Background. There is a higher risk of complications associated with the performance of bronchoscopy in patients aged 80 or older than in younger patients. Virtual bronchoscopy and rapid on-site evaluation are novel methods that can reduce the risks associated with bronchoscopy in this patient group. Patients and Methods. Elderly patients suspected to have lung cancer who underwent bronchoscopy (pre-group, n=24, from June 2017 to June 2018), virtual bronchoscopy and a rapid on-site evaluation after bronchoscopy (post-group, n=26, from July 2018 to August 2019) were retrospectively surveyed regarding their characteristics, bronchoscopic procedures and the clinical courses. Results. There were significantly fewer patients in the post-group than in the pre-group in whom lung cancer could not diagnosed based on the findings of the first bronchoscopy procedures and those who were diagnosed with illness at the second examination (one out of three patients vs. six out of seven patients in the post-group and pre-group, respectively, p=0.048). Thus, virtual bronchoscopy and a rapid on-site evaluation demonstrated a greater diagnostic accuracy. The accuracy was 0.75 in the pre-group and 0.96 in the post-group. Conclusion. Virtual bronchoscopy and a rapid on-site evaluation with bronchoscopy improved the diagnostic yield with the collection of appropriate specimens in patients aged 80 or older.

Background. The characteristics of macroscopic thoracoscopy under local anesthesia in patients with malignant pleural effusion have yet to be established. The purpose of the present study was to demonstrate the characteristics of macroscopic thoracoscopy under local anesthesia for the diagnosis of malignant pleural effusion. Objectives and Methods. From January 2008 to April 2019, thoracoscopy was performed on 49 patients with malignant pleural effusion. The cause of malignant pleural effusion, thoracoscopic findings, pleural effusion tumor markers, and hyaluronic acid level were retrospectively examined. The results were compared with those of seven patients with tuberculous pleurisy as a benign disease. Results. The most common cause of malignant pleural effusion was pulmonary adenocarcinoma. Thoracoscopic findings of adenocarcinoma and squamous cell carcinoma showed various findings, including protruding lesions, pleural adhesions, and vascular lesions. In contrast, small cell carcinoma showed many large nodules. Significant differences were not noted in thoracoscopic findings between pathological types. Malignant mesothelioma had significantly greater pleural thickening than primary lung cancer. Primary lung cancer had significantly more nodular lesions, significantly fewer pleural red flare lesions, and slightly higher adhesions than tuberculous pleurisy. Pleural effusion tumor markers were significantly higher in cases of primary lung cancer than in malignant mesothelioma. Conclusions. The present study found no significant differences in thoracoscopic findings among pathological types of primary lung cancer, and it was difficult to discriminate the pathological types by thoracoscopic findings alone. The findings of multiple nodular lesions were more likely to be malignant than benign disease, suggesting that the findings may be useful for distinguishing benign from malignant pleural lesions when combined with pleural effusion tumor markers.

Background. It is possible to evaluate the peripheral bronchus by ultrathin bronchoscopy. Case. A 75-year-old man underwent bronchoscopy to examine the cause of blood sputum in X−2 and an inflammatory polyp was found located at the carina of the trachea. One year later, the inflammatory polyp was found to have disappeared, but the finding of class V cancer was obtained by cytology from a right main bronchus lavage specimen. We could not detect the site of cancer by computed tomography. As a result, we performed bronchial lavage in each bronchus, and the site of lesion was thus determined to be on the right B⁵. The precise site was identified using an ultrathin bronchoscope (UTB). Conclusion. We located the site of cancer by performing both bronchial lavage in each bronchus and UTB.

