Methods of combining the different transbronchoscopic techniques to increase the diagnostic yield in lung cancer were evaluated. Among the 145 subjects studied there were 118 cases of primary lung cancer and 27 cases of metastatic lung cancer. The histological types of the 118 cases of primary lung cancer were as follows : squamous cell carcinoma 45 cases adenocarcinoma 44 cases, small cell carcinoma 23 cases and large cell carcinoma 6 cases. The cases were classified according to bronchoscopic findings, histological type and clinical stage. The diagnostic yields of each transbronchoscopic procedure as well as the overall diagnostic yield obtained by their combination were assessed. The diagnostic yield obtained during the first bronchoscopic examination was 84.7% in primary lung cancer and 74.1% in metastatic lung cancer with an overall diagnostic yield of 82.2%. In cases of primary lung cancer, transbronchial biopsy was the procedure which provided the highest diagnostic yield followed by bronchial brushing and bronchial lavage procedures, while in cases of metastatic lung cancer the highest diagnostic yield was obtained through bronchial brushing followed by transbronchial biopsy and bronchial lavage procedures. In addition to transbronchial biopsy, carrying out transbronchial aspiration cytology, bronchial brushing, bronchial lavage and cytological study of sputum collected for three consecutive days after the bronchoscopic examination resulted in increased diagnostic yields in all cases. There were no significant differences among the overall diagnostic yields obtained in each clinical stage. It was concluded that in order to increase the diagnostic yield of lung cancer through bronchoscopy, it is very available to carry out all the procedures including transbronchial biopsy, transbronchial aspiration cytology, bronchial brushing, bronchial lavage and three-day pooled sputum cytology.

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Using fine strips of the mucous membrane of tracheal epithelium of fetal (22 through 29 days of gestation) and newbom rabbits (2 and 9 days after birth), appearance of cilia and ciliary beat were studied by scanning and transmission electron microscopes, the micro- photo oscillation method, and a high speed video-camera. In fetal trachea, ciliated cells were found to appear on day 24 of gestation by electron microscopy, and increased in density with the progress of gestation. Short cilia were irregular in orientation. Day 24 of gestation was the first time when ciliary beat was observed on the mucosa and cilia already had the beat frequency of adult rabbits. Most cilia of fetal rabbits showed the same pattern of movements as in adult rabbits in a TV monitor except short cilia which did not show coordinated movement. We conclude that cilia acquired normal beat frequency at a very early stage of their growth whereas coordination of the beat appears in the later stage.

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Fiberoptic bronchoscopy was performed in 20 cases of liver cirrhosis with esophageal varices before and after endoscopic injection sclerotherapy (EIS) to assess the change of bronchial mucosa. Submucosal vessel dilatation (SVD) was recognized in 18 of 20 cases. SVD was more marked in the left main bronchus than in the right main bronchus and trachea, and it was seen extending around the area of cartilaginous rings and longitudinally in the membranous portion. The degree of SVD was classified into 4 groups to study the relationship between SVD and the endoscopic changes of esophageal varices. It was more marked in patients with F3 than F1, and in the patients with upper than lower location. Bronchial ulceration was recognized in 6 of 20 cases (30%), and in one or more areas of the left main bronchus in 5 cases, in addition to one case of ulceration in bilateral main bronchi. There was no correlation with the degree of esophageal varices and total dose of sclerosant. However it increased significantly according to decrease of hepatic functional reserve (p<0.05). SVD tended to decrease following EIS while bronchial ulceration worsened. It was suggested that the mechanism of development of these two findings correlated with hemodynamic changes of mediastinal venous anastomosis and arterial oxygenic pressure.

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Bronchial webs are rare and only 5 cases, including the present case, have been reported in the world literature. A 43-year-old woman presented with a complaint of bloody sputum. Physical examination was unremarkable. The chest X-ray showed collapse of the right middle and lower lobes. Fiberoptic bronchoscopy disclosed a bronchial web in the right truncus intermedius. Histologically the web consisted of the fibrous tissue covered by stratified columnar epithelium. Bronchography showed a web with bronchiectasis distal to it. Endoscopic Nd-YAG laser therapy was performed in order to reopen the site of stenosis. In this case the bronchiectasis and the lobar collapse seem to have occured secondarily to the bronchial web.

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A 78 year-old female was diagnosed as primary tracheal adenoid cystic carcinoma by a bronchofiberscopic examination. On admission, the serum levels of SLX and CA 19-9 were 137.6U/ml and 153.1U/ml respectively. Immunohistochemical stainings for SLX and CA 19-9 on the biopsied specimen were both positive. After Nd-YAG laser and irradiation therapy, the serum levels of SLX and CA 19-9 decreased. SLX and CA 19-9 were considered to be useful as tumor markers of adenoid cystic carcinoma in this case.

