To assess the reconstruction of bronchial blood flow in lung allografts with immunosuppression by FK-506, left lung allo-transplantation was performed in 26 adult mongrel dogs. The recipient dogs were administered FK-506 intramuscularly at a dose of 0.1mg/kg/day. Bronchial mucosal blood flow(BMBF) at the second carina in the graft lungs and the carina in the recipient was measured with an Advance Laser Flowmeter. The L/C ratio (blood flow at the second carina of a graft/blood flow at the carina of the recipient) was 1.05±0.24(n=11) in normal lung of control dogs. The L/C ratio decreased to 0.57±0.09(n=9) after transplantation, and recovered to 1.03±0.10(n=7) 3 weeks after surgery. During rejection, the L/C ratio was significantly lower in severe rejection than mild rejection or normal lungs 3 weeks after transplantation: 0.56+0.33(n= 2) V.S. 0.98±0.11(n=4) or 1.03±0.10(n=6) (p<0.01). We concluded that reconstruction of the BMBF in canine lung allografts with immunosuppression of FK 506 is accomplished 3 weeks after transplantation, and the bronchial circulation is not influenced in allograft lungs with mild reiection but influenced in allograft lungs with severe rejection.

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We investigated patients undergoing resection for primary lung cancer. They included 29 patients in whom histological examination was made with an intraoperative frozen section and the stump was judged negative histologically postoperatively, and 4 patients in whom a frozen section was not needed during operation and the stump was judged positive histologically postoperatively, in total 33 patients. Tracheoplasty or bronchoplasty was performed in 8 of the 33 patients. Those in whom the stump was judged negative based on a intraoperative frozen section, but relapse of stump was observed after operation numbered 5 and 4 of 5 died of cancer. Radiotherapy was not performed in any of them. On the other hand, relapse of stump was not observed in any of patients in whom the stump was positive and who received radiotherapy postoperatively, and some survived for a long time. In patients in whom relapse of stump occurred after operation and in those in whom the stump was found positive postoperatively, the visual distance from the tumor to the stump was within 15mm and the tissues were affected by squamous cell carcinoma in all of them. The above findings suggested that postoperative radiotherapy should be considered even though the bronchial stump was negative when an intraoperative rapid specimen was used.

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Residual cancer at the bronchial stump was revealed histologically in 12 patients who underwent lobectomy or pneumonectomy with mediastinal lymph node dissection for squamous cell carcinoma of the lung. These patients were divided into 3 histological categories as follows : intraepithelial residual cancer (4 patients), intrabronchial residual cancer (3 patients) and peribronchial residual cancer (5 patients). All 4 patients with intraepithelial residual cancer had no lymph node metastasis or minimal intrapulmonary lymph node metastasis are alive without evidence of local recurrence, regardless of whether postoperative irradiation was performed or not. All 8 patients with intrabronchial or peribronchial residual cancer relapsed locally, and 7 of them died of local recurrence. These results suggest that the presence of intraepithelial residual cancer will not always result in local recurrence even if there is no postoperative treatment, if there is no lymph node metastasis or only intrapulmonary lymph node metastasis.

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Bronchoscopic examination yielding negative results in lung cancer patients have negative consequences on the prognosis and clinical evolution of these cases due to delays in initiating an early and appropriate therapeutic strategy. With the object of improving the diagnostic yield in such cases we assessed the backgrounds of 20 lung cancer patients in which the bronchoscopic studies were not diagnostic. Among these patients there were 17 patients with solitary pulmonary lesions (85%). The right upper lobe apical segments (S^1) and the right lower superior segments (S^6) were the areas more frequently affected. Concerning the size of the tumors, in 8 cases the tumor was less than 20mm and in 9 cases it was 20mm or more. Among the latter group, there were 5 cases (56%) with old fibrotic lesions. Eleven cases had only one bronchoscopic examination, whereas in 7 cases the examination was performed twice. There were 5 cases of tumor with size less than 20mm in the group in which bronchoscopic procedure was carried out only once, of these cases 4 had lesions in the right upper lobe apical segments (S^1) and 3 in the superior segments of the lower lobe (S^6). In 5 out of 11 cases with only one bronchoscopic study the final diagnosis was confirmed by echography-guided tumor biopsy. We concluded that in view of the low diagnostic yield obtained in cases of lung cancer with tumor localized in segments that are difficult to approach transbronchoscopically (S^6, S^1) as well as in those with old fibrotic lesions, the percutaneous biopsy might be considered as an alternative diagnostic approach.

