[Non-chondromatous hamartoma].

A 69-year-old female visited our hospital because of dyspnea. Chest X-ray showed an abnormal shadow in the right lower lung field. Chest computed tomography (CT) showed a round, well-circumscribed, homogenous subpleural nodle of 8 mm in diameter in the right lower lobe, which had no calcification and no pleural indentation. Bronchofiber scope, abdominal CT, brain magnetic resonance imaging (MRI), bone scintigraphy could not establish definitive diagnosis. Scince the possibility of malignancy could not be excluded throughout, video-assisted thoracoscopic surgery was performed to obtain confirmed diagnosis. Pathological examination revealed non-chondromatous hamartoma of the lung. Non-chondromatous hamartoma should be considered in the differential diagnosis of pulmonary nodles. We report a rare case of non-chondromatous hamartoma.

Alpha-1-antitrypsin deficiency (Siiyama) as indication for lung transplantation: proper timing for surgical intervention.

The authors report a new familial case of alpha-1- antitrypsin (AAT) deficiency with severe pulmonary emphysema and hemoptysis. A severely reduced serum AAT level of the proband, a 56-year-old farmer's wife and her sister were observed. Mutation analysis of the AAT gene was performed using allele-specific polymerase chain reaction (PCR) analysis followed by direct sequencing. The proband and her younger sister proved to be homozygous for PISiiyama. Although home oxygen therapy was induced in addition to previous medications including bronchodilators and cardiovascular conditioning, the proband's rate of decline of forced expiratory volume at one second (FEV1) was progressing. Lung transplantation was therefore advisable for the patient. Clinical analysis on Japanese cases reported in the literature shows that the rate of decline of FEV1 is one of the most convenient prognostic factors to find proper timing for surgical intervention. Lung transplantation is one of the best reliable current therapies to improve quality of life of severely impaired patients.

[Pulmonary large cell carcinoma contiguous to bullae with massive bullous hematoma and hemoptysis; with special reference to 20 cases of Japanese reports].

A 50-year-old man with continuous hemosputa and large hematoma of left upper lobe contiguous to bilateral emphysematous bullous disease was admitted for surgery to stop hemorrhage and to resect left lung hematoma and multiple bullae. Bullectomy and neodymium yttrium aluminum garnet (Nd-YAG) laser irradiation to bullae of left upper lobe performed successfully with maximum preserved pulmonary function of it. Pathological examination, however, revealed anaplastic carcinoma inside bulla of S(1+2)c with minimal invasion into adhered parietal pleura (p 3). Left upper lobectomy was carried out with complete mediastinal lymph node dissection (ND 2 b). The final pathological diagnosis was large cell carcinoma of left S(1+2)c with the staging pT3N0M0 and stage II. The patient lives actively in daily life more than 7 years without any recurrence. Clinical analysis of Japanese 20 cases of lung carcinoma with initial signs of hemosputa and/or hemoptysis contiguous to emphysematous bullae elucidate following important facts. Hemosputa and hemoptysis play important role for early finding and diagnosis of lung cancer contiguous to bullous disease, especially in patients of early clinical stage with or without computed tomography (CT) exams and promise to better surgical prognosis and survivals as compared with non hemosputa ones.

[Successful surgical repair of emphysematous giant bullae of the elderly with severely depressed pulmonary function].

A 71-year-old male was admitted to an emergency hospital owing to severe dyspnea of sudden onset. Bilateral tension pneumothorax with two giant bullae occupying more than the third of the right lung was disclosed on the chest X-ray. Bilateral chest drainages and cardiopulmonary resuscitation were performed. He could be freed from ventilatory support several days after tracheostomy and was referred to our hospital. The pulmonary function was severely depressed: VC (%) 1.20 l (40%) and FEV1.0 (%) 0.55 l (46%). In spite of oxygen inhalation he could not keep sitting due to dyspnea (Hugh-Jones grade V). Right multiple bullectomy was performed successfully and his postoperative course was uneventful. He was discharged eight weeks later. Seven months after surgery his pulmonary function was remarkably improved: VC (%) 2.05 l (64%) and FEV1.0 (%) 0.94 l (46%). He became to walk almost equally with a healthy man one year later (Hugh-Jones grade II).

Quantitative assessment of dyspnea during exercise before and after bullectomy for giant bulla.

