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Background Pleurography (PG) has been described previously but has not gained popularity. PG can determine the exact air leak points in the lung, which is important for treating pneumothorax and pleural fistulas. We believe that the usefulness of PG should be reassessed, and here we describe the method, air leak detection rate, and common complications. Methods From the 1210 cases of pleural fistulas that were treated at our institution between March 2015 and October 2018, 275 patients with recurrent primary pneumothorax or secondary spontaneous pneumothorax were selected for this study. PG was performed in 127 patients with persistent air leakage during exhalation. In addition, 35 patients with postoperative complications of air leakage persisting for 7 days or longer were included. Results Air leak points were detected in 119 patients (73%), in the apex of the lung in 65 cases, in the basal segment in 13 cases, and in the middle lobe or lingular segment in 9 cases. There were 8 cases of hilar lesions, 12 cases of S6 lesions, 8 cases of upper lobe lesions other than apex, and 4 cases of upper mediastinal lesions. Complications within 30 days were observed in 10 cases (6.2%), with 8 grade 2 cases involving fever, 1 grade 3 case involving infection, and one grade 1 case with abdominal distension. Conclusions The incidence of grade ≥3 adverse events after PG was 0.6%, which is considered acceptable. Our findings suggest that PG is a safe examination method to identify air leaks before surgery for pleural fistulas., Graphical abstract Pleurography (PG) can be easily performed with fluoroscopy in any facility. We performed PG in 162 cases, in which the rate of occurrence of adverse events of grade ≥3 was 0.6%. Air leak was detected by PG in 73% of cases. PG may be useful as a preoperative examination for awake video-assisted thoracoscopic surgery, during which leak testing is difficult. By assessing adhesions with PG, a change to the first port safe position, avoiding adhesions, was possible in 19% of cases. PG may provide useful information for surgical management.

A 65‐year‐old woman was brought to the emergency unit with an approximately 6‐month history of persistent fever and cough. Chest computed tomography (CT) demonstrated a 16‐cm heterogeneous mass with adjacent large cyst (approximately 4.0 cm). The patient underwent CT‐guided biopsy, and benign solitary fibrous tumour (SFT) was immunohistochemically diagnosed. As the symptoms were thought to be due to enlargement of the tumour, surgery was deemed necessary, and the tumour was successfully resected. Based on morphological and immunohistochemical examination of the resected specimen, the final diagnosis was dedifferentiated SFT (DSFT). Follow‐up CT verified disappearance of the pulmonary cyst. The cyst was speculated to be caused by a check valve mechanism, which may also suggest a rapid growth of the tumour. At the time of writing, 2 years post‐operatively, no tumour recurrence has been identified. This represents the first report of intrathoracic giant DSFT with a cystic lesion returning to normal lung parenchyma., A 65‐year‐old woman was brought to the emergency unit with an approximately 6‐month history of persistent fever and cough. Chest computed tomography demonstrated a 16‐cm heterogeneous mass with adjacent large cyst. The tumour was successfully resected, and the final diagnosis was dedifferentiated solitary fibrous tumour.

Key message When a chest computed tomography (CT) scan is performed in the diagnosis and treatment of coronavirus disease 2019 (COVID‐19) pneumonia, the possibility of lung neoplasm should be kept in mind if the ground‐glass nodule (GGN) shows features that are non‐specific for viral infection, such as solitary nature, relative roundness, well‐defined borders, and distance from the pleura., When a chest computed tomography (CT) scan is performed in the diagnosis and treatment of coronavirus disease 2019 (COVID‐19) pneumonia, the possibility of lung neoplasm should be kept in mind if the ground‐glass nodule (GGN) shows characteristics that are non‐specific for viral infection, such as solitary nature, relative roundness, well‐defined borders, and distance from the pleura.

