Background. Interventional therapeutic bronchoscopy can provide immediate and gratifying palliation, leading to improvement of the quality of life in those patients. Many patients with central airway obstruction caused by malignant tumors are surgical candidates on the basis of either physiologic or oncologic criteria. Methods. We retrospectively examined all patients who underwent interventional therapeutic bronchoscopy in Tokyo Medical University and specifically analyzed the effectiveness of airway stenting for patients with advanced lung cancer lesion. Results. From 1994 through 2008, 110 patients underwent interventional therapeutic bronchoscopy because of central airway obstruction caused by malignancy. Ninety-three of those patients underwent the procedures because of advanced lung cancer with central airway obstruction. The histology included 20 adenocarcinomas, 30 squamous cell carcinomas, 6 large cell carcinomas, 3 small cell carcinomas. Airway stenting itself could not contribute toward survival benefit, but interventional therapeutic bronchoscopy with airway stenting was performed in 59 advanced lung cancer patients with central airway obstruction with no intraoperative death. Percutaneous cardiopulmonary support (PCPS) was initially prepared or intraoperatively required in 5 patients. Median overall survival time was 6.2 months and 1 year survival rate was 25.2%. 24 patients died within 3 months after stenting. Many patients of lung cancer with airway stricture caused by tracheal carina invasion unfortunately died within 3 months after stenting. Conclusion. Stenting for central airway obstruction is a highly dangerous method. Only after thoroughly exploring all other treatment options, can those patients in whom airway stenting is truly indicated, which may contribute to informed quality of life, although it is only palliative therapy.

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Background. Lung mucosa-associated lymphoid tissue (MALT) lymphoma is uncommon and its etiology is unknown. Case. A 63-year-old woman who had been treated for nontuberculous mycobacteriosis consulted our clinic because of an abnormal shadow on her chest X-ray film. Chest CT revealed a right upper lobe irregular shadow, right middle lobe sphenoidal shadow and sharply-marginated left hilar nodule. Bronchoscopy and biopsy yielded a diagnosis of adenocarcinoma in the right upper lobe irregular shadow. In addition, Mycobacterium avium was detected in the bronchial lavage fluid. In fluorodeoxyglucose positron emission tomography (FDG-PET), we found significant accumulation of FDG only in the right upper lobe. She underwent right upper and middle lobectomy as her lung cancer was concluded resectable. Result. Postoperative pathological findings revealed that the MALT lymphoma lesion consisted of an aggregation of lymphocytes and lymphoepithelial lesion were adjacent to adenocarcinoma in the right upper lobe, and we also found a MALT lymphoma lesion and caseous necrosis with giant cell granuloma in the right middle lobe, which confirmed the co-existence of pulmonary mycobacteriosis. Conclusion. This was a rare case of synchronous MALT lymphoma, nontuberculous mycobacteriosis and lung cancer.

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Background. Bronchoplasty started to spread rapidly in the 1980s, and is currently one of the standard surgical methods for lung cancer in Japan. In bronchoplasty, the extent of resection varies depending on the type of surgical procedure, that is, wedge resection and sleeve resection. We report herein 3 cases of sleeve resection in an attempt to discuss the surgical procedure of anastomosis between two bronchial stumps with a substantial size discrepancy. Bronchoplasty is classified into sleeve resection or wedge resection according to the extent of bronchial resection. From our experience, we report on anastomosis performed in cases with significant differences of the airway diameter. In this procedure, we sutured along a triangular area formed by connecting 2 points in the transitional regions, one towards the membranous portion and the other towards the tracheal ring area, of the stump on the oral side and the center of the membranous portion, approximately 1.5 cm from the margin of the stump towards the mouth, in order to reduce the tracheal and bronchial diameters before the anastomosis. Case. Case report 1: A 74year-old man who underwent right middle and lower sleeve resection for squamous cell carcinoma of lower lobe of the right lung (cT3N2M0). Case report 2: A 67-year-old man who underwent left lower and lingual sleeve resection for squamous cell carcinoma of the lower lobe of the left lung (cT3N1M0). Case report 3: A 62-year-old man who underwent right-sleeve pneumonectomy for squamous cell carcinoma of the lower lobe of the right lung (cT4N2M0). Conclusion. We present 3 cases of bronchoplasty with significant differences in airway diameter in site of anastomosis.

