We investigated the usefulness of bronchoalveolar lavage (BAL) in the diagnosis of pulmonary complications in 9 patients receiving chemotherapy for malignancies. Diagnoses were made by BAL in 6 patients (67%) in whom pulmonary hemorrhage was detected in 4 and pneumocystis carinii pneumonia in 2 patients. Two cases of pulmonary hemorrhage had bleeding tendencies with thrombocytopenia (platelets below 3.0×10^4/mm^3). We reviewed the three undiagnosed cases, and their final diagnoses were pulmonary infiltration of lymphoma cells, graft versus host reaction disease, and miliary tuberculosis. No patients had complications associated with BAL. In pulmonary complications during chemotherapy for malignancies, pulmonary hemorrhage was most common. We concluded that BAL is useful for the diagnosis of pulmonary hemorrhage and infection occurring during chemotherapy for malignancies.

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Thirty-five pneumonectomies were performed between January 1988 and December 1995. Postoperative bronchopleural fistulas (BPF) occurred in 4 patients (11.4%), all of which were on the right side. As initial symptoms, 3 patients had cough and 1 patient had bloody sputum. The interval from the initial operation to the onset of BPF was 17-18 days in 3 patients and 7 months in one patient. Closed drainage and washing were performed in all cases. We tried to close the fistula by fiberoptic bronchoscopic therapy. However, these attempts were not successful. In 3 patients, omentum-plombage was performed after cleaning the thoracic cavity. Two of these 3 patients recovered completely, but one developed empyema again. In that patient, fenestration of the chest wall was performed. For BPF after pneumonectomy, fiberoptic bronchoscopic therapy was not useful, but omentum-plombage after drainage was very useful.

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Differential diagnosis between lung cancer and tuberculosis is still extremely important. Usually it takes 4-8 weeks to obtain the results of cultures for acid-fast bacilli, which sometimes causes delay in the diagnosis of both lung cancer and tuberculosis. The Mycobacterium Tuberculosis Direct (MTD) test is an assay for the rapid detection of Mycobacterium tuberculosis by means of detecting the ribosomal RNA using Mycobacterium tuberculosis-specific DNA probes after amplifying RNA in the samples. It takes only 4 hours to obtain results by the MTD test. This assay has been mainly used for sputum specimens, but we employed it for the detection of tubercle bacilli in bronchial lavage fluid. Of a total of 540 specimens from bronchial lavage fluid, 524 were negative on both MTD and culture, 14 were positive on both MTD and culture, 1 was MTD-positive and culture-negative, and 1 was MTD-negative and culture-positive. The coincident rate of both assays was 99.6%. We concluded that MTD test is a useful and reliable method to detect Mycobacterium tuberculosis in bronchial lavage fluid.

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Five lung cancer patients with stenosis in the lower trachea and the main stem bronchus were treated by inserting a long T-tube into the main stem bronchus. In four patients the airway had to be secured before the insertion of the T-tube due to severe stenosis. The distal end of the T-tube was inserted into the left main bronchus in four patients and into the right main bronchus in one patient. In three patients a side aperture in the T-tube was made at the orifice of the contralateral main stem bronchus in order to maintain the contralateral ventilation and to facilitate the drainage of secretions. All patients died of cancer 12 days to five months after inserting the T-tube. Phonation and oral food intake was possible until death in all patients. Three patients were able to stay home for one to two months before death. At the terminal stage an extracorporeal limb was utilized for suction and oxygen administration. Insertion of a long T-tube with a side aperture at the main stem bronchus is a useful method in securing the airway in patients with stenosis in the lower trachea and the main stem bronchus due to malignant tumor.

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A 66-year-old female heavy smoker (smoking index : 920) complained of night cough. CT of the chest showed a 4 cm mass with a cavity in the right lung (S^<10>). Bronchoscopic findings additionally showed a slightly elevated lesion at the bifurcation of B^<1+2> and B^3 of the right lung and a small area of mucosed hypertrophy at the bifurcation of the left upper and lower lobe bronchi. Histologically, these three tumors were squamous cell carcinomas. The two tumors detected only by bronchoscopic examination were endoscopic early stage squamous cell carcinomas. Therefore, we diagnosed synchronous triple lung cancer. We performed right lower lobectomy for the right S^<10> tumor, and continuous piecemeal forceps resection with Nd-YAG laser therapy for the other two early stage tumors. We considered that it is necessary to choose the most appropriate therapy for multiple lung cancers. Case reports of triple lung cancers in women are very rare. This paper describes this very rare case with a review of the Japanese literature.

