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Background: Endocytoscopy (ECS) provides a magnification of approximately 450× for real-time observation of lesion nuclei. Using ECS, we aimed to evaluate whether sufficient samples for diagnosis can be obtained during bronchoscopy. We also investigated whether ECS can enable two-class diagnosis of malignant or non-malignant transbronchial biopsy specimens in real-time during bronchoscopy., Methods: This was a single-facility, prospective, observational, ex vivo study. Forty cases with localized peripheral pulmonary lesions underwent transbronchial biopsy with endobronchial ultrasonography using a guide sheath. Each biopsy specimen was immediately observed and evaluated endocytoscopically after the collection by the bronchoscopic procedure., Results: Thirty-seven cases were enrolled. The diagnostic accuracy achieved by ECS was 91.9% (34/37). The agreement rate between the endocytoscopic evaluation and pathological diagnosis of each specimen (170 specimens) was 65.3% (111/170). The median time required for endocytoscopic evaluation per specimen was 70 s. When we judged a specimen to be malignant a second time on ECS evaluations of five specimens in one case, pathologically malignant specimens were collected in 26 of 27 cases (96.3%)., Conclusions: ECS with methylene blue staining may aid in the two-class diagnosis of malignant or non-malignant transbronchial biopsy specimens during bronchoscopy. This may reduce the number of tissue biopsies., (© 2022 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.)

Endobronchial ultrasonography with a guide sheath (EBUS-GS) improves the accuracy of bronchoscopy. The possibility of differentiating benign from malignant lesions based on EBUS findings may be useful in making the correct diagnosis. The convolutional neural network (CNN) model investigated whether benign or malignant (lung cancer) lesions could be predicted based on EBUS findings. This was an observational, single-center cohort study. Using medical records, patients were divided into benign and malignant groups. We acquired EBUS data for 213 participants. A total of 2,421,360 images were extracted from the learning dataset. We trained and externally validated a CNN algorithm to predict benign or malignant lung lesions. Test was performed using 26,674 images. The dataset was interpreted by four bronchoscopists. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the CNN model for distinguishing benign and malignant lesions were 83.4%, 95.3%, 53.6%, 83.8%, and 82.0%, respectively. For the four bronchoscopists, the accuracy rate was 68.4%, sensitivity was 80%, specificity was 39.6%, PPV was 76.8%, and NPV was 44.2%. The developed EBUS-computer-aided diagnosis system is expected to read EBUS findings that are difficult for clinicians to judge with precision and help differentiate between benign lesions and lung cancers., (© 2022. The Author(s).)

A light blue line (LBL) was observed along the edge of a lesion using narrow band imaging under saline injection during bronchoscopy in an 82-year-old patient with a lobulated mass on the left B 4 . The histopathological diagnosis was hamartoma with ciliated bronchial epithelium, and we speculated that LBL appeared around the ciliated bronchial epithelium., Competing Interests: Noriaki Kurimoto received personal fees from Olympus Corporation, Chugai Pharmaceuticals Inc. and Eli Lilly Japan K.K. outside the submitted work. Yukari Tsubata received grants and personal fees from Daiichi Sankyo Co., Ltd. and AstraZeneca K.K., and personal fees from Chugai Pharmaceuticals Inc. outside the submitted work. Takeshi Isobe received a grant and personal fees from Daiichi Sankyo Co., Ltd.; personal fees from AstraZeneca K.K., Pfizer Japan Inc. and Nippon Boehringer Ingelheim Co., Ltd.; and grants from Pearl Therapeutics Inc. and Janssen Pharmaceutical K.K. outside the submitted work., (© 2022 The Authors. Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology.)

Background: Some randomized controlled trials have evaluated the effects of low-dose computed tomography (CT) screening on lung cancer mortality in heavy smokers. Based on the results of those trials, our CT screening program recommended screening for people aged ≥40 years with a history of smoking. This retrospective study aimed to verify the validity of our CT screening program and elucidate the current state of CT screening program., Methods: We retrospectively examined lung cancer detection in 25,189 participants who underwent chest CT screening by a mobile low-dose CT screening unit in the 10-year period from April 2009 to March 2019. Participants were recruited at Japan Agricultural Cooperatives (JA) Shimane Kouseiren. Participants requested CT screening for lung cancer. CT images were read by two pulmonologists., Results: Lung cancer was identified in 82 of the 25,189 participants over 10 years, an overall lung cancer detection rate (percentage of lung cancers detected among all participants) of 0.33%. Lung cancer among never smokers accounted for 54.9% of the detected cases. The lung cancer detection rate was similar for smokers versus never smokers. The stage IA detection rate (percentage of stage IA lung cancers among all lung cancers detected) was 62%, while the stage Ⅳ detection rate was 10%., Conclusions: Chest CT detected lung cancer in never smokers as well as current or former smokers. Our CT screening program was not effective for never smokers; thus, further study of the effectiveness of CT screening in never smokers is needed., Competing Interests: Conflict of Interest The authors declare no conflict of interest., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