Background: In many diseases, there is a relationship between the ratio of the diameter of the pulmonary artery (PA) to that of the aorta (Ao) on chest computed tomography (CT). The aim of this study is to examine whether the PA/Ao ratio at diagnosis of idiopathic pulmonary fibrosis(IPF) and combined pulmonary fibrosis and emphysema (CPFE) is associated with the pulmonary hypertension. At present time, there is no analysis of PA/Ao ratio in CPFE. Methods: The present study included 125 patients diagnosed with IPF or CPFE at a single center from April 2014 to March 2019. The diameters of the PA and Ao on chest CT at initial diagnosis were analyzed retrospectively.The images are classified according to An Official ATS/ERS/JRS/ALAT Clinical Practice Guideline(2018). The diameter of the PA was measured at the subjective bifurcation. The diameter of the Ao was measured at the same slice. These imaging analysis were performed by two pulmologists. Results: The number of IPF and CPFE were 60(48％) and 65 (52％). IPF images were categorized into four types : UIP/ Probable/ Indeterminate/ Alternative Diagnosis, 33/ 37/ 48/ 7 cases, respectively. The mean PA and Ao diameters were 29.75mm and 34.75mm, and the mean PA/Ao ratio of IPF and CPFE were 0.830 and 0.883. The PA/Ao ratio is significantly increased in the IPF group (p the Indeterminate＋Alternative Diagnosis group (0.883 vs 0.825, p Conclusions: The progression of fibrosis or the presence of emphysema in CPFE may suggest pulmonary hypertension in pulmonary fibrosis.

A 51‐year‐old man was referred to our hospital, with a dumbbell‐shaped nodule measuring 40 mm in the right upper lobe of the lung. He was a current smoker with diabetes mellitus and bronchial asthma. The transbronchial biopsy was performed. However, definitive diagnosis was not obtained from the excised specimens. Bacterial culture of bronchial lavage fluid also yielded negative results, including for tuberculosis. After eight months of observation, the tumour had slightly increased in size. Surgery was planned to resect the tumour for definitive diagnosis. Because of the size of the tumour, a lobectomy of the lung was scheduled with the patient's consent. Four small incisions, each less than 1.2 cm long, were made in the chest wall for thoracoscopic surgery. To remove the specimen, we made a 3‐cm longitudinal incision 1 cm below the xiphisternal joint. The patient complained of no chest pain after surgery. The post‐operative course was uneventful., This study describes video‐assisted thoracic surgery (VATS) with minimal chest incisions to prevent chronic post‐operative intercostal neuralgia and paraesthesia, using a small subxiphoid incision only to remove the specimen.

Background The current state of thoracoscopic technology allows less invasive surgical procedures and requires fewer ports and incisions. Totally video-assisted thoracic surgery with a single port has emerged as the least invasive thoracoscopic approach. However, uniportal video-assisted thoracic surgery brings about considerable difficulties, necessitating the development of skillful techniques as well as specific surgical devices. In such situations as dense pleural adhesion and anatomical abnormality, it may be more burdensome, necessitating the conversion to conventional multiportal video-assisted thoracic surgery or even to thoracotomy. To troubleshoot these situations, we herein propose the use of additional technique which could support to sustain the confident operative field for uniportal video-assisted thoracic surgery. This procedure also provides the same cosmetic outcomes as uniportal video-assisted thoracic surgery. Case presentation A previously healthy, 77-year-old female was referred to our hospital, with a lung adenocarcinoma measuring 28 mm in the right upper lobe. Uniportal video-assisted thoracoscopic surgery was planned to resect the tumor. During operation, we found the incomplete interlobar fissure between the upper and the middle lobe and the abnormal lobulation of the upper lobe. Therefore, the modified marionette technique was introduced to make the procedure safer and easier. This technique proposed herein consists of employing the untethered gripping forceps to retract the lung, not requiring additional traumatic trocars. The postoperative course was uneventful and the patient `was discharged in 1 week after a modified uniportal video-assisted thoracic surgery for the right upper lobectomy. Conclusions The modified marionette technique produced sufficient operative views to attain uniportal video-assisted thoracic surgery safely in this case, rendering operative conversion unnecessary.

