The application of combined video-mediastinoscopy and video-thoracoscopy has remained infrequent, despite preliminary demonstration of its technical feasibility. Cyto-pathological diagnoses should be carried out in order to achieve accurate diagnoses, especially in groups of patients (1) with lesions in both the mediastinum and the hemithorax, (2) with lung cancer which has the probability of being up-staged if this combined technique before surgery were used and (3) those who underwent induction therapy. For these purposes, this technique is one of a very reliable method. This article reviews the rationales and the techniques of this method.

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Background.Mycobacterium avium-inracellulare complex (MAC) pulmonary disease with associated nodules and bronchiectasis is an increasingly prevalent condition. This condition is often difficult to diagnose in the early stages of the disease, because of the limited effectiveness of sputunm culture cytology. The effectiveness of bronchoscopy in the isolation and diagnosis of MAC in respiratory secretions is still unclear. Purpose and Methods. 0ver a three-year period, we examined the effectiveness of bronchoscopy in 45 non-HIV-infected patients who had clusters of small peripheral lung nodules. These nodules were associated with changes of the draining bronchi detected by high-resolution CT (HRCT). Results. A total of 22 of 45 patients (48.9%) had cultures positive for MAC. In the MAC-positive group, 10 patients tested positive for disease in sputum and 22 tested positive for disease in bronchial washings. A total of 13 of 45 patients (28.9%) fulfilled the American Thoracic Society criteria for pulmonary MAC disease, and 9 (20.0%) others with cultures positive for MAC did not fulfill the criteria. Radiographic measures and sputum cultures of 13 of 16 patients (81.3%) with negative cultures revealed no further disease progression. Conclusions. We found that HRCT was a useful technique in the diagnosis of MAC-pulmonary disease. We also found that bronchoscopy was a more sensitive diagnostic technique than sputum culture, analysis in the differential diagnosis of MAC pulmonary diseases.

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Case. A 58-year-old woman was admitted to our hospital because of hemoptysis in March 2003. The chest X-ray on admission was normal, but CT showed infiltration in the right upper lobe. Bronchoscopic examination showed a non-pulsatile polypoid nodule covered with normal mucosa in the right B^2a. Right bronchial arteriogram revealed a convoluted and dilated bronchial artery and bronchial artery-pulmonary vein shunt was also shown in middlelate artery phase. From these findings, we diagnosed racemose hemmangioma of the bronchial artery. We performed bronchial artery embolization (BAE) of the right upper bronchial artery using tomado coils. Results. After one month bronchofiberscopy showed that the polypoid nodule had almost disappeared. There was no recurrence of hemoptysis after the BAE procedure. Conclusions. BAE with tornado coils can be effective to treat hemoptysis due to hemangioma.

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Background. Sarcoidosis has a similar pathogenesis to that of several other autoimmune disorders, and patients with a combination of diseases have been reported. Case report. A 57-year-old woman had been given a diagnosis of rheumatoid arthritis at age 34. Fever (≧38.3℃) persisting for more than one month, dry cough, loss of appetite, and weight loss occurred. Chest CT showed mediastinal lymphadenopathy, ground glass opacities in both lower lobes and multiple nodules in the right lower lobe. In addition, the BALF CD_4/CD_8 ratio was elevated and transbronchial lung biopsy showed non-caseous epitheliod cell granulomas. Accordingly, the diagnosis of sarcoidosis was established. Conclusion. We reported a case of sarcoidosis following rheumatoid arthritis.

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Background. We report a case of mucoepidermoid carcinoma of the lung. Case. A 39-year-old woman with high fever was seen by her home doctor. As chest X-ray film indicated pneumonia of the left upper division segment, the patient was referred and admitted to our hospital. Bronchoscopic examination demonstrated a tumor occluding the left upper lobe bronchus. Biopsy yielded a diagnosis of mucoepidermoid carcinoma. Therefore, left upper lobectomy and lymph node dissection was performed. Resection of the upper lobe bronchus was performed under fiberoptic bronchoscopic observation. The bronchial stump did not demonstrate any tumor cells on intraoperative pathological examination. Surgical duration was 5 hours 5 minutes and intraoperative blood loss was 170 ml. The postoperative course was uneventful and she was discharged on the 11th postoperative day. The polypoid tumor was 23×12 mm in size and protmded from the bronchial wall into the orifice of the left upper bronchus with a 3 mm stalk. The histological examination of the resected material demonstrated a low-grade malignant mucoepidermoid carcinoma with no lymphatic metastasis. The pathological stage was IB (T2NOMO). Comparative genomic hybridization analysis was performed due to the chromosomal imbalance detected in the tumor, but there was no chromosomal region considered to show a gain or loss. More than 3 years and 6 months after resection, the patient is alive without recurrence.

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Background. Increasing number cases of congenital bronchial atresia have been reported due to the development of radiological modalities, cases of acquired bronchial atresia are rare. We encountered one case of acquired bronchial atresia. Case. A 55-year-old woman presented with cough, chest pain, and an abnormal shadow was found on her chest X-ray film. Bronchofiberscopic examination and chest CT findings revealed occlusion of the left B^6 with infiltration peripheral to that point. She was prescribed antibiotics. Her symptoms and chest X-ray findings improved. Six months after her first visit, she complained of hemoptysis, and she was admitted to our hospital. Chest CT showed the enlargement of multiple low attenuation areas in the opacity peripheral to the point of occlusion. The echoguided aspiration culture test revealed Pseudomonas aeruginosa. She underwent left S^6 segmentectomy because of repeated pulmonary infection. The pathological examination did not reveal the typical findings of congenital bronchial atresia, and we diagnosed acquired bronchial atresia. The etiology of the bronchial obstruction was unknown. Conclusion. We concluded that we must consider not only congenital bronchial atresia but also acquired bronchial atresia in cases of bronchial obstruction.

