This study was performed to evaluate the safety and effectiveness of anesthesia for diagnostic bronchoscopy by intravenously administered fentanyl citrate (Fentanest) in a series of 391 cases. Fentanest (0.05mg) was given intravenously at the beginning of the procedure. During bronchoscopy, an additional 0.05mg was given as needed (initial study period) or every 20 minutes (later study period). At the end, naloxone was given to reverse the effect of fentanest. Eight cases (2.0%), all with poor respiratory reserve, suffered from prolonged hypoxemia during bronchoscopy. Complications of this method included 2 cases of prolonged hypotension, 3 of transient respiratory arrest and 2 of delayed recovery from anesthesia. All cases of complications recovered with treatment, and no examination had to be interrupted or cancelled. The response of the patients to a questionnaire after bronchoscopy was favorable, with only 38.2% in initial study period and 22.5% in alter study period replying that it was "hard" to have bronchoscopy. The number of patients who complained of cough was especially reduced in later study period. We concluded that this method, which could be safely administered even in elderly cases, was very effective in reducing the discomfort of patients during diagnostic bronchoscopy.

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Ten cases of bronchial carcinoid tumors (typical : 3, atypical : 7) which underwent surgery in our department during the past 18 years were analyzed clinically. Five were central type and five were peripheral type. As symtoms, cough and hemosputum were the predominant but four cases were asymptomatic. Seven patients had positive bronchoscopic findings but forceps biopsy could verify accurate diagnosis in only two cases. Operative procedures applied to the 10 cases consisted of 2 sleeve lobectomies, 1 segmentectomy for typical carcinoid tumors, and 1 pneumonectomy, 6 lobectomy for atypical carcinoid tumors. All cases underwent lymph node dissection. The overall 5-year survival rate of 2 typical (one case of non-cancer death was excluded) and 7 atypical carcinoid tumors were 100% and 60%, respectively. Three of them survived more than 10 years. As to DNA ploidy pattern, diploid was dominant irrespective of pathological type (typical or atypical), lymph node metastasis and distant metastasis. One of 2 aneuploid cases metastasized to the rectum six months after the operation. Treatment of carcinoid tumor should be as conservative as possible because of it's relatively good prognosis. In atypical cases, lymph node metastasis was recognized in three cases (43%). Therefore, post operative immunochemotherapy seemed to be necessary for atypical cases.

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Three cases of endobronchial involvement of non-Hodgkin's lymphoma were experienced. To the best of our knowledge, there have been 37 reported cases of endobronchial involvement of non-Hodgkin's lymphoma identified by bronchoscopic examination. These and our own cases were endoscopically classified into 3 types and investigated. Type I ; Elevated tumor mass was found in 19 cases. 11 of which were recurrent disease. This type was characterized by the radiological findings of a hilar mass or atelectasis. Type II ; Multiple submucosal nodules were found in 12 cases All of them were in patients with advanced disease (stage IV), and the radiological findings of parenchymal infiltration were frequently seen in this type. Type III ; Diffuse submucosal infiltration was found in 9 cases. The radiological findings of this type were similar to those of type I, however, 6 cases were initial disease, and their courses were worse than those of type I. In 29 of 40 cases in which data in available, long-term survival was obtained with combined radiotherapy and chemotherapy. Although it has been thought that endobronchial involvement of non-Hodgkin's lymphoma was associated with disseminated disease and was less common than of Hodgkin's disease, it may not be as rare as had been thought. In patients with non-Hodgkin's lymphoma, radiological findings of a hilar mass, atelectasis or parenchymal infiltration may indicate endobronchial involvement. It is important to clarify the frequency of endobronchial involvement and to evaluate the implication for staging, therapy and prognosis. If confirmed by further investigation, bronchoscopic findings may be contributory to evaluation of the prognosis of patients with intrathoracic non-Hodgkin's lymphoma.

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A 62-year-old male was admitted to Omuta-kinen Hospital for surgical treatment of early gastric cancer. Partial gastrectomy was performed on March 17th, 1989. Histological examination of the resected specimen revealed well differentiated adenocarcinoma. A coin lesion in the right upper lung field was demonstrated on the Chest X-ray film taken on admission. Bronchoscopic examination revealed a reddish tumor protruding from the left anterolateral wall of the trachea, 2.5cm below the vocal cord. Histological findings of the bronchoscopically biopsied specimen were compatible with those of squamous cell carcinoma, although cytology of broncheal washing from the right upper lobe was negative for malignant cells. This was a case of double synchronous development tracheal and gastric cancer which is very rare.

