Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) represents a new technology in the field of bronchoscopy. EBUS-TBNA has been well established as a useful and safe procedure in the evaluation of mediastinal and/or hilar lymphadenopathies. Objective. The aim of the present study was to assess the utility of EBUS-TBNA in confirming pathological diagnoses. Methods. Fifty-one patients with mediastinal and/or hilar lymphadenopathies who underwent EBUS-TBNA for pathological diagnosis between April 2009 and March 2011 were retrospectively analyzed. Results. A total of 58 mediastinal or hilar lymph nodes in 51 patients were examined. EBUS-TBNA confirmed diagnosis in 44 of 51 patients (86.3%) by pathological diagnosis in 48 of 58 lymph nodes samples (82.7%). EBUS-TBNA confirmed diagnoses of malignancy in 32 patients, and benign diseases in 14 cases, including tuberculosis, sarcoidosis, and inflammatory diseases. The remaining 5 patients with negative EBUS-TBNA results were found to have pathological diagnoses by computed tomographic-guided percutaneous needle biopsy or mediastinoscopic biopsy. The respective sensitivity of EBUS-TBNA at individual lymph node stations were as follows: right paratracheal aspirates, 75%; subcarinal aspirates, 89%; left interlobar aspirates, 80%; other lymph node station aspirates, 100%; and overall, 82.8%. Moreover, the respective diagnostic yield 5 of aspiration according to lymph node size were as follows: 10-15 mm, 60%; 16-20 mm, 68%; 21-25 mm, 83%; greater than 25 mm, 100%. There were no complications associated with the procedures. Conclusion. We obtained a diagnostic accuracy rate comparable with that of several systematic reviews. In this study, EBUS-TBNA was shown to have a high diagnostic yield and is less invasive as a procedure for evaluating mediastinal or/and hilar lymphadenopathies.

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Case. A 63-year-old Japanese woman with right bronchiectasis was admitted to our hospital because of hemoptysis in 2010. She had undergone right lower lobectomy due to severe bronchiectasis and recurrent hemoptysis even after bronchial artery embolization in 2006. Chest computed tomography (CT) revealed cavitary lesions in the right upper and left lower lobes, bilateral diffuse centrilobular small nodular opacities and an exacerbation of bronchiectatic lesions in the right middle lobe. Fiberoptic bronchoscopy was performed for the evaluation of hemoptysis in March of 2010. 16S ribosomal RNA gene sequencing clone library analysis of the cultivated isolates of the bronchial washing specimen obtained from the right upper lobe revealed Nocardia abscessus. Antimicrobial treatment with intravenous meropenem followed by oral administration of sulfamethoxazole-trimethoprim for 6 months improved the symptoms and chest CT findings. Conclusion. Pulmonary nocardiosis induced by N. abscessus is rare, and 16S ribosomal RNA gene sequencing analysis of the bronchial washing specimen was useful for microbial diagnosis of the present patient.

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Background. Airway stenting for severe central airway stenosis is an inherently dangerous procedure. Failure of the stenting causes death. This report presents a case of tracheal stenting using a percutaneous cardiopulmonary support system (PCPS) due to central airway obstruction. Case. A 66-year-old man was given a diagnosis of squamous cell carcinoma of the lung, and underwent left pneumonectomy in 2006. It recurred at the left main bronchus stump, and esophageal stenting was performed for a tracheoesophageal fistula in 2010. He was transported to our hospital after sudden respiratory arrest at home. He required mechanical ventilation for tracheal compression because of the esophageal stent inserted in 2011. PCPS was started beforehand because it had been impossible to ventilate during the original stenting without a tracheal tube. Expandable metallic stents were placed in the right main bronchus and the trachea. He was successfully weaned from mechanical ventilation after the procedure. Conclusion. PCPS should be considered in cases in which respiratory distress or unstable circulatory condition can be anticipated during the operation.

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Background. Acinic cell carcinoma is a malignant neoplasm in which cells differentiate into serous acinic cells. Most acinic cell carcinomas originate from the salivary glands, particularly the parotid glands. Acinic cell carcinomas originating from the bronchus or the lung are extremely rare, and only 17 cases have been reported in the international or Japanese literature. Case. The patient was a 55-year-old man in whom an abnormal shadow was detected on chest radiography performed for diagnosing another disease. Chest CT revealed a sharply delineated 20-mm-diameter nodule on the right S^4b. Bronchoscopy revealed obstruction of the right B^4b by the lesion, and biopsy yielded a diagnosis of adenocarcinoma. Under a diagnosis of primary lung cancer, we performed right middle lobectomy with lymphadenectomy. On the basis of a histological examination, the patient was given a diagnosis of acinic cell carcinoma. As there were no lesions in other organs, we confirmed the diagnosis of acinic cell carcinoma originating from the bronchus. The patient is alive and has been recurrence free for 5 years. Conclusion. We report an extremely rare case of acinic cell carcinoma originating from the bronchus and summarize the findings of previously reported cases.

