[Recurrence of a stage I thymoma after resection]

A 61-year-old man had a non-invasive thymoma. The tumor recurred in the aortocaval groove 6 months after thymothymectomy. The second tumor was a non-invasive, lymphocytic thymoma with polygonal cells, and was similar to the first one. The tumor may have been a multicentric thymoma, with malignant cells remaining in thymic tissue behind the brachiocephalic veins. To resect thymomas, extended thymectomy should be done to prevent recurrence from the remaining thymic tissue. CT scans should be obtained for long-term follow up after surgery, to detect any recurrence in its early stage.

[Postoperative changes of maximum inspiratory and expiratory pressures in 3 pneumonia cases occurring after surgery for empyema]

We examined preoperative and postoperative maximum inspiratory (MIP) and expiratory (MEP) pressures in 3 cases who died of postoperative pneumonia occurring more than one month after open drainage thoracotomy for empyema. All cases showed reduction of MIP and MEP to less than 20 cmH2O one month after surgery, then suffered of pneumonia. On the other hand, the other 3 cases with empyema who underwent open drainage thoracotomy and recovered without complication showed recovery of MIP and MEP one month after surgery. In conclusion, for the cases that underwent thoracic surgery, postoperative MIP and MEP are the index of respiratory condition such as deep diaphragmatic breathing and ability of efficient coughing, and can be an early prediction of late onset pneumonia after thoracic surgery.

[Exacerbation of idiopathic interstitial pneumonia after lobectomy for lung cancer]

A 51-year-old man was found to have cancer in the left lung during treatment for idiopathic interstitial pneumonia. He underwent a left upper lobectomy because pulmonary function was judged to be adequate and because the interstitial pneumonia was not severe. After the operation, acute exacerbation of interstitial pneumonia occurred, and respiratory failure developed. Immediate steroid therapy alleviated his condition. Acute exacerbations of idiopathic interstitial pneumonia after pulmonary resection are usually fatal, and cases such as this are very rare.

[A case of tracheal stenosis caused by invasion of recurrent lung cancer palliated with dumon stent after Nd-YAG laser and bouginage using of tracheal tube]

The patient was 67 year-old male with tracheal stenosis caused by invasion of recurrent lung cancer after right upper sleeve lobectomy. He visited to our hospital for the purpose of palliation with tracheal stent. But rigid bronchoscope cannot be passed through its lesion because of severe stenosis. So the bouginage was performed. This method was that tracheal tube was inserted into his trachea through the hole of tracheotomy during six days following Nd-YAG laser therapy. After this treatment, rigid bronchoscope was inserted into the trachea and Dumon stent was placed safely and easily. It seems to be an useful palliation for patients with severs invasive tracheal stenosis.

[Use of an expandable metallic stent in patients with superior vena cava syndrome--comparison of angiographic findings and autopsy findings]

To evaluate the usefulness of expandable metallic stens (EMS) in patients with superior vena cava (SVC) syndrome, we compared venographic findings obtained before EMS insertion with findings at autopsy. Stents were inserted into the SVC in 10 patients. An autopsy was done in 7 of the 10 patients. At autopsy, the lumen of the SVC was patent in 4 patients; in those 4 patients venography before EMS insertion showed that the SVC was obstructed by extramural compression. These results suggest that extramural compression without direct invasion of the tumor is the best indication for insertion of an EMS. At autopsy, the lumen of the SVC was obstructed by direct invasion of a tumor in 2 patients; in those 2 patients venography showed wall irregularity and lumen narrowing caused by tumor invasion. However, in those 1 patients SVC syndrome either did not recur or recurred in only a mild form after EMS insertion. The results in these 2 patients suggest that if collateral circulation does not develop, insertion of an EMS is indicated also in patients in whom the SVC is obstructed by direct invasion of a tumor. In the remaining patient, the lumen of the SVC was found at autopsy to be obstructed by a thrombus. SVC syndrome developed in this patient 430 days after EMS insertion. In 1 of the 7 patients, an EMS was inserted into the left innominate vein and also into the SVC. Venography before EMS insertion showed that the vein was obstructed by extramural compression without direct invasion of the tumor, but the EMS was found at autopsy to be completely obstructed by a thrombus. This suggests that insertion of an EMS into the left innominate vein is not indicated this vein is easily obstructed by thrombi because of its anatomical location.

[A case of bronchogenic carcinoma associated with pulmonary infarction which showed a tumorous shadow]

The patient was 69-year-old male with bronchogenic carcinoma associated with another abnormal shadow in the same left lower lobe. Its shadow was considered whether obstructive pneumonia or intrapulmonary metastasis before thoracotomy. Pathological examination revealed that this lesion was pulmonary infarction. It may be rare that bronchogenic carcinoma is associated with pulmonary infarction showing tumorous shadow. The staging and operative indication of lung cancer should be carefully determined which associate with abnormal shadow on the same lung field.

