Diagnostic methods were in 186 patients who surgically treated under a diagnosis of primary lung cancer at our department during the past 4 years. Cancer was diagnosed cytologically using sputum specimens obtained by brushing or washing via bronchoscopy in 67 patients (36.0%) or by a combination of diagnosis and bronchoscopic biopsy or percutaneous biopsy in 91 (48.9%). The definitive diagnostic rate in all patients was 84.9%. A false-positive diagnosis was made in 2.0% of cases. To eliminate such false-positive cases, nuclear DNA content was measured by flow cytometry using cell materials from patients diagnosed cytologically and compared with the amount of nuclear DNA in their surgical specimens. Measurement of cell materials was possible in all cases, and a correlation was observed between the two nuclear DNA values. Objective and detailed diagnosis can be expected by combining morphological diagnosis with measurement of nuclear DNA content, which reflects biological cell malignancy.

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The concentraions of prostaglandins (PG) and histamine were measured in sputum of the patients with bronchial asthma and chronic airway diseases, such as chronic bronchitis, bronchiectasis and diffuse panbronchiolitis. In asthmatics, the concentration of histamine in sputum was significantly higher than that of cases of chronic airway diseases. By contrast, the contents of PGE_2, PGF_<2alpha>, 6-keto PGF_<1alpha> and thromboxane A_2 in the sputum of the patients with chronic airway diseases were significantly higher than in asthmatics. Based on these observations, we evaluated the therapeutic effects to reduce the sputum production by chlorpheniramine in asthmatics and aspirin inhalation in chronic airway disease. Aspirin inhalation proved to be effective to reduce the sputum volume in cases with excessive sputum production in chronic airway disease. However, chlorpheniramine was not effective in reducing sputum production in asthmatics. These results suggest that the mechanisms underlying the excessive production of sputum in asthma and chronic airway diseases may be different, and that aspirin inhalation may be useful in the treatment of the excessive production of sputum in patients with chronic airway diseases.

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We previously reported that selective brushing of all bronchial branches was very useful for detection of the location of cancer in patients with positive sputum cytology. However, it is difficult to detect the location of cancer in some cases using this examination. From 1986 to 1989, in 11 of 118 cases with positive sputum cytology, bronchofiberscopy had to be performed three times or more in order to detect the location of the cancer. The clinical courses, bronchoscopic findings, radiologic findings, and cytologic findings of these 11 cases were analysed. Two of these 11 cases had cancer lesions in the upper respiratory tract, 1 had a lung cancer lesion within the field of bronchoscopic visibility, and the remaining 8 had lung cancer lesions beyond the field of bronchoscopic visibility. Five of the 8 cases had no abnormal radiologic findings, but an abnormal shadow was detected with chest CT in each of remaining 3 cases, retrospectively. In two of these 3 cases an abnormal shadow abutted upon the mediastinal structures. In cases with positive sputum cytology in which it is difficult to detect the location of cancer, diagnosis requires a thorough examination of the upper respiratory tract and of the lung heyond the field of bronchoscopic visibility.

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In the past five years, we retrospectively studied 33 patients with metastases to the lung from tumors in distant sites who underwent flexible fiberoptic bronchoscopy. Bronchoscopic examination revealed bronchial involvement in 12 patients (36.4%). Their primary sites included the breast (four cases), rectum (two cases), uterus (two cases), colon, stomach, kidney, and thyroid. The patients were considered to be divided into two groups by bronchoscopic findings as follows : (I) polypoid protrusions (five patients) ; and (II) diffuse intramural invasion (seven patients). Polypoid type endobronchial metastasis were observed in patients with renal cancer, thyroid cancer, rectal cancer (1/2 cases), uterine cancer (1/2 cases), and breast cancer (1/4 cases), while diffuse type were observed in patients with breast cancer (3/4 cases), gastric cancer, colon cancer, rectal cancer (1/2 cases), and uterine cancer (1/2 cases). Several metastatic routes of malignant tumors to the bronchi have been suggested. In our study, metastasis to the bronchial wall by the bronchial arteries in polypoid type cases, and a route through the peribronchial lymphatics in diffuse type cases were suggested by pathological findings.

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In our institute, tracheostomy is performed mainly in cases of blunt chest trauma requiring frequent endotracheal suctioning due to massive tracheobronchial bleeding and/or assisted ventilation. After the tracheostomy tube was removed, we performed bronchofiberscopic examination weekly and we observed the healing process of the tracheostomy wound from inside the trachea. From 1975 to 1988 there were 87 patients who underwent tracheostomy. Among these patients 50 cases were eligible for this study. In these patients, the tracheostomy tube was inserted from 4 days to 52 days (mean 10.3 days). In 46 cases the wound of tracheostomy healed without deformity leaving a linear scar. It was found that tracheitis and small granulation of the oral side of the tracheostoma are normal findings of the healing process of tracheostomy. Three patients revealed stenosis at the tracheostomy site due to polypoid granulation, one patient showed stenosis at the tracheostomy. To prevent healing with deformity, the tracheal ring had better been incised linearly and the tracheostoma should be managed carefully to avoid infection.

