Thirteen patients with low-grade malignancy originating in the respiratory tract (5 mucoepidermoid carcinomas, 3 adenoid cystic carcinomas, 5 carcinoid tumors) were treated surgically in our institute during the past 10 years. Surgical management and the outcome in these patients were evaluated clinically. Of the 13 patients, eight were men and five were women aged from 17 to 79 years old, with a mean age of 50 years old. Nine of 13 patients presented symptoms secondary to bronchial irritation or obstruction : hemoptysis in four, cough in three, stridor in one and recurrent pneumonia in one. Pathological diagnoses of the tumors were made on the basis of preoperative bronchoscopic biopsy in only 6 out of 13 patients and the remainder were diagnosed intra- or postoperatively. Surgical procedures consisted of tracheobronchoplasty without lung resection in two (1 tracheal sleeve resection, 1 bronchial sleeve resection), bronchoplasty with lung resection in 5, lobectomy in 5 and pneumonectomy in 1. Lymph node metastasis was found in only one case, a patient with carcinoid tumor who underwent left lower sleeve lobectomy. Postoperative radiotherapy was performed in only one patient with adenoid cystic carcinoma. There was no operative death although a 79-year-old patient died of right pneumothorax on the 48th day after left pneumonectomy for mucoepidermoid carcinoma. Surgical outcomes was generally good. Eleven patients are alive well without recurrence, except one who died of liver metastasis 34 months after the operation for atypical carcinoid tumor. The 5 year survival rate was 80.1% and the mean survival period was 49 months.

View full abstract

To study the pathophysiology of chronic eosinophilic pneumonia (CEP), we analyzed bronchoalveolar lavage (BAL) cells in 5 patients with CEP obtained from involved lung segments. The total cell count and the absolute number of eosinophils and lymphocytes were increased in patients, compared with those of healthy volunteers. Two-color analysis of T cells revealed that the absolute numbers of CD4^+CD29^+ cells and CD8^+S6F1^+ cells were increased in patients, compared with those of healty volunteers. Furthermore, we examined the change in BAL cells during steroid therapy after abnormal shadows on the chest X-ray film disappeared. The total cell count and the absolute number of eosinophils were normal, but the absolute numbers of lymphocytes, CD4^+CD29^+ cells and CD8^+S6F1^+ cells remained increased. These results indicate that lymphocytes, particularly CD4^+CD29^+ cells and CD8^+S6F1^+ cells, may play a critical role in the pathophysiology of CEP.

View full abstract

In transbronchial lung biopsy, specimens should be as large, as many, and obtained in as short a time as possible for better clinical and pathological diagnosis. Multibite forceps (MBF), which have long stems, can keep biopsy specimens within its sheath, enable four consecutive biopsies without removing the forceps from the bronchoscope. We examined its practicality compared with conventional forceps at three institutes. Using combination of rigid and flexible fiberoptic bronchoscopes under general anesthesia, 30 cases were examined by both MBF and conventional forceps. Under local anesthesia with flexible fiberscope, 15 cases were examined. There were 28 disseminated interstitial lung diseases and 6 endobronchial lesions examined under general anesthesia (4 cases had both lesions), 10 cases of diffuse lesions, 2 cases of endobronchial lesions, and 3 cases of peripheral coin lesions examined under local anesthesia. Under general anesthesia, consecutive biopsies were performed 4 times on average. The total number of biopsy specimens was 10 on average. The handling of the MBF was easy in 23/30 cases, the time of procedure was shortened in 24/30 cases, larger specimens were obtained in 19/30 cases. The results of MBF under general anesthesia were excellent. On the other hand, under local anesthesia, the number of specimens acquired consecutively was 2 on average. In total, 3.6 sites on average were biopsied. The handling of MBF was rather difficult in 3/15 cases, the time reduction was achieved in 7/15 cases, and larger specimens were obtained in 8/15 cases. The evaluation varied according to the individual case. We concluded that MBF is useful to obtain larger specimens in a shorter time especially under general anesthesia. Its longer rigid portion makes the passage more difficult in the bent position. The handling is somewhat more difficult under local anesthesia. However, there seems to be improvement in handling with experience. Because of its larger tip, it is not suited for localized lesions. However, it is useful for diffuse interstitial lesions. The quality of specimens obtained with MBF was also excellent for pathological diagnosis.