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Background. A congenital bronchoesophageal fistula is rare in elderly patients. An adult case of congenital bronchoesophageal fistula was successful treated by surgery. Case. A 66-year-old woman was admitted with chronic cough and hemosputum. The patient had experienced several episodes of pneumonia since childhood. Chest computed tomography (CT) demonstrated a bronchoesophageal fistula communicating between the middle of the thoracic esophageal diverticulum and the right B^6, which corresponds to type I + III of the Braimbridge classifications. The patient underwent resection of the fistula and right lower lobectomy of lung. Esophagoscopy was used during operating to avoid postoperative stenosis. The resected specimen met the criteria of Brunner, congenital bronchoesophageal fistula. The postoperative course was uneventful, and she is doing well at 1.5 years after surgery without recurrence of the symptoms. Conclusion. We reported an adult case in which congenital bronchoesophageal fistula was treated successfully by surgery.

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Background. Cancer of the mediastinal and hilar lymph nodes is rare. Case. A 64-year-old man was diagnosed with prostate carcinoma 6 months before admission to the hospital. He subsequently underwent hormonal therapy, and a tumorous lesion of the thorax was detected. After diagnostic examination that included endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), we diagnosed the patient with multi-station cancer of the mediastinal and hilar lymph node (adenocarcinoma, non-prostatic carcinoma). Therefore we began concurrent chemotherapy (cisplatin + vinorelbine, 4 cycles) and thoracic radiotherapy (total dose 70 Gy) in accordance with the treatment protocol for multi-station N2 non-small-cell lung cancer. The treatment resulted in complete remission. Conclusion. In almost all cases reported, cancer of the mediastinal and hilar lymph nodes was diagnosed surgically. EBUS-TBNA has recently gained popularity, and because of its relatively low invasiveness, cancer of the mediastinal and hilar lymph nodes can be diagnosed easily by using this technique. This case suggests that concurrent chemoradiotherapy can be used for treatment of cancers like stage III non-small-cell lung cancer.

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Background. Silicone stent placement for central airway obstruction has become widespread as an effective therapy which gives patients immediate relief from respiratory symptoms, and various devices or procedures have been developed. For obstruction of the main carina, a Dumon^[○!R] Y-stent (Tracheobronxane^<TM> Y; Novatech; La Ciotat, France) is currently employed. We report a case of small cell lung cancer with symptoms of central airway obstruction who underwent double Y-stent placement on the involved main carina and carina between the right upper lobe bronchus and the truncus intermedius. Case. A 57-year-old man who visited a medical practitioner with a complaint of progressive dyspnea was referred to us because of wheezing and hypoxia. It revealed that the main carina and the carina between the right upper lobe bronchus and the truncus intermedius were severely obstructed by mediastinal or hilar lymphadenopathy. He was diagnosed as small cell lung cancer by endobronchial ultrasoundguided transbronchial needle aspiration and underwent double Y-stent placement in the main carina and the carina between the right upper lobe bronchus and the truncus intermedius 5 days after admission. Symptoms improved and chemotherapy started immediately was so effective that the tumor size was remarkably reduced and double Y-stent successfully removed. Conclusion. We performed double Y-stent placement on a patient with severe respiratory symptoms because of central airway obstruction. Symptoms improved dramatically and enabled curative chemotherapy.

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Background. Very few reports have documented the use of the patch-closure method for the peripheral bronchi. Case. A 67-year-old man with a mass measuring 5 cm diameter in the lower lobe of the left lung was admitted to our hospital. On transbronchial lung biopsy, adenocarcinoma was diagnosed. The interlobar and lobar metastatic lymph nodes directly invaded into the bronchial wall at the proximal portion of upper lobe bronchus and lower lobe bronchus. For this patient who underwent complicated bronchial resection due to the metastatic nodal invasion into the bronchus, we performed left lower lobectomy with patch-closure of the bronchial defect using the pericardium and intercostal muscle flap, and with meticulous lymphadenectomy. The postoperative course was uneventful and no evidence of complications was found. Three months later, the surface of the pericardial patch graft was covered by smooth bronchial epithelium. Conclusion. Although we must be careful in selecting the indications of this bronchial patch-closure for proceding patients with lung cancer, we consider that this method can be a useful option in selected patients.

