/microliter and serological tests for HIV were positive by both EIA and Western blot methods. The culture of the bone marrow specimens was positive for mycobacteria other than M. tuberculosis, and the bacilli were identified as Mycobacterium avium. Thus, his disease was eventually diagnosed as disseminated Mycobacterium avium complex (MAC) infection. In the past reports, the diagnosis of disseminated MAC infection was most often made by blood cultures, however, the isolation of MAC from bone marrow is another sensitive and specific method for the diagnosis of this infection. In some cases, bone marrow examination would be useful to diagnose disseminated MAC infection.

It has been well known that tuberculous meningitis cases have moderate pleocytosis with mononuclears as predominating cell type in cerebrospinal fluid (CSF). But there are some reports of tuberculous meningitis in which polymorphonuclears was predominant in CSF. In this study, we investigated differential cell counts of CSF in 4 tuberculous meningitis cases. In 3 of the 4 cases, the CSF had a polymorphonuclears preponderance on admission. The elevated ratio of polymorphonuclears seemed to relate with the severity of the disease, and the ratio declined promptly after the initiation of chemotherapy. The 2 cases, which showed extremely high ratio of polymorphonuclears, showed poor prognosis, one died and the other had the severe sequelae such as notable disturbances of consciousness with hydrocephalus. This study suggests that differential cell counts of CSF is a useful measures to predict the prognosis and to follow up patients with tuberculous meningitis. The finding of a polymorphonuclears preponderance in CSF would suggest the severity and activities of the disease and should be considered as an alarm sign in tuberculous meningitis.

We compared automatic stapling with hand suturing in the rate of bronchopleural fistula. Twenty two hundred forty one patients of 25 hospitals, who were performed lobectomy or pneumonectomy for lung cancer from the year of 1990 to 1992, were investigated about the occurrence of bronchopleural fistula. The rate of bronchopleural fistula following lobectomy were 0.9% (11/1,227 cases) in automatic stapling, and 1.1% (8/753 cases) in hand suturing; there was no difference. However, there was a higher rate of the fistula with the use of automatic stapling devices in pneumonectomy. The rate was 11.2% (11/98 cases) in automatic stapling, and 1.2% (2/166 cases) in hand suturing. Automatic stapling may lead to bronchopleural fistula in pneumonectomy. Moreover, addition of hand suturing to automatic stapling was thought to prevent the fistula.

A 39-year old male visited the hospital complaining of perianal pain, swelling and redness. Under the diagnosis of an anal abscess, drainage was performed repeatedly. As the wound failed to heal and fistulae were detected, excision of entire tract was performed. On histopathological examination of the resected fistulae, caseous necrosis, Langhans giant cells, and epithelioid cell infiltration were found and diagnosed as anal tuberculosis. Chest X-ray showed cavitary lesion with infiltrative shadow in right upper lobe. Acid-fast bacilli were positive in sputum, and the diagnosis of pulmonary tuberculosis was confirmed. Anti-tuberculosis therapy was immediately started with good response to treatment. As tuberculosis of anal region is so rare recently and there is no characteristic clinical picture, it is very difficult to diagnose it pre-operatively. In some cases such as ours, pulmonary or other tuberculosis is accompanied with anal tuberculosis. Therefore, accurate diagnosis of anal tuberculosis is needed to find other tuberculosis early. As anal tuberculosis is rarely diagnosed correctly before operation on the basis of the clinical picture, the histopathological examination of the excised fistula is mandatory for the correct diagnosis of anal tuberculosis.

Thallium-201 (201Tl) and Gallium-67 (67Ga) scintigraphies were performed on 62-year-old male with silicosis combined with lung cancer (squamous cell carcinoma). In 67Ga and early 201Tl images, radiotracer uptakes were observed in both sites of cancer and silicosis, and thus, it was impossible to differentiate cancer mass from the large opacity of pneumoconiosis. On the other hand, in the 201Tl delayed images, 201Tl was localized only in cancer mass, while it was washed out from the large opacity. Our findings indicated that 201Tl early and delayed scintigraphy findings were very useful to differentiate lung cancer from silicosis.