Incremental exercise testing using a cycle ergometer was performed in eight patients with giant bulla before and after bullectomy to assess dyspnea. There was a significant positive linear relationship between dyspnea expressed in the Borg scale (BS) and oxygen consumption (VO2) during exercise in all subjects. From these correlations, we introduced the following three new parameters for quantitative assessment of dyspnea: the Borg scale slope (BSS); the threshold load of dyspnea (TLD); and the breakpoint load of dyspnea (BLD), representing the slope of the regression line, onset of dyspnea on the regression line, and the maximum oxygen consumption before the subjects interrupted exercise, respectively. After surgery, the BSS showed marked decrease, and the TLD and BLD showed significant increase. Therefore, the reduction in the dyspnea with peak exercise after surgery was thought to be, at least in part, based on the delay of dyspnea onset, the decrease in dyspnea sensitivity, and the improvement in exercise capacity. The improvement in dyspnea during exercise in patients with giant bulla after surgery was extensively evaluated by newly introduced parameters based on BS-VO2 regression line.

[Current problems in valvular surgery].

Based upon our experiences of 661 valvular operations for these 10 years, we discussed about three major topics in valvular surgery. The first is the current status of valve repair versus replacement. The second is on the changing aspects of patients undergoing valvular surgery. Finally difficult problems in the treatment of infective endocarditis was discussed.

[Single lung allotransplantation of Japanese monkeys--an immunohistological appraisal of the acute rejection].

Eleven orthotopic single lung allotransplantations of Japanese monkeys (Macaca fuscata) were done without immunosuppression. In the 7 monkeys acute rejection was obvious on chest X-ray and hematoxyline-eosin (HE) staining of the biopsied specimen. On the chest X-ray film, progressive interstitial shadow of the grafts became apparent at the third postoperative day, and they turned out completely radiopaque at the 6th- or 7th postoperative day. The HE staining revealed prominent perivascular edema at the second postoperative day. Perivascular round cell infiltration appeared at the third day and the massive round cell infiltration was observed in the perivascular region, vascular wall and alveolar wall with the thickening of the alveolar wall. Immunostaining with human antilymphocyte monoclonal antibodies was also performed. CD8 positive cells (suppressor/cytotoxic T cell) were observed in the perivascular region at the second postoperative day, and CD8 positive cells and CD4 positive cells increased in number as the rejection progressed. Judging from the positive immunological cross reactivity between Japanese monkey and human, the early diagnosis of the acute rejection of the grafted lung may be possible by detecting the perivascular CD8 cells, even in the human-beings.

[Results and problems of cardiac surgery in the elderly (70 years of age or older)].

Fifty-nine cardiac patients with 70 years of age or older were operated in our Department from 1979 to 1990. The mean age was 73.1 years old, and the male/female ratio was 27/32. The operative procedures performed were CABG in 35 cases, the closure of VSP in 4 cases, the valve surgery in 17 cases and the others in 3 cases. In CABG cases, the operative and late mortalities of the elderly patients were both 2.9% (1 case each), which were comparable to those of the younger patients. The restriction of the bypass grafting only to the key coronary arteries to reduce the operative time was considered to be important. In VSP cases, three of four patients were operated in the acute phase, one being lost because of in-hospital contamination. In the valve group, 24% (4 cases) were lost in the early postoperative period, which was much higher than that of the younger patients (7.2%). The earlier decision of the operation and the use of smaller prosthetic valve avoiding time-consuming aortic root enlargement were considered to be important to reduce the mortality. It is concluded that the results of cardiac surgery in the elderly patients could be satisfactory if one considers its peculiarity well.

[Successful resection of mediastinal and abdominal recurrent tumors of esophageal leiomyosarcoma 12 years after surgery].

A 57-year-old woman admitted to our hospital in October, 1988 because of the tumor of the abdominal wall and abnormal shadows of right chest wall and right upper mediastinum. Her esophagus had been resected and reconstructed by the stomach roll because of the esophageal leiomyosarcoma in May, 1976. Clinical examinations revealed that the abdominal mass and chest shadows were the recurrence of the leiomyosarcoma. The abdominal tumor was resected on 17th October, 1988. On 14th December, 1988 right thoracotomy was performed. Chest wall tumor (40 x 30 x 20 mm) and mediastinal tumor (45 x 40 x 35 mm) were resected completely. The mediastinal tumor was adhered to the remnant esophageal muscle layer. Microscopic section of the tumor showed spindle cell sarcoma with fine calcification, and it was diagnosed as the metastatic leiomyosarcoma.

[Malignant fibrous histiocytoma of the rib: a case report of repetitive extensive resections and reconstruction of the chest wall].

