We evaluated the relationship between primary lung cancers less than 15mm in diameter and associated bronchi, and further investigated TBB yield. Subjects included 17 cases who underwent resection; 13 cases of adenocarcinoma, 2 cases of squamous cell carcinoma, 1 case of adenosquamous cell carcinoma, and 1 case of carcinoid. Resected lungs of 7 cases are inflated according to a modification of the Heizman's method, sliced axially at 1 mm thickness, imaged soft X-rays and correlated with preoperative 1-mm-slice HRCT and the pathological findings. The relationship between lesions and associated bronchi was classified into 4 types. We evaluated TBB results in relation to tumor size, type, order of associated bronchi, and visibility under X-ray fluoroscopy. Visible cases under X-ray fluoroscopy with Type I and II bronchus (positive bronchus sign) proximal to 6th order bronchi had better TBB yield.

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Results of silicon stents inserted into malignant airway obstruction were reviewed, especially according to bronchoscopic findings. All new patients with malignant disease undergoing studded silicon stent insertion at the UCSD Medical Center during a-3 year period between 1996 and 1998 were included in this study. Although we inserted silicon stents in 47 patients, 17 died within two months after the procedures. We analyzed consequences of silicon stents in surviving 30 patients. Of all patients, 53% had abnormal bronchoscopic findings on bronchoscopic inspection. Additional tumor growth occurred in 30%. Finally, stent-related complications occurred in only 23%. Furthermore, almost all abnormal bronchoscopic findings could be safely resolved with an additional intervention such as laser ablation, removal of the stent and additional of stent insertion. We concluded that silicon stent is beneficial for palliation of malignant airway stenosis.

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Various disadvantages of expandable metallic stents (EMS) have been pointed out as airway stents, especially in the trachea. It can be damaged by coughing, kinking may occur during placement, and it cannot be removed easily. However, EMS do not inhibit ciliary movement as do silicon stents, and their strong point is that they allows mucociliary transport because of its interstices. We examined the indications and other advantages of the placement of EMS based on experience with 5 patients who received placement of EMS in the left or the right main bronchus of 4 terminal stage lung cancer patients and an esophageal cancer patient with unilateral pulmonary atelectasis. The 5 patients were 3 women and 2 men, 3 with left and 2 with right main bronchial stenosis. Pulmonary atelectasis was relieved completely in 4 cases, though upper lobe atelectasis remained in one patient with right pulmonary atelectasis. After placement of the EMS, we additionally performed chemotherapy, irradiation, and cauterization (heat probe) of the affected bronchus and stent-in-stent, except in the patient with esophageal cancer. The average survival was 332.4 days after placement of the first EMS. During this period, no damage or kinking of the EMS or dyspnea was recognized. Furthermore, in the cases of stent crossing the right upper lobe branch, left second carina, or both, atelectasis could be completely relieved by EMS. However, this would probably have been impossible by a tube stent such as the Dumon stent. It was suggested that EMS would be useful in the main bronchi of cases with some problems in the trachea. Furthermore, EMS is more likely to be indicated than a tube stent in a cases of stents crossing the right upper lobe branch or left second carina.

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Eight cases of tracheobronchial inflammatory polyp were reported. The mean age was 60.6±12.5 years old and 6 were men. Seven were heavy smokers. Bloody sputum and abnormal chest X-ray were recognized in 3 patients, a sense of pharyngeal discomfort was felt by one, and one patient complained of fever. Four out of the 8 cases were complicated with some other lung disease. All polyps were solitary and smooth surfaced and in many cases were hemispherical and whitish or pink. Four were located in the trachea and 4 in bronchi. In only one case, the polyp was removed by electrocautery using a polypectomy snare. In other cases, the polyps were almost totally removed by forceps. The main histopathologic findings were interstitial edema and fibrotic change with inflammatory cells infiltration. The causative factors were unknown in many cases, however the fact that almost all patients were smokers suggested that chronic irritation in the airway by smoking is possibly involved in the etiology of inflammatory polyps.

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Some adenocarcinomas situated adjacent to the visceral pleura are similar to those within the pulmonary parenchyma in terms of the findings suggestive of shrinkage. We assessed the usefulness of 3D CT reconstruction images (multiplanar reconstruction images, MPR images) for three cases of lung cancer. Although all cases were adjacent to visceral pleura they seemed to be nodules surrounded by normal lung parenchyma with a well defined outer margin. There were tangential shadows of vessels between the chest wall and the outer margin of the tumor. MPR images showed that the vessels came from the lower portion of the tumor deriving from expansion of the lower portion of the tumor. There is a possibility that nodules may be in contact with the visceral pleura when only the outer margin of the tumor is well defined and vessels are recognized between the chest wall and the tumor on CT. In these cases, assessment of pleural invasion is an important factor in lung cancer staging.

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We studied 3 cases of erythromycin (EM)-resistent diffuse panbronchiolitis (DPB). EM-resistent cases were characterized by strong inflammatory findings, severe general conditions, as well as long-term duration of disease preceding to strart EM therapy. EM-ineffective cases were with long-term duration, or having pseudomonas colonization with severe bronchiectatic changes, or presenting with emphysematous changes. We concluded that EM therapy should start as early as possible at the beginning of disease.

