Background. Pulmonary actinomycosis and foreign body aspiration are indications for surgery. Case. A 70-year-old man with body weight loss, productive cough, and sputum was admitted to the previous hospital. Chest computed tomography (CT) revealed right lower pneumonia and a foreign body in the right lower bronchus. Bronchoscopy revealed a polypoid mass of B8+9, a white foreign body, and suspected actinomycetes on cytology. He received antibiotic therapy for six months. Chest CT revealed improvement of the pneumonia, and bronchoscopy revealed the remaining polypoid mass and foreign body. It was not successfully removed with flexible bronchoscopy. He was therefore referred to our hospital to receive treatment with rigid bronchoscopy. The foreign body and polyp were completely removed by rigid bronchoscopy. During his follow-up visit, he had no recurrence of pulmonary actinomycosis. Conclusion. We successfully treated suspected pulmonary actinomycosis and foreign body aspiration using antibiotics followed by removal of the foreign body via rigid bronchoscopy.
Background. Clinicians should consider the possibility of pulmonary amyloidosis as a differential diagnosis of diffuse cystic lung disease. Case. A 72-year-old man was referred to our hospital because of a chest abnormality with multiple pulmonary cysts under a diagnosis of polymyalgia rheumatica and Sjögren's syndrome. A transbronchial lung cryobiopsy revealed amyloid deposition in the bronchus, pulmonary artery wall, and alveolar septum, so we diagnosed him with pulmonary amyloidosis associated with Sjögren's syndrome. In addition, we speculated that the pulmonary cysts had been caused by the loss of elastic fibers in the alveolar walls due to amyloid deposition. Conclusion. A transbronchial lung cryobiopsy is considered a useful strategy for the diagnosis and elucidation of various conditions in pulmonary amyloidosis.
Background. In the radical closure of an open-window thoracostomy, it may be difficult to clean the empyema cavity and close the fistula during in cases in which closure of the fistula cannot be achieved. Case. The patient was a 42-year-old man who underwent open-window thoracotomy for empyema with a fistula. He was subsequently referred to our hospital as the fistula had not been closed, and the empyema cavity had not been thoroughly cleaned. As B6a was identified as the responsible bronchus on chest CT, we decided to perform bronchial occlusion. An Endobronchial Watanabe Spigot (EWS) was inserted into the B6a and B6 inlets. As the infection of the pyothorax was controlled with bronchial occlusion, radical closure using a pedicled latissimus flap was performed 3 months later. There was no recurrence of empyema until 18 months postoperatively. Conclusion. We believe that the control of fistula and infection through bronchial occlusion using an EWS is useful for the radical closure of an open-window thoracostomy.
Background. Central airway obstruction (CAO) is a fatal state that must be resolved promptly. Case. The patient was a 89-year-old man who could not move on his own due to respiratory discomfort. He was brought to our hospital in an ambulance. The initial diagnosis was an asthmatic crisis and he was treated for asthma. However, his respiratory condition did not improve. Endotracheal intubation was attempted but was difficult, and so emergency tracheostomy was required. During tracheostomy, cardiopulmonary arrest occurred. He was resuscitated by cardiopulmonary resuscitation and tracheostomy was completed. After tracheostomy, bronchoscopy revealed a tumor which had become incarcerated in the left main bronchus. The tumor was large and difficult to remove. We grasped the tumor with a basket forceps and removed it along with the tracheostomy tube. The patient's subsequent clinical course has been good. The diagnosis was laryngeal cancer, cT2N0M0 Stage II. We decided on radiotherapy in accordance with the patient's condition and in consideration of his advanced age. He completed radiotherapy (63 Gy/28 Fr). At present, the patient visits the outpatient clinic regularly for follow-up. There have been no signs of recurrence. Conclusion. A dropped laryngeal tumor caused by endotracheal intubation can induce cardiopulmonary arrest due to CAO. When the presence of a tumor in the upper respiratory tract is suspected, the procedure to secure the airway must be carefully performed.
Background. Endobronchial hamartomas show various macroscopic findings and properties depending on the ratio and localization of the interstitial components. Case. A 49-year-old Japanese man was found to have an abnormal chest shadow at a medical examination. Chest computed tomography (CT) showed a well-defined nodule 8 mm in size at the inlet of left B9-10, suggesting an endobronchial tumor. On bronchoscopy, the lesion was a light-red polyp, and the surface was a cauliflower-like. The polyp was easily deformed and stretched by a cough or forceps biopsy. The bronchoscopic findings suggested a tumor of epithelial or subepithelial origin. Tumor resection and laser ablation were performed using a flexible bronchoscope, considering the bronchoscopy findings, CT findings, and biopsy results. The diagnosis of endobronchial hamartoma was made. The surface morphology and flexibility atypical of endobronchial hamartomas were due to the presence of subepithelial myxoid tissue with rich proteoglycans and mucopolysaccharides and the localization of the interstitial components. Conclusion. We experienced a case of endobronchial hamartoma with an atypical cauliflower-like form. It is important to determine whether or not bronchoscopic tumor resection is appropriate for treatment and to perform laser ablation in order to preserve the lungs.