Catamenial pneumothorax (CP) is generally caused by intraperitoneal air leaking from the uterus into the thoracic cavity via a defect in the endometrial tissue of the diaphragm and is usually detected in the right thorax. We report a case of left-sided CP caused by endometriosis in the visceral pleura and with no abnormal findings in the diaphragm. A 33-year-old female patient presented at the end of a course of low-dose contraceptive pills for pelvic endometriosis, with spontaneous pneumothorax in the left chest. Chest CT revealed a bulla in the left upper lung lobe. The patient underwent partial resection of the lung. Immunohistochemistry confirmed the presence of endometrial stromal tissue in the visceral pleura and confirmed this as the cause of pneumothorax since there were no observable abnormalities in the diaphragm. This case suggests that immunohistochemical examination of patients with spontaneous pneumothorax can detect alternative endometrial lesions.

Background Birt-Hogg-Dubé syndrome (BHDS) is a recently recognized inherited multiple cystic lung disease causing recurrent pneumothoraces. Similarly to the lesions in patients with lymphangioleiomyomatosis (LAM), the pulmonary cysts are innumerable and widely dispersed and cannot all be removed. We recently described a total pleural covering (TPC) that covers the entire visceral pleura with oxidized regenerated cellulose (ORC) mesh. TPC successfully prevented the recurrence of pneumothorax in LAM patients. The purpose of this study was to evaluate the effect of an ORC pleural covering on pneumothorax recurrence in BHDS patients. Results This retrospective study enrolled a total of 81 pneumothorax patients with the diagnosis of BHDS who underwent 90 covering surgeries from January 2010 to August 2017 at Tamagawa Hospital. During the first half of the study period, a lower pleural covering (LPC) which covered the affected area with ORC mesh was mainly used to treat 38 pneumothoraces. During the second half of the study period, TPC was primarily performed for 52 pneumothoraces. All the thoracoscopic surgeries were successfully performed without serious complications (≥ Clavien-Dindo grade III). The median follow-up periods after LPC/TPC were 66/34 months, respectively. Pneumothorax recurrence rates after LPC at 2.5/5/7.5 years postoperatively were 5.4/12/42%, respectively; none of the patients who had underwent TPC developed postoperative pneumothorax recurrence (P = 0.032). Conclusions TPC might be an effective option for surgical treatment of intractable pneumothorax in patients with BHDS. Electronic supplementary material The online version of this article (10.1186/s13023-018-0790-x) contains supplementary material, which is available to authorized users.

A 34-year-old male with frequent recurrence of right pneumothorax was admitted to our hospital. He was a current smoker and outwardly male without genital aplasia. He was diagnosed as tuberous sclerosis complex (TSC) at 2 year-old and underwent transcatheter arterial embolization for right renal hemorrhage due to renal tumor 2 years ago. Chest Computed Tomography showed that he had multiple tiny round cystic lesions with thin wall in both lungs. The recurrent pneumothorax was expected to be associated with TSC-Lymphangioleiomyomatosis (LAM). Video-assisted thoracic surgery was successfully performed. The operative and histological findings revealed that the bullae were classified into two groups; emphysematous bullae and bullae due to LAM. His postoperative course was uneventful. TSC-LAM is extremely rare, but in some cases the clinical recognition might be escaped due to subtle findings of bullae in early LAM, resulting in diagnosis as spontaneous pneumothorax.

Adrenocortical carcinoma (ACC) in childhood is rare: in 2002, only three new cases were reported in Japan. Although there is no established therapeutic management system, margin-free complete surgical excision of the tumor is very important to a satisfactory outcome. We report a case of ACC with bilateral pulmonary metastasis in a 10-year-old boy. Preoperative chest computed tomography (CT) showed pulmonary metastasis with near-water density. The patient was treated successfully with complete surgical resection of the primary tumor and adjuvant chemotherapy, including mitotane. After bilateral lung surgery for the metastatic lesions, the plasma dehydroepiandrosterone sulfate level became negative.