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Bronchial mucosal bridging is occasionally found following treatment for squamous cell carcinoma or small cell carcinoma. This report describe a rare case of mucosal bridging detected after chemoradiotherapy for adenocarcinoma. A57-year-old woman was admitted with an abnormal chest X-ray film. Chest CT scans revealed a tumor in the right S^3, which was approximately 5 cm in diameter, and adjacent to the mediastinum. Bronchoscopy revealed a stenotic right upper bronchus and a tumor obstructing B^1 and B^2. The diagnosis was adenocarcinoma (c-T4N2M0). After concurrent chemoradiotherapy, the tumor decreased in size. Bronchoscopy after treatment showed good patency of the right upper bronchus and a mucosal bridge at the orifice of B^1.

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A 72-year-old man was admitted to our hospital because of fever, sputum and dyspnea. He had had difficulty in breathing for several years. We diagnosed pneumonia due to acute exacerbation of bronchiectasis. Though we treated him with antibiotics, antimicrobial-resistant Pseudomonas aeruginosa was found in the sputum and symptoms debilitated. After 200mg ciprofloxacin orally twice a day was initiated, sputum culture became negative and he recovered. He has been well for 22 months since the beginning of CPFX chemotherapy. These findings suggest that the medium-dose, long-term new-quinolone chemotherapy is useful as treatment for bronchiectasis.

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A 75-year-old man with old pulmonary tuberculosis and chronic respiratory insufficiency was admitted to our institution because of hemoptysis. Because of continued hemoptysis, bronchial arteriography was carried out. The angiographic findings showed hypervascularization, bronchopulmonary shunt of both bronchial arteries and hypervascularization of the left intercostal artery. Therefore, a super-selective bronchial artery embolization of the right bronchial artery and the left intercostal artery was performed using platinum coils, guidewire and an infusion catheter. When the platinum coil had just been passed through the infusion catheter by pushing the coil pusher into the left bronchial artery, the guiding catheter was removed from the left bronchial artery. However, the coil floated from the left bronchial artery into the descending thoracic aorta. We removed it from the descending thoracic aorta using a basket catheter. The patient has made a good recovery with no further hemoptysis.

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A 20-year-old man injured in a traffic accident. Nine days after the injury, the left main bronchus became occluded due to granulation tissue formation, and atelectasis of the left lung developed. Dilatation of the bronchus with a balloon catheter was initially performed but yielded only temporary dilatation of the lumen. Restenosis due to the redevelopment of edema or granulation soon appeared. Thirty days after the injury, sleeve resection of the left main bronchus was performed. He had an uneventful postoperative course, and results of examination of respiratory function, pulmonary blood flow scintillation studies, and bronchoscopy performed one year later had all returned to nearly normal levels. No abnormality was observed on long-term monitoring of progress after surgery. Though there are reports of successful balloon dilatation for the treatment of bronchial stenois, this treatment is thought to be ineffective when inflammations is in the acute phase, as in the present case.

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A 35-year-old man was admitted to our hospital for the treatment of traumatic injury. Right lung contusion was diagnosed with laceration of the right main bronchus. We immediatly performed right pneumonectomy. After surgery, we noticed the tracheal stenosis due to tracheal cartilage rupture and inserted an expandable metallic stent (EMS) into the trachea. Six months later, rhexis of the EMS caused tracheal stenosis. EMS was replaced by a Dynamic stent, but it migrated to near the vocal cord two months later. Although the Dynamic stent was replaced by a Dumon stent, it also migrated immediately after this treatment. The Dumon stent was finally fixed by suturing to the trachea. Although there are many sorts of tracheal stents today, we must carefully choose the most suitable one for each patient.

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We reported two cases of blunt complete transection of cervical trachea. One case, a 21-year-old man, had a complete cervical tracheal transection combined with esophageal transection and bilateral reccurent nerve injury in a motor bicycle accident. In other case, a 55-year-old man, suffered complete cervical tracheal transection in a power shovel, with combined cervical spine and bilateral reccurent nerve injury. Both underwent primary end-to-end tracheal anastomosis. If the airway can be maintained the prognosis of patients with complete transection of the cervical trachea is generally good. It is suggested that extensive examination during and after operation is very important for these cases.

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