Background. Tracheobronchomegaly (Mounier-Kuhn syndrome) is a rare disorder characterized by an abnormal enlargement of the trachea and main bronchi, and associated with recurrent respiratory tract infections. Case. A 64-year-old female patient visited our hospital due to an abnormal enlargement of the trachea and main bronchi found on chest computed tomography (CT) images taken at a local clinic. Bronchoscopy showed a dilated trachea and main bronchi with complete collapse during cough or forced expiration: tracheobronchomalacia. Bronchoscopy also revealed the granular white lesions in the right inferior lobar bronchial mucosa, a biopsy of which showed amyloid deposition. Conclusion. We experienced a case of tracheobronchomegaly with amyloid deposition.
Case. A 74-year-old man was referred to our hospital because of wheezing and dyspnea in January X. Chest computed tomography revealed multiple tracheal tumors, and bronchoscopy detected multiple tracheal neurofibromas from just below the vocal cords down to the carina. The patient underwent endotracheal stenting, but was admitted to our hospital four times within a 4-6 month period due to pneumonia. We then referred him to a dentist in our hospital where he received oral care, including scaling, brushing guidance, and removal of tongue coating for chronic periodontitis. Following discharge, he visited a local dentist every 8-10 days and brushed his teeth three times a day. He has not been readmitted due to pneumonia for 1 year and 9 months. Conclusion. Many patients suffer from recurrent pneumonia after endotracheal stenting for relief of breathlessness. Oral care, an optimal method for prevention of aspiration pneumonia, might have contributed to the prevention of pulmonary infection, and can therefore be considered as one of the effective treatments for the management of patients who have undergone endotracheal stenting.
Background. It has been suggested that patients with sarcoidosis are at an increased risk of development of cancer. Case. A 73-year-old man complaining of fever, fatigue and abnormal visual field presented with chest X-ray abnormalities. Chest CT showed bilateral multiple nodular lesions in the lung fields, tumor in the mediastinum and hilar lymphadenopathy. Positron emission tomography/computed tomography showed excessive FDG uptake in the mediastinal tumor, bilateral hilar lymph nodes, and the right testis. Bronchoscopy and transbronchial biopsy confirmed the diagnosis of sarcoidosis, and the patient was started on oral corticosteroid therapy. Since the right testis became bigger, so orchidectomy of the right testis was performed, and histopathology of the resected specimen revealed the diagnosis of malignant lymphoma. The chest CT showed enlargement of the subcarinal lymph node, and EBUS-TBNA of the lymph node revealed metastasis from the malignant lymphoma. Conclusion. Both malignant lymphoma and sarcoidosis can be associated with positive uptake on FDG-PET, making it difficult to differentiate between the two when they occur concurrently. We encountered a case of malignant lymphoma and sarcoidosis occurring concurrently, which made precise timely diagnosis difficult.
Background. The complications of bronchoplasty, including anastomotic stenoses, bronchopleural fistulae (BPF) and bronchovascular fistulae, are due to problems at the anastomotic sites. We report a case of a late-onset fistula at the distal side of the bronchial anastomosis after an extended sleeve lobectomy. Case. The patient was a 68-year-old man. His tumor originated in the hilum of the upper lobe and invaded directly to the truncus intermedius. In order to avoid a pneumonectomy, we performed an extended sleeve lobectomy; upper lobectomy, S6 segmentectomy, and double sleeve (pulmonary artery plasty and bronchoplasty). The right main bronchus, middle lobe bronchus, B7, and B8-10 were connected by a triple barrel anastomosis. The anastomotic site was wrapped with an intercostal muscle flap. One month postoperatively, bronchoscopy revealed a white coating at the bronchial anastomosis; therefore, we suspected ischemia of the bronchial anastomosis and performed hyperbaric oxygen therapy. We discovered a BPF at the distal side of the bronchial anastomosis that was not wrapped with the intercostal muscle flap. Because there were no pulmonary arteries exposed near the fistula and the dilation of the fistula cavity, we decided to observe the patient without intervening surgically. At the 3-year follow-up, there was no evidence of recurrence or enlargement of the cavity. Conclusion. This is the first case report of a BPF at the distal side of a bronchial anastomosis after bronchoplasty. Because the cavity was a localized internal fistula, we obtained a good clinical course without any surgical interventions.