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A case of pulmonary blastoma was reported with respect to the clinical value of bronchoscopic findings. A 59 year-old man was admitted with complaints of fever and hemosputum. Chest roentgenogram showed the mass lesion with the size of 8×10cm in the right upper lung field. Bronchoscopy revealed a polypoid lesion which obstructed the right upper lobe bronchus but the type of submucosal tumor spread could not be recognized. The pathological examination of biopsied material showed atypical columnar epithelial cells with glandular structure formation. PR was obtained by the injection of carboplatin through the bronchial artery, and B^1 and B^3 could be identified by bronchoscopy. Right upper sleeve-lobectomy was performed under a diagnosis of adenocarcinoma of T2N2M0. Pathological findings of resected material showed the glandular structure of atypical epithelial cells, bizarre blastic cells and chondromatous differentiation. Submucosal invasion in the bronchial wall was not recognized. The final pathological diagnosis was pulmonary blastoma. On retrospective analysis, the bronchoscopic findings did not suggest the extension of adenocarcinoma toward the central airway. In summary, the possibility of pulmonary blastoma should be emphasized in cases with the mass lesions in the peripheral lung field and endobronchial polypoid lesion without the bronchoscopic findings suggesting submucosal tumor spread.

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Bronchoscopic findings on lung involvement of mediastinal malignant lymphoma (diffuse B cell and mixed type), in a 78-year-old Japanese man, were recorded. The patient was hospitalized with cerebral infarction, and fell into a coma 1 month after admission. Chest X-ray films on admission showed a tumor shadow in the right lower lung field suggestive of primary lung cancer. On bronchoscopic examination 1 month after admission, a localized submucosal tumor in the right middle lobe bronchus, accompanied by a small shallow depression, was encontered. Two months later, the tumor became enlarged with a fragile uneven surface, and obstructed the bronchial lumen. Transbronchial lung biopsy failed to confirm the diagnosis of malignant lymphoma. The patient died 4 months after admission, and, at autopsy, the diagnosis of mediastinal lymphoma with infiltration to the right lung was made. Thus, the patient had no medication for malignant lymphoma, and the natural course of its bronchial lesion may be revealed. The bronchoscopic findings suggested that the secondary bronchial lesion of non-Hodgkin's lymphoma may be a submucosal and/or ulcerative infiltrating type tumor.

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Three cases of active endobronchial tuberculosis with pleurisy were reported. A 22-year-old female patient who suffered from fever, cough, sputum and right chest pain had no abnormality in her plain chest roentgenograms except for right pleural effusion. Bronchofiberscopic findings showed an ulcer with a white necrotic coat at the orifice of the right middle lobe bronchus. The second case, a 53-year-old male, was referred to our hospital because of fever after left pleural effusion was pointed out on his chest x-ray. The bronchoscopic findings showed a white necrotic coat in left B_6. The third case, a 54 year-old female who suffered from left chest pain was admitted with bilateral infiltration shadows and left pleural effusion on her chest x-ray. Bronchofiberscopy showed an ulcer with a white necrotic coat at the orifice of the left upper division bronchus. In all three patients, smears for tubercle bacilli were positive. They all had tuberculous tracheobronchial disease and pleurisy. Neverthless, there appeared to be a difference in pathogenesis between case 1, 2 and case 3. Namely, tuberculous lymphadenitis of the hilus in cases 1 and 2 and pulmonary tuberculosis in case 3, respectively, seemed to play a key role in the simultaneous development of endobronchial tuberculosis and pleurisy. Special attention should be paid to endobronchial involvement in patients with pleural effusion following primary infection.

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We performed bronchial emblization using dental impression material in a case of pyelo-bronchial fistula accompanied with candida fungemia. A 44-year-old woman with diabetes was admitted to our hospital because of high fever and abdominal pain. Cultures of arterial blood, urine and sputum yielded candida glabarata. An X-ray film of the chest showed pneumonia. Inspite of administration of antimycotic agent, the candida pneumonia worsened and artificial ventilation was required. However, an air leak through a renal fistula was found and pyelography revealed a pyelo-bronchial fistula. Operation to close the fistula could not be done due to severe respiratory distress. In order to improve respiratory failure, we performed broncho- alveolar lavage using antimycotic agent against candida pneumonia and bronchial embolization using dental impression material to close the fistula. The air leak was stopped and partial resection of the left lower lung was possible. She was discharged in good general condition.

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A 77-year old man with a dental foreign body in the right bronchus is reported. The foreign body was tightly lodged in right B^<10> and could not be removed by any forgeign body forceps. A basket forceps was introduced through the small gap between the foreign body and the bronchus, but the slippedy foreign body was dropped and became impacted. Repeated bronchoscopies failed to remove it. It was subsequently removed successfully by transpleural bronchotomy.

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A case of mediastinal teratoma diagnosed by transbronchial lung biopsy is reported. A 21-year-old female was introduced to our hospital, complaining cough and white discharge. Chest X-ray demonstrated an abnormal shadow in the left hilum and upper lobe. Computed tomography depicted a tumorous mass in the anterior mediastinum. Fiberoptic bronchoscopy revealed obstruction of the left B^3c which was filled with white keratinous material. The diagnosis of teratoma was made by a white hair obtained from transbronchial lung biopsy of the left S^3c. The resected specimen confirmed the diagnosis of teratoma.