Background. Granulomatosis with polyangiitis (GPA) is a small vessel, systemic vasculitis that is classified as an anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitis. The cytology of bronchoalveolar lavage fluid (BALF) in GPA has never been thoroughly investigated due to the small number of patients. Case. We report the case of a 62-year-old man who was admitted to our hospital with a one-week history of exertional dyspnea and hemosputum. He had a history of chronic sinusitis, acute otitis media, and bronchial asthma for three years. The patient's serology was positive for anti-proteinase 3 ANCA. On high-resolution computed tomography (HRCT), diffuse consolidation and ground-glass opacities were observed in the lung fields. The patient underwent bronchoscopy and was diagnosed with diffuse alveolar hemorrhage (DAH). Moreover, adenocarcinoma in situ (AIS) was strongly suspected because the BALF showed countless atypical glandular cells. The histological findings obtained from transbronchial lung biopsy also supported the diagnosis of AIS. After treatment with corticosteroid pulse therapy; however, the pulmonary shadows on HRCT significantly improved. Moreover, in the lung specimens taken at bronchoscopy, organizing pneumonia was observed, without malignancy. Hence, AIS was finally excluded from the diagnosis. The patient was diagnosed with GPA based on the history of chronic sinusitis and pulmonary symptoms. He was successfully treated with a combination of corticosteroids and immunosuppressants. Conclusion. This is a rare case of GPA and DAH that mimicked AIS due to cellular atypicality. Even when histology supports a diagnosis of malignancy, GPA should be included in the differential diagnosis to prevent diagnostic delay and treatment failure.

Background. Surgical resection is the preferred treatment for patients presenting with localized bronchial carcinoids. However, no definitive treatment has yet been established for bronchial carcinoids. Case 1. A woman in her 50s was referred to our hospital because of an intraluminal tumor in the right main bronchus on chest computed tomography that was pointed out during a medical checkup. The tumor was resected endoscopically with high-frequency electrosurgical snaring and it was thereafter diagnosed to be a typical carcinoid. No recurrence has so far been seen during a one-year follow-up. Case 2. A man in his 40s was referred to our hospital because of an abnormal shadow on a chest X-ray that was pointed out during a medical checkup. Chest computed tomography showed an intraluminal tumor in the right basal bronchus. Thoracoscopic right lower lobectomy was performed in addition to lymph node dissection (ND2a-1) and the tumor was diagnosed to be an atypical carcinoid. No recurrence has so far been seen during a five-year follow-up. Conclusion. Checking the size, location, tissue type and extension of the tumor is important to select the optimal treatment for bronchial carcinoids.

Background. There have only been a few reports regarding the biopsy of metastatic thoracic vertebral lesions using a convex-type ultrasonic bronchoscope. Case. A 77-year-old man underwent surgery for gastric cancer (stage IA) and rectal cancer (stage IIIA) in February X−3 and surgery for primary lung adenocarcinoma in the right upper lobe (stage IB) and lung metastasis of rectal cancer in the right lower lobe in May X−2. In August X, follow-up chest computed tomography revealed right hilar lymph node swelling and an eighth thoracic vertebral tumor (approximately 50 mm in size). The vertebral tumor was in contact with the right main bronchus and accompanied by destruction of the bone cortex. We suspected metastasis of gastric cancer, rectal cancer or lung adenocarcinoma based on his medical history and performed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the hilar lymph nodes and thoracic vertebral tumor. An immunohistochemical examination of tissue specimens revealed the recurrence of lung adenocarcinoma. Conclusion. We encountered a rare case of thoracic vertebral metastasis of lung adenocarcinoma that was in contact with the right main bronchus and diagnosed using EBUS-TBNA.

Background. Löfgren syndrome is an acute subtype of sarcoidosis with arthritis, erythema nodosum, and bilateral hilar lymphadenopathy; this disorder is extremely rare in Japan. Case. A 32-year-old man presented with an acute fever, arthralgia in both knees, sore throat, and pain in the back of his head. Erythema nodosum was observed along a navy-colored tattoo on his right shoulder that he had received approximately 10 years ago. Chest computed tomography (CT) revealed multiple random nodules, bronchovascular band thickening, and interlobular septal thickening that predominantly involved the bilateral upper lobes. Consolidation was observed on the left upper lobe. ¹⁸F-fluorodeoxyglucose (FDG) -positron emission tomography (PET) -CT revealed an abnormal uptake in the parotid glands, lung, liver, and bilateral supraclavicular, hilar, mediastinal, and epigastric lymph nodes and erythema nodosum and a right axillary lymph node with a mildly abnormal uptake. Bronchoscopic findings showed network formation, hypervascularization, and distention of the capillaries, with a cobblestone appearance. A transbronchial lung biopsy and transbronchial biopsy were performed. Pathological findings demonstrated non-caseating necrosis with epithelioid granuloma, leading to a diagnosis of sarcoidosis. A diagnosis of Löfgren syndrome was made based on the clinical course. Conclusion. We herein report a rare case of Löfgren syndrome, which is a subtype of sarcoidosis with acute symptoms, in Japan.

