We retrospectively prepared step sections of the transbronchial lung biopsy (TBLB) materials which revealed nondiagnostic findings in their original sections in patients with diffuse lung disease, and evaluated the significance of the examination of step sections in the diagnosis of diffuse lung disease. Of 131 cases with nondiagnostic TBLB findings, the preparation of step sections resulted in specific findings in 6 cases (malignancy 3 cases, tuberculosis 1 case, cryptococcosis 1 case and viral infection 1 case), and histopathological changes consistent with the clinical diagnosis in 25 cases. The step section preparation was especially useful for the detection of epithelioid granuloma and tumor tissue in patients with sarcoidosis and carcinoma, respectively, while its contribution to the diagnosis of collagen-vascular disease, hypersensitivity pneumonitis, atypical pneumonia and pneumoconiosis was relatively small. The step section preparation was also useful for the detection of bronchiolitis obliterans. In addition, step sections uncovered clinically unnoticed infection (purulent exudate in the alveolar space) in 6 cases, 3 of whom actually developed pneumonia thereafter. Thus, the preparation of step sections was considered to be useful clinically in 37 cases (28.2%). The preparation of step sections is recommended before a further diagnostic procedure is chosen, when TBLB performed in patients with diffuse lung disease reveals nondiagnostic findings.

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The quantitive changes of glycosaminoglycans in tumor tissue of human lung cancers (6 squamous cell carcinomas, 7 small cell carcinomas and 10 adenocarcinomas) were studied. Normal lung tissues contained of 3.38μmol uronic acid/g dry weight glycosaminoglycans which consisted of hyaluronic acid, chondroitin sulfates, dermatan sulfate and heparan sulfate. The total amount of glycosaminoglycans in human lung caner tissues increased 1.7 to 3.5 times in comparison with that in normal lung tissues. The increase in tissue content of glycosaminoglycans was accompanied by an increase in the chondroitin sulfate level in every histologic type of lung cancer, as well as marked increase in hyaluronic acid level in squamous cell carcinomas, and a moderate increase in small cell carcinomas. The concentrations of dermatan sulfate and heparan sulfate in lung cancer tissues did not show any significant changes compared with those in normal lung tissues. The increase in total amount and changes in the composition of glycosaminoglycans in human lung cancer tissue were closely related to the histologic type of the tumor. In adenocarcinomas, some acid glycoprotein with sialic acid was simultaneously detected during the separating course of glycosaminoglycans, which was considered to be derived from mucinous substances related to adenocarcinoma cells.

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Platelet activating factor (PAF) has recently been demonstrated to play an important role in allergic diseases such as bronchial asthma. Changes in airway wall thickness have recently been suggested to cause excess airway narrowing of asthma. In this study, the authors examined the bronchial hyperresponsiveness to histamine in guinea pig induced by intravenous administration of PAF by measuring dynamic compliance and dynamic respiratory resistance. Moreover, a new formula which can exclude the effect of the changes of the airway wall thickness was proposed. With this formula, the administration of PAF was suggested to induce airway wall to be thickened. The ratio of bronchial smooth muscle constriction by histamine was significantly enhanced by the administration of PAF (p<0.05). Moreover, antagonists such as CV3988 and CV6209 inhibited the effect of PAF. The above results suggest that PAF may be an important mediator affecting bronchial hyperresponsiveness.

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Pulmonary function tests were performed in 18 cases of obstructive sleep apnea in supine and sitting positions and the relationship between pulmonary function and polysomnographic data was analyzed. %FRC and PaO₂ were reduced in the supine position compared with those in the sitting potition. It was suggested that the reduction of PaO₂ was mainly caused by the elevation of CC/FRC ratio in supine position. The relationship between pulmonary function data and polysomnographic data were analyzed, and an inverse relationship between %FRC in sitting position and desaturation was observed and also a positive relationship between PaO₂ in the supine position mean-nadir SO₂ was found. Saw-tooth sign and V_E50/V_I50>1 on flow-volume curves were not related to the apnea index and desaturation index. These results indicate that the F-V curve is not useful for the diagnosis of OSA.

