Background. Airway foreign bodies may cause suffocation and pneumonia. Therefore, accurate diagnosis and expeditious removal are needed. However, we sometimes experience difficulty in removing foreign bodies from the airway by bronchoscopy. Methods. We examined the clinical characteristics of 15 cases of foreign body managed in our institute over the past 19 years, and evaluated characteristic difficulties during bronchoscopic removal. Results. The mean age of cases was 58 years. Four patients had dementia as their underlying disease. Episodes of aspiration occurred in 10 patients. Dental foreign bodies were seen in 9 patients (60%). Chest X-ray films detected foreign bodies in 11 patients (73%), and chest computed tomography identified them in all patients. Alligator forceps and basket forceps were mainly used for removal. Fogarty forceps were also used in combination with the above in 2 patients. The foreign body was removed during the first procedure in 12 patients; however, further procedures were needed (20%) in the remaining 3 patients: using different bronchoscopic techniques, tracheotomy and surgical resection, respectively. The characteristics of these 3 cases were as follows; granulation forming around a sharp foreign body obstructing the bronchus for a prolonged period, inability of the patient to lie still due to dementia, and tracheal stenosis after tracheotomy. Conclusion. Characteristic difficulties during bronchoscopic removal were granulation around the foreign body, inability of the patient to lie still, and tracheal stenosis. When difficulties in bronchoscopic removal are expected, it is necessary to prepare a variety of devices in advance.

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Background. Lymphangioleiomyomatosis (LAM) is generally considered to be a disease which affects women of childbearing age. Recently, a case of a woman of over 40 years old highlights progress in medical and diagnostic technology. Case. A 61-year-old woman with no history of smoking was admitted because of pneumonia. Chest CT showed several areas of consolidation in bilateral lower lobes and multiple thin-walled cysts of varying sizes (max dimension, 25 mm) throughout bilateral lung fields. After the successful treatment of her pneumonia with a course of antibiotics, we investigated possible causes of multiple cysts. Although it was not possible to differentiate between the various cystic pathologies, LAM was suspected based on HRCT findings, therefore we performed video assisted thoracoscopic lung biopsy (VATS). Because we observed some LAM cells on the cyst wall upon histopathological investigation, which stained positively for HMB45 antibodies, we diagnosed LAM. Early LAM occurring after menopause such as in this case has no symptoms and no signs outside the chest, and as a result, diagnosis is difficult. Conclusion. When multiple thin-walled cysts of unknown origin are noted on chest CT images, the presence of LAM is possible in postmenopausal women. In addition, because pathological diagnosis is necessary and material obtained by transbronchial lung biopsy (TBLB) may not be diagnostically useful, VATS is preferable to TBLB to obtain evaluable specimens for definitive diagnosis.

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Background. Endobronchial hamartomas are comparatively rare disease. We encountered a patient of endobronchial hamartoma with repeated obstructive pneumonia. Case. A 25-year-old man had been treated for pneumonia 4 times in the previous year. He was admitted to our hospital on an emergency basis with a diagnosis of left pneumonia in June, 2010. Computed tomography showed a lesion measuring 17 mm in maximum dimension that extended from the left upper lobe bronchus to the left main bronchus, and complete atelectasis was noted in the left upper lobe. Brochoscopic examination demonstrated a tumor protruding from the left upper lobe bronchus into the main bronchus, occupying more than 90% of the main bronchial lumen. The orifice of the left upper lobe was not observed on bronchoscopy. Therefore, we considered that endobronchial intervention would be difficult, and we diagnosed endobronchial hamartoma by biopsy. At surgery, we first performed a lingular segmentectomy, but the stem of the tumor could not be located. After a left upper lobectomy, it became clear that the stem of the tumor was located in the cartilaginous portion on the upper segment in the upper lobe bronchial orifice. We then resected the left main bronchus in a wedge shape and removed the tumor. Conclusion. In this case, because of the location and the size of the tumor, we performed lobectomy with wedge resection of the main bronchus.

