Background. Talc pleurodesis is the standard treatment worldwide for malignant pleural effusions. In Japan, talc for pleurodesis was only put on the market in December 2013. Therefore, the amount of research targeted at Japanese patients is still small. Objective. To investigate the efficacy and safety, and to analyze risk factors and prognosis, of talc pleurodesis. Methods. We retrospectively analyzed 26 patients with malignant pleural effusions who underwent talc pleurodesis from January 2014 to March 2015 at our institution. All patients underwent talc slurry pleurodesis. We evaluated the efficacy according to the phase II clinical trial that was conducted prior to the sale of talc. In the analysis of the risk factors and prognosis, we entered the patients who died or were lost to follow-up in the "ineffective" group. These analyses used censoring one month after the last administration. Result. Out of the 20 patients who were not dead or lost to follow-up, the treatment was effective for 16 (80%). Out of all 26 patients, 10 patients developed a fever (38%). Other serious adverse events were not observed. Poor performance status (PS) and hypoalbuminemia were significant risk factors for poor outcomes following talc pleurodesis. This suggests that poor general condition is a risk factor for poor prognosis following pleurodesis. In the analysis of prognosis, we assigned patients to two groups, depending on PS and hypoalbuminemia, derived from an ROC curve. The groups of poor PS and hypoalbuminemia were significantly associated with a poor outcome. Conclusion. The results of our investigation on the efficacy and safety of talc pleurodesis confirm the findings of other studies. Patients with a poor general condition were at risk of poor outcomes and prognosis after the treatment. These results suggest that we need to carefully consider the status of the patients and whether we should perform pleurodesis.

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Background. We report our experience with a patient who was found to be an HTLV-1 carrier after being diagnosed with pneumocystis pneumonia. This patient's HTLV-1 infection rapidly transformed into adult T-cell leukemia/lymphoma (ATLL). Case. The patient was a 61-year-old woman who visited a local physician complaining of fever and a productive cough. Chest radiography revealed infiltration in the upper right lung field. She was given antibiotics for community-acquired pneumonia, although she was subsequently referred to our hospital, based on her lack of improvement. Chest computed tomography revealed infiltrative shadows and ground glass opacities in both upper lobes. The patient was treated for pneumocystis pneumonia after a diagnosis via bronchoscopy. Although a close examination of the underlying disease revealed that the patient was anti-HTLV-1-positive, no definitive diagnosis of ATLL was established, and the patient was diagnosed as an HTLV-1 carrier. However, blood testing with Southern blotting revealed monoclonal proliferation among the HTLV-1-infected cells. We subsequently observed rapid swelling of the inguinal lymph nodes and manifestation of a rectal tumor, which confirmed a transformation to ATLL. Conclusion. In case of opportunistic infection in HTLV-1 carriers, careful observation is important, due to the possibility of transformation into ATLL.

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Background. There have been many reports on the usefulness of endobronchial Watanabe spigot (EWS). However, additional treatment has been often needed after this procedure because of the presence of interlobar collateral ventilation. Case. A 59-year-old man was found to have interstitial pneumonia during chemotherapy for advanced lung cancer, and treatment with corticosteroid was initiated. He developed left-sided spontaneous pneumothorax. Although chest drainage was performed, the continuous pulmonary air leakage continued. We opted for treatment by bronchial occlusion with EWS rather than surgery to avoid exacerbation of the interstitial pneumonia. We determined the affected bronchus by balloon occlusion test and pleurography. There was an immediate decrease in the amount of air leakage after bronchial occlusion with the EWS. However, the leakage itself continued. We therefore performed the thoracographic fibrin glue sealing method (TGF) as an additional treatment, which stopped any further air leakage. Conclusion. The combination of EWS and TGF can be an effective treatment option for intractable pneumothorax.

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Background. Pulmonary actinomycosis sometimes forms cutaneous and pleural fistula, but it rarely demonstrates bronchopleural fistula. Case. A 70-year-old man who had undergone a right middle and lower lobectomy about 50 years previously due to tuberculosis, presented with a productive cough. A chest roentgenogram showed lung consolidation with a cavity in the right upper lung; therefore recurrent tuberculosis was initially suspected. Bronchoscopic observation revealed white necrotic substance in the resected stump of the right B⁶ and a diagnosis of pulmonary actinomycosis was confirmed based on an analysis of biopsy specimens taken from the whitish substance. The patient was given oral Sulbactam/Ampicillin and an improvement of the lesion was observed. However, hemoptysis later occurred which led us to perform bronchial artery embolization. Bronchoscopic re-observation one year later revealed the white necrotic substance in the right B⁶ to have disappeared, the lumen of both the right B² and B⁶ were dilated and formed a bronchopleural fistula. A huge grey tissue mass consisting of actinomyces was seen in the pleural space. The administration of antibiotics was continued for 40 months. Thereafter, the disease condition stabilized under observation with no further medication. Conclusion. Bronchoscopic observation made it possible to confirm the history of bronchopleural fistula formation due to pulmonary actinomycosis.