Background. The diagnosis of airway foreign body aspiration in the elderly tends to be delayed with various reasons. Case. An 81-year-old woman without any previous history of pneumonia visited a medical clinic because of persistent cough for 2 months. She had wheezing on her chest and was treated for bronchial asthma, but she did not recover. The chest X-ray image showed infiltrates in her right lower lung field, and then she was came to our hospital. The chest CT images disclosed infiltrates in her right lower lobe and a low density area in the orifice of the right B8+B9+B10. The bronchoscopic examination revealed a foreign body occluding the bronchus and severe granulation tissue formation in the surrounding mucosa. After the examination, a foreign body was expectorated spontaneously and thought to be a soybean from its gross appearance, microscopic findings, and recollection of eating soybeans 9 months previously. We diagnosed soybean aspiration complicating obstructive pneumonia, and treated her with ampicillin/sulbactam and prednisolone for 7 days, then the chronic cough improved and the granulation in the bronchial mucosa and the pneumonic shadow disappeared. Conclusion. Clinicians should consider airway foreign bodies in the elderly who have chronic cough even if they are not aware of aspiration and the foreign bodies are not visible on plain film.
Background. We report a case in which tracheal stenosis and granulomatous polyp were managed through appropriate treatment of Kommerell's diverticulum. Case. A 76-year-old man had undergone total arch replacement and thoracic endovascular aortic repair (TEVAR) for a Kommerell's diverticulum in 2015. He experienced respiratory difficulty in 2017. As his symptoms did not improve, he underwent chest computed tomography (CT) and bronchoscopy; the patient was then transferred to our department and hospitalized owing to suspicions of a tracheal tumor. Considering the possibility of tracheal stenosis due to the enlargement of Kommerell's diverticulum resulting from an endoleak, the patient underwent a second TEVAR. Bronchoscopic biopsy was performed after total interruption of blood flow into the Kommerell's diverticulum. A polyp-like lesion was identified in the lower trachea; histopathological examination revealed a granulated tissue lesion. Extubation was performed on postoperative day 3, after which improvement was noted in the tracheal stenosis caused by the granulomatous polyp. The granulomatous polyp improved by tracheal tube compression and biopsy. CT and bronchoscopy performed 2 months postoperatively revealed no tracheal stenosis caused by compression of the Kommerell's diverticulum. Conclusions. Kommerell's diverticulum is an extremely rare condition characterized by an abnormal protrusion in the left subclavian artery with localized cystic dilatation. As the enlargement of a Kommerell's diverticulum can result in severe tracheal stenosis, determining the appropriate treatment strategy is of paramount importance.
Background. Pulmonary carcinosarcoma is a rare primary lung malignancy, with an admixture of carcinomatous and sarcomatous components. When the carcinomatous element is fetal adenocarcinoma, we must distinguish carcinosarcoma from pulmonary blastoma. It is difficult to diagnose them from small biopsies. Case. A 71-year-old man presented, complaining of exertional dyspnea and left chest and back pain for 2 months. A chest X-ray revealed left pleural effusion. In pleural effusion, there were atypical cells with eccentric nuclei, consistent with adenocarcinoma. Thoracoscopy performed under local anesthesia showed many polypoid lesions of visceral and parietal pleura. Biopsy of the lesion revealed a biphasic structure with epithelial cells and mesenchymal spindle cells which was diagnosed as blastomatoid pulmonary carcinosarcoma. Conclusion. We reported a case of blastomatoid pulmonary carcinosarcoma diagnosed by thoracoscopy under local anesthesia.
Background. Bronchopleural fistula after lung resection for lung cancer is a highly morbid complication. The treatment of this complication remains a challenge for thoracic surgeons, and few reports have shown spontaneous recovery of a completely opened bronchopleural fistula with conservative therapy. Case. A 66-year-old man underwent a right lower lobectomy for primary lung cancer, which was detected during an examination for another disease. On the 23rd post-operative day, a bronchoscopy and chest drain air leak revealed a bronchopleural fistula, which was completely opened on the 36th day after the operation. On the 65th post-operative day, however, the bronchopleural fistula had spontaneously recovered due to appropriate thoracic drainage with the chest drainage tube placed directly under the fistula, anti-biotics therapy, plus nutrition. After the recovery of the bronchopleural fistula, a high negative pressure using a drainage tube-similar to vacuum-assisted-closure therapy-was used to achieve closure of the empyema cavity on the 80th post-operative day. Conclusion. Conservative therapy may be an effective strategy for bronchopleural fistula, especially in asymptomatic patients.
