Selective brushing was performed in all the respective segmental bronchi in both lungs of 105 patients with positive or suspected positive indications of lung cancer as revealed by sputum cytology. As a result, 18 borderline lesions in 16 cases and 58 lung cancer lesions in 51 cases were diagnosed. The percentage of localization yield lesions was 47.1% for Class III cases, 82.4% for Class IV cases and 100% for Class V cases ; on the whole, localization was possible in 62.9% of all the cases. Comparison of the diagnoses made before and after brushings of all branches showed that the rate of localization increased from 14.7% to 47.1%, and that the diagnosis of borderline lesions was also possible. Regarding the results obtained on the first examination, the rate of localization increased from 64.1% to 93.9%, and in particular, an improvement from 0% to 88.9% was noted in those cases in which abnormal bronchoscopic findings were not observed. With respect to the diagnosis of multiple primary lung cancer, prior to the use of this brushing technique, a postoperative second cancer was confirmed in 12.1% of operated cases, whereas after introduction of this method concurrent multiple primary lung cancer was diagnosed in 15.2% of lung cancer cases before treatment. Based on the above results, it was concluded that the application of this brushing method is of value in the following cases : diagnosis of cases that are otherwise difficult to diagnose, detection of borderline lesions, and diagnosis of concurrent multiple primary lung cancer. In addition, this brushing method has made possible the detection of multiple intraepithelial lesions, leading to a more precise diagnosis of diseases of the respiratory system in the near future.

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In order to evaluate the effect of therapy on non-measurable and unresectable lung cancer, bronchoscopic examinations were performed in 36 cases with lung cancer before and after therapies. The endoscopic findings were analyzed in terms of the degree of stenosis, the depth and the longitudinal extent of the cancer lesion. Stenosis disappeared in eight of thirty-five cases after therapy. The lesion in the epithelial layer, subepithelial layer and extramuscular layer disappeared in 9, 3 and 6 cases after treatment, respectively. There was a correlation between the disappearance of epithelial involvement and prognosis. We scored the bronchoscopic findings of the cancer lesion according to the depth and the longitudinal extent of the lesion. The effects of therapy were classified into three groups ; 14 improvement, 8 no change and 14 progressive disease. There was a significant correlation between the improvement of lesions in the epithelial layer and the prognosis of the patient, especially in the primary mucosal type of lung cancer. We conclude that scoring bronchoscopic findings is useful not only to evaluate the effects of therapy objectively but also to predict the prognosis of lung cancer cases in which it is difficult to assess the tumor extent by conventional chest roentgenograms.

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Owing to the marked increase of frequency in using bronchofiberscope for examination of various kinds of pulmonary diseases, we were obliged to re-use bronchofiberscope for many patients after prompt sterilization and disinfection. In such circumstances, the authors encountered two incidences of bacterial contamination as a result of brochofiberscopy. The cause of these mixed-infections were analayzed and countersteps for them were considered. As a result, no more such concentrated mixed-infection cases were experienced. The cases of contamination and countersteps were reported. In October 1986, Pseudomonas aeruginosa were consecutively detected in the samples of 10 patients who underwent bronchial washing via a bronchofiberscope. On examination, it was found out that there were residual bacteria in the suction channel, even after washing and sterilization of bronchofiberscopes. As a countersteps for mixed infection, disinfection time (immersion of bronchofiberscopes in glutaraldehyde solution) was prolonged up to 30 minutes. However, two months later, atypical Mycobacteria were again consecutively detected from bronchial washing samples of 14 patients. In this occasion, residual atypical Mycobacteria were detected not only from the suction channel of the bronchofiberscope but also from compartments of the endoscope washer, such as the cleaning compartment, detergent-bottle, and even in a disinfectant-bottle. For elimination of these mixed-infections, the disinfectant solution was changed to Tego-51 (alkalidiaminoethyl glycine) which has strong sterilizing effect against acid-fast bacteria, Pseudomonas, gram-positive and-negative bacteria and also methicillin-resistant Staphylococcus aureus. Using this disinfectant, the sterilization time was prolonged up to 40 minutes. In addition, all compartments of the endoscope washer were distinfected once a month by irrigation with Tego-51 solution. At the same time, the numbers of available bronchoscopes were increased to increase time between re-use. As a result of these countersteps, there were no mixed-infection through bronchofiberscopy.

