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Small cell lung carcinoma (SCLC) and pulmonary large cell neuroendocrine carcinoma (LCNEC) are both classified as lung neuroendocrine carcinoma (NEC). It has recently been reported that the special AT-rich sequence-binding protein 2 (STAB2), known as a colorectal cancer marker, is also expressed in NECs occurring in various organs including the lung. However, few studies have examined any differences of SATB2 immunopositivity between SCLC and LCNEC. We investigated SATB2 expression in 45 SCLC and 14 LCNEC cases using immunohistochemistry as well as the expression of caudal-type homeobox 2 (CDX2) and keratin (KRT) 20. The LCNEC cases were more frequently positive for SATB2 (ten out of 14, 71%) than the SCLC ones (seventeen out of 45, 38%) with a statistically significance (P = 0.035). Furthermore, two LCNEC cases were positive for CDX2 while no positive findings were observed for any SCLC cases, the difference of which, however, was not statistically significant (P = 0.053). KRT20 was negative in all LCNEC and SCLC cases. These results require our attention when we use SATB2 and CDX2 as colorectal cancer markers because their expression in pulmonary NECs can lead to a misdiagnosis that the tumor is of metastatic colorectal adenocarcinoma, especially when the patient has a past history of colorectal cancer. Analyzing the relationship between the demographic/clinical variables and the SATB2 expression in the SCLC cases, just high Brinkman index (≥ 600) was significantly related to the positivity of SATB2 (P = 0.017), which is interesting considering the strong relationship between SCLC and smoking.

Several inflammation-based scoring systems and nutritional indicators have been shown to have relevance to survival of patients with non-small cell lung cancer (NSCLC).The present study examined preoperative and pathological factors in patients who underwent curative resection for non-small cell lung cancer, with the aim to elucidate risk factors for early recurrence within 1 year of surgery. Patients with NSCLC who underwent surgery from January 2009 to December 2014 were retrospectively investigated. Routine laboratory measurements including carcinoembryonic antigen were performed before surgery, and pathological information was collected after surgery. Patients with recurrence within 1 year after surgery were considered as early recurrence group (ERG), those with recurrence after 1 year were as late recurrence group (LRG), and those without recurrence were as no recurrence group (NRG). Multivariate analysis between ERG and LRG revealed Glasgow prognostic score (GPS) and CRP-to-albumin ratio (CAR) as independent risk factors for early recurrence. Multivariate analysis between ERG and LRG + NRG confirmed CAR, vascular invasion, and pathological stage as risk factors for early recurrence. These findings indicated that CAR and GPS were confirmed to be risk factors for early recurrence, in addition to pathological factors.

Introduction Surgery for N2 stage IIIA NSCLC is not recommended in major guidelines. Nevertheless, it has been noted that single-station N2 may have a better prognosis than multistation N2 and that surgery can be performed as the main therapeutic option. Methods We conducted a prospective phase II study for single-station clinical N2 (cN2) NSCLC to evaluate the efficacy and safety of surgical resection without induction therapy. Complete resection with lobectomy, bilobectomy, or pneumonectomy followed by ipsilateral mediastinal lymphadenectomy was performed in 32 of 34 enrolled patients, whereas the remaining two patients underwent incomplete resection. Three-quarters of the patients underwent subsequent adjuvant chemotherapy. Results The 5-year overall survival rate was 58.5% (95% confidence interval: 41.9–75.4) for all 34 patients, and eight patients (23.5%) with pN0 or pN1 seemed to have been enrolled. The 5-year overall survival rates for single-station cN2 without and with hilar node enlargement were 81.3% and 37.5%, respectively (p = 0.025). Surgical mortality was 0% for all, and no considerable perioperative complications were noted; however, two patients died of interstitial pneumonia and unknown cause within 3 months after surgical resection. Conclusions This is the very first prospective study on the surgical approach for cN2 NSCLC, and our result partially validated the proposed classification of the N descriptor in the new staging system. The treatment for single-station cN2 without hilar node enlargement would better if it were similar to that for cN1 disease. Induction chemotherapy or chemoradiotherapy may not be needed for such an entity.

