To evaluate features of endobronchial tuberculosis, we compared bronchofiberscopic findings with histopathologic findings of tissue obtained by transbronchial biopsy in 42 cases of endobronchial tuberculosis. Bronchofiberscopic findings were classified into four groups : phase I (early phase) showing intramucosal nodules (2 cases) ; phase II (active phase) showing ulcer formation (17 cases) ; phase III (healing phase) showing endobronchial polyps (13 cases) ; and phase IV (scarring phase) showing fibrotic scarring (10 cases). Histopathologic findings revealed epithelioid cell granulomas beneath bronchial epithelium corresponding to phase I, defects in the bronchial mucosa due to necrosis and epithelioid cell granulomas corresponding to phase II, squamous metaplasia of repaired bronchial epithelium and granulation tissue corresponding to phase III, and relatively normal bronchial mucosa corresponding to phase IV. Transbronchial biopsy was useful for diagnosis of phase I endobronchial tuberculosis. Although most previous studies had considered phase II and phase III as one stage, we feel these should be considered separately in order to comprehend the process of endobronchial tuberculosis. We conclude that the present bronchofiberscopic classification for endobronchial tuberculosis is of clinicopathological significance.

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Oxygenation is necessary to treat hypoxemia caused by bronchoscopic procedures. There are some reports on changes in arterial blood gas describing the oxygenation method and suitable dose during bronchoscopy, but oxygenation in most studies has been via a nasal tube. We modified a trachea tube for improved tracheal oxygenation. Result of oxygenation via a nasal tube and via the modified trachea tube were compared in terms of blood gas dynamics. The cuff of trachea tube was removed, and 0.51/min pure oxygen was administered to the trachea via the thin tube without a cuff (A group, N=25), and 21/min pure oxygen was administered via a nasal tube (B group, N=19). PaO_2 values was compared to with and without oxygenation during bronchoscopic procedures. PaO_2 values of A and B group were inceased 16.6Torr, 9.1Torr significantly compared to without oxygenation. Between two groups, A group was inceased in significance than B group. This oxygenation method via the modified trachea tube can be spread out of trachea directly. In particular, it was suggested that hypoxemia during bronchoscopy in patients with poor respiratory function could be prevented.

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The accuracy of transbronchial biopsy (TBB) was evaluated in 128 patients with solitary lesions on chest X-ray films that could not be visualized by bronchoscopy. Of the 128 patients, 90 (70.3%) underwent biopsy and diagnostic specimens were obtained in 80%. The detection rate varied depending on the location of the lesion. The detection rate was significantly lower in segment B^1 of the right lung. In addition to biopsy specimens and bronchial curetting, washing and sputum specimens obtained after bronchoscopy were useful for cytologic examination.

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A 72-year-old female, in whom diffuse panbronchiolitis (DPB) had been clinically diagnosed, who had been followed up for 10 years, was admitted because of bloodysputum. Fiberoptic bronchoscopy revealed an elevated lesion in the left main bronchus. The biopsy specimen revealed dense lymphoid cell infiltration in the subepithelial layer. The constituent cells were positive for 4KB5 and L26 immunostaining, and were negative for UCHL-1 and CD3 immunostaining. We diagnosed the case as low grade B cell lymphoma limited to within the bronchus. Thereafter DPB was wellcontrolled by clarithromycin. One year later, fiberoptic bronchoscopy revealed that the lymphoma had disappeared. It is considered that low-grade B cell lymphoma in the bronchus arises from bronchus-associated lymphoid tissue (BALT). In this case, it is suggested that the improvement of bronchial inflammation induced spontaneous regression of BALT lymphoma.

