Three-dimensional CT (3D-CT) by helical CT scanning was performed in 7 cancer patients with tracheobronchial stenosis (1 case with squamous cell carcinoma, 2 cases with adenocarcinoma, 3 cases with small cell carcinoma and 1 case with esophageal caner). 3D-CT imaged a tapering of the airway with a smooth surface in cases with extramural compression and a tapering of the airway with an irregular surface in cases with tumor invasion. In one of the two cases which had tumor invasion of the tracheobronchial wall, it was impossible to differentiate stenosis due to tumor invasion from extramural compression based on the 3D-CT findings. Multiplanar reconstruction (MPR) was useful in evaluating tumor invasion of the tracheobronchial wall. Complete obstruction was not found during the bronchoscopic examination in any of the 7 cases, but 3D-CT imaging showed complete obstruction of the tracheobronchial airway in 2 cases. 3D-CT provided good imaging for evaluation of tracheobronchial stenosis after insertion of the expandable metallic stent (EMS). The problem involved in evaluating tracheobronchial stenosis by 3D-CT are that 3D-CT does not enable differentiation between stenosis due to tumor invasion and extramural compression.

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Lidocaine is an anesthetic agent widely used for fiberoptic bronchoscopy. However, they attention is rarely paid to the amount of lidocaine give to the patients during each examination. We performed fiberoptic bronchoscopy, including examination, biopsies, brushings and washings in 1124 patients, using a small amount of lidocaine (average dosage per patient was 240mg), sprayed by the use of a Jackson nebulizer and instilled through a catheter made of Teflon inserted into the channel of the bronchoscope. There was no case of lidocaine poisoning. By the conventional method of anesthesia for fiberoptic bronchoscopy without a catheter, some of lidocaine may be aspirated, thus although there is a difference in the amount of lidocaine the effective quantity delivered to the trachea and the bronchus may be the same. We examined lidocaine amounts and plasma lidocaine concentration of 22 patients (aged from 37 years old to 81 years old) who gave their informed consent. The result was that the amount of lidocaine used and the plasma lidocaine concentration using the catheter were both lower than when it was not used. We conclude that the Teflon catheter is effective in reducing the lidocaine amount given for anesthesia for fiberoptic bronchoscopy. In addition we managed bleeding and subsequent clouding of the lens during the examination by retracting the catheter slightly into the channel and instilling a small amount of saline and lidocaine through the cathter, which would clear prevented cough and subsequent new bleeding. Amounts of epinephrine can also be reduced by using the catheter.

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Tissue hypoxia at the anastomosis is one of the major causes of anastomotic complication after tracheoplasty. To investigate changes in the tissue oxygen tension after tracheoplasty, submucosal tissue oxygen tension of the trachea (PtO_2) was measured by polarography in adult mongrel dogs. The study was performed to examine the changes of PtO_2 at the anastomosis and at the carina after resection of 10 tracheal rings. In this study, PtO_2 was serially measured before and immediately after operation, and on day 3, 7, 14, 21 and 28 after operation. Bronchoscopic findings, histologic findings, and microangiographic findings were also analyzed in the study. The PtO_2 ratio (PtO_2 of the anastomosis was divided by that of the carina) was 0.86±0.25 before operation, 0.57±0.34 immediately after operation, 0.30±0.11 on the 3rd post operative day (POD), 0.47±0.25 on the 7th POD, 0.60±0.17 on the 14th POD, 0.70±0.23 on the 21st POD and 0.85±0.19 on the 28th POD. The PtO_2 ratio immediately after operation, at the 3rd, the 7th and the 14th POD decreased significantly compared to that prior to operation (p<0.05). Bronchoscopic study showed edema and congestion of the mucosa at the 3rd POD at the site of anastomosis, which gradually resolved. By the 21st POD, edema and congestion of the mucosa disappeared. Neovascuralization of microvessels studied by microangiography showed that at the 3rd POD there were no vessels crossing the anastomosis, but by the 7th POD some small vessels crossed the anastomosis and by the 21st POD the anastomosis was completely covered with small vessels. In conclusion, bronchoscopic, histologic and microangiographic findings after tracheoplasty corresponded to the change in PtO_2 at the anastomosis.

