The neodymium-yttrium-aluminum-garnet (Nd-YAG) laser has proven to be a useful therapeutic tool for the management of endobronchial obstructive lesions. The purpose of this study was to reassess the present status of Nd-YAG laser therapy for tracheobronchial malignant tumors. Between February 1983 and December 1995 in 9 institutions, 82 patients received Nd-YAG laser therapy for tracheobronchial stenosis, obstruction, or hemoptysis due to tracheobronchial malignant tumors. Twelve patients received laser therapy alone. Perioperative radiotherapy was performed in 54 patients (66.6%). Metallic stents were inserted into the trachea or main stem bronchi in 19 patients and surgical treatment was performed in 13 patients following laser therapy. Six of the 7 patients with multiple lung cancer had undergone lobectomy for a first lesion, and received radiotherapy following laser treatments for a second or third cancer. Good symptomatic relief was obtained in 90.2% of the patients. The operative mortality rate was 0.55%, and the morbidity rate was 2.7%. Complications occurred in 5 patients : airway bleeding in 3, cardiac arrest in one and reocculusion in one. One patient died of uncontrollable bleeding. The median survival time was 8.9 months in the patients without surgical resection. The 5-year survival rate was 50.0% in the patients with surgical resection following Nd-YAG laser treatment. Nd-YAG laser therapy is useful as a palliative treatment of obstructive tracheobronchial disease. When the lesion is malignant, concurrent radiotherapy, insertion of stent or surgical resection is needed to prevent reobstruction.

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Evaluation of bronchial wall invasion and mediastinal lymph node metastasis of lung cancer was affected using Tracheobronchial ultrasonography with an Olympus EU-M20 and UM-2R (12MHz) or UM-3R (20MHz). Peribronchial lymph nodes and bronchial walls of resected lobes were examined ultrasonographically. Hilar and mediastial lymph nodes were detected clearly, especially with the UM-3R (20MHz). The layered structure of the bronchial wall was observed in clinical cases and bronchial cartilage was detectable.

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In cases of bronchial constriction caused by malignant diseases, we performed endobronchial high dose rate brachytherapy inside a stent using a microSelectron HDR after placing the stent in the respiratory tract for the purpose of achieving effective treatment of the primary disease as well as maintaining the respiratory tract. Initially, the necessity of dose correction when using indwelling stent was tested. An applicator for the bronchus connected to a microSelectron HDR and a dosimeter were fixed in a water phantom made of acrylic resin at a distance of 20mm using an eye protector for systemic irradiation, and then, immersed in water. Dumon stents (10, 13 and 15mm in inside diameter, 50mm long ; Novatech) were used. In order to examine the difference between the materials, Z stents (6, 8, and 12mm in inside diameter, 50mm long ; Cooks) were also tested. In the test of each stent, the dose was measured at 4 different points (20, 22, 28 and 36mm) from the radiation source simultaneously, and the cumulative doses for 2 minutes at each point were compared. In the control group, the dose was measured twice without using a stent. In the stents, the deviation of dose due to the stent was less than 1% at all the measuring points. Therefore, in intra-stent endobronchial high dose rate brachytherapy, contribution of radiation-scattering caused by the stent was found to be less than 1%, and no particular correction for the curative radiation dose was thought necessary. On the basis of these results, endobronchial high dose rate brachytherapy using microSelectron HDR inside the stent was performed by placing a Dumon stent in the carina to treat recurrence in the left main bronchus after right pneumonectomy.

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Participants who were 50 years of age or older and with a cigarette index of 600 or more were screened annually by both sputum cytology and chest X-ray for the early detection of lung cancer in the Miyagi Program. From 1982 to 1992, 119, 240 examinations were made. Sputum specimens showed moderately atypical squamous cells (sputum diagnosis "C") in 465 cases (0.39%), suspicious cells or borderline atypical cells (sputum diagnosis "D") in 301 cases (0.25%), and cancer cells (sputum diagnosis "E") in 287 cases (0.24%). In the "E" cases, sputum specimens showed malignant cells with low grade atypia in 159 cases (sputum diagnosis "E1") and frankly malignant cells in 128 cases (sputum diagnosis "E2"). Among 588 cases with sputum diagnosis D or E, there were 229 cases (38.9%) of primary lung cancer, and 34 cases (5.8%) of upper respiratory tract cancer, 3 cases (0.2%) of metastatic lung cancer and 42 cases (7.1%) of dysplasia (borderline lesion) which were confirmed by bronchoscopic examination, especially selective brushing of all bronchial branches. Upper respiratory tract cancers were located in the larynx, pharynx, oral cavity, maxillary sinus and nasal cavity. Of the 229 primary lung cancers, 208 (90.8%) were squamous cell carcinoma, 14 (6.1%) adenocarcinoma, 4 large cell carcinoma, 2 small cell carcinoma and one was other cell type cancer. Among the 208 squamous cell carcinoma cases, 156 carcinomas (75%) were roentgenographically occult. It is often difficult to localize carcinomas by bronchoscopy and a thorough investigation is necessary. We must carefully follow up the cases with sputum diagnosis D or E, but in which localization is not confirmed.