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Case. A 73-year-old man was referred to our hospital because of hoarsness. Chest computed tomography (CT) showed mediastinal lymphadenopathy (#7 and #4R) and a small nodule in left lower lung field. Positron emission tomography (PET)-CT revealed accumulation in both lesions. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of a subcarinal lymph node was performed. Tissue specimens from a subcarinal lymph node showed diffuse proliferation of medium-sized atypical lymphoid cells with high N/C. Immunohistochemical staining of these specimens showed Burkitt lymphoma (BL). Conclusion. To our knowledge, this is a rare case of BL diagnosed by EBUS-TBNA.

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Background. Bronchial stent insertion is a suitable method to treat a malignant airway stenosis. Anesthetic management, such as general, inhalational or intravenous anesthesia, and airway management are various methods used at various institutions according to the kind of bronchial stent. After placement of a laryngeal mask airway (LMA) while maintaining appropriated anesthesia using target-controlled infusion (TCI) of propofol, a tracheal stent was inserted using a flexible bronchoscopy. Case. An 82-year-old woman presented complaining of hemoptysis and dyspnea related to recurrent esophageal carcinoma. It was compressed posteriorly by the side of the tracheal membrane and trachea, for about 5 cm approximately 4 cm blew the vocal cords, resulting in a shape 5-mm of slit. Under TCI of propofol, a LMA was inserted with the patient breathing spontaneously. She underwent insertion of expandable metallic scents (EMS) using flexible bronchoscopy. The performance status (PS) improved from 4 to 2 and she was discharged the hospital on foot. One month later, the stent showed good patency well. Conclusion. A tracheobronchial stent insertion using flexible bronchoscopy, LMA and propofol TCI is effective for airway stent insertion, however the stent should be selected according to the specific clinical situation.

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Background. We report a rare case of endobronchial metastasis from renal cell carcinoma. Case. A 59-year-old man was admitted because of bloody sputum and cough. Bronchoscopy revealed a tumor about 12 mm in diameter in the trachea. Because he had previously undergone left renal resection due to renal cell carcinoma, the tumor was suspected to be endobronchial metastasis from renal cell carcinoma. The tumor was resected by bronchoscopy using an electrosurgical snare, without bleeding. Conclusion. We report a case of endobronchial metastasis from renal cell carcinoma. Endoscopic resection with high frequency electrosurgical snare was safe and useful in this case.

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Background. Lung/bronchial carcinoids are classified as typical or atypical based on their pathological features. Typical carcinoids grow slowly, rarely metastasize to other organs and rarely recur after surgery. We report a case of typical carcinoid observed over a period of 15 years, which recurred 9 years after surgery and a year later metastasized multiply to the liver. Case. A 69-year-old man attended our hospital complaining of several hemoptyses during 1995. Bronchoscopy revealed a polypoid tumor which obstructed the orifice of the right upper lobe bronchus. Right upper lobectomy and systematic hilar and mediastinal lymphadenectomy was performed in 1996. Pathological examination confirmed the tumor was a typical bronchial carcinoid (pT2aN0M0, stage IB) without invasion to the bronchial stump. In 2005, bronchoscopy showed multiple polypoid tumors near the bronchial stump. We diagnosed pathologically that this tumor was a localized recurrence of the typical bronchial carcinoid, and argon plasma coagulation was performed. One year later, ^<18>F-fluorodeoxy glucose positron emission tomography (FDG-PET) demonstrated multiple accumulations in the mediastinum and liver. A transdermal needle biopsy of the liver tumor showed metastatic typical carcinoid. Each tumor grew slowly, and he has remained symptom-free up to May 2011. Conclusion. Even after radical operation for typical bronchial carcinoids, we should conduct long term observation since local recurrence and metastasis, although rare, do occasionally occur.

