Background. The use of stereotactic body radiotherapy (SBRT) is useful in the treatment of stage I non-small cell lung cancer, metastatic lung tumors, and patients in whom surgery or chemotherapy is not recommended due to complications or advanced age. SBRT precisely targets and delivers radiation to the tumor despite the movement of the tumor during respiration using methods that track respiratory tumor motion; thus, it has a decreased effect on the surrounding normal tissue. One of the methods is real-time tumor-tracking radiotherapy (RTRT). When the tumor movement exceeds 10 mm during respiration, four gold markers are placed within 3 cm from the edge of the tumor, and only when the marker reaches the desired position, is the treatment beam activated. Aim and Methods. We aimed to evaluate the safety and efficacy of the gold marker placement and RTRT. Patients in whom gold markers were placed and RTRT was performed at our hospital between February, 2013 and August, 2015 were retrospectively evaluated. Results. Gold markers were placed in 25 patients with age 41-88 years. There was only one patient in whom marker placement was disrupted by bleeding, and the respiratory condition of the patient stabilized the following day. For one patient, one marker was lost during placement. Before the treatment was initiated, 4 patients lost their markers and 2 needed a second placement. Marker placement was cancelled for one patient as SBRT was performed instead. No markers were lost between the planning of computed tomography and the end of the treatment. Radiation pneumonitis occurred in 18 patients (Common Terminology Criteria for Adverse Events Grade 1: 13 cases and Grade 2: 5 cases). The observation periods ranged from 4 to 31 months (with a median of 22 months), and the local control rate was 100%. The 1-year survival rate was 95.6%. Conclusion. RTRT and gold marker placement are safe with few complications and deliver good treatment results.

Introduction. Recently, the number of limited surgeries such as partial resections and segmentectomies has increased concurrent with the increasing rate of small lung cancer. Ensuring accurate surgical margins is an important aspect of limited surgery. Various methods for lung marking have been reported, and we chose to use virtual-assisted lung mapping (VAL-MAP). With this technique, virtual bronchoscopy is performed via computed tomography images using a free imaging software program, and preoperative transbronchial lung markings are made under virtual bronchoscopy guidance. We herein report the usefulness of this method. Patients and Methods. From February 2014 to March 2016, 35 cases (39 lesions) underwent pulmonary resection after preoperative VAL-MAP. A total of 106 markings (average of 2.7 markings per lesion) were made. We will describe the detailed VAL-MAP method. Result. Of the 106 markings, 87 (82.1%) were identified during surgery, and lung resection was safely done in all cases, with only 1 complication (mild pneumothorax; 2.9%). The surgery completion rate was almost identical to that using the conventional VAL-MAP method. Conclusion. VAL-MAP using free imaging software program was useful for preoperative lung marking.

Background. Since the diagnosis of pulmonary malignant lymphoma can be difficult to establish with a transbronchial biopsy, it is often necessary to obtain specimens by a surgical lung biopsy. The aim of this study was to describe the utility of bronchoscopy for the diagnosis of malignant lymphoma in our hospital. Materials and Methods. We retrospectively reviewed the medical records of 16 patients with pathologically proven malignant lymphoma. The patients underwent bronchoscopic examinations from 2009 to 2015. Results. There were 5 male and 11 female patients in the study, with a median age of 70 years (range, 20-82 years). Six patients were diagnosed with mucosa-associated lymphoid tissue lymphomas, eight with diffuse large B-cell lymphoma, and two with Hodgkin's lymphoma. The chest computed tomography (CT) findings were variable and included a pulmonary mass (≥3 cm) in 7 patients and mass-like consolidation in 5 patients. Specimens for a definitive diagnosis were obtained by a transbronchial biopsy (n=9), surgical lung biopsy (n=5), CT-guided needle biopsy (n=1), and lymph node biopsy via mediastinoscopy (n=1). Six patients underwent an endobronchial lesion biopsy, and in 5 patients, a transbronchial biopsy provided the definitive diagnosis. Conclusion. In our hospital, 9 patients received a definitive diagnosis of malignant lymphoma thanks to a transbronchial biopsy. A biopsy from an endobronchial lesion was useful for the diagnosis of malignant lymphoma.

Background. Local anesthetic thoracoscopy is a procedure that can be performed by internists, as evidenced by many conference presentations and numerous articles. However, few reports discuss the degree of procedure difficulty. Subjects. A survey was conducted among 31 junior doctors who performed local anesthetic thoracoscopy examinations in patients with unexplained pleural effusion between March, 2008 and November, 2016. The doctors were asked to take the survey after performing the thoracoscopy examination, and the degree of difficulty they experienced in the procedure was assessed. The survey results were scored and analyzed by the Kruskal-Wallis test, where P<0.05 was considered statistically significant. Results. Thirty-one junior doctors (18 men and 13 women) performed thoracoscopy surgeries. The median number of years since becoming a doctor was 4 (range: 3 to 6), and the median duration of the thoracoscopy examination was 43 minutes (range: 28 to 66 minutes). The examination led to the diagnosis of several diseases, including pleural metastasis of lung adenocarcinoma (n=7), tuberculous pleurisy (n=7), and malignant pleural mesothelioma (n=4). Ten items in the survey were significantly different among respondents (P<0.001) according to the Kruskal-Wallis test. The most difficult part of operation process was maneuvering the optical fiber, and the second-most difficult part was ascertaining the thoracic cavity findings. In addition, maneuvering the optical fiber was significantly more difficult (P<0.025) in malignant diseases than in benign diseases, based on the Mann-Whitney U test results. Regarding the reason for this difference in difficulty, diffuse nodules are observed throughout the parietal pleura in cases of tuberculous pleurisy, but in pleural metastasis of lung adenocarcinoma, masses are localized in some cases. Conclusion. The most difficult part of the procedure in this study was maneuvering the optical fiber, and the second-most difficult part was ascertaining the thoracic cavity findings.

