[in Japanese]

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Mediastinoscopy has been widely performed as the gold standard for the histopathological N-staging of the mediastinum for lung cancer patients, particularly in Western countries. Although mediastinoscopy requires general anesthesia and is to a certain extent invasive, morbidity and mortality related to it are considerably low. It can offer highly detailed mediastinal mapping, including bilateral lymph node stations, and excellent detectability of micrometastases in non-swollen lymph nodes. Not only standard cervical mediastinoscopy but also Chamberlain's anterior mediastinoscopy or extended mediastinoscopy can be performed to assess station #5/6 lymph nodes that are located outside the accessible range of cervical mediastinoscopy. Such a combination enables the accurate N-staging of the entire mediastinum without any blind spots. Usefulness of lymphadenectomy by the cervical-mediastinoscopic approach and post-induction re-mediastinoscopy have also been outlined.

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Background. We report 2 cases of acute exacerbation of idiopathic pulmonary fibrosis (IPF) with diffuse alveolar hemorrhage (DAH). Case. Case 1: A 64-year-old man in whom IPF had been diagnosed and treated conservatively since October 2000 was admitted to our hospital due to bloody sputum and hypoxemia in May 2001. Since chest X-ray and computed tomography (CT) findings demonstrated diffuse ground glass opacity (GGO) in both lung fields, he was given with high-dose corticosteroid therapy for acute exacerbation of IPF. He died 7 days after admission due to respiratory failure with right pneumothorax. The autopsy findings showed infiltration of inflammatory cells to the pulmonary interstitium, hyaline membrane formation and alveolar hemorrhage against a background of honeycomb lung. Case 2: A 78-year-old man had been given a diagnosis of IPF and observed since October 2006 was admitted to our hospital due to dyspnea in January 2007. Chest X-ray and CT revealed bilateral diffuse infiltration in all lung fields. His bronchoalveolar lavage fluid under mechanical ventilation was bloody. His respiratory failure was improved by high-dose corticosteroid therapy. Conclusion. Case reports on DAH associated with acute exacerbation of IPF are relatively rare, and these findings are considered to reflect an uncommon pathological condition.

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Background. There are much gastric cancer, breast cancer and lung cancer for a primary tumor of the pulmonary lymphangitis carcinomatosa, and it is rare that colon cancer becomes a primary tumor. We report a case of initial onset of pulmonary lymphangitis carcinomatosa caused by ascending colon cancer. Case. A 63-year-old man had complaints of severe cough and dyspnea 2 months ago, therefore he was transferred to our hospital for further examinations and therapy. Chest roentgenogram showed a diffuse interstitial shadow and chest CT scan revealed markedly thickened bronchovascular bundles and alveolar septa, while abdominal CT showed no abnormal findings. We doubted lymphangitis carcinomatosa and searched a primary tumor. Colonoscopic findings showed ascending colon cancer (type-II) with lymphatic vessel infiltration of moderately differentiated adenocarcinoma by immunohistological examination. Under bronchoscopy, immunocytological findings of the bronchoalveolar lavage fluid showed a cluster of adenocarcinoma cells staining cytokeratin (CK) 7 negative, and CK20 positive. We diagnosed pulmonary lymphangitis carcinomatosa caused by ascending colon cancer. He was treated with combination chemotherapy but died due to respiratory failure 48 days from his first medical examination. Conclusion. This was a rare case of initial onset of pulmonary lymphangitis carcinomatosa caused by colon cancer, and was able to be diagnosed immunohistologically.

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Background. Gastric tube-to-tracheal fistula, a rare complication of esophagectomy for esophageal cancer, is often life threatening and sometimes difficult to rescue even with surgical intervention. Case. A 57-year-old man who had undergone transthoracic esophagectomy and a two-field lymphadenectomy for esophageal cancer suffered from empyema and mediastinitis, 12 days postoperatively. Bronchoscopy revealed a large gastric tube-to-tracheal fistula that necessitated surgical intervention. During surgical reexploration, after completely excising the gastric tube, a large defect, approximately 8cm in size, was observed in the trachea and the right main-stem bronchus, which was reconstructed with a latissimus dorsi myocutaneous flap. Subsequently, distant metastases of esophageal cancer were detected, and he died 113 days after operation. Conclusion. Application of a latissimus dorsi myocutaneous flap to the tracheobronchial defect resulting from a gastric-tube-to-tracheal fistula after esophagectomy for esophageal cancer successfully resolved this life-threatening condition.