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Case. The patient was a 74-year-old man who expectorated bloody sputum in July 2003. A diagnosis of squamous cell carcinoma (Class V) was established based on sputum cytology. A nodular lesion 4 mm in diameter was detected at the orifice of the left B^3 and was diagnosed as early stage central lung cancer. As surgery was judged difficult due to poor lung function, the tumor was ablated by microwaves. The patient was followed up and regularly underwent sputum cytology and narrow band imaging (NBI) bronchoscopy. However, in December 2008, a 5-mm nodular lesion was detected at the bifurcation between the left B^4 and B^5, and in May 2009, a flat lesion with a diameter of several millimeters was detected at the orifice of the left B^5a. Both lesions were diagnosed with squamous cell carcinoma by biopsy and ablated by microwaves. There has been no recurrence for the last 2 years and the patient is currently being followed up. Conclusion.NBI-supported bronchoscopy may be useful to detect early stage lesions. Microwave coagulation therapy is effective for early stage central lung cancer with a diameter of 5 millimeters.

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Background. Surgical resection is the curative treatment of choice in patients with bronchial carcinoid. However, there are many cases with contraindications for surgical resection. Case. A 71-year-old woman undergoing chemotherapy after right-hemicolectomy for cecal cancer was referred to us because of an endobronchial tumor. The left basal segmental bronchus was occluded almost completely by a bronchial carcinoid. As the determinant of her prognosis was cecal cancer, it was important to prevent obstructive pneumonitis and hemoptysis by resecting the tumor palliatively. We performed bronchial artery embolization and local injection of ethanol before interventional bronchoscopy. The tumor became necrotic and regressing after bronchial artery embolization and ethanol injection, which enabled us to resect the tumor with little bleeding. Conclusion. In palliative treatment for bronchial carcinoid, bronchial artery embolization and ethanol injection can enable endobronchial resection less invasive and safer.

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Background. We report a pediatric case of remove of bronchial foreign body using a laryngeal mask airway and flexible bronchoscopy. Case. A 18-month-old girl accidentally inhaled a peanut. Afterwards she entered another hospital with a chief complaint of wheezing and received antibiotic treatment. On the next day, an abnormal shadow was pointed out, which was suspected to indicate a foreign body, in the left main bronchus. Chest computed tomography (CT) scan was carried to our hospital. On the same day, after the airway was cleared using a laryngeal mask airway (LMA size 2.0) under general anesthesia, a flexible bronchoscope (external diameter 4.0 mm) was inserted. The foreign body was successfully removed with a balloon-tip catheter. The foreign body was a peanut. Conclusion. By using a laryngeal mask airway, we could maintain available ventilation and enable a smooth procedure using a flexible bronchoscope while removing a pediatric bronchial foreign body.

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Background. Mediastinal emphysema is known as one of the complications of asthma exacerbations. However, submucosal emphysema of the trachea is seldom observed and the relationship between mediastinal emphysema and tracheal submucosal emphysema remains unclassified. Case. A 16-year-old girl was treated at a local clinic with inhaled corticosteroids because of bronchial asthma. She was referred to our hospital because she developed a severe exacerbation of her bronchial asthma combined with massive mediastinal and subcutaneous emphysema. A chest CT image on admission showed circle-shaped soft tissue with a thin wall inside the trachea containing an area of air density. We suspected submucosal emphysema of the trachea. She could not drain her hyper-viscous sputum by herself and her dyspnea remained. Therefore, we performed bronchoscopy. When we removed her sputum carefully during bronchoscopy, there was no evidence indicating submucosal emphysema of the trachea. After the removal of her sputum, both her mediastinal emphysema and dyspnea improved. Conclusion. We describe a unique case showing submucosal emphysema of the trachea combined with massive mediastinal emphysema during an asthma exacerbation. It is possible that an increasing number of similar patients will present, because of the remarkable progress of high-resolution CT, and that further intensive observations of submucosal emphysema of the trachea will be useful to clarify the occurrence mechanisms of mediastinal emphysema with bronchial asthma.

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Background. Pleomorphic carcinoma of the lung is rare, and a diagnosis is difficult pathologically. Therefore, it is usually diagnosed intraoperatively. Case. A 78-year-old woman was admitted to our hospital because of hemoptysis. Chest CT images showed a mass in the left main bronchus, and bronchoscopy revealed a bronchial polypoid tumor. A tumor biopsy demonstrated pleomorphic carcinoma of the lung. Thoracic radiotherapy and chemotherapy was performed, and the tumor was temporarily reduced. However, her general condition then worsened again, followed by kidney, bone and brain metastases, and she died. Conclusion. We report a rare case of pleomorphic carcinoma of the lung which was diagnosed by transbronchial biopsy.

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