Background. In general inhalation injury, heat damages the pharynx, vocal cord and larynx in the upper air way. We encountered a case of smoke inhalation injury from permanent tracheostoma on the fifth day. Case. A 59-year-old woman presented with dyspnea, who had tracheostomy due to laryngeal cancer and hepatic cirrhosis. She was selling toasted pieces of rice cake along the street at the new year festival. There was no burn around the neck. Bronchoscope showed the severe inflammation with friability, copious carbonaceous deposits and obstruction in the trachea and bronchus. Observation of the sub-bronchus was impossible due to the embolus. After humidifying by natural saline, the embolus was able to be suctioned by bronchoscope. Edema of the mucosa of trachea and bronchus remained the third day of admission, and repeated bronchoscopic suction improved the damaged mucosa the seventh day. Conclusion. Dyspnea was induced not on the morrow, but several days after smoke inhalation from the treacheostoma. Therefore, constant attention to the respiratory condition is required.
Background. Gefitinib has been reported to be effective for patients with non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations even with poor performance status (PS). Here, we report a case of successful treatment of gefitinib administration through a nasogastric tube in a patient with EGFR mutation-positive lung adenocarcinoma associated with bronchoesophageal fistula. Case. A 69-year-old woman complained of dyspnea and was admitted to an emergency hospital. Imaging tests revealed tracheal stenosis caused by mediastinal lymph node enlargement. She was transferred to our hospital under mechanical ventilation because of progressive severe hypoxia. Although tracheal stenosis improved by central necrosis of mediastinal lymph node metastasis on admission, tracheoesophageal fistula was observed. She was diagnosed with primary lung adenocarcinoma (cT4N2M1a, stage IV) and the EGFR mutation exon 19 deletion was detected. Because it was impossible to administer tracheoesophageal fistula orally, gefitinib was administered through a nasogastric tube. The fistula was closed three weeks after gefitinib administration and the tumor decreased in size, which resulted in improvement in PS. Conclusion. Gefitinib administration through a nasogastric tube is useful for patients that are positive for EGFR mutations with tracheoesophageal fistula and poor PS.
Background. Tracheal cancer is a rare neoplasm. Although a few instances of tracheal squamous cell carcinoma (SCC) associated with human papillomavirus (HPV) have been reported, there are no case reports in relatively young patients. Case. A 34-year-old man suffering from dyspnea underwent chest computed tomography that revealed a polypoid tumor at the tracheal carina. The tumor measured 2.0×1.6×1.0 cm, and we could not rule out extratracheal invasion. We performed urgent tumor resection using bronchoscopy to make a pathologic diagnosis and to prevent asphyxia. The pathologic examination showed well-differentiated SCC. After 6 weeks, to achieve R0 resection, we performed carinal resection and reconstruction through a posterolateral thoracotomy. Pathologic examination showed no remaining malignant cells. Multiplex polymerase chain reaction confirmed HPV type 6 DNA in the tumor resected in the first operation. At his 1-year follow-up, there was no evidence of recurrence and no trouble with the anastomosis; he did not require adjuvant therapy. Conclusions. Our patient is a rare example of a younger individual with tracheal SCC associated with HPV-6. When dealing with upper respiratory tract tumors, clinicians should keep in mind the association of HPV and SCC, even in younger patients.
