Tumors in the tracheobronchial tree: CT and FDG PET features

Multimodality imaging of pediatric airways disease: indication and technique

Congenital and acquired airway anomalies represent a relatively common albeit diagnostic and therapeutic challenge, even for the most skilled operators in dedicated centers. Airway malformations encompass a wide spectrum of pathologies involving the larynx, trachea and bronchi, esophagus, mediastinal vessels. These developmental lesions are often isolated but the association of two or more anomalies is not infrequent. From the traditional chest X-ray to the newest applications of Optical Coherence Tomography, non- or mini-invasive diagnostic techniques represent useful tools to integrate invasive procedures. Comprehensive knowledge of the characteristics of each diagnostic test is mandatory for its useful application. The aim of our paper is to analyze the clinical indications for Imaging the Airway disease in pediatric population, and describe the diagnostic techniques. Only by a close interaction between all the operators involved in diagnosis and treatment of pediatric airway, as it happens in Multidisciplinary Airway Team, the non- or mini-invasive imaging is effective.

Central airway pathology: clinic features, CT findings with pathologic and virtual endoscopy correlation

Objectives

To describe the imaging features of the central airway pathology, correlating the findings with those in pathology and virtual endoscopy. To propose a schematic and practical approach to reach diagnoses, placing strong emphasis on multidetector computed tomography (MDCT) findings.

Methods

We reviewed our thoracic pathology database and the central airway pathology-related literature. Best cases were selected to illustrate the main features of each disease. MDCT was performed in all cases. Multiplanar and volume-rendering reconstructions were obtained when necessary. Virtual endoscopy was obtained from the CT with dedicated software.

Results

Pathological conditions affecting the central airways are a heterogeneous group of diseases. Focal alterations include benign neoplasms, malignant neoplasms, and non-neoplastic conditions. Diffuse abnormalities are divided into those that produce dilation and those that produce stenosis and tracheobronchomalacia. Direct bronchoscopy (DB) visualises the mucosal layer and is an important diagnostic and therapeutic weapon. However, assessing the deep layers or the adjacent tissue is not possible. MDCT and post-processing techniques such as virtual bronchoscopy (VB) provide an excellent evaluation of the airway wall.

Conclusion

This review presents the complete spectrum of the central airway pathology with its clinical, pathological and radiological features.

Teaching points

• Dividing diseases into diffuse and focal lesions helps narrow the differential diagnosis.

• Focal lesions with nodularity are more likely to correspond to tumours.

• Focal lesions with stenosis are more likely to correspond to inflammatory disease.

• Posterior wall involvement is the main feature in diffuse lesions with stenosis.

Tracheobronchial tumors

Tumors of trachea and bronchi are uncommon and can occur in the form of benign or low- and high-grade malignant tumors. Although tracheobronchial tumors (TBTs) represent only 0.6% of all pulmonary tumors, they are clinically significant. Delays in diagnosis of these tumors commonly occur because the signs and symptoms caused by these tumors are nonspecific and chest radiographs are often considered unremarkable. Therefore, novel radiological techniques and better access to flexible bronchoscopy enable detection of larger number of TBT. The purpose of this article is to provide a review of tracheal and bronchial tumors and discuss significant aspects of the different TBT with focus on clinical manifestations and diagnostic procedures.

18F-FDG PET/CT of Bronchial Mucous Gland Adenoma

Bronchial mucous gland adenoma is a very rare benign tumor that arises from the bronchial mucous-secreting glands. Its detection and appearance using F-FDG PET/CT has not been well characterized. We present a case of a 59-year-old man with FDG-avid mucous gland adenoma that mimicked lung cancer on F-FDG PET/CT.

Imaging of Diseases of the Large Airways

Imaging of the large airways is key to the diagnosis and management of a wide variety of congenital, infectious, malignant, and inflammatory diseases. Involvement can be focal, regional, or diffuse, and abnormalities can take the form of masses, thickening, narrowing, enlargement, or a combination of patterns. Recognition of the typical morphologies, locations, and distributions of large airways disease is central to an accurate imaging differential diagnosis.

