Background. Bronchoscopy is an important procedure for diagnosing respiratory diseases. Education on bronchoscopy should be based on trainees' abilities, self-assessment, and needs. However, no detailed studies have been performed in these fields. We conducted a self-assessment and assessed the need for learning techniques in bronchoscopy. Methods. We provided a questionnaire to pulmonologists at Chiba University Hospital and affiliated hospitals. The participants answered questions on the characteristics and difficulty of bronchoscopy using a 5-point Likert scale. The same scale was used to assess their understanding and practice of bronchoscopy techniques, and to check whether they would like to participate in seminars and/or workshops. The obtained answers were analyzed by dividing the participants into "not good" and "good" groups. Results. A total of 42 participants filled out the questionnaire. Twelve (28.6%) participants answered that they were not good at bronchoscopy, while eight (19.0%) participants answered that they were good at bronchoscopy. The "not good" group was characterized by female participants of younger age, along with participants who did not obtain a specialist certificate. However, when compared to the "good" group, there were no significant differences. Regarding the understanding and performance each bronchoscopy technique, the "not good" group had a lower score than the "good" group on all items on the questionnaire. Conversely, regarding participation in a seminar or workshop, the "not good" group scored higher points in infection control, insertion of bronchoscope, airway evaluation, positioning of the guide sheath, and performance of transbronchial lung biopsy. Nevertheless, there were no significant differences between the two groups. Conclusion. The participants considered bronchoscopy procedures to be difficult and had difficulty performing many bronchoscopy techniques. In addition, they preferred on-site instruction focusing on actual procedures. Knowledge is necessary for the acquisition of technique. Therefore, a curriculum combined teaching knowledge and techniques should be developed.

Background. Displaced bronchus is rare. We experienced a case of complete video-assisted thoracoscopic middle lobectomy for lung cancer with displaced B³. Case. A 68-year-old woman was found to have an abnormal shadow in the right middle lung during follow-up of eosinophilic pneumonia. Chest computed tomography (CT) showed a nodule 3.1 cm (solid lesion 2.2 cm) in size in her right middle lobe. Primary lung cancer (clinical T1cN0M0, stage IA3) was suspected. A preoperative three-dimensional CT reconstructed image showed the right B³ branching from the middle bronchus. Result. No minor fissure was observed, and B³ branched from the middle bronchus. Middle lobectomy was therefore performed by dividing B⁴⁺⁵ before dividing the incomplete lobulation, and lymph node dissection 2a-2 was added. The final diagnosis was adenocarcinoma, pathological stage T1cN0M0, stage IA3. Conclusion. We reported a case of middle lobectomy for lung cancer with displaced B³ and incomplete lobulation managed by the bronchus-first method. Extension of lung resection should be determined based on the localization and progression of the tumor.

Background. Pulmonary vein stenosis following catheter ablation may go unnoticed by pulmonary physicians. Case. A 69-year-old male. He had a catheter ablation for atrial fibrillation at the ages of 67 and 68. On health screening, the chest X-ray at our hospital revealed a ground-glass opacity in the left middle and lower lung fields. A chest CT revealed a ground-glass opacity and clearly-demarcated infiltrative shadow in the left upper lobe one month later, and he was admitted to our hospital. Blood was found in the bronchoalveolar lavage fluid, and a transbronchial lung biopsy revealed organizing pneumonia. Pulmonary vein stenosis was diagnosed after reviewing the chest CT on admission and reconstructing it into three-dimensional images. Conclusion. When there is a history of catheter ablation, pulmonary vein stenosis should be considered.

Background. Racemose hemangioma of the bronchial artery is an important disease that can cause hemoptysis. Case. A 56-year-old man visited the emergency room of our hospital because of hemoptysis. Chest computed tomography showed bilateral pulmonary emphysema and a dilated and convoluted blood vessel in the right upper lobe. After making a diagnosis of racemose hemangioma of the right bronchial artery by bronchial artery angiography, bronchial artery embolization (BAE) was performed using an absorbable gelatin sponge sheet. Because hemoptysis recurred, bronchoscopy was performed. It revealed a dark red vessel in the right bronchus intermedius, which was compatible with racemose hemangioma of the right bronchial artery. Thoracoscopic ligation of the right bronchial artery was successfully performed. Conclusion. When hemoptysis is difficult to control by BAE in patients with racemose hemangioma, surgical ligation of the bronchial artery is a useful therapeutic option.

