We attempted bronchial obstruction therapy with a fiberoptic bronchoscope in a case of giant bulla of lung which had enlarged progressively. A 59 year-old man, complaining of dyspnea from bullous emphysema, was in shock because of severe compression by an enlarged bulla in the right lower lobe. He improved soon after percutaneous puncture of the enlarged bulla and thoracic drainage but a large amount of air-leakage persisted thereafter. A Swan-Ganz catheter was inserted into the bronchus using fiberopticbronchoscope to find the supply airway of the bulla with its balloon and then bronchial obstruction therapy was performed with many small pieces of Spongel in saline. Soon after the procedure, air-leakage stopped and the bulla disappeared. The right lower lobe regained almost normal volume and his daily activity improved significantly. This is an easy and safe procedure and should be attempted in some cases of large bullae.

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We performed transbronchial lung biopsy (TBLB) 63 times in 57 patients with suspected diffuse panbronchiolitis (DPB). TBLB revealed positive findings in 33 of the 63 trials (52.4%). The ratio of the specimens which contained bronchioles to the total specimens obtained was 121/274 (44.2%). We further analyzed the ratio of positive biopsies between the upper lobe and the lower lobe. The ratio was the same in both lobes, not only for all the specimens obtained from each lobe but also for those specimens containing bronchioles. From these results, it may be concluded that the lesions of DPB appear evenly in each lobe. In the absence of severe complications, TBLB thus seems to be an effective and safe technique by which to obtain a histological diagnosis in this disease.

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Simultaneous bronchoalveolar lavage (BAL) was carried out at the affected and non-affected (sub) segments in 30 patients with pulmonary tuberculosis. In comparison with the control group, significant increases of lymphocyte proportion, IgG/Alb, and Fibronectin/Alb in BAL fluid were observed not only at sites affected by pulmonary tuberculosis, but also in non-affected segments. Furthermore, the proportion of lymphocyte and IgG/Alb correlated significantly between affected and non-affected segment. These results suggest that in pulmonary tuberculosis immune and inflammatory products are recruited in non-affected parts of the lung as well as at the affected site.

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In order to decide the appropriate lidocaine administration dose for bronchofiberscopy, the plasma concentrations of lidocaine were measured in twenty patients at the end of bronchofiberscopy. The mean total dose of lidocaine during bronchofiberscopy was 402±145mg (7.2±2.5mg/kg), and plasma concentrations of lidocaine averaged 2.7±1.3μg/ml. In two patients, plasma concentrations of lidocaine exceeded toxic levels of 5.0μg/ml (6.3μg/ml, 5.9μg/ml). Saliva and bronchial secretions collected during bronchofiberscopy, contained lidocaine corresponding to 45±19% of the total administration dose of lidocaine. Plasma concentrations of lidocaine did not correlate with the following, (1) the total dose of lidocaine, (2) the total dose per kilogram body weight, (3) the lidocaine dose administered after intubation, (4) the lidocaine dose per kilogram body weight administered after intubation, (5) the lidocaine dose remaining in the bronchial tree, (6) the lidocaine dose per kilogram body weight remaining in bronchial tree. Considering the pharmacokinetics of lidocaine and the rate of lidocaine remaining in bronchial tree, it would seem to be safe to use lidocaine in doses less than 5mg/kg during bronchofiberscopy.

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Bronchial filling was performed in five cases of pneumothorax with continuing air leakage and four cases of barotrauma. Oxycel cotton was used as the filling agent. Bronchial drainage was located in the upper lobes in seven of the nine cases, and was found in more than two branches in eight of the nine cases. Filling proved successful after one trial in seven of the nine cases while the rest required two fillings. Filling was immediately followed by disappearance of air leakage. The bronchoscopic filling procedure can be the first choice in the management of pneumothorax with continuing air leakage because of its minimal invasion ease of application.

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This study was performed to investigate the presence of Ia-like antigen as a marker of activated T cells in bronchoalveolar lavage fluid (BALF) from patients with sarcoidosis (SAR), idiopathic interstitial pneumonia (IIP), pneumoconiosis (PC), hypersensitivity pneumonitis (HP) and healthy volunteers (HV). We also examined the peripheral blood of the above-mentioned groups. In the four disease groups, the ratio of activated T cells to pan T cells (ATR) in BALF and peripheral blood was significantly higher in comparison with HV. ATR in BALF was markedly higher than that in peripheral blood in the four mentioned above disease groups and in HV. We compared the relationship between the activated T cell number and 2T cell subset numbers, OKT4^+T cell numbers and OKT8^+T cell numbers. In SAR, IIP and PC, the activated T cell numbers and the OKT4^+T cell numbers were significantly correlated (r=0.91, 0.94, 0.91 ; p<0.01 : respectively). On the other hand, the coefficient of correlation between activated T cell numbers and OKT8^+T cell numbers was 0.68(p<0.05), 0.95(p<0.01) and 0.57(p>0.05), respectively. There was no significant relationship between activated T cell numbers and OKT4^+T cell numbers, nor between activated T cell numbers and OKT8^+T cell numbers in HV. These results suggest that BALF-activated T cells bearing OKT4^+ have an important role in the pathogenesis of SAR and PC. However in the case of IIP, BALF-activated T cells bearing OKT8^+ were responsible for the pathogenesis as much as activated T cells bearing OKT4^+.