We performed endocytoscopy (ECS) for the ex vivo evaluation of mesothelioma in specimens biopsied during medical thoracoscopy in three patients. We evaluated 19 biopsy specimens based on the density of nuclei and irregularity in the nuclei shape using ECS and compared them with the histopathological findings. All 10 specimens considered malignant based on ECS were diagnosed as malignant based on histopathology. The nine specimens evaluated as non-malignant based on ECS consisted of six specimens diagnosed as malignant based on histopathology and three diagnosed as non-malignant based on histopathology. ECS was feasible and had some utility for ex vivo ultra-magnifying imaging of thoracoscopic biopsy specimens from patients with mesothelioma.

A 28-year-old man had a cavitary lesion in the upper right lobe with a tree-in-bud appearance on chest computed tomography (CT). Diagnostic bronchoscopy was performed. An ultrathin bronchoscope in the right B2aiiβxyy reached the cavity. We filled the cavity with saline under direct bronchoscopic visualization. We suspected a blood vessel was present in the cavity wall based on narrow-band imaging. Bronchial lavage of the cavity was performed. Next, endobronchial ultrasonography (EBUS) using a guide sheath was performed with a thin bronchoscope. EBUS showed a pulsating blood vessel in the cavity wall. Bronchial lavage collected with ultrathin and thin bronchoscopy revealed Mycobacterium kansasii . Observation of vessels in the wall of a cavitary lesion with ultrathin bronchoscopy and EBUS may be useful for avoiding severe bleeding associated with biopsy of a cavitary lesion., (© 2021 The Authors. Respirology Case Reports published by John Wiley & Sons Australia, Ltd on behalf of The Asian Pacific Society of Respirology.)

Background : Although platinum-combination chemotherapy is widely used to treat advanced non-small cell lung cancer (NSCLC), not all elderly patients benefit from this regimen. In this retrospective study, we aimed to evaluate whether the Glasgow Prognostic Score (GPS), an indicator of systemic inflammation and malnutrition, could predict the tolerability and efficacy of platinum-combination chemotherapy among elderly patients with NSCLC. Methods : The eligibility criteria included patients aged ≥ 70 years with NSCLC treated with first-line platinum-combination chemotherapy at Shimane University Hospital between January 2015 and December 2018. Results : Thirty-two patients with NSCLC (median age, 74 years) were included. The GPS scores were 0-1 for 19 patients and 2 for 13 patients. Four chemotherapy cycles were completed by 57.9% and 30.8% of patients in the GPS 0-1 and GPS 2 groups, respectively. The GPS 0-1 group experienced better outcomes than the GPS 2 group (response rate : 26% vs. 15%, P = 0.67 ; median progression-free survival : 4.1 vs. 2.1 months, P = 0.0026 ; median overall survival : 22.8 vs. 9.6 months, P = 0.0092). Conclusions : Platinum-combination chemotherapy demonstrated promising efficacy among elderly NSCLC patients with a GPS 0-1. Therefore, GPS may be crucial in determining whether treatments recommended for younger patients are suitable for older patients with NSCLC. J. Med. Invest. 68 : 260-264, August, 2021.

Background: Various procedures for bronchoalveolar lavage (BAL) have been developed. BAL needs a wedge between the bronchoscope and the inner surface of the bronchus. The feasibility of performing BAL at the targeted position cannot be determined until immediately before the procedure. We examined BAL performed using a balloon catheter to evaluate the stability of the procedure itself and quality of the specimen obtained., Methods: The main inclusion criteria were diffuse lung disease with a shadow in the B 5 a area. The tip of a disposable balloon catheter was passed through the orifice of the B 5 a bronchus, and the balloon was expanded at the B 5 a bronchus. A 50-mL syringe containing saline was instilled, and gentle hand suction was performed. This procedure was repeated two more times (total: 150 mL)., Results: In all the 13 patients, the balloon of the catheter was inflated at the B 5 a bronchus. The median recovery rate was 34.92% ± 13.22%. These values were comparable to previously obtained BAL data (control group, N = 56) from our facility. The BAL fluid findings and final diagnosis, with the exception of one undiagnosed case, were consistent. Overall, four patients suffered an adverse event during BAL (hypoxemia). All cases were managed by increasing the oxygen flow rate, and the adverse event did not affect the subsequent examinations., Conclusions: Using a balloon catheter enabled us to perform BAL at the intended bronchus. The quality of the obtained specimen was also acceptable., (Copyright © 2019 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Intrapulmonary bronchogenic cysts are rare in adults and most are outside the trachea and bronchi. There are reports of clear link with the trachea, but the cyst itself occurs outside the trachea. Thus, bronchoscopy will not reveal the cause, which often leads to a diagnosis by surgical resection. We herein report an extremely rare case of an intrapulmonary bronchogenic cyst that was located entirely within the left main bronchial lumen. Bronchoscopy revealed a shiny and smooth surface mass with abundant blood vessels in the lumen that blocked the left main bronchus. The patient was successfully treated with bronchoscopic resection and remained stable at 16 months of follow-up. To our knowledge, this is the first reported case of an intrapulmonary bronchogenic cyst located entirely within the bronchial lumen.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS TBNA) is fundamental to the diagnosis of lung cancer, as many patients present with more advanced stages of lung cancer, with enlarged hilar and mediastinal lymph nodes. It also represents a way to sample pulmonary masses directly to make the diagnosis, whereby no other accessible tissue is present and the mass sits adjacent to a large central airway. Very importantly also, EBUS TBNA is the widely accepted first procedure in lung cancer staging. A combined procedure of EUS TBNA can be performed to improve diagnostic accuracy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