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Background. Pulmonary pneumatoceles are thin-walled, air-filled cavities that mainly occur as a complication of pulmonary infection in infants and children. Pneumatoceles caused by bronchial foreign body are rare. Case. A 70-year-old man who had been under treatment for chronic obstructive pulmonary disease and bronchial asthma was hospitalized for an asthma attack. He presented with bloody sputum the morning after the discharge. Chest radiography revealed a cavitary lesion with a niveau in the lower part of the left lung. Chest CT revealed a pneumatocele with a small volume of fluid in the left lingular lobe and foreign bodies in the left lower bronchus. Although bronchoscopic treatment was recommended, bloody sputum disappeared and soybeans which had been taken at home on the day of discharge were expectorated on a cough attack, resulting in the decreased size of the pneumatocele. Conclusion. We report a case of pneumatocele caused by bronchial foreign bodies. Soybean aspiration was the cause of the pneumatocele and bloody sputum.

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Background. Sometimes a bronchial occlusion is necessary in order to cure empyema with a bronchopleural fistula. In the case of large fistula, it is necessary to add additional techniques to the EWS. Case. A 77-year-old man received a left upper lobectomy for treatment of destroyed lung by pulmonary aspergillosis. He developed a postoperative empyema with a bronchopleural fistula, and was treated by serratus anterior plombage. After 7 years, he developed empyema with a large broncheopleural fistula. We tried occlusive bronchial fistula by EWS, but did not succeed. We can occlude the fistula with EWS made thicker in diameter by winding the absorbable suture reinforcement, and pulled the sewn nylon yarn gripping projections of the EWS from empyema cavity. We reconstructed the anterolateral thigh flap. Seven months following surgery no migration of EWS was seen. Conclusion. When the fistula part is short, antegrade placement is difficult in bronchial fistula, In this case a bioabsorbable non-woven fabric (Neoveil) sewing retrograde EWS occlusion method was useful.

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Background. Emergence of new hilar or mediastinal lymphadenopathy is common after surgical resection for lung cancer. However, there is not only the possibility of recurrence of lymph node metastasis of lung cancer but also those of other diseases. Case. A 78-year-old woman was noted to have new mediastinal lymphadenopathy with increased ¹⁸F-fluorodeoxy-glucose (FDG) uptake on positron emission tomography/computed tomography (PET/CT) scan, 15 months after surgical resection for lung cancer (pT1aN0M0, p-stage IA). Recurrence of lymph node metastasis following the resected lung cancer was assumed, but ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) revealed caseous epithelioid cell granuloma. Further, QuantiFERON^® TB-3G was positive. Therefore, mediastinal lymph node tuberculosis was diagnosed. Following 6 months of anti-tuberculous therapy, mediastinal lymph node enlargement was diminished and FDG uptake on PET/CT scan was decreased. Conclusion. We recommend obtaining adequate tissue samples by utilizing EBUS-TBNA for the definitive diagnosis of hilar or mediastinal lymphadenopathy of postoperative lung cancer.

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Background. In sarcoidosis, a solitary nodular shadow is an extremely rare and an atypical finding on chest radiography. Recently, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been established as an effective method for definitive diagnosis of mediastinal lymph node enlargement. Case. The patient in our case was a 49-year-old woman. She visited a local doctor with right back pain as a chief complaint. She was referred to our hospital initially, because chest radiography showed a 20-mm solitary nodular shadow in the right upper lung field. Chest computed tomography (CT) showed right hilar and mediastinal lymph node enlargement; 18F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET) was also performed. The findings of CT and FDG-PET strongly indicated primary lung cancer in the right upper lobe. Bronchial endoscopy and EBUS-TBNA were performed for a definitive diagnosis. The results confirmed that the solitary nodule in the right S³ was not malignant. However, a non-caseating granuloma was observed in the lymph node (#2R); EBUS-TBNA was again performed. Taken together, the findings of EBUS-TBNA and the results of subsequent detailed examinations led to a definitive diagnosis of sarcoidosis. Conclusion. When bronchial endoscopy and EBUS-TBNA are performed for a solitary nodular shadow, which shows strong positive FDG findings, the occurrence of sarcoidosis as a differential diagnosis needs to be confirmed in examinations, even though sarcoidosis is very rare.

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