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We perpared a silicone stent with a ring-trimmed surface assuring increased stent fixation to the tracheobronchial wall and easier implantation via the flexible bronchoscope. This new stent was easily introduced in 6 patients under local anesthesia, 4 in the left main bronchus and 2 were tracheobronchial stents. Duration of stenting was 3 months to 12 months, there was no stent migration. 2 cases of tracheobronchial stent suffered from mucostasis. In 2 autopsy cases with duration of stenting 3 and 4 months, it was revealed that there were impressions on the internal surface of bronchus corresponding to stent surface with ring-trimming. In both cases, histologically mucosal layers disappeared and cartilaginous rings denuded on the bronchial lumen. It was suggested that close attachment of the stent surface to the bronchial mucosa offered good fixation.

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A 61-year-old female was admitted to the hospital with a dry mouth, arthralgia and dyspnea. Chest CT study revealed reticular shadows with multiple bullae in both. Bronchofiberscopy revealed dryness of bronchus and a white nodule in the right lower bronchus (B^8). The bronchial biopsy specimen revealed amyloid deposits consisting of homogenous and acellular materials. The nodular type of bronchial amyloidosis with rheumatoid arthritis and Sjogren's syndrome is very rare. The pathophysiology of this case was discussed.

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A 23-year-old woman was admitted to our hospital with atelectasis of the left upper lobe after treatment of pulmonary tuberculosis. Bronchofiberscopy revealed complete obstruction of the left upper lobe bronchus. Chest MRI showed patency of the segmental bronchi of the left upper lobe, so sleeve resection of the left upper lobe bronchus was performed. The lobe that had been collapsed for 6 months recovered after the operation. Bronchoplasty for tuberculous bronchial lesions is a useful procedure.

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We report a case of a 70-year-old man who had bronchobiliary fistulae after several laparotomies. He was admitted with hemoptysis. After BAE and TAE, hemoptysis was eliminated and fistulae were treated with catheter drainage.

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A 50-year-old female was refered to our hospital because of cough and fever. Chest X-ray and CT scans revealed localized bronchiectasis and pneumonia of the left basal segments. She was treated with antibiotics, but the symptoms continued. Angiography revealed dilated inferior phrenic artery-to-pulmonary artery shunt. Preoperative transcatheter embolization with steel coils was performed. Adhesion between the left lower lobe and the diaphragm was remarkable but ablated smoothly with a small amount of hemorrage, then left basal segmentectomy was performed. In this case, preoperative transcatheter embolization was effective in decreasing intraoperative bleeding.

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An 81-year-old male with rheumatoid arthritis (RA) started to complain of shortness of breath in 1992. His chest X-ray showed reticulonodular shadows throughout both lung fields. He was diagnosed as eosinophilic pneumonia (EP) by transbronchial lung biopsy (TBLB) and bronchoalveolar lavage (BAL). Prednisolone (PSL) resulted in remission. Afterwards he was followed up without corticosteroid treatment. After 3 years he relapsed and the therapy was resumed with a low maintenance dose of PSL. After half a year he complained of dyspnea again and his chest X-ray showed migrating patchy shadows, mainly in the upper lung fields. The diagnosis of BOOP was made based on the TBLB findings of lymphocytes accumulation. This is a rare case which showed both EP and BOOP in the same individual clinical course and this finding suggests that both diseases belong to the same category in terms of pathological process.

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The case was a 55-year-old male with a history of childhood asthma and recurrent bronchial asthma since age 47. He was admitted with cough, stridor, chest discomfort and bilateral abnormal shadow on chest X-ray. He had eosinophilia, elevated serum IgE, positive immediate and delayed skin reactions to Aspergillus fumigatus, precipitating antibody against Aspergillus fumigatus by the technique of Ouchterlony and severe bronchiectasis. Bronchoscopy showed eosinophillic mucoid impaction which was a mass shadow on chest X-ray. The computed tomography revealed a bronchiectatic change after the mass shadow disapeared following corticosteroid administration. Eosinophillic mucoid impaction is considered to play a some role in the bronchiectasis of allergic bronchopulmonary aspergillosis.