Purpose: The correlation of advanced cancer with inflammation and/or nutrition factors is well known. Recently, the advanced lung cancer inflammation index (ALI) was developed as a new prognostic tool for patients with advanced lung cancer. In this study, we examined whether ALI results are correlated with prognosis of patients with early stage lung adenocarcinoma who undergo lung resection. Methods: From January 2009 to December 2014, 544 patients underwent lung resection due to primary lung cancer at Dokkyo Medical University Hospital, of whom 166 with pathological stage IA lung adenocarcinoma were retrospectively investigated in this study. ALI was calculated as follows: Body Mass Index (BMI; kg/m2) × albumin (g/dL)/neutrophil- to-lymphocyte ratio (NLR). Results: Multivariate analysis revealed that gender, red cell distribution width (RDW), NLR, and ALI were parameters significantly correlated with overall survival (OS). Patients with an ALI value less than 22.2 had an inferior 5-year OS rate as compared to those with a value of 22.2 or higher (p

Purpose In the present study, we examined the relationship between intraoperative pleural lavage cytology findings and presence of epidermal growth factor receptor (EGFR) gene mutations. Methods We investigated 160 patients who underwent surgical treatment for primary lung adenocarcinoma at our hospital from January 2011 to December 2013 to determine the presence of EGFR gene mutations and pleural lavage cytology. Results In all, 52 subjects (31.5%) were positive EGFR gene mutations, of whom 38 were found to possess the Exon 21 L858R mutation. Intraoperative pleural lavage cytology examinations were performed in 160 subjects and 12 had positive results, of whom 6 were positive for EGFR gene mutations, which was the Exon 21 L858R mutation in all. In a comparison between subjects possessing the Exon 21 L858R mutation and those negative for EGFR gene mutations, lavage cytology-positive (p = 0.02) and vascular infiltration-negative (p = 0.01) were characteristics of the Exon 21 L868R mutation-positive group. Conclusion Subjects positive for the EGFR Exon 21 L858R mutation had a higher positive rate of intraoperative pleural lavage cytology than those not possessing EGFR mutations.

Idiopathic interstitial pneumonias (IIPs) are associated with an increased risk of lung cancer. Glasgow prognostic score (GPS), which uses serum C-reactive protein (CRP) and albumin levels to indicate systemic inflammatory response and nutrition level, has been reported to be a predictor of overall survival in patients with various types of cancer. We evaluated the usefulness of GPS for prediction of survival of patients with both lung cancer and IIPs following a lung resection procedure. Patients with IIPs who underwent lung cancer resection from January 2006 through December 2015 were investigated. Routine laboratory measurements, including serum CRP and albumin for determining GPS, were performed before the operation. Univariate and multivariate analyses with a COX proportional hazards regression model were used to identify independent risk factors for overall survival (OS), relapse-free survival (RFS), cancer-specific survival (CSS), and other disease-specific survival (ODSS). A total of 135 patients underwent lung resection during the study period. Multivariate analysis selected sublobar resection (p = 0.035), UIP pattern (p = 0.025), and GPS of 1–2 (p = 0.042) as predictive factors associated with OS, while GPS of 1–2 (p = 0.039) was shown to be a predictive factor associated with RFS. Multivariate analysis also revealed pTNM (p

PURPOSE We examined whether redox balance during the perioperative period is associated with long-term survival of patients after undergoing lung resection. METHODS Patients who underwent surgery for lung cancer from January to June 2013 at our institution were investigated. Serum was collected during the operation, and on postoperative day (POD) 3 and 7, and the levels of derivatives of reactive oxygen metabolites (d-ROMs) and biologic antioxidant potential (BAP) were measured. RESULTS In all, 21 patients (69 ± 7 years old) were enrolled, of whom 9 underwent video-assisted thoracoscopic surgery. Comorbidities in the patients included chronic obstructive pulmonary disease in eight and idiopathic pulmonary fibrosis in five. d-ROM values on POD 3 and 7 were significantly increased as compared to those obtained during the operation (p