View full abstract

It is important to assess airway function in the management of pulmonary diseases. For this purpose, bronchoalveoral lavage (BAL), transbronchial biopsy (TBB), and sputum examination have been widely used. However BAL and TBB are invasive methods, and sputum is not always obtained spontaneously. To decide the clinical usefulness of induced sputum examination, we examined 1) its usefulness for diagnosis and 2) complication evoked by the procedure in patients with pulmonary tuberculosis, lung cancer and bronchial asthma. The numbers of specimen collection and the diagnostic value of induced sputum examination were compared with those of spontaneous sputum examination. The rate of sample collection and the diagnosis were higher in induced sputum examination than in spontaneous sputum examination. In asthma patients, the number of eosinophils was significantly higher than that in the non-asthma patients. Concerning the complications of the procedure, there were only 3 patients who complained of nausea, and 3 patients had asthma attacks. No patients showed decrease of O_2 saturation and FEV_<1.0>. We concluded that induced sputum examination is useful and safe technique for the evaluation of pulmonary disease.

View full abstract

Right upper sleeve lobectomy is the modality of choice for lung cancer invading to the orifice of the right upper bronchus. A case of bronchoplasty for lung cancer is reported. Anastomosis was conducted between the tracheal wall and the truncus intermediate bronchus, because of the anomalous bronchus (B^1) arising from the tracheal wall. A 46-year-old male suffered from dry cough and sputum and he consulted another hospital in March 1997. An abnormal shadow on his chest X-ray film was pointed out and he was admitted for further examination and proper treatment in April 1997. The chest X-ray showed an ill-defined mass shadow in the right hilum, 5.0×4.0 cm in size. The chest CT revealed a nonhomogeneous tumor which obstructed the orifice of the right upper bronchus (B^<2+3>). An anomalous bronchus (B^1) arising from the tracheal wall was also detected. Bronchofiberscopy revealed an abnormal orifice (B^1) on the right side of the trachea. The orifice of B^<2+3> was obstructed by the polypoid tumor, and the biopsy specimens revealed squamous cell carcinoma. Pulmonary angiography showed A^1 arising from the right trunk, wedge-shaped obstruction of the truncus superior artery (A^<2+3>) and encasement of the ascending artery (A^2b). Right upper sleeve lobectomy and mediastinal node dissection were conducted. The anastomotic sites were the right tracheal wall proximally and the truncus intermedius distally. Angioplasty with Gore-tex patch was done after a partial resection of the pulmonary artery. The postoperative stage was p-T3N2M0, stage IIIA.

View full abstract

A 53-year-old man was admitted due to progressive sore throat, resistant cough and dysphonia. Chest radiographs revealed infiltrating shadows and cavities in both upper lung fields. His sputum specimen was positive for acid-fast bacilli. A small yellow nodule was present in the epiglottis. Laryngeal and pulmonary tuberculosis were diagnosed. A 26-year-old woman was admitted to our institution with persistent fever, cough, dysphagia and dysphonia. Her chest radiographs showed many small nodules throughout the lung field. Many small yellow nodules were also present in the epiglottis. Her sputum specimen was positive for acid-fast bacilli and therefore miliary and laryngeal tuberculosis were diagnosed. Both patients received a full course of antituberculosis treatment with satisfactory results in both. Because the diagnosis of laryngeal tuberculosis is difficult to make based on clinical findings, it is important to carry out fiberscopic examinations of the larynx in patients with persistent cough, dysphonia and throat pain.