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A 60-year-old woman was admitted to our hospital because of hemoptysis and an abnormal shadow on chest X-ray. She had been given anti-tuberculosis agents including Rifampicin for three months at another hospital. Chest X-ray and computed tomogram showed atelectasis of the right upper lobe and bronchofiberscopy revealed complete occlusion of the right upper lobe bronchus by a polypoid lesion. Bronchial mucosal biopsies were performed repeatedly, The pathological findings showed infiltration of mononuclear cells and squamous metaplasia of the bronchial epithelium which suggested to be inflammatory bronchial polyp. She was then treated by the same combination of anti-tuberculosis agents as had been given previously and the broncho-pulmonary lesion improved. It was considered that the lesion was attributable to reversible aggravation of bronchial tuberculosis. The clinical course, including changes in bronchofiberscopic findings, is reported.

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A case of lung torsion after lobectomy diagnosed by bronchoscopic examination was reported. A 75-year-old man underwent a right upper lobectomy for lung cancer. Low grade fever and hemosputum continued postoperatively and a decrease of radiolucency in the right middle and lower lung fields on chest X-ray film appeared subsequently. On the 11th postoperative day bronchoscopic examination revealed a distorted and stenotic middle lobe bronchus. Torsion of the middle lobe was suspected and a rethoracotomy was performed immediately. The middle lobe was twisted 180° clockwise around its bronchovascular pedicle. A part of the infarcted middle lobe was resected. After the reoperation his clinical couse was uneventful. This complication was reported to be potentially life-threatening. Therefore, as prophylactic management, fixation of a remaining lobe, should be performed and a bronchoscopic examination, which is useful for accurate diagnosis, is recommended, if such a condition be suspected.

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A 62-year-old man with pulmomary metastases from renal cell carcinoma was treated with immunotherapy (interleukin-2) and endoscopic YAG laser therapy. Interleukin-2 was injected 6 days for week 4 years. Endoscopic YAG laser therapy was performed 30 times in 3 years with a total energy was 128, 316 Joules. He now works five days a week in his company and enjoys a normal life.

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Six cases of fungus ball type pulmonary aspergillosis were admitted to the authors' hospitals. The patients were treated with transbronchofiberscopic intracavitary infusion (TBII) of Amphotericin B via a catherter inserted through a bronchofiberscope. After several (7&acd;31) infusion of Amphotericin B, the fungus ball disappeared in 5 of 6 cases. The only side effect was fever on the day of infusion, but it was tolerable. The transbronchofiberscopic intracavitary infusion therapy was a useful and safe method for the treatment of fungus ball type aspergillosis.

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A 51-year-old female with tracheobronchomalacia had been suffering from severe cough and attack resembling bronchial asthma for three years. The patient's medical history included pulmonary tuberculosis at age 33 years. Chest x-ray and CT scan on admission showed atelectasis of the right upper lobe and flat, narrow airway deformity from the lower trachea to both main bronchi. In addition to these findings, bronchoscopy showed complete obstruction of the right upper bronchus, which was thought to be due to the tuberculosis. Because of the severe constriction of the right main bronchus, right pneumonectomy was judged necessary. Spanplasty was performed using the patient's rib span, but it did not relieve the stenosis of the trachea and left main bronchus. Severe stenotic symptoms occurred and ventilation in the supine position became impossible. Therefore, re-spanplasty was performed with a modified ringed EPTFE graft to anchor the membranous part to the outer pendent formation. The patient's postoperative course was without complications and recovery was uneventful ; the frequency of cough and bronchial asthma like attacks decreased remarkably.

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Two cases of tracheobronchopathia osteochondroplastica (TO) were reported. Case 1 was an 84-year-old male complained of cough, sputum, and fever. A chest X-ray film showed infiltration in the right lower lung field due to aspiration pneumonia. Case 2 was an 83-year-old female complained of hemosputum, hemoptysis, and fever. A chest X-ray film showed infiltration in the bilateral lower lung fields due to bronchiectasis, with pneumonia. CT findings revealed calcified plaques and nodules involving the anterior and the lateral aspects of the tracheal wall but not the posterior membranous portion in both cases. Fiberoptic bronchoscopic findings revealed multiple small yellowish-white or white nodular protrusions in the anterior and lateral wall of the trachea and the bilateral major bronchi in Case 1 and of the trachea in Case 2, but not the posterior membranous portion either Case 1 or Case 2. Histological examinations of biopsy specimens from the tracheal wall showed squamous metaplasia and ectopic bony tissue under the tracheal epithelium in both cases. A diagnosis of tracheobronchopathia osteoplastica was made in Case 1, and tracheopathia osteoplastica in Case 2. TO is a relatively rare benign disease characterized by ectopic and multiple submucosal cartilaginous and/or bony nodules lining the trachea and/or the bronchi. Eighty-six patients with TO have been reported from 1938 until 1991 in Japan. Clinical features were briefly reviewed. Although the etiology of this disease is unknown, it was considered that chronic inflammation was present in the walls of the trachea and/or the bronchi.

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