Multidimensional evaluation of tracheobronchial disease in adults

The large airways can be affected by a wide spectrum of acquired benign and malignant diseases. These lesions may present as focal or diffuse processes and with narrowing or widening of the airway. Some of these may be asymptomatic for quite some time and may be incidentally detected on imaging, while others may be symptomatic, causing airway compromise. There may be a characteristic radiograph and computed tomography (CT) appearance, suggesting a narrow differential. When the imaging findings are not definitive, tissue may be obtained for pathological analysis. It behooves the radiologist to be familiar with the pathologic findings that correlate with the radiographic or CT appearance of the most frequently seen large airway lesions. In this way, we may improve our diagnostic accuracy. This paper will present the imaging findings of the most prevalent tracheobronchial lesions along with any associated pathology. Teaching Points • The large airways can be affected by many acquired benign and malignant diseases.• Large airway lesions may present as focal or diffuse processes, with narrowing or widening.• There may or may not be characteristic imaging appearance of large airway disease.• If imaging findings are not definitive, tissue may be obtained for pathological analysis.

Thoracic Myoepithelial Tumors: A Pathologic and Molecular Study of 8 Cases With Review of the Literature

Thoracic myoepithelial tumors (MTs) are a rare group of tumors showing predominant or exclusive myoepithelial differentiation. They are poorly characterized from both a morphologic and genetic standpoint, in particular features that separate benign from malignant behavior. We examined the histologic and immunohistochemical features of 8 primary thoracic MTs and performed fluorescence in situ hybridization for EWSR1, FUS, PLAG1, and HMGA2, as well as several partner genes. Half (4/8) of the MTs occurred in large airways, and 3 had infiltrative borders. All cases showed immunoreactivity for epithelial markers, in conjunction with S100 protein or myogenic markers. MTs showed morphologic characteristics analogous to MTs at other sites, with no tumors having ductal differentiation. Necrosis and/or lymphovascular invasion was present in 5 cases, with mitotic activity ranging from 0 to 6 mitoses/2 mm² (mean 1). Metastases occurred in 2 cases, and no patients died of disease. Gene rearrangements were identified in half of the cases, with EWSR1-PBX1, EWSR1-ZNF444, and FUS-KLF17 fusions identified in 1 case each and 1 case having EWSR1 rearrangement with no partner identified. No cases were found to have HMGA2 or PLAG1 abnormalities. Compared with fusion-negative tumors, fusion-positive tumors tended to occur in patients who were younger (50 vs. 58 y), female (1:3 vs. 3:1 male:female ratio), and demonstrated predominantly spindle and clear cell morphology. Using a combined data set of our case series with 16 cases from the literature, poor prognosis was significantly correlated with metastases (P=0.003), necrosis (P=0.027), and ≥5 mitoses/2 mm²/10 high-power field (P=0.005). In summary, we identify a subset of thoracic MTs harboring rearrangements in EWSR1 or FUS, and our data suggest that necrosis and increased mitotic activity correlate with aggressive clinical behavior.

Outcome of incidentally detected airway nodules

Low-dose chest computed tomography (LDCT) screening increased detection of airway nodules. Most nodules appear to be secretions, but pathological lesions may show similar findings. The National Comprehensive Cancer Network (NCCN) recommends repeating LDCT after 1 month and proceeding to bronchoscopy if the nodules persist. However, no reports exist about incidentally detected airway nodules. We investigated the significance of airway nodules detected by LDCT screening.We screened patients with incidental airway nodules detected by LDCT in the Seoul National University Hospital group. The characteristics of computed tomography, bronchoscopy, pathology and clinical findings were analysed.Among 53 036 individuals who underwent LDCT screening, 313 (0.6%) had airway nodules. Of these, 186 (59.4%) were followed-up with chest computed tomography and/or bronchoscopy. Seven (3.8%) cases had significant lesions, including leiomyoma (n=2), endobronchial tuberculosis (n=2), chronic inflammation (n=1), hamartoma (n=1) and benign granuloma (n=1). The remaining 179 lesions were transient, suggesting that they were secretions.The use of LDCT for lung cancer screening demonstrated the low incidence of airway lesions. Most lesions were transient secretions. True pathological lesions were rare, and no malignant lesion was found. The current recommendation of the NCCN guideline is a reasonable approach that can avoid unnecessary bronchoscopy.

Malignant tracheal tumors: a review of current diagnostic and management strategies

PURPOSE OF REVIEW

This article reviews the current literature for the purpose of developing a practical approach for the diagnosis and management of primary tracheal tumors.

RECENT FINDINGS

Because of nonspecific symptoms, tracheal tumors remain a diagnostic challenge. Currently available management strategies are not being optimally utilized due to lack of physician awareness and knowledge. The use of newer diagnostic modalities has increased diagnostic accuracy resulting in earlier detection in recent years. This review describes currently available diagnostic modalities along with relatively newer ones such as virtual bronchoscopy, anatomic Optical Coherence Tomography, spectroscopic techniques, and endobronchial ultrasonography. We will review and discuss management strategies including surgical options, adjuvant therapies, and interventional pulmonary techniques including their role in palliation.