Background Purely localized, oligometastatic, and widely metastatic tumors are likely to require different therapeutic strategies. Although surgical procedures for isolated pulmonary, brain, or adrenal metastases from lung cancer have been extensively evaluated, most data are from retrospective studies; accordingly, we conducted a prospective multicenter trial. Methods Patients were eligible if they had previously untreated clinical T1-2N0-1 lung cancer with single-organ metastasis, or single-organ metachronous metastasis after complete resection of pathologic T1-2N0-1 lung cancer. Metastatic lesions were classified into three groups: group A included metastasis in single organs other than brain or lung; group B included synchronous brain metastasis; and group C included pulmonary metastasis. The treatment intervention was surgical resection of metachronous metastasis or of both synchronous metastasis and primary lung cancer. Results From December 2002 through June 2011, 36 patients were enrolled. Two patients were ineligible, and the remaining 34 were analyzed; 6 (18%) had a benign lesion and no metastasis, 5 patients (15%) underwent incomplete resection of primary lung cancer, and 20 patients (59%) underwent complete resection of both primary lung cancer and metastasis. The 5-year survival rate for these 20 cases was 44.7%. Conclusions Clinical T1-2N0-1 lung cancer with a single-organ metastatic lesion was a good candidate for surgical resection. A 5-year survival rate of about 40% can be expected, which could be comparable with that for stage II non-small cell lung cancer.

Background An outbreak of cholangiocarcinoma occurred among workers in the offset color proof-printing department at a printing company in Japan. The aim of this study was to clarify the characteristics of the patients with cholangiocarcinoma. Methods This was a retrospective study conducted in 13 Japanese hospitals between 1996 to 2013. The clinicopathological findings of cholangiocarcinoma developed in 17 of 111 former or current workers in the department were investigated. Most workers were relatively young. Results The cholangiocarcinoma was diagnosed at 25–45 years old. They were exposed to chemicals, including dichloromethane and 1,2-dichloropropane. The serum γ-glutamyl transpeptidase activity was elevated in all patients. Dilated intrahepatic bile ducts without tumor-induced obstruction were observed in five patients. The cholangiocarcinomas arose from the large bile ducts. The precancerous or early cancerous lesions, such as biliary intraepithelial neoplasia and intraductal papillary neoplasm of the bile ducts, as well as non-specific bile duct injuries, such as fibrosis, were observed in various sites of the bile ducts in all eight patients for whom operative specimens were available. Conclusions The present results showed that cholangiocarcinomas occurred at a high incidence in relatively young workers of a printing company, who were exposed to chemicals including chlorinated organic solvents.

Acute exacerbation (AE) of idiopathic interstitial pneumonia (IP) is a potentially fatal postoperative complication following lung cancer resection. Postoperative pyothorax (PP) following development of a bronchopleural fistula (BPF) after lung surgery induces continuous inflammation and may affect the occurrence of AE. We investigated the relationship between AE and PP in patients who underwent pulmonary resection for lung cancer.A total of 941 patients who underwent lung resection due to primary lung cancer from 2006 to 2015 at our hospital were investigated.Of the 941 enrolled patients, 137 (14.6 %) had idiopathic IP and were predominantly male (p 0.01). Pathological stage Ia and adenocarcinoma were observed at significantly high rates in the non-IP group (p 0.01). Patients with IP showed a tendency for a higher percentage of PP (p = 0.054). Of the 137 patients with IP, 17 (12.4 %) showed postoperative AE. Furthermore, PP was observed in three cases in the AE(+) group and two in the AE(-) group. PP had a correlation with a significantly higher incidence of AE (p = 0.007).PP was found to be a significant risk factor for postoperative AE in lung cancer patients undergoing a pulmonary resection. Since IP itself is likely a risk factor for PP, prevention of BPF is important for patients with IP, as it can lead to PP.