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Background. There are many case reports related to occupational hypersensitivity pneumonitis (HP) in Japan, but there are few reports of HP in citrus fruit farmers. Case. A 62-year-old woman employed at a citrus fruit farm was hospitalized because of dyspnea, fever and cough in February 2010. Chest computed tomography revealed diffuse centrilobular micronodules and diffuse panlobular ground-glass opacities in both lung fields, and she suffered from hypoxemia while breathing room air. After admission, both her symptoms and laboratory data rapidly improved. The number of lymphocytes in her bronchoalveolar lavage fluid was elevated, and transbronchial lung biopsy specimens showed non-necrotizing epithelioid cell granuloma. An environmental workplace provocation test was positive, and we diagnosed occupational HP. Aspergillus and Paecilomyces were detected in the workplace, and precipitating antibodies against Penicillium, which is often adherent to the surfaces of citrus fruit, were positive on an immunodiffusion test. Furthermore, she was positive for serum anti-Trichosporon asahii antibody. Although we could not clearly determine the involved antigen, we suspected these fungi. Conclusion. It is necessary to pay attention to the possibility of occupational HP in citrus fruit farmers in the differential diagnosis.

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Background. Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma is relatively rare. Its diagnosis is determined by the pathological findings of pulmonary tissue, but there have been several cases in which it was difficult to distinguish MALT lymphoma from reactive lymphoid infiltration, because of the small size of biopsy tissue samples obtained by bronchoscopy. Case. A 64-year-old woman was referred to our hospital in 1996 because of an infiltrative shadow in the right upper lung field, on a chest X-ray film obtained at a routine health check. We performed bronchial mucosal biopsy of the upper right lobe by bronchoscopy in 2005. The pathological findings suggested pulmonary MALT lymphoma, but we could not confirm the diagnosis. In 2009, we applied the fluorescence in-situ hybridization (FISH) method to formalin-fixed bronchial tissue specimens obtained in 2005 after a new specimen treatment. Finally, the API2-MALT1 chimeric gene, characteristic of MALT lymphoma, was detected in a specimen and led to a confirmed diagnosis of pulmonary MALT lymphoma. Conclusions. The detection of the API2-MALT1 chimeric gene by FISH is now available, not only for frozen tissues, but also for tissue specimens fixed in formalin after re-treatment of the sample. This method was useful for retrospective studies of the API2-MALT1 chimeric gene in formalin-fixed tissue samples by FISH.

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Background. Endobronchial aspergillosis remains an insufficiently elucidated disease. Case. A 77-year-old man was admitted to our hospital in October 2009 because of chest pain and atelectasis of the left upper lobe noted on a chest X-ray film. He had a history of lung cancer treated with chemotherapy and stereotactic radiotherapy 5 years previously. Bronchofiberscopy demonstrated mucoid impaction in the left upper bronchus at the site of the previous lung cancer lesion, and Aspergillus was detected on a pathological examination. However, there was no sign of recurrence of lung cancer. Although he had no symptoms of bronchial asthma, bronchial hyper-responsiveness was detected. His laboratory data showed elevated IgE (RIST) and IgE (RAST) levels, but although a skin test for Aspergillus was positive, there was no evidence of bronchiectasis on chest CT findings. Therefore, we diagnosed allergic bronchopulmonary aspergillosis-seropositive (ABPA-S). A mucous plug was removed by bronchofiberscopy and he was treated with itraconazole. Thirteen months later, his X-ray and bronchofiberscopic findings had improved. Conclusion. We report a case of ABPA-S that arose at the site of a previous radiation exposure.

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Background. Recent case reports regarding mucoid impaction of bronchi (MIB) and allergic bronchopulmonary mycosis (ABPM) caused by Schizophyllum commune (S. commune), a basidiomycetous fungus, have indicated a need for more successful therapies. However, the effective treatment has not yet been established. Case. A 68-year-old woman was referred to our hospital because of persistent cough and wheezing lasting at least 4 years. Chest X-rays showed an infiltrative shadow in the right lower lung field. Chest CT scans revealed partial collapse in the right B^8 bronchus, which suggested a mucous plug, and an infiltrative shadow in the right S^8. Laboratory tests showed a high serum IgE level and mild eosinophilia. The bronchoscopic findings in the right B^8 showed thick yellow mucous plugs, which consisted histologically of eosinophil accumulation with hyphae while the culture revealed S. commune. We diagnosed this case as MIB and ABPM caused by S. commune. A transbronchial removal of this mucous plug relieved her symptoms and diminished abnormal shadows in the chest X-ray. Following this treatment, no recurrence has been observed for 18 months. Conclusion. We experienced a case of ABPM/MIB caused by S. commune whose clinical course was improved by transbronchial removal of a mucous plug.

