Background. Midazolam is the most frequently used sedative in addition to topical anesthetics for flexible bronchoscopic procedures, including endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), in Japan. However, cough caused by airway irritation sometimes make it difficult to conduct these procedures, especially EBUS-TBNA, with midazolam. Recent reports have shown that the combination of various pharmacological sedatives results in favorable responses for both patients and bronchoscopists. Purpose. To evaluate the superiority of sedation with propofol and dexmedetomidine in comparison to midazolam alone during EBUS-TBNA. Patient and Methods. Thirty-nine patients who had undergone EBUS-TBNA from June 2016 to December 2017 at Yokohama City University Medical Center were enrolled. Subjects who received only EBUS without TBNA were excluded. All EBUS-TBNA procedures were performed after intubation using a conventional bronchoscope. The examination time, diagnosis rates, and frequency of adverse events in the propofol and dexmedetomidine (PD) group were retrospectively compared with those in the midazolam (M) group. Results. Although the number of punctures were not significant, the time required per puncture was significantly shorter in the PD group than in the M group. As a result, the time to complete EBUS-TBNA procedures was significantly shorter in the PD group than in the M group (19.4±7.9 vs 34.2±9.7 min, p<0.0001). The frequency of adverse events was lower in the M group than in the PD group, although no severe events were observed in either group. Conclusion. Sedation with propofol and dexmedetomidine during EBUS-TBNA reduced the examination time and was safe under appropriate monitoring and supportive therapies.
Background. Thoracoscopy under local anesthesia is a useful tool for diagnosing pleural effusion with a reportedly high diagnostic rate; however, there are limited reports regarding its usefulness and safety in patients with undiagnosed pleural effusion despite thoracentesis or a closed pleural biopsy. Objective. To evaluate the usefulness and safety of thoracoscopy under local anesthesia for diagnosing pleural effusion that has gone undiagnosed despite thoracentesis or a closed pleural biopsy. Methods. We retrospectively evaluated the clinical characteristics, diagnosis based on thoracoscopy under local anesthesia, diagnostic rate, and complications among patients with undiagnosed pleural effusion who had undergone thoracoscopy under local anesthesia at the Japanese Red Cross Wakayama Medical Center between January 2012 and December 2018. No cases had been diagnosed by thoracentesis before thoracoscopy. Results. Of the 50 patients (men: 39, median age: 72.5 years), carcinomatous pleurisy was diagnosed in 14 (28%), malignant mesothelioma in 11 (22%), benign asbestos pleurisy in 10 (20%), tuberculous pleurisy in 2 (4%), non-tuberculous mycobacterium pleurisy in 1 (2%), rheumatoid pleurisy in 1 (2%), empyema in 1 (2%), hepatic pleural effusion in 1 (2%), drug-related pleural effusion in 1 (2%), and cases of indeterminate origin in 8 (16%). The diagnostic rate of thoracoscopy was 84%. Complications associated with thoracoscopy included 5 (10%) patients with subcutaneous emphysema and 2 (4%) patients with postoperative empyema. All 7 patients recovered with treatment, and no deaths were registered within 1 month after thoracoscopy. Conclusion. Thoracoscopy under local anesthesia is a useful and safe diagnostic tool for diagnosing as-yet-undiagnosed pleural effusion.
Background. Pulmonary cryptococcosis sometimes presents with centrilobular micronodules on chest computed tomography (CT) and may be difficult to clinically distinguish from pulmonary tuberculosis. Case. A 77-year-old woman experienced miliary tuberculosis during follow-up period for an old case of pulmonary tuberculosis while undergoing antitubercular therapy with isoniazid (INH), rifampicin (RFP) and ethambutol (EB) for one year. Six months after the end of antitubercular treatment, chest CT revealed a small nodule with centrilobular micronodules around bronchiectasis in the right S4. On admission to our hospital, the shadows had deteriorated further. Based on these findings, we initially suspected recurrent pulmonary tuberculosis. Flexible fiberoptic bronchoscopy was performed because there were no significant findings in her sputum, and Cryptococcus neoformans (C. neoformans) was identified from the culture of the bronchial lavage fluid. As examinations of other organs showed no abnormalities, pulmonary cryptococcosis was diagnosed. After starting oral fluconazole (FLCZ) therapy, the small nodule with centrilobular micronodules improved. Results. Bronchial lavage was useful for the diagnosis of pulmonary cryptococcosis showing chest shadow with atypical features after antitubercular treatment. Conclusion. If patients present with pulmonary shadows deteriorating after antitubercular treatment and show negative sputum smears of acid-fast bacilli, we should aggressively perform examinations, such as bronchoscopy, in consideration of possible diagnoses other than recurrent pulmonary tuberculosis.
