A group of 64 cases with histologically reported residual tumour on the bronchial margin after resection for bronchial carcinoma has been examined. Carcinoma in situ of the bronchial mucosa was described in nine cases, invasive carcinoma of the bronchial mucosa in 29, peribronchial malignancy in 18, and lymphatic permeation in eight. Survival with peribronchial malignancy and lymphatic permeation was poor. Nevertheless, the finding of earlier workers that residual mucosal tumour at the margin of the resected bronchus may not adversely affect survival has been confirmed. The reason for the prolonged survival of some patients despite reported tumours of the bronchial stump mucosa may be that such reports are sometimes artefactual, and two possible mechanisms for this are discussed.

Tracheal tumours were removed surgically from two patients and diagnosed as carcinoid tumours by routine light microscopy. At a later date, electron microscopy was performed on stored tumour tissue and no neurosecretory granules were found in either case. One showed features of a glomus tumour and the other of an acinic cell tumour. Only two glomus tumours appear to have been reported previously in the trachea, and no acinic cell tumours. Electron microscopy is thus sometimes of great assistance in diagnosing accurately unusual tumours of the lower respiratory tract.We have seen two patients in the last five years with tracheal neoplasms that were diagnosed by routine pathological methods as carcinoid tumours. To confirm the diagnosis before publication, we examined each tumour under the electron microscope. To our surprise, the electron micrographs clearly demonstrated that neither could be a carcinoid tumour. One was a glomus tumour and the other an acinic cell tumour. Reports of only two glomus tumours of the trachea were found,1 2 and the acinic cell tumour appears to be the first on record in the trachea. Case 1 CLINICAL HISTORYA 50-year-old man presented, as tracheal tumours often do, with "late onset asthma". After receiving unsuccessful treatment with steroids and bronchodilators, he was referred almost moribund for resection of a tracheal tumour. The tumour could be seen in the plain chest radiographs but was clearer in the tomograms, lying in the lower one-third of the trachea (fig-). It was excised together with a cylinder of trachea through a right thoracotomy incision, and the trachea was reconstructed by end-to-end anastomosis.Address for reprint requests: Professor BE Heard, Cardiothoracic Institute and Brompton Hospital, London SW3 6HP.After operation he developed sputum retention and pneumonia and required mechanical ventilation and repeated bronchoscopy. An empyema developed which was drained, and he became endotoxaemic and anuric. All supportive measures proved inadequate and he died on the fifteenth postoperative day. A necropsy was not performed. PATHOLOGYThe surgical specimen consisted of a cylinder of trachea 2-5 cm long, containing a smooth round polypoid neoplasm 2 5 x 1-5 x 1-0 cm, occupying most of the lumen and arising from the posterior wall.Routine paraffin sections stained with haematoxylin and eosin revealed irregular masses of mediumsized uniform polyhedral cells with central, delicately stained round nuclei, surrounded by a small amount of moderately eosinophilic cytoplasm (fig 2). Mitoses were rare. Many vascular channels traversed the tumour, and tumour cells were present in the tracheal muscle coat, and through to the edge of the specimen. It was originally diagnosed as a carcinoid tumour. The respiratory epithelium over the growth showed squamous metaplasia. At a later date, small pieces were taken from the tumour which had been stored in aqueous formalin and were post-fixed in glutaraldehyde and osmic acid, and embedded in Araldite. Sections 1 ,tm thick were cut an...

In a previous article we have analyzed the structure of the growing pig lung and correlated the findings with cardiorespiratory function studies on the same animals (J. Appl. Physiol: Respirat. Environ. Exercise Physiol. 45: 806-817, 1978). The present study analyzes the pulmonary and systemic vascular responses to acute hypoxia in some of those animals at three ages, 2-4, 5-8, and 9-12 wk, the lung of the 12-wk-old pig being structurally similar to that of the adult. In all anesthetized animals, acute hypoxia (5 min 10% fractional inspired oxygen concentration) increased mean pulmonary arterial pressure (Ppa) and total pulmonary resistance (TPR). The increase over base line of Ppa was 41.3% in animals aged 2-4 wk; 83.0% in those aged 5-8 wk, and 136.9% in those aged 9-12 wk; for TPR the increase in the three age groups was 66.4, 92.4, and 138.9%, respectively. This difference in vasoactivity with age is associated with the progressive extension of smooth muscle into the intra-acinar arterial tree, which we have previously shown is an important feature of the structural remodeling that occurs during postnatal lung development in both man and swine.