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We studied the clinical features of extrapulmonary malignancies discovered by sputum cytology in lung cancer mass screening. All cases were the male squamous cell carcinomas except one malignant lymphoma of nasopharynx. The most common sites were the larynx (supra-glottic lesion in 10 cases, glottic lesion in 14 cases, subglottic lesion in one case, one unknown case). And each lesion was detected in oral floor, maxillary sinus, nasopharynx, oropharynx, hypopharynx and nasal cavity. Of the malignancies detected by sputum cytology in mass screening, 14.1% consisted of extrapulmonary lesions. Most of them were Ti cases. In cases with extra-laryngeal tumor and in some cases with supraglottic tumor, repeated bronchoscopic procedures were necessary for localization. Thus, in cases with cytologically positive sputum, more attention should be paid to the otorhinolaryngeal region.

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Seven laryngotracheal stenosis patients were treated by inserting a silicone tracheal T tube with a longer intratracheal portion than the standard T tube (long T tube). The cause of airway stenosis was tuberculosis in one patient, relapsing polychondritis in one patient, tracheal invasion of bronchogenic carcinoma in 2 patients, tracheal invasion of esophageal carcinoma in 3 patients. Two patients with benign disease had stenosis extending from the larynx to the lower trachea and 5 patients with malignancy had stenosis in the lower trachea. All patients complained of dyspnea and intubation or tracheostomy was performed before the T tube insertion. In patients who were intubated before tracheostomy, T tube was inserted when tracheostomy was performed. In other patients a tracheostomy tube was inserted before T tube insertion. In the patient with relapsing polychondritis the T tube moved distally and caused ulceration of the carina. In a patient with esophageal carcinoma the distal end of the T tube moved into the right main bronchus. In these cases, the distal limb was shortened and the long T tube was reinserted. There were no other troubles concerning the long T tube. A long T tube had been in place for 56 months before permanent extubation in a tuberculosis patient and one has been in place for 26 months in the relapsing polychondritis patient. All 5 patients with malignancy died within 10 months after insertion of the long T tube. In all the patients, phonation and expectoration of sputum were possible. The quality of life in patients with the long T tube was maintained at a good level and no major trouble concerning the long T tube was experienced.

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A 70-year-old man, heavy smoker, consulted his family doctor because of cough and sputum. He was subsequently admitted to our hospital as chest X-ray film showed a tumor shadow in the left hilum and cytological examination of the sputum proved positive. Bronchofiberscopic findings on admission revealed a nodular tumor with superficial infiltration at the orifice of left B^<1-2> and at the bifurcation between the right middle and lower bronchi, thickening of the right upper trifurcation and complete occlusion of left B^6 by a tumor. Apart from the lesion in left B^6, the other three lesions were consistent with endoscopic hilar early lung cancer. Histopathological findings demonstrated squamous cell carcinoma, one was carcinoma in situ. As the four lesions were mutually isolated and there were no metastase to lymph nodes or distant organs, this was considered to be a case of primary quadruple lung cancer. After bronchial arterial infusion and systemic chemotherapy using CDDP, VDS and MMC, bronchofiberscopic findings revealed no cancerous tissue remaining, indicating the effectiveness of chemotherapy for quadruple lung cancer. Subsequently radiotherapy of the tumor in left S^6 was performed in addition to the chemotherapy. The patient has survived for three years since treatment, with no apparent recurrence of lung cancer.

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A 23-year-old female patient, who had been treated for tuberculosis for one year and 4 months developed atelectasis of the left lung for a period of 4 months. Fiberscopic examination demonstrated stenosis of the left main bronchus due to bronchial tuberculosis. The left chest was opened with standard thoracotomy. The left lung was collapsed but easily re-expanded with positive pressure ventilation. Resection of the stenotic left main bronchus was done without lung resection. The post operative course was uneventful and demonstrated ventilation and perfusion lung scan revealed the tendency to improvement of ventilation and perfusion.