Background. Tracheal/bronchial granular cell tumor is relatively rare. There are few reports of endobronchial granular cell tumor being followed up endoscopically. Therefore, it is difficult to decide a follow-up period or choose adequate treatment strategies. Case. A man in his 60s was admitted to our hospital due to hemosputum. Chest X-ray and computed tomography scan were normal. Bronchoscopy revealed a raised portion at the left upper and lower bifurcation. A diagnosis of granular cell tumor without malignant cells was made based on transbronchial biopsy. Subsequent follow-up every 7-13 months, totaling 4 times, revealed no further changes. No treatment has been performed, and at present, after 33 months, there is no indication of tumor enlargement. Conclusion. We report a case of endobronchial granular cell tumor that was followed up for 33 months endoscopically. Conducting a careful follow-up for at least 5 years is considered essential.
Backgrounds. EGFR-tyrosine kinase inhibitors (TKIs) are key drugs for the treatment of EGFR mutation-positive lung cancer. However, resistance will eventually be acquired, and one mechanism for this acquisition is transformation. Case. A 71-year-old man with post-operative recurrent lung adenocarcinoma harboring EGFR exon 19 deletion received afatinib, and a partial response was achieved. However, multiple lung nodules and mediastinum lymphadenopathy were detected. Progressive disease was suspected, so he underwent transesophageal endoscopic ultrasound-guided fine needle aspiration. The specimen showed non-small-cell lung cancer with neuroendocrine morphology and positive neuroendocrine markers, possible large-cell neuroendocrine carcinoma (LCNEC). LCNEC was clinically diagnosed, and the EGFR mutation was negative. Double cancer of adenocarcinoma and LCNEC, not transformation, was diagnosed. Conclusion. Transformation during EGFR-TKI therapy has been reported, but double cancer has never been described previously. Because the treatment strategy is different, it is important to differentiate double cancer from transformation.
Background. Bronchogenic cysts are developmental foregut anomalies that are usually located within the mediastinum or lung parenchyma. Bronchogenic cysts with rim calcification are very rare. Case. The present case involved a 35-year-old female patient who presented with pleuritic chest pain on her right side. Chest CT showed a large cystic mass with rim calcification and effusion in the right thorax. We performed partial resection of the right lower lobe. A pathological examination revealed a cyst lined by bronchial epithelium with calcification and inflammatory change in the cyst wall. The cyst was diagnosed as an intrapulmonary bronchogenic cyst. Conclusion. We encountered a case of intrapulmonary bronchogenic cyst with rim calcification. The presence of rim calcification was considered to be due to chronic inflammation.
Background. Cases of malignant lymphoma derived from the trachea or bronchus are relatively rare. Case. A woman in her 60s had a history of cervical cancer after an operation and Tolosa-Hunt syndrome. Bilateral pulmonary multiple nodules were detected by follow-up computed tomography (CT) after an operation for cervical cancer. Three months later, reexamination of CT showed a polypoid lesion at the left side of the lower trachea in addition to multiple nodules. Bronchoscopic findings showed a tracheal polypoid lesion. We performed a biopsy. The pathological findings of the biopsy showed a reactive hyperplasia of lymphoid follicles. Yearly follow-up CT showed no abundance pattern for four years. After five years, we performed a pathological reevaluation of a biopsy specimen obtained from another pathologist. Bronchus-associated lymphoid tissue (BALT) lymphoma was diagnosed, which corresponded with the immunostaining results. Although low-grade B-cell lymphoma had progressed on an annual basis, no clinical findings or imaging changes were noted over four years of follow-up. Occasional steroid use prevented the progress of the disease. Conclusion. The diagnosis of malignant lymphoma derived from the trachea is difficult to differentiate from reactive hyperplasia of lymphoid follicles. Careful follow-up of a tracheal tumor and the reevaluation of pathological findings should be performed, even if the lesion is initially diagnosed as benign. Careful clinical follow-up and an accurate pathological evaluation were important in our case.
