Background and Objective. Thoracoscopy is an essential procedure for the definitive diagnosis of malignant pleural mesothelioma(MPM). However, in some cases of early-stage MPM, it is difficult to detect a lesion even through conventional thoracoscopy. In the present study, to improve the diagnostic accuracy of thoracoscopy on MPM, autofluorescence imaging(AFI) and a narrow band imaging(NBI) system were assessed in combination with the conventional method. Subjects and Methods. Thoracoscopy combined with AFI and NBI was performed on 12 patients with pleural fluid retention, suspected of MPM. Thoracoscopy under local anesthesia and video-assisted thoracoscopic surgery(VATS) were performed on 7 and 5 patients, respectively. Examination was carried out using a flexible bronchoscope(Olympus BF-F260) for AFI and a conventional white light thoracoscope(Olympus LTF-240) for NBI. Results. In 7 of 12 patients, a diagnosis of MPM was made by pleural biopsy using thoracoscopy combined with AFI and NBI. Autofluorescence thoracoscopy showed that nodules suspicious for mesothelioma were clearly visualized as magenta fluorescence, while the intact pleura appeared green in color. In the cases of MPM, thoracoscopy with NBI demonstrated emphasized irregularity of the pleura compared with findings on conventional white light thoracoscopy, and abnormal pink/white nodules with increased vessel growth were easily detected. Conclusion. Thoracoscopy combined with AFI and NBI is a novel tool for the diagnosis of MPM. There is a possibility that this procedure may make it possible to distinguish between pleural lesions due to MPM and the intact pleura more accurately.

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Case. A 77-year-old man was admitted to our hospital in March 2006, because of progressive loss of body weight and dyspnea on exertion. He had a past history of abnormal chest X-ray findings suggesting a fungus ball in a bulla at the apex of the left lung in May 2005. However, he had discontinued visiting medical facilities. On admission, the fungus ball increased in size, and blood examination revealed Aspergillus antigen. On examination with a bronchovideoscope, a fungus ball was observed in the left B^3b. Its surface appeared to be rugged, glossy and mucopurulent, and granules like small seeds seemed to be embedded in it. Furthermore, fungal colonies suggesting Aspergillus sp. were obtained from culture of bronchial secretions. From these clinical course and signs, chronic necrotizing pulmonary aspergillosis was diagnosed. We administered micafungin and then voriconazole intravenously followed by oral administration of itraconazole with a maintenance dose of 200mg/day. Six months later, the volume of the fungus ball as estimated on CT films showed a 44% decrease compared with that on admission. Conclusion. The present case was unique in that the fungus ball could be observed under direct vision with the bronchovideoscope, which feature allowed topical and accurate delivery of fungicides.

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Background. Pulmonary/bronchial carcinoids are comparatively rare disease, and account for 1-2% of all primary tumors of lung. In histopathology, they are classified into typical and atypical carcinoid. Typical carcinoid seldom involves lymph node and has good prognosis, compared with atypical carcinoid. We experienced a case of typical pulmonary carcinoid with extensive lymphatic vessel invasion. Case. A 56-year-old woman had a medical examination, and a 10mm nodular shadow was pointed out in the left middle lung field on chest X-ray. Chest CT showed a 12×9mm nodular lesion in S^8 of the left lung. Transbronchial biopsy revealed typical carcinoid. She underwent thoracoscopic left lower lobectomy of the lung and systematic lymphadenectomy. Pathologic examination of the resected specimen confirmed a diagnosis of typical carcinoid without mitosis and necrosis, with chromogranin immunoreactivity and MIB-1 index of less than 1%. Tumor cells invaded lymphatic vessels extensively. It is unusual of typical carcinoid. Conclusion. Surgens must beware of lymphatic vessel invasion even in a case of typical carcinoid.