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A 67 year old Japanese male visited to orthpedic clinic because of prostatic carcinoma metastatic to the lumbar spine. A routine Chest X-ray showed multiple calcificatied lesion in the bilateral middle and lower lung lobes, Then, the patient was transferred to our clinic. Bronchofiberscopy revealed the presence of several, (a number of) elevated, yellow nodules in the tracheobronchial trees. Histologically, the nodule were found to be deposits of eosinophilic amorphous material in the submucosa, which stained pink with congo red. Since the material kept affinity for Congo-red after the treatment of KMnO_4, we regarded the material as amyloid of AL protein, Further examinations showed no Bence Jonce protein in the urine and no myeloma cells in the bone mallow. No clinical evidence of amyloid deposits was found in the other organs So, we diagnosed the patient as a primary amyloidosis extensively involving the tracheobronchial trees and lung.

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A 41-year-old nonsmoking man working for a ferromanganese industry that manufactures batteries developed a slight dry cough after inhaling ferromanganese for about 1.5 hours due to wearing a mask with no filter, and had difficulty in breathing. On general examination it was found that he had tachypnea and a slight fever. The fever was thought to be due to the ferromanganese. But his breathing sounds were normal and he showed no other symptom. Laboratory findings showed slight hypoxemia and depression of FVC on pulmonary function test. Chest X-ray and CT films revealed no abnormality. Bronchoscopy showed slight redness in all bronchi. As a result acute manganese bronchitis was diagnosed. Eleven days after the inhalation his symptoms and signs improved following conservative treatment. This case is the first reported case of acute manganese bronchitis.

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A case of lung cancer in a segment of the tracheal bronchus and a review of 14 cases of lung cancer in anomalous bronchi were reported. The patient, a 39-year-old housewife, had a solitary pulmonary nodule on mass survey chest X ray. Chest tomogram and CAT scan showed an anomalous tracheobronchial tree. The right B^1 bronchus branched from the right wall of the lower trachea and B^<2+3> bronchus branched from the right main bronchus. There was no variation in vascular structures. Lung cancer arising in a tracheal bronchus is rare, and only 14 other cases have been reported. Knowledge of this uncommon variant was needed in performing surgery.

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The patient was a 71-year old woman who complained of right cervical tumor and wheezing. Tracheal invasion of thyroid cancer was suspected on the basis of CT scan. Bronchofiberscopy revealed a smooth surfaced and yellow white colored tracheal tumor with a stalk that was located in the left side of the 10th tracheal ring from canna. Double tumors were diagnosed because thyroid cancer and tracheal tumor were not considered to be continuous on the basis of bronchofiberscopic examination. First, we performed Nd-YAG laser therapy for the tracheal tumor to open the air way then the tumor disappeared. The histological examination of the biopsy specimen revealed squamous metaplasia. Secondly, we performed right thyroidectomy. The tracheal wall was intact macroscopically. Nd-YAG laser therapy for a tracheal tumor is a low-risk and effective method. This is the first case of tracheal tumor associated with thyroid cancer reported in Japan.

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Two cases of sleeve resection for tracheal obstruction in whom previous thoracic surgery had been performed are presented. The first case was a 56 year old male, had undergone left thoracoplasty at the age of 20. Resection of 9 tracheal carcilagenous rings with stenosis and end-to-end anastomosis of the trachea was performed. The stenosis was caused by endotracheal intubation when contract a hepatic coma. The second case was a 67-year-old male with metastatic tracheal carcinoma. Left lower lobectomy and mediastinal lymph node resection had been performed for lung cancer at the age of 65. Resection of 4 tracheal carcilagenous ring and end-to-end anastomosis of the trachea were performed. Preoperatively, both cases, there was worry concerning insufficient mobilization around the trachea due to severe adhesion resulting from the previous thoracic surgery. In the first case, collar incision with total mid-sternotomy was successfully performed for cervical tracheal stenosis. In the second case also, total mid-sternotomy was satisfactorily performed instead of a standard thoracotomy for a lower mediastinal tracheal obstruction. Based on our experience, we considered several problems concerning reconstruction of the trachea, a surgical approach and mobilization of the mediastinal trachea.