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The movement of the cephalic margin of the zone of apposition (ZOA) of the diaphragm associated with ventilatory movement was measured using ultrasonograpy in 24 healthy subjects and 45 patients with various pulmonary diseases. A transducer was placed on the lower chest wall, and movement of the cephalic margin of ZOA was measured during maximal inspiratory maneuver and expiratory maneuver from end expiratory position in supine and sitting positions in healthy subjects, and in the supine position in patients. In healthy subjets, there was a linear relationship between inspiratory or expiratory volumes and movement of the cephalic margin of ZOA. Movement in the supine position during vital capacity maneuver was 103.0±15.6 (mean ± SD), 106.6±17.2, 108.5±18.2, and 114.8±16.3mm on the left anterior, right anterior, left posterior, and right posterior axillary lines, respectively. In the supine position, movement on the right posterior axillary line was significantly larger than that measured on other axillary lines (p<0.05). Movement during maximal inspiratory maneuver in the supine position was significantly larger than that in the sitting position (p<0.01). Movement during maximal expiratory maneuver in the supine position was significantly smaller than that in the sitting position (p<0.01). Patients showed decreased movement and great differences in movement between the left and right anterior axillary lines. Seven patients out of 28 with normal spirograms showed decreased movement on either or both sides. These data suggest that: 1) the movement of the cephalic margin of ZOA reflects diaphragm displacement; and 2) difference in ventilatory function of right and left hemithorax can be detected by movement of the cephalic margin of ZOA.

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Incremental exercise test with a bicycle ergometer was performed on thirty eight patients (11 patients with chronic obstructive pulmonary disease, 6 patients with interstitial lung disease, 21 patients with preoperative check up for respiratory disease). In 34 patients except four patients with interstitial lung disease, there was a close correlation between dyspnea expressed on the Borg scale (BS) and oxygen consumption (V_O2) (r=0.778-0.998).
To evaluate dyspnea in more quantitative manner, we introduced three parameters by the BS-V_O2 regression line. The Borg scale slope (BSS) represents the slope of the regression line, threshold load of dyspnea (TLD) represents the onset of dyspnea on the regression line, and the breakpoint load of dyspnea (BLD) represents the maximum oxygen consumption before the subject interrupted exercise. BSS had significant negative correlations with VC, %VC, FEV_1.0, TLC, DL_CO, and %DL_CO. TLD and BLD had significant positive correlations with VC, FEV_1.0, DL_CO, and %DL_CO. No correlation was found between dyspnea evaluated by the Hugh-Jones classification and the parameters of pulmonary functions (VC, FEV_1.0, DL_CO) at rest.
From these findings, we conclude that the degree of dyspnea sensation on exercise correlated with parameters of pulmonary function at rest, and that these newly introduced parameters using the Borg scale were useful for a quantitative assessment of dyspnea in health and disease.

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It has been reported that angiotensin converting enzyme inhibitor (ACE-I) elicites dry cough more frequently in women than in men. This study was designed to evaluate whether airway cough receptors are more sensitive in women than in men.
Cough threshold to inhaled tartaric acid was measured in 33 men and 29 women. In non-atopic and non-smoking subjects, geometric mean value of cough threshold in women was 10.0 (GSEM, 1.29)%, which was significantly (p<0.02) lower than that in men, 22.5 (GSEM, 1.30)%. In non-atopic men, the cough threshold was significantly (p<0.05) lower in smokers (9.3 (GSEM, 1.57)%) than in non-smokers. In non-smoking women, the cough threshold was significantly (p<0.02) lower in atopic subjects (4.2 (GSEM, 1.33)%) than in non-atopic subjects.
These results demonstrated that airway cough receptors may be more sensitive in women, smoking men and atopic women.

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Pleural aspergillosis is not a common disease and we recently experienced a case of Aspergilus empyema with bronchopleural fistula. A 76 year-old man was admitted to our hospital with productive cough and fever. Chest X-ray films showed infiltration in the right lower and left middle field and rather lucent area (clearing) in the right lower lung. Antibiotic therapy was administered but no improvement was obtained.
Chest CT scan and right bronchogaraphy revealed empyema in the right back portion and bronchopleural fistura in the right lower lobe. Needle aspiration biopsy was performed and Aspergillus fumigatus was isolated from pus. A diagnosis of Aspergillus empyema with bronchopleural fistula was made. We began intrapleural administration of miconazole and empyema was improved partially. For the complete treatment, right lower lobectomy and decortication were performed, but unfortunately he died of acute pneumonia 16 days after operation.

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A myelo dysplastic syndrome (MDS), refractory anemia with excess of blasts (RAEB), that occurred in a patient with small cell lung cancer (SCLC) during a period of complete response (CR) was reported. A 66-year-old female patient was diagnosed as SCLC in March, 1985. Induction chemotherapy (CDDP, ADM, VCR, VP-16) achieved CR in May, 1985. She had received maintenance chemotherapy (CDDP, ADM, VCR (or VDS), VP-16) and chest irradiation (48.6Gy) until May, 1988. The hematologic findings revealed MDS and she was admitted in June, 1989. She died one month after onset of MDS because of pneumonia. An autopsy showed no evidence of recurrence of small cell carcinoma in the primary site and other organs.
There is a possibility of the risk of secondany leukemia following long term chemotherapy and irradiation in patients with SCLC, and the role of treatment after the achievement of CR in patients with SCLC remains to be clarified.