View full abstract

A 35-year-old woman with a clinical diagnosis of Wegener's granulomatosis had been followed up at another hospital. The diagnosis was made because she had abnormal shadow on chest X-ray which had been detected since 1982, with typical symptoms of hematuria and a saddle nose. In March, 1996, she was admitted to our hospital complaining of wheezing and dyspnea. Emergency endotracheal intubation was performed after bronchoscopy which demonstrated marked subglottic stenosis. She underwent tracheotomy followed by the administration of steroids and immunosuppressive drugs. Subglottic srenosis improved rapidly after therapy. However, multiple depressed lesions persisted in the tracheal wall. The administration of co-trimoxazole (Sulfamethoxazole-Trimethoprim) resulted in complete healing of the lesions except for a mild cicatricial stricture. With the widespread use of bronchoscopy, it is well-known that Wegener's granulomatosis is frequently associated with airway lesions. The subglottis is a common site of Wegener's granulomatosis. In the present case, significant changes in airway lesions were observed by bronchoscopy.

View full abstract

A 63-year-old man had a two-month history of nasal obstruction, epistaxis and purulent nasal discharge. He was given antibiotics at the Ear, Nose and Throat Department of our hospital, however, symptoms did not improve. He was admitted on April 1997, because his condition worsened progressively with productive-cough, hearing loss, otalgia and painful oral ulcers. Clinical picture showed sinusitis, ulcerative bronchitis and glomerulonephritis. A confirmatory diagnosis of Wegener's granulomatosis (WG) was made by elevated C-ANCA titer and histopathologic finding of nasal biopsy specimen. He was treated with daily cyclophosphamide and prednisolone. After standard treatment of WG, C-ANCA titer was withdrawn and the nasal lesion was improved immediately. However, because microhematuria and endobronchial lesions did not recover, he was treated with pulse therapy of methylprednisolone. After treatment of pulse therapy, microhematuria and the endobronchial lesion improved markedly. C-ANCA titer reflected overall disease activity, but not the endobronchial inflammatory activity of WG. Bronchofiberscopy was useful in the diagnosis and management of WG.

View full abstract

A 62-year-old man was referred to our hospital after category E was detected by sputum cytology screening. The chest X-ray film and computed tomography failed to reveal an abnormal shadow. Bronchofiberscopic findings did not show the hilar type lung cancer, and washing cytology showed no cancer cells. Three months later, squamous cell carcinoma was diagnosed by washing cytology from the right lung. After one week, cancer cells were obtained by washing cytology from the right lower lobe bronchus, and after admission, cancer cells were obtained by washing cytology from right B^6. The clinical stage was occult carcinoma (TXN0M0), right S^6 segmentectomy was performed. The pathologic specimen showed moderately differentiated squamous cell carcinoma in the peripheral S^6c. The largest tumor dimension was 2.8mm×2.5mm. The pathological stage was I (T1N0M0).

View full abstract

We report two cases of pulmonary actinomycosis diagnosed and treated by thoracoscopic lung tumor resection. The first case was a 78-year-old man complaining only of a productive cough. Chest X-ray revealed a small nodule with pleural indentation in the peripheral right segment 2 in which a few blood vessels were involved. These findings suggested primary lung cancer. The second case was a 44-year-old man in whom a chest abnormal shadow was found in an annual health check. He had no symptoms. Chest X-ray revealed a small nodule in the peripheral left segment S^<1+2> attached widely to the adjacent pleura. The paucity of symptoms and their radiological findings of vascular and local pleural involvement made it difficult to differentiate the disease from malignant lung tumor. Thoracoscopic findings of both cases showed local pleural attachment, however pleural fluid could not be seen. Antibiotics were not administered in one case after resection in which the pleural involvement was slighter, and complications or recurrence were not observed. We believe this disease should be included in the differential diagnosis of primary lung cancer. In the case of small lesions located in the periphery of the lung like these two cases, thoracoscopic partial lung resection is a safety and useful method of diagnosis and treatment.