[Squamous cell carcinoma of the lung associated with palmo-plantar hyperkeratosis]

Palmo-plantar hyperkeratosis (PPH) is a diffuse keratoderma of the palms and soles that has been reported to be associated with internal malignancies such as lung and esophageal carcinomas. When PPH is associated with malignancy the prognosis is poor. The present patient was a 48-year-old man with PPH who suffered from squamous cell carcinoma of the lung. The pathological stage was T4N2M1 and the patient died of recurrent tumor 17 months after surgery. Because the prognosis of lung carcinoma associated with PPH is poor, patients with these conditions should undergo frequent medical examinations, which should include chest radiography and cytologic examination of sputum.

[Maximal inspiratory and expiratory pressures long after lung resection]

Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured long after lung resection with reference to operative procedure and vital capacity (VC). MIP and MEP were measured before surgery and 3 months after surgery in 80 patients who underwent lung resection. The procedures were pneumonectomy in 4 cases, lobectomy in 42 cases, segmentectomy in 3 cases, and wedge resection in 31 cases. Postoperative MIP, MEP, and VC were expressed and analyzed as percents of their respective preoperative values (MIP(%), MEP(%), VC(%)). Patients who underwent lobectomy had significantly lower MIP(%) and MEP(%) than did those who underwent wedge resection (p < 0.001). Both MIP(%) and MEP(%) correlated significantly with VC(%) (p < 0.001). Pulmonary resection can continue to affect both pulmonary function and respiratory muscle strength even 3 months after surgery.

[A case of Von Recklinghausen's disease associated with a hemothorax due to a rapidly growing malignant schwannoma]

A 17-year-old man with Von Recklinghausen's disease was admitted to our hospital because of progressive dyspnea on exertion. A chest X-ray film showed a massive left pleural effusion. Thoracentesis revealed dark blood. Hemothorax was diagnosed, and digital subtraction angiography (DSA) was done. DSA revealed a large mass that was supplied with blood via the inferior phrenic artery, but revealed no active bleeding. An intercostal tube was inserted and 1700 ml of dark blood was drained. A chest X-ray film taken after drainage revealed a giant mass showing an extra-pleural sign in the left lung field. A thoracotomy was done to determine the source of bleeding. A giant tumor with hypervascular tissue was seen, and was diagnosed as a malignant schwannoma. No spontaneous hemorrhage from the artery was seen. The source of the hemothorax was believed to be hemorrhage from the tumor vessels. The tumor was treated conservatively, but it continued to grow rapidly and the patient died of respiratory failure. Five other patients have been reported to have hemothorax associated with Von Recklinghausen's disease. The sources of the hemothorax were reported to be hemorrhage from tumor vessels, or spontaneous rupture of the subclavian artery, an intercostal artery, or an intercostal vein.

[Obstructive sleep apnea syndrome associated with superior vena cava syndrome]

A 43-year-old man was admitted suffering from dyspnea on exertion and edema of the neck and face. Chest X-ray film and CT scan revealed a mediastinal tumor and a right pleural effusion. A biopsy of the tumor revealed poorly differentiated carcinoma. Severe snoring at night and excessive daytime sleepiness were noticed after admission. Nocturnal oxygen desaturation was documented with a pulse oximeter, and obstructive sleep apnea syndrome was diagnosed on the basis of results of respiratory inductive plethysmography. The severity of snoring and oxygen desaturation during sleep correlated well with the progression of facial swelling. Combination chemotherapy (carboplatin 300 mg/m2 day 1, vindesine sulfate 3 mg/m2 day 1 and 8) was started but no improvement was seen. An expandable metallic stent was inserted into the stenotic vena cava, and the facial swelling, snoring, and oxygen desaturation during sleep were promptly relieved. In this case, obstructive sleep apnea was caused by edema and vascular congestion in the upper airway, and by the decrease in pharyngeal inspiratory muscle function caused by superior vena cava syndrome.

[Clinicopathological examination of the relation between Clara cells and smoking]

The relations between the number and cell area of Clara cells and smoking were examined in the lung tissue of 71 subjects by immunohistochemistry, using an anti-protein 1 antibody, which is a marker of Clara cells. The smokers showed significantly lower numbers of Clara cells than the non-smokers (p < 0.05). Although the mean non-smoking time in the ex-smokers was as long as 9 years, the ex-smokers showed a somewhat lower number of Clara cells than the non-smokers. The cell area of Clara cells was the same for smokers and non-smokers. We found that smoking reduces the number of Clara cells.

