Background. Pleomorphic carcinoma of the lung is often diagnosed based on its pathological characteristics assessed during an operation or at autopsy. We herein report a case of pleomorphic carcinoma of the lung that was diagnosed by a transbronchial biopsy. Case. An asymptomatic 75-year-old woman was referred to our hospital because nodular shadows were found on chest X-ray. Chest computed tomography showed a tumor shadow with a long axis of 4 cm progressing along the bronchus lumen alone with a 1.2-cm nodule. After performing a biopsy of this tumor using a bronchoscope, we diagnosed it as pleomorphic carcinoma. We performed upper lobectomy and diagnosed the patient with pleomorphic carcinoma of lung with pT2N0M0 stage IB and hamartoma. Conclusion. This case was able to be diagnosed by a transbronchial biopsy because the tumor progressed along the bronchus lumen and consisted of spindle cells and giant cells.

Background. Inflammatory myofibroblastic tumor (IMT) is a rare tumor defined as a distinctive lesion composed of a myofibroblastic spindle cell proliferation accompanied by inflammatory infiltrates. We resected an endobronchial polypoid IMT using a high-frequency electrosurgical snare. Case. A 56-year-old man complained of cough, wheezing and bloody sputum. Chest computed tomography revealed an endobronchial tumor in the right main bronchus, and fluorine-18 fluorodeoxyglucose-positron emission tomography of the tumor showed an abnormal accumulation with a maximum standardized uptake value of 34.1, suggesting malignant potential. He was referred to our hospital for a further examination and treatment. Bronchoscopy showed a polypoid tumor arising from the cartilage portion of the right main bronchus. Endobronchial polypectomy of the tumor was performed using an electrosurgical snare with a high-frequency to generate heat. A histopathological examination of the tumor showed the proliferation of spindle cells with inflammatory infiltrates. On immunohistochemical staining, the tumor cells were positive for vimentin and anaplastic lymphoma kinase. After a month of endoscopic polypectomy, we performed coagulation using argon plasma coagulation at the surgical margin. Follow-up bronchoscopy showed no sign of recurrence after 16 months of treatment. Conclusion. Endoscopic polypectomy by electrosurgery with a high-frequency snare may be a useful method of treating endobronchial IMT.

Background. Primary endobronchial malignant lymphoma is a rare entity. Case. A 72-year-old man was referred to our hospital because chest computed tomography performed as part of a regular checkup for asbestosis showed a thickened bronchial wall extending from the left main bronchus to the secondary carina. Although he had a cough for 2 months, he did not visit a clinic. Bronchoscopy showed an irregular thickened bronchial wall extending from the left main bronchus to the secondary carina with mild stenosis of the left superior lobar branch. Mucosa-associated lymphoid tissue (MALT) lymphoma was diagnosed on the basis of biopsy specimens. We adopted a wait-and-see approach because the cough was improving and the lesion was localized to the left bronchus. Bronchoscopy performed 6 months later revealed spontaneous regression. Conclusion. Spontaneous regression of primary endobronchial MALT lymphoma was recognized during a regular checkup for asbestosis.

Background. It is emphasized that bronchoscopy is not routinely performed for airway evaluation in relapsing polychondritis because the procedure has been reported to exacerbate airway inflammation. Recently, it is considered that virtual bronchoscopy (VB) imaging can be a useful modality for noninvasive observation. We could compare flexible bronchoscopy findings with VB images, and assess the similarity between both modalities. Case. A 47-year-old woman was referred to our hospital with prolonged cough and arthralgia. The chest CT revealed thickening of the tracheal wall. Flexible bronchoscopy showed erythema and swelling of the tracheal and bronchial walls. We started oral prednisolone therapy, resulted in immediate improvement of her symptoms, so we diagnosed relapsing polychondritis. Afterward she had exacerbation of tracheal stenosis, and we placed an airway stent. Thus we could compare flexible bronchoscopy with VB findings at the same time, and the image of VB showed good concordance with that of flexible bronchoscopy. Conclusion. VB imaging can be a useful modality for evaluating the airway morphology of relapsing polychondritis noninvasively.