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Since 1978, twenty nine cases of early stage hilar lung cancer were resected in our hospital. Out of them, 14 cases were diagnosed as the superficial infiltrating type of squamous cell carcinoma. A total of 17 superficial cancer lesions were studied bronchoscopically and histopathologically. In 13 sites, the cancers were limited to within the intraepithelial layer or subepithelial layer, and in 4 sites they extended beyond the smooth muscle layer. In both pathological conditions, the mucosal surfaces showed loss of normal luster were pale in color and revealed fine granular changes. Thickened and friable bronchial bifurcations were also recognized in all cases. In areas where tumors invaded beyond the smooth muscle, the mucosal surfaces showed coarse granular changes and interruption or loss of longitudinal folds. Although squamous metaplasia, closely resembling intraepithelial carcinoma bronchoscopically showed thickening and hardening of the spur, the same irregularity of the mucosal surface was not observed nor was the friability observed in intraepithelial carcinoma recognized in the former. We would like to emphasize that these difference between intraepithelial cancer and squamous metaplasia are probably responsible for the histological findings in submucosal layers. That is, the infiltration of mononuclear cells and capillary proliferation occur significantly in early stage luno cancer, while increase in collagen fibers is frequently seen in squamous metaplasia.

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Tracheobronchial inflammatory polyp is said to be a rare disease. A case of bronchial inflammatory polyp with recurrent pneumonia in the right lower lobe for the last four years is reported. The patient was a 60 year-old male and he underwent fiberoptic bronchoscopy. The procedure revealed a polypoid lesion that almost entirely obstructed the orifice of the right lower lobe bronchus. The polyp was solitary, white and irregular in surface with lobulation. The above diagnosis was confirmed by the biopsied specimen. Nd-YAG laser treatment was carried out since the polyp was a solitary benign lesion with little risk of bleeding. The polyp was almost completely removed with remarkable improvement of chest X-ray and laboratory data. In most cases reported previously, the treatment of inflammatory polyp was bronchoscopic removal by forceps. However, Nd-YAG laser treatment is also a useful procedure for inflammatory polyp.

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Since 1982, 48 cases of roentgenographically occult squamous cell carcinoma of the lung were resected at the authors' institution. In only 2 of the resected specimens, was metastasis to a peribronchial lymph node found. In Case 1, bronchoscopic examinations showed a tumor in the membranous portion of the left main bronchus and a thickened bifurcation between the upper and the lower lobe bronchus. Biopsy specimens from the site of the proposed resection line (slightly proximal to the tumor) demonstrated no carcinoma cells, but a fresh frozen section from the margin of resection after pneumonectomy disclosed carcinoma. Therefore, an additional resection of 1.5 cm of the main bronchus was required. Histologically, carcinoma extended from the main bronchus to the upper lobe bronchus, B^6 and the proximal portion of the lower lobe bronchus with marked involvement of lymphatic vessels and invaded deeply into the adventitia. At the additionally resected bronchial margin, in situ carcinoma was present in the superficial layer and a tumor nest in a lymphatic vessel was recognized. Metastasis to a lymph node (#10) was demonstrated. After operation, radiotherapy and chemotherapy were performed. In Case 2, a tumor was found in the membranous portion of the orifice of the left upper lobe bronchus at bronchoscopy. Left upper lobectomy and sleeve resection of the bronchus were performed. Histologically, carcinoma infiltrated from the orifice of the upper lobe bronchus to the orifice of the lingular bronchus and each segment of B^3 with deep invasion into the adventitia. A metastatic pribronchial lymph node was recognized in the region where an extrabronchial invasion was demonstrated in a minimal portion of the bronchus. The results, especially in Case 1, emphasized that it can be very difficult to preoperatively determine the range of extension of early lung cancer in the lymphatic vessels. These two patients are alive and well 35 and 18 months later, respectively.

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A case of superior vena cava obstruction associated with dilatation of bronchial submucosal vessels is reported. This case is a 18-year-old male who was diagnosed as having mediastinal tumor (malignant germ cell tumor) for which irradiation and chemotherapy were administered at 16 years of age. The patient is now in complete remission. Fiberoptic bronchoscopy showed dilated submucosal vessels which extended from trachea to both upper lobe bronchi and to intermediate bronchus along the longitudinal axis of the bronchi. Angiogram and chest CT disclosed that the superior vena cava was completely obstructed and that the blood from the upper half of the body returned to the inferior vena cava via well developed collateral pathwaies (azygos, hemiazygos vein). It is well known that bronchial blood from the hilar region drains through the bronchial veins into the azygos or hemiazygos vein, whereas blood from the remaining parts of the bronchi reaches the pulmonary veins via the bronchial venous plexus. Therefore, the dilated submucosal vessels in this case were supposed to be bronchial veins which developed because of the disturbance of drainage into the azygos or hemiazygos vein, or because of the reversed pathway leading from the azygos or hemiazygos vein to the pulmonary vein.