[Cyst puncture and injection of contrast medium for diagnosis and treatment of pericardial cyst]

We present two cases of pericardial cyst diagnosed by cyst puncture and the injection of contrast medium. The first patient was a 48-year-old man. He was admitted for the evaluation of an abnormal chest X-ray which demonstrated a mass lesion inseparable from the right heart border. CT scan confirmed the mass in the anterior cardiophrenic angle. The mass was quite homogeneous, with an attenuation value of -0.3 HU. Under CT guidance a 21-G needle was inserted into the cyst and 3 ml of clear fluid was obtained, and then contrast medium was injected. A thin smooth walled cyst was outlined by the CT scan. A presumptive diagnosis of pericardial cyst was made. Surgery was performed and the diagnosis was confirmed. The second patient was a 24-year-old woman. An abnormal shadow was noted at annual check up. CT scan confirmed the mass in the anterior cardiophrenic angle. The mass was quite homogeneous, with an attenuation value of +10.4 HY. We made the diagnosis of pericardial cyst by cyst puncture and injection of contrast medium. The CT scan after three months showed no recurrence of the pericardial cyst. We consider that pericardial cyst can be diagnosed clearly by cyst puncture and the injection of contrast medium, and only percutaneous aspiration of the cyst fluid may be sufficient for the treatment.

[Two cases of re-expansion pulmonary edema following decortication of tuberculous empyema]

Two cases of re-expansion pulmonary edema following decortication of a tuberculous empyema are presented. The period of compression of the whole lung by empyema was relatively short in both cases. One case showed incomplete expansion of the whole right lung after preoperative drainage, and re-expansion pulmonary edema of the whole right lung after decortication, which was treated by mechanical ventilation and steroid therapy. The other case showed incomplete expansion of the right middle and lower lobes after preoperative drainage, and re-expansion pulmonary edema of the right middle and lower lobe after decortication, which was treated by steroid therapy. In cases of tuberculous empyema with a relatively short course, re-expansion pulmonary edema may occur in a lung incompletely expanded by preoperative drainage.

[Autopsy case of non-invasive thymoma associated with pancytopenia and hypogammaglobulinemia]

A 57-year-old male presented with palpitations and dyspnea on exertion. Examination of the peripheral blood and bone marrow showed pancytopenia with marked red cell aplasia. Hypogammaglobulinemia was also recognized. Chest X-ray and CT showed a mass in the anterior mediastinum. A biopsy showed thymoma. Two months after admission, the patient died of sepsis secondary to worsening pancytopenia and hypogammaglobulinemia. Autopsy showed non-invasive spindle cell type thymoma and a marked decrease of hematogenous cells. Review of the literature indicates that pancytopenia associated with thymoma is resistant to all forms of treatment and its prognosis is poor.

[A case of undifferentiated carcinoma of the thyroid with compression stenosis of the cervical and mediastinal trachea which was dilated by the expandable metallic stents]

The patient was a 64-year-old male with undifferentiated carcinoma of the thyroid which constricted the trachea. The radiation therapy did not reduce the size of the tumor, and did not improve the dyspnea. Bronchoscopy and tomography showed a compression stenosis of the cervical and mediastinal trachea. It was difficult to insert the T-tube because of the large mass of the neck. Therefore, three EMSs were inserted into the stenotic area of the trachea. Immediately after the insertion of the EMSs, the lumen of the trachea was dilated, and the dyspnea was improved. The patient died of the tumor 7 weeks after the insertion of the EMSs. Autopsy showed that the trachea was dilated by EMSs.

Cytofluorometric analysis of metastases from lung adenocarcinoma with special reference to the difference between hematogenous and lymphatic metastases

Metastatic tumors in the brain, liver, and regional lymph nodes (20 cases each) from patients with adenocarcinoma of the lung were examined by cytofluorometric analysis, and compared with the respective primary lung tumors. The nuclear DNA content of tumor cells was significantly increased in metastatic tumors in the brain and liver compared with the primary (P less than 0.01). However, the DNA content of metastatic tumors in regional lymph nodes was almost identical to that of the primary tumor in many instances. From the viewpoint of the nuclear DNA content of lung adenocarcinoma, blood-borne tumor cells in the brain and liver were considered likely to constitute a discrete tumor cell subpopulation, i.e., probably a more malignant one, different from the major subpopulation in the primary tumor, whereas lymphatic metastases in regional lymph nodes were similar to the primary. The subpopulation with an increased DNA content in hematogenous metastases were thought to have originated from a minor subpopulation in the primary tumor or to have developed at the metastatic site.