Background. The usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for diagnosing hilar and mediastinal lymph node lesions is well-recognized. However, there have been few reports concerning the usefulness of EBUS-TBNA for diagnosing amyloidosis presenting as hilar and mediastinal lymphadenopathy. Case. A 77-year-old woman was referred to us for a hilar and mediastinal lymphadenopathy assessment after receiving treatment for colorectal cancer and lung cancer. We found deposits of amyloid in mediastinal lymph node lesions on EBUS-TBNA and made a final diagnosis of AL amyloidosis. Conclusion. EBUS-TBNA is a minimally invasive test and useful for diagnosing amyloidosis presenting as mediastinal lymphadenopathy because a sufficient tissue sample can be obtained. It should thus be considered as a diagnostic tool option.

Background. Tuberculous pleurisy and peritonitis are often challenging to diagnose because of limited specific laboratory findings. Case. A 78-year-old woman admitted for abdominal pain who had been initially diagnosed with peritonitis of unknown cause was referred to our department due to bilateral pleural effusion. The pleural fluid showed an exudative effusive nature with mononuclear cell predominance and high adenosine deaminase levels. Thoracoscopy under local anesthesia was performed due to suspicion of tuberculous pleurisy, a diagnosis that was confirmed based on tuberculosis polymerase chain reaction and pathological findings of the biopsied pleural tissue. The patient received treatment with three anti-tuberculosis drugs (isoniazid, rifampicin, and ethambutol), after which the peritonitis and bilateral pleural effusion improved. Conclusion. Thoracoscopy under local anesthesia was useful for the diagnosis of an unusual case of tuberculous pleurisy that presented with bilateral pleural effusion following peritonitis.

Background. Performing surgery for a central airway tumor can require extensive invasiveness and substantial surgical stress. Case. A 67-year-old man was referred to our hospital for left-side pneumothorax and an evaluation of a right lower bronchial tumor on chest computed tomography. Bronchoscopy showed a tumor occluding the orifice of the right lower bronchus. A bronchoscopic biopsy was performed, and a pathological examination revealed large cell neuroendocrine carcinoma of the lung. The bronchoscopic findings showed a small nodule at the spur between the right middle bronchus and the right lower bronchus, but it was not deemed malignant by a frozen-section examination. We resected the tumor, which had extended to the truncus intermedius and occluded the orifice of the right lower lobe bronchus, using argon plasma coagulation with a flexible bronchoscope under general anesthesia. We further performed video-assisted thoracoscopic right lower lobectomy and lymph node dissection (ND2a-2). The resected bronchial stump was not malignant on a frozen-section examination. The postoperative progress was good, and the patient was discharged. Conclusion. By combining bronchoscopic and surgical treatment for tumors extending into the central bronchus, complete resection was possible under a minimally invasive approach.

Background. Actinomycosis with peripheral lung lesions is difficult to diagnose by bronchoscopy and often requires surgical lung resection to differentiate it from lung cancer or pulmonary tuberculosis. Case. A 47-year-old man presented to our hospital with cough and bloody sputum. Chest computed tomography revealed the presence of a localized infiltrative lesion with internal bronchiolar dilatation in the peripheral area of the right S¹. Bronchoscopy was performed, and biopsy samples were obtained several times from the lesion using endobronchial ultrasonography with a guide sheath. Based on the results of anaerobic culture, the patient was diagnosed with pulmonary actinomycosis caused by Actinomyces graevenitzii. After six months of treatment with amoxicillin, the lesion had almost disappeared; slight scarring was observed. Thereafter, there was no recurrence. Conclusion. Pulmonary actinomycosis may be a differential diagnosis for peripheral lung lesions with internal bronchiectasis. When performing bronchoscopy, it is important to obtain samples several times from inside the lesion and submit those specimens for anaerobic culture.

Background. We report a case of carcinomatous pleuritis as late recurrent breast cancer 33 years after initial surgery, diagnosed using thoracoscopy under local anesthesia. There are few cases of recurrent breast cancer occurring more than 30 years after surgery. Case. A 75-year-old woman was admitted to our hospital with progressive dyspnea on exertion. She had undergone mastectomy for right breast cancer 33 years before presentation. Chest CT showed bilateral pleural thickening and small amount of pleural effusion, but we could not obtain enough pleural fluid specimens for examination due to the thickened chest wall. We performed thoracoscopy under local anesthesia, and large white nodules were observed sporadically on the wall, visceral pleura and on the diaphragm. Histopathological examination revealed ductal and cribriform structures, and together with the results of immunostaining, a diagnosis of carcinomatous pleuritis as late recurrence of breast cancer was made. Conclusion. We report a case of carcinomatous pleuritis that recurred 33 years after breast cancer surgery, which was successfully diagnosed using thoracoscopy under local anesthesia.