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A case of agenesis of the right middle lobe, which is a very rare condition, is reported. A 48-year old woman was admitted for examination of an abnormal chest shadow. Chest X-ray showed a mass shadow in the left lower lung field, but in the right lung no definite abnormal shadow was pointed out. The mass was diagnosed as adenocarcinoma, and left lower lobectomy was performed. On bronchoscopy the orifice of the right middle lobe bronchus was not present. On bronchography absence of the right middle lobe bronchus was confirmed, and there was downward displacement of the right B^3b and upward displacement of the right B^<8+9>. Pulmonary angiography showed the absence of the middle lobe artery. As chest CT revealed that emphysematous change and mucocele were not present in the right lung, bronchial atresia was ruled out in this case.

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A 57-year-old man had undergone right upper lobectomy and S^6a partial segmental resection for squamous cell carcinoma that developed in B^3b and had been complicated with pulmonary tuberculosis. Seven months after the operation, he was readmitted complaining of persistent cough and dyspnea on exertion. The chest roentgenogram showed severe loss of volume of the right middle lobe and compensatory overinflation of the right lower lobe. Bronchofiberscopy of the right bronchus revealed stenosis of the truncus intermedius and the middle lobe bronchus and protrusions in the orifice of the basal segmental bronchus. As bronchography, pulmonary arteriography, ventilation and perfusion scintigraphy and aerosol inhalation scintigraphy suggested that the residual bronchial stenosis widely disturbed the ventilation and perfusion of the right lung, he underwent pneumonectomy. The pathological investigation of the resected lung revealed that the protrusions of the bronchial wall were composed of folded bronchial cartilage. It was considered that in this case, stenosis and protrusions of the residual bronchus developed by bending of the bronchus and folding of the bronchial wall caused by movement and reexpansion of the residual lung after right upper lobectomy and S^6a partial segmental resection.

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A case of squamous cell carcinoma of the right B^3a bronchus had metastatized to a hilar lymph node (N1), although the tumor was limited to within bronchial cartilage layer on post-surgical histologic examination. The patient was a 74-year-old male who had undergone curative external irradiation to an early laryngeal carcinoma seven months before. A right upper lobectomy was perfomed because of an accidentally discovered, endoscopically squamous cell carcinoma of polypoid type in right B^3a. The possibility of metastasis from the laryngeal carcinoma was reasonably ruled out because of its early stage and the absence of local relapse. Pathological study revealed a metastatic hilar lymph node, although the B^3a lesion did not extend beyond the bronchial cartilage. The literature on cases of clinically carly squamous cell carcinoma of the lung which metastatized to regional lymph nodes was reviewed, and implications for the treatment of such tumors was also discussed.

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A 64-year-old male underwent right upper lobectomy for lung cancer. Eighteen months later, he was admitted with fever, chest pain and cough. The chest roentogenogram showed air space in the right apical pleural space and suggested bronchial fistula. Fiberoptic bronchoscopy revealed mucosal swelling and sutures covered with a white coating at the bronchial stump. Actinomycotic sulfur granules were identified by transbronchial biopsy. Bronchial fistula was not detected by bronchography. He underwent treatment with antibiotics and his symptoms and bronchoscopic findings improved. Aspergillosis of the bronchial stump is well known, however, reports of actino-mycosis diagnosed by bronchoscopy are very rare. This case suggests we should be consider the possibility of actino-mycosis at the bronchial stump following resection.

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A 57-year-old female was admitted for treatment of pulmonary and mediastinal lymph node metastases. She had undergone a segmental resection of the mandible on a diagnosis of squamous cell carcinoma of the gingiva one year previously. The chest X-ray film and chest CT showed a right hilar mass with a cavity and which surrounded the pulmonary artery. Bronchoscopic examination revealed two fistulae on the right wall of the trachea and the right main bronchus. These fistulae were connected through the cavity of the right hilar mass. The right pulmonary artery was observed pulsating inside the cavity. No massive hemoptysis occurred until her death two months after admission. We reported the first case that a pulmonary artery was directly observed through tracheal and bronchial fistula by bronchoscopic examination.

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Most bronchial foreign bodies are found easily when they are aspirated. We reported a case of bronchial foreign body found at intubation using a bronchoscope because of severe pneumonia The patient was admitted to our hospital because of pneumonia and shock. At nasal intubation using a bronchoscope, whitish granulomatous tumors were found in the lower trachea and carina. After the patient was recovered, further examination was performed. At bronchoscopy revealed a foreign body (probably chicken bone) in the left lower lobe bronchus. Granulomatous tumor was thought to be inflammatory polyp histologically. Precise examination of chest X-ray is important even in emergency cases. Furthermore, this reported case indicates that intubation using a bronchoscope is useful.