According to the 2012 annual report of the Japanese Association for Thoracic Surgery, the total number of surgical procedures performed for the treatment of lung cancer had reached 35,667. Patients over 70 years of age comprised 52% of those surgical cases, and those over 80 years 12%. This tendency has been increasing annually. Although hospital mortality rates in elderly patients over 80 years of age and others were almost the same, 30% of elderly patients died from other diseases, as reported by the Japanese Joint Committee of the Lung Cancer Registry in 1999. Therefore, current preoperative physiological and oncological risk evaluations of elderly patients do not appear to be sufficient. The Japanese Association for Chest Surgery planned and performed a multiinstitutional prospective cohort study of elderly patients with lung cancer who underwent thoracic surgery to answer clinical questions surrounding such risk evaluations.

Purpose: Maximum standardized uptake values (SUVmax) at the primary lesions of non-small-cell lung cancer in (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT), and the microscopic local extension of tumors were examined to develop reliable criteria to determine candidates for sublobar resection., Methods: We retrospectively analyzed 209 patients who underwent lobectomy, bilobectomy, or pneumonectomy with systematic lymph node dissection. Preoperative SUVmax at the primary lesion, microscopic lymphatic, venous, and pleural invasion in addition to lymph node metastases in the resected specimens were examined. Receiver operating characteristic analyses were used to predict an optimal cutoff for lymph node metastases., Results: With receiver operating characteristic analysis, the areas under the curve for SUVmax and tumor size were 0.693 and 0.545, respectively, suggesting SUVmax superiority for prediction of lymph node metastases with a cutoff of 2.9. When a tumor was ≤2.0 cm (n = 41, 19.6 %), the percentages of microscopic lymphatic invasion, venous invasion, pleural invasion, and lymph node metastases were 12.2, 7.3, 4.9, and 17.1 %, respectively. When SUVmax was <3.0 (n = 91, 43.5 %), these percentages were 15.4, 3.3, 7.7, and 8.8 %, showing that SUVmax could efficiently exclude nodal metastases in more cases than tumor size. The postoperative 5-year survival rate was 86.6 % in patients with SUVmax < 3.0 and 58.1 % in patients with SUVmax ≥ 3.0 (p < 0.001)., Conclusions: (18)F-FDG uptake value was more useful than tumor size for selecting patients with non-small-cell lung cancer suitable for intentional sublobar resection.

Rationale: The combination of an ultrathin bronchoscope, navigational technology, and endobronchial ultrasound (EBUS) seems to combine the best of mutual abilities for evaluating peripheral pulmonary lesions, but ultrathin bronchoscopes that allow the use of EBUS have not been developed so far., Objectives: To compare the diagnostic yield of transbronchial biopsy under EBUS, fluoroscopy, and virtual bronchoscopic navigation guidance using a novel ultrathin bronchoscope with that using a thin bronchoscope with a guide sheath for peripheral pulmonary lesions., Methods: In four centers, patients with suspected peripheral pulmonary lesions less than or equal to 30 mm in the longest diameter were included and randomized to undergo transbronchial biopsy with EBUS, fluoroscopy, and virtual bronchoscopic navigation guidance using a 3.0-mm ultrathin bronchoscope (UTB group) or a 4.0-mm thin bronchoscope with a guide sheath (TB-GS group)., Measurements and Main Results: A total of 310 patients were enrolled and randomized, among whom 305 patients (150, UTB group; 155, TB-GS group) were analyzed. The ultrathin bronchoscope could reach more distal bronchi than the thin bronchoscope (median fifth- vs. fourth-generation bronchi; P < 0.001). Diagnostic histologic specimens were obtained in 74% (42% for benign and 81% for malignant lesions) of the UTB group and 59% (36% for benign and 70% for malignant lesions) of the TB-GS group (P = 0.044, Mantel-Haenszel test). Complications including pneumothorax, bleeding, chest pain, and pneumonia occurred in 3% and 5% in the respective groups., Conclusions: The diagnostic yield of the UTB method is higher than that of the TB-GS method. Clinical trial registered with www.umin.ac.jp/ctr/ (UMIN 000003177).