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Because of the low incidence of bronchial fistula, the efficacy of automatic stapling devices for pulmonary resection is widely recognized. However, clinical experiences have been obtained mainly from lung cancer cases and there are no reports concerning pneumonectomy with the help of stapling devices in severe infectious thoracic diseases. We report our experience in 6 cases of infectious diseases of formidable degree. ETHICON PROXIMATE RL 30 was used for stapling. Pneumonectomy was performed for 3 total empyemas with bronchial fistulae, 1 total empyema complicated with malignant lymphoma and sepsis, 1 severe tuberculosis case which had acquired resistence against almost every potent anti-tuberculosis drugs. In 2 total empyema cases, severe postoperative empyema developed but the bronchial closure was so secure that it was possible to carry out abundant intrathoracic lavage and to achieve complete sanitation of the thoracic space without recourse to thoracoplasty. The three pneumonectomy cases had uneventfull postoperative courses. A case of destroyed lung which had undergone left pneumonectomy with interrupted suture closure of the bronchus using nylon thread developed postoperative empyema and bronchial fistula complicated with contralateral aspiration pneumonia. Transsternal and transpericardial closure of the left main bronchus with the help of the stapling device was carried out to control the aspiration. This patient died 3 weeks later due to the already wide-spread pneumonia but the closure of the left main bronchus was complete throughout the course. The stapling device is considered to be particularly useful for pneumonactomy or for closing the main bronchus in severely infected case.

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Measurement of bronchial mucosal blood flow (BMBF) is very important for the diagnosis and therapy of respiratory diseases. We attempted a sample method to measure BMBF noninvasively by spectrophotometry. In 5 mongrel dogs [before and after administration of isoproterenol], we measured bronchial mucosal blood flow by the hydrogen gas clearance method (direct method) and by spectrophotometry of the bronchial coloration findings (indirect method) red, green and blue at wave lengths simultaneously during bronchoscopy. Experimental results indicated that objective evaluation of the intensity ratio of the redness (% red) and the intensity ratio of the greenness (% green) of the bronchial mucosal coloration findings was the most suitable method to estimate bronchial mucosal blood flow spectrophotometrically. In clinical studies, there was a significant linear correlation (r=0.645, p<0.01) between actual bronchial mucosal blood flow measured by the direct method and % red. In addition there was a significant inverse correlation (r=-0.752, P<0.01) between actual bronchial mucosal blood flow and % green. The above result suggested that bronchial mucosal blood flow can be evaluated non-invasively by spectrophotometry of the bronchial mucosal coloration findings.

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Malignant cells were detected in the sputum of a 59-year-old man with normal chest roentogenograms, who visited Tokyo Medical College Hospital for a precise check-up. Fibroptic bronchoscope revealed a slightly protruding tumor at the bifurcation of right B^2 and B^3_a. The biopsy specimen revealed squamous cell carcinoma and Nd-YAG Laser therapy was performed. On the 18 th day, after laser therapy, on the strong request of the patient right-upper lobectomy with mediastinal lymph node dissection was performed. Histologically, no cancer cell was detected in the resected specimens. This is the first case who was cured by only Nd-YAG Laser irradiation and proved curity by the operation. This demonstrated that Nd-YAG Laser therapy can be very effective in early hilar type squamous cell carcinomas under certain conditions.

