Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic procedure with a high yield for lesions adjacent to the airways, particularly for the staging of non-small cell lung cancer. However, complications associated with EBUS-TBNA, such as mediastinitis and lymphadenitis, were recently reported. Thus, we investigated whether EBUS-TBNA caused severe infection by examining associations between fever and clinical features. Methods. We retrospectively evaluated 75 patients who underwent EBUS-TBNA and had needle wash solution cultures. These patients had undergone EBUS-TBNA to diagnose lesions adjacent to the airways from April 2011 to November 2013. All cases had received prophylactic intravenous antibiotics only once after EBUS-TBNA. Most cases were also administered additional oral prophylactic antibiotics for 3 days. We evaluated fever occurrence within one week after EBUS-TBNA. Results. EBUS-TBNA needle wash cultures were positive for 48 (64.0%) patients. All bacterial isolates were typical oropharyngeal commensal flora. Significant fever (≥38℃) was found in 9 cases (12.0%). These patients recovered only by cooling and/or by a single administration of non-steroidal anti-inflammatory drugs. There were no associations with fever and clinical features, including malignancy of punctured lesions, echo features, total puncture times, peripheral biopsy done at the same time, additional oral prophylactic antibiotics, or positive for needle wash cultures. Conclusion. Within one week after EBUS-TBNA, significant fever was recorded for 12.0% of cases, and needle cultures showed bacterial growth in 64.0% of cases. No serious complications occurred, such as mediastinitis or abscess formation. To obtain more data on serious complications, we must examine more cases. The usefulness of prophylactic antibiotics administration after EBUS-TBNA requires discussion, and prospective clinical trials are warranted.

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Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield for lesions adjacent to the airway. The samples obtained by EBUS-TBNA can be used for cytological as well as histological diagnosis. The aims of this study were to evaluate advantages and disadvantages of both cytological and histological diagnosis of EBUS-TBNA specimens and to evaluate utility of the combination of cytology and histology. Methods. The patients who underwent EBUS-TBNA from November 2008 to September 2010 were enrolled in this study. Cytological and histological diagnoses and pathological findings were retrospectively reviewed. Rapid on-site cytological diagnosis did not apply during examination. The final diagnosis was confirmed by EBUS-TBNA diagnosis, surgery, or six months' follow-up after EBUS-TBNA. Results. We evaluated 173 lesions (92 patients): 169/173 lesions (97.7%) could be diagnosed by cytology alone, and 122/173 lesions (70.5%) could be diagnosed by histology alone. However, combination of cytology and histology enabled 170/173 lesions (98.3%) to be diagnosed. We diagnosed 41 lesions as lung cancer or lymph node metastasis of lung cancer and in 39 lesions (95.1%) of those, the histological type of lung cancer could be determined. In histology, by additional immunostaining, 5 lesions could be diagnosed as lung cancer, and by additional molecular investigation, 1 lesion which was diagnosed as mediastinal lymph node metastasis of lung cancer was revealed to have epidermal growth factor receptor (EGFR) mutation. False negatives were found in 11/173 lesions (6.4%) at final diagnosis. Conclusion. There are advantages and disadvantage of the cytological and histological diagnosis. The combination of cytology and histology can increase the yield of EBUS-TBNA diagnosis.

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Background. Pleural mesothelioma is a malignant tumor caused by asbestos exposure that is rarely cured with treatment. This condition is known to progress to malignant pleuritis and directly invade neighboring tissues and organs, and distant metastasis has been reported in a few cases. Case. A 68-year-old man suffered from chest pain and shortness of breath. Chest CT showed left multiple pleural tumors with chest wall invasion and a nodular lesion in the right S^6 segment, while bronchofiberscopy revealed a polypoid tumor in the right B^6 segment. A transbronchial biopsy subsequently led to a pathological diagnosis of malignant pleural mesothelioma, which was confirmed on a biopsy of the left chest wall tumor directly invading the pleura. Conclusions. To the best of our knowledge, this is the first case of a metastatic polypoid tumor in the bronchus derived from malignant pleural mesothelioma which was diagnosed using bronchofiberscopy.