Background. Pulmonary hamartoma is the most common benign lung tumor type. Most such cases are parenchymal hamartoma, while some are endobronchial hamartoma. Case. A 40-year-old man presenting with obstructive pneumonia was admitted to our hospital. An endobronchial tumor in the left lower lobar bronchus was observed on chest computed tomography. A bronchoscopic examination revealed a smooth-surfaced polypoid tumor occluding the left lower lobar bronchus. A transbronchial biopsy revealed no diagnostic findings, so bronchoscopic resection using electrosurgical snaring was performed. Accordingly, a histopathological analysis led to the diagnosis of endobronchial cartilaginous hamartoma. Since a tumor obstructing the orifice of the left B⁶c had persisted, video-assisted left S⁶ segmentectomy was performed for radical surgery. The postoperative pathological findings revealed that some parts of the endobronchial tumor had expanded to the pulmonary parenchyma. Conclusion. We herein report a case of pulmonary hamartoma that was confirmed to have expanded to the pulmonary parenchyma after bronchoscopic resection for an endobronchial tumor. In some cases of endobronchial hamartoma, expansion to the pulmonary parenchyma occurs, and caution must be exercised in its treatment.

Background. A double lumen tube (DLT) is widely used when separate lung ventilation is required in respiratory surgery. In cases of long-term endotracheal intubation or tracheostomy, reports of airway stenosis after tube removal are scattered, but reports of subglottic stenosis early after DLT removal are rare. Case. An 83-year-old woman who was 144 cm tall and weighing 48.7 kg underwent thoracoscopic left upper lobectomy for primary lung cancer. On the 3rd postoperative day, wheezing and central airway stenosis sound were heard, and bronchoscopy revealed bronchial stenosis just below the glottis. She started steroid inhalation with the systemic steroid β-agonist and the oral agent tranilast, but the symptoms worsened, and emergency tracheostomy was performed 6 days after the operation. Subsequently, the subglottic stenosis gradually improved, and the tracheostomy tube was removed 20 days after the operation. The patient was discharged 22 days after the operation. Conclusions. To prevent subglottic stenosis after extubation, it is necessary to first select an appropriately sized DLT and to switch to a bronchial blocker when there is resistance during insertion.

Background. We report a case in which a bronchial foreign body that could not be removed by initial flexible bronchoscopy was successfully removed using virtual bronchoscopic navigation during a re-examination. Case. A man in his 30s accidentally swallowed polishing equipment during treatment at a dental clinic. Chest images from a nearby medical institution showed a bronchial foreign body of approximately 16 mm in the right S¹⁰. The patient was referred to our department for the removal of a foreign body. Emergency flexible bronchoscopy was performed to remove the foreign body, but the removal was abandoned because the foreign body could not be found in the bronchial lumen of the right lower lobe. Surgery and removal by rigid bronchoscopy were also considered, but we decided to use a flexible bronchoscope again in an attempt at minimally invasive removal. We performed a virtual bronchoscopic navigation that targets a foreign body for a re-examination. Although the foreign body was not found on the re-examination, it was successfully removed using the virtual bronchoscopy findings and fluoroscopic imaging as a guide. Conclusion. Virtual bronchoscopic navigation may be useful for removing bronchial foreign bodies that have strayed into the distal lumen of the bronchus.

Background. We herein report a case where a patient developed a massive paraffinoma after undergoing extraperiosteal paraffin plombage. Case. A 72-year-old man had developed pulmonary tuberculosis and had thus undergone extraperiosteal paraffin plombage when he was 23 years old. Although he experienced no side effects for decades, at 69 years of age he started to expectorate bloody sputum intermittently, while also expectorating white solid bodies, which were thought to be pieces of paraffin. At 71 years of age, bronchial arterial embolization was performed due to the onset of massive hemoptysis. A mass in the left lung, which had previously been regarded as tuberculosis sequelae, gradually increased in size, thus leading to the occurrence of chest pain. A percutaneous biopsy was performed to determine whether the mass was a malignant tumor. We discovered multiple vacuoles where paraffin had been, as well as the presence of reactive granulation tissue. As a result, we made a diagnosis of paraffinoma. The tumor slowly continued to increase in size. Conclusion. We herein described a rare case of paraffinoma following extraperiosteal paraffin plombage.