Background. Among patients with a primary malignant tumor of the trachea, those with tracheal adenoid cystic carcinoma have a relatively good prognosis. However, perineural invasion beyond gross tumor boundaries has been noted in a few cases. The most common tumor metastasis is hematogenous. Case. A 73-year-old man visited a physician because of a decreased swallowing function and paralysis of the right upper extremity. Horner syndrome on the right side was also noted, and the patient was referred to our department under suspicion of Pancoast syndrome. Chest computed tomography showed a tracheal mass 3 cm in diameter, whereas cervical magnetic resonance imaging indicated a contiguous neuromatous lesion extending from the C5-8 and T1 nerve roots to the brachial plexus on the right side. A bronchoscopic biopsy of the tracheal mass led to a histopathological diagnosis of adenoid cystic carcinoma. Examination of a biopsy specimen from the brachial plexus lesion also indicated adenoid cystic carcinoma, and a diagnosis of distant metastasis from the primary tracheal lesion was determined. The patient was provided the best supportive care. Death from malignancy occurred approximately two years after the diagnosis. Conclusion. We encountered a rare case of tracheal adenoid cystic carcinoma with metastasis to the brachial plexus that caused Horner syndrome and right upper extremity paralysis.

Background. Diffuse pulmonary meningotheliomatosis (DPM) shows multiple nodules on chest computed tomography (CT) and is often diagnosed by a surgical biopsy. Case. A 43-year-old woman was visiting the Department of Diabetes and Endocrinology of our hospital for panhypopituitarism treatment. She was referred to our department upon observation of multiple 1- to 5-mm ground-glass nodules in both lungs on chest CT. Although the size of the nodules did not change after five months of follow-up, CT findings suggested metastatic lung tumor. A transbronchial lung cryobiopsy (TBLC) was therefore performed from the left B⁸a and B⁹a. Histological findings revealed minute pulmonary meningothelial-like nodules, which were considered to correspond to the ground-glass nodules on chest CT. We diagnosed her with DPM based on the histological and CT results. Conclusion. A TBLC may be useful for diagnosing multiple ground-glass nodules including DPM.

Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has a low incidence of complications, but care must be practiced, as infectious complications carry the risk of becoming serious. We herein report a case of purulent lymphadenitis after EBUS-TBNA that improved by drainage with EBUS-TBNA. Case. A 33-year-old man was referred to our hospital because of abnormal chest shadows. Computed tomography (CT) showed bilateral hilar, mediastinal and abdominal lymphadenopathy and nodular shadow with cavity in right upper lung. Sarcoidosis was pathologically diagnosed by EBUS-TBNA via the #7 lymph node. Brain magnetic resonance imaging revealed brain lesions, and high-dose steroid therapy was started 11 days after bronchoscopy. The patient had a fever when he came to our department for a follow-up visit 39 days after bronchoscopy (day 1). We performed CT again, which showed swelling of the #7 lymph node with an internal low-density area, and increased white blood cells and C-reactive protein levels were also observed on blood tests. He was thus diagnosed with purulent lymphadenitis, and antibiotic treatment was started. Blood tests and a CT reexamination on day 5 showed no improvement, so purulent drainage was performed on day 6 using EBUS-TBNA. A purulent specimen was submitted for a bacteriological examination, and multiple anaerobic bacteria were detected. Continued antibiotic treatment improved his condition. Conclusion. Drainage of purulent lymphadenitis with EBUS-TBNA may lead to a favorable outcome.

Background. Cryptococcosis is a deep-seated mycosis caused by a capsular yeast infection with Cryptococcus sp.. Cryptococcus sp. mainly infects the lungs and central nervous system, and laryngeal and tracheal lesions are rare. Case. An 82-year-old woman was diagnosed with Hodgkin lymphoma in January X−3 and achieved a complete response after chemotherapy. Computed tomography (CT) of the chest taken in May X to monitor lymphoma progress revealed a nodular shadow in the lower lobe of the right lung and coughing and hoarseness started simultaneously. Blood tests were positive for Cryptococcus neoformans antigen, and bronchoscopy was performed for a diagnosis. A biopsy of the right S⁶ node and nodular protrusions in the trachea was performed. C. neoformans was culture-positive in the tissue, and cryptococcosis was diagnosed. After treatment with fluconazole, the patient's hoarseness improved, the pulmonary nodular shadow was reduced on chest CT, and bronchoscopy showed improvement of the laryngeal and tracheal lesions. Conclusion. When cryptococcosis is suspected in immunocompetent patients, it is important to check for bronchial and laryngeal lesions.

