Introduction. We developed a new method for diagnosing malignant lesions of the pleura using 5-aminolevulinic acid (5-ALA) and an autofluorescence imaging system. 5-ALA is metabolized to protoporphyrin IX, which is a precursor of heme and remains in malignant cells, exhibiting red fluorescence at about 630 nm. After the oral administration of 5-ALA (4 hours before, 20 mg/kg), pleural malignant lesions were observed using an autofluorescence imaging system under thoracoscopy. Materials and Methods. From January 2017 to April 2019, we performed this procedure for a total of 130 patients: 82 cases of lung cancer suspected of pleural invasion, 32 cases of metastatic lung tumor, 7 cases of malignant pleural mesothelioma and 9 cases of intrathoracic benign disease. This study was a prospective study. Results. 1) In many malignant lesions including pleural infiltration, red fluorescence was recognized in contrast to the green autofluorescence exhibited by normal tissues. For malignant lesions located near the pleura, the significance of marking the tumor site at the time of a biopsy was also found. 2) The diagnosis of lung cancer pleural invasion was 81.0%, specificity 62.5%, positive predictive value 52.3% and negative predictive value 87.5% for pl0 or pl1 (pl1 or pl2) cases for pl1 to pl2 cases. However, for adenocarcinoma only, the sensitivity was 93.9%, specificity 74.3%, positive predictive value 60.8% and negative predictive value 96.2%. Of the cases in which fluorescence observation was possible even with pl0, 88.9% were diagnosed as preoperative PL1. Thease cases were pl0 pathologically, but the tumor was in contact with the pleura. 3) Pleural disseminated lesions were found in 6 cases, but in 2 cases, the diagnosis was difficult by white-light imaging but possible by our new method. Conclusion. If the tumor was in contact with the pleura and had invaded or was suspected of having pleural invasion, localization of the lesion could be made. This approach may facilitate the diagnosis of pleural dissemination, which can be difficult to detect.

Objective. Reports on the co-occurrence of lung cancer and pulmonary aspergillosis have been observed in Japan; however, the cause remains poorly understood. We therefore examined the clinical characteristics of patients with the co-occurrence of lung cancer and pulmonary aspergillosis. Patients. Among 1149 lung cancer patients who visited our department from 2013 to 2018, we analyzed those with pulmonary aspergillosis. Methods. After excluding the cofounding factors, we retrospectively examined the diagnostic methods, imaging findings, and the likelihood of co-occurrence. Results. A total 6 patients (5 men and 1 woman, all ≥60 years old) were found to have co-occurring lung cancer and pulmonary aspergillosis. All patients had a history of smoking, and 5 had undergone steroid treatment or been treated for a malignant tumor. After a simultaneous diagnosis of lung cancer and pulmonary aspergillosis in 4 cases, the pulmonary aspergillosis was eliminated following lung cancer in 2 patients. Conclusion. Smoking and steroid administration may influence co-occurrence of pulmonary aspergillosis as well as rate complications after cancer treatment in cases of lung cancer.

Background. Pulmonary mucormycosis, an invasive fungal disease that occurs in immunocompromised hosts, exhibits a progressive clinical course and is associated with a poor prognosis. Case. In an 8-year-old girl, chest computed tomography performed during induction chemotherapy for recurrent acute myeloid leukemia revealed rapidly progressive extensive infiltration in the left lower lung. A bronchoscopic examination revealed a large, white, torose lesion in the left lower bronchus. A transbronchial biopsy confirmed the diagnosis of pulmonary mucormycosis. Upon this diagnosis, owing to the infeasibility of surgical resection, the patient was initially administered systemic liposomal amphotericin B therapy and received repeated transbronchial injections of amphotericin B. However, the therapy was ineffective, and the fungal lesion consecutively progressed to the left upper trunk. To restore her bone marrow function, left pneumonectomy was performed. Thereafter, no recurrence of mucormycosis was noted. Conclusion. This report describes a case of pulmonary mucormycosis diagnosed by a transbronchial biopsy. Surgical resection in addition to the early diagnosis and antifungal therapy is critical in the treatment of pulmonary mucormycosis.

Background. Influenza infection can cause secondary bacterial infections and can be severe in high-risk groups with underlying disease. Case. A 69-year-old woman with type 1 diabetes was hospitalized for diabetic ketoacidosis. She developed bacterial pneumonia after type B influenza infection. Therefore, ampicillin combined with sulbactam was started, but the infiltrative shadow continued to expand and showed a region of poor contrast in contrast-enhanced computed tomography that we diagnosed as a lung abscess. We performed bronchoscopy, and Capnocytophaga sputigena was isolated and identified from bronchoalveolar lavage fluid. We changed antibiotics to piperacillin combined with tazobactam, and the lung abscess improved thereafter. Conclusion.Capnocytophaga spp. can be an etiologic pathogen for lung abscess after influenza infection in compromised host.