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Background. Tracheobronchial amyloidosis is a rare disease showing nonspecific respiratory symptoms, so that it is not easy to distinguish it from other respiratory disorders. Case. A 71-year-old man had been treated for bronchial asthma since his forties. He was admitted to our hospital because of cholecystitis, and cholecystectomy was performed under general anesthesia. Since post-surgical ventilatory support could not be withdrawn, he was referred to our department. Review of computed tomography of the chest, which was taken at the time of admission in order to rule out the possibility of dissecting aortic aneurysm, demonstrated irregularly thickened tracheobronchial walls accompanied by calcification. Bronchoscopy revealed multiple elevated lesions in the tracheobronchial walls, and biopsy of the lesion revealed submucosal deposition of AL-type amyloid. Since there were no signs of amyloid deposition in other organs, or of multiple myeloma, we diagnosed tracheobronchial amyloidosis. Conclusion. When computed tomography of the chest reveals abnormalities of the airway wall, even in cases previously diagnosed as bronchial asthma, it is important to rule out other diseases including amyloidosis by performing bronchoscopy.

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Background. Hamartomas represent the commonest benign neoplasm affecting the lung, but multiple hamartomas of the lung are very rare. We report a patient with endobronchial hamartoma and parenchymal hamartoma. Case. A 52-year-old man had been diagnosed as having asthma at the age of 50 years. Despite increasing his treatment, his asthmatic symptoms had gradually worsened. A chest X-ray film showed a small nodule in the middle field of the left lung. A chest computed tomography confirmed a small nodule in the left upper lobe and also demonstrated an endobronchial lesion partially obstructing the left main bronchus. Endobronchial hamartoma was resected completely by transbronchial endoscopic surgery with an electrosurgery snare. After a month, we performed wedge resection of the small nodule without complications and he made an uneventful recovery. The histology was classical hamartoma.

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Background. Many pulmonary diseases can be caused by a variety of drugs. We examined a case of drug-induced pulmonary disease induced by carbocisteine which was successfully treated with suplatast tosilate after discontinuance of carbocisteine. Case. A 30-year-old man had been treated with oseltamivir and carbocisteine for influenza A. After 5 days of treatment, his fever and cough persisted and he was admitted to a neighborhood hospital. His chest radiograph demonstrated worsening infiltrative shadows and he was referred to our hospital. After discontinuing carbocisteine, he was treated with suplatast tosilate, after which the clinical symptoms and radiographic infiltrates disappeared. We established a diagnosis of drug-induced pulmonary disease because of the lymphocyte stimulation test for carbocisteine. Conclusion. We should consider that carbocisteine, which is quite frequently used in daily clinical work, can lead to drug-induced pulmonary disease. Moreover, we suggest that suplatast tosilate can be used for treatment of drug-induced pulmonary disease.

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Background. The high efficacy and tolerance of silicone stents in the treatment of tracheobronchial stenosis have been well-documented. However, placement of silicone stents is impossible in all cases because of the need of rigid bronchoscope insertion. We therefore preoperatively dilate the stenotic site and obtain the suitable patency for stent size. Cases. Case 1 was a 65-year-old woman with severe tuberculous stenosis of the left main bronchus. Case 2 was a 64-year-old man, with a permanent tracheal stoma due to laryngeal cancer, who had developed a granulation stricture at the anastomotic site after right upper sleeve lobectomy performed for squamous cell lung cancer. In both cases, the bronchial lumens were pin-hole-like strictures and developed re-stenosis with lung atelectasis following repeated balloon dilatations. We conducted bougienage and then placement of pediatric Dumon stents, via the use of a small size conventional endotracheal tube, for both cases. After stenting showed good patency and suitable position, the patients remain free of obstructive pneumonia. Conclusion. Bougienage and placement of pediatric Dumon stents using small endotracheal tube are effective in the management of patients with severe cicatrizing bronchial stenosis when the rigid bronchoscope is not indicated.