We evaluated the effect of an extracellular phosphate-buffered lung preservation solution (EP-TU solution) on acute postoperative graft function and recipient survival in a Japanese series of cadaveric lung transplantation.The subjects were ten patients who received lung grafts preserved with EP-TU solution at three of four designated lung transplant centers between 2000 and 2005. Three of the patients underwent single lung transplantation and seven underwent bilateral lung transplantation. Postoperative graft function was evaluated by primary graft dysfunction (PGD) grade (0-3), arterial oxygen tension/inspired oxygen fraction (PaO(2)/FiO(2)) ratio, and the previously reported chest roentgenogram score (CRS, 0-4) during the first 48 h after intensive care unit admission. Survival rates were also calculated.The average graft ischemic times for the first and second grafts were 431 and 571 min, respectively. The average PGD grade ranged from 0.5 to 1.0 and the average PaO(2)/FiO(2) ratio ranged from 350 to 400 Torr during the 48 h. The average CRS was always under 1.0. Survival rates at 30 days and 5 years were 90 and 80%, respectively.EP-TU solution promoted excellent postoperative lung graft function and enhanced recipient survival rates, despite a long average preservation time.

Carinal resection and reconstruction for lung cancer, termed carinaplasty, is a rare operation, and the procedure remains challenging and few reports have been presented. We analyzed complications, local control, and manner of recurrence in patients who underwent a carinaplasty and compared the results to those who underwent an ordinary bronchoplasty. Among 766 patients who underwent surgery for primary lung cancer at our institutions, 82 bronchoplasty procedures were performed, while 6 of those who received a bronchoplasty underwent a carinaplasty. Three of 6 patients who received a carinaplasty underwent the montage method, and other 3 patients underwent the one-stoma method. There were no operative deaths in patients who underwent a carinaplasty, while there was 1 operative death in the group of patients who underwent an ordinary bronchoplasty. Complications in the anastomotic site were observed in 33% in the carinaplasty group and 5.3% in the ordinary bronchoplasty group (P=0.011). There was no significant difference in regard to local recurrence between the groups (P=0.620). In conclusion, our results show that a carinaplasty is a technically demanding but useful procedure to avoid a pneumonectomy in patients with locally advanced lung cancer.

Background The ability to express genes with potential immunoregulatory capacity could reduce allograft rejection (AR). This study examined the effect of ex vivo lipid-mediated transbronchial human interleukin-10 (hIL-10) gene transfer on AR and the intragraft cytokine profile in a rat model of lung transplantation. Methods Left single lung transplants were performed between a highly histoincompatible combination of inbred rats. The donor left lung was extracted and intrabronchially instilled with a plasmid encoding hIL-10 (IL-10 group) or Escherichia coli β-galactosidase (control group), mixed with a cationic lipid. At 3 and 6 days after transplantation, the degree of AR was graded histologically (stage 1–4) and several pathologic categories of inflammation were scored on a scale of 0 to 4 according to the percentage of involvement. Intragraft cytokine profile was examined by real-time reverse transcription polymerase chain reaction. Results The stage of AR (3.1 ± 0.4 vs 3.8 ± 0.4) and the pathologic scores for edema (2.3 ± 0.8 vs 3.2 ± 0.4), intraalveolar hemorrhage (0.3 ± 0.5 vs 2.2 ± 0.8), and necrosis (0.3 ± 0.5 vs 1.2 ± 0.4) in the IL-10 group were significantly decreased compared with the control group at Day 6. IL-2 and tumor necrosis factor-α messenger RNA expression levels on Day 3 were significantly decreased in the IL-10 group. Conclusions Ex vivo lipid-mediated transbronchial hIL-10 gene transfer attenuated acute inflammation associated with AR, which was related to decreased levels of proinflammatory cytokine gene expression in a rat model of lung transplantation.

【目的】難治性気胸の術後合併症リスク評価．【対象と方法】高齢者難治性気胸手術症例43例に対し，術前背景因子，術前臓器機能因子，術前評価可能な麻酔手術侵襲等について比較検討し，単変量解析によるリスク評価を行った．続いて多変量解析を行い，高齢気胸術後合併症リスク評価を試みた．【結果】男性41例女性2例で，術後合併症は10例（23.3％）で認められた．諸因子別網羅的解析では，全25項目中血清TP，Alb，chE，Na＋低値群およびPS，酸素投与群，麻酔スコア値で有意であった．すべての因子による多変量解析ではPS低値群にて有意に合併症が発生した（odds比：73.7，P＝0.003）．【結語】高齢者難治性気胸ではperformance status不良，低栄養状態，低Na群および酸素吸入群は全身麻酔手術ハイリスク群である．

