Background. Indications for surgical treatment have not been clarified for patients with cN2 non-small cell lung cancer (NSCLC). In the validation of surgical outcomes of cN2/pN2, better results have been obtained from patients with single-station-pN2 (single pN2) compared with patients with multiple-station-pN2 (multiple pN2). Therefore, patients with single cN2 have a possibility of better prognosis by surgical treatment, and the diagnosis of N-factor, including the number of metastatic station, seems to be important. However, it is difficult to determine the number of metastatic mediastinal lymph node stations using CT or PET-CT. Purpose. To examine the usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of N-factor, including the number of metastatic stations, in NSCLC patients suspected of having mediastinal lymph node metastasis on CT or PET-CT. Patients and Methods. The subjects were 64 NSCLC patients, who were suspected to have metastatic mediastinal lymph node stations based on their imaging assessment. They had undergone EBUS-TBNA for the diagnosis of N-factor, including the number of metastatic stations, in the 7-year period between April 2007 and March 2014. Their outcomes were examined retrospectively. Results. When evaluation was performed using imaging alone, 33/64 patients had single N2 disease and 31/64 patients had multiple N2 or N3 disease. When EBUS-TBNA was performed, 38/64, 8/64, and 18/64 patients were found to have cN0-1, single cN2, and multiple cN2 or cN3 disease, respectively. Resection was performed in 46 patients with cN0-1 or single cN2 disease, and 31/64, 10/46, and 5/46 patients were given diagnosis of pN0-1, single pN2, and multiple pN2 disease, respectively. Except for 17 patients with multiple pN2 or pN3, in 14 patients (pN0-1: 10 patients, single pN2: 4 patients), the therapeutic strategy was changed to surgical treatment due to EBUS-TBNA. Conclusion. The results of this study showed that the addition of EBUS-TBNA to CT or PET-CT was useful in improving the diagnosis of N-factor, including the number of metastatic stations, and in changing the therapeutic strategy to surgical treatment.

View full abstract

Background. There are 2 streams of bronchial branching; the axial branches bifurcate to the same size, and the smaller branches (lateral branches) fill the empty spaces between the axial branches. Case. A man aged about 60 had rectal cancer (pT1N0M0, pStage I), and underwent low anterior resection 2 years ago. The following year, a nodule was found in right segment 4 on chest CT images. On chest CT images obtained with a 64-multidetector (0.5 mm slice and 0.4 pitch), the lateral branch from the right B^4ai was connected to peripheral lesion of 14 by 10 mm peripheral lesion. Endobronchial ultrasonography using a guide sheath (EBUS-GS) was performed. A thin bronchoscope 4 mm in the external diameter was inserted in the right B^4ai and showed obstruction of the lateral branch of B^4ai. About 7 ml of saline was injected into B^4ai and expanded the orifice of the lateral branch. The ultrasonic probe was inserted into the lesion and specimens were obtained through the guide sheath. The pathological diagnosis was adenocarcinoma. Conclusion. Before the bronchoscopic procedure, we could plan to reach to the peripheral lesion through the lateral branch.

View full abstract

Background. Pulmonary fibrosis of Hermansky-Pudlak syndrome is usually distributed diffusely and symmetrically; asymmetrical progression of pulmonary fibrosis is rarely seen. Case. A 47-year-old man, given a diagnosis of pulmonary fibrosis based on his chest radiograph of February 2010, was admitted in December 2011. On admission, a chest radiograph showed bilateral interstitial infiltrates, and a chest computed tomography image revealed that the distribution of fibrosis had progressively worsened. From childhood, the patient had oculocutaneous albinism, horizontal nystagmus, and bleeding diathesis. Abnormal platelets with empty dense granules were observed by electron microscopy, and those findings led us to diagnose his disease as Hermansky-Pudlak syndrome. Although we treated with N-acetyl cysteine and pirfenidone, dyspnea has worsened. Moreover, ventilation/perfusion lung scintigraphy showed both ventilation and perfusion deficits on the left lung, in addition to progressive left lung dominant fibrosis. Conclusion. We encountered a Hermansky-Pudlak syndrome patient with asymmetrically progressed pulmonary fibrosis.