Background: The relationships between the subtypes defined by the new international histologic classification of lung adenocarcinoma (IASLC/ATS/ERS) and epidermal growth factor receptor (EGFR) mutations were studied., Patients and Methods: We retrospectively reviewed 320 patients with lung adenocarcinoma (162 women, 158 men; mean age, 69 years) who had undergone complete resection, focusing on the new histologic subtypes and EGFR mutations. The clinical stage was IA in 196 patients, IB in 95, IIA in 10, IIB in 10, IIIA in 6, and IV in 3., Results: The most prevalent subtype was papillary (35.0%), followed by acinar (29.4%), lepidic (13.1%), solid (7.2%), adenocarcinoma in situ (6.6%), minimally invasive adenocarcinoma (6.3%), micropapillary (1.6%), and invasive mucinous adenocarcinoma (1.0%). These subtypes were predictive for both postoperative disease-free and overall survival. EGFR mutations, detected in 40.6% of all cases, were most frequent in acinar (48.4%), followed by minimally invasive adenocarcinoma (45.0%) and papillary (43.8%). They were least frequent in the solid subtype (17.4%). EGFR mutation status did not affect postoperative disease-free or overall survival., Conclusion: The outcome after complete resection for lung adenocarcinoma was predicted by the proposed subtype classification. Because EGFR mutations were found in all subtypes, mutation analyses are essential to identify patients with postoperative relapse who would benefit from EGFR-tyrosine kinase inhibitor therapy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Endobronchial ultrasonography using a guide sheath (EBUS-GS) is an increasingly common bronchoscopic technique, but currently, no methods have been established to quantitatively evaluate EBUS images of peripheral pulmonary lesions., Objectives: The purpose of this study was to evaluate whether histogram data collected from EBUS-GS images can contribute to the diagnosis of lung cancer., Methods: Histogram-based analyses focusing on the brightness of EBUS images were retrospectively conducted: 60 patients (38 lung cancer; 22 inflammatory diseases), with clear EBUS images were included. For each patient, a 400-pixel region of interest was selected, typically located at a 3- to 5-mm radius from the probe, from recorded EBUS images during bronchoscopy. Histogram height, width, height/width ratio, standard deviation, kurtosis and skewness were investigated as diagnostic indicators., Results: Median histogram height, width, height/width ratio and standard deviation were significantly different between lung cancer and benign lesions (all p < 0.01). With a cutoff value for standard deviation of 10.5, lung cancer could be diagnosed with an accuracy of 81.7%. Other characteristics investigated were inferior when compared to histogram standard deviation., Conclusions: Histogram standard deviation appears to be the most useful characteristic for diagnosing lung cancer using EBUS images., (© 2015 S. Karger AG, Basel.)