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Background. The long-term outcome of bronchial tuberculosis (TB) after treatment not well understood. Case. A 71-year-old woman was admitted to our hospital with stridor and left obstructive pneumonia caused by bronchial re-stenosis. She was initially treated for bronchial TB at the age of 25. Left main bronchial stenosis was detected by chest CT, when she visited her primary care doctor due to stridor at age 57. At age 59, she underwent bronchial dilation procedure for bronchial stenosis in another hospital. During the present hospitalization, after managing the obstructive pneumonia, endobronchial airway dilation was performed by an electrosurgical knife and argon plasma coagulation. The stenotic site was successfully dilated using an electrosurgical knife followed by balloon bronchoplasty with flexible bronchoscope. No signs of re-stenosis were observed for 6 months after the dilation procedure. Conclusion. Airway stenosis might occur after long-term treatment of bronchial TB. Past history of bronchial TB is important information for the diagnosis of bronchial stenosis caused by TB and the differential diagnosis of stridor.

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Background. In malignant tumors, it is difficult to distinguish recurrence of the tumor or a complication of inflammatory disease as the cause of mediastinal lymphadenopathy. We reported two cases of mediastinal lymphadenopathy due to non-tuberculous mycobacterium comorbidity in malignant tumors using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Case (1). A 51-year-old man, who had been given a diagnosis of hypopharyngeal carcinoma and given chemotherapy in 2010, was referred to our hospital because of pneumonia in the left lung in 2011. Chest CT revealed hilar/mediastinal lymphadenopathy, so recurrence of hypopharyngeal carcinoma was suspected. We performed EBUS-TBNA of lymph node (#7) and suspected non-tuberculous mycobacterium-induced intrathoracic lymphadenopathy. Case (2). A 33-year-old man, in whom Kaposi's sarcoma with AIDS was diagnosed in 2012 and was treated by chemotherapy and antiretroviral therapy, was referred to our hospital because FDG-PET revealed mediastinal lymphadenopathy. We performed EBUS-TBNA of lymph node (#7) and suspected non-tuberculous mycobacterium-induced intrathoracic lymphadenopathy. Conclusion. Although it is difficult to diagnose non-tuberculous mycobacterium in cases of mediastinal lymphadenopathy in malignant tumor, EBUS-TBNA was useful in the differential diagnosis between the recurrence of the tumor and the complication of inflammatory disease.

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Background. Mitomycin-C (MMC) reportedly has an effect on granulation suppression, and many cases of tracheal stenosis caused by benign disease have received topical MMC treatment worldwide. However, in Japan, this treatment modality is still rarely used. Case Report. A 31-year-old man received treatment for a fracture of his left femur under general anesthesia when he was 18 years old. He became aware of discomfort in his pharyngeal portion one year previously, and he had wheezing 8 months ago. He went to hospital and was prescribed medicine. However, as no improvement was made, he was finally referred to our Respiratory Medicine department. Bronchoscopy showed scarring stenosis of the entire tracheal circumference approximately 3 cm away from the vocal cord to the peripheral side, so he was referred to us for bronchial intervention. In the operation, we resected scar tissue, and applied MMC to the resected area. Result. The postoperative course was non-eventful and the patient was discharged from hospital one week later. At bronchoscopic examination 3 months after surgery, there was no restenosis by granulation and/or scar tissue hyperplasia. There has been no recurrence 3 years after surgery. Conclusion. Although long-term follow-up is necessary to confirm these results, we believe that the suppressive effect of MMC on granulation hyperplasia could be effective in preventing relapse of tracheal stenosis.

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Case Report. We diagnosed rectum cancer (stage II) in a 63-year-old man in 2010 and performed rectectomy. He underwent left upper lung lobe lobectomy due to metastasis and received chemotherapy. However, in 2013, a chest computed tomography indicated lymph node metastases of the left mediastinum and hilum with invasion into the left main bronchus. He also had bloody sputum. Bronchoscopy revealed tumor invasion into the left main bronchus with bleeding. Liquid thrombin was sprayed on the lesion at the end of the bronchoscopy. He suddenly developed severe diaphoresis and dyspnea 4 minutes after bronchoscopy. Wheezing was heard on auscultation, and the oxygen saturation level dropped to 60%. An anaphylactic reaction was suspected, and the patient was given methylprednisolone and epinephrine. He recovered several hours later. He had no history of bronchial asthma. His vital signs were stable during bronchoscopy, and therefore, we suspected that the liquid thrombin used prior to completing the bronchoscopic examination was responsible for the anaphylactic reaction. Conclusion. This is the first report of an anaphylactic reaction to liquid thrombin during bronchoscopy. We should consider the possibility of an anaphylactic reaction if patients suddenly suffer dyspnea after receiving liquid thrombin.