Awake video-assisted thoracic surgery (VATS) is a therapeutic option for patients with intractable secondary spontaneous pneumothorax (SSP) complicated by impaired pulmonary function. The preoperative identification of air leak points is one of the keys to the success of this procedure. We describe how we performed saline-filled computed tomography (CT) thoracography to detect pleural fistulae in three patients with intractable SSP. Saline-filled CT thoracography showed bubble signs in two patients and an air–water level in bulla in one patient. The preoperative identification of air leak points resulted in successful awake VATS for all three patients. Our experience demonstrates that saline-filled CT thoracography is a useful diagnostic tool for SSP, especially when used in preparation for awake VATS when minimally invasive procedures are desirable.

Background Tranilast is an anti-allergic agent known to inhibit the release of histamine, interleukin-1β, transforming growth factor β1, and platelet-derived growth factor from various cells and currently is used to treat allergic diseases, keloids, and hypertrophic scars. We evaluated the ability of tranilast to inhibit the development of obliterative airway disease (OAD) in a rat model of heterotopic tracheal transplantation. Methods We transplanted tracheal segments from donor rats (Brown Norway) into subcutaneous pouches in major histocompatibility complex-incompatible recipient rats (Lewis). At Days 21 and 28 after transplantation, we histologically assessed the harvested allografts scored the degree of OAD, on a scale from zero to 4 as previously described, caused by fibroproliferative tissue. Results Recipient animals treated orally with 400 mg/kg/day tranilast throughout the experiment showed significantly decreased OAD compared with control animals, with a histologic score of 1.1 ± 0.4 vs 3.0 ± 1.3, respectively (mean ± SD, p = 0.007), at Day 21 after transplantation and 2.0 ± 1.4 vs 3.9 ± 0.4, respectively (mean ± SD, p = 0.017), at Day 28 after transplantation. Conclusion These results showed that treatment with tranilast significantly decreased fibroproliferative airway changes associated with allograft rejection in a rat model of tracheal transplantation, suggesting that tranilast may be useful in preventing bronchiolitis obliterans after lung transplantation.

Background . There have been no reports evaluating the completeness of systematic nodal dissection with video-assisted thoracic surgery (VATS). In order to elucidate the completeness of the dissection, we have conducted a prospective trial with patients having primary lung cancer. Methods . Patients with clinical stage I lung cancer were the candidates for this study. Thoracotomy was performed with a small skin incision of 7 cm to 8 cm in length. Through these small wounds and two trocars, pulmonary resection was performed and then hilar and mediastinal lymph nodes were dissected. After that, a standard thoracotomy was carried out by another surgeon to complete systematic nodal dissection. Results . Video-assisted thoracic surgery lobectomy with lymph node dissection was accomplished in 17 right lung cancer patients and 12 left lung cancer patients. On the right side, the average numbers of resected lymph nodes by VATS and remnant lymph nodes were 40.3 and 1.2, respectively. The average weights of dissected tissues by VATS and remnant tissues were 10.0 g and 0.2 g, respectively. On the left side, there were 37.1 and 1.2 lymph nodes and 8.3 g and 0.2 g of weight of dissected tissues. No nodal involvement was observed in the remnant lymph nodes. Conclusions . The lymph node dissection with VATS was technically feasible and the remnant ("missed" by VATS) lymph nodes and tissues were 2% to 3%, which seems acceptable for clinical stage I lung cancer.