Objectives: Correlations between maximum standardized uptake value (SUVmax) in fluorodeoxyglucose positron emission tomography (FDG-PET) and IASLC/ATS/ERS histopathologic subtypes of lung adenocarcinoma remain unclear. Therefore, the aim of this study was to retrospectively clarify associations between SUVmax and adenocarcinoma subtypes with postoperative outcomes., Materials and Methods: Associations of SUVmax measured in preoperative FDG-PET/CT and histologic subtypes of lung adenocarcinoma resected in our hospital were analyzed retrospectively. Overall and disease-free survival rates after surgery were calculated by the Kaplan-Meier method, and survival differences between patient groups were tested by the log-rank test. Multivariate analysis for survival was performed using the Cox regression model., Results: A total of 255 patients (130 men and 125 women; mean age, 69 years; range, 22-88 years) were included in the study. Clinical stages included IA in 151 patients, IB in 79, IIA in 9, IIB in 10, and IIIA in 6. SUVmax was closely associated with histologic subtype in resected specimens (p<0.0001). Values were highest in micropapillary predominant invasive adenocarcinoma (MPA) followed by solid predominant (SPA), invasive mucinous (IMA), acinar predominant (APA), papillary predominant (PPA), lepidic predominant (LPA), minimally invasive adenocarcinoma (MIA), and adenocarcinoma in situ (AIS). When the subtypes were classified into three subgroups [group A, AIS+MIA+LPA (low risk); group B, APA+PPA+IMA (intermediate risk); and group C, SPA+MPP (high risk)] by expected postoperative prognoses, there were significant differences in SUVmax among the subgroups corresponding to recurrence risk (p=0.0001)., Conclusion: Preoperative SUVmax was closely associated with both adenocarcinoma subtype and aggregated subgroups, reflecting malignant grade of the tumor and prognosis., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Spirometry is used to physiologically assess patients with central airway obstruction (CAO) before and after interventional bronchoscopy, but is not always feasible in these patients, does not localize the anatomic site of obstruction, and may not correlate with the patient's functional impairment. Impulse oscillometry may overcome these limitations. We assessed the correlations between impulse oscillometry measurements, symptoms, and type of airway narrowing, before and after interventional bronchoscopy, and whether impulse oscillometry parameters can discriminate between fixed and dynamic CAO., Methods: Twenty consecutive patients with CAO underwent spirometry, impulse oscillometry, computed tomography, dyspnea assessment, and bronchoscopy, before and after interventional bronchoscopy. The collapsibility index (the percent difference in airway lumen diameter during expiration versus during inspiration) was calculated using morphometric bronchoscopic images during quiet breathing. Variable CAO was defined as a collapsibility index of > 50%. Fixed CAO was defined as a collapsibility index of < 50%. The degree of obstruction was analyzed with computed tomography measurements., Results: After interventional bronchoscopy, all impulse oscillometry measurements significantly improved, especially resistance at 5 Hz, which decreased from 0.67 ± 0.29kPa/L/s to 0.38 ± 0.17kPa/L/s (P < .001), and reactance at 20 Hz, which increased from -0.09 ± 0.11 to 0.03 ± 0.08 (P < .001). Changes in dyspnea score correlated with resistance at 5 Hz, the difference between the resistance at 5 Hz and the resistance at 20 Hz, and the reactance at 5 Hz, but not with spirometry measurements. The type of obstruction also correlated with dyspnea score, and showed distinct impulse oscillometry measurements., Conclusions: Impulse oscillometry measurements correlate with symptom improvements after interventional bronchoscopy. Impulse oscillometry might be useful to discriminate variable from fixed central airway obstruction. (University Hospital Medical Information Network, http://www.umin.ac.jp/english, ID000005322).

Duplication of the trachea is an extremely rare condition that has been infrequently reported in the medical literature. We report an adult case with complete tracheal duplication associated with unilateral atelectasis, which was incidentally detected by computed tomography. Tracheal duplication should be considered as a possible cause of severe atelectasis in adults.

In the staging of mediastinal lymph nodes before lung cancer surgery, endobronchial ultrasound transbronchial needle aspirations (EBUS-TBNA) have proven to be highly sensitive and specific as well as safe. Although positron emission tomography/computed tomography (PET/CT) has been a major development in the preoperative workup of patients with lung cancer, EBUS-TBNA has superior test performance and PET/CT cannot be regarded as a substitute for tissue sampling with EBUS-TBNA. In general, EBUS-TBNA staging is needed for any patient with CT nodes greater than 1 cm in short axis, or PET-positive mediastinal nodes., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Rationale: Lateral airway pressure can provide valuable physiological information during bronchoscopy., Objectives: To evaluate tracheal obstruction during intervention., Methods: To prospectively measure lateral airway pressure during bronchoscopy using a double-lumen catheter in 15 healthy subjects and 30 patients with tracheal obstruction. Pressure difference was used to evaluate the site of maximal obstruction. The angle between pressure recordings on either side of the stenosis was measured simultaneously (pressure-pressure curves) to assess the degree of tracheal obstruction., Measurements and Main Results: In the experimental study, the angle of the pressure-pressure curve was unaffected by breathing maneuvers whereas the pressure difference was affected. In healthy subjects, no pressure difference between the carina and trachea was observed during tidal breathing, and the angle was close to 45°. In patients with tracheal obstruction, the dyspnea scale, pressure difference, and angle changed significantly beyond 50% obstruction (P<0.0001). After stenting, the pressure difference disappeared and the angle was close to 45°. The degree of tracheal obstruction was significantly correlated with the pressure difference (r=0.83, P<0.0001) and angle (r=-0.84, P<0.0001). The cross-sectional area, dyspnea scale, pulmonary function tests, pressure difference, and the angle significantly improved after procedures (P<0.0001). Responder rates on the modified Medical Research Council Scale were 84.6% for obstructions above 80%, and 58.8% for obstructions between 50 and 80%., Conclusions: The direct measurement of pressure difference and the angle of the pressure-pressure curve represent a new assessment modality for the success of interventional bronchoscopy. Measuring lateral airway pressure could estimate the need for additional procedures better than bronchoscopy alone.