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We report a case of a fluid-fluid level seen on magnetic resonance (MR) images of a bronchogenic cyst. A 68-year-old man was admitted for persistent hiccup. Routine chest radiograph showed a smooth, round opacity in the left posteromedial basilar area. Although unenhanced computed tomography (CT) scans revealed a posterior mediastinal mass with homogeneous attenuation similar to that of skeletal muscle, contrast-enhanced CT scans demonstrated the nonenhancing cystic mass. Cardiac gated T1-weighted MR imaging disclosed a fluid-fluid level within the cyst. The dependent fluid layer was mildly hyperintense compared to the overlying layer. On T2-weighted MR imaging the cyst had a markedly hyperintense signal. The posterior mediastinal cyst was completely resected by video-assisted thoracic surgery and the pathological diagnosis was a bronchogenic cyst. At surgery, they cyst was ruptured with emission of nonhemorrhagic serous and mucinous fluids. The fluid-fluid level on T1-weighted MR imaging may possibly have been due to dependent layering of the proteinaceous mucinous fluid within the cyst. The present results indicate the unusual occurence of a fluid-fluid level on T1-weighted MR imaging of a nonhemorrhagic mediastinal bronchogenic cyst.

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A 64-year-old man was admitted complaining a productive cough, high fever and hemoptysis. He had a history of a foreign body aspiration (a piece of metal) when he was 4 years old, and the foreign body was excreted in stool. Bronchoscopy showed bleeding from the left basal bronchus, and a tracheoesophageal fistula. His symptoms improved by bronchoarterial embolization and administration of antibiotics. Previous reports document few cases of delayed diagnosis of traumatic tracheoesopageal fistula. We report a case of delayed diagnosis of traumatic tracheoesophageal fistula more than 60 years after the original trauma.

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A 59-year-old man complaining of cough and hemoptysis was admitted to our hospital. His chest X-ray film showed a 4×3 cm well-defined shadow in the right lower lung field. Bronchoscopy showed a tumor protruding from B^9. Transbronchial biopsy revealed bronchial carcinoid. Operative findings showed that the tumor was located in S^9, and that metastasis to hilar and mediastinal lymph nodes was suspected. Right lower lobectomy with mediastinal lymph node dessection was performed. Histopathological examination revealed typical carcinoid with No.10 hilar lymph node metastasis. The pathologico staging was stage II (T2N1M0). If this were a typical carcinoid, this case would have been required radical operation rather than limited operation. In regard to the indications of limited resection for typical carcinoid, more detailed criteria are needed based on many accumulation of more cases and clinical studies.

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A 79-year-old man, who underwent surgery for left pyothorax 30 years previously, received right lower lobectomy and irradiation for lung cancer in 1994. Since 1995, he complained of dyspnea for developing right pyothorax. On August 17, 1996, he was admitted to our hospital emergently for acute cardiopulmonary insufficiency which responded to ventilatory support and cardiac massage. However, severe brain-damage impaired his normal respiratory function. A tracheostomy was performed for prolonged mechanical ventilation on August 26. On November 18, fresh blood spurted from mouth, and this bleeding was controlled by inflating the balloon on the tracheal tube. On November 21, 90 days after the tracheostomy, he died of massive hemorrhage from the innominate artery. Autopsy revealed a fistula between innominate artery and trachea at level of the 6th tracheal cartilage, where the balloon was placed.

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A 44-year-old heavy male smoker complained cough and sputum. Chest X-ray film showed no abnormal shadow, but bronchoscopic findings revealed a polypoid tumor with a smooth surface at the orifice of the right basal bronchus. The histological diagnosis was solitary bronchial papilloma. Right basal segmentectomy was carried out. The resected tumor specimen had arisen from the bifurcation between B^7 and B^8, no malignant cells were detected in spite of further examinations. Solitary bronchial papilloma is relatively rare, and to our knowledge, only 37 cases including our cases, have been reported in the Japanese literature. In 2 cases, bronchial papillomas developed malignant change, and in 5 cases, those tumors were accompanied by lung cancer. It was considered that solitary bronchial papilloma should be surgically resected whenever possible.

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A 60-year-old man visited our hospital with dysphagia and high fever. An abnormal shadow was seen on his chest X-ray film. Esophagobronchial fistula was found out by fiberoptic bronchoscope, and esophageal cancer was diagnosed by endoscopic biopsy. Chest X-ray film showed severe pneumonia in the left lower lobe. After admission, a Dumon stent was inserted into the left main bronchus to seal the fistulae. Since the fistulae was incompletely sealed by the airway stent, we used an esophageal balloon stent. The stent with a balloon, made of silicone, was inserted into the esophagus. Because the fistulae was completely sealed, be able to drink fluid and palalysis of the reccurrent nerve did not occur. Double stenting is an effective method to improve the quality of life of patients with fistulae involving the esophagus and the airway.