Background. Solitary extramedullary plasmacytoma of bronchiolar origin is rare. We herein report a case of solitary extramedullary plasmacytoma of bronchiolar origin diagnosed by bronchoscopic resection using a high-frequency electrosurgical snare. Case. A 60-year-old man with a slight fever and cough was diagnosed with a left pulmonary hilar mass and obstructive pneumonia on chest computed tomography. Bronchoscopy revealed a red tumor 10 mm in diameter protruding from the left lower lobe bronchus. A portion of the tumor was biopsied using biopsy forceps, but a definitive diagnosis could not be made. The majority of the tumor was excised using a high-frequency electrosurgical snare under general anesthesia and submitted for a pathological examination. The tumor showed infiltration of multinucleated foreign body giant cells and plasma cells with prominent nucleoli in acidic amyloid deposits. The infiltrated plasma cells were κ-chain-positive and λ-chain-negative. A solitary extramedullary plasmacytoma was diagnosed, because no lesions in other organs were identified. Local radiotherapy was performed and the tumor disappeared. Conclusion. An endoscopic diagnosis using a high-frequency electrosurgical snare should be considered for endobronchial tumors of unknown origin, considering the possibility of this pathology.

Background. Pulmonary leiomyoma is a rare disease that account for only 0.04% of all lung tumors. It is classified into two types: bronchial and pulmonary parenchymal. Treatment options that preserve the respiratory function are preferred. However, the choice of treatment can be challenging, especially for bronchial leiomyomas that develop distally to the lobar bronchus. Case. The patient was a man in his 60s who presented with exertional dyspnea. Upon an examination, a nodule obstructing the left lower lobe bronchus was discovered, leading to his referral to our hospital. Bronchoscopy revealed that the tumor obstructed the left lower lobe bronchus inlet, and chest computed tomography revealed lower lobe atelectasis. A bronchoscopic biopsy did not lead to a definitive diagnosis; however, leiomyoma was suspected because smooth muscle code-like proliferation was observed, and positron emission tomography showed no accumulation. As it was determined that removal using a bronchoscope would be difficult, he was referred for thoracic surgery, and S⁶ segmentectomy with wedge resection of the lower lobe bronchus was performed. The resected specimen showed that a sessile tumor had developed from the root of B⁶, which occluded B⁶ and protruded into the lumen of the lower bronchial canal. The pathological diagnosis was a leiomyoma. The patient's dyspnea on exertion disappeared after surgery. Conclusion. Segmentectomy with wedge resection of the bronchus is a valuable surgical technique for preserving the respiratory function in leiomyoma arising at the bifurcation of segmental branches, especially when endoscopic treatment is not feasible.

Background. Malignant pleural mesothelioma (MPM) is a malignant tumor arising from the pleura. It is sometimes difficult to differentiate from primary lung cancer, which originates in the lung parenchyma. Case. A 67-year-old man visited a primary physician with the chief complaint of exertional dyspnea. Chest computed tomography (CT) showed a huge mass in the right upper lobe of the lung and a nodule suggestive of pleural dissemination. The patient was referred to our department for an initial examination. Fluorodeoxyglucose-positron emission tomography (¹⁸FDG-PET) -CT revealed multiple metastases to the lymph nodes, bones, and bilateral adrenal glands. Primary lung cancer arising from the right upper lobe was initially suspected and a bronchoscopy examination was performed. However, a transbronchial biopsy (TBB) of an invasive tumor on the mucosa of the right B³a bronchus resulted in a definitive histological diagnosis of malignant mesothelioma (epithelial type), contrary to radiographic imaging. The patient was diagnosed with stage IV MPM (cT4N2M1). Nivolumab plus ipilimumab was given as the first-line therapy, and CT showed a partial response after two courses. However, the disease progressed owing to peritoneal dissemination during the 3rd course. Conclusion. There are few reports of cases where a TBB has been able to be used to diagnose malignant mesothelioma. We herein report a case of pseudo-lung carcinomatous mesothelioma with radiographic images that could be mistaken for typical primary lung cancer with multiple distant metastases.

Background. Tracheal rupture due to intubation is a rare complication. Both conservative and surgical therapies are appropriate for treating membranous tracheal ruptures. Case. During myocardial infarction treatment, a 77-year-old woman was placed on a ventilator and extubated. However, her heart failure worsened, and she was re-intubated. After intubation, hemoptysis was observed, and a bronchoscopic examination confirmed a laceration of the posterior membranous wall of the tracheal tree, spanning 3.5 cm. Since neither pneumomediastinum nor pneumothorax was present, a cuff was placed centrally above the laceration, and conservative treatment was performed. Granulation tissue grew, and the injury was cured in approximately two months. Conclusion. Extensive rupture of the tracheal membrane following endotracheal intubation can be cured.