Background: Endobronchial ultrasonography (EBUS) has been used in diagnosing peripheral lung cancer and has allowed for higher rates of peripheral lung cancer diagnosis. However, no studies have reported that fluoroscopy time is shortened by the use of endobronchial ultrasonography. We aimed to investigate whether fluoroscopy time is shortened using endobronchial ultrasonography., Methods: We retrospectively researched fluoroscopy time in terms of the rate of diagnosis, lesion size, age, gender, histologic type and lesion site in 147 cases of malignant lesions from January 2006 to September 2007 at the Tokai University Hospital. The location of the bronchial brush or biopsy forceps was confirmed by fluoroscopy without endobronchial ultrasonography with guide-sheath group in 96 of the 147 cases, while fluoroscopy with endobronchial ultrasonography guide sheath group was confirmed in 51 cases., Results: The result was that fluoroscopy time was significantly shortened in the endobronchial ultrasonography guide-sheath group (4.08 ± 3.27 min) compared with the non-endobronchial ultrasonography guide-sheath group (7.06 ± 3.99 min), but there was no significant difference between either groups in terms of bronchoscopic diagnosis, lesion size, age, gender, histologic type and lesion site., Conclusion: The use of endobronchial ultrasonography guide sheath allows a reduction in fluoroscopy time and may reduce the adverse effects of radiation exposure on patients and staff.

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become widespread, but reports of complications are rare., Case: An enlarged mediastinal lymph node (4R) was detected in a 67-year-old man 33 months after surgery for rectal cancer, and we performed EBUS-TBNA to confirm the diagnosis. He was then admitted to hospital 13 days after the procedure, with cough, a swollen mediastinal fatty area around the 4R lymph node, and elevated WBC and CRP levels. After a diagnosis of acute mediastinitis was confirmed we gave him antibiotics, which improved his symptoms, the mediastinal fatty area and his WBC and CRP levels., Conclusion: We have to be aware of the possibility of acute mediastinitis after EBUS-TBNA of necrotic lymph nodes.

Background: Epidermal growth factor receptor (EGFR) mutational analysis has become essential in determining a therapeutic strategy for lung cancer. This study validated the reliability of recently generated rabbit monoclonal antibodies that recognise specific mutations of the EGFR protein., Patients and Methods: Pulmonary adenocarcinoma tissue from 20 previously genotyped specimens was prepared for immunohistochemical staining by two antibodies that recognise products of in-frame deletions in exon 19 (E746&#95;A750del) and a point mutation that replaces leucine with arginine at codon 858 in exon 21 (L858R) of the EGFR gene., Results: The findings of EGFR-mutation-specific immunohistochemistry were concordant with the results of DNA analysis in 18 of 20 tested samples leading to 90% sensitivity and 100% specificity of the method., Conclusion: This immunohistochemical assay for products of representative EGFR gene mutations may be performed reliably using tissue specimens from resected pulmonary adenocarcinomas.

Endobronchial ultrasonography (EBUS) can be performed using either the balloon or direct contact method. We established that EBUS using 20 MHz probe shows 5 layers of the cartilaginous portion of extrapulmonary bronchus and intrapulmonary bronchus, and 3 layers of the membranous portion. EBUS for peripheral pulmonary lesions has 2 main impacts in bronchoscopic diagnosis. One impact is to analyze the internal structures of peripheral pulmonary lesions, and another impact is to detect the location of peripheral pulmonary lesions during bronchoscopy. EBUS using a guide sheath (EBUS-GS) provides the pathway to peripheral pulmonary lesions. One advantage of EBUS-GS lies in the repeatability of access to the bronchial lesion for sampling. Another advantage of EBUS-GS lies in its ability to protect against bleeding into proximal bronchus from the biopsy site. The final advantage of EBUS-GS is the ability to obtain short-axis bronchial views of peripheral pulmonary lesions. For the successful EBUS-trans-bronchial needle aspiration (TBNA), there are some knacks. One knack is not to puncture the bronchial cartilage by the needle. For getting adequate specimens, the stylet is important part of the needle. After the needle is removed from the bronchoscope, the stylet is inserted into the needle once again to push out the specimens on the filter paper.

Differences in central airway wall structure in patients with various forms of expiratory central airway collapse can be identified by endobronchial ultrasound using a 20 MHz radial probe. In tracheobronchomalacia due to relapsing polychondritis, the cartilage is thick and irregular while the membranous portion is normal. In malacia due to chronic inflammation after tracheotomy, the cartilage is thick and irregular and the membranous portion is also thick. In excessive dynamic airway collapse associated with COPD, on the contrary, the cartilage is normal and the posterior membrane is thin when compared to the normal airway wall structures identified in a patient with physiological dynamic airway collapse. These findings may support the hypothesis that various clinical forms of expiratory central airway collapse are not only different morphologically, physiologically and aetiologically, but also structurally.