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Deformation of the residual bronchus after left or right upper lobectomy can cause severe stenosis or lung torsion. The authors studied the effect of preservation of the pulmonary ligament on preventing deformation of the residual bronchus in 55 cases. Of these, the pulmonary ligament was excised in 39 cases (group A) and in the other 16 cases it was preserved (group B). Group A was further classified into two groups : the bronchial stump was closed with interrupted sutures (group A-(1) 18 cases) or TL-30 autosuture (group A-(2) 21 cases). We closed the bronchial stump following lobectomy according to the methods proposed by Sweet with mediastinal lymph node dissection (R2a) in all cases. Two patients of group A-(1) (11.1%) and three patients of group A-(2) (14.3%) complained of respiratory discomfort but nobody in group B had any complaints. Fiberoptic bronchoscopy was performed in 19 patients (group A-(1) 8 cases, group A-(2) 6 cases, group B 5 cases) after over one week following the operation. Deformation of the residual bronchus was detected in 5 cases of the 8 the group A-(1) cases examined (62.5%) and all 6 cases of the group A-(2) cases examined (100%) but mild bronchial deformation was detected in only one of the 5 cases of group B.

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There are many methods of bronchial closure. We investigated methods of bronchial closure in relation to the development of bronchopleural fistula in 1155 patients who underwent lobectomy or pneumonectomy for lung cancer during the past 12 years. The incidence of bronchopleural fistula were analyzed in relation to bronchi that were closed and the method of closure. The incidence was 4.1%, 8.1% and 0.7% in the main bronchi, truncus intermedius and lobar bronchi, respectively. Statistically significant differences in incidence were observed between the main and lobar bronchi (p<0.05), and between truncus intermedius and lobar bronchi (p<0.01). The lowest incidence was 0% and 3.8%, in the main bronchi and the truncus intermedius closed by manual suturing and folding the cartilage. In the lobar bronchi, the lowest incidence was 0%, when closure was performed by stapling with 4.8mm leg length staple. In conclusion, we recommend the manual suture and folding the cartilage for the closure of main bronchi or the truncus intermedius, and stapling with the 4.8mm leg length staples for lobar bronchi.

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A 66-year-old woman, who had received medication for chronic articular rheumatism including 3mg/day prednisolone since 1973, underwent total hip joint replacement under general anesthesia on July 6, 1994. After the operation, marked subcutaneous emphysema and dyspnea occurred. Bronchoscopic findings revealed a laceration of the membranous portion of the middle portion of the trachea. Intermittent suction of the subcutaneous emphysema was performed using 16 gauge needles, but the emphysema did not improve. On the fifth postoperative day, direct closure of the laceration was carried out with placement of a pedicled intercostal muscle flap. The postoperative course was uneventful.

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A 61-year-old woman complained of cough. Her chest X-ray revealed collapse of the right middle and lower lobes and several calcified nodules in the right hilum. Chest CT scan demonstrated one of these calcified nodules to be situated at the orifice of truncus intermedius. Bronchoscopic examination revealed an obstruction by a broncholith with an irregular surface and a residual stone in the bronchial wall on the mediastinal side at the orifice of the truncus intermedius. We attempted bronchoscopic extraction of the stone, but the stone moved into the peripheral bronchus and became invisible due to the stenosis of the truncus intermedius. Repeated bronchoscopic examination showed the broncholith tightly obstructing the orifice of the right B^<9+10>. After several bronchoscopic procedures, the extraction of the stone was carried out successfully using a cytology curette and grasping forceps. The broncholith mainly consisted of calcium phosphate. The decalcified structure appeared to be that of a lymph node, which suggests that the calcified lymph node penetrated into the lumen of the truncus intermedius and eventually formed a broncholith.

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A 49-year-old woman with no history of bronchial asthma was admitted to our hospital because of productive cough. Her chest roentgenogram showed a mass in the left lower lung field. Laboratory findings showed peripheral eosinophilia and pulmonary function tests revealed mild obstructive respiratory impairment. CT showed a "gloved finger shadow" transiently. Bronchography with iopamidol revealed cystic bronchiectasis of the 4th and 5th order of bronchi but alveolograms we not obtained. Histological examination by transbronchial biopsy demonstrated bronchocentric granuloma. Positive immediate and late skin reaction to A. fumigatus antigen and precipitating antibodies against A. fumigatus antigen resulted in a diagnosis of allergic bronchopulmonary aspergillus (ABPA). ABPA accompanied by cystic bronchiectasis is rare, and is thought to represent an advanced stage. In this case, cystic lesions were demonstrated on a chest X-ray film taken three years previously. The course of ABPA should be carefully followed even when asymptomatic.