Lung cancer associated with Sweet's syndrome is extremely rare. There are only seven reports of such cases. As far as could be determined from a comprehensive search, there is no reported operative case of lung cancer with this syndrome in the world literature. A 75-year-old Japanese man was diagnosed as having Sweet's syndrome. A chest computed tomography (CT) scan to screen for malignant lesions associated with this syndrome revealed an abnormal shadow in the lung. Although [(18)F]2-fluoro-2-deoxy-D: -glucose positron emission tomography showed no abnormal uptake, lung cancer was most strongly suspected by chest CT. His erythema improved rapidly with steroid therapy and he underwent a segmentectomy (S(6)) of the right lower lobe. A pathological examination revealed lung adenocarcinoma (pT1N0M0: Stage Ia). The patient was discharged from the hospital without any worsening of Sweet's syndrome. We herein report a first operative case of an early stage lung adenocarcinoma with this syndrome.

Objective: To understand the molecular pathogenesis of lung cancer and to establish a novel therapeutic application, we examined the genetic alterations in lung cancer, and studied the effects of gefitinib and siRNA-mediated knockdown of EGFR on lung cancer. Methods: We analyzed mutations in EGFR, KRAS, TP53, and ERBB2 in 198 surgically resected lung cancer specimens. We then analyzed the effects of gefitinib and siRNA treatment on lung adenocarcinoma cell lines. Results: Mutations in EGFR were found only in adenocarcinoma (35 of 106 adenocarcinoma), mainly in females (73%). Mutually exclusive mutations of EGFR and KRAS genes were observed.Mutations of EGFR were well associated with a positive response to gefitinib. Cells with EGFR mutations were very sensitive to gefitinib as well as siRNA-mediated knockdown of EGFR, those with KRAS mutations responded poorly, and those without mutations of KRAS and EGFR showed moderate responses to both treatments. Conclusions: Our present results imply that (1) mutation analyses of EGFR and KRAS provide valuable information about whether or not to apply treatments targeting against EGFR and the selection of dosage for such treatments, and (2) siRNA-mediated knockdown is effective in lung adenocarcinomas with EGFR mutation, probably in those with resistance to gefitinib by acquired mutation in EGFR.

症例は65歳，男性．胸腺腫を合併した重症筋無力症（MGFA分類IIIb期）の診断で当院神経内科に入院．抗コリンエステラーゼ薬内服，血漿交換療法，メチルプレドニゾロン1000mg/日×3日間のステロイドパルス療法を施行し，以後ステロイド50mg/日の内服となった．ステロイド導入後約1カ月の胸部CTでは指摘された腫瘤は画像上消失していた．拡大胸腺摘出術を施行し，術後病理診断は胸腺腫（Muller-Hermelink分類混合型，WHO分類Type B2）の退行性変化であった．術前にステロイド導入を行った胸腺腫合併重症筋無力症においては，胸腺腫の退縮の可能性もあることを念頭に置くことが肝要である．

症例は22歳，男性．平成18年9月頃から呂律が回りづらく徐々に悪化していた．筋力の低下も出現し，当院神経内科紹介され精査を施行され筋緊張性ジストロフィーと診断された．スクリーニングの為撮影した胸部CTにて前縦隔腫瘍を指摘され平成19年2月当科紹介となった．確定診断を得るため摘出生検を施行した．術後は手術室にて抜管可能であったが喀痰が多く，喀出も不良であり高炭酸ガス血症を生じ，胸部X線写真上無気肺を認め気管支鏡下に喀痰吸引を施行した．第4病日より歩行を開始してから喀痰も自己喀出可能となり術後12日目に退院となった．筋緊張性ジストロフィーは周術期管理に関して注意が必要とされ，術前に十分な説明と対処法を考慮しておくことが重要であると考えられた．