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A 57 year-old woman was aware of breath odor and visited to our hospital. There were no abnormal findings in her physical examination and chest X-ray. Multiple polyps in the trachea and both main bronchi were discovered by fiberoptic bronchoscopy. They were 0.1-0.5cm in diameter. In a histological examination, squamous metaplastic epithelial cells and numerous inflammatory cells infiltrating subepithelially were seen. No malignant cells were found.
The patient had suffered from chronic sinusitis for 15 years, and it was suggested that the development of the tracheo-bronchial polyps was associated with chronic sinusitis.

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A case of idiopathic interstitial pneumonia (IIP) with pneumothorax and pneumomediastinum was presented. A 52-year-old male was admitted with the complaint of cough, fever and dyspnea. Chest roentgenogram revealed bilateral reticulonodular shadow and right pneumothorax. Radiological, laboratory and clincal findings were consistent with the diagnosis of acute exacerbation of IIP. Repeated chest CTs showed diffuse interstitial opacities and the presence of pneumothorax and pneumomediastinum. Furthermore, honeycombing and bullous change progressed markedly for two months. The mechanisms of pneumothorax and pneumomediastinum were speculated to be due to the rupture of those cystic lesions which had grown rapidly on follow-up CTs. It was suggested that the formation of honeycombing occurred within a few months and the increasing of honeycombing might be accompanied by so-called acute exacerbation of IIP.
We propose that follow-up CTs were useful for the chronological study for interstitial lesions of IIP.

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41 year-old male with liver cirrhosis accompanying severe hypoxemia was presented. Shortly after the diagnosis of liver cirrhosis, he suffered from exertional dyspnea and cyanosis. Though home oxygen therapy had been prescribed for 2 years, hypoxemia gradually progressed accompanied by persistent cough, mucous sputa and intermittent fever. The chest X-ray revealed bilateral interstitial shadow particularly localized in lower lung fields. The arteriovenous shunt ratio was shown to be 24% by oxygen method. Perfusion lung scan using ^99mTc-labeled MAA revealed perfusion defects in bilateral lung fields and radionuclide uptake was strongly demonstrated in the kidneys. These clinical data suggested that severe hypoxemia was probably due to multiple arteriovenous shunt. With further progression of hypoxemia for 4 months, he died of hepatic failure and pulmonary infection.
Autopsy showed Miyake's type B cirrhosis. Multiple pleural and subpleural arteriolar nevi were demonstrated grossly and microscopically. There were no arteriovenous malformations demonstrated after injection of bariumgelatin solution into the pulmonary artery. Histologically, irregulary dilated vessels were found in the lung parenchyma beneath the pleura and filled with blood and injection material.
These clinical and pathological findings provided evidence that the mechanism of arterial desaturation was pulmonary arteriovenous shunting due to liver cirrhosis.

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A 32-year-old housewife with AT III abnormality visited our out-patient clinic because of dyspnea on April 14, 1988, and was diagnosed as bronchial asthma of non-atopic type. In spite of treatment, her asthmatic symptom did not improve. Therefore, she was admitted to our department on August 12 for a detailed examination and more effective therapy. Xanthine derivatives and β₂ stimulant were ineffective, and only steroid hormone was effective to some degree. Pulmonary perfusion scan revealed that her pulmonary thromboembolism had become worse. Then she was treated with AT III concentrate and urokinase and her asthmatic symptom was significantly improved and steroid hormone could be easily reduced. Her asthmatic symptom was suggested to be due to progression of pulmonary thromboembolism. We were not able to find any other report of a case with AT III abnormality presenting as bronchial asthma due to pulmonary thromboemboloism.

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A 45 year-old male was admitted to Tokyo University Hospital because of a submandibular tumor. Biopsy specimen of the tumor showed medium-sized non-Hodgkin's lymphoma of follicular type and immunoperoxidase staining of frozen sections demonstrated an overwhelming predominance of B lymphocytes with IgM, lambda chain. In the meanwhile, chest X-ray taken on admission showed an ill-defined consolidation with a tumor-like appearance in the right middle lung field. Transbronchial biopsy of this lesion revealed massive infiltrations of small and medium sized lymphocytes, having the same markers as those of submandibular tumor (IgM, lambda chain) and an analysis of bronchoalveolar lavage showed a significant increase of CD19-positive B lymphocytes. Reviewing of check-up X-ray films showed the lung lesion to have preceded the submandibular tumor and to have increased its size in several years. On the basis of the similarity of histological and immunohistochemical findings between pulmonary and submandibular tumor, and considering the time course of the appearance of these tumors, we concluded that these tumors were of the same histological nature and had originated in the lung and metastasized to submandibular gland.
This is a relatively rare case of pulmonary lymphoma metastasizing to the submandibular gland, in which transbronchial biopsy specimen and analysis of lymphocytes in bronchoalveolar Lavage were helpful in establishing the diagnosis.

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