View full abstract

Background. Primary tracheobronchial mucosa-associated lymphoid tissue (MALT) lymphoma is an uncommon disease. We report a case in which temporary use of a silicone stent was very effective for severe airway stenosis caused by tracheal tumors. Case. A 75-year-old man was admitted to our hospital with dyspnea. Chest computed tomography (CT) showed eccentric thickening of the bronchial wall and intraluminal stenosis. Bronchoscopic examination revealed multiple polypoid tumors with a cobblestone appearance in the trachea, which caused remarkable stenosis. Results. Using a rigid bronchoscope under general anesthesia, we cored out the tumors and obtained some samples. At the same time, we implanted a Dumon-Y stent to relieve the airway stenosis. After stenting, dyspnea was significantly relieved. Based on the pathological findings and the absence of any other lesions on detailed systemic examinations, we finally diagnosed primary tracheobronchial MALT lymphoma. The tracheobronchial tumors responded to treatment with rituximab and the stent was removed 8 months later. The patient has been in complete remission for more than 5 years. Conclusion. Temporary use of a silicone stent can be an effective treatment option for patients with MALT lymphoma who have severe airway stenosis caused by the tumors.

View full abstract

Background. Cases of synchronous multiple lung cancer are increasing, because of greater frequency of periodic medical checkups and opportunities to receive CT scans. Case. An 81-year-old man was referred to our hospital for an abnormal opacity detected on chest CT. Chest CT revealed a nodular lesion in the lower lobe of the right lung, as well as right hilar and mediastinal lymphadenopathy. FDG-PET revealed distinct accumulation in the lesion in the lower lobe of the right lung and in the enlarged hilar-mediastinal lymph nodes. Transbronchial lung biopsy of the nodule yielded a diagnosis of squamous cell carcinoma. Ultrasound-guided transbronchial needle aspiration of an enlarged mediastinal lymph node revealed a diagnosis of small cell carcinoma. Conclusions. When performing bronchoscopy for multiple lesions showing distinct accumulation on FDG-PET, synchronous multiple lung cancer or the presence of entirely different diseases should be considered and adequate biopsy for each of the lesions should be performed.

View full abstract

Background. Mesalazine (Pentasa^[○!R]) is a drug used for treatment of inflammatory bowel diseases. We report a case of mesalazine-induced eosinophilic pneumonia. Case. A 74-year-old man was found to have ulcerative colitis and administration of mesalazine was started. He returned with fever and cough one month after the start of mesalazine administration. Based on the findings of ground-glass opacities and infiltrative shadows in both the upper lung fields on chest CT, increase in the number of eosinophils in the bronchoalveolar lavage fluid, and lymphocyte and eosinophil infiltration of the alveoli on transbronchial lung biopsy, we diagnosed drug-related eosinophilic pneumonia caused by mesalazine. The clinical condition and chest radiographic findings improved after the mesalazine was withdrawn and prednisolone (0.5 mg/kg/day) treatment was started. Conclusions. While the occurrence of a drug-related pulmonary disorder caused by mesalazine is rare, in cases of pulmonary lesions occurring in patients with inflammatory bowel disease, the differential diagnosis should include not only infectious diseases and extracolonic manifestations of inflammatory bowel diseases, but also the possibility of a drug-related pulmonary disorder.

View full abstract

Background. The occurrence of late bronchial fistula more than 10 years after lung resection is rare. Case. A 70-year-old man had received right upper lobectomy due to tuberculosis 30 years previously. He also had received completion pneumonectomy for lung cancer (squamous cell carcinoma) 12 years previously. He was admitted to our hospital because of cough and low grade fever in September, 2008. His chest CT showed the presence of right bronchopleural fistula. We attempted the closure of the bronchial fistula with interventional procedures using bronchoscopes, but the fistula did not close. Then we performed fenestration, and the infected wound was periodically cleaned by changing the dressing for about two months. The wound was closed by thoracoplasty and latissimus dorsi muscle flap patch, but re-fenestration was performed because of the recurrence of the fistula. When we removed the residual non-absorbable sutures in the bronchial stump from the open wound, the fistula closed spontaneously. Pedicled omentopexy with thoracoplasty was performed in February, 2010. The postoperative course was uneventful, without recurrence of the bronchopleural fistula. Conclusion. The residual non-absorbable sutures in the bronchial stump are believed to have affected the healing of the fistula in this case.