Background. Malignant pleural effusion rarely occurs in patients with renal cell carcinoma. We herein report a case of small renal cell carcinoma diagnosed by thoracoscopy under local anesthesia. Case. A 61-year-old man presented to our department with cough and dyspnea on exertion. Chest imaging showed right pleural effusion with multiple pleural nodular lesions. Thoracoscopy under local anesthesia revealed irregular nodules of various sizes on the parietal pleura. A parietal pleural biopsy confirmed pleural metastasis of renal cell carcinoma. There was no evidence of lymph node metastasis, and the primary tumor size in the greatest dimension was 1.8 cm. At this time, tyrosine kinase inhibitor therapy was initiated. Conclusion. We experienced a case of small renal cell carcinoma diagnosed because of pleural effusion. Malignant pleural effusion is associated with advanced malignancy, so the diagnosis of primary tumor is often clear. However, in this case, the primary tumor was small, and thoracoscopy under local anesthesia was useful for the definitive diagnosis.
Background. Extraskeletal osteosarcoma may metastasize to the thorax, but it is difficult to distinguish from malignant mesothelioma including an osteochondral component. Case. An 84-year-old man was admitted to our hospital with coughing because of left pleural effusion. In addition to left pleural effusion observed on chest computed tomography, the left and right pleural membranes were thickened with calcification, and tumorous lesions with mineralization were found in both lungs and the retroperitoneum. Thoracoscopy was performed for a pathological diagnosis using the pleural effusion and a biopsy of the left pleura. Thoracoscopy revealed white nodules with a size of 5 mm and a smooth surface occurring frequently throughout the parietal pleura. Biopsy specimens from two of these nodules were collected using snares. Both parts underwent immunohistochemical staining. However, we were unable to distinguish between extraskeletal osteosarcoma and malignant mesothelioma including an osteochondral component by the pathological diagnosis alone. Conclusions. Identifying the pathological differences between extraskeletal osteosarcoma and malignant mesothelioma located in the thoracic cavity is difficult, and additional clinical information is needed in order to make a diagnosis.
Background. While cases of synchronous double cancer of the thyroid cancer and lung cancer are often reported, it may be difficult to differentiate them from thyroid cancer alone with lung metastases based solely on image findings. Case. A 76-year-old woman was considered to have papillary thyroid cancer with multiple distant metastases based on computed tomography (CT) findings of calcification in the thyroid gland and multiple lung nodules as well as the results of cytology. An abnormal uptakes was detected in the hilar, mediastinal lymph nodes and bones on positron emission tomography (PET)-CT. Considering the possibility of complication with lung cancer, we performed endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of the subcarinal lymph node. Consequently, Napsin-A, EGFR mutation-positive lung adenocarcinoma was diagnosed and synchronous double cancer of the papillary thyroid cancer (cT2N1bM0/Stage II) and lung cancer (cT4N3M1c/Stage IVB) was considered. After the administration of afatinib, the abnormal lesions except for that in the thyroid gland had regressed significantly. Conclusion. In cases of papillary thyroid cancer with hilar or mediastinal lymphadenopathy, EBUS-TBNA for those lymph nodes may be useful for differentiating synchronous double cancer of papillary thyroid cancer and lung cancer from thyroid cancer alone with lung metastases.
Introduction. We herein report a case of severe asthma that was difficult to treat with mechanical ventilation. Case. A 54-year-old man. Medical History. The patient inhaled a β-agonist at the time of an asthma attack, experienced sudden dyspnea, and sought emergency treatment. Procedure. We made a diagnosis of asthma attack and decided to provide ventilatory support. We repeatedly administered intramuscular injections of adrenaline and systemic steroids. However, ventilation failure persisted, and respiratory acidosis progressed. We therefore provided extracorporeal membrane oxygenation (ECMO). A day after the admission, adrenaline was administered to the trachea, and bronchospasm with subsequent improvement was observed. Thereafter, the asthma attack subsided gradually, and the respiratory condition improved. We discontinued ECMO at 63 hours after the indication; the patient was extubated the following day. He was discharged 18 days after admission. Discussion. In cases of asthma attacks that are difficult to treat with mechanical ventilation, prompt ECMO should be performed, and in potentially fatal cases, the intratracheal administration of adrenaline may be useful.
