Background. The detection of foreign bodies in the respiratory tract is often difficult in patients with decreased sensorium. Case. A man in his 50s presented to our hospital with cardiopulmonary arrest due to acute myocardial infarction. After resuscitation and percutaneous coronary angioplasty, a chest computed tomography scan was performed for prolonged aspiration pneumonia, and a foreign body in the respiratory tract was suspected. A flexible partial denture in the right main bronchus was identified via flexible bronchoscopy and was removed using a snare forceps. Conclusion. We encountered a case of a foreign body (denture) in the airway that was aspirated while the patient's consciousness was impaired, which was difficult to diagnose. In cases when structures are found in the tracheal lumen, the exclusion of foreign bodies in addition to sputum is important.

Background. Foreign body granulomas due to bronchial sutures (suture granulomas) are rare. To our knowledge, this is a very rare Japanese case of a suture granuloma that was resected using rigid bronchoscopy. Case Presentation. A 68-year-old man underwent right upper lobectomy and lymph node dissection for squamous cell carcinoma in 2010. Computed tomography of the chest showed an enhanced nodule in the right main bronchus. He was referred to our hospital due to suspected malignancy. Bronchoscopy was performed in December 2018; the pathological diagnosis was a granuloma. However, its cause remained unclear. Follow-up bronchoscopy was performed in May 2020; a black suture was found in the center of the granuloma, and a light blue suture appeared in the right main bronchus after cauterization with argon plasma coagulation. The pathological diagnosis confirmed a suture granuloma due to a 3-0 polyester suture that had been used during the surgery in 2010. It was resected using rigid bronchoscopy in September 2020. Conclusion. We encountered a rare case of suture granuloma that was successfully removed using rigid bronchoscopy.

Case. A 62-year-old man with lung squamous cell carcinoma (cT2bN3M0, cStage IIIB according to the 8th edition of Union for International Cancer Control) received carboplatin+nab-paclitaxel treatment in combination with radiation therapy (30 Gy) to improve airway constriction; however, pleural dissemination emerged. The chemotherapy regimen was switched several times based on tumor progression, and he received eighth-line S-1 treatment four years after the initial diagnosis, by which point the enlargement of the primary tumor had resulted in right main bronchial obstruction. Therefore, endobronchial tumor debulking was performed, and an uncovered stent was inserted into the right superior lobar bronchus through the right main bronchus. However, chest computed tomography and bronchoscopy performed one month later revealed in-stent tumor infiltration. The uncovered stent was replaced with a covered stent, and photodynamic therapy (PDT) was initiated for the tumor mass surrounding the right main bronchus. He received nineth-line vinorelbine treatment with a good performance status. Conclusion. Endobronchial interventions, such as tracheobronchial stents, and PDT play a pivotal role in the treatment of lung cancer with central airway constriction, helping to preserve the performance status of patients who can be treated with effective chemotherapy regimens.

Background. Herbal medication has been assumed to be safe, with relatively few side effects. However, drug-induced pneumonitis caused by herbal medication is being recognized with increasing frequency thanks to the rise in its use. Case. A 54-year-old-woman consulted a local doctor with a complaint of a fever and received a prescription for antibiotics (cefditoren pivoxil), antipyretic (acetaminophen), and herbal medicine (Saiko-keishitou). However, the situation did not improve, and dyspnea appeared, so she was referred to our department. She had severe type I respiratory failure at the initial diagnosis; therefore, we started artificial ventilation management. Chest computed tomography showed diffuse ground-glass opacity in both lung fields and traction bronchiectasis in some parts. In addition, significant lymphocytosis was detected in the bronchoalveolar lavage fluid; therefore, drug-induced pneumonitis was our differential diagnosis. After steroid pulse, the findings of clinical examinations, such as the respiratory evaluation and imaging, had markedly improved. Saiko-keishitou was positive in the drug lymphocyte stimulation test submitted upon admission. Conclusion. To our knowledge, drug-induced pneumonitis caused by Saiko-keishitou has not been previously reported. We herein report this case with a review of the literature.

