Serial bronchofiberscopic examinations were performed during combination chemotherapy in newly diagnosed patients with small cell lung cancer (SCLC). The bronchoscopic findings after chemotherapy in 41 patients who achieved radiographically complete responses (CR) revealed normal findings in 9, scarring of the bronchus in 17 and findings of residual tumor such as thickening of the bronchial bifurcation, accentuated longitudinal folds or extrinsic compression of the bronchial lumen in 15. Out of the 26 patients with normal findings or scarring on bronchoscopic examination, 15 (58%) relapsed in the chest. Out of the 15 patients with endoscopically residual tumor, 13 (87%) relapsed. Vascular engorgement was seen in 30 (76%) of 41 patients on bronchoscopic examination after chemotherapy. There were no differences in relapsing rates between the groups with and without vascular engorgement. Since September 1986 previously untreated patients with SCLC have been examined by bronchofiberscopy after every course of chemotherapy. The maximum response to chemotherapy developed within three courses in most cases. Serial bronchofiberscopy during treatment for SCLC is useful in the following situations : in confirming a CR to therapy on chest roentgenogram, in discontinuing or adding further therapy, and in monitoring for early detection of local relapse.

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Pre-operative fiberoptic bronchoscopy and computed tomography (CT) were performed on 33 patients with advanced esophageal carcinoma, and the accuracy of the diagnosis by fiberoptic bronchoscopy and/or CT were compared in terms of evaluation of tracheobronchial invasion of the esophageal carcinoma. Fiberoptic bronchoscopy had 100% sensitivity and 45% specificity, with an overall accuracy of 65% in the diagnosis of tracheobronchial invasion. CT had 55% sensitivity and 68% specificity, with 64% overall accuracy. The accuracy rate was equivalent in both fiberoptic bronchscopy and CT. In conclusion, fiberoptic bronchoscopy seems evaluated first in the diagnosis of tracheobronchial invasion of esophageal carcinoma, followed by CT in confirming the site and grade of the involvement.

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In order to investigate the diagnostic effectiveness of transbronchial lung biopsy (TBLB) and subsequent responsiveness to the therapy, cases of collagen vascular diseases with pulmonary involvement in which TBLB was performed between September 1977 and October 1987 were reviewed. The total number of cases was 31 including rheumatoid arthritis (15 cases), polymyositis (5 cases), progressive systemic sclerosis (4 cases), systemic lupus erythematosus (2 cases) and Sjogren's syndrome (5 cases). TBLB was performed 38 times in these 31 cases, revealing positive findings in 27 cases (87.1%), and in 32 of 38 procedures (84.2%). In 20 of 27 positive cases, prednisolone therapy was given, and 18 of 20 cases were responsive. All cases of rheumatoid arthritis and Sjogren's syndrome showing alveolitis revealed by TBLB were responsive to prednisolone therapy. On the other hand, cases of polymyositis and progressive systemic sclerosis in which TBLB revealed alveolitis or bronchoalveolar lavage (BAL) revealed elevation of the proportion of lymphocytes or polymorphonuclear cells were responsive to prednisolone therapy. Open lung biopsy was performed in only one case. The pathologic diagnosis of this case was pulmonary multiple nodular amyloidosis.

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From 1984 to 1986, 286 cases with a solitary pulmonary lesion suspected of malignancy were evaluated by bronchofiberscopy and percutaneous needle biopsy, among which 64 case were finally diagnosed as lung tuberculosis. Tuberculous bacilli were obtained in 9 (14%) by smear, and in 6 by culture (23% cumulatively). Transbronchial or percutaneous biopsies were diagnostic in 14 and 6 respectively, totalling 33 of 64 (47%) positive diagnosis of tuberculosis. Necrosis in the biopsied material could be interpreted as suggesting tuberculosis under some conditions, and such cases could be followed cautiously as benign from the clinical point of view. Thus more than half of the tuberculosis cases, which at first were suspected of malignancy, could be diagnosed properly. We believe that through this process the neccesity of exploratory thoracotomy for undiagnosed cases with solitary pulmonary nodules could be reduced.