View full abstract

Background. Multiple primary lung cancer is observed in approximately 1-2% of all lung cancer cases, and the number of patients with multiple lung cancer is increasing as diagnostic imaging technology improves. We report a patient found to have double primary lung cancer of squamous cell and small cell histologies using a bronchoscope. The patient received curative treatment for both lung cancers. Case. A 74-year-old man was admitted to our hospital with precordial discomfort. Chest computed tomography (CT) revealed tumor shadows in the left upper and right lower lobes, in addition to right hilar lymph-node swelling. Transbronchial biopsy of a left B^3c tumor revealed squamous cell carcinoma in the left upper lobe and transbronchial needle aspiration cytology of a right #11i lymph node revealed small cell carcinoma in the right lower lobe and right hilar lymph-node metastasis. He underwent curative resection of the left upper lung and concurrent chemoradiotherapy for the small cell carcinoma of the right lung. Result. Although the concurrent chemoradiotherapy was discontinued due to the suspicion of drug-induced interstitial pneumonia after the completion of the second cycle of chemotherapy, both tumors were well controlled. Conclusion. We successfully conducted curative treatment for synchronous bronchoscopically diagnosed double primary lung cancer in the patient.

View full abstract

Background. Cases of resectable solitary lung metastasis from pancreatic cancer are very rare. Cases. Case 1: A 53-year-old woman underwent surgery for pancreatic cancer in 2004. Five years after the operation, a solitary tumor, suspected to be metastatic lung cancer based on the cytodiagnosis of a preoperative bronchoscopic examination, was pointed out in the right upper lobe (S^2) on CT. We performed bilobectomy of the right upper and middle lobes due to the completely fused minor fissure. As of December 2014, she has been free of recurrence for more than 5 years. Case 2: An 81-year-old woman, who had undergone surgery for recurrence for 3 years, was noted to have an abnormal shadow on a chest CT. Further workup, including fluorine-18-fluorodeoxyglucose-PET, which revealed two masses in the right upper (S^1) and middle lobe (S^4). The mass in the middle lobe was suspected to be metastatic lung cancer based on the cytodiagnosis of a preoperative bronchoscopic examination specimen. We performed VATS lobectomy of the right middle lobe, and partial resection of the upper lobe. The pathological diagnosis revealed metastatic lung cancer in both of the upper and middle tumors. As of December 2014, she had local recurrence in right lower lobe. Conclusion. If solitary lung metastasis is found, we consider that a preoperative bronchoscopic examination is required.

View full abstract

Introduction. There are several devices for removing airway foreign bodies using flexible bronchoscopy. Therefore, making an appropriate choice in each situation is important. Here, we present two patients with dental crowns as airway foreign bodies, which were successfully removed by a snare loop device. Cases. Case 1: An 85-year-old man was admitted to our hospital because of an airway foreign body, consisting of a dental crown in the left main bronchus. He aspirated the crown during dental treatment, but he had no respiratory symptoms. Case 2: A 71-year-old man was admitted to our hospital and underwent tracheostomy because of cerebral hemorrhage sequelae. He suddenly demonstrated tachypnea and cyanosis. Chest X-ray was performed, and showed that he had aspirated a dental crown. In both cases, we tried to remove the crowns with flexible bronchofiberscopy using grapsing or basket-type forceps in combination with a balloon, but we were unsuccessful. Therefore, we tried the snare loop device and easily caught the proximal portion of the dental crown in the wire loop portion. We moved the crowns to the trachea, and finally removed them with an intubation tube. Conclusion. The snare loop device may be a useful option for removing airway foreign bodies.