Background Pulmonary pleomorphic carcinoma (PPC) is a rare type of non-small-cell lung cancer that belongs to the family of sarcomatoid carcinomas and is associated with poor prognosis. We investigated the expressions of tumor-related genes in resected PPC specimens. Methods Specimens resected from patients with PPC from July 2006 through April 2012 were investigated. Tumor segments were collected from the specimens by micro-dissection to extract mRNA, then RT-PCR was performed according to Dannenberg’s tumor profile method for semi-quantitation of tumor-related gene mRNA. To compare with other types of lung cancer, data from stage-matched adenocarcinoma (AC) and squamous cell carcinoma (SCC) cases in our database were also examined. Results The gene expression levels of thymidylate synthase were significantly higher in PPC and SCC as compared to the AC specimens (p

Secondary immune thrombocytopenia is a rare paraneoplastic syndrome of lung cancer. We report a case of pulmonary pleomorphic carcinoma with newly diagnosed secondary immune thrombocytopenia. On referral, the patient's complete blood cell count was normal; however, it showed marked thrombocytopenia after 1 month. Blood biochemistry and bone marrow puncture showed normal findings. We speculated that he had immune thrombocytopenia associated with the lung cancer and planned lung resection. Sleeve middle and lower lobectomy was successfully performed with preoperative intravenous immunoglobulin and intraoperative platelet transfusion. His platelet count was restored and maintained a normal level at 8 months after the operation.

Anastomotic complications of tracheo-bronchoplasty often lead to critical postoperative conditions and deteriorated QOL. Operative approaches, tension-reducing techniques and wrapping procedures for improvement of anastomotic circulation depend on the localization and range of the involved lesions. In this study, intrathoracic tracheal reconstructions were evaluated from the viewpoint of complications in 36 cases: 11 middle and lower tracheal resections, 12 right pneumonectomies (RP), 6 left pneumonectomies (LP), and 7 right upper lobectomies (RUL) with carinal resection.The results were as follows: (1) Postero-lateral thoracotomy is a standard approach for RP and RUL, except for the cases requiring a combined resection of the SVC. For RUL cases with carinal reconstruction, release techniques and wrappings are essential because of frequent anastomotic complications. (2) An operative approach for LP hasn't been established so far. However, clamshell incision and reconstructions under ECMO have provided better visibilities in certain anastomoses. (3) Median sternotomy with a collar incision is convenient for middle and lower tracheal reconstructions because of its availability for immediate release techniques and wrappings.

A 29-year-old woman presented with a 4 x 3.5 cm circumscribed mass located in the left upper lobe, which had not been detected in a chest roentgenogram that was taken 3 years prior. Bone scintigraphy using technetium-99m methylene diphosphonate revealed an increased uptake of the isotope in the mass, indicating increased osteoplastic activity. She underwent surgical resection of the mass and the pathologic diagnosis was endobronchially located pulmonary hamartoma, which contained bone marrow tissue. An extremely rare case of pulmonary hamartoma showing rapid growth and involving bone marrow tissue is presented.

We present here a rare case of left-side catamenial pneumothorax, in which endometrial tissue pleura was found on the visceral pleura histologically. A chest roentogenogram confirmed the left pneumothorax, but did not reveal bullae or any associated anomalies, in a 41-year-old woman with three documented episodes of left-side pneumothorax occurring every menstruation. Video-assisted thoracoscopic surgery revealed not only tiny holes in the diaphragm, but also a scattered small brown spots on the visceral pleura. Histological examination of the lung sections revealed the existence of endometrial tissue on the visceral pleura with disrupted pleural elastic fibers. Our case suggests that cyclic erosion of the visceral pleura by the implanted endometrial tissue caused air leakage from the lung, in addition to the most accepted concept that air is aspirated into the thoracic cavity via the abdomen through the acquired fenestration of the diaphragm.

OBJECTIVE Lung cancer located in the paravertebral region occasionally invades the rib head (T3) and not the spine (T4). In such cases, a costotransverse ligament release (CTLR) method may be useful for complete resection without performing a vertebrectomy. METHODS Eighteen patients with lung cancer underwent chest wall resection between 2001 and 2009 at our institutions. Of those, 7 who underwent chest wall removal with rib head resection via a CTLR method (group A) and 11 without rib head resection(conventional distal rib resection, group B) were retrospectively analyzed. RESULTS Three patients in group A underwent induction chemoradiotherapy. All rib head resections were performed via a CTLR approach without postoperative complications. There were no deaths within 30 day in group A and 1 in group B. The mean number of resected rib heads was 2.1 in group A, while 2.0 ribs were removed in group B. There was no significant difference for operation time between groups A and B(332±112 vs. 287±114 mins, p = 0.449). Local recurrence was seen in 0 patients in group A and 3 in group B(p = 0.13). The median survival time was 1489 and 727 day, respectively, while 5-year survival rates were 0.48 and 0.41, respectively. CONCLUSION A rib head resection via a CTLR method is an effective procedure for T3 lung cancer infiltrating the rib head.