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Recent studies have reported that a relative increase in primary adult tuberculosis in advanced nations has produced unusual clinical and roentgenographic presentations because of the complex interaction of a variety of factors involving the host, environment, and infectious agents. To assess the value of fiberoptic bronchoscopy and transbronchial biopsy (FBS/TBB) for evaluating patients who had active tuberculosis, we reviewed the records of 27 tuberculous patients diagnosed by FBS/TBB among 1527 cases who underwent fiberoptic bronchoscopy at Yamagata Prefectural Central Hospital from January 1982-September 1987. The evaluations included cases of fiberoptic bronchoscopoy with aspirations of bronchial secretions and washing fluid, and TBB. All aspirated bronchial secretions and washing fluid were always stained and cultured for Mycobacteria in our hospital. All patients in this study had an absense of acid-fast bacilli on prebronchoscopy sputum smears or an inability to produce sputum. Only 6 of 27 patients (22.2%) were suspected of having tuberculosis and 11 of 27 (40.7%) were suspected of lung cancer before fiberoptic bronchoscopy. Immediate diagnoses were made from microscopic specimens obtained from 21 of 27 (77.7%) FBS/TBB procedures. TBB had the best yield for microscopic diagnosis. In 6 of 27 patients delayed diagnoses were made because of negative microscopic specimens which become positive only on culture. The most frequent roentogenographic change was consolidation, which was found in 12 patients. Cases with positive smears of bronchial secretions had wider consolidation fields than cases with positive TBB specimens. Only 5 (18.5%) had cavitary lesions. Endobronchial involvement was found in 12 of 27 patient who underwent FBS. The abnormal bronchoscopic findings included ulcerative granuloma (2 patients), and redness and swelling of the mucosa (10). In conclusion, tuberculosis should be considered as a diagnostic possibility in patients even with negative sputum smears. FBS/TBB can improve the ability to document active tuberculosis and provide a sensitive means of making immediate diagnosis.

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Benign endobronchial tumors are extremely rare among pulmonary tumors. We experienced 6 cases of benign endobronchial tumors (2 cases of hamartoma, 2 cases of pleomorphic adenoma, 1 case of glomus tumor, 1 case of neurinoma) and here we describe the clinical characteristics and the result of endoscopic Nd-YAG laser treatment. One of the pleomorphic adenoma cases and the glomus tomor case were female and the others were male. The ages ranged from 35 to 57 years with an average of 43. The average duration from initial symptom to definitive diagnosis was 3 years. In 4 cases the tumor was located in the trachea and 2 cases (one hamartoma and the glomus tumor) were located in the bronchus. Endoscopically, all cases had a smooth surface covered with tracheal or bronchial mucosa, and there were 3 nodular type tumors and 3 polypoid type tumors (one of the pleomorphic adenomas and the 2 bronchial cases). We performed endoscopic Nd-YAG laser treatment for these tumors. In all cases, the tumor disappeared completely and the site where the base of tumor had been located showed good mucosal regeneration. No tumor recurrence had been recognized at periods ranging from 41 to 66 months in all cases. Namely, we think endoscopic Nd-YAG laser treatment was curative treatment for the benign endobronchial tumors and should be performed in such cases instead of surgical resection.

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A simple and easy method of intraoperative oxygen delivery during tracheo-bonchoplasty is reported. The necessary apparatus is as follows ; a 5 French Nelaton's catheter (3 mm in outer diameter) is inserted into the open trachea or bronchus and utilized for intraoperative oxygen supply. The catheter is connected to the mixed-air outlet of an anesthetic device (any model). Respiration during tracheo-bronchoplastic procedure is maintained by pure oxygen delivered through this catheter at a rate of 6-10 L per minute. There is no tidal ventilation, therefore there is no chest movement. Oxygen insufflation with the Nelaton's catheter remaining in the intratracheal tube was carried out initially on three patients requiring thoracic surgery other than tracheobronchoplasty. The rate of rise of PaCO_2 during 20 minutes of insufflation was 1.42, 1.44, 1.36 Torr/minute respectively, the average being 1.41 Torr/minute. No abnormal change in ECG or hemodynamic status was recognized during the procedure. In one case, insufflation was extended for 45 minutes with an end PaCO_2 value of 67.8 Torr. PaO_2 values in all cases were maintained over 470 Torr during the procedure. The rate of rise of PaCO_2 in the cases requiring tracheo-bronchoplasty was 1.89 Tor/minute in a carinal resection case, 1.52 Torr/minute in a right sleeve lobectomy case, and 1.02 Torr/minute in a crico-tracheal anastomosis case, the average being 1.48 Torr/minute. PaO_2 values remained satisfactory. As there was no mediastinal movement during the insufflation and the thin catheter posed almost no hindrance in the operative field, it was quite easy to perform anastomosis. Postoperative courses were uneventful in all cases.

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A case of bronchial mucous gland adenoma in a 16 year-old female complaining of productive cough and hemosputum was reported. Her chest X-ray film showed right lower lobe atelectasis. Bronchoscopy revealed a smooth, round polypoid tumor projecting into the lumen of the right basal bronchus. Right lower lobectomy was performed and the tumor was diagnosed histologically as bronchial mucous gland adenoma. Bronchial mucous gland adenoma is an extremely rare disease among benign tumors of bronchus. We clinically reviewed 37 cases of bronchial mucous gland adenoma described in the world literature.