Background Spontaneous pneumothorax is a major and frequently recurrent complication of lymphangioleiomyomatosis (LAM). Despite the customary use of pleurodesis to manage pnenumothorax, the recurrence rate remains high, and accompanying pleural adhesions cause serious bleeding during subsequent lung transplantation. Therefore, we have developed a technique of total pleural covering (TPC) for LAM to wrap the entire visceral pleura with sheets of oxidized regenerated cellulose (ORC) mesh, thereby reinforcing the affected visceral pleura and preventing recurrence. Methods Since January 2003, TPC has been applied during video-assisted thoracoscopic surgery for the treatment of LAM. The medical records of LAM patients who had TPC since that time and until August 2014 are reviewed. Results TPC was performed in 43 LAM patients (54 hemithoraces), 11 of whom required TPC bilaterally. Pneumothorax recurred in 14 hemithoraces (25.9%) from 11 patients (25.6%) after TPC. Kaplan-Meier estimates of recurrence-free hemithorax were 80.8% at 2.5 years, 71.7% at 5 years, 71.7% at 7.5 years, and 61.4% at 9 years. The recurrence-free probability was significantly better when 10 or more sheets of ORC mesh were utilized for TPC (P = 0.0018). TPC significantly reduced the frequency of pneumothorax: 0.544 ± 0.606 episode/month (mean ± SD) before TPC vs. 0.008 ± 0.019 after TPC (P

Even with advances in non-invasive diagnosis of diseases such as cancer or inflammatory diseases, tissue biopsy coupled with histopathologic examination remains the gold standard in establishing an accurate diagnosis.1–2 Generally, effective tissue diagnosis is fundamentally based on biopsying lesions that are suspicious based on visual inspection. Nevertheless, numerous mucosal conditions, such as dysplasia in ulcerative colitis or Barrett’s esophagus, are not always readily recognizable visually, and thus mandate surveillance protocols that involve random biopsies.3 To effectively sample large organs such as the colon, numerous biopsies are required,4 which can be time consuming. Moreover, due to the size of current forceps and the associated mucosal trauma and to the serial operation of the forceps, the number of random biopsies that can be realistically carried out is limited. Consequently, the current standard of care for cancer surveillance in ulcerative colitis patients is performed with at least 33 sequential biopsies (4-quadrant biopsies every 10 cm), which we estimate cumulatively samples less than 0.3% of colonic mucosa. The low sampling coverage may be ineffective at detecting precancerous or cancerous lesions, especially for early, small lesions that are also the most treatable.

症例は29歳, 男性. トラック運転中に居眠りをして大型トラックに追突, ハンドルで前胸部を強打した. 近医に搬送され気管分岐部裂傷の診断を得て, 当科に紹介された.気管支鏡検査上, 気管分岐部竜骨の左右主気管支接合部が損傷し直径約8mmの裂孔が認められた.受傷約24時間後に手術を開始.竜骨の損傷が比較的広範なため, 明らかな損傷部のみのdebridementと単純縫合閉鎖では術後縫合不全や肉芽性狭窄の危険性が高いと考え, 気管分岐部を切除しMontage型再建術を行った.術後, 気管・気管支吻合部合併症をきたすことなく良好に経過し第29病日に退院した.気管分岐部損傷に対する分岐部切除再建術の報告はこれまでないが, 竜骨の広範な破壊を伴う症例に対しては, 積極的にこの術式を考慮してよいと考える.