A forty-seven-year-old woman visited our hospital in March 1987 suffering from the local recurrence of the tumor. Her right 7th and 8th rib had been resected 2 years and 11 months before because of the malignant fibrous histiocytoma (MFH) originated from the right 7th rib. In May 1987, wide resection of the right lateral chest wall and partial resection of the right diaphragm were done. Dacron meshed silicon plate (Silastic) and musculocutaneous flap of the right latissimus dorsi were used to reconstruct the chest wall. Seven months after the second operation, local recurrence occurred again on the anterior chest wall, involving the right diaphragm and right lower lobe of the lung. In March 1988, extensive resection of the anterior chest wall with partial resection of the right diaphragm and the right lower lobe was followed by reconstruction of the chest wall by Silastic. The patient recovered uneventfully without any respiratory disturbances after both operations which included wide resection of the chest wall. Multiple pulmonary metastases were found 4 months after the operation, and she died of respiratory failure 7 months after the final operation. Although MFH was one of the most common sarcomas of the soft tissues, only one case of the MFH originated from the rib had been reported previously in this country. Silastic was proved to be a useful prosthesis for the reconstruction of widely resected chest wall.

Immunohistochemical and histometrical studies of the human thymus with special emphasis on age-related changes in medullary epithelial and dendritic cells.

Age-related changes in medullary epithelial and dendritic cells in the human thymus were examined quantitatively using immunohistochemistry and histometry. The material used was thymic biopsy specimens obtained from 105 patients during cardiac surgery, none of whom had immunological abnormalities. By using keratin and tissue polypeptide antigen markers to identify epithelial cells and S-100 protein and LN-2 markers to identify dendritic cells, the numbers of these cells in the medulla were counted morphometrically. The relative proportions of the cortex, medulla, Hassall's bodies, perivascular space, connective tissue and fatty tissue were evaluated using a computer image-analysis system and the respective relative volumes were calculated. Our results indicate that the number of medullary dendritic cells/mm2 and the relative volume of cortical thymocytes decrease steadily up to the age of 40 years, whereas no major change was found in the number of medullary epithelial cells/mm2.

[A case of metastatic lung tumor of the colon cancer with ova of schistosoma japonicum in the resected lung specimen].

A 69-year-old man underwent right middle lobectomy because of the tumor lesion in the right middle lung. He had ever been in Celebes and China (riverside area of the Yangtze), the infected area of schistosomiasis japonica, for military service during the World War II. Resected lung specimen was carefully examined at the department of pathology in our hospital. Several ova of Schistosoma japonicum were discovered scattered in the specimen, and the pathological feature of the lung lesion was revealed to be metastasis of the sigmoid colon cancer which was resected 4 years ago at a certain hospital. The ova of Schistosoma japonicum were also distributed near the colon lesion. Recently in Japan, it is said, acute infected case of schistosomiasis japonica has been ceased, however, in cases of chronic stage of this disease, hepatoma or lower intestinal cancers are still discovered through the careful follow up study.

[Respiratory failure after thymectomy in myasthenia gravis: evaluation of preoperative influencing factors and preventive managements against postoperative respiratory dysfunction].

Postoperative respiratory function was evaluated in 94 patients with myasthenia gravis after thymectomy. Preoperative clinical and pulmonary function data were submitted to statistical analyses. The duration of respiratory support and intratracheal intubation time were significantly correlated to % vital capacity, the clinical stage of myasthenia gravis, and the clinical stage of thymoma. Statistical analyses proved that anticholinesterase drugs taken in immediate postoperative period contributed to the improvement of postoperative respiratory function, and non-depolarizing muscle relaxants, i.e. d-tubocurarine which had been considered to be contraindicated in myasthenia gravis was found to be beneficial immediately after the operation in patients with severely deteriorated respiratory function preoperatively.

[Combined aortic and mitral valve replacement with or without preservation of posterior mitral apparatus].

Seventy patients who underwent aortic and mitral valve replacement were reviewed. 37 patients had the mitral valve replaced with preservation of posterior mitral apparatus (AVR and modified MVR; modified group), and the others without (AVR and conventional MVR; conventional group). Hospital deaths occurred in 4 patients (12.1%) in conventional group and in only 1 patient (2.7%) in modified group. Four out of these five hospital deaths were due to low output syndrome (LOS). The other one died of unknown cause. Severe LOS, necessitating intra-aortic balloon pumping, occurred in 4 (12.1%) in conventional group and in 2 (5.4%) in modified group. In the early postoperative period modified group showed better left ventricular function than conventional group in terms of cardiac index and left ventricular stroke work index. Cardiac performance was evaluated by means of echocardiography at the time of discharge. Modified group showed better fractional shortening and shorter PEP/ET (pre-ejection period/ejection time). These findings suggest that the lower mortality of modified group is due to better left ventricular function preventing LOS in the early postoperative period, and that preserving the posterior mitral apparatus has a more beneficial effect on postoperative left ventricular function even in combined valve disease.