Background. Bronchopulmonary actinomycosis is a chronic granulomatous inflammatory disease that is difficult to diagnose by bronchoscopy. The appropriate duration of treatment of actinomycosis has been widely debated. Case 1. A 59-year-old woman was referred to our institution with atelectasis in the right lower lobe. Bronchoscopy revealed that the orifice of the right lower bronchus was obstructed by an inflamed polyp. A biopsy of the polyp from the peripheral side of the bronchus confirmed the diagnosis bronchopulmonary actinomycosis. The polyp disappeared after seven months of antibiotic therapy. Case 2. A 53-year-old woman was referred to our institution with a fever and hypoxemia. Bronchoscopy revealed that the left B5 bronchus was obstructed by an inflamed polyp. Bronchial lavage after a tissue biopsy revealed Gram-positive filamentous bacilli, suggesting bronchopulmonary actinomycosis. The polyp regressed after seven months of antibiotic treatment. Conclusion. A biopsy from the peripheral side of a bronchial polyp using endobronchial ultrasonography with a guide sheath is useful for the diagnosis of actinomycosis with an inflamed polyp. The reduction in size of an inflamed polyp caused by actinomycosis can assist in the evaluation of the efficacy of antibiotics.
Background. Racemose hemangioma of the bronchial artery is a rare disease characterized by enlarged and convoluted bronchial arteries with abnormal anastomosis to the pulmonary arteries or veins, that can cause hemoptysis. Case. Case 1. A 73-year-old man was admitted to our hospital because of severe hemoptysis during bronchoscopy. A right upper lobectomy was performed immediately. Histopathological examination confirmed the diagnosis of a secondary racemose hemangioma of the bronchial artery. Case 2. A 74-year-old woman presented with hemoptysis from the morning of admission. On the following day, while in hospital, she suffered a cardiac arrest due to massive hemoptysis. Bronchial artery embolization (BAE), lobectomy, and ligation of the bronchial artery were performed. Histopathological examination confirmed the diagnosis of a primary racemose hemangioma of the bronchial artery. Conclusion. We encountered two cases of racemose hemangioma of the bronchial artery that caused massive hemoptysis. BAE is considered a less invasive than lobectomy and an effective treatment. Lobectomy is an effective treatment for massive hemoptysis especially when the bleeding point is identified. Ligation of the bronchial artery is less invasive than lobectomy and preserves lung function. It is effective in advanced cases that do not respond to BAE.
Background. The lung volume reduction coil (LVRC) has been developed in recent years. LVRC, made of preformed nitinol wire, shows promise in lung volume reduction regardless of the presence of collateral ventilation by 'grasping' lung parenchyma. LVRC has been approved for the treatment of emphysema in 25 countries, but has yet to be approved in Japan. Here in, we report the first case of bronchoscopic lung volume reduction using LVRC in a Japanese patient with chronic obstructive pulmonary disease (COPD). Case. A 76-year-old man with severe COPD (stage IV) had been continuously treated at our outpatient department since 2009. His dyspnea symptoms continued while undergoing triple therapy treatment and rehabilitation. We performed bronchoscopic lung volume reduction with 12 LVRC (100 mm×8, 125 mm×4) that were implanted in the right lower lobe. Two months after the initial procedure, 11 LVRC (100 mm×4, 125 mm×7) were implanted in the left lower lobe. Results. Three months after the secondary procedure, the patients' six-minute walk distance improved by 75 m and the modified Medical Research Council dyspnea scale improved from 3 to 2. Conclusion. This is the first report for bronchoscopic lung volume reduction with LVRC in a patient with COPD in Japan. No serious adverse events occurred during procedures and clinical improvements were observed for exercise capacity and the subjective symptoms for this patient.
Background. Bronchial anomalies are rare. We report a case of right upper lung cancer with missing B2, B3 and a displaced anomalous B6 bronchus. Case. A 76-year-old woman was admitted to our hospital for detailed examination after the detection of a chest X-ray abnormality. Chest CT and bronchoscopy showed a tumor in the right upper lobe. In addition, the A2, A3, V2, and V3 of the right lung were missing, and B6 branched from the intermediate bronchus. Since the pathologic diagnosis was lung adenocarcinoma, we performed right upper lobectomy. Bronchial anomalies are thought to be associated with anomalous blood vessels. In our case, preoperative 3D-CT showed that V1 and a small pulmonary vein flowed into the upper pulmonary vein. While the small vein was thought to flow from the right upper lobe, intraoperative observation showed that it was actually a pulmonary vein arising from S6. Conclusion. 3D-CT is often useful when planning operative procedures. However, it is difficult to identify the inlet and outlet portions of the blood vessel when the blood vessel shows positional abnormality. Thus, intraoperative observation is also important for achieving safe surgical outcomes.