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A 73-year-old man, a heavy cigarette smoker, presented at a local hospital complaining of hemoptysis for a period of one month. He had been a victim of the atomic bomb in Hiroshima. Prior to admission to our hospital, he expectorated a fleshy mass 4.1 cm long and 1.4 cm in diameter. Fiberoptic bronchoscopy revealed a polypoid mass obstructing the right truncus intermedius and protruding into the main bronchus beyond the right upper lobe. He underwent a right middle and lower lobectomy. The primary site of the tumor was at the orifices of the middle lobe bronchus and the basal bronchus. The tumor showed intrabronchial branching growth into every segmental bronchus of the middle and lower lobes. It was diagnosed as a poorly differentiated squamous cell carcinoma. He died on the 130 th postoperative day with clinical evidence of an intraabdominal metastatic mass.

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A 70-year-old male with tracheal adenocarcinoma displaying longitudinal infiltration is reported. The patient had complained of sputum since June 1986. In May 1988, adenocarcinoma cells were detected by sputum cytology, though his chest X-ray showed no abnormal findings. Fiber-optic bronchoscopy revealed multiple nodular lesions, less than 5 mm in size, in the tracheal wall. Transbronchial biopsy and brushing cytology yielded a diagnosis of poorly differentiated tubular adenocarcinoma, which was classified as bronchial gland cell type according to cell subtyping. This tumor originated from the lateral wall of the trachea approximately 3 cm above the carina and extended by longitudinal tumor infiltration. This case was accompanied by esophageal cancer. However, these two tumors were considered to be synchronous double cancers, since the histologic type of the esophageal cancer was squamous cell carcinoma.

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A 76-year-old man came to our hospital because of persistent cough. Chest X-ray film showed obstructive pneumonia in the right upper lobe. Bronchoscopy revealed a tumor occluding the orifice of B^3. Bronchoscopic biopsy was performed and more than half of the tumor was removed by chance. The histology of the tumor was diagnosed as hamartoma with bone marrow formation. Although the orifice of B^3_a proved to be patent, that of B^3_b was still occluded. Therefore, surgical partial tumorectomy was done. Obstructive pneumonia disappeared clearly after the tumorectomy and the patient is being followed up carefully with bronchoscopic observation.

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A 26-year-old asymptomatic male was referred to our department for detailed investigation of abnormal chest shadows. Chest X-ray film on admission revealed bilateral hilar lymphadenopathy and cotton like shadows in both lung fields. Systemic lymphadenopathy and swelling of bilateral parotic glands was detected, and small nodules were palpable in the muscles of the upper extremities. There was a small nodule on the left lower lip. Serum ACE level was 44.5 U/ml. Ga scintigram showed no abnormal accumulation in the upper extremities. Bronchoscopic findings showed redness and vascular dilatation of the mucosa, but no characteristic findings of sarcoidosis such as yellow plaques. Pathological findings obtained by transbronchial lung biopsy revealed epitheloid granulomas without caseous necrosis. Histologically, the nodular mass in the right bicep muscle was a granuloma composed of epitheloid cells, and showing characteristics of the sarcoidosis without caseous necrosis. It is well known that muscular involvements are common in sarcoidosis, but palpable muscular nodules are very rare. Including our case, 38 cases of sarcoidosis with palpable muscular nodules have been reported in Japan. Bronchoscopic findings included redness, vascular dilatation and yellow plaques. In half of the reported cases, the nodules were in the upper extremities.

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Racemose hemangioma of the bronchial artery is an extremely rare disease. Recently, the authors experienced a case of suspected bilateral racemose hemangioma of the bronchial artery detected by bronchial arteriography. The patient, a 29-year-old female, was admitted to our hospital with hemoptysis. Bronchoscopic findings revealed gushing bleeding from the lingular bronchus. Bronchial arteriography performed to determine the cause of the bleeding, showed remarkable vascularization with dilation of the left S^5 and the middle lobe bronchial artery, furthermore, showed bronchial-pulmonary artery shunt. After hemostasis was achieved, bronchoscopy revealed a stenotic deformity of the left B^5b and the middle lobe bronchus. Although pathological examination was not performed, this case was suspected to be bilateral racemose hemangioma of the bronchial artery, based on examination findings, absence of inflammatory findings and underlying disease. In cases of hemoptysis and/or bloody sputum of unknown origin, the possibility of vascular diseases should be considered, as in this case.