To clarify the results of treatment of secondary empyema following lung resection complicated with internal fistula, 81 cases treated at 31 different institutions during the 5 years period from 1983 to 1987 were analysed. 1) All cases of thoracic empyema treated surgically and secondary empyema following lung resection complicated with internal fistula did not decreased during the study period, in spite of the remarkable decrease of surgical cases for pulmonary tuberculosis. 2) The highest rate was observed in males over 50 years of age. 3) Bacteriologically positive case in empyema space was occupied about 70%. 4) 196 operations (including drainage) of 17 types were performed on 81 patients. Only 16% of the cases were successfully treated with one stage of operation. 5) Principal surgical procedure applied in cases under this study was drainage followed by closure of fistula with muscle plombage and with or without thoracoplasty. Case of air plombage and omental pedicle flap plombage have increased recently in Japan. 6) Success rate was 55.6%, failure rate was 32.1% and the mortality was 12.3%. These results indicate the difficulty involved in treatment. Therefore, to avoid occurrence of secondary empyema cases, careful selection of surgical indication, sufficient training in surgical technique and good preoperative and postoperative management are crucial.

944 cases of thoracic empyema were treated surgically in a 6-year period (from 1981 through 1986) in 37 institutions under supervision of Ryoken. Preoperative backgrounds, operative modes and surgical results are evaluated. Preoperative backgrounds are as follows; Acute cases comprised only 5.5% of the total. Primary cases outnumbered postoperative ones, the former occupying 65.8% of the total. Fistulous empyema comprised 68.6% of the total. Extension of the empyema; total empyema 56.0%, partial empyema 44.0%. Concerning respiratory reserve, those with FEV1/VCpr (to be denominated RI) less than 40 comprised 44.3% of the total. As to bacteriological findings; positive 49.9%, negative 40.0%, unknown 10.1%. Surgical modes; Pleuroresection 20.8%, decortication 22.4%, space-reducing 28.6%, air-plombage 9.7%, open drainage 6.8%, closed drainage 4.3%, others 7.4%. Overall results; success 83.8%, unsuccess 11.5%, death 4.7%. Those with positive microorganisms and RI less than 40 fared most poorly; success 73.2%, unsuccess 19.7% death 7.1%. Those with negative microorganisms and RI more than 41 fared most well; success 97.9%, unsuccess 1.5%, death 0.5%. Success rate with regard to surgical modes; air-plombage 95.7%, decortication 95.3% pleuroresection 92.6%, space-reducing 80.0%, closed drainage 68.3%, open drainage 29.7%.

Multiple primary cancers were found after surgery in 80 (2.5%) of 3,154 patients with lung cancer. Patients with squamous cell carcinoma most frequently suffered from multiple primary cancers. The period up to discovery of the second primary cancers was within two years in 78.8% of the patients. Second primary cancers were most frequently observed in the lung, followed by the stomach, colon and rectum. Second primary cancers were found in the lung in 26 patients, 14 of these (53.8%) having squamous cell carcinoma. Multiple primary cancers were noted in 2.8% of 1,210 lung cancer patients who underwent stage I curative operation and 2.4% of the remaining 1,944 cases. As to prognosis, 14 patients survived for more than three years after the second primary cancers were found.

Costus root oil is a new primary sensitizer for examining the delayed, cell-mediated immune system. Ninety-nine patients with lung cancer were tested for skin reactions to costus root oil. The incidence of positive reactions to costus root oil decreased with the progress of lung cancer. The percentage of lung cancer patients who survived was significantly greater for positive than for negative patients. This study shows that skin reactions to costus root oil are related the tumor growth and prognosis in lung cancer.

Results of methyl heptine carbonate skin tests were compared with DNCB skin test results in 155 patients with chest diseases. Reactions to methyl heptine carbonate and DNCB were similar in 142 of 155 patients (92%). Forty-two lung cancer patients and 42 control patients were tested for their reactions to methyl heptine carbonate. The reactions were positive in 52% of the lung cancer patients and in 98% of the controls (p less than 0.01). The incidence of methyl heptine carbonate reactions decreased as the lung cancer stage advanced. The 6-month mortality rate was 10% in nonresponders compared to 77% in responders to methyl heptine carbonate (p less than 0.01). This study shows that reactions to methyl heptine carbonate correlate with tumor stage and prognosis in lung cancer.

One gram of cefmenoxime (CMX) was administered to each of 10 patients by a one shot intravenous injection at the beginning of surgery. At 30, 60, 90, 120 minutes after the administration, concentrations of CMX in venous blood, bone marrow blood and bone tissue were assayed by the agar-well method. CMX was smoothly transmigrated after the injection from venous blood to bone marrow blood and bone tissue, and effective concentrations higher than MIC80 values were maintained for several hours. CMX, therefore, appears to be a useful drug for the prophylaxis and the treatment of postoperative infections.