Background. IgG4-related lung disease is a new category of disorders, and its clinicopathologic features have not yet been clearly defined. Case. A 65-year-old man presented with abnormal shadows on a chest radiograph. His chest CT revealed mediastinal lymphadenopathy and an endobronchial tumor in the left upper division of the bronchus. The lesions gradually enlarged. Multiple infiltrative shadows and ground-glass opacities (GGO) appeared in both lung fields, accompanied by peripheral blood eosinophilia. Bronchoscopy was performed and mild eosinophilia was found on bronchoalveolar lavage (BAL). Transbronchial lung biopsy (TBLB) findings showed lymphoplasmacytic and eosinophilic infiltration in the peribronchial interstitium. We performed bronchoscopic endobronchial tumor resection, and the pathological findings showed lymphoplasmacytic infiltration with marked interstitial fibrosis and eosinophilic infiltration. An increased number of IgG4-positive plasma cells were detected by immunostaining. IgG4-related lung disease was diagnosed based on elevated serum IgG4 levels and pathological findings. Conclusion. We report a rare case of IgG4-related lung disease with various bronchopulmonary lesions and eosinophilia in the peripheral blood.

View full abstract

Background. Plastic bronchitis is sometimes associated with influenza viral infection in children, especially in those who have a history of bronchial asthma. Case. An 8-year-old boy with a history of bronchial asthma complained of cough and wheezes, and was admitted to a clinic after dyspnea and chest pain developed. An asthma attack and pneumonia were diagnosed and he was hospitalized. Despite the administration of antibiotics, steroids and a bronchodilator, acute respiratory failure developed due to complete atelectasis of the right lung. After transferral to our hospital, the bronchoscopic removal of mucus impaction was performed under general anesthesia by laryngeal mask ventilation. The right bronchial tree was completely occluded by a massive mucus plug. The airway was cleared following suction extraction of the mucus through a bronchofiberscope, and a laryngeal mask was exchanged for an endotracheal tube for adequate positive pressure ventilation. He was discharged 9 days after the intervention. Pathologically, an influenza virus was detected in the removed mucus plug. Conclusion. We effectively and safely treated a case of severe plastic bronchitis by tactical airway control.

View full abstract

Background. Lipoma is a well-known benign tumor. It is known as chondrolipoma, if nodules of chondrocytes are found within the lipoma. To the best of our knowledge, there have been no reports of chondrolipoma of the bronchus in the literature. Case. A 70-year-old smoking man with a history of treatment for bronchial asthma was admitted to our hospital for cough, sputum and wheezing. Chest roentogenography and computed tomography demonstrated a tumor in his left main bronchus. Bronchofiberscopic examination revealed a polypoid tumor on the left bronchial wall, which showed fluctuation in respiratory parameters. The tumor was resected by electrosurgery with an electric snare. After resection of the tumor, the patient's wheezing ceased. Chondrolipoma was diagnosed by pathological review. At the time of writing, no signs of recurrence have seen for a year since surgery. Conclusion. We presented a case of chondrolipoma of the bronchus. Bronchoscopic resection of a bronchial tumor with an electric snare should be an initial approach of choice, because it is a quick and minimally invasive treatment, and enables thorough pathological evaluation.

View full abstract

Background. Approximately 2% of patients with a greater than 20-year history of chronic pyothorax which developed after artificial pneumothorax for treatment of pulmonary tuberculosis, then develop pleural malignant lymphoma (pyothorax-associated lymphoma, PAL). It has been suggested that chronic inflammatory stimulation transforms normal lymphocytes into lymphoma cells, leading to tumor development in the pyothorax. Case. A 77-year-old man had suffered from artificial pneumothorax of the left lung due to pulmonary tuberculosis from age 18 to 21 years. He visited our hospital because of cough, low grade fever (about 37℃), and an abnormal shadow on chest radiography. Thoracic CT images showed chronic pyothorax with shadows extending from the pyothorax wall to the bronchus in the left lung. Bronchoscopic findings revealed white mucus and yellowish polypoid lesions occluding the orifice of the left superior segmental bronchus, which was diagnosed as diffuse large B-cell lymphoma by a transbronchial biopsy. In situ hybridization showed a nuclear expression of Epstein-Barr virus early ribonucleic acid (EBER) in numerous tumor cells, and PAL was diagnosed. The patient attained complete remission after 6 courses of R-CHOP chemotherapy. Conclusion. We encountered a rare case of PAL with an endobronchial lesion.