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A 60-year-old man was admitted complaining of exertional dyspnea. Chest X-ray film revealed diffuse reticulonodular changes over both lung fields. Bronchoscopic findings was normal in the trachea, main bronchi and all segmental bronchi. However transbronchial lung biopsy (TBLB) specimens revealed diffuse deposits of eosinophilic amorphous material in the alveolar septa and blood vessel walls. With Dylon staining, the deposited material showed green birefringence by polarizing microscopy. Further examinations revealed amyloid deposits in the rectum and skin, thus this case was diagnosed as primary amyloidosis. We reported that the diagnosis of pulmonary amyloidosis was established by TBLB.

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It is important to distinguish broncholithiasis from lung cancer, because these patients commonly complain of hemosputum, fever, cough, sputum and chest pain. Previously these patients were operated on but recently bronchoscopic removal of the broncholith is performed. We experienced one case of a broncholith. The patient was 64 years old. She was admitted for obstructive pneumonia in 1985 and in 1987. Chest roentgenogram, CT, tomography showed a broncholith in the right middle lobe bronchus. Bronchofiberscopy showed that the stone was movable, so we attempted bronchoscopic removal of broncholith, and succeeded. The maximum demension of this broncholith was 13 mm which was the largest among Japanese reports. There was slight bleeding but no treatment was needed.

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A 55-year-old man with silicosis, having a 41-year occupational history as a glass-worker, was admitted to our hospital because of hemoptysis accompanied by expectoration of stones. His chest roentgenogram indicated middle lobe syndrome of the right lung. Broncholithiasis was strongly suspected and fiberoptic bronchoscopy was carried out to confirm it, but no stone was observed although there was marked stenosis produced by inflammatory granulation tissue in the truncus intermedius. Atelectasis and pulmonary suppuration of the right middle and lower lobes developed thereafter : The inflammation did not respond well to fairly intensive treatment with antibiotics and persisted for more than one year. Improvement was eventually obtained after when he had expectorated several stones of various sizes several times. Bronchoscopic reexamination, performed about one year after the first examination, revealed a black stone surrounded by protruding granulation tissues which almost completely occluded the truncus intermedius. The expectorated stones were analyzed by x-ray and fluorospectrophotometrically, and on the basis of the results of analysis of their chemical compositions we assumed that the stones had originated from lymph nodes which had been calcified by silicosis and had perforated into the bronchus.

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A case of central airway obstruction caused by bilateral vocal cord paralysis is reported. A 74-year-old man was hospitalized with a chief complaint of severe dyspnea and hypercapnea. For six years prior to his admission, he had been bothered with intermittent dyspnea and wheezing, and had been treated for bronchial asthma and pulmonary emphysema at several other hospitals. On examination inspiratory and expiratory wheezes were audible over both lung fields and the trachea. The arterial blood gas analysis disclosed the PaO_2 was 61.5 torr, PaCO_2 60.6 torr, and pH 7.43. The pulmonary-function test revealed normal vital capacity and normal forced one-second expiratory volume, but the flow-volume curve showed decreased peak expiratory flow and markedly reduced maximal inspiratory flow. Bronchoscopic examination demonstrated that bilateral vocal cords were immobilized in the midline position. A diagnosis of idiopathic bilateral vocal cord paralysis was made after further examinations. the patient received tracheotomy, and the PaCO_2 returned to normal immediately after the operation, and PaO_2 in three weeks. This case emphasizes that idiopathic vocal cord paralysis can be important cause of central airway obstruction, and careful evaluation of patient history, physical examination and pulmonary function test is essential in establishing the diagnosis.

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