Background. The management of a wound accompanied by bronchial fluid from a bronchial fistula and bronchial pneumonia is troublesome after cavernostomy for pulmonary aspergillosis. Following surgery, the bronchial artery is enlarged and tortuous, and bronchial bleeding can arise. Thus, we must select an optimal treatment method for bronchial fistula and bronchial bleeding. Bronchial occlusion using an endobronchial Watanabe spigot (EWS) for the bronchial fistula and bronchial artery embolization (BAE) for pulmonary bleeding can be effective. Case. The patient was a 60-year-old woman who underwent administration of an antifungal agent by bronchoscopy for pulmonary aspergillosis accompanied by a large cavity with a fungus ball. The patient's condition did not improve, and she was referred to our department. We performed cavernostomy and fenestration. Dyspnea and cough caused by a bronchial fistula at the wound site improved after repeatedly performing bronchial occlusion using EWS. We developed a novel method to attain direction and control of the EWS using guidewire for bronchial occlusion. Daily exchange of gauze and adhesive elastic bandage facilitated the patient's discharge. Bronchial bleeding was noted during regular follow-up at our department, BAE was performed, and the bronchial bleeding improved. Conclusion. The performance of repeated bronchial occlusion and BAE to treat bronchial fistula and pulmonary bleeding after cavernostomy and fenestration for pulmonary aspergillosis is a valid treatment option.

Background. Glomus tumors are rare mesenchymal tumors composed of smooth muscle cells and normal glomus body cells. Glomus tumors of the trachea-bronchus are very rare. Case. A 56-year-old man with asthmatic symptoms visited our hospital. A respiratory function test revealed airway obstruction. Chest computed tomography (CT) revealed a polypoid lesion of 15 mm in diameter in the left upper bronchus. The interrupted appearance of the left main bronchus was observed in trachea-bronchus using a 3D-CT software program. Bronchoscopy revealed a hypervascular polypoid lesion in the left main bronchus. First, the polypoid lesion was removed by rigid bronchoscopy to make a diagnosis, and then the left bronchus was surgically reconstructed. Positive staining of the α-smooth muscle actin of the tumor indicated a glomus tumor. An analysis using the 3D-CT software program revealed that the interrupted appearance of the left main bronchus had disappeared after surgery, and the respiratory function (FEV_1.0/FVC) and respiratory impedance normalized after surgery. Conclusion. We experienced a rare case of a patient with asthmatic symptoms due to a glomus tumor of the left main bronchus. The analysis of the trachea-bronchus by a 3D-CT software program as well as conventional CT was very useful for evaluating the outcomes of treatment.

Background. The widespread application of high-resolution computed tomography (CT) has increased the detection of small pulmonary nodules, and various marking techniques have been proposed. Case. A 68-year-old man who received low anterior resection for colon cancer was found to have a solitary small lung tumor on chest CT. The clinical diagnosis was metastatic lung tumor from the colon cancer. This tumor was located in the right S⁶c mid-zonal area and was close to the basal segment. During the operation, a bronchoscope was inserted peripherally to the B⁶c running near the tumor to ensure a sufficient surgical margin. The light of the bronchoscope was confirmed from the pleural surface, so right S⁶ segmentectomy was performed. Conclusion. This procedure was considered useful as a non-invasive method of transbronchial marking.

Background. An increasing number of bronchial bifurcation anomalies are being discovered due to the increased usage of bronchoscopy and chest computed tomography (CT). Case. A 68-year-old female was referred to our department after presenting with abnormal shadows in the chest during a medical checkup. Chest CT showed a 40-mm tumor extending from the upper lobe to the middle lobe of the right lung that was suspected of being well-differentiated adenocarcinoma. In addition, an anomalous bifurcation of the right bronchus with the upper and middle lobar bronchi forming a common trunk was found. We decided to diagnose and treat the patient with right upper-middle lobe resection, as the lesion extended from the upper to middle lobes of the right lung. Operation. The common trunk formed by the upper-middle lobar bronchi emerged from an area between the right pulmonary artery (A1+3) and the right superior pulmonary vein. After arteriovenous treatment, the base of the common trunk was cut, and the upper-middle lobe of the right lung was removed. Conclusion. The upper and middle lobar bronchi of the right lung forming a common trunk emerged from between the right pulmonary artery (A1+3) and the right superior pulmonary vein, resembling the mirror image of the normal left bronchus. This type of bronchial anomaly is rare and has only been reported in three cases so far.

Background. Solitary bronchial glandular papilloma is a rare disease. In the 20-year period from 2000 through 2019, only four cases were reported in the literature. Therefore, no consensus regarding the treatment of the disease has been reached. Case. A 61-year-old woman presented with a persistent cough and wheezing that had lasted for five years. She was referred to our hospital because an abnormal shadow had been found during a medical examination in January 200X-1, and chest computed tomography showed a tumor located in the left main bronchus. Bronchoscopy demonstrated a polypoid tumor that obstructed the left main bronchial lumen by 90%; however, the peripheral bronchus in the area demonstrating stenosis observed with a microbronchoscope appeared to be normal. The pathological diagnosis was bronchial glandular papilloma. During follow-up, an increase was noted in size, but no association with human papillomavirus infection was noted, and there was no potential predisposition toward malignancy. Therefore, bronchoscopic tumor resection was conducted with a high-frequency electrosurgical snare and argon plasma coagulation. In the following two months, there was no evidence of tumor recurrence or symptoms. Conclusion. We experienced a case of solitary bronchial glandular papilloma wherein the tumor was able to be resected safely using a high-frequency snare under bronchoscopy.

