Background. Endoscopic ultrasound with bronchoscope-guided fine needle aspiration (EUS-B-FNA) is a useful biopsy technique that is widely applicable to lesions that can be approached through the esophagus. However, they are not widely used in clinical practice. In this study, we examined the utility of EUS-B-FNA as a first-line biopsy technique based on the examination results of patients who underwent EUS-B-FNA. Methods. Between April 2020 and November 2022, 45 patients (39 with mediastinal lesions and 6 with pulmonary lesions) underwent EUS-B-FNA. We retrospectively evaluated the diagnosis rate, the presence of complications, and the retrieval rate of genetic mutations and the programmed cell death ligand 1 (PD-L1) expression in non-small cell lung cancer based on the medical records. Results. A specific diagnosis was made in 93.3% of the patients. The only complication was a mild mediastinal hematoma. Gene panel test results were available for 75% of the cases, and the PD-L1 expression was obtained in 82.4% of the cases. Conclusions. The diagnostic yield and safety of EUS-B-FNA as a first-line procedure were comparable to previous reports. EUS-B-FNA is an option for lesions that can be biopsied transesophageally and is a highly useful technique for patients who are in a poor condition.

Background. Pulmonary veno-occlusive disease (PVOD) is a disease in which pulmonary vascular resistance increases due to stenosis/occlusion of the pulmonary veins, resulting in pulmonary hypertension. We herein report a case of respiratory failure due to alveolar hemorrhage and thrombocytopenia due to hypersplenism induced by right heart failure. Case. An 18-year-old man was admitted to the hospital for a fever and type I respiratory failure. Laboratory data showed thrombocytopenia (platelet count: 22,000/μl) and chest computed tomography (CT) showed ground-glass opacities predominantly in the bilateral lower lobe, bilateral pleural effusion, and thickening of the interlobular septum. A cardiac catheter test revealed pulmonary hypertension, and bronchoscopy revealed alveolar hemorrhage. In addition, a pulmonary function test showed a decreased diffusion capacity. Based on these findings, the patient was diagnosed with PVOD. Although non-invasive positive pressure ventilation therapy was temporarily required, the respiratory condition, pulmonary opacities, and thrombocytopenia gradually improved with body fluid management and supplemental oxygen therapy. The patient was discharged from the hospital after the introduction of home oxygen therapy. Conclusions. PVOD may induce subclinical alveolar hemorrhage, and bronchoscopy proved useful for an early diagnosis in the present patient. Furthermore, hypersplenism due to severe right heart failure might have caused thrombocytopenia in this case.

Background. Cryptococcal pleuritis is a rare disease. There are few case reports on cryptococcal pleuritis diagnosed by thoracoscopy under local anesthesia. Case 1. A 78-year-old man was referred to our hospital due to left pleural effusion on chest radiography. We performed thoracoscopy under local anesthesia for the diagnosis. Pleural culture was positive for Cryptococcus neoformans, and cryptococcal pleuritis was diagnosed. Case 2. A 79-year-old man was referred to our hospital due to left pleural effusion on chest radiography, and we performed thoracoscopy under local anesthesia for the diagnosis. Yeast-like fungi with capsule forms in pleural biopsy specimens were detected, and cryptococcal pleuritis was diagnosed histopathologically. Case 3. The patient was a 78-year-old man with corticosteroid therapy for cryptogenic organizing pneumonia. During treatment with corticosteroids, chest radiography showed right pleural effusion, and we performed thoracoscopy under local anesthesia. Pleural culture was positive for Cryptococcus neoformans, and cryptococcal pleuritis was diagnosed. Conclusion. A pleural biopsy via thoracoscopy under local anesthesia is useful for diagnosing cryptococcal pleuritis.

Background. Fistula empyema is frequently treated surgically, but when surgical treatment is difficult, bronchial occlusion is another option. Case. An 88-year-old man with a right empyema presented to a local doctor and was treated conservatively with chest-tube drainage and antibiotics. During the course of treatment, a significant air leak from the chest tube persisted, so the patient was transferred to our department and diagnosed with fistula empyema. After admission, we decided to use the Endobronchial Watanabe Spigot (EWS) bronchial occlusion technique with intraoperative cone-beam computed tomography (CBCT) at the bronchial fistula site identified on chest CT. Four EWSs were inserted into the right B⁶, and CBCT was performed. Intraoperative CBCT confirmed that the bronchus had been successfully occluded. Following the operation, the air leak was repaired, and the dead space was reduced. The patient was discharged after the drain was removed. Conclusion. We experienced a case in which fistula empyema was treated successfully with bronchial occlusion with EWS using CBCT. CBCT is an effective tool for ensuring reliable bronchus occlusion.