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A case of atypical carcinoid originating from the bifurcation between the right middle and right lower lobe bronchi was reported. Although it was difficult to diagnose from chest X-ray examination, two abnormalities based on the bronchial obstruction by the tumor were observed. One was that the slow maneuver vital capacity was larger than the forced vital capacity, and the other was that the pulmonary blood flow to the right middle lobe decreased remarkably. It was also observed by bronchoscopic examination that the right middle bronchus was obstructed by the carcinoid tumor during normal breathing and it reopened during deep inspiration. When there is reversible bronchial obstruction by the tumor, the ventilatory disturbance and/or the change in local pulmonary blood flow was occasionally be useful for detecting the intrabronchial tumor.

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A 75-year-old woman was admitted to our hospital with cough, stridor, and shortness of breath. The chest roentgenogram and CT scan on admission showed severe stenosis of the lower trachea and both main bronchi. Bronchofiberscopy revealed diffuse and smooth-surfaced submucosal tumor that bled easily therefore it was difficult to obtain the biopsy specimen. After 5 weeks of 30mg prednisolone therapy, stenosis was decreased. We could safely obtain the specimen from the tumor and diagnosed adenoid cystic carcinoma of the trachea. Fortytwo Gy of radiation therapy achieved moderate effect.

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A 47-year-old asymptomatic male was referred to our hospital for further examination of the abnormal shadow on the chest X-ray. CT examination showed that the shadow was calcification of the cartilage of the first rib, but also incidentally demonstrated a tracheal mass. Bronchoscopic examination under local anesthesia showed a small sessile tumor on the posterior membranous portion of the trachea five rings above the carina. The tumor was diagnosed as benign leiomyoma histopathologically. Operation was performed through a right posterolateral thoracotomy, and the tumor was excised easily under the muscosal layer by the incision of the membranous portion of the trachea. The defect was repaired with direct suture and the mediastinal pleura was also repaired. The patient was discharged after an uneventful postoperative recovery and bronchoscopy showed normal findings of the trachea without stenosis at two months after the operation. Forty months of follow-up were uneventful. Leiomyoma of the trachea is a rare bening tumor and only 39 cases have been reported in the literature (including our case). In most cases the patients had been treated for brochial asthma or bronchitis because of the symptoms (cough, wheezing, dyspnea, hemoptysis) before correct diagnosis. Some patients presented severe dyspnea due to tracheal obstruction, and two cases were reported to have died despite the benign disease. On the other hand, three of 39 cases were asymptomatic and were diagnosed incidentally. They were treated successfully just like our case.

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Although leiomyoma as a primary tracheal tumor is rare, this tumor was observed in a 72-year-old woman with lung cancer. A primary adenocarcinoma was found in the right upper lobe. She underwent right upper and middle lobectomy and R2b radical removal (p-stage I ; T1, N0, M0). The leiomyoma, 5 mm in diameter, was found in the right margin of the membraneous portion about 1.5cm above the carina. Although noninvasive therapy is usually conducted for tracheal leiomyoma, surgery was chosen in the present case because the operation for lung cancer was done simultaneously. Using a double lumen bronchial tube for ventilation, the leiomyoma was placed between the two cuffs of the bronchial tube, and partial tracheal resection was performed without employing any complicated procedures such as surgical field cannulation. To our knowledge, this is the first report on tracheal leiomyoma accompanying lung cancer. The surgical techniques and discussion with related literature were presented.

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It is difficult to diagnose primary pulmonary lymphoma preoperatively and discriminate from other lymphoproliferative diseases. We reported 2 cases of resected primary pulmonary MALT type lymphoma. The first case was diagnosed as MALT type lymphoma based on the preoperative diagnosis by immunohistological examination of TBLB specimen. The other case was also strongly suspected to be a MALT type lymphoma preoperatively based on bronchial brushing cytology, flow cytometric analysis of BALF and elevation of serum γ-globulin level. When this disease is suspected, diagnose can be performed by flow cytometric analysis of BALF and immunohistological examination of TBLB specimens. In addition to these techniques, it is essential to prove rearrangement of immunoglobulin genes and T cell receptor genes for definitive diagnosis.

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