Case. A 75-year-old male patient visited our hospital due to an abnormal shadow found on chest X-ray taken at a health checkup. Since primary lung cancer was suspected based on chest plain computed tomography (CT) images, respiratory endoscopy using endobronchial ultrasonography with a guide sheath (EBUS-GS) was performed. On ultrasound scanning, high-luminance ultrasound images showed solid diffuse lesions with internal heterogeneity, therefore a transbronchial lung biopsy was performed for the lesion sites. The patient was subsequently diagnosed with pulmonary amyloidosis based on the pathologic findings. After whole body screening, localized nodular pulmonary amyloidosis was diagnosed. Since the patient had no subjective symptoms, follow-up observation was performed after the diagnosis. However, the lesions showed an increasing trend after five months of follow-up observation, so thoracotomy for partial pneumonectomy was performed for total resection of the lesions. The diagnosis of nodular pulmonary amyloidosis was supported by the resected pathology specimen, and there has been no recurrence in the five months since resection. Conclusion. We experienced a case in which localized nodular pulmonary amyloidosis was diagnosed based on the results of EBUS-GS, which was performed to treat an abnormality detected during a health checkup.

Background. There have been few case reports regarding the long-term follow-up of tracheal stents. Case. A 40-year-old woman took organic phosphorus to commit suicide. She needed mechanical ventilation support and underwent tracheostomy. She was found to have airway stenosis due to a granulation tissue lesion, and a T-tube stent was left in place after laser and balloon dilation. Destruction of tracheal cartilage was observed by radial probe endobronchial ultrasound. A silicone stent was used to replace a T-tube. Frequent silicone stent exchange and laser resection were necessary. We fixed the silicone stent to the trachea using nylon sutures, which enabled long-term stenting without the need for bronchial toilet. Twelve and a half years later, the patient presented to our hospital complaining of breathing difficulty. A bronchoscopic examination revealed granulation tissue at the caudal end of the stent. After the removal of the stent and granulation tissue, airway obstruction and stenosis were not observed. Re-insertion of the stent was not carried out. After 12.5 years of stenting, her trachea was thought to have sclerosed, probably due to scar formation around the trachea and aging. Conclusion. The removal of tracheal stenting was successfully performed after the longest stenting duration on record, namely 12.5 years.

Background. Benign asbestos pleural effusion, which is non-tumor associated effusion caused by exposure to asbestos, has the diagnostic criteria of direct or indirect exposure to asbestos, a lack of evidence of any other disease related to pleural effusion, and a lack of malignant tumor detected within 3 years after the detection of effusion. We herein report 3 cases identified by autopsy. Case. Each case developed synchronous or asynchronous bilateral effusion, leading to restrictive ventilator impairment by progressive thickening of the pleura, and subsequently died of pneumonia or respiratory failure. The duration from the first detection of effusion to death was within 3 years for all cases (9 months, 29 months and 15 months). Conclusion. Because of the progressive nature and poor prognosis of benign asbestos pleural effusion, careful follow-up is necessary. We also found thoracoscopy to be invaluable in the diagnosis process.

Background. Granulomatosis with polyangiitis (GPA) is a rare disease, and its clinical diagnosis can occasionally be difficult. Case. A 63-year-old woman was examined at our hospital for cough with excessive sputum production. Chest computed tomography (CT) revealed multiple masses in the bilateral lower lobes of the lungs. Bronchoscopy and a CT-guided needle biopsy revealed no significant findings; however, lung cancer was suspected. After 2 months, she developed a fever with a temperature of 38°C on consecutive days. Repeat chest CT revealed enlarged masses with cavitation in the right lower lobe. On repeat bronchoscopy, a histological examination showed multinucleated giant cells, necrotic tissue with neutrophils, and granuloma formation. Elevated levels of serum proteinase-3-antineutrophil cytoplasmic antibody (11.9 U/ml) were found on blood testing. GPA was eventually diagnosed. Conclusion. GPA should be considered in patients presenting with multiple masses in the bilateral lungs.

Background. Endobronchial hamartoma is a relatively rare disorder, and most cases have been observed in central bronchi. We report a case of endobronchial hamartoma in the peripheral bronchus observed directly by an ultra-thin bronchoscope. Case. A 66-year-old man presented at another hospital complaining of dry cough. He was referred to our hospital with a diagnosis of a small bronchial nodule in the right middle lobe on chest computed tomography. Ultra-thin bronchoscopy revealed a yellowish white polypoid lesion in the right B⁵aiβxx. We did not perform bronchial biopsy, because of the risk of bleeding. Later, right middle lobectomy was performed. The resected tumor was diagnosed as chondromatous hamartoma. Conclusion. We observed endobronchial hamartoma in the peripheral bronchus by an ultra-thin bronchoscope. The ultra-thin bronchoscope is useful in the differential diagnosis of disorders in the peripheral bronchus.