View full abstract

Background. Papillary type squamous cell lung carcinoma is a variant of squamous cell carcinoma and a rare disease which must be distinguished from isolated papilloma. We experienced a case of papillary type squamous cell carcinoma which was difficult to distinguish from isolated papilloma on biopsy. Case. In a man aged 68, an abnormal shadow in the right upper lung field was found on a chest X-ray film with a soft tissue density mass lesion in the right upper lobe. Peripheral obstructive pneumonia was also confirmed by chest CT. Both examinations were performed due to fever onset in November 2008 during treatment for alcohol dependency. The patient was referred to our hospital for further examinations. His smoking history was 20 cigarettes per day for 50 years. Upon bronchoscopy for confirmation of a central lesion, a polypoid mass with a granular surface was observed protruding into the right upper lobe. Even though it was diagnosed as atypical papillary type squamous papilloma on initial biopsy, the affected part was removed by a high-frequency snare since atypical histology was also observed and therefore we could not definitively exclude a cancer. The tumor was located near the orifice of B^3 bronchus and it developed from the orifice toward the central side, the final tissue diagnosis was determined to be papillary type squamous cell carcinoma. Since then we have been monitoring the patient without prescribing additional treatment due to social factors. Conclusion. A sample of the whole tumor based on high-frequency snare excision is required to diagnose papillary type squamous cell carcinoma, since it is difficult to distinguish from isolated papilloma.

View full abstract

Background. Pulmonary involvement of malignant lymphoma is relatively rare, and there are few reports of endobronchial involvement because its diagnosis requires bronchoscopic examination. Case. A 22-year-old man was admitted to our hospital with a high fever. Chest CT showed bilateral multiple nodular shadows and a low density mass with cavity formation in the left lower lobe. Bronchoscopic findings showed multiple plaque-like mucosal lesions with a cobblestone appearance in the left main bronchus. Histopathological examination of the biopsy specimen indicated anaplastic large cell lymphoma, although we could not reach a definitive diagnosis by either transbronchial biopsy and left supraclavicular lymph node biopsy. Therefore, right lung biopsy on video assisted thoracic surgery was performed, and a diagnosis of nodular sclerosing Hodgkin lymphoma was made. After 2 cycles of chemotherapy, both pulmonary and endobronchial lesions had almost disappeared. Conclusion. Although a diagnosis Hodgkin lymphoma with endobronchial involvement at the first medical examination is very rare, it is necessary to perform bronchoscopy for definitive diagnosis and accurate disease staging.

View full abstract

Background. Combination chemotherapy of cisplatin (CDDP) and pemetrexed (MTA) is a standard regimen for patients with inoperable malignant pleural mesothelioma. However, the effect of this regimen can be insufficient. Case. A 55-year-old man presented with dyspnea on exertion since March 2006. He visited another hospital previously in January 2007, where right pleural effusion was found and he was referred to our hospital. Histology by pleural biopsy under video-assisted thoracoscopic surgery (VATS) demonstrated malignant pleural mesothelioma. The patient received chemotherapy with CDDP and MTA after drainage of the right pleural effusion. However, after 2 cycles of CDDP+MTA, he had a fever and right pleural effusion remained. Exploratory thoracoscopy was performed to check the right pleural space and to drain the right pleural effusion. Intrapleural CDDP was administered after exploratory thoracoscopy. After these procedures, his pleural effusion disappeared, and he underwent 4 additional cycles of CDDP+MTA. After 6 cycles of CDDP+MTA, he achieved complete response and no recurrence was seen 3 years after chemotherapy, no other treatment. Conclusion. We report a case of malignant pleural mesothelioma successfully treated with CDDP and MTA therapy combined with intrapleural CDDP.

View full abstract

Background. Sarcoidosis with pleural involvement is rare. We report a case of sarcoidosis involving the bronchi, lungs, and pleura which developed into pneumothorax diagnosed by video-assisted thoracoscopic surgery. Case. A 27-year-old man visited a local physician because of prolonged dry cough. A chest X-ray film showed bilateral diffuse pulmonary infiltrates, and he was referred to a pulmonologist at our institution. Clinical images, including chest CT and gallium scintigraphy, suggested pulmonary sarcoidosis. A pulmonary function test revealed both obstruction and stenosis. Fiberoptic bronchoscopic examination showed partial or complete obstruction of the peripheral bronchi. Sarcoidosis was clinically diagnosed based on these findings. But steroid treatment would be introduced, soon after diagnosis pneumothorax developed on the left side. He was then referred to a thoracic surgeon. Result. Partial resection of the apex of the left lung, including bulla and nodules were performed by video-assisted thoracoscopic surgery. Thoracoscopic findings showed funiform adhesion and multiple small perforations on the parietal pleura at the apex. Biopsy of the parietal pleura was not performed. Histopathological examination of the resected lung demonstrated non-caseating epithelioid cell granuloma. His pulmonary function improved after surgery and steroid treatment. Conclusion. For pulmonary sarcoidosis which developed into pneumothorax, diagnosis and treatment were simultaneously performed using video-assisted thoracoscopic surgery.

View full abstract