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A case of bronchial lipoma in a 52 year-old man complaining of productive cough and hemosputum was reported. Bronchoscopy revealed a smooth, round polypoid tumor, reddish-yellow in color, projecting into the lumen of the left basal bronchus. Bronchography showed complete obstruction of the orifice of left B^<9+10>. Bronchoscopic biopsy specimens were not sufficient for histological diagnosis. Therefore we performed endobronchial resection of the tumor using an electrosurgical snare through a flexible fiberoptic bronchoscope. The tumor were resected satisfactorily, and histological examination yielded diagnosis of bronchial lipoma. Bronchial lipoma is an extremely rare disease among benign tumors of the lung; only 12 cases have been reported in Japan. It is considered that endoscopic electrosurgery can be very useful in such cases of benign endobronchial tumors.

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A 46 year-old woman had been treated with minocycline for acute upper respiratory tract infection, but 14 days after the beginning of the treatment, she developed dry cough, fever and patchy infiltrates in both middle and lower lung fields on chest X-ray examination. Pulmonary function tests revealed restrictive disturbance and decreased diffusion capacity. After cessation of the administration of the drug use, her complaints, laboratory data and chest X-ray findings improved rapidly. Lung tissue specimens obtained by transbronchial lung biopsy showed granulomatous alveolitis with Mas-son's body formation. Bronchoalveolar lavage fluid (BALF) indicated an increase in total cell count and marked eosinophilia (29.1%). Analysis of lymphocyte subpopulations revealed an increase in OKIal^+ lymphocytes. Whereas the results of a lymphocyte stimulation test (LST) performed on peripheral blood lymphocytes to detect the possible role of minocycline were negative, BALF lymphocytes used for the test proved positive. In addition, the provocation test of the drug was also positive. Based on these findings, we diagnosed this case as minocycline-induced pneumonitis. The result of LSTs strongly suggests the role of BALF lymphocytes is more important as material for the test than peripheral blood lymphocytes to diagnose drug-induced pneumonitis.

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A 47 year-old male case of endobronchial chondromatous hamartoma was reported. He had complained of common cold-like symptoms. His chest X-ray film showed pneumonia in the lower field and a round shadow at the orifice of the left lower bronchus. The tumor was found benign by several biopsies but we could not determine a definitive diagnosis of it. The tumor was enucleated with ease. We clinically reviewed 27 cases of endobronchial hamartoma described in the Japanease literature.

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Nine patients with lung cancer underwent sleeve lobectomy and pulmonary artery reconstruction. All patients were male ; eight had squamous cell carcinoma, and one adenocarcinoma. Sleeve lobectomy consisted of left upper lobectomy in 5, right upper sleeve lobectomy in 3 and left lower lobectomy in 1. Five patients are alive and doing well, the longest period of survival being 5 years and 6 months. Four patients died 3 due to tumor recurrence and one due to bronchoplastic dehisence. The five-year survival rate of these patients was 35.7%. This procedure is useful for the preservation of pulmonary function and for radical treatment of cancer patients.

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Bronchoscopy was performed on a 73 year-old female who complained of hemoptysis. Multiple submucosal plaques were located in the lower part of the trachea and the bilateral main bronchi, subsequently the right lower lobe, the left upper and lower lobe orifices were extremly narrowed by the plaques. Transbronchoscopic biopsies of the bronchi revealed submucosal amyloid deposits. Rectal and skin biopsies failed to demonstrate amyloid deposits, and the patient was free of any diseases known to yield secondary amyloidosis. The amyloid in this case was stained positively with Congo-red after potassium permanganate treatment, as well as by light chain k type immunoglobulin by PAP method. Consequently the amyloid was interpreted as being composed of AL protein k type. Plasma cells infiltrating around the amyloid deposits were also stained positively with the light chain k type, suggesting some role played by the plasma cells in the production of the amyloid.

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A 60 year-old man with a 10-year history of rheumatoid arthritis complained of dry cough and exertional dyspnea. Pneumonitis was suspected following physical examination and chest roentgenogram. Pneumonitis was revealed histologically by the first transbronchial lung biopsy (TBLB) procedure, but the pneumonitis activity seemed to be low because the area of the lesion was limited and normal alveoli were still present in the lung. The symptoms resolved following treatment with antibiotics. One month later, the patient complained of fever and exertional dyspnea and exacerbation of pneumonitis was suspected. A second TBLB revealed active pneumonitis and a necrobiotic lesion. Prednisolone was administered and the symptoms improved. Fifteen cases of rheumatoid arthritis with pulmonary involvement, 14 cases of pneumonitis and one of pleuritis, have been treated in our division. Among the 14 cases of pneumonitis, 7 were diagnosed as rheumatoid pneumonitis, 3 as pneumonitis due to gold salts, and one was caused by both rheumatoid arthritis and gold salts. However, in 3 cases, it could not be decided whether the cause was due to rheumatoid arthritis or gold salts. We conclude that not only a precise investigation of the illness in patients should be carried out including a histological examination, but also that an immunological approach is necessary in order to make a differential diagnosis between rheumatoid pneumonitis and pneumonitis due to gold salts.

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