Background. Recently, the incidence of malignant pleural mesothelioma has increased in Japan. The tendency to increase will continue 20-30 years from now. Although mesothelioma is suspected in cases presenting with diffuse pleural thickness or hemorrhagic pleural effusion, mesothelioma is only confirmed by cytological testing. Objective. The aim of this study was to evaluate thoracoscopy, imaging procedures and biochemical tests for the diagnosis of mesothelioma. Methods. We assessed clinical and thoracoscopy findings in 14 mesothelioma patients who underwent thoracoscopy under local anesthesia in our hospital from June 2004 to July 2011. Results. We confirmed asbestos exposure, a major cause of mesothelioma, in only 7 of the 14 patients (50%). Pleural plaques were demonstrated on CT in only 3 of the 14 patients (21%). In contrast, pleural plaques were found in 9 of 13 patients (69%) by thoracoscopy. The CYFRA level in the pleural fluid was elevated in 6 of 7 patients (86%). The CEA level was normal in all cases (100%). Furthermore, in all of the 14 cases, the CYFRA level was elevated and the CEA level was normal. The sensitivity of pleural effusion cytology was 70% (7 patients of 10 patients) in the epithelioid type mesothelioma and 0% (0 patients of 4 patients) in the sarcomatoid type mesothelioma. No significant difference was demonstrated between the epithelioid and sarcomatoid types. Conclusion. Mesothelioma should be suspected when there is a clinical history of asbestos exposure, pleural plaques, and abnormality in pleural biochemical markers. It is important to make a definitive diagnosis of mesothelioma by thoracoscopy plus biopsy.

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Background. Amyloidosis of the upper and lower respiratory tracts and amyloidosis complicated with Sjogren's syndrome are commonly focal, and only a few have been reported to be systemic. Case. Sjogren's syndrome was diagnosed 7 years ago and lymphoma of the mucosa-associated lymphoid tissue (MALT) 5 years ago in a 67-year-old woman. The patient was also found to have pulmonary lesions with cysts and nodules. Initial bronchoscopy showed amyloid deposits in the bronchi; however, the findings of imaging studies revealed deterioration of the patient's condition, and she also experienced hoarseness. Therefore, bronchoscopy was repeated. AA amyloidosis was diagnosed in the patient on the basis of the biopsy findings of a nodule in the left lung. Conclusion. Her condition was considered to be systemic amyloidosis secondary to chronic inflammation due to MALT lymphoma and Sjogren's syndrome, presenting as lesions in the subglottic region, gastrointestinal tract, and eye sockets.

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Background. Treating pediatric cases of bronchial foreign bodies is difficult. We herein report a pediatric case of a bronchial foreign body that was removed using a 2.8mm ultra-thin flexible bronchofiberscope. Case. A 19-month-old girl with suspected aspiration of food was taken to our hospital. Chest computed tomography (CT) showed a cord-like foreign body in the left main bronchus. The bronchial foreign body was successfully removed with a 2.8mm ultra-thin flexible bronchofiberscope and catheter forceps under general anesthesia. The foreign body was a fish bone. Conclusion. 2.8mm ultra-thin flexible bronchofiberscopy is a useful method for treating pediatric cases of bronchial foreign bodies.

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Background. Middle mediastinal tumors are rare, and making a preoperative diagnosis of these lesions is difficult due to the presence of surrounding great vessels. Case. A 78-year-old man was admitted to our hospital due to a cough. Computed tomography and magnetic resonance imaging of the chest revealed a middle mediastinal tumor measuring 3.6 cm in diameter. A bronchoscopic examination under local anesthesia was attempted; however, the procedure was aborted due to respiratory failure caused by tracheomalacia. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) under general anesthesia was performed; however, the paucity of the specimen obtained did not lead to a diagnosis. Subsequently, we performed mediastinoscopy. It was difficult to visualize the tumor under the mediastinoscopic view. The mass was ultimately detected with certainty using EBUS and biopsied with mediastinoscopy biopsy forceps. Pathological examinations demonstrated a neoplastic lesion containing spindle cells. Immunohistochemical staining revealed that the tumor was positive for S-100 proteins, and the patient was diagnosed with schwannoma. Conclusion. This case indicates the usefulness of mediastinoscopy with EBUS for diagnosing middle mediastinal tumors.

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Background. It is often difficult to differentiate dysplasia from carcinoma in situ using white light bronchoscopy (WLB) alone. WLB combined with narrow band imaging (NBI), however, has been proven to be useful for detecting and assessing dotted vessels at sites of abnormal fluorescence. Case. A 65-year-old man was admitted to our institution with an abnormal chest shadow in the lingular segment. A white light examination revealed redness and swelling at the bifurcation of right B^6 and basal bronchus. A light reddish-brown area was identified on a fluorescence examination. The NBI image visualized the lesion with unclear margin and brownish dotted vessels in some areas within the lesion. Although it is difficult to distinguish between carcinoma in situ and dysplasia based on bronchoscopic findings, the biopsy specimens revealed a histopathological diagnosis of mild dysplasia. Conclusions. NBI proved useful for assessing the regular pattern of dotted vessels and border clarity at abnormal sites under fluorescence. NBI may facilitate the accurate discrimination between dysplasia and carcinoma in situ.