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Background. We report a case of thoracic empyema with a bronchopleural fistula for which surgical closure was difficult; however, we were able to overcome this problem by bronchial occlusion performed with the use of a guidewire. Case. The patient was a 64-year-old man who developed thoracic empyema due to a ruptured anastomosis after surgery for esophageal cancer. The ruptured anastomosis healed with conservative treatment, but the thoracic empyema lead to the development of a bronchopleural fistula, which proved to be difficult to treat. The patient was referred to our department. Although surgical fistula closure, fenestration, and thoracoplasty were performed, the patient's condition did not recover. Therefore, bronchoscopic occlusion of fistula was performed. With the use of a guidewire, we filled the bronchopleural fistula with solid silicone dental impression material. Thereafter, thoracoplasty and plombage of the pectoralis major myocutaneous flap were performed, and the thoracic empyema was subsequently treated successfully. Conclusion. We reported a case of thoracic empyema with bronchopleural fistula, which we treated successfully by bronchial occlusion.

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Background. Relapsing polychondritis(RP) is a rare inflammatory disease of unknown etiology, affecting cartilages or connective tissues throughout the body. In the respiratory system especially, involving cricothyroid or tracheal cartilage frequently causes a critical situation because of airway stenosis. We report here in a successful case of RP treated with an Ultraflex^[○!R] stent. Case. A 57-year-old man had clinical features such as increase in inflammatory reactions, thickening of the tracheal wall, and saddle nose deformity in April 2006. He underwent a rib cartilage biopsy, and had been given a diagnosis of RP. Since then, prednisolone had been given orally. In November of the same year, the patient suddenly complained of dyspnea and fell into a coma. He was taken to hospital by ambulance and underwent emergency medical care. Shortly thereafter, endotracheal intubation was performed and he was transferred to our hospital. Results. After tracheotomy, Ultraflex^[○!R] stents were placed in the trachea, and both main bronchi. On the day of the stent placement, he was taken off the mechanical ventilator, and we replaced the tracheotomy tube with a T-tube. Four months after a stent placement, the patient is performing normal daily activities without any episode of airway narrowing. Conclusion. The Ultraflex^[○!R] stent is useful in RP, but remains controversial for in long-term management. Carrying out regular follow-up is mandatory.

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Background. Rice cakes can cause rapid suffocation, and lifesaving in such a situation is difficult. Case. A 78-year-old man consulted our hospital because of sudden dyspnea during a meal. His left breathing sound was very weak, and he had severe acute respiratory failure. He had a cerebral infarction in 2002. The larynx was not obstructed. Emergency bronchoscopy was performed because highly dense objects were detected in the bronchus of left upper and lower lobe bronchi and right lower lobe on chest CT. We removed foreign bodies(rice cakes) with suction, biopsy clamps, curettes and a snare, the respiratory failure improved promptly. Conclusion. We resuscitated a case of acute respiratory failure caused by multiple bronchial obstructions with swallowed rice cakes. In sudden respiratory failure occurring when eating rice cakes, we should consider bronchial obstruction by rice cakes regardless of no laryngeal abnormality. As rice cakes show high absorption value in CT, CT is useful before bronchoscopy for the diagnosis of swallowed rice cakes. Bronchoscopy confirmed diagnosis and was lifesaving.

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Background. Pulmonary actinomycosis is often too difficult to make a definitively diagnose, because it is often necessary to distinguish it from lung cancer, tuberculosis, and fungal infection. Case. A 69-year-old woman was admitted to our hospital because of refractory hemoptysis. Chest computed tomography(CT) revealed a cavity about 1.5cm in diameter with focal bronchiectasis in the right S^6. A white mass was shown in the right B^6ciiβ by an ultra-thin bronchoscope. The definitive diagnosis of pulmonary actinomycosis was made by transbronchial biopsy and bronchial lavage cytology from the biopsy specimen because of detection of sulfur granules and drusen. Although the infiltrative shadow on chest CT had improved after administration of amoxicillin for 9 months, hemosputurn and the cavity on CT has been remained. Therefore operation was performed. The postoperative course has been uneventful with no signs of recurrence. Conclusion. We reported a case of pulmonary actinomycosis with hemoptysis diagnosed by ultra-thin bronchoscopy. Cases of pulmonary actinomycosis with recurrent hemosputum and residual lesion after medication may require surgery.

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