Background. A cryobiopsy has been widely used in recent years; however, while there are many reports of peripheral lung lesions, there are few reports of central airway lesions from Japan. Purpose. To evaluate the efficacy and safety of a cryobiopsy for central airway lesions. Methods. We retrospectively reviewed 11 patients who underwent a cryobiopsy for central airway lesions between September 2019 and December 2022 in our hospital. The efficacy was assessed based on the pathological diagnostic yield for central airway lesions, while the safety was assessed based on bleeding and worsening of the respiratory status. Results. The pathological diagnostic yield of a cryobiopsy was 100%. Bleeding was observed in 10 of the 11 patients (90.9%) but was well controlled in all patients. No cases of a worsening respiratory status after a cryobiopsy were noted. Some patients achieved successful recanalization and improved respiratory symptoms. Conclusion. A cryobiopsy for central airway lesions is a safe technique with a good pathological diagnostic yield. Further studies on cryobiopsy for central airway lesions should be performed in Japan.

Background. Transbronchial cryobiopsies have been widely referenced in conference presentations and research articles. However, few reports have discussed the difficulty in performing this procedure. Subjects and methods. The subjects were 19 training doctors who performed transbronchial cryobiopsies between August 1, 2019, and March 9, 2023. The doctors were asked to take a survey regarding the difficulty they experienced when performing transbronchial cryobiopsies. The questionnaire results were scored and ranked according to the average score. Results. The 19 training doctors comprised 13 men and 6 women. The median number of years post-qualification was 5 (range: 3-7), and the median time required to perform a transbronchial cryobiopsy was 53 (range: 40-90) minutes. Among the nine surgical procedure items, the part of the procedure reported to be the most difficult to perform was the biopsy itself using a cryoprobe. The second-most difficult part to perform was identifying of the biopsy target on a fluoroscopic image. The diagnostic rate among the subjects was 84.2%, which did not differ markedly from that of bronchoscopy instructors or specialists. Conclusion. The most difficult part of medical procedure was the biopsy itself using a cryoprobe. The second-most difficult part was identifying the biopsy target on fluoroscopic image.

Background. Primary small intestine carcinoma (SIC) is rare and often progresses rapidly, and its metastasis makes treatment difficult. This is the first report of a histological diagnosis being obtained via pulmonary metastasis bronchoscopy of primary SIC. Case. A 66-year-old woman was hospitalized for intestinal obstruction. A tumor accompanied by spicula and pleural indentation on the left hilum and right adrenal tumor was confirmed, leading to suspicion of primary lung cancer. However, this lesion was identified as primary SIC upon enterectomy for release of intestinal obstruction. Bronchoscopy revealed complete obstruction of the left B⁶ because of a protruding tumor. As a biopsy confirmed pathological findings that were identical to SIC, pulmonary metastasis was diagnosed. Chemotherapy was unsuccessful, and the patient died after four months. Conclusion. Endoscopic findings of a metastatic pulmonary tumor can provide various findings regarding the primary tumor and histology. Furthermore, it is necessary to perform identification while considering the possible existence of a different primary tumor, even if the imaging findings do not contradict the diagnosis of primary lung cancer.

Backgrounds. Traumatic cysts are cystic lesions that develop due to an increase in airway pressure caused by blunt trauma, most commonly traffic trauma. Although most shrink spontaneously, no reliable treatment has yet been established, so their appropriate management and distension tendency remain unclear. Case. A 66-year-old woman who had been diagnosed with idiopathic pulmonary fibrosis, and placed on corticosteroids and immunosuppressive drugs, was later hospitalized after her fibrosis became acute. To diagnose the cause of the acute exacerbation, bronchoalveolar lavage (BAL) was performed bronchoscopically. The cyst was found to have enlarged, causing the dyspnea to worsen accordingly. Suspecting the check valve as the cause of the exacerbation, we inserted an endobronchial Watanabe spigot (EWS), a bronchial filling technique, in the responsible bronchus. This resulted in a transient but significant reduction of the cyst and relief of the dyspnea. Conclusion. These results suggest that bronchial filling may be successful when surgical resection is not possible for a progressively enlarging pulmonary cyst. However, careful studies are needed to identify the responsible bronchus and determine the ideal properties of the filling material.