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Background. Round atelectasis is an uncommon form of lung collapse associated with pleural abnormalities. Case. The patient was 56-year-old man who presented with a right pneumothorax. A chest X-ray and chest CT scan showed a right pneumothorax with a 49-mm mass shadow in the right lower lobe. The mass, which came in contact with the cavity of the pneumothorax, was accompanied by a curved shadow in the bronchi and vessels. Bronchoscopy was performed, and a transbronchial lung biopsy revealed fibrosis of the alveolar wall consistent with a diagnosis of round atelectasis. Conclusions. Although round atelectasis associated with spontaneous pneumothorax is rare, clinicians should take this condition into consideration in the differential diagnosis of lung masses associated with pneumothorax.

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Background. In the treatment of giant pulmonary giant bullae, surgical resection is generally performed. However, due to the low pulmonary function and poor general condition of the patient, it is often difficult to perform surgery. Case. A 61-year-old man with history of acute respiratory distress syndrome (ARDS) due to severe influenza pneumonia was admitted to our hospital with a left pneumothorax and bulla in the right lung. Although the left pneumothorax improved following drainage, the size of the right bulla increased. Due to the patient's low pulmonary function and recent history of a pneumothorax, surgical treatment was considered inappropriate. We therefore decided to perform bronchoscopic drainage and autologous blood injection to reduce the volume of the giant bulla. The giant bulla completely reduced using this method. Conclusions. This new technique is a viable option for treating giant bullae, especially in high-risk patients.

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Background. We herein report a case of pulmonary epithelioid hemangioendothelioma (PEH) that was detected during a routine medical checkup and was diagnosed based on the findings of a transbronchial lung biopsy (TBLB). Case. A 44-year-old male was admitted to our hospital, due to multiple small nodular shadows on a chest radiograph obtained during a medical examination conducted in December 2006. A chest CT scan showed multiple well-defined nodules. We suspected multiple lung metastases or PEH and performed TBLB. Immunohistochemically, the tumor cells strongly reacted to factor VIII-related antigen and CD34. As a result, PEH was diagnosed. Conclusions. Thus far, most of cases of PEH have been diagnosed using surgical lung biopsies. However, this case was diagnosed using TBLB, which could be therefore also be used in other cases.

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Background. We report a patient with prolonged postoperative pulmonary fistula treated with thoracic drainage between the right clavicle and first rib and bronchial embolization. Case. A 74-year-old man with right-sided lung cancer was treated at our hospital with right lower lobectomy and mediastinal lymph node dissection. Second and third surgical interventions and pleurodesis were subsequently performed because of prolonged postoperative pulmonary fistula. He recovered and was discharged. Fourteen days later, he was readmitted for recurrent pulmonary fistula. Because of pleural adhesion, thoracic drainage was performed through the space between the right clavicle and first rib. Bronchography revealed that the right B^1 bronchus was responsible for the pulmonary fistula, and bronchial embolization was performed. Dye injected into the pleural space flowed into the B^1 bronchus, which was still exhibiting air leakage. He underwent further bronchial embolization. Because a small amount of pulmonary fistula persisted, he was discharged from the hospital with a thoracic catheter in place. The catheter was removed in the outpatient department, 70 days after the initial bronchial embolization. Conclusion. Drainage into the apical portion of the thoracic space between the clavicle and first rib should be considered when adhesion limits drainage of the root. Bronchography and dye injection into the thoracic space can effectively identify the culprit bronchus during bronchial embolization.

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Background. Fungal infections after lung transplantation are a complication with high mortality. We describe a case complicated by bronchial aspergillosis after bilateral lung transplantation. Case. A 53-year-old woman was given a diagnosis of severe bronchiectasis and underwent bilateral lung transplantation following the brain death of the donor. Although she received prophylaxis with itraconazole (ITCZ) immediately after transplantation, Aspergillus fumigatus was detected in sputum culture 3 months after transplantation. Bronchoscopy showed two masses covered with a white membrane at the anastomotic site of the right main bronchus and the bifurcation of the left upper and lower lobe bronchi. Large numbers of filamentous fungi were confirmed histologically. Therefore, the antifungal drug was changed to voriconazole (VRCZ). One year after transplantation, the white lesion had disappeared on bronchoscopy, and no fungus was found by sputum culture. Although the VRCZ had been continued, 1.5 years after transplantation, Penicillium spp. and A. niger were detected in sputum culture. She is being followed carefully. Conclusion. Fungal infection after lung transplantation may be asymptomatic. Frequent examinations of sputum and bronchoscopy are required for early diagnosis because the efficacy of prophylactic antifungal agents is not clear.