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Background. We encountered a rare case of endobronchial granular cell tumor with cough and bloody sputum. Case. A 24-year-old woman was admitted because of cough and bloody sputum. She was a Philippina and had been in Japan for 5 years. Chest X-ray film showed an infiltrative shadow in the left middle lung field and chest CT showed tumor at the orifice of the left lingular bronchus and bronchiectatic change of the left lingular bronchus with obstructive pneumonia. Bronchoscopy revealed a polypoid lesion at the orifice of the left lingular bronchus. Diagnosis of granular cell tumor was obtained by transbronchial biopsy. The tumor consisted of cells with eosinophilic granules and S-100 protein- and NSE-positive materials in the cytoplasm. As respiratory symptoms and obstructive pneumonia were suspected to be attributable to the endobronchial tumor, lingular segmental wedge resection was performed. The specimen revealed granular cell tumor, which proliferated in the left lingular bronchial lumen. Conclusion. In a case of endobronchial granular cell tumor with symptoms of cough and bloody sputum, lingular segmental resection was performed to eliminate the risk of obstructive pneumonia.

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Case. A 64-year-old Japanese man with hepatitis C virus-related cryoglobulinemia and membranoproliferative glomerulonephritis (MPGN) was treated with interferon-α (IFN-α) from September of 2002. His clinical manifestations and the resulted laboratory examinations for hepatitis and MPGN improved dramatically after initiation of IFN-α treatment. Unfortunately, the IFN-α had to be tapered off and halted because thrombocytopenia was presented and recognized as one of the side effects of IFN-α. He soon suffered hemoptysis, fever, and exacerbation of dyspnea even though we halted the IFN-α. When he was admitted to the First Department of Internal Medicine, Shinshu University School of Medicine on February 21, 2003. Reticular purpura was present on his extremities. Laboratory examinations showed anemia, thrombocytopenia, as well as DNA antibodies and positive crvocrit. The chest roentgenogram showed diffuse ground grass opacities and alveolar septal thickening in both lungs. His bronchoalveolar lavage fluid (BALF) contained bloody fluid with hemosiderin-laden macrophages. There was no evidence of malignancy, infection, or heart failure. Therefore, the diagnosis of hepatitis-C virus-related cryoglobulinemia complicated with alveolar hemorrhage was made. His alveolar hemorrhage was controlled after treatment with prednisolone, however, it reoccurred with exacerbation of dyspnea when the prednisolone was tapered. He ultimately died despite pulse methylprednisolone therapy. Conclusion. This case suggests that the HCV infection may possibly induce autoimmune disorders, such as cryoglobulinemia, MPGN, systemic lupus erythematosus (SLE) and so on.

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Background. ln patients with tracheobronchial stenosis, placement of a Dumon stent is not an easy procedure if the use a rigid bronchoscope is always required. Especially in emergency cases, a simple and safe method of stent placement without use of a rigid bronchoscope is desirable. Case. A 57-year-old man who had been intubated for two months following coronary artery bypass grafting (CABG) was transferred from another hospital because of wheezing and dyspnea. Chest X-ray and thoracic computed tomography revealed tracheal stenosis, and the flexible bronchoscopic view showed severe tracheal stenosis 3 cm above the carina on the oral side. An emergency tracheotomy was performed and the patient was then intubated with an endotracheal tube via the tracheal stoma. Three weeks following successful dilation of the tracheal stenosis and cure of the infection surrounding the tracheal stoma, a Dumon stent was placed via the endotracheal tube. Conclusion. Staged placement of a Dumon stent in patients with tracheal stenosis may prove to be a simple and safe method that avoids use of a rigid bronchoscope in emergency procedures.

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Background. Broncholithiasis is a rare disorder and most cases have been observed in central bronchi. We report a case of broncholithiasis in the peripheral bronchus observed directly by an ultrathin bronchoscope. Case. A 68-year-old woman complaining of sputum visited our department with an abnormal shadow on a chest X-ray detected on a lung cancer screening. Her medical history included lung tuberculosis at 18 years of age. Chest high resolution CT showed ectasis of the right B^2a bronchus with calcification and segmental atelectasis. Bronchoscopy revealed that the right B^2a bronchus was deformed and fillled with mucoid impaction. Thus, elimination of the mucoid impaction and additional treatment by expectorant and antiphlogistics was performed for 3 months. After treatment, segmental atelectasis improved and broncholithiasis was observed at the orifice of the right B^2aii by an ultrathin bronchoscope. Conclusion. We observed broncholithiasis in a peripheral bronchus by an ultrathin bronchoscope. The ultrathin bronchoscope is useful in the differential diagnosis of disorders presenting segmental atelectasis, such as communityacquired pneumonia, cancer and broncholithiasis.

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Background, We encountered a case of bronchial atresia presenting niveau. During its course, the fluid mucocele level gradually elevated. Case. A 24-year old woman was found to have a round mass shadow in the right lower lung field by chest X-ray in October 1999. She was admitted to our hospital for detailed examination. A diagnosis of bronchial atresia was made based on the chest X-ray film, chest CT film, bronchography film and bronchoscopy. Subsequently, chest X-ray films have been taken regularly, and we observed a niveau in the mucocele on a chest X-ray film in August 2002. During the course the air fluid level elevated. Conclusion. Although the mechanism was unclear, we supposed that the bronchial mucocele might have been drained from collateral airways, for example, via Kohn's pores or Lambert's canal, and then it's level might have elevated again by bronchial gland secretion.

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