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A 67-year-old male accidentally swallowed a metal staple while working as a carpenter arround 1962. Occasional stridor occured in 1967, and a bronchial metal foreign body was detected in a local hospital. But he left it untreated. On November 19, 1990, he visited a local hospital, to undergo an operation for left inguinal hernia. A bronchial foreign body was detected again, and he was referred to our department on November 20. Fiberoptic bronchoscopy revealed a U shaped foreign material from the right main bronchus to the intermediate bronchus with its saddle on the peripheral side, surrounded by thick granulation tissue and resultant marked narrowing of the right main bronchus. We were unable to remove the foreign body with forceps and the bronchial mucosa readily bled. Even after antibiotic treatment and steroid inhalation, removal was impossible because the tips of the legs of the U-shaped body were buried in the granulation tissue. Therefore we cauterized the granulation tissue using a contact laser for 4 times. The entire staple was identified and removed by fiberptic bronchoscopy after cauterization.

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Pulmonary involvement in ulcerative colitis is very rare. The authors present a case of tracheobronchial lesions following proctocolectomy for ulcerative colitis. A 33 year-old non-smoking female began to complain of productive cough 3 months after protocolectomy. The chest X-ray showed no abnormality. Sputum culture yielded no bacteria. Since neither antibiotics nor cough medicines were effective for cough, fiberoptic bronchoscopy was performed. Numerous white nodular lesions were scattered in the trachea and bronchus. Histologically, the biopsy specimen of the nodular lesion showed squamous metaplasia of the epithelium and infiltration of inflammatory cells in underlying connective tissue. Inhaled beclomthasone dipropionate (BDI) relieved the cough and the tracheobronchial lesions disappeared bronchoscopically. In this case, there appeared to be a close relationship between ulcerative colitis and the tracheobronchial lesions.

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A 78-year-old man was admitted with hemoptysis. Chest X-ray showed infiltration in the right lower lung field. Bronchoscopy revealed bronchial bleeding from right B^5, and a hemispherical polypoid lesion at the anterior wall of the trachea. The polypoid lesion was identified microscopically as inflammatory polyp of the trachea. The relation between the inflammatory polyp and hemoptysis was unclear. We should get hold of cause of the inflammatory polyp of the airway should be determined and appropriate treatment performed.

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Time-related changes in bronchoalveolar lavage were observed in three cases of summer-type hypersensitivity pneumonia over a period of 2 to 3 years. When symptoms were present, the total cell count, lymphocyte and neutrophil ratio increased, while the CD4/CD8 ratio decreased. In winter, spring and symptomless summer, the total cell count, neutrophil ratio and CD4/CD8 all tended to normalize, but the lymphocyte ratio still remained high. A case undergoing steroid therapy showed a recovery of lymphocyte ratio as well as other parameters, but the lymphocyte ratio showed abnormal values after cessation of steroid therapy. House removal and/or reconstruction of their residence suppressed symptom recurrence, causing slow improvement of the CD4/CD8 and a decrease in the fungal antibody titer, but those still remained the lymphocyte ratio high.

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A 61-year-old man presented with febrile and productive cough. Laboratory examination showed peripheral eosinophilia and elevated serum IgE concentration. Immediate and late skin reactivity to Aspergillus antigen, and precipitating antibody against Aspergillus antigen were positive. An X-ray film of the chest showed an infiltrative shadow. From these results, this case was diagnosed as an allergic bronchopulmonary aspergillosis. He has never experienced bronchial asthma or dyspnea, and his respiratory threshold of acetylcholine was insignificantly low (10, 000 μg/ml ; normal range>10, 000μg/ml). Therefore it was thought that he did not have typical asthma. An X-ray film of the chest revealed a cavitary lesion in the left lung field. It was difficult to differentiate this case from lesions of the pulmonary tuberculosis or pulmonary suppuration. Histological examination disclosed that the inner wall of the cavity consisted of bronchial wall with eosinophilic infiltration. Thus, it was suggested that the genesis of the cavity was due to bronchiectasis.

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The author previously employed a conventional intratracheal tube as a transient airway stent for tracheal stenosis. However, in some case it seemed advantageous to insert a permanent indwelling stent for lung-term use. We developed a new silicone stent tube with silicone rings around the outside, and employed it in case of stenosis of the trachea. It was inserted through a flexible bronchofiberscope under local anesthesia. Two cases successfully treated using the stent are reported. Case 1 : A 59-year-old male had tracheal stenosis, approximately 3.5cm in length, due to local recurrence of lung cancer. He did well after insertion of a stent 9mm in external diameter and 5mm in internal diameter, but died of cancer metastasis three months later. Case 2 : A 27-year-old female had tracheal stenosis, 4.0cm in length, due to advanced adenoid cystic carcinoma. Her condion was good and she did not have dyspnea after insertion of a stent, 9mm in external diameter and 5mm in internal diameter, and was discharged uneventfully. Our new stents are useful for tracheal stenosis and can be easily inserted through a bronchofiberscope.

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