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Thin section rapid CT was performed in 3 patients with roentgenographically occult lung cancer detected by sputum cytology. These 3 cases were shown by thin section rapid CT, as widening of a bronchial bifurcation, endobronchial stenosis and thickening of the bronchial wall. These findings may suggest the location of endobronchial lung cancer. Thin section rapid CT may provide the useful information concerning endobronchial lesions.

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A 69-year-old man of radiologically occult lung squamous cell carcinoma was diagnosed by sputum cytology. Bronchoscopic findings showed a small tumor at the orifice of right B^7 and a continuous superficial lesion spread to the truncus intermedius. Right middle and lower lobectomy was performed, but intraoperative microscopic examination revealed residual carcinoma on the bronchial stump. Therefore, wedge resection of right main bronchus was performed. Histological specimens showed a tumor of right B^7 and widespread carcinoma in situ that continued to the right main bronchus extending 51mm length. The histology of the surgical margin of the bronchus should be examined carefully at operation, because invasion of cancer is sometimes more extensive than had been expected preoperatively based on the bronchoscopic findings.

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A 3-cm mass in the hilum of the right lung was found on chest X-ray film in a 25-year-old woman. Bronchofiberscopy revealed mucosal redness and swelling as well as vascular dilatation mainly in the left wall of the right upper lobe bronchus. B^3 was stenotic due to compression, and B^3_b was almost obstructed, suggesting compression and infiltration by pulmonary adenocarcinoma. Although biopsy of the abnormal region and transbronchial aspiration cytology of the extramural mass were performed, no definitive diagnosis could be made preoperatively. During the operation pulmonary cancer was ruled out. Because the mass showed severe adhesion around B^3_b and because moderate bleeding was seen from the capsule, enucleation was considered to be difficult and upper lobectomy was performed. Histological examination of resected tissue yielded a diagnosis of Castleman's disease of the hyaline vascular type. Although this condition is not rare, patients with this condition usually present with no abnormarities when examined by bronchofiberscopy. In paticular, the severe stenosis seen in the present case has not been reported. This paper mainly discusses the broncofiberscopic findings and methods for definitive diagnosis of this condition.

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A 41 year-old man visited our hospital with a four years history of a homogeneous tumor like shadow with a clear border in left S^3. Bronchoscopy showed a polypoid tumor obstructing left B^3. A left upper lobectomy was performed and the tumor was diagnosed as an endobronchial hamartoma. Clinical findings concerning 56 cases of endobronchial hamartoma in the Japanese literature were discussed.

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An expandable metallic stent was used to treat a left bronchial stenosis due to recurrence of the tumor in a 50-year-old male patient with a stage-IIIB pulmonary squamous cell carcinoma which had been responding well to chemoradiotherapy. The stent expanded sufficiently to increase the diameter of the lumen and resolve brnochial stenosis. However, two times endoscopic laser excisions were also required to granulation tissue developing around the stent during the first 50 days of insertion. The patient has become free from exertional dyspnea and severe cough over the next 4 months.

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A 52-year-old female was admitted with cough and sputum. Chest X-ray and chest CT showed atelectasis of the left upper lobe. Bronchofiberscopic examination revealed a tumor obstructing the left upper bronchus. Diagnosis by bronchoscopic biopsy and removal of the tumor was attempted many times, but failed. Left upper sleeve lobectomy was performed. Three foreign bodies (pieces of wood) in the resected specimen were demonstrated. It is necesary to suspect foreign bodies in such cases.

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A successful fiberscopic treatment with fibrin glue for tracheal injury is shown in this report. A forceful endotracheal intubation in a case of acute respiratory failure resulted in a longitudinal tear at the membranous portion of the lower trachea in a 60-year-old woman. She was referred to the Intensive Care Unit of our hospital with severe pneumothorax and mediastinal emphysema. It was impossible to perform an emergency operation because of her severely ill condition. Closure of the tear could be accomplished by applying fibrin glue through a fiberoptic bronchoscope, which was carried out twice. At the second trial, the procedure was successfuly done by setting an inflated Sengstaken-Brakemore tube in esophagus immediately behind the tracheal laceration. We recommend that fibrin glue application through the bronchofiberscope might be a useful treatment, which avoids major thoracic surgery, for acute tracheal laceration in severely ill patient.

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A 15-yr-old male, known to have bronchial asthma and hyperventilation syndrome, developed acute inspiratory stridor. Spirometry indicated extrathoracic airway obstruction, and a bronchofiberoptic examination disclosed narrowing in the hypopharynx with an abnormally shaped epiglottis which trembled on the inspiratory phase, but no abnormality in vocal cord or trachea. The stridor attack did not respond to the treatment such as inhalation of adrenergic agonists, anticholinergic agents and steroid, gurgling with atropine sulfate or xylocaine, and aminophylline or steroid injection. After administration of sedatives, the stridor suddenly disappeared. Psychotherapy decreased occurrence of subsequent stridor attack. It is suggested that psychogenic laryngo-pharyngeal spasm may be causative of upper airway obstruction with respiratory distress.