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Background. While pulmonary involvement by malignant lymphoma is not rare, there has been no report of malignant lymphoma associated with multiple pulmonary nodules and endobronchial polyps at the same time. We report a case of mucosa-associated lymphoid tissue (MALT) lymphoma with multiple pulmonary nodules and endobronchial polyps associated with Sjogren syndrome. Case. A 63-year-old woman presented because of an abnormal chest shadow on a routine health checkup X-ray film. Chest computed tomography showed multiple unevenly sized nodules diffusely distributed throughout both lungs. Bronchoscopy showed multiple polyps in the trachea and bilateral main bronchi. The results of biopsies of polyps in the right main bronchus showed MALT lymphoma. In addition, this patient had Sjogren syndrome. Conclusion. It is necessary to consider the possibility of malignant lymphoma when multiple polyps are detected by bronchoscopy, particularly in patients with chronic inflammatory disorders such as Sjogren syndrome.

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Background. Pseudomembranous Aspergillus tracheobronchitis, which shows striking findings in the bronchi, is a rare form of pulmonary aspergillosis. Case. We describe a case of pseudomembranous Aspergillus tracheobronchitis in an asthma patient who was receiving inhaled fluticasone propionate therapy. Bronchofibroscopy revealed a characteristic white mucus layer throughout the trachea and bronchi. Histological examination of a biopsy specimen showed numerous branched hyphae suggestive of Aspergillus in the mucosa. Pseudomembranous Aspergillus tracheobronchitis is a rare disease that usually occurs in immunocompromised patients. Conclusion. We believe that both asthmatic inflammation in the airway and inhaled corticosteroid therapy might have contributed to the development of pseudomembranous Aspergillus tracheobronchitis.

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Background. Bronchial granular cell tumors are rare. Furthermore only 5 cases of bronchial granular cell tumors accompanying lung cancer have been reported in Japan. Case. A 44-year-old man with blood-stained sputum and cough was referred to our hospital, because a cavitary lesion was pointed out in the left upper lung field on chest X-ray films in another medical clinic. Chest CT images showed a cavitary lesion 6 cm in diameter in left S^<1+2>. On bronchoscopy, the cavitary lesion in the left upper lobe was diagnosed as non-small cell lung cancer. A polypoid lesion was also unexpectedly discovered at the orifice of the right upper bronchus. Biopsy revealed a granular cell tumor, because HE stain showed oval cells containing eosinophilic granules and anti-S-100 antibody and NSE staining were positive on immunohistochemical studies. We performed left upper lobectomy by video-assisted thoracoscopic surgery for the lung cancer and we followed the granular cell tumor by observation. Conclusion. Bronchial granular cell tumor is still rare. However, numbers of incidentally-found cases with bronchoscopy are increasing recently. We believe that careful observation of whole bronchial lumen by bronchoscopy is important even if preceding diagnostic imaging, including CT scans, do not show any signs of abnormalities.

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Background. Pleomorphic carcinoma is a rare malignant tumor of the lung, and centrally located tumors show endobronchial growth in rare cases. We report a surgical case of pleomorphic carcinoma with tumor expectoration. Case. A 71-year-old man with a chief complaint of bloody sputum was referred to our hospital for the evaluation and treatment of a nodule in the right lower lobe. Bronchoscopy showed a polypoid tumor in the orifice of the right lower bronchus, and pleomorphic carcinoma was suspected from the histopathological findings of biopsied specimens. After detailed preoperative examinations of the heart for a period of two months, the intrabronchial tumor showed elongated polypoid growth reaching into the trachea, not invading the mucosa of the bronchus intermedius or the right main bronchus, on a second bronchoscopic examination. We were worried about the injury of the intratracheal tumor at the time of intubation with a double-lumen endobronchial tube for one-lung ventilation, and therefore we injected ethanol into the tip of the intratracheal tumor to reduce the tumor volume. Five days later, the patient suddenly expectorated a piece of the tumor, 10 cm in length and stick-shaped. He underwent a middle and lower lobectomy, which yielded a diagnosis of stage IIA pleomorphic carcinoma. Conclusion. In this case, to avoid injury of the polypoid intratracheal tumor at the time of intubation, we injected ethanol into the tip of the intratracheal tumor and a part of the tumor extending from the right lower bronchus to the trachea was expectorated before surgery. To the best of our knowledge, this is the first case of expectoration of a pleomorphic carcinoma, and the expectorated tumor is the largest one reported in the literature. However, causal association between the ethanol injection and tumor expectoration could not be confirmed.

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