Background: We investigated whether artificial neural networks (ANNs) could diagnose pathology of lymph nodes by feeding B-mode images from convex-type echobronchoscopy to ANNs., Methods: Subjects comprised 91 patients who had undergone endobronchial ultrasonography transbronchial needle aspiration at our hospital between April 2005 and March 2007. Diagnosis was lymph node metastasis from lung cancer in 66 patients, and sarcoidosis in 25 patients. Layered ANNs consisting of input, middle layers, and output layers were prepared. Back-propagation was chosen as a learning algorithm. For the malignant findings, images obtained from six patients with lymph node metastasis of lung cancer (ie, adenocarcinoma, two patients; squamous cell carcinoma, two patients; small cell carcinoma, two patients) were used. As benign findings, typical images obtained from three patients with sarcoidosis were used. For each image used for supervised training, 5, 10, or 15 regions of interest were randomly selected. Repeated learning comprised either 500,000 or 1,000,000 repetitions. A total of five thoracic surgeons were asked to diagnose the pathology base on the same images. Accuracies were compared between ANNs and thoracic surgeons., Results: The diagnostic accuracy of the surgeon with 5 years of experience and that of the surgeon with 1 year of experience were 78% and 51%, respectively, compared to 91% for the ANNs., Conclusion: Assessment of B-mode images by ANNs may offer a useful basis for automatic diagnostic methods.

Endobronchial ultrasonography (EBUS) with a radial scanning probe provides cross-sectional images of peripheral pulmonary lesions. We devised a technique of EBUS for the diagnosis of peripheral pulmonary lesions. EBUS using a thick guide sheath (GS) [2.5 mm in diameter] covering a miniature probe, and 150 lesions were evaluated in a prospective open study. In the procedure of EBUS-GS, the probe covered by a GS is introduced into the lesion via the working channel of a bronchoscope. The probe is withdrawn, while the GS is left in situ. A brush or biopsy forceps is introduced through the GS into the lesion. EBUS visualized the image in 93% of the peripheral pulmonary lesions. One hundred sixteen (77%) of 150 EBUS-GS procedures were diagnostic. Cases in which the probe was located within the lesion, had a significantly higher diagnostic yield (105/121, 87%) than when the probe was located adjacent to it (8/19, 42%). Diagnostic yield from EBUS-GS in lesions < or = 10 mm (16/21, 76%), 10<, < or = 15 mm (19/25, 76%, p=0.99, chi2), 15<, < or = 20 mm (24/35, 69%, p=0.41, chi2), and 20<, < or = 30 mm (33/43, 77%, p=0.96, chi2) were similar, demonstrating the efficacy of EBUS-GS even in lesions < or = 20 mm in diameter.

We describe a case of primary mucinous (colloid) adenocarcinoma of the lung. The patient was a 61-year-old male with a peripheral mass of the left lung. Retrospectively, the mass, which showed slow growth later, could be seen in a chest X-ray 3 years before surgery. The tumor was filled with a gelatinous substance resembling strawberry jelly, macroscopically. Microscopically, it was mucin with a small amount of malignant cells (adenocarcinoma). Diagnosis was mucinous (colloid) adenocarcinoma, which is a very rare intrapulmonary neoplasm. Mucinous (colloid) adenocarcinoma is suspected when a gelatinous substance like strawberry jelly is observed intraoperatively in the lung.

Study Objectives: To assess the efficacy and complications of interventional bronchoscopic techniques in treating airway stenosis due to tracheobronchial tuberculosis., Design: Case series., Setting: Respiratory care centers at two tertiary care referral teaching hospitals in Japan, Hiroshima City Hospital and Okayama Red Cross Hospital., Patients and Interventions: A total of 30 patients were admitted to the hospital with a diagnosis of tracheobronchial tuberculosis between January 1991 and January 2002. Of those 11 patients received interventional bronchoscopy, including stent placement, laser photoresection, argon plasma coagulation (APC), balloon dilatation, cryotherapy, and endobronchial ultrasonography (EBUS). One patient with complete bronchial obstruction underwent a left pneumonectomy., Results: Six patients underwent stent placement after balloon dilatation, while the remaining five patients underwent only balloon dilatation. In six patients, Dumon stents were successfully placed to reestablish the patency of the central airways. Two patients first had Ultraflex stents implanted but had problems with granulation tissue formation and stent deterioration caused by metal fatigue due to chronic coughing. Dumon stents then were placed within the Ultraflex stents after the patient had received treatment with APC and mechanical reaming using the bevel of a rigid bronchoscope. In four patients, EBUS images demonstrated the destruction of bronchial cartilage or the thickening of the bronchial wall. The main complications of Dumon stents are migration and granulation tissue formation, necessitating stent removal, or replacement, and the application of cryotherapy to the granuloma at the edge of the stent., Conclusion: Interventional bronchoscopy should be considered feasible for management of tuberculous tracheobronchial stenosis. Dumon stents seem to be appropriate, since removal or replacement is always possible. Ultraflex stents should not be used in these circumstances because removal is difficult and their long-term safety is uncertain. EBUS could provide useful information in evaluating the condition of the airway wall in cases of tracheobronchial tuberculosis with potential for bronchoscopic intervention.