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We report a case of post-completion-pneumonectomy bronchopleural fistula with empyema successfully treated by bronchoscopic closure with fibrin glue following unsuccessful surgical closure using an omental pedicle flap(OPF). A 71-year-old woman who had undergone completion pneumonectomy for a recurrent primary lung cancer was admitted for closure of the bronchopleural fistula Surgical closure using an OPF was unsuccessfully performed, and empyema developed. A bronchoscopic closure of the fistula was successful. Insufficient fixation of the OPF to the bronchial stump was the cause of failure in closing the fistula. Omentopexy is a useful procedure for postpneumonectomy bronchopleural fistula but fixing the OPF tightly to the bronchial stump is essential.

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A 67-year-old male was admitted because of persistent bloody sputum. Bronchoscopic observation disclosed right B^7b as the source of bleeding, which could be stopped temporarily by injection of thrombin solution and compression with the tip of the bronchoscope. However, his bloody sputum recurred and persisted. In order to halt bleeding by bronchial embolization, an ERCP catheter was inserted into B^7b through a bronchoscope, and fibrin glue was injected. As a result, effective hemostasis was obtained. This technique induced only slight rejection reaction, and the patient developed no frequent cough, fever or obstructive pneumonia. A slight amount of endobronchial bleeding may require no specific treatment and can be cured by conservative treatment. However, massive hemoptysis require active treatment, for example, bronchoscopic treatment, embolization of the bronchial artery or pulmonary lobectomy must be performed because of the possibility of death by suffocation as a result of bronchial obstruction. Determination of the bleeding site and definitive hemostasis are essential to the treatment of endobronchial bleeding. Our technique enable hemostasis by embolization with injection of fiblin glue through a bronchoscope after determination of the bleeding site. It is thought to be worth attempting for the treatment of peripheral endobronchial hemorrhage.

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A 64-year-old woman had a bronchogenic cyst with all bronchial structures. CT showed this tumor had CT number 48.8H There was a pedicled cyst behind the descending aorta and on the left pulmonary artery. The cyst seemed to be inserted into the A-P window from the posterior side. Cystectomy was carried out by thoracotomy and the cyst was found to consist of a single cavity filled with darkgreen mucus. Pathologically this cyst had all bronchial structures (ciliated epithelium, bronchial gland, cartilage, smooth muscle).

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A case of Relapsing Polychondritis(RP) had no particular respiratory symptoms, but marked lesions in the tracheal cartilage were revealed by fiberoptic bronchoscopy. Treatment with 60mg Prednisolone(PSL) and Indomethacin was not effective. He was then given 150mg of dianminodiphenyl sulfone(DDS) daily for 5 months, resulting in a marked improvement in tracheal lesions and inflammatory markers. The authers reviewed 82 cases with RP in Japan eseliterature and discussed their courses and therapies. It was concluded that the periodical fiberoptic bronchoscopy was necessary and that DDS therapy was very effective for the patient with RP.

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A case of long-standing intrabronchial vegetable foreign body was complicated with massive hemoptysis. An eleven-year-old girl was admitted to our hospital with massive hemoptysis (300ml, twice). Her chest roentgenogram showed ground-glass appearance and vascular convergence in the right lower lung field and chest X ray CT revealed a nodular lesion in right S^9 and localized bronchiectasis of right B^9. Bronchial angiography revealed dilatation and proliferation of the bronchial artery surrounding right lower bronchus, and shunt bronchial and pulmonary arteries. On questioning, the patient's parent recalled that she had choked on a hedge at age 2. Fiberoptic bronchoscopy under general anesthesia revealed a foreign body in right B^9a, and right basal segmentectomy was performed. The nodular lesion which had been recognized by chest Xray CT was markedly dilated and thickened bronchial walls with intraluminal plant fragments. Massive hemoptysis was likely caused by localized chronic bronchitis and bronchiectasis due to the long-standing intrabronchial foreign body.

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