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We encountered two patients who developed summer-type hypersensitivity pneumonitis in the northern part of Niigata Prefecture. A 39-year-old woman was referred to our hospital because of cough, fatigue and fever. Chest X-ray films and chest computed tomographic (CT) images revealed ground-glass opacity, and pulmonary function tests showed restrictive impairment and reduced diffusing capacity. Bronchoalveolar lavage (BAL) showed a low CD4/8 ratio, and the lymphocyte fraction was high. A transbronchial lung biopsy (TBLB) specimen revealed noncaseating granuloma and Masson bodies. The patient's condition improved after treatment with oral prednisolone. Another case was a 46-year-old housewife who was admitted to our hospital because of low-grade fever and exertional dyspnea. Chest X-ray films and CT images showed ground-glass opacity. The lymphocyte fraction in BALF was high, and the CD4/8 ratio was low. TBLB specimen disclosed noncaseating granuloma. Steroid treatment was effective. Serum from both patients contained antibodies to Trichosporon cutaneum and T.asahii. Provocation tests were positive in both cases. Neither patient had any relapse after remodeling the bathroom in the first case, and moved to another house in the second case. Previous reports indicate that summer-type hypersensitivity pneumonitis is rare in the northern part of Niigata Prefecture. However summer-type hypersensitivity pneumonitis may occur in any part of Japan, and in any season.

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A 69-year-old man was admitted with a polypoid tumor of squamous cell carcinoma in the left main bronchus and atelectasis. Radiation therapy was perfomed after informed consent had been obtained, although left pneumonectomy was also indicated. After 64Gy conventional thoracic radiotherapy, Nd-YAG laser, endobronchial brachytherapy with Co-60 and photodynamic therapy (PDT) were added to treat the residual cancer. Six months after PDT, balloon dilation was successfully performed for bronchial stenosis at the site of the previous treatments. Because his symptoms were not severe, his clinical course was followed after the balloon dilatation. There was no evidence of recurrence 2.5 years later and he led on his independent daily life. There are several non-surgical therapeutic options for endobronchial tumor, and their results are may be improved by combination thrapy if necessary. Because the main purpose of these therapies is the conservation of pulmonary function, we should be careful about possible complications.

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A 18-year-old male was admitted to our hospital because of an abnormal shadow on chest X-ray. Bronchoscopy revealed that left B^3 was occluded by the well vascularized and yellow polypoid lesion. He underwent an operation for a definite diagnosis and therapy. The histologic diagnosis was inflammatory psedotumor, fibrous histiocytoma type. Cases of inflammatory pseudotumor with polypoid lesion of proximal airway are rare in adults. Inflammatory pseudotumor should be on the list of differential diagnose in cases of lung tumor with a polypoid lesion in the proximal bronchus.

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We report a case of broncholithiasis treated successfully by surgery. A 51-year-old woman complained of persistent cough and was admitted to the Chiba University Hospital. Chest X-ray film and computed tomography revealed that the right middle lobe was completely atelectatic because of bronchial obstruction, and calcification of a peribronchial lymph node. Bronchoscopic examination demonstrated a granulation at the orifice of the middle lobe bronchus, causing complete obstruction. After middle lobe lobectomy the symptoms disappeared. Although tuberculosis was not proved pathologically, it appeared that a calcified hilar lymph node due to old tuberculosis infection had perforated the bronchial lumen, based on roentgenographic and surgical findings.

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Tracheobronchopathia Osteochondroplastica (TO) is a relatively rare disease characterized by the presence of ectopic cartilage and/or bone formation in the trachea or bronchi, or both. A 75-year-old man with TO associated with adenocarcinoma of the lung is reported. He had a mass in his right upper lobe. Bronchoscopic findings showed many small yellow-white nodules in the walls of the trachea and right main bronchus except for the posterior membranous portion. The biopsy specimen from a tracheal lesion showed ectopic cartilage and bony tissue under the epithelium and the specimen from the pulmonary lesion showed adenocarcinoma. TO associated with adenocarcinoma of the lung was diagnosed. For treatment of the lung cancer, resection of the right upper lobe was performed. The postoperative course was uneventful.

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We report a case of 68-year-old man with tracheobronchopathia osteochondroplastica detected by chest CT during preoperative workup for stomach carcinoma. Chest CT showed a markedly calcified 12×10/mm polypoid protrusion 3 cm above the carina. Bronchoscopy revealed an irregularly surfaced polypoid mass in the right wall of the trachea and many small nodular lesions on walls of the lower portions of the trachea and main bronchi, except for the membranous protion. Biopsied specimens showed pronounced change of bronchial cartilage diagnostic for tracheobronchopathia osteochondroplastica.

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During endoscopic resection of tracheal tumors, tumor impaction is the main cause of respiratory embarrassment. We report a case in which a hook wire was inserted into the tumor before bronchoscopic resection in order to avoid tumor impaction. The hook wire was composed of 3 parts, i.e.the hook needle, pusher and sheath. The hook and pusher were inserted into the sheat which was passed through the bronchoscope. Before resecting the tracheal tumor, the hook was extended and inserted into the tumor by means of the pusher. As a result, the hook wire caught the tumor allowing it to be removed safely. This simple method prevents tumor impaction in a main bronchus during endoscopic resection of tracheal tumor.

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