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Background. Primary mediastinal large B-cell lymphoma (PMBL) is a rare disease that is thought to arise from thymic B-cells. It is often difficult to obtain diagnostic materials due to crushed artifacts or extensive necrosis, fibrosis, or cystic changes of the lesion and/or the lack of extramediastinal lesion. In such situations, mediastinoscopy or thoracoscopy is required. Case. A 38-year-old woman presented with fever and dyspnea on effort. Since a chest X-ray film showed a large amount of pleural effusion on the right side, she was referred to our hospital. Chest computed tomography (CT) scan revealed a bulky tumor mass, 11cm in diameter, extending to the right hemithorax. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the mediastinal tumor revealed CD20-positive atypical lymphocytes in these specimens. PMBL was diagnosed based on the immunophenotype and clinical manifestations. Conclusion. EBUS-TBNA appears useful for the diagnosis of PMBL.

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Case. A 77-year-old man, who presented with bilateral lower-extremity edema for 3 years, was admitted because of repeated pleural effusion lasting 1 year. The pleural fluid revealed eosinophilia at onset; however, lymphocytosis was observed in the fluid on admission. Thoracoscopic biopsy specimen of the pleura showed inflammatory cell infiltrates, and pleural lymphangiectasia was observed by immunohistochemistry. The patient was suspected to have yellow nail syndrome based on the diagnostic criteria, presenting with 2 of 3 main clinical findings. The exact cause is unknown, although the patient suffered from a necrotizing and eosinophilic granuloma of the lung 7 years previously, suggesting a possible association with a parasitic infection. Conclusion. In patients with refractory pleural effusion with lymphedema, physicians should consider yellow nail syndrome, and thoracoscopic pleural biopsy can be helpful in detecting lymphangiectasia.

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Background. Endobronchial inflammatory polyps are rare, and their causes have not been completely clarified. We report a case of endobronchial inflammatory polyp with Stenotrophomonas maltophilia which was resected. Case. A 66-year-old man complaining of bloody sputum was admitted to our hospital because tumor was observed in the left B^<1+2> by chest CT. Thin-slice bronchoscopy showed a tumor and white coat in the left B^<1+2> which resembled a polyp. A diagnosis of inflammatory polyp was made because transbronchial tumor biopsy and culture found no other significant changes. Since we were not able to deny the possibility of malignancy, thoracoscopic segmentectomy for the left B^<1+2> was performed. The pathological findings, showed no malignant signs, but chronic inflammatory changes were recognized. Later, Stenotrophomonas maltophilia was detected from the bacterial culture. It was considered one of the factors of an endobronchial inflammatory polyp.

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Background. The rate of detection of anomalous bronchi is about 0.6%. The majority of cases involve a displaced bronchus, mostly in the right upper lobe. Two cases of right upper lung cancer with a displaced anomalous bronchus are reported. Case 1. Chest CT revealed a 5.6×4.5 cm mass in the right upper lobe in an 81-year-old man. Bronchoscopic examination showed that the right B^1 diverted from the right main bronchus near the carina. Curetting was performed through the right B^3a, and squamous cell carcinoma was diagnosed. The clinical stage was cT2bN0M0 Stage IIA, and a right upper lobectomy was performed. The right B^1 and B^2+B^3 were cut with the Sweet method using a stapling device. Case 2. Chest CT revealed a 3.7×3.0 cm mass in the right upper lobe of an 83-year-old man. Bronchoscopic examination showed that the right B^1+B^3 diverted from the right side of the trachea near the carina, and the right B^2 diverted from the truncus intermedius near B^6. Curetting was performed through the right B^1a, and squamous cell carcinoma was diagnosed. The clinical stage was cT2aN0M0 Stage IB, and a right upper lobectomy was performed. The right B^1+B^3 and B^2 were cut with the Overholt method using a stapling device. Conclusion. Careful preoperative examination and planning of the operative procedures are needed in cases of lung cancer with a displaced anomalous bronchus.

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Background. The utility of the virtual bronchoscopic navigation system (VBN) for small peripheral pulmonary lesions is widely known. However, applications of VBN as a guide for diagnosing mediastinal or hilar lesions have yet to be reported. Case. A 49-year-old woman consulted a local doctor with dyspnea on exertion. Chest computed tomography (CT) showed tumor adjacent to the left pulmonary artery. She was referred to our hospital, where she subsequently underwent bronchoscopy. Tumor was not visible on bronchoscopy, so we performed transbronchial needle aspiration (TBNA) of B^<1+2>c; however, no tumor could be diagnosed. TBNA of the upper dorsal B^<1+2>a inlet was then performed under VBN guidance. Histopathological examination revealed mucosa-associated lymphoid tissue (MALT) lymphoma of the lung. Conclusion. Conventional TBNA for mediastinal and hilar lesions is a fairly blind technique that does not allow visualization of the target. We suggest that TBNA under VBN guidance is an effective diagnostic approach for mediastinal and hilar lesions.

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