View full abstract

A 45-year-old woman was admitted to our hospital because of dyspnea. Systemic lupus erythematosus (SLE) was diagnosed by the presence of photosensitivity, oral ulcer, arthritis, lymphocytopenia and positive antinuclear antibody. Chest X-ray film on admission showed reticulogranular shadows in both lung fields without cardiomegaly. Electrocardiogram showed non-specific inverted T waves. Blood examinations showed normal renal function, and PaO_2 was 85.6 Torr. After fiberoptic bronchoscopy including bronchoalveolar lavage and transbronchial lung biopsy was performed, the patient became shocked. She died of acute heart failure 24 hours later. The autopsy revealed diffuse alveolar damage with pulmonary edema and dilated myocardium without myocarditis nor myocardial infarction. It is considered that hypoxia during fiberoptic bronchoscopy could cause myocardial stunning. This patient is the second case of SLE complicated by heart failure induced by fiberoptic bronchoscopy. Therefore, fiberoptic bronchoscopy should be selected carefully in patients with SLE.

View full abstract

A 29-year-old man complained of a cough of about three weeks' duration, without wheeze or dyspnea. His chest X-ray films showed no abnormality. Laboratory findings were as follows : sputum cytologic findings showed eosinophilia ; methacholine inhalation test by the asthograph method (Chest 80, 600, 1981 : Chest 109, 1525, 1996) was normal (Dmin : 22.5 units) ; and antibody to Mycoplasma pneumoniae (normal : less than 40 times) was elevated to 320 times. Therefore, eosinophilic bronchitis without asthma (Lancet 1, 1346, 1989) was diagnosed, associated with Mycoplasma pneumoniae infection. His cough was treated with a macrolide antibiotic (CAM : clarithromycin) and H_1 antihistamine. After 8 months, the patient again visited our hospital because of a recurrence of chronic cough without wheeze or dyspnea. Antibody to Mycoplasma pneumoniae was elevated to 160 times, suggesting persistent Mycoplasma pneumoniae infection. In addition, he showed hyperresponsiveness to methacholine (Dmin : 18.7 units). At that point, we diagnosed cough-variant asthma. The patient had a favorable response to therapy with pranlukast, a peptide leukotriene receptor antagonist. We speculate that Mycoplasma pneumoniae infection may cause some cases of cough-variant asthma, and we conclude that pranlukast may be useful for the treatment of cough-variant asthma.

View full abstract

We examined a 77-year-old man who had aspirated a pickled Japanese apricot seed and a 3-year-old girl who aspirated a peanut by multi planar reconstraction and 3D-CT imaging (3D-CT bronchography, 3D-CT bronchoscopy). In both patients 3D-CT imaging gave us a better special understanding compared with axial CT imaging and made it easier to remove, the foreign bodies. We conclude that 3D-CT imaging is useful in patients with tracheal foreign body, especially because it is difficult to perform fiberoptic bronchoscopy in children.

View full abstract

We report a case of Heerfordt syndrome, a rare syndrome in patients with sarcoidosis. A 32-year-old woman was admitted to our hospital because of reduced sight, disturbance of left facial movement, and general fatigue. On physical examination, the patient had slight fever, peripheral type left facial nerve palsy and swollen of parotid glands. A chest roentogenogram and a CT scan showed bilateral hilar lymphadenopathy. ^<67>Ga-citrate scintigraphy revealed abnormal uptake in orbits, salivary glands, mediastinum, and hilus. Uveitis was diagnosed by opthalmological examination. Bronchoalveolar lavage study showed marked increase of lymphocytes and increased ratio of CD4/CD8 subsets in BAL fluid, while no definite pathological diagnosis was obtained from transbronchial lung biopsy. On the basis of these findings, Heerfordt syndrome was diagnosed. The patient was successfully treated with oral prednisolone.

View full abstract