Study Objective: To assess the ability of endobronchial ultrasonography (EBUS) using a guide sheath (EBUS-GS) to diagnose peripheral pulmonary lesions., Method: We devised a technique for EBUS-GS covering a miniature probe, and 150 lesions were evaluated in a prospective open study. In this procedure, the probe covered by a guide sheath is introduced into the lesion via the working channel of a bronchoscope. The probe is withdrawn, while the guide sheath is left in situ. A brush or biopsy forceps is introduced through the guide sheath into the lesion., Results: One hundred sixteen of 150 EBUS-GS procedures (77%) were diagnostic. Cases in which the probe was located within the lesion had a significantly higher diagnostic yield (105 of 121 cases, 87%) than when the probe was located adjacent to it (8 of 19 cases, 42%) [p < 0.0001, chi(2)]. The diagnostic yield from EBUS-GS in lesions 10 to 15 to 20 to

Endobronchial ultrasonography (EBUS) allows visualization of the tracheobronchial tree with real-time ultrasound and permits visualization of the internal structure of pulmonary lesions, which may narrow the differential diagnosis. The indications for EBUS are to (1) determine the depth of tumor invasion of tracheobronchial lesions, (2) define positional relationships with the pulmonary artery and veins and hilar structures and determine the extent of tumor invasion, (3) visualize paratracheal and peribronchial lymph nodes and metastatic lesions and enable EBUS-guided transbronchial needle aspiration (TBNA), and (4) localize and diagnose peripheral pulmonary lesions (benign or malignant). New and evolving applications of EBUS will increase the cost-effectiveness of EBUS in the diagnosis and treatment of thoracic diseases.

Airway stenting at the wave-speed flow-limiting segment (the choke point) is assessed. We determined prospectively the precise location of the choke point using the flow-volume curve, endobronchial ultrasonography, ultrathin bronchoscopy, and three-dimensional computed tomography scan before and after stenting in 64 patients with extrincic compression due to lung cancer. We noted distinct flow-volume curve patterns specific to the type of stenosis. The tracheal stenosis group indicated fixed narrowing patterns with an expiratory plateau, bronchial stenosis group dynamic collapse patterns with an expiratory flow deterioration (choking), carinal stenosis group combined fixed and dynamic patterns, and extensive stenosis group complex patterns containing elements of all the former. After stenting, almost full-function patterns with significant improvement in PEF were observed in all groups (p < 0.01, p < 0.05, p < 0.001, p < 0.01, respectively). In patients with extensive stenosis, implantation of additional stents was required when the choke points were observed to have migrated to the areas of malacia with cartilage destruction by the tumor. Secondary stenting at migrated choke points resulted in a significant improvement in PEF over the initial stenting (p < 0.01). Stenting at the choke point improved expiratory flow limitation by increasing the cross-sectional area, supporting the weakened airway wall and relieving dyspnea.

To evaluate the utility of endobronchial ultrasonography (EBUS) in selecting appropriate candidates with centrally located early-stage lung cancer for photodynamic therapy (PDT) with curative intent, we performed EBUS before PDT in 18 biopsy-proven squamous cell carcinomas (including three carcinoma in situ) that had been considered to be appropriate candidates for PDT by conventional bronchoscopy and high-resolution computed tomography (HR-CT). Nine lesions were diagnosed as intracartilaginous by EBUS and subsequently PDT was performed. Long-term complete remission has been achieved in these patients with a median follow-up term after PDT of 32 months. The remaining nine lesions were diagnosed as extracartilaginous by EBUS and were considered candidates for other therapies such as surgical resection, chemotherapy, and radiotherapy, although two were invisible by HR-CT, three were superficial, and five were < or = 1 cm in diameter on observation by bronchoscopy. The depth of tumor invasion estimated by EBUS was proven to be accurate by histopathologic findings in six specimens after surgical resection. We conclude that EBUS is a useful technique that might be considered in addition to conventional bronchoscopy and HR-CT to improve the efficacy of PDT in patients with centrally located early-stage lung cancer.