SUMMARY

Early detection along with improved surgical and interventional pulmonology techniques has led to a decline in the death rates from tracheal cancer in recent years. However, further studies are required to define the role of chemotherapeutic agents, combination therapies, and novel techniques such as tracheal transplantation, in the management of primary tracheal tumors. More robust evidence-based studies are needed to provide evidence for clinical practice guidelines for the treatment of primary tracheal tumors.

Multi-detector computed tomography imaging of large airway pathology: A pictorial review

The tracheobronchial tree is a musculo-cartilagenous framework which acts as a conduit to aerate the lungs and consequently the entire body. A large spectrum of pathological conditions can involve the trachea and bronchial airways. These may be congenital anomalies, infections, post-intubation airway injuries, foreign body aspiration or neoplasms involving the airway. Appropriate management of airway disease requires an early and accurate diagnosis. In this pictorial essay review, we will comprehensively describe the various airway pathologies and their imaging findings by multi-detector computed tomography.

Case Reports on the Differentiation of Malignant and Benign Intratracheal Lesions by 18F-FDG PET/CT

Malignant tracheal tumors (primary and secondary) are rare and benign tumors of the tracheobronchial tree are also rare. Few reports have been issued on the F-fluorodeoxyglucose (F-FDG) positron emission tomography (PET) findings of tracheal tumors or benign nontumorous tracheal lesions, which have been mainly studied by computed tomography (CT). The author reports 2 cases of intratracheal lesions with quite different F-FDG PET/CT findings. The first case was of a 73-year-old woman with colon cancer treated by hemicolectomy and subsequent adjuvant chemotherapy. Follow-up F-FDG PET/CT after 6 years revealed a hypermetabolic fungating mass (SUVmax: 5.8) in the distal trachea and biopsy confirmed intratracheal metastasis. The second case involved a 61-year-old man with tongue cancer who underwent mouth floor mass excision and right supraomohyoid neck dissection with submental flap reconstruction. Tracheal lesion was incidentally found during a F-FDG PET/CT follow-up study conducted 1 year later. A benign intratracheal condition with low FDG uptake (SUVmax: 1.2) and the lesion was not visualized by neck CT 4 months later. F-FDG PET/CT uptake was helpful in differentiating benign and malignant intratracheal lesions.

Imaging of Large Airways Disorders

OBJECTIVE

Recent technical advances, including the routine use of CT thin sections and techniques such as 2D minimum-intensity-projection and 3D volume images, have increased our ability to detect large airways diseases. Furthermore, dedicated CT protocols allow the evaluation of dynamic airway dysfunction.

CONCLUSION

With diseases of the large airways more commonly seen in daily practice, it is important that radiologists be familiar with the appearances, differential diagnosis, and clinical implications of these entities.

Bronchial fibroepithelial polyp: a clinico-radiologic, bronchoscopic, histopathological and in-situ hybridisation study of 15 cases of a poorly recognised lesion

BACKGROUND AND AIMS

Bronchial fibroepithelial polyp is an uncommon, poorly recognised lesion, lacking clear diagnostic criteria at histology, but possibly mimicking neoplastic growth on clinico-radiologic and histopathological grounds. The aim of this study was to define the clinico-pathological features, bronchoscopic appearance and treatment of bronchial fibroepithelial polyp.

METHODS

We collected the largest series of bronchial fibroepithelial polyps (15 consecutive cases), including clinico-pathological, bronchoscopic, radiologic and histological features.

RESULTS

Overall, there were 13 males and 2 females, with a mean age of 68 years at diagnosis. Eight patients were asymptomatic, whereas four presented with haemoptysis, two with fever, cough and pneumonia-like opacity, and one with dry recurrent cough. Mean size of the lesion was 6.5 mm (range, 2-20 mm) without any prevalence for segmental bronchi. Lesions larger than 10 mm were always symptomatic and visible at computed tomography scans. At bronchoscopy, the lesion appeared as a firm endobronchial nodule with hard consistency and glistening, whitish, smooth surface. A multilobulated and sepimentated surface was observed in the largest polyps. Whatever the size, histological features were quite similar in all cases, consisting in a polypoid lesion with a dense, collagenous, hypocellular stroma with some thin-walled, ectatic vessels and a regular respiratory mucosa on surface. In-situ hybridisation with human papillomavirus probe was negative in all the eight tested cases.