Background. We herein report two cases with unique patterns of lung metastasis from pancreatic cancer. Case 1. A 69-year-old man was referred to our hospital for a detailed examination of dry cough and dyspnea. Chest computed tomography (CT) showed multi-located infiltrative and nodular opacities along the broncho-vascular bundle. As he did not respond to antimicrobial treatment, bronchoscopy was performed. Multi-located bronchial subepithelial lesions were revealed. A direct biopsy led to a diagnosis of adenocarcinoma. Through contrast-enhanced CT of the whole body, we diagnosed him with pancreatic cancer and lung metastasis mainly due to subepithelial invasion of the respiratory tract. Case 2. A 49-year-old man who had originally been healthy visited our hospital due to an abnormal chest shadow at a medical examination. Chest CT showed diffuse rough granular and small patchy opacities that were diffusely localized with a random pattern. A transbronchial biopsy did not lead to a diagnosis, and diffuse shadow worsened with the appearance of dry cough during follow-up. A thoracoscopic lung biopsy led to a diagnosis of mucinous adenocarcinoma showing alveolar epithelial replacement growth. Contrast-enhanced CT of the whole body revealed an irregular mass in the pancreas. Through endoscopic ultrasound-guided fine needle aspiration, the diagnosis of pancreatic cancer was obtained. Pathologically, we diagnosed him with diffuse lung metastasis of pancreatic cancer. Conclusion. We experienced two cases of pancreatic cancer with various modes of lung metastasis, through both imaging and pathological findings. We herein report these valuable cases.

Background. Although respiratory infections that develop after a transbronchial lung biopsy (TBLB) for lung cancer patients are rare, these are complications that should be avoided because they lead to delayed cancer treatment and difficult surgical procedures. Case 1. A 53-year-old man developed a lung abscess 16 days after TBLB and underwent right upper lobectomy 24 days after the TBLB. A blood transfusion was required; otherwise the postoperative course was uneventful. The patient remained alive after receiving adjuvant chemotherapy. Case 2. A 57-year-old man who developed pneumonia 7 days after TBLB underwent right upper lobectomy 43 days after TBLB, after previously receiving antibiotics and corticosteroids. Meticulous surgery was needed because of adhesion. Despite receiving adjuvant chemotherapy, the patient developed local recurrence in the apical chest wall 1 year after surgery, for which he received radiation therapy. Four years later, the lesion recurred, and chemotherapy was administered. Case 3. A 65-year-old man developed empyema 5 days after TBLB and underwent surgery 16 days after TBLB. Surgery revealed fibrinopurulent empyema, and a right middle and lower lobectomy were performed. The postoperative course was uneventful. The patient remains alive without receiving adjuvant chemotherapy. Conclusion. Surgery without prior TBLB is an option for patients with a high risk of respiratory infection due to TBLB; however, prophylactic antibiotic treatment is essential for these patients.

Background. Empyema with bronchopleural fistula often causes severe respiratory failure due to the inhalation of pus. Although bronchial occlusion is useful, it can be difficult to identify the bronchi responsible for air leakage. Case. A 58-year-old man was hospitalized with a lung abscess and bronchopleural fistula with empyema. A chest tube was placed and drained, but severe respiratory failure due to the inhalation of pus into the left lung occurred. Ventilator management and extracorporeal membrane oxygenation were introduced to maintain the blood oxygen concentration and improve pneumonia. To resolve the intractable air leakage, bronchoscopy was performed. However, there were multiple air leaks, and the responsible bronchi could not be identified. Indigo carmine was administered intrathoracically through the chest tube to identify the leaking bronchi. Repeated bronchial occlusion using an Endobronchial Watanabe Spigot reduced the air leakage. Conclusion. We believe that indigo carmine intrathoracic administration is useful for identifying the responsible bronchi in cases with multiple air leaks, and even in cases of bronchopleural fistula with severe respiratory failure, multimodality treatment may save lives.