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Bronchial asthma is one of the essential criteria for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). In this case report, we experienced a case suspected to be ABPA that did not have asthma. An infiltrative shadow in the right middle lung field was pointed out on the chest X-ray of a 52-year-old man who presented with a slight dry cough. Chest CT revealed loss of volume due to mucoid impaction in the right middle lobe. Blood examination showed elevated levels of eosinophil counts (20.0%) and IgE concentration (1755IU/ml). Immediate skin reactivity for Aspergillus antigen was strongly positive, but its serous precipitating antibody was negative. Although these findings did not fulfill the criteria of ABPA, we suspected ABPA clinically and started to administer 30mg/day of prednisolone. One week after, he coughed up brown mucous plugs at home. After that, chest CT showed an improvement in volume of the right middle lobe and central bronchiectasis in it. Hypereosinophilia and high IgE serum levels also improved. From the clinical point of view, we concluded that this case was suspected to be ABPA unaccompanied by bronchial asthma.

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We report a 68-year-old case of bucillamine-induced interstitial pneumonitis. She had been suffering from rheumatoid arthritis (RA) since 1995, and had been treated with bucillamine since April, 1996 with good result. However, after taking bucillamine for about 80 days, dry cough and dyspnea on effort developed and was admitted. Those manifestations worsened daily. Pulmonary function test revealed a restrictive pattern and blood gas analysis showed hypoxia. Interstitial changes were seen in bilateral lung fields on X-ray and computed tomography (CT) film. RA activity was low. We performed bronchoalveolar lavage (BAL) and trance bronchial lung biopsy (TBLB). A drug lymphocyte stimulating test (DLST) using bucillamine was done both with blood and BAL. Although the former was negative, the latter was positive. The CD4/CD8-ratio of BAL was remarkably low, and lymphocytes invasion to alveolar walls was found in TBLB specimens. We diagnosed her lung injury was bucillamine-induced interstitial pneumonitis, and started steroid therapy with 50mg/day of PSL. Her pulmonary function recovered and clinical manifestations disappeared quickly. Not a small number of cases of lung injury during bucullamine therapy for rheumatoid arthritis have been reported since 1989, but its mechanism remains unknown. This case suggests that the contribution of hypersensitivity reaction (Cooms & Gell type IV) to the development of bucillamine-inducted interstitial pneumonitis.

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A 47-year-old man was admitted to our hospital with fever and dyspnea. One month prior to admission, he was given minocycline for a cold by his home doctor. Three weeks later, he was again given minocycline for recurrent fever. However, his symptoms became exacerbated, and dyspnea developed. Chest X-ray film and CT revealed bilateral infiltrate shadow. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy were performed. The BAL fluid contained 53.4% lymphocytes, 25.8% eosinophile, and 19.8% macrophages. The concentration of eosinophil cationic protein in BAL fluid was higher (105μg/dl) than in the blood (18.8μg/dl). Values of ECP/albumin were 690.8μg/g in the BAL and 0.59μg/g in the blood. Pathological findings of the lung were compatible with acute eosinophilic pneumonia. Lymphocyte stimulation tests for minocycline were negative in both BAL and peripheral lymphocyte. However, symptoms improved on cessation of minocycline. We concluded that acute eosinophilic pneumonia is can be induced by hypersensitivity reaction to minocycline, and that eosinophil granule proteins play an important role in the pathogenesis of acute eosinophilic pneumonia.

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We present a case of sarcoidosis with primary acute pulmonary cavitation in which all cavitary lesions resolved spontaneously without any treatment. The patient's chest X-ray film revealed bilateral infiltrates with nodular opacities. The chest computed tomography (CT) findings showed multiple bilateral nodular opacification with some cavities. The diagnosis was made by transbronchial lung biopsy. Bacteriological studies yielded negative results. Without any treatment, chest CT scans revealed spontaneous resolution of the cavitary lesions and decrease of the bilateral nodular opacities 50 days later.

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In March, 1995, a 59-year-old male was found to have malignant melanoma of the maxilla. He underwent total maxillectomy and was treated postoperatively with chemotherapy. He was followed up as an out-patient. In March, 1996, he suffered from fever and cough. Chest roentgenograms showed infiltrative shadow in the right lower lung field. Tomography and chest computed tomography revealed an obstruction at the orifice of the right basal bronchus, and a black tumor was found on bronchoscopy. Obstructive pneumonia caused by endobronchial metastasis from maxillary melanoma was diagnosed. In cases with malignant melanoma multiple or solitary nodule shadows are common chest roentgenographic findings. Endobronchial metastasis, however, is uncommon. In this case, there was on obvious abnormality on the chest X-ray films during follow-up, but, the patient suffered from obstructive pneumonia due to metastatic lesion of melanoma. Chest CT and bronchoscopy are useful to detect lung metastasis, including endobronchial metastasis from melanoma.

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