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Case. A 57-year-old man was referred to our hospital due to spontaneous pneumothorax of the right lung. Chest computed tomography showed a large cavity in the upper lobe of the right lung, and the right lung was almost completely collapsed. Mycobacterium intracellulare was detected in the sputum and purulent pleural effusion. Continuous deaeration was performed after placing a thoracostomy tube, but the patient's condition did not improve at all. The patient also had a productive cough and developed a fever. Increased shadows were noted in the left lung due to nontuberculous mycobacterial infection. This was thought to be the influx of pleural effusion from the right lung to the left lung. Therefore, it was decided to position endobronchial Watanabe spigots (EWS) in the B^1, B^2, and B^3 areas of the upper lobe of the right lung, for the purpose of preventing further influx of pleural effusion and improvement of the refractory pneumothorax. The filling of EWSs in the B^1 region of the right lung was insufficient with spontaneous coughing-up of the filled EWSs. Therefore, a curette was used to facilitate the filling with a stronger force, that is, an EWS was put into the region after plunging a curette into it. Results. The use of a curette was useful for positioning the EWS, in particular, into the B^1 region which is located in a higher position in the lung and thus cannot be visualized. It was also possible that EWSs were plunged firmly into the desired bronchus with no coughing-up of them. The aggravation of nontuberculous mycobacterial infection in the left lung improved thereafter although it was difficult to achieve complete cure of the pneumothorax in this patient. Conclusion. The present case indicated the usefulness of a curette in the filling of EWSs in a pneumothorax patient.

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Background. Vagal nerve Schwannoma in the mediastinum is very rare and preoperative diagnosis is difficult. To our knowledge, this is the first case with vagal nerve Schwannoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Case. A 39-year-old man with Behcet's disease was consulted to our hospital because of an abnormal shadow on a chest X-ray. Enhanced computed tomography (CT) revealed 9 25×20mm right mediastinal tumor located dorsal to the right main bronchus. To diagnose this tumor, EBUS-TBNA was performed. Immunohistochemical staining showed S-100 positive spindle cell clusters in the specimens and diagnosed this tumor as vagal nerve Schwannoma. Therefore, resection of the tumor by video-assisted thoracic surgery was carried out. Indeed, the tumor covered the vagus nerve. Conclusion. This case indicated that EBUS-TBNA may be useful for diagnosis of the mediastinal tumor such as vagal nerve Schwannoma.

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Background. Pulmonary cryptococcosis in immunocompromized patients often presents pulmonary infiltration and pleural effusion as well as a solitary nodule. Case. A 71-year-old woman was admitted to a hospital because of chronic cough. Her past history included a partial lung resection for adenocarcinoma of the lung and a thymectomy for myasthenia gravis. She had been treated with immunosuppressants. Since the chest CT scan showed a single nodule in the left upper lobe, mediastinal lymphadenopathy and pericardial effusion, the patient was referred to our hospital on suspicion of recurrence of the lung cancer. Bronchoscopic examination revealed a submucosal polypoid tumor on the anterior wall of the trachea and whitish protruding lesions at the carina. A diagnosis of pulmonary cryptococcosis was made by histopathological examination of the endotracheal biopsy specimens and positive serum cryptococcal antigen. The symptoms and radiographic abnormalities improved after one year of treatment with fluconazole. Conclusion. Diagnosis of pulmonary cryptococcosis requires close attention, because its unusual presentations with lymphadenopathy, tracheal invasion and pericardial effusion resemble lung cancer and tuberculosis.

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Background. Stent placement is a standard method to treat central airway stenoses and is becoming increasingly used with device development. Case. A 31-year-old woman underwent left sleeve pneumonectomy through a median sternotomy with cardiopulmonary bypass for adenoid cystic carcinoma arising from left main bronchus. Radiation treatment started 9 weeks after the operation. Two weeks later, she began to feel dyspnea, and bronchoscopy revealed pinhole-shaped stenosis of the truncus intermedius due to tumor regrowth. Then, Dumon Y stent placement was performed on the carina between the right upper lobe bronchus and the truncus intermedius under general anesthesia with V-V bypass. Postoperative course was uneventful, and radiotherapy was performed. Conclusion. A Dumon Y stent was successfully placed on the bronchial stenosis of truncus intermedius after left sleeve pneumonectomy. V-V bypass was useful to assist oxygenation during respiratory arrest.