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We reported 8 cases of congenital bronchial anomalies in the adult ; 5 cases of esophagobronchial (E-B) fistula, 1 of bronchobiliary (B-B) fistula and 2 of bronchial atresia (BA). Four cases of E-B fistula were females aged 41, 68, 72, 40 and one was male aged 58. The patient with B-B fistula was a 32-year-old male. All of them had a past history of recurrent respiratory infection for two to 30 years. The two BA patients were both male aged 25 and 38. One of them repeated pneumonia from childhood and the other was pointed out by annual examination. Esophagography and esophagoscopy were the most useful diagnostic methods for E-B fistula, while bronchography and bronchoscopy were most useful for B-B fistula and BA. Fistulectomy with or without partial or segmental resection of the lung was performed in cases of E-B and B-B fistula. Lobectomy and segmentectomy were performed for two patients of BA respectively. Their postoperative courses were uneventful except in one case of E-B fistula who died 4 months after surgery due to bronchopleural fistula. Limited surgery should be performed for congenital bronchial anomalies in the adult and should yield good results by preserving pulmonary function.

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Three cases of bronchial tuberculosis (TB) complicated by malignant tumors were seen among 13 TB patients between June 1986 and May 1989. The 13 TB patients consisted of 2 males and 11 females whose ages ranged from 39 to 85 years, with a mean of 73 years. They visited our hospital for a medical check-up in 6 cases, bloody sputum in 2, cough and fever in 4 and asthma in 1. Abnormal findings were observed on chest X-ray in the right middle lobe in 6 cases, right upper lobe in 4, left upper lobe in 1 and right and left lobes in 2. The type of bronchial TB was type II (intramucosal nodule type) in 5 cases, type III (granulation type) in 2, type IVa (cicatricial but non-stenotic type)+LN (lymph node perforation type) 2, and IVb (cicatrical and stenotic type) in 4. Of the 13 patients, 3 were complicated by malignant tumors : Patient 1 (an 82-year-old woman), who was symptomatic and had abnormal chest X-ray findings, was diagnosed as having type III bronchial TB 2 weeks after the diagnosis of esophageal cancer. Patient 2 (an 85-year-old man) was diagnosed as having cancer of the pancreatic tail one year after the diagnosis of type IVb bronchial TB in a medical check-up. Patient 3 (a 70-year-old woman) was diagnosed as having gastric cancer 5 months after the diagnosis of type IVb bronchial TB in a medical check-up. The incidence of pulmonary TB complicated by malignant tumor is believed to be high in the elderly. From the present experience also, we strongly believe that close examination of the chest is not sufficient in elderly patients and that it is necessary to keep in mind the complication of malignant tumor.

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In a fifty-eight year old male patient who showed massive bronchorrhea (more than 500ml/day), fever, and right pneumonia-like infiltration on plain chest x-ray film, elevated levels of CA 19-9 in sputum (590.2U/ml) and serum (742.8U/ml) were noticed. Transbronchial lung biopsy demonstrated typical bronchioloalveolar cell carcinoma and positive staining on the corresponding tumor cells using alkali-phosphatase conjugated anti-CA 19-9 antibody. Despite three courses of cancer chemotherapy the patient's condition deteriorated and he died on the 101th hospital day. Levels of CA19-9 in bronchorrhea fluids, however, is dissociated from those of serum CA19-9 through clinical course. In cases of lung cancer with massive bronchorrhea, measuring of local levels of tumor marker together with serum tumor marker may provide additional information about diagnosis and disease activity.

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A 55 year-old man was admitted to our hospital because of squamous cell carcinoma of the bronchial stump. His medical history included an operation for squamous cell carcinoma of the truncus intermedius in 1987. He underwent completion pneumonectomy. Microscopic findings of the stump revealed carcinoma in situ. We assume that he had a recurrent bronchogenic carcinoma, however, it is difficult to distinguish local recurrences from multiple lung cancers. Postoperative bronchoscopic examination should be carried out periodically to detect early stage local recurrences.

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A 50-year-old man had a 17-month history of stridor, dyspnea and hyperimmunoglobulinemia E. He had been treated with various antiasthmatic medications without significant results. Routine PA X-ray revealed a vague soft tissue opacification which protruded into the tracheal air column. Tomography comfirmed the presence of a tumor in the upper third of the trachea. Fiberoptic bronchoscopy (FOB) showed a smooth-sufaced tracheal tumor which was diagnosed as adenoid cystic carcinoma. Accurate estimation of the tumor extension was difficult because the tumor grew submucosally. Adenoid cystic carcinoma is a low grade malignant tumor characterized by slow and local infiltrative growth and a prolonged clinical course. For the purpose of early diagnosis of adenoid cystic carcinoma of the trachea, chest tomography and FOB should be performed in patients who complain of persistent stridor and dyspnea during antiasthmatic treatment.

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