Background. Allergic bronchopulmonary aspergillosis (ABPA) commonly occurs in patients with cystic fibrosis (CF) in Western countries. However, in Japan, the prevalence of CF is very low. Although there are many patients who present with non-CF bronchiectasis, a clinical entity similar to CF, only a few reports have described such patients developing ABPA. Case. A 61-year-old man with bronchiectasis had been visiting our hospital for a long time. Pseudomonas aeruginosa was persistently detected in his sputum. During the course of the disease, he presented with wheezing and yellow sputum resembling a mucus plug. His peripheral blood tests indicated hypereosinophilia, an elevated serum IgE level, and positive precipitating antibodies against Aspergillus fumigatus. Chest X-ray showed new infiltrative shadows in the right lower lung region. Bronchoalveolar lavage showed an increase in eosinophils. A histological examination of the transbronchial biopsy revealed peribronchial and interstitial eosinophilic infiltration. Based on these findings, he was diagnosed with ABPA. Oral corticosteroid treatment was initiated, resulting in a favorable response despite chronic Pseudomonas aeruginosa infection. During steroid tapering, recurrence and pulmonary infections were observed. After recovering from the complications, the patient maintained long-term remission. Conclusion. We encountered a rare case of ABPA in a patient with non-CF bronchiectasis.

Background. The phosphate binder sevelamer hydrochloride is a high-molecular-weight polymer. It becomes gelatinous and expands eight-fold in aqueous solutions. Sevelamer crystals deposited on the mucosa can lead to mucosal injury. Case. A 67-year-old man with chronic renal disease had received maintenance hemodialysis for about 4 years. In early June of X, he choked on a tablet of sevelamer hydrochloride (Phosblock^®) before breakfast. He felt continuous discomfort in his pharynx and mild dyspnea. His respiratory symptoms worsened during hemodialysis that afternoon. Chest computed tomography showed stenosis of the left basal bronchus and atelectasis of the left S⁸. Bronchoscopy showed edematous mucosa from the left lower lobe bronchus to the basal bronchus and gel-like white foreign bodies adhering to the basal bronchus, thought to be bronchial foreign bodies of sevelamer hydrochloride. We removed the bodies as much as possible using biopsy forceps and a brush. Conclusion. Sevelamer hydrochloride has a property of expanding on water absorption. Therefore, sevelamer aspiration is likely to cause airway obstruction. It is also necessary to be aware of the risk of mucosal injury due to sevelamer crystals.

Background. Although inflammatory myofibroblastic tumor (IMT) is regarded as a type of inflammatory pseudotumor with a role in the repair mechanism of inflammation, the concept of the tumor has recently shifted to a malignant tumor with the potential for local invasion, recurrence, and metastasis. We herein report a rare case of IMT of the pleura. Case. A 79-year-old man with a history of occupational asbestos exposure was admitted to our hospital with a complaint of dyspnea on exertion. Chest CT revealed left pleural effusion and pleural thickening. Because no malignant findings were detected in the pleural tumor specimen biopsied by thoracoscopy under local anesthesia, he was diagnosed with benign asbestos pleural effusion. During the follow-up period, the left pleural effusion and pleural thickening were exacerbated, and he was referred to our department for rebiopsy. We performed video-assisted thoracoscopic pleural tumor resection under general anesthesia followed by a histopathological examination, which revealed that the tumor was an IMT. Because of massive pleural dissemination in the intrathoracic cavity and the patient's poor physical condition, radical excision was contraindicated. The tumor was ALK-negative, and chemotherapy was not indicated. The patient died approximately 2 months after surgery. No effective treatment was found. Conclusion. Because the diagnosis of pleural IMT by thoracoscopic biopsy under local anesthesia is difficult, early radical resection with the aim of performing diagnostic therapy under general anesthesia is recommended.

Background. We report the safety and efficacy of transbronchial biopsy for endotracheal lesions of primary pulmonary lymphoma (PPL) in the clinical setting. Case. The patient was a 59-year-old man who presented with abnormal shadows on chest radiography at an annual health examination. Chest computed tomography (CT) revealed granular and linear shadows in the right upper lobe. Approximately 2 years passed with the shadows improving and exacerbating; then a 60-mm sized tumor shadow appeared at the same site, suggesting severe stenosis of the central bronchus near the tumor. Bronchoscopy revealed a paving stone-like white elevated lesion obstructing from outside the lower part of the trachea to the entrance of the right main bronchus. A biopsy was not performed because the right main bronchial lumen was highly constricted and the procedure was considered to be associated with a high degree of risk. CT-guided biopsy was performed at a later date, leading to the diagnosis of diffuse large B-cell lymphoma. Chemotherapy was started for the patients, which resulted in complete remission. Conclusion. This is a case of PPL that was diagnosed by CT-guided biopsy. For the histological diagnosis of central airway lesions in PPL, it is necessary consider the safety and accuracy of biopsy methods with reference to the lumen findings.