Background. Tracheal diverticulum is a rare disease which is normally incidentally detected by computed tomography (CT). Recent studies have reported the use of an improved imaging technique for the detection of tracheal diverticulum. We herein report a case of multiple tracheal diverticula. Case. A 58-year-old man visited our hospital due to chronic cough and an abnormal chest shadow. CT showed cystic lesions in the right posterolateral trachea and the carina. However, bronchoscopy revealed small holes on the right side of the membranous trachea and carina. The patient was therefore diagnosed with multiple tracheal diverticula caused by cough-variant asthma. The patient was started on treatment with a cough suppressant, corticosteroid, and β-agonist. Conclusion. Tracheal diverticulum is often detected by the presence of certain respiratory symptoms; however, it occasionally coexists with respiratory diseases. A detailed examination and appropriate treatment are therefore important in patients with symptomatic tracheal diverticulum.

Background. We herein report the first detailed case of locally advanced small-cell lung cancer (SCLC) with endotracheal/endobronchial metastases at the time of the diagnosis. Case. A 59-year-old man presented to another hospital with cough and abnormal findings on chest X-ray. He was referred to our hospital because of atelectasis in the left lower lobe and multiple discontinuous nodules in the left main bronchus on chest computed tomography (CT). A bronchoscopic examination revealed multiple nodules in the upper trachea and left main bronchus. We performed a biopsy, and a histological examination of these nodules revealed SCLC. We diagnosed him with limited-disease (LD) SCLC and administered curative chemoradiotherapy. The nodules disappeared on chest CT and bronchoscopy after treatment, and he has not developed any recurrence. Conclusion. This report highlights the possibility of curative treatment for LD-SCLC with endotracheal/endobronchial metastases.

Background. Bronchopleural fistula and acute respiratory distress syndrome are serious complications that can occur after lobectomy for lung cancer. Case. A 76-year-old woman underwent video-assisted right lower lobectomy for lung adenocarcinoma. Two days after the operation, the patient developed postoperative acute respiratory distress syndrome associated with aspiration pneumonitis caused by an esophageal hiatus hernia. Ventilator management, steroid therapy, and antibiotic therapy were initiated after the onset of acute respiratory distress syndrome. The patient's general condition gradually improved after these treatments, and she was weaned off the ventilator. However, widespread subcutaneous emphysema suddenly occurred. We found bronchopleural fistula in the B⁴ segmental bronchus in the middle lobe and diagnosed it as empyema with bronchopleural fistula. The cause of this bronchial fistula was believed to be the use of soft-coagulation device during surgery, surrounding tissue infection due to aspiration pneumonia, and steroid treatment and ventilator management for acute respiratory distress syndrome. After inserting an Endobronchial Watanabe Spigot into the right middle lobe bronchus, the air leakage from the bronchopleural fistula stopped, and the inflammation in the thoracic cavity subsided. The patient's condition gradually improved, and she was discharged. Conclusion. The patient developed bronchopleural fistula in the middle lobe bronchus after right lower lobectomy for lung cancer. In this case, Endobronchial Watanabe Spigot treatment for the middle lobe bronchopleural fistula was remarkably effective and surgical treatment was not required.

Background. While surgical and endoscopic approaches are the treatments of choice for patients with esophago-pulmonary fistula, this complication is generally intractable. We herein report a case of delayed postoperative esophago-pulmonary fistula that was closed via bronchoscopy and enteroscopy using an Endobronchial Watanabe Spigot (EWS). Case. A 76-year-old man underwent surgery for gastroesophageal junction carcinoma. Subtotal esophagectomy combined with gastrectomy, splenectomy, cholecystectomy and esophagoenterostomy was performed. The patient complained of coughing and sputum production immediately after liquid swallowing two years after the operation and was diagnosed with esophago-pulmonary fistula. We attempted to obstruct the fistula with clipping, coiling, and histoacryl embolization several times, which did not resolve the condition. Stenting with a covered expandable metallic material was also unsuccessful because it gave the patient discomfort. As we were able to identify the responsible subsegmental bronchus by instilling indigo carmine via a nasogastric tube, embolization of the responsible subsegmental bronchus with EWS was performed four years after the initial operation. The patient's symptoms eventually resolved by subsequent treatment via an enteroscopic approach. Conclusion. Combined bronchoscopic and enteroscopic therapy with EWS led to the successful healing of an intractable esophago-pulmonary fistula.