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Background. We are often unsuccessful in our efforts to treat empyema with a pulmonary fistula because the pulmonary fistula is not sealed sufficiently. The Endobronchial Watanabe Spigot^[○!R] (EWS) is a silicon implant plug used to treat pulmonary fistulae, hemoptysis and intractable pneumothorax. Embolization with EWS is one option in the management of empyema with a pulmonary fistula. Case. A 78-year-old woman previously in good health came to the emergency department of our hospital with severe respiratory distress. Computed tomography of the chest revealed a left pneumothorax, and multiple nodules with cavities in both lungs. She was hospitalized with a diagnosis of left spontaneous pneumothorax and lung abscesses. Then, antituberculosis drugs were initiated to combat the Mycobacterium avium complex. In this case the air leakage from the left lung did not heal; hence, operation was considered necessary. First a fenestration operation was performed to clean up and sterilize the empyema cavity. After that, an operation was performed to seal the pulmonary fistula. A retrograde approach utilizing EWS was performed in combination with surgery to seal the pulmonary fistula using absorbable fibrin sealant patch (TachoSil^[○!R]). The operation achieved complete resolution of the air leak and the postoperative course was uneventful and without complications. Conclusion. The EWS technique using a new retrograde approach seems to be a superior and safe option for the treatment of empyema with a pulmonary fistula.

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Background. The need to remove a foreign body via bronchoscopy in a normal adult twice is rare. Case. A 68-year-old man consulted our hospital for treatment for yellow sputum in December 2007. Chest CT showed a shadow with calcification in the right main bronchus. Based on the CT findings and the patient's history of an episode of getting on a fish bone stuck in his throat while eating, we suspected a foreign body and performed bronchoscopy. The bronchoscope showed a foreign body in the right main bronchus, which was subsequently removed. The foreign body was thought to be the bone of a sea bream. Approximately four years later, chest CT and bronchoscopy showed a shell between the left upper and lower bronchi, which we removed via bronchoscopy. Conclusions. Patients with a history of bronchial foreign bodies, even normal adults, should be evaluated for the possibility of a second foreign body and then be followed carefully.

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Background. In the management of bronchial leiomyoma, endoscopic treatment is often the method of choice to preserve pulmonary function. However, for sessile tumors, it is difficult to determine the positional relationship between the bronchial structure and the planned cutting plane of the tumor, making it hard to snare the tumor endoscopically. Applying a novel approach to these problems, we have successfully treated a sessile bronchial leiomyoma. Case. Computed tomography on a 49-year-old woman with persistent cough, low-grade fever and dyspnea revealed a round tumor obstructing the orifice of the left lower lobe bronchus, with consolidation in the corresponding lung field. The tumor was diagnosed as leiomyoma by bronchoscopic biopsy. Its base was sessile, so we constructed a virtual bronchoscopy image to determine the positional relationship between the bronchial structure and the tumor. On this basis, we were convinced that endoscopic resection would be possible. In preparation for the resection, we made an incision to the bridging fold at the base of the tumor, which was helpful to stabilize the snare. We were then able to resect the tumor by high frequency cauterization. Thereafter, the infiltrates in the left lower lobe decreased. Conclusion. We report a case of bronchial leiomyoma resected by high frequency cauterization with the aid of virtual bronchoscopy imaging and stabilization of the snare by means of an incision at the base of the tumor.

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Background. While the diagnosis of pulmonary actinomycosis requires bacterial proof and characteristic pathological findings, the rate of diagnosis with conventional bronchoscopy is low. Here we report on a case of pulmonary actinomycosis for which we performed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to examine a lung shadow and we were able to diagnose pulmonary actinomycosis through histopathological and bacteriological examination. Case. The patient was a 32-year-old male who was experiencing a dry cough from approximately three months prior to a hospital visit. Two months later, he underwent plain chest radiography and was informed of the presence of an abnormal shadow. The dry cough subsequently worsened and chest radiographs taken at another hospital suggested lung cancer. The patient was subsequently referred to our hospital and examined in July 2013. Chest computed tomography (CT) indicated a tumoral lesion with somewhat indistinct borders extending from the right superior lobe S^2 to the inferior lobe S^6. It was decided that an approach with conventional bronchoscopy would be difficult. Transbronchial detecting of the lesion was possible with convex probe endobronchial ultrasound (CP-EBUS) of the same region, and EBUS-TBNA was performed. Histopathological findings revealed a relatively large bacterial mass (druzen) surrounded by neutrophils, with morphological findings suggestive of actinomycetes. Therefore, EBUS-TBNA was repeated to obtain a definitive bacteriological diagnosis. Therefore, we were able to prove that the pathogen was Actinomyces israelii and diagnosed the patient with pulmonary actinomycosis. Conclusion. With EBUS-TBNA, specimens were collected with minimal invasiveness from the lesion focus, tissue culture was conducted, and we were able to reach a diagnosis of pulmonary actinomycosis. Pulmonary actinomycosis can be diagnosed with EBUS-TBNA. When improvement is observed with long-term antibacterial treatment, surgical resection is sometimes unnecessary.