Background. While broncholithiasis is a rare disease, we should consider its possibility if calcification is observed. Case. We herein report a 76-year-old man who required tracheostomy and gastrostomy after subarachnoid hemorrhaging and leg amputation for arteriosclerosis obliterans. The patient had been diagnosed with right empyema at another hospital and referred to our hospital for treatment. At our hospital, the patient was diagnosed with obstruction pneumonia with a calcified foreign body using computed tomography. We planned to remove the calcified foreign body using bronchoscopy at the right inferior lobar bronchus. Bronchoscopy revealed a yellow-white broncholithiasis that was subsequently removed. On histopathology, the foreign body was found to be a bacterial colony with calcification and diagnosed as endobronchial actinomycosis using Gram, Grocott, and Fite method (positive Gram and Grocott staining but negative Fite method). After 3 weeks, the patient was transferred to his previous hospital because of improvement in his condition. Conclusion. If a compromised patient is diagnosed with obstruction pneumonia with a calcified foreign body, we should suspect the existence of infection caused by indigenous bacteria in the oral cavity, such as actinomycosis.

Background. Paratracheal air cyst (PTAC) is the general term used for radiographically defined cystic structures with air density found in soft tissues of the paratracheal region. Although 12.9-16.6% of PTACs are reportedly connected to and communicate with the trachea, there have been no reports of PTACs being connected with the thoracic cavity. Case. The patient was a 25-year-old man who had undergone bullectomy for left spontaneous pneumothorax at another medical institution 7 years ago. This time, the patient was transported emergently to our institution due to a chief complaint of right chest pain. The patient was seen and diagnosed with right tension pneumothorax based on computed tomography (CT) of the chest, after which thoracic cavity drainage was initiated. Since air leaks continued thereafter, bullectomy was performed the next day. During the surgery, 4 small stomas, 2-5 mm in size, were found in the thoracic apex. Re-reviewing the chest CT at the time of hospitalization revealed a 10 mm free air space in the posterior right side of the trachea. This along with the intraoperative findings suggested that the PTAC was communicating with the thoracic cavity. Conclusion. The PTAC in the present patient had not been detected 7 years ago and was thought to have formed a posteriori, with the possibility of being related to pneumothorax.

Background. It is very difficult to secure an airway in a trachea that is nearly completely obstructed by mediastinal endotracheal tumors, both during the initial response and during tumor resection. We herein report a surgical airway management method for mediastinal endotracheal tumors using an ultra-thin bronchoscope as a guide with insertion of a ventilation tube via the cricothyroid ligament. Case. A 60-year-old woman developed airway stenosis caused by a 20-mm endotracheal tumor at the mediastinal inlet. She was unable to lie in a supine position due to dyspnea. To prevent worsening of her respiratory condition by sedation during endotracheal intubation or extracorporeal circulation induction, we performed cricothyrotomy with the patient in a sitting position under spontaneous breathing. We inserted a Mini-Trach^® II into the trachea, via which we inserted an ultra-thin bronchoscope. We identified the tumor and advanced the bronchoscope to the distal end of the tumor. Using the bronchoscope as a guide, we then advanced the Mini-Trach^® II to the distal end of the tumor and resected the tumor using a bronchoscope inserted through the mouth while ventilating with the Mini-Trach^® II, thus relieving the tracheal stenosis. The tumor was diagnosed as adenoid cystic carcinoma, and tracheal resection was performed at a later date. Conclusion. Surgical airway management by ultra-thin bronchoscope- guided cricothyrotomy is an option for achieving rapid airway management and subsequent tumor resection in patients with mediastinal endotracheal tumors.