We report here a case of right lung cancer with right aortic arch. A 67-year-old woman with right aortic arch was found to have a 3-cm squamous cell carcinoma arising in the right middle lobe. Right middle lobectomy with lymphadenectomy was performed via right thoracotomy. Although a unique operative view required particular attention in identifying nodes in the mediastinum, we were able to perform the operation without specific techniques.

The most serious complication that can occur during mediastinoscopy is hemorrhage from large vessels in the mediastinum, whereas there are few articles relating to injury to major vessels. We describe a case of 77-year-old male with mediastinal lymphadenopathy, who underwent a mediastinoscopy procedure. When the pretracheal lymph nodes adjoining the right pulmonary artery were biopsied, a massive amount of bleeding spilled out through the scope. Immediately, the scope was removed from the body and the bleeding was controlled with digital compression at the skin incision. Then we closed the incision in a three-layer manner without any gauze packing in the mediastinum. Although some reports recommended gauze packing for massive bleeding during mediastinoscopy, we believe not all cases need gauze packing because bleeding from a low-pressure circulation system component into closed compartment, such as mediastinum, would cease without resulting in a large hematoma or pseudoaneurysm.

Five patients with invasive thymomas and postoperative associated diseases were studied clinically and histologically three had myasthenia gravis (MG), one had a skin rash, interstitial pneumonia and hypogammaglobulinemia, and one had pure red cell aplasia (PRCA) and hypogammaglobulinemia. Total tumor resection was performed in four patients, and partial resection in one, who had massive pleural dissemination. Thymectomy was performed in the patient with preoperative PRCA, right pneumonectomy in one patient, and right upper lobectomy in one. The epithelial cells in four of the tumors were polygonal, and there were spindle-shaped in the patient with preoperative PRCA. Metastasis and/or local regrowth of the thymomas occurred in two patients, one of whom received chemotherapy. MG was treated with prednisolone and/or azathiopurine, and PRCA was treated with prednisolone and protein anabolic hormone. One patient died of brain metastasis, and three of complications. Only one patient is still alive.In conclusion, metastasis or recurrence of thymoma is likely to be the cause of postoperative associated diseases, and treatment of metastasis or recurrence may be helpful in the management of associated diseases.

We report herein the rare case of a patient with endotracheal papillary adenocarcinoma of the goblet cell type. The tumor existed in the upper trachea, obstructing 95% of the airway, and prompt palliation was required. Endotracheal polypectomy was successfully performed in this patient using electrosurgery with a new snare designed for the respiratory tract. The procedure took only a few minutes and the dyspnea was relieved promptly without any complications. The alternative techniques for palliation of bronchial stenosis are also discussed.

J Thorac Cardiovasc Surg 1998;116:651-2

group (n 8) received these solutions supplemented with 3-AB (100 M) or 4-HQ (10 M). Left ventricular function (dp/dt) and release of cardiac enzyme were measured before and after cardioplegic arrest. After reperfusion, NAD levels were assessed and the tissues were examined immunohistochemically for oxidative stress and apoptosis. Results: During reperfusion, the PARS inhibitor groups showed higher dp/dt and lower creatine phosphokinase level. The cardiomyocytes of PARS inhibitor groups also preserved higher NAD levels. Immunohistochemical study of oxidative stress revealed a lesser extent of nuclear and a lower fraction of apoptosis in the PARS group than the control group. Conclusion: Cardioplegic solution supplemented with PARS inhibitors enhances myocardial protection by suppressing oxidative stress and overactivation of PARS.