A case of complete cleft sternum is presented along with the nomenclatuie of sternal defects. It is recommended that the term ectopia cordis should be applied only to cases in which the heart and thoracic viscera are genuinely ectopic. A 10-day-old infant from Saudi Arabia was admitted to the Brompton Hospital in January 1974. She was the product of a full-term, uncomplicated pregnancy and normal delivery. The parents and three siblings were well and without congenital abnormality.On examination the infant was well nourished and weighed 3-4 kg. There was an ellipse of abnormal, partly ulcerated pink skin on the anterior chest with no apparent sternum deep to it (fig la). This left a defect between the ribs, which was up to 5 cm across. The heart and thoracic viscera could be seen and felt to move paradoxically in this defect during respiration, and protrude through it alarmingly when the child cried (fig lb). It was possible to approximate the ribs in the midline by applying gentle lateral pressure. This manoeuvre did not embarrass resriration or affect blood pressure. The heart sounds, which were normal, and the cardiac impulse were most easily detected to the right At operation a vertical elliptical incision was made excising the abnormal skin. The pericardium, which was adherent to the skin, was opened inadvertently and immediately closed by suture. A complete cleft sternum was found; the sternal bands were well formed and converged inferiorly to the linea alba of the abdominal musculature. There was no deficiency of the abdominal musculature or diaphragm, but the pectoral and sternomastoid muscles were separated by the span of the sternal defect. The sternal bands were dissected free of the pleura and their medial borders freshened. They were then approximated with interrupted nylon sutures without difficulty. Cardiorespiratory embarrassment did not occur, and the closure was completed with subcutaneous and skin layers. No muscular layer was required as the pectoral and sternomastoid muscles assumed a normal position with closure of the sternum.The child made an uneventful recovery and was discharged from hospital on the eleventh day after operation.We have recently reviewed this child who is now a healthy 5-year-old. She has developed normally and is asymptomatic. Physical examination is unremarkable apart from an inconspicuous midline scar and an apex beat which is still displaced to the right. The thoracic cage is welldeveloped, symmetrical, and without deformity. 303 on 11 May 2018 by guest. Protected by copyright.

When adding 22 cases of bronchial adenomata seen in the Brompton Hospital to the more than 100 cases previously documented, Foster-Carter (1941) stated that no death had ever been recorded from malignant change in a bronchial adenoma. Price-Thomas (1954), reporting a personal series of 41 bronchial adenomata treated in the Brompton and Westminster Hospitals, concluded that 'the incidence of malignancy is so low that it is possible for practical purposes to ignore it'. More recent papers have, however, questioned the use of the term bronchial adenoma, emphasizing not only the varying behaviour of the four tumour types included in the term-the bronchial carcinoid, the adenoid cystic carcinoma (cylindroma), the muco-epidermoid tumour, and the true bronchial mucous gland adenoma-but also the differing degrees of malignancy of the bronchial carcinoid itself (Donahue, Weichert, and Ochsner, 1968;Meffert and Lindskog, 1970;Tolis et al., 1972;Turnbull et al., 1972). In a Mayo Clinic series of 215 cases of bronchial carcinoid (Arrigoni, Woolner, and Bernatz, 1972), 23 (11%) were considered to have atypical histological features and, of these, 70% metastasized and 30%/O were dead after a mean survival of 27 months. This is to be contrasted with the usual bronchial carcinoid five-year survival of 80% or more (Overholt, Bougas, and Morse, 1957; Donahue et al., 1967). 245 on 7 May 2018 by guest. Protected by copyright.

The management and results of treatment in 181 children with coarctation of the aorta are presented. In this series, 79% of the patients presented in the first year of life and 55% presented as neonates. One hundred and fifty patients were operated on, with a total surgical mortality of 21%. Only one surgical death occurred in those operated on after 3 months of age. The higher mortality in young infants is closely related to associated cardiac anomalies and to the frequency of aortic and isthmal hypoplasia. Our findings suggest that neonates presenting with heart failure and coarctation should be operated on early, as the surgical mortality under 6 weeks is 45%, whereas there is an 86% mortality in neonates who were not operated on. Analysis of follow-up indicates that when operation can be performed electively the optimal period for sugical treatment is between 6 months and 1 year of age. If operation is performed after this age, there may be persistent systemic hypertension despite relief of aortic obstruction.

No abstract

Idiopathic mediastinal fibrosis is a rare disease of unknown aetiology. It is a benign condition in which abnormal proliferation of fibrous tissue occurs within the mediastinum, leading to constriction and obliteration of local structures, particularly the great veins. It is a rare cause of superior vena caval obstruction (1-2%) but one that is potentially amenable to surgical palliation. The results of venous reconstruction in five patients with superior vena caval obstruction secondary to idiopathic mediastinal fibrosis are reported. Reversed autogenous saphenous vein grafts were used in two patients, woven silicone rubber prostheses in two, and bovine pericardial conduits in one patient. Useful long term results were obtained in three patients, but the bovine pericardial graft and one of the vein grafts failed within a few weeks.Idiothaphic mediastinal fibrosis is a benign condition first described in 1757 by John Hunter.' It is characterised by abnormal proliferation of fibrous tissue within the mediastinum, and may be regarded as one of a group of similar fibrosclerotic conditions, which include retroperitoneal fibrosis, pseudotumour of the orbit, Reidel's thyroiditis, Dupuytren's contracture, and Peyronie's disease. The histological similarity between mediastinal fibrosis and retroperitoneal fibrosis in particular, and the observation that they often coexist in the same patient, has led to the belief that they may represent the same pathological process.The aetiology of idiopathic mediastinal fibrosis is obscure, but various factors have been implicated, in particular infection with tuberculosis and histoplasmosis, the drug methysergide, and autoimmune processes.