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Background. Pulmonary vein stenosis is a relatively uncommon, but potentially devastating complication of catheter ablation for the treatment of atrial fibrillation. Case. A 74-year-old woman was admitted because of hemoptysis. Bronchoscopic findings showed marked development of bronchial vessels, redness and swelling of the mucosa of the left bronchus. Computed tomography scan demonstrated occlusion of the left inferior pulmonary vein and stenosis of the left superior pulmonary vein. Furthermore, perfusion scintigram showed marked hypoperfusion on the left side. Owing to her previous history of catheter ablation for atrial fibrillation at another hospital, she was diagnosed with left pulmonary vein stenosis as a result of catheter ablation. Conclusion. Pulmonary vein stenosis as a result of catheter ablation is relatively rare, however it is an important differential diagnosis for hemoptysis after therapy.

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Background. Langerhans cell histiocytosis (LCH) is a disease in which Langerhans cells derived from dendritic cells infiltrate a various organs and is considered smoking-related lung disease. Case. A 27-year-old woman with a 10-year smoking history was referred to our institution with dry cough and dyspnea on exertion. Chest radiographs showed reticulonodular opacities in the bilateral lung fields. High-resolution CT revealed a thin wall cavitary lesions about 10 mm in diameter and multiple small nodules. Transbronchial lung biopsy specimens revealed peribronchiolar granulomatous lesions with infiltrations of Langerhans cells and eosinophils and we made a diagnosis of LCH. Dynamic MRI of the liver showed small nodules with high intensity and large nodules with ring enhancement in the arterial phase, and hepatomegaly. Percutaneous liver biopsy specimens revealed accumulation of Langerhans cells. After smoking cessation for 3 months, both pulmonary and liver lesions improved rapidly. Conclusion. Smoking cessation is the key strategy for not only pulmonary LCH but also hepatic lesions at an early stage.

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Background. Several reports have showed that amyloid deposit in mucosa-associated lymphoid tissue (MALT) lymphoma tissue might be a factor of indicative of poor prognosis. We encountered a case of pulmonary MALT lymphoma which was diagnosed 12 years after surgical treatment of gastric MALT lymphoma. Both pulmonary and gastric MALT lymphomas were found to have amyloid deposit in those lymphoma tissues. We report this case with pertinent literature in regard to amyloid deposit in MALT lymphoma. Case. A 70-year-old man, who had total gastrectomy at age 58, was referred to our clinic for a right hilar mass on his chest X-ray film. Bronchoscopy revealed redness and irregular swelling of the mucosa of the right main bronchus. Transbronchial biopsy showed follicular accumulation of CD20-positive small type B-lymphocytes with amyloid deposit in the bronchial mucosa. Pulmonary MALT lymphoma with amyloid deposit was diagnosed. His MALT lymphoma grew steadily and he presented with recurrent bacterial pneumonia. Finally, he died due to severe pneumonia with empyema at age 74. We performed autopsy. Results. A tumor with a large cavity was found in the right lower lobe. Both of lungs showed severe sclerosis. Microscopic finding revealed infiltration of CD20-positive small B-lymphocytes and AL amyloid deposits in pulmonary tissues and many other organs. His gastric specimen which was resected at age 58 was reviewed and amyloid deposits were found in his gastric MALT lymphoma tissues. Conclusion. We estimate that MALT lymphoma with amyloid deposit may represent a high tumor activity and tendency of dissemination to other organs.

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Background. For airway stenosis due to the benign disease such as background tuberculosis, the Dumon silicon stent is frequently used. Case. The medical history was pulmonary tuberculosis associated with spinal caries at the age of 13. In October, 2001, spinal column anterior curvature worsened to cause compression stenosis of the left main bronchus. Therefore, we inserted a 12 mm diameter, straight Dumon tube (DT) of 30 mm in length. However, the DT migrated to the peripheral side, and carina and the right main bronchus was compressed by the spinal column, causing dyspnea. In July, 2007, the lower trachea became stenotic with a slit-shaped right main bronchus and obstructed left main bronchus. Therefore we replaced the DT with a Dumon Y stent using a rigid bronchoscope. Because the spinal column anterior curvature had increased compared with 2001, the rigid bronchoscopy procedure was difficult. As worsening of stenosis due to the spinal lordosis might become problematic, it seems to be necessary to consider methods other than rigid bronchoscopy.

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