View full abstract

Background. An endobronchial leiomyoma is a rare benign pulmonary tumor. Case. A 63-year-old man experienced bloody sputum and was referred to our hospital in June 2014. A chest CT scan demonstrated ground glass opacities in the right middle and lower lobes, which were considered to be due to aspiration. A pedunculated polyp was found at the entrance of the right lower bronchus (B^<10>), which was accompanied by bleeding. A 5mm white nodular lesion with a smooth surface was found at the entrance of the left lingular bronchus. The polyp in the right lower bronchus had no evidence of malignancy and was diagnosed as an inflammatory polyp. Three weeks later, bronchoscopic reexamination was performed, revealing that the polyp was no longer present. At this time, a biopsy of the nodular lesion in the left lingular bronchus was performed. Histopathologic findings were spindle-shaped tumor cells growing in crossing bundles, and these tumor cells were positive for α-SMA and desmin by immunohistochemical examination, leading to the diagnosis of an endobronchial leiomyoma. Conclusion. A case of endobronchial leiomyoma was serendipitously discovered during a thorough examination for hemosputum. Numbers of incidentally-found cases with bronchoscopy are increasing recently. We believe that careful observation of the whole bronchial tree by bronchoscopy is important even if preceding diagnostic imaging, including CT scans, do not show any signs of abnormalities.

View full abstract

Background. Pulmonary tumor thrombotic microangiopathy (PTTM) is caused by obstruction of pulmonary arterioles with microembolisms of tumor cells and thrombi, and manifests as rapidly progressive pulmonary hypertension and hypoxia. Case. A 78-year-old woman, who had been operated on for gastric cancer at the age of 76 years, consulted our hospital complaining of cough and respiratory distress on exercise since a month. She had severe hypoxia with an oxygen saturation of 86% when breathing room air, but her pulmonary function test revealed only slight impairment of diffusing capacity. Ultrasound cardiography showed severe pulmonary hypertension. Her respiratory and circulatory state deteriorated rapidly, and she died 6 days after the first visit. Post-mortem pathology revealed moderately differentiated adenocarcinoma cells with fibrin thrombi plugging the pulmonary arterioles, which led to a diagnosis of PTTM. Conclusion. An antemortem diagnosis of PTTM is very difficult. When patients show severe hypoxia without notable radiographic findings and/or severe abnormalities of respiratory function tests, a history of malignancy and the presence of pulmonary hypertension are clues that can lead to a diagnosis of PTTM.

View full abstract

Background. Established precautions or treatment approaches for lung abscesses that occur as a complication of transbronchial biopsy (TBB) have not been reported. Case. A 77-year-old man presented with cough. Computed tomography of the chest showed an aerated mass in the right upper lobe and right hilar regions, mediastinal lymphadenopathy, and a narrowed right superior lobe bronchus. We diagnosed lung cancer based on the TBB findings. The patient became febrile the day after the TBB and was treated with antimicrobials. However, the treatment effects were limited because the mass had partly developed into an abscess. As the cavity inside the mass grew larger, he became to present with severe hemoptysis. He underwent surgery to remove the mass, which was successful. Conclusion. Lung abscesses that are a complication of TBB of a tumor, especially those with air spaces or a narrowed bronchus, should be treated carefully. We propose that the avoidance of excessive biopsies or the brushing of this type of tumor are effective precautions. In addition, surgery to remove the mass should be actively considered in addition to the administration of antimicrobials if the abscess becomes enlarged.

View full abstract

Background. Pulmonary coccidioidomycosis is a fungal disease which is endemic in California and Arizona in the United States and Mexico. Chronic pulmonary coccidioidomycosis, mainly with nodular or cavitary lesions, were often diagnosed by surgical lung biopsies. Since laboratory workers become infected by inhalation of cultured specimens, samples suspected of containing Coccidioides must be handled with great care as a precaution. Case. A 37-year-old man who had lived in Arizona from 2008 to 2010 presented with cough and hemoptysis in January 2010. Pulmonary tuberculosis was suspected based on his chest X-ray film exhibiting a cavity in the right upper lung field. The smears of sputum and gastric juice, a tuberculosis transcription-reverse transcription concerted (TRC) reaction, and QuantiFERON^[○!R]TB-3G were all negative. Therefore, on suspicion of pulmonary coccidioidomycosis from his travel history to Arizona, we performed transbronchial lung biopsy (TBLB), which provided a histological diagnosis of coccidioidomycosis. Conclusion. Although chronic pulmonary coccidioidomycosis is rarely diagnosed by TBLB, it is important to consider the possibilities from travel history when we perform bronchoscopy of nodules or cavitary lesions.

View full abstract