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Background. Massive hemoptysis, a life-threatening condition, requires adequate and prompt treatment. We describe such a case in which bronchial artery embolization (BAE) was unsuccessful and rescue was performed by repetitive endobronchial embolization. Case. A 83-year-old man under treatment for non-tuberculous mycobacterial infection was transferred to our hospital because of massive hemoptysis. Emergency bronchoscopy under general anesthesia revealed active bleeding from the right middle lobe bronchus, and we stopped bleeding temporarily by spraying thrombin via the bronchoscope. Sequentially performed bronchial artery embolization (BAE) was successful in controlling hemoptysis, which was confirmed by bronchoscopy. However, massive hemoptysis recurred on the next day. The event prompted us to perform bronchial embolization (B^5) by using an endobronchial Watanabe spigot (EWS) and a metallic coils, resulting in excellent control of the hemoptysis. The patient has been free from hemoptysis after the procedure. Conclusion. Bronchoscopy under general anesthesia was useful in identifying the bleeding point safely, controlling bleeding temporarily, and facilitating BAE. Moreover, the effect of BAE was easily confirmed directly by bronchoscopy. For cases in which BAE was unsuccessful, like our case (accounting for more than 10%), bronchial embolization should be performed immediately. In managing cases of massive hemoptysis, bronchoscopy under general anesthesia followed by BAE is essential. However, bronchial embolization is also required in a certain percentage of cases that are unsuccessfully treated.

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Background. Removal of a airway foreign body is not uncommon in clinical practice, but we encountered an unusual foreign body and describe its extraction. Case. The patient was a 49-year-old man who, when sucking on a hair crab leg, inhaled the shell along with the meat. The next day dyspnea developed and he was admitted to our hospital. Stridor was present. Chest X-ray showed decreased radio-opacity of the left main bronchus. Chest CT examination revealed a foreign body in the left main bronchus. Flexible bronchofiberscopic examination showed a foreign body in the left main bronchus. We grasped the crab shell with alligator forceps and tried to remove it, but because the spines on the shell surface had penetrated the bronchial mucosa, it was difficult to dislodge and move the shell and the shell moved to the periphery. We then cracked the shell and pulled out the meat. After that, we broke the shell lengthwise, and when it was completely torn the shell was expelled by coughing. Conclusion. Breaking the crab shell and tearing it lengthwise proved to be an effective method for removing it from the main bronchus.

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Case. A 59-year-old man suffering from left upper lobe pneumonia was referred to our hospital for further examinations. Chest computed tomography (CT) showed the left upper lobe replaced by a consolidated shadow with air bronchogram. Bronchofiberscopy revealed that a diffuse submucosal lesion was the cause of edematous stenosis of the left upper lobe bronchi. Transbronchial biopsy, however, failed to yield a definitive pathological diagnosis, and the specimens revealed infiltration of many lymphocytes with little cytological atypia. Eventually, CT-guided lung biopsy led to a definitive diagnosis of bronchus-associated lymphoid tissue (BALT) lymphoma. We judged that hepatitis would be exasperated by chemotherapy, and therefore surgical resection was selected instead. Because the lobe adhered the neighboring lobe, left pnuemonectomy was performed. Unexpectedly, the postoperative pathological diagnosis demonstrated that the surgical margin of the left main bronchus was positive for tumor cells. Conclusion. Our case indicates that BALT lymphoma with submucosal infiltration may be a pitfall in exactly evaluating tumor extension.

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Case 1. A 73-year-old man was admitted to our hospital for evaluation of a pulmonary nodule in the right S^<10> segment and #3, #7 mediastinal lymphadenopathy. On ^<18>F-fluorodeoxyglucose positron emission tomography (^<18>FDG-PET), the nodule showed substantial uptake of ^<18>F-fluorodeoxyglucose. Bronchoscopic biopsy did not yield diagnostic material. Mediastinoscopic lymph node biopsy showed fibroblasts and histiocytes. Case 2. A 74-year-old man was admitted to our hospital for evaluation of #3, #7 mediastinal lymphadenopathy. On ^<18>FDG-PET, the nodule showed substantial uptake of ^<18>F-fluorodeoxyglucose. Mediastinoscopic lymph node biopsy showed granuloma formation with multinuclear Langhans giant cells. Conclusion. Asbestosis should be considered as a possibility when interpreting the ^<18>FDG-PET of patients with mediastinal lymphadenopathy.

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