Background. Bronchogenic cysts are commonly located in the middle mediastinum and rarely occur in the posterior mediastinum. We report a case in which a mediastinal bronchogenic cyst required differentiation from a neurogenic tumor. Case. A 40-year-old man was admitted to our hospital with a clearly circumscribed and low-density mass of 3.1 cm in diameter. It was located posterior to the descending aorta and was detected by thoracic CT scan during a medical examination. Four-dimensional (4D) -CT showed that the mass was improperly mobile, which suggested that the tumor was not derived from the visceral pleura or lung, and we preoperatively diagnosed the mass as a posterior mediastinal tumor (e.g., a neurogenic tumor). The lesion was removed by thoracoscopic surgery. The tumor was located near the sympathetic stem and was easily removed, as there was no adhesion or infiltration. The tumor was diagnosed as a bronchogenic cyst based on a postoperative pathological evaluation. Conclusion. It is important to include bronchogenic cysts in the differential diagnosis of any mass in the posterior mediastinum.
Background. Thyroid transcription factor 1 (TTF-1) -positive colon cancer that metastasizes to the bronchi of the lung is relatively rare. Case. A 72-year-old man experiencing bloody sputum for one year was admitted to our hospital due to an abnormal shadow on chest X-ray. Computed tomography showed a 4-cm tumor in the central area of the left upper lobe of the lung. Bronchoscopy revealed bleeding from the left superior segmental bronchus, so only lavage cytology was performed. The patient was diagnosed with adenocarcinoma. A systemic search revealed that the patient also had sigmoid colon cancer, and imaging results suggested the patient had synchronous double cancers. We prioritized lung tumor resection and performed left upper lobectomy. The tumor filled the bronchial lumen, and its histological findings were similar to those of the colon cancer. Immunohistochemical staining results were almost consistent with lung metastasis from the colon, but the lung tumor was TTF-1-positive. Additional immunohistochemical staining of the colon biopsy specimen showed the same pattern of the lung tumor. Therefore, the patient's final diagnosis was colon cancer with lung metastasis. Conclusion. We herein report a rare case of endobronchial metastasis from TTF-1-positive colon cancer.
Background. We experienced a case of right coronary artery (RCA) air embolism following a transbronchial lung biopsy (TBLB). Case. A 57 years old man complained of cough and dyspnea. He was treated with anti-biotics but his symptoms did not improve. Chest X-ray and computed tomography (CT) showed ground glass opacity in the bilateral lung field, so interstitial pneumonia was suspected. Bronchoalveolar lavage (BAL) and a TBLB were performed. During the procedure, there was no issues, but the patient was coughing a bit excessively. Immediately after TBLB, he reported left chest pain. An electrocardiogram (ECG) revealed ST-segment elevation. Chest CT showed the existence of air in the RCA, ascending aorta and left ventricle. We diagnosed him with air embolism of RCA following a TBLB. He was observed in the intensive-care unit, and the following day, chest CT showed the disappearance of air, and no issues with his cardiac function were noted on transthoracic echocardiography. Conclusion. Air embolism of the RCA following a TBLB is a very rare adverse event, but should receive close attention. Emphysematous changes in the lung and cough may be risk factors for air embolism.
Background. Malignant lymphoma occasionally presents with opacities in the pulmonary parenchyma; however, this condition might be difficult to diagnose using a transbronchial lung biopsy. Case. A 44-year-old woman received chemotherapy for peripheral T cell lymphoma, not otherwise specified, at 42 years old. She remained in remission for two years, after which she developed wet cough, and chest computed tomography revealed right lower lobe consolidation. Her condition did not improve despite antibiotic administration, and she was referred to our hospital for further management. We performed an endobronchial ultrasound-guided transbronchial biopsy using guide sheath with a concurrent cryobiopsy and obtained specimens from the right B8a. A histopathological examination showed tumor cells within the necrosis only in specimens obtained by a cryobiopsy. On an immunohistochemical examination, we observed cells that were immunopositive for CD3 and Epstein-Barr virus-encoded small RNA-in situ hybridization, leading to the diagnosis of relapsed T cell lymphoma. Therefore, she was transferred to the department of hematology for chemotherapy. Conclusion. We describe a patient diagnosed with relapsed T cell lymphoma based on cryobiopsy findings.
Background. Tracheal diverticulum is a rare disease with few reports on perforation. Case. We herein report the case of a woman with bronchial diverticulum who developed bronchial perforation during lung cancer surgery. The surgery was performed while the patient was in a left lateral position, and single-lung ventilation of the left lung was performed (35 Fr, double lumen). Intubation was conducted by the attending anesthesiologist with no adverse findings, and single-lung ventilation was initiated after 8 min. The surgery began 21 min after intubation, and marked mediastinal emphysema intrathoracically was observed via the first port. The patient was placed in a supine position, where an observation of the airway revealed a 3-mm diverticulum and air bubble adhering to the right side of the carina; it was determined that perforation of the tracheal diverticulum had occurred due to positive-pressure ventilation. Computed tomography findings confirmed the presence of a 3-mm tracheal diverticulum at the same site. It was confirmed that the surgery could be continued with single-lung ventilation without problems related to oxygenation. When the surgery resumed, the mediastinal pleura was opened up to the thoracic cavity to drain the mediastinal emphysema, and a 20-Fr trocar catheter was placed in the thoracic cavity at the end of the surgery. Conclusion. Despite the lack of reports on tracheal diverticulum perforation during anesthesia management, injury due to positive-pressure ventilation is a possible situation, and to prevent an abnormality, it is necessary to take measures while carefully considering the association of such a management approach with this condition.