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Background. Tracheobronchial metastasis of colon cancer is rare and its poor prognosis can oncological emergencies. Case. An 82-year-old man who presented with bloody sputum and dyspnea was admitted. He received rectal cancer resection 4 years previously and bilateral pulmonary metastasis resection 2 years before the present admission. His chest CT scan showed multiple tumors in the trachea, the left main bronchus and the right lower lobe of the lung. Bronchoscopy revealed that a polypoid tumor obstructing the left main bronchus accompanied with longitudinal stenosis of the trachea. We considered that his endotracheal cancer could not be resected, and we decided to employ airway intervention as palliative treatment. We maintained his airway with a rigid bronchoscope, excised the protruding tumors by electrosurgical snaring, and inserted an expandable metallic covered stent. His clinical symptoms disappeared after the intervention although his cancer was still remained. According to the guidelines of colorectal cancer treatment, chemotherapy was strongly recommended for his status. Conclusion. Since tracheobronchial metastasis of rectal cancer show poor resectability, airway intervention could provide a better quality of life.

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Background. Measurement of adenosine deaminase (ADA) is useful to diagnose tuberculous pleurisy, but some cases have low pleural effusion ADA levels. Case. A 93-year-old woman had undergone chemotherapy for malignant lymphoma of the small intestine, which did not relapse after chemotherapy. She was admitted to our hospital with right chest pain and dyspnea caused by a right pleural effusion. After admission, thoracentesis was performed, and the pleural effusion was found to be exudative and lymphocyte-dominant, with a low ADA level and no malignancy. Thoracoscopy was then performed under local anesthesia, and many yellowish-white, small nodules were seen on the parietal and visceral pleura. Microscopic examination of the pleural specimens showed epithelioid granuloma with caseous necrosis, yielding a diagnosis of tuberculous pleurisy. Her symptoms improved and the right pleural effusion decreased with INH, RFP, and EB treatment. Conclusion. Even in elderly patients, thoracoscopy under local anesthesia can be safe and useful for diagnosing tuberculous pleurisy.

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Background. Invasive thymoma displaying polypoid growth due to endobronchial metastasis is rare. Case. A 70-year-old man was found to have a mediastinal tumor 60 mm in diameter and multiple nodules in bilateral lung fields. Thymectomy and pulmonary wedge resection of the left lower lobe were performed, and histological examination showed a thymoma (type A, the WHO classification) with multiple lung metastasis (stage IVb, the Masaoka staging system). Six years after surgery, the thymoma metastasized to the left lower bronchus and displayed endobronchial polypoid growth. Bronchoscopic resection of the polypoid lesion was performed using a high-frequency electrosurgical snare. Chemoradiotherapy was performed by respiratory oncologists but the tumor developed again three years later. Bronchoscopic resection was performed using a high-frequency electrosurgical knife again. Three days after resection, a covered expandable metallic stent was placed in the left main bronchus to maintain the airway. Conclusion. Thymoma with endobronchial metastasis is rare. In the present case, bronchoscopic resection using a high-frequency electrosurgical knife followed by expandable metallic stent placement was effective.