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A 54-year-old male was admitted to our hospital whose chief complaints were cough and sputum and who had an abnormal shadow on chest roentgenogram. Bronchoscopically, a reddish and polypoid tumor not covered by epithelium protruded into the right upper lobe bronchus and almost completely occluded the bronchial lumen. Biopsy yielded a preoperative diagnosis of squamous cell carcinoma, therefore right wedge upper lobectomy was performed. Postoperatively the tumor was found to have arisen from a 5th order bronchus of right B^2b and extending to the right upper lobe bronchus as a long pedunculated polyp, distally invading the periphery lung parenchyma. The histologic type was adenosquamous carcinoma. The incidence of adenosquamous carcinoma is minimal and the details of its characteristics are still unclear. This case was thought to have unique macroscopic and bronchoscopic findings.

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A 65-year-old man complained of bloody sputum six months after radical nephrectomy due to renal cell carcinoma. Bronchoscopy revealed no abnormal finding. Nine months later, bronchoscopic findings showed a polypoid tumor arising from left B^8 bronchus and transbronchial biopsy revealed metastasis from the renal cell carcinoma. Left lower lobectomy of the lung was performed because of a solitary pulmonary metastasis and continuing bloody sputum. Examination of the resected specimen revealed two other small lesions in S^6 and S^<10> which were direct endobronchial metastases identical to the B^8 tumor. Multiple endobronchial metastases of renal cell carcinoma are rare without metastasis to the pulmonary parenchyma or other organs. Endobronchial metastasis which may not be found by bronchoscopic observation should be kept in mind in case of bloody sputum appearing after resection of renal cell carcinoma.

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We report three cases of lung cancer with postoperative tracheal metastasis detected by bronchofiberscopy. Case 1 : A 61-year-old man complained of bloody sputum 17 months after right upper lobectomy for small cell lung cancer. Bronchofiberscopy and biopsy revealed a metastatic tumor in the lower trachea. The patient was treated by irradiation. Bronchofiberscopy showed recurrent tumors three times after the first recurrence. He was treated with irradiation each time but died of cancer 76 months after surgery. Case 2 : A 73-year-old man underwent left pneumonectomy for squamous cell carcinoma. Multiple tiny tracheal polypoid recurrent tumors were detected by bronchofiberscopy 15 months after surgery. The patient was treated by irradiation and the tumors were completely disappeared. Though there was no recurrence after irradiation, he died of renal failure 48 months after surgery. Case 3 : A 66-year-old man underwent right middle and lower bilobectomy for squamous cell carcinoma. Multiple tracheal recurrent tumors were detected by bronchofiberscopy 15 months after surgery. The patient was treated with 60Gy irradiation and continuous low dose CDDP chemotherapy, but he died of cancer 21 months after surgery. Tracheal metastasis after operation for lung cancer may not be so frequent, but it can be detected by frequent periodic follow up examinations by bronchofiberscopy.

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A 68-year-old woman was admitted to our hospital with a productive cough. The chest X-ray and CT revealed an non-homogeneous shadow in the right lower lung field. An ulcerative lesion with silver-colored substance was observed in the right lower bronchus by bronchofiberscopic examination. This substance was a broncholith which composed mainly of calcium phosphate. Histological examination of a specimen obtained by transbronchial biopsy of this lesion showed inflammatory cell infiltration with necrotic tissue. Mycobacterium tuberculosis was isolated from a bronchial washing. We concluded this endobronchial tuberculosis was caused by transbronchial perforation of active tuberculous lymph node with calcification. After 4 months anti-tuberculous treatment with INH, RFP, EB and SM bronchofiberscopic examination showed remarkable improvement without stenosis.

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An 83-year-old woman with no notable past history was admitted with dyspnea and stridor. Her chest X-ray, CT, and pulmonary function tests showed no abnormal findings. Bronchofiberscopy revealed projection of the membranous portions of trachea into the airway after hyperventilation, although no abnormalities were observed during normal ventilation. These findings suggested tracheobronchomalacia. Respiratory rehabilitation including pursed-lip and abnormal breathing was effective. This case indicated that tracheobronchomalacia was important in the differntial diagnosis of dyspnea in elderly patients.

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