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A 62-year-old man was admitted with a complaint of hemosputum. He had been working for 49 years in a vehicle factory and had a Brinkman index of 860. After further examination, four lesions were discovered : at the distal end of the right lower lobar bronchus, the middle lobar bronchus, the right B^3b and the left B^3b+c. All of them appeared to be polypoid and were proved to be squamous cell carcinomas histologically. He was treated by combined therapy with 7 courses of carboplatine and irradiation (right 50 Gy, left 48 Gy) and showed a complete response. A complete response has been observed in each lesion for 34 months to date. Since a potential major problem for this patient in the future is that another carcinoma might be induced metachronously in the lungs or other organs, he is being followed up with special attention to this risk.

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Endobronchial lipoma is a rare benign lung tumor, of which only 20 cases have been reported in Japan. Even though endobronchial lipoma is histologically benign, it can cause irreversible damage to peripheral lung as a result of bronchial occlusion. This finding suggests that early diagnosis and treatment are necessary in such cases. A 72-year-old woman was admited to our hospital on April 23 1987 with symptoms of bronchitis, cough and bloody sputum. Chest X-ray film showed mild cardiomegaly alone and bronchoscopic examination revealed a smooth mass on the anterolateral wall of the right main bronchus. The biopsy specimen from the mass showed mature adipose and fibrous tissue and the histological diagnosis was endobronchial lipoma. Endoscopic YAG laser vaporization was performed twice, because of irritable symptoms of bronchus. Immediately after vaporization, bronchoscopy showed mild redness of bronchial mucosa, but there was no recurrence even three months later.

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Endometriosis is usually found in the myometrial tissue, and is called internal endometriosis. External endometriosis occurs outside of the uterus and it apparently can occur in any location of the body. Lesions have been described in the appendix, large and small bowel, stomach, gall bladder, spleen and kidney etc. Intrathoracic endometriosis, included in this group, is categorized as pleural or diaphragmatic disease or parenchymal disease. The former often complicates catamenial pneumothorax, and in the latter catamenial hemoptysis or bloody sputum is found often. Pulmonary endometriosis is very rare disorder, and as far as we know, only twenty five cases were reported in the literature. We experienced a case of bronchial endometriosis. A 64-year-old Japanease woman complaining of bloody sputum received bronchoscopy and bronchial endometriosis was diagnosed. The lesion was present in the lateral wall of the right basal bronchus, and was a low whitish elevated lesion with a central depression. Histological findings of the specimen obtained by transbronchial biopsy showed endometrial gland and surrounding stroma. This may be the first reported case of the bronchoscopic findings of bronchial endometriosis.

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We experienced two cases of broncholithiases. Case 1 was a 58-year-old male presenting with bloody sputum. His chest roentgenogram showed an infiltrative shadow in the right lower lung field and bilateral hilar calcifications. Right middle lobectomy was perfomed. Histological examination showed a broncholith in the right B^5a, destroyed bronchial wall and dilated distal bronchi. Case 2 was a 54-year-old female presenting with hemoptysis. Her chest roentgenogram showed atelectasis of the right middle lobe and bilateral hilar calcifications. Bronchoscopy revealed a broncholith at the orifice of the right middle lobe bronchus. The broncholith was expectorated with a cough. It was suggested that the broncholiths were derived from calcified lymph nodes in these two cases. Analysis of broncholiths showed that both had a similar component, which is significantly different from other reports.

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Two adult cases of intratracheal foreign body with baseline disease, which were treated by fiberoptic bronchoscope, are reported. Case 1 was a 75-year-old male, admitted because of disturbance of consciousness. His chest roentogenogram showed a small abnormal shadow in the right lower lung field, and his broncho scopic findings revealed an artificial tooth in the right lower bronchus. We removed the foreign body using a Fogarty balloon catheter vie the fiberoptic bronchoscope. Case 2 was a 63-year-old male, admitted due to serious cough and poststernum discomfort with bloody sputum. His chest plain roentgenogram showed no remarkable findings but his mediastinal tomogram indicated a small square shadow at the carina. His bronchoscopic findings revealed the plastic cap of his nebulizer in the carina obstructing the lumen of the right main bronchus. We removed the foreign body using a Fogarty balloon catheter and basket catheter vie the fiberoptic bronchoscope. It was considered that treatment with fiberoptic bronchoscope is useful in cases of intratracheal foreign body but many accessoried and techniques are needed for this approach.

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In atelectatic cases caused by tumor airway obstruction, high frequency electrosurgical snare or Nd-YAG laser have been conventionally used. A microwave tissue coagulation apparatus has recently been used in the field of gastroenterology but has not yet been used for bronchoscopy. In an atelectatic patient with tumor obstruction the left main bronchus, this microwave tissue coagulation apparatus was used to re-open the airway. The result was successful, indicating that the microwave tissue coagulation method is effective to remove tumors in the bronchus and has superior hemostatic capacity.

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