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Background. Pulmonary vein stenosis is a rare disease that can occur congenitally or postoperatively. It occurs following surgical procedures such as catheter ablation or total anomalous pulmonary venous connection repair. Case. A 57-year-old man underwent treatment with catheter ablation for paroxysmal atrial fibrillation in April 2008 and April 2010. From January 2011, the patient frequently began exhibiting bloody sputum. A chest CT scan taken in August 2011 revealed alveolar opacity, ground-glass opacity, and interlobular septal thickening in the left lobes. Chest enhanced CT scan also demonstrated complete occulusion in the left upper lobe and stenosis in the left lower lobe. The lung ventilation-perfusion scan revealed the mismatch between normal ventilation and decreased left pulmonary blood flow. Furthermore, stenosis of the left inferior pulmonary vein was revealed by trans-esophageal echocardiography. In addition, bronchoscopy revealed edematous change of bronchial mucosa and an increase in submucosal vascularity. The patient was conclusively diagnosed with left pulmonary vein stenosis complicating atrial fibrillation catheter ablation, which caused the bloody sputum. Insertion of a stent into the stenotic region made the narrowed pulmonary vein open up. Conclusion. While there are many causes for bloody sputum, iatrogenic pulmonary vein stenosis should be differentiated when patients have a history of procedures such as ablation, as in the present case.

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Background. Tracheal tumors are rare, and since it is difficult to distinguish them by plain chest X-ray, most cases require chest CT for diagnosis. It is well known that narrowing of the central airway reveals flattening of the limbs of the flow-volume loop. But there are few reports investigating the characteristics of forced oscillation technique (FOT) in these settings. Case. A-52-year-old woman was referred to our hospital because of gradually progressing dyspnea. She had been treated for bronchial asthma, but her condition worsened. There were no abnormal findings in exhaled nitric oxygen, chest X-ray, and laboratory findings except flattening of limbs on spirometry and increasing resistance measured by the FOT with MostGragh. Chest CT demonstrated round mass in the trachea, which was diagnosed as adenoid cystic carcinoma. Intervention with laser ablation improved the stenosis and thereby her physical findings, peak expiratory flow, and resistance measured by FOT increased. Conclusions. Narrowing of the central airway shows increasing of the resistance measured by FOT. So, in addition to the chest CT and spirometry, FOT may be useful in the diagnosis and evaluation of the treatment of tracheal tumors.

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Case. A 67-year-old man initially presented for further examination of a tumor shadow in his right upper lobe, detected during a health check. A forceps biopsy via bronchoscopy revealed necrosis only and no specific diagnosis was obtained. Following this, he was referred to our hospital. His chest radiography and contrast-enhanced computed tomography (CT) showed an infiltrative shadow with an air-bronchogram, and a low-attenuation area in the infiltrates. A percutaneous biopsy under ultrasonic guidance detected two species of bacteria and necrosis, with no evidence of malignancy. We diagnosed lung abscess with bacterial pneumonia, and treated him with antibiotics (piperacillin/tazobactam, 13.5 g/day) for two weeks. However, chest CT showed exacerbation of the infiltrative shadows. We performed a right upper lobectomy because we thought his disease was medically intractable. Pathological examination of the resected material revealed pleomorphic carcinoma with suppurative inflammation inside the tumor and extensive organizing pneumonia around the tumor. Conclusion. This was an instructive case on the differential diagnosis between pleomorphic carcinoma and a lung abscess, and that between bacterial and organizing pneumonia.

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Background. Diagnosing endobronchial tuberculosis is associated with potential clinical pitfalls, as the disease lacks specific clinical and imaging features. In this report, we describe a difficult case of endobronchial tuberculosis presenting with left lower lobe atelectasis that was ultimately diagnosed on bronchoscopy for suspected lung cancer. Case. A 61-year-old man with a chief complaint of coughing was found to have left lower lobe atelectasis on chest imaging. The sialyl Lewis X (SLX) level was elevated, and positron emission tomography computed tomography (PET-CT) showed a high uptake in the airway wall, extending from the left lower bronchus to the site of peripheral pulmonary atelectasis. In addition, bronchoscopy revealed occlusion of the left basal bronchus by white-coated protruding lesions, and a diagnosis of endobronchial tuberculosis was made based on the findings of acid-fast staining and Mycobacterium tuberculosis polymerase chain reaction (PCR) of the patient's suctioned sputum. The pulmonary atelectasis disappeared after anti-tuberculosis chemotherapy, and a retrospective review of the imaging findings suggested the possibility of endobronchial tuberculosis, including features of bronchial wall thickening on CT and accumulation patterns on PET-CT. Conclusions. It is important to recognize the possibility of endobronchial tuberculosis in cases of atelectasis and carefully evaluate the imaging findings.

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