CONCLUSION

Despite the benign behaviour of bronchial fibroepithelial polyps, it is important to fix some robust diagnostic criteria in order to avoid misdiagnoses leading to unnecessary aggressive treatment. Differential diagnosis mainly includes inflammatory polyps, hamartomas and papillomas.

Imaging of the central airways with bronchoscopic correlation: pictorial essay

A wide variety of pathologic processes, both benign and malignant, affect the central airways. These processes may be classified into 4 distinct groups: anatomic variants, lesions that result in focal or diffuse airway narrowing, and those that result in multinodular airway disorder. Key to the accurate assessment of the central airways is meticulous imaging technique, especially the routine acquisition of contiguous high-resolution, 1-mm to 1.5-mm images. These images enable high-definition axial, coronal, and sagittal reconstructions, as well as advanced imaging techniques, including minimum intensity projection images and virtual bronchoscopy. Current indications most commonly include patients presenting with signs and symptoms of possible central airway obstruction, with or without hemoptysis. In addition to diagnosing airway abnormalities, computed tomography (CT) also serves a critical complementary role to current bronchoscopic techniques for both diagnosing and treating airway lesions. Advantages of CT include noninvasive visualization of the extraluminal extent of lesions, as well as visualization of airways distal to central airways obstructions. As discussed and illustrated later, thorough knowledge of current bronchoscopic approaches to central airway disease is essential for optimal correlative CT interpretation.

Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids

BACKGROUND

Pulmonary carcinoids (PCs) are rare tumors. As there is a paucity of randomized studies, this expert consensus document represents an initiative by the European Neuroendocrine Tumor Society to provide guidance on their management.

PATIENTS AND METHODS

Bibliographical searches were carried out in PubMed for the terms 'pulmonary neuroendocrine tumors', 'bronchial neuroendocrine tumors', 'bronchial carcinoid tumors', 'pulmonary carcinoid', 'pulmonary typical/atypical carcinoid', and 'pulmonary carcinoid and diagnosis/treatment/epidemiology/prognosis'. A systematic review of the relevant literature was carried out, followed by expert review.

RESULTS

PCs are well-differentiated neuroendocrine tumors and include low- and intermediate-grade malignant tumors, i.e. typical (TC) and atypical carcinoid (AC), respectively. Contrast CT scan is the diagnostic gold standard for PCs, but pathology examination is mandatory for their correct classification. Somatostatin receptor imaging may visualize nearly 80% of the primary tumors and is most sensitive for metastatic disease. Plasma chromogranin A can be increased in PCs. Surgery is the treatment of choice for PCs with the aim of removing the tumor and preserving as much lung tissue as possible. Resection of metastases should be considered whenever possible with curative intent. Somatostatin analogs are the first-line treatment of carcinoid syndrome and may be considered as first-line systemic antiproliferative treatment in unresectable PCs, particularly of low-grade TC and AC. Locoregional or radiotargeted therapies should be considered for metastatic disease. Systemic chemotherapy is used for progressive PCs, although cytotoxic regimens have demonstrated limited effects with etoposide and platinum combination the most commonly used, however, temozolomide has shown most clinical benefit.

CONCLUSIONS

PCs are complex tumors which require a multidisciplinary approach and long-term follow-up.

Multiphasic multidetector computed tomography study of a rare tracheal tumor: granular cell tumor

Our aim is to present the case report of a woman affected by tracheal granular cell tumor analysed by multiphasic contrast-enhanced multidetector CT. The tumor presents as polypoid lesion (diameter 13 mm), with smooth and well-defined margins, elevated contrast enhancement in arterial phase, and a modest release of contrast in venous phase. This pattern is quite different from the other tracheal tumours. We have performed a comprehensive review of literature to assess all cases of granular cell tumors of the trachea; only 40 cases are reported. Of these, no one focused on the contrast enhancement aspect, so our work is the first showing a specific pattern in multidetector computed tomography (MDCT) of the tracheal granular cell tumour and may help in differential diagnosis.

Atypical presentation of typical carcinoid

Bronchial carcinoid tumours can present with symptoms of distal airway obstruction, local airway irritation or bleeding due to hypervascularity. Presentation with a spontaneous pneumothorax (SP) is rare. We present a case of typical endobronchial carcinoid tumour that presented with a SP. We explored the possible mechanisms of this rare presentation, especially the check-valve mechanism of airway obstruction, which was evident during the fiberoptic bronchoscopic examination.

Role of 68Ga-DOTATOC PET/CT in initial evaluation of patients with suspected bronchopulmonary carcinoid

PURPOSE

The objective of this study was to evaluate the