Background. Autoimmune pulmonary alveolar proteinosis (aPAP) is rarely complicated by ulcerative colitis (UC). Case. A 24-year-old man was receiving treatment for UC as an outpatient in the Department of Gastroenterology at our hospital. Abnormal chest findings were detected during an annual medical examination, and he was referred to our department. Chest computed tomography showed diffuse ground-glass opacity and bilateral crazy paving pattern. A bronchoalveolar lavage fluid analysis revealed a milky-white gross appearance with the accumulation of periodic acid-Schiff-positive fine granules in the alveolar space in transbronchial lung biopsy specimens. The serum anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibody titer was increased at 48.3 μg/ml, which led to the diagnosis of aPAP. Conclusion. We encountered a case of aPAP with concomitant UC. Although it is reported that anti-GM-CSF antibody titers are increased in patients with inflammatory bowel disease, the reasons for the rarity of aPAP being complicated with UC remain unclear. Further investigations and the accumulation of more cases will improve our understanding of this clinical question.
Background. A thoracoscopic biopsy under local anesthesia is reported to be effective for the diagnosis of pleural diseases; however, it is necessary to obtain sufficiently-sized tissue specimens. We herein report a case in which a full-thickness pleural biopsy from the thickened parietal pleura permitted the diagnosis of adenocarcinoma that was impossible to be diagnosed by a flexible forceps biopsy. Case. A 74-year-old man with a history of asbestosis was referred to our hospital because of right pleural effusion. As we were unable to diagnose the etiology of the pleural effusion by thoracocentesis, we performed thoracoscopy under local anesthesia. No obvious focal lesions were recognized on the surface of the parietal pleura, and the parietal pleura was stiff and thick. We were able to obtain only very small specimens using flexible forceps. We therefore performed a full-thickness pleural biopsy, which revealed small adenocarcinoma lesions in the fibrously thickened pleura. A further examination identified gastric carcinoma as the origin of the carcinomatous pleurisy. Conclusion. A full-thickness pleural biopsy is useful in cases of suspected malignant pleural effusion not accompanied by tumorous lesions on the parietal pleura.
Background. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is reportedly a useful diagnostic procedure for intrapulmonary nodules. However, most previous studies were conducted only in patients with lung nodules adjacent to the trachea or bronchus. Few reports have described the potential benefit of this procedure for diagnosing nodules without bronchial wall involvement. Case. The patient was a 78-year-old man with a history of thyroid cancer after right-side thyroidectomy. Multiple pulmonary nodules were incidentally found on coronary computed tomography angiography (CCTA), and the patient was referred to the pulmonary department. None of the nodules, including the largest one (2.5 cm in right S6), were reachable by a transbronchial biopsy because of either their size or location. There were no EBUS-TBNA-tappable lymph nodes. One of the nodules in right S6 located near the right lower lobe bronchus was targeted. Convex probe EBUS (CP-EBUS) revealed a heterogeneous-density right S6 nodule. The biopsy was successfully performed without any complications. The patient was diagnosed with relapsed thyroid cancer by EBUS-TBNA. Conclusion. EBUS-TBNA may be an effective and safe diagnostic procedure for lung nodules without bronchial wall involvement.
Background. Primary angiosarcoma of the bone is an extremely rare form of vascular bone tumor, accounting for <1% of primary malignant bone tumors. Its histological findings are characterized by formation of anastomosing blood vessels lined by endothelial cells. It tends to involve the long, tubular bones of the extremities, and more than half of cases are found with metastasis, especially to the lung. Once metastasis to the lung has occurred, patients usually present with symptoms such as dyspnea, chest pain, and hemoptysis. Case. An 80-year-old woman was referred to our hospital for the further evaluation of abnormal X-ray findings of her right humerus, with only slight range of motion restriction. Upon arrival, she was also diagnosed with anemia, thrombocytopenia, and elevated D-dimer levels, which satisfied the criteria for disseminated intravascular coagulation. In addition, chest X-ray showed diffuse infiltrative shadows in both lungs, and chest computed tomography (CT) showed bilateral consolidation with ground-glass opacity. The further investigation of the lungs was prioritized over her shoulder pain, and bronchoalveolar lavage was performed. The fluid collected was fresh and blood-like and contained hemosiderin-laden macrophages, confirming the diagnosis of diffuse alveolar hemorrhaging. In addition, a biopsy of the right humerus was performed at the site where magnetic resonance imaging showed a destructive lytic lesion with irregular borders of fractured bone. Immunohistochemical staining revealed the tumor cells to be positive for cluster of differentiation 31 and 34 and negative for cytokeratin and thyroid transcription factor-1, and she was diagnosed with angiosarcoma. Conclusion. We herein report a rare case in which angiosarcoma was coincidently diagnosed in connection with diffuse alveolar hemorrhaging without CT findings suggesting lung metastasis. Neoplastic diseases should not be forgotten as differential diagnoses of diffuse alveolar hemorrhaging.