A 72-year-old male suffered a traumatic tear of the descending aorta and multiple rib fractures in a railway accident. The chest X-ray film revealed fractures of the left 5th to 11th ribs and hemo-pneumothorax, but no mediastinal hematoma suggesting aortic rupture. We operated 25 hours after the trauma because of shock state due to massive bleeding in the pleural cavity. During surgery a tear of the descending aorta was observed at the level of the 7th thoracic vertebral body. The fractured edge of the left 7th rib protruded into the pleural cavity. This seemed to be the cause of the aortic tear. Our case is the first clinical report of a thoracic aortic tear caused by such a mechanism. Multiple rib fractures near the vertebrae can cause aortic damage.

The first successful lung transplantation (LTx) was performed in 1983. Since then, more than 10 000 LTx have been performed in the world, with approximately 1000 new cases each year in recent years. Lung transplantation is established as the ultimate treatment for end-stage pulmonary diseases. Clinical application of LTx was delayed in Japan because of difficulty in acceptance of brain death. The Japanese Brain Death Act (JBDA) for organ transplantation was enforced in October 1997. Now, LTx from a brain-dead cadaver donor (BDCD) becomes a clinical option for end-stage lung diseases in this country. Four LTx centers were selected and the registration of candidates for LTx started in August 1998. In total, up until May 2001, 51 patients had been registered on a waiting list. Patients’ diseases for LTx in Japan are different from those in the US and Europe. So far, primary pulmonary hypertension (PPH; n = 23), idiopathic pulmonary fibrosis/interstitial pneumonia (IPF/IIP; n = 8), lymph- angioleiomyomatosis (LAM; n = 7) and bronchiectasis (BE; n = 6) are the major indications for LTx in Japan. Fourteen patients (27%) have died while waiting for LTx and only eight patients (14%) have received lung allografts. The BDCD are quite precious and, thus far, only 13 donors have become available after enforcement of the JBDA. Although the average utilization of BDCD for LTx was reported to be only 10–20%, positive utility of marginal donors in Japan has led to a higher rate (five of 13; 36%). Six LTx were performed from five BDCD. These included five single LTx (LAM n = 3; IPF/IIP n = 2) and one bilateral LTx (PPH n = 1). Because there are few BDCD in Japan, living-donor lobar LTx (LDLTx) is thought to be the optimal choice for selected patients. Eight LDLTx (BE n = 2; bronchiolitis obliterans n = 2; IPF/IIP n = 2; LAM n = 1; and PPH n = 1) have been performed. All recipients who received a LTx in Japan are alive and doing well at present.

Clinical Summary A 52-year-old woman with a previous history of vasospastic angina presented with an asymptomatic mediastinal mass on her routine follow-up chest roentgenogram. Values shown by means of hematologic and biochemical examinations were within normal range. A computed tomographic scan demonstrated a mass of 40 mm in diameter with a smooth margin adjacent to the trachea, superior vena cava, and ascending aorta. It showed high enhancement, although the degree of enhancement was lower than that of the surrounding vascular structures. Because a vascular tumor was suspected, digital subtraction angiography was performed, but this did not show feeder arteries or other vascular staining. Magnetic resonance imaging suggested high intensity on the T1-weighted image and low intensity on the T2-weighted image. No flow void was demonstrated (Figure 1, A). A diagnosis of lymphoadenopathy, such as Castleman disease or a malignancy, was given by radiologists. An ordinary bronchoscopic examination also showed no abnormal lesion. XBF-UC40P, a new prototype bronchofiberscope with an electrical curved linear array method, clearly showed a cystic mass with blood flow by using the power Doppler mode (Figure 1, B). No definite findings were detected on abdominal and cardiac echocardiographs. Because a vascular tumor was strongly suggested on the basis of endobronchial ultrasonography (EBUS), surgical removal of the mass by means of video-assisted thoracotomy was performed. Macroscopically, the mass seemed to be a varix of the azygos vein. No abnormal findings were observed in the superior vena cava and right atrium. The wall of the cyst was very thin, and delicate manipulation was absolutely necessary in dissecting the tumor (Figure 2, A). Pathologic examination of the excised tumor showed it to be a hemangioma composed of various cavities separated by fine septa lined with attenuated endothelium not unlike the hemangiomas of other regions. The wall of the tumor was composed of smooth muscle and connective tissues (Figure 2, B). The postoperative course was uneventful.