目的. 東北大学呼吸器外科および仙台厚生病院にて切除された2220症例の肺癌患者を対象に, 臨床像ならびに喫煙が予後に及ぼす影響における男女差の検討を行なった. 方法. 1952年から2000年において, 当施設にて切除された原発性肺癌手術症例のうち喫煙指数が把握できた2220例 (男性1617例, 女性603例) を対象とした. 結果. 女性では男性に比し, 腺癌の比率が高く, 男性は扁平上皮癌と大細胞癌の比率が高かった. 男女とも非喫煙者の5年生存率は喫煙者より有意に良好であった. 男女とも喫煙指数の増加によって腺癌の比率の減少が認められた. 癌死の割合が最も少なく, 非癌死の影響を観察するのに適切であると考えられる病理病期IA期症例にて検討したところ, 男性では全死因にて喫煙者の予後が有意に不良であったが, 肺癌死のみで生存曲線を比較すると非喫煙者と同等の予後であった. 結論. 喫煙と関連してI期腺癌男性患者にて非癌死が増加することが示された. I期腺癌女性患者において喫煙の影響は明らかとはならなかったが, 喫煙者の全死因での生存率は不良であり, 肺癌切除後の予後改善という観点からも両性での禁煙指導の重要性が示された.

症例は37歳男性.2001年7月より左側胸部痛があり近医を受診し, 胸部X線写真上, 左下肺野に腫瘤影を指摘されるも放置していた.その後同年10月より左側胸部腫脹が出現し, 疼痛も増悪したため再度近医を受診し, 当科紹介された.理学的所見としては左側胸部に皮膚発赤, 腫脹, 発熱を伴った弾性硬の腫瘤を触知し, 血液学的検査にて軽度炎症所見を認めた.胸部CTでは左側胸部に直径約10cmの腫瘤が存在し, 更に腫瘤は連続性に後縦隔, 左下葉の一部にまで達していた.気管支鏡では確定診断が得られず, 経皮的吸引細胞診を施行し, 肉腫が疑われ, 手術を施行した.病理の結果放線菌症との診断が得られ, Amoxicillin経口投与にて退院した.術前診断に苦慮した, 稀な進行期放線菌症の一例を経験したので報告する.

Long-term survival has become achievable after bone-marrow transplantation, but various pulmonary diseases due to chronic graft-vs.-host disease have been recognized. Particularly, bronchiolitis obliterans is a life-threatening complication with no effective remedy. Bilateral pneumothorax associated with bronchiolitis obliterans is rare, but it requires careful attention. In a 42-year old man with intractable pneumothorax after bone marrow transplantation and surgical procedures, extensive thoracolysis was effective as an acute treatment for this disease.

局所進展型非小細胞肺癌症例4例に対し, シスプラチン (CDDP) +ビノレルビン (VNB) による術前化学療法を2～3コース施行し, PR2例, MR2例の臨床的効果を得た.手術適応ありと評価された3例に対し手術を施行し, Ef2 2例, Ef3 1例の組織学的効果を得た.術前化学療法の副作用として, 全例にGrade 3の白血球減少を認めたがG-CSF製剤の使用により速やかに改善した.輸血を必要とした血色素量減少を認めたのは1例であった.また放射線照射を加えた3コース目を実施した症例ではGrade 3の悪心・嘔吐を認めたが, CDDP+VNBによる術前化学療法の毒性は概ね許容範囲内であった.今後更に症例を重ね, 有用性を検討していきたい.

A thorough understanding of gastric cancer at the molecular level is urgently needed. One prominent oncogenic microRNA, miR-21, was previously reported to be upregulated in gastric cancer.We performed an unbiased search for downstream messenger RNA targets of miR-21, based on miR-21 dysregulation, by using human tissue specimens and the MKN28 human gastric carcinoma cell line. Molecular techniques include microRNA microarrays, cDNA microarrays, qRT-PCR for miR and mRNA expression, transfection of MKN28 with miR-21 inhibitor or Serpini1 followed by Western blotting, cell cycle analysis by flow cytometry and luciferase reporter assay.This search identified Serpini1 as a putative miR-21 target. Luciferase assays demonstrated direct interaction between miR-21 and Serpini1 3'UTR. miR-21 and Serpini1 expression levels were inversely correlated in a subgroup of gastric cancers, suggesting a regulatory mechanism that included both of these molecules. Furthermore, Serpini1 induced growth retardation of MKN28 and induced vigorous G1/S arrest suggesting its potential tumour-suppressive function in the stomach.Taken together, these data suggest that in a subgroup of gastric cancers, miR-21 is upregulated, inducing downregulation of Serpini1, which in turn releases the G1-S transition checkpoint, with the end result being increased tumour growth.