Background. We herein report a patient who developed a mediastinal emphysema and contralateral tension pneumothorax during bronchial embolization indicated for a refractory pulmonary fistula. Case. The patient was a 67-year-old woman who complained of dyspnea after coughing. She was diagnosed with right pneumothorax and admitted to a hospital. Despite placement of two chest drains, no symptom improvement was seen, so she was transferred to our hospital for surgery. Bronchial embolization was indicated, after which she developed remarkable subcutaneous emphysema in the left anterior chest area. She later suffered a decreased level of consciousness and oxygenation, so tracheal intubation was urgently performed. Computed tomography revealed left pneumothorax, mediastinal emphysema, subcutaneous emphysema, and retroperitoneal emphysema, and left thoracic drainage was performed. Her condition stabilized thereafter, and she was discharged from the hospital 10 days after bronchial embolization. Four months later, she had experienced no pneumothorax recurrence. Conclusion. To date, there have been no reports on contralateral pneumothorax during bronchial embolization. For this reason, we discuss and report this rare case.

Background. An acute exacerbation of interstitial pneumonia (IP) is a potential complication in the treatment of pneumothorax with IP, and the surgical outcome is poor. There are few reports of favorable outcomes following surgery for pneumothorax associated with pleuroparenchymal fibroelastosis (PPFE). Case. The patient was a 69-year-old man who was under treatment with home oxygen therapy for PPFE. He developed bilateral small pneumothoraces. The left pneumothorax progressed at the follow-up evaluation. Therefore, left thoracic drainage was performed, and pleurodesis therapy with an autologous blood patch was performed 6 times, but there was no improvement. Thoracoscopic repair of the lung fistula involving the left pneumothorax was performed after placement of a thoracic drain on the right side. We devised a surgical technique and performed lung-protective ventilation to prevent the acute exacerbation of IP. He was discharged from the hospital on the 9^th day after surgery with no complications. In the 5 months since surgery, there has been no recurrence of the left pneumothorax. Conclusion. This case suggests that a favorable outcome can be obtained by performing surgery with attention to the acute exacerbation of IP, even in patients with refractory pneumothorax and PPFE.

Background. Few studies have investigated whether endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) can be conducted without a balloon for a definitive diagnosis of mediastinal lymphadenopathy. Case 1. A woman in her 70s with an allergy to rubber gloves. During an examination for uveitis, CT showed multiple enlarged lymph nodes in #4R and #7. Case 2. A man in his 40s presented with an allergy to rubber gloves. Follow-up CT after the surgical treatment of lung adenocarcinoma revealed an enlarged lymph node (#7). Results. EBUS-TBNA was performed in these two cases to definitively diagnose enlarged mediastinal lymph nodes without a balloon. In Case 1, #7 and #4R had short diameters of 10 mm and 15 mm, respectively, while in Case 2, #7 had a short diameter of 17 mm. The lesion was delineated and punctured without a balloon. Case 1 was diagnosed with sarcoidosis, and case 2 was diagnosed with recurrent lung adenocarcinoma. Conclusions. It is crucial to carefully assess whether the target lesion is puncturable before the examination when performing EBUS-TBNA without a balloon.

Background. Patients with rheumatoid arthritis often present with pleural effusion. Amyloidosis is a rare cause of massive pleural effusion. Case. A 71-year-old woman with a 35-year medical history of rheumatoid arthritis was referred to our hospital. Four years previously, her renal function had begun to deteriorate. Gradually, she started complaining of dyspnea and developed massive left pleural effusion. She underwent thoracoscopic pleural biopsy under local anesthesia, which revealed amyloid deposition in the parietal pleura. The patient was diagnosed with pleural lesions secondary to AA amyloidosis associated with rheumatoid arthritis. After treatment with etanercept, her serum amyloid A protein levels decreased. Her dyspnea improved as her pleural effusion decreased. Conclusion. When patients with rheumatoid arthritis develop refractory pleural effusion, it is important to include pleural amyloidosis as a differential diagnosis and to perform a pleural biopsy to search for amyloid deposition.