Background. Lipoid pneumonia is a type of pneumonia characterized by the presence of fat-phagocytic macrophages in the lungs. It can be caused by numerous factors, such as airway obstruction from tumors and gastroesophageal reflux disease. Case. An 80-year-old man with ALK-positive lung adenocarcinoma underwent surgery and was receiving alectinib for postoperative recurrence. He developed a productive cough, and computed tomography revealed ground-glass opacity in the S² of the right lung. The possibility of drug-induced pneumonia or aspiration pneumonia was considered, and despite discontinuing alectinib and administering antibiotics, there was no improvement. During bronchoscopy, it was observed that digestive fluid was dripping into the right lung B², and lipophagocytic macrophages were found in the bronchoalveolar lavage fluid. He was diagnosed with lipoid pneumonia caused by gastroesophageal reflux. After receiving steroid treatment, the opacity in his lungs disappeared. Conclusions. The observation of digestive fluid dripping into the affected bronchus during bronchoscopy was crucial in identifying the cause of lipoid pneumonia. When performing bronchoscopy, we should be alert for dynamic phenomena in the airways.

Background. In rare cases, suture material is found in the bronchial lumen after respiratory surgery. Case. A 67-year-old woman underwent thoracoscopically assisted right S⁶ segmentectomy for lung cancer. In the operation, B⁶a and B⁶b+c originated separately from B⁶, stapling both B⁶a and B⁶b+c. Air leakage was observed at the stump of B⁶a and closed with Teflon pledgets; no complications were seen after the operation. Fifteen months after the operation, the patient visited our hospital with gradual worsening of cough and dyspnea. Chest X-ray showed an infiltrative shadow, so we suspected pneumonia and performed computed tomography, which showed a high-density structure in the truncus intermedius, resulting in obstruction of the truncus intermedius. Suspecting a bronchial foreign substance, we performed bronchoscopy, and a white foreign substance was found in the truncus intermedius. The foreign substance was easily removed. The symptoms improved after removal of the foreign matter, which consisted of surgical sutures and pledgets. We experienced a case wherein sutures and pledgets migrated to the bronchial lumen 15 months after radical resection for lung cancer. Conclusion. We hypothesized that granulation from the bronchopleural fistula caused the sutures and Teflon pledgets to migrate to the bronchial lumen.

Background. Low-grade endometrial stromal sarcoma (LG-ESS) is a rare uterine tumor and metastases to the lungs has been reported. We report a difficult case of pulmonary metastases from LG-ESS presenting diffuse cystic lung disease. Case. A 45-year-old woman underwent radical resection for LG-ESS. During hormone therapy as adjuvant treatment, multiple cystic lesions in bilateral lungs were observed on chest computed tomography. Diffuse cystic lung disease such as lymphangioleiomyomatosis was suspected. The pathological diagnosis was not obtained by bronchoscopy, but resection of cystic lesions by video-assisted thoracic surgery provided a definitive diagnosis of LG-ESS pulmonary metastases. The pulmonary metastases were progressive, but subsequent systemic treatment for LG-ESS resulted in favorable disease control. Conclusion. It is important to take a reliable diagnostic approach to cystic lung lesions in patients with LG-ESS, considering the possibility of metastatic tumors.

Background. Many patients with bronchial foreign bodies present to the hospital complaining of chronic respiratory symptoms such as cough. We report a case of involving the bronchoscopic removal of fish bone that had been aspirated two years previously along with a review of the relevant literature. Case. A 71-year old woman presented to our hospital complaining of cough. In October 20XX, the chest computed tomography (CT) showed atelectasis in the left lobe and a mass with a high-density line at the entrance of the left lobe branch. Results. Bronchoscopy revealed a fish bone in the left upper lobe. Considering the risk of airway bleeding, the patient was referred to an advanced medical institution where respiratory surgical assistance is available and bronchoscopic removal of the fish bone was performed. Since bleeding was observed during the procedure, the fish bone was removed by grasping forceps while stopping the bleeding. Conclusion. In patients with complaints of chronic cough, it is important to conduct a detailed medical interview about aspiration, and to perform radiological imaging, mainly CT, at an early stage. Moreover, when removing fish bones, it is important to assume the potential for airway bleeding and to perform a preoperative examination and make appropriate preparations.