Claudin-7 is a tight junction protein that plays an important role in tumorigenesis, tumor invasion and metastasis. We examined the clinical significance of claudin-7 expression in 75 postsurgical non-small cell lung cancer (NSCLC) patients. Claudin-7 expression was measured immunohistochemically and was found to be high in 25 patients (33.3%) and low in 50 (66.7%). Survival was significantly poorer in patients with claudin-7-low than in those with claudin-7-high NSCLCs (P=0.024). In particular, survival was significantly poorer in patients with claudin-7-low than in those with claudin-7-high squamous cell carcinomas (P=0.011). A reduced expression of claudin-7 was associated with poor outcome in NSCLCs. Claudin-7 may thus be a useful biomarker and a potential therapeutic target in patients with NSCLC.

There are several reports describing [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) findings in patients with lymphomatoid granulomatosis (LYG). We report a case of grade I LYG that showed increased uptake of FDG. The patient was a 63-year-old Japanese male who underwent an FDG-PET/computed tomography (CT) scan in screening for a malignant lesion. Increased uptake of FDG [maximum standard uptake value (SUV(max)), 3.7] was observed in the right hilar region in FDG-PET and enhanced CT revealed a round, abnormal mass that also showed increased FDG uptake. The patient had no previous symptoms. A tumor biopsy was performed and the histological diagnosis was grade I LYG. Therefore, increased SUV(max) in FDG-PET might be useful for diagnosing of LYG.

Clinical Summary A 52-year-old woman with a previous history of vasospastic angina presented with an asymptomatic mediastinal mass on her routine follow-up chest roentgenogram. Values shown by means of hematologic and biochemical examinations were within normal range. A computed tomographic scan demonstrated a mass of 40 mm in diameter with a smooth margin adjacent to the trachea, superior vena cava, and ascending aorta. It showed high enhancement, although the degree of enhancement was lower than that of the surrounding vascular structures. Because a vascular tumor was suspected, digital subtraction angiography was performed, but this did not show feeder arteries or other vascular staining. Magnetic resonance imaging suggested high intensity on the T1-weighted image and low intensity on the T2-weighted image. No flow void was demonstrated (Figure 1, A). A diagnosis of lymphoadenopathy, such as Castleman disease or a malignancy, was given by radiologists. An ordinary bronchoscopic examination also showed no abnormal lesion. XBF-UC40P, a new prototype bronchofiberscope with an electrical curved linear array method, clearly showed a cystic mass with blood flow by using the power Doppler mode (Figure 1, B). No definite findings were detected on abdominal and cardiac echocardiographs. Because a vascular tumor was strongly suggested on the basis of endobronchial ultrasonography (EBUS), surgical removal of the mass by means of video-assisted thoracotomy was performed. Macroscopically, the mass seemed to be a varix of the azygos vein. No abnormal findings were observed in the superior vena cava and right atrium. The wall of the cyst was very thin, and delicate manipulation was absolutely necessary in dissecting the tumor (Figure 2, A). Pathologic examination of the excised tumor showed it to be a hemangioma composed of various cavities separated by fine septa lined with attenuated endothelium not unlike the hemangiomas of other regions. The wall of the tumor was composed of smooth muscle and connective tissues (Figure 2, B). The postoperative course was uneventful.