Background. Patients with mental disorders are likely to aspirate various objects and the characteristics vary, but the removal of material aspirated due to abnormal eating behavior by bronchoscopy has rarely been reported. Case Presentation. The patient was a 52-year-old man attending a hospital for schizophrenia. Bloody sputum was noted upon coughing during eating, and the patient visited the outpatient clinic of our hospital. Rales were heard in the right chest, and stenosis was noted in the orifice of the right upper pulmonary lobe on chest CT, for which bronchoscopy was performed. The orifice of the right upper lobe was narrowed, a foreign body was present in the airway, and it was removed using biopsy forceps. On histological examination of the foreign body, actinomycetes adhered to its surface and a few inflammatory cells were present. Squamous metaplasia was observed in the surrounding bronchial mucosa. It was subsequently clarified by an interview that he had experienced an episode of aspiration during eating 2 weeks before the episode of bloody sputum, and wheezing had appeared since then. The wheezing resolved after bronchoscopy, and stenosis in the bronchial orifice improved. His speech therapist observed abnormal eating behavior as the cause of aspiration. Conclusion. Aspiration occurred due to abnormal eating behavior. It is important to rapidly perform bronchoscopy when aspiration is suspected based on an interview and examination. Attention should be paid to the fact that aspiration occurs due to abnormal eating behavior, which is a neurologic manifestation in patients with schizophrenia, in addition to swallowing disorder.

Background. Endobronchial metastasis from malignant melanoma has been occasionally described but, in a strict sense, no report of endotracheal metastasis from amelanotic malignant melanoma (AMM) has been so far described. Case. The patient was a 93-year-old woman. On February 2004, a physical examination disclosed a reddish tumor in the heel region that was pathologically diagnosed as AMM at stage IIIB/T4aN1bM0. Therapy with cytotoxic drugs and radiation induced significant size reduction of the primary tumor and metastatic lymph nodes but subsequently the patient presented wheezing during inhalation and SpO₂ decline. The chest CT revealed an intraluminal mass in the main bronchus. A bronchoscopy study disclosed an intraluminal polypoid nodular mass with a smooth surface in the main bronchus and obstructing 90% of the trachea. Resection of the tumor using a high-frequency snare was performed through a flexible bronchoscopy followed by hemostasis with argon plasma coagulation. Pathological findings of the biopsy specimen were consistent with AMM, confirming the diagnosis of endotracheal metastasis. Residual tumor was then treated with external radiation (32 Gy/8 fr). Conclusion. Findings in this patient suggest that the tumor in the airway lumen was not caused by local spreading of cancer cells from the lungs or lymph node metastasis; therefore, in a strict sense, this is an extremely rare case of endotracheal metastasis from AMM.

Background. There have been many reports concerning the utility of the Endobronchial Watanabe Spigot (EWS). Cases. Case 1: A 63-year-old man was diagnosed with right lung cancer, malignant pleural effusion, and right pneumothorax. Conservative treatment, including chest tube drainage, failed to resolve his condition. We then attempted EWS followed by pleurodesis. The pulmonary air leaks persisted and we performed pleurodesis repeatedly, after which the air leaks disappeared. The chest tube was removed and we initiated systemic chemotherapy. Case 2: A 64-year-old man was diagnosed with right lung cancer and pulmonary aspergillosis. Systemic chemotherapy was initiated; however, left pneumothorax was detected by chest radiograph. Conservative treatment, including chest tube drainage, failed to resolve his condition. We then attempted pleurodesis with EWS and the pulmonary air leaks remained. We repeated pleurodesis, after which the air leaks disappeared. The chest tube was removed and we re-initiated systemic chemotherapy. Conclusions. EWS can be an effective treatment for advanced lung cancer with secondary spontaneous pneumothorax.

Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been reported to be a useful and safe diagnostic method, but recently there have been some reports of EBUS-TBNA-induced mediastinitis. Case. A 67-year-old man presented with a nodule in the right lower lobe and mediastinal lymphadenopathy (#7 lymph node), we suspected lung cancer. EBUS-TBNA was performed on the #7 lymph node. The patient developed a fever 2 days after the procedure. Chest computed tomography (CT) showed enlargement and inflammation of the mediastinum 5 days after the procedure, based on which acute mediastinitis was diagnosed. A therapeutic antibiotic regimen was commenced; however, mediastinitis developed on the 8 days after the EBUS-TBNA. Drainage was subsequently performed, and an antibiotic regimen continued for about 6 weeks, by the end of which the patient recovered. A mediastinal effusion culture revealed Streptococcus constellatus of Streptococcus milleri group (SMG), form part of the normal flora commonly found in the mouth. Conclusion. We reported a case of mediastinitis caused by SMG after EBUS-TBNA. In cases where there is an EBUS-TBNA of necrotic lymph nodes or failure of oral hygiene, prophylactic antibiotic use or oral care should be considered to prevent mediastinitis.

Background. Lymphadenopathy due to silicosis, is one of the rare causes of benign esophageal-bronchial fistula. We report a case of esophageal-mediastinum fistula caused by silicosis-lymphadenopathy which was difficult to distinguish from tuberculous lymphadenitis, because of a granuloma proven in a biopsy tissue during an upper gastrointestinal endoscopic examination and with a positive result of interferon-gamma release assay test. Case. A 75-year-old man with chronic hepatitis C had an upper gastrointestinal endoscopic examination screening for esophageal varices, and an esophageal ulcer was found. A contrast CT scan revealed multiple mediastinal lymphadenopathy and esophageal-mediastinum fistula. A total of 5 upper gastrointestinal endoscope examinations did not detect malignancy but only one granuloma. A positive result of interferon-gamma release assay test suggested a diagnosis of tuberculosis. However acid-fast stain tests, PCR tests and cultures were all negative. Video assisted thoracic surgical biopsy of mediastinum lymph nodes was done, and it was found that the esophageal-mediastinum fistula was due to silicosis-lymphadenopathy. We only maintained observation and confirmed that the fistula was closed. Conclusion. We report a case of esophageal-mediastinum fistula caused by silicosis-lymphadenopathy which was difficult to distinguish from tuberculous lymphadenitis.

Background. Although some cases of methotrexate (MTX)-associated lymphoproliferative disorder (LPD) have been reported, cases of MTX-LPD with pulmonary nodules are less common. In addition, cases in which bronchial nodules due to MTX-associated with LPD directly observed by bronchoscopy are extremely rare. Case. A 73-year-old woman with rheumatoid arthritis (RA) had been treated with MTX and salazosulfapyridine since June 2011. She was admitted due to sore throat and a right enlarged tonsil in November 2014 and MTX-LPD was suspected. MTX therapy for RA was therefore discontinued and her sore throat improved. However, the symptom relapsed in February 2015. Chest computed tomography (CT) in June of the same year showed multiple nodular shadows in bilateral lungs, and demonstrated the augmentation of the shadows. Therefore, she was introduced to our department and underwent bronchoscopy. The lung and bronchial biopsy findings were consistent with diffuse large B-cell lymphoma (DLBCL), and we diagnosed MTX-LPD based on the clinical course. Conclusions. Physicians should be aware of possible MTX-LPD when multiple nodules are observed in lungs and bronchi in patients with RA with MTX treatment.

Background. Pleomorphic carcinoma is defined as either a non-small cell lung carcinoma combined with neoplastic spindle and/or giant cells or a carcinoma that consists of only spindle and giant cells. At least 10% of the carcinoma should comprise spindle and/or giant cells for it to be classified as a pleomorphic carcinoma. Since it rarely occurs, few case reports have been reported. Case. A 72-year-old male visited our hospital due to exertional dyspnea. A chest X-ray and computed tomography revealed right pleural effusion and multiple pleural nodules. Based on thoracoscopic pleural biopsy, a history of asbestos exposure and his clinical course, we diagnosed malignant pleural mesothelioma. Thereafter the tumor increased expansively and he died. Autopsy confirmed a pleomorphic carcinoma of lung. Conclusions. Generally the diagnosis of pleomorphic carcinoma of lung is rarely established since it requires large tissue specimens by surgical resection and it is often diagnosed as other pulmonary tumors. The frequency of pleomorphic carcinoma of lung is rare and its clinical course is heterogeneous. Further accumulation of the number of cases is necessary.