Background. Primary pulmonary malignant lymphomas account for 0.5% to 1% of all primary pulmonary malignancies, with B-cell lymphomas accounting for 70% to 80% and T-cell lymphomas being rare. Case. An elderly woman in her 80s was referred to our hospital for further examination and treatment due to a consolidation in the left upper lung field on chest X-ray. Contrast-enhanced computed tomography revealed a mass integrated with lymph nodes in the left upper lobe as well as enlarged lymph nodes in the subtracheal bifurcation, contralateral hilar lymph node, and peripancreatic lymph node. A transbronchial biopsy of the left upper lobe was performed, and histopathological findings showed numerous small lymphocytic infiltrates in the interstitial lung. Immunostaining revealed CD3 (+), CD4 (+), CD8 (-), and CD20 (-), leading to a diagnosis of T-cell lymphoma. The patient tested positive for human T-cell leukemia virus type-1 (HTLV-1) antibodies, raising suspicion of adult T-cell leukemia-lymphoma (ATL). However, HTLV-1 proviral DNA was not detected in the biopsy tissue. The patient was subsequently referred to the hematology department of another hospital, where left pleural effusion was identified. ATL cells were detected in the effusion, confirming the diagnosis of lymphoma-type ATL. The patient showed a positive response to cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) therapy. Conclusion. Lymphoma-type ATL has a poor prognosis. A prompt diagnosis was achieved in this case through bronchoscopy, enabling the timely initiation of treatment.

Background. Endoscopic ultrasound bronchoscope-guided fine-needle aspiration (EUS-B-FNA) is useful for diagnosing mediastinal lesions. Case. A 70-year-old woman underwent right submandibular adenectomy for a submandibular gland tumor at our hospital in October 2009, and the surgical pathology revealed pleomorphic adenoma. In July 2019, multiple pulmonary nodules were found incidentally, and a computed tomography-guided needle biopsy or surgical lung biopsy was recommended, as bronchoscopy was difficult owing to nodule localization; however, the patient refused treatment. In March 2023, at 84 years old, the patient was referred to our hospital for palliative radiation after the discovery of a metastatic bone tumor at the cervical spine (C6) and multiple enlarged pulmonary nodules. Endobronchial ultrasonography with a guide sheath (EBUS-GS) was performed on the central lesion with a positive air bronchus sign in the left upper lobe (B¹⁺²), but the rapid on-site cytologic evaluation was negative. Consequently, we performed EUS-B-FNA, taking samples of the pulmonary nodules through the esophagus. The pathological findings of the EUS-B-FNA tissue specimen were comparable to those of the 2009 pleomorphic adenoma surgical specimen, so the patient was diagnosed with lung metastases of pleomorphic adenoma. Conclusion. EUS-B-FNA proved suitable for diagnosing lung metastases of pleomorphic adenoma.

Background. Evidence supports the efficacy of segmentectomy for early lung cancer with a diameter of ≤2 cm. Case. A 76-year-old man had ground-glass opacity (GGO) that was diagnosed as lung adenocarcinoma according to a computed tomography (CT) -guided lung biopsy. An analysis of SYNAPSE VINCENT™ on CT revealed that the GGO existed in S^* of atypical bronchus originating from B⁸a, and the S^* was supplied by A⁹⁺¹⁰. Virtual assisted lung mapping (VAL-MAP) was performed to confirm the location of the GGO and area of resection. In the operation, A⁶, two branches of A^* from A⁹⁺¹⁰, B⁶ and atypical bronchus from B⁸a were resected to perform S⁶+S^* segmentectomy. A pathological examination revealed adenocarcinoma, pT1miN0M0, stage IA1. Conclusion. Recent increases in the need for segmentectomy for lung cancer are expected to increase our chances of encountering cases that involve the right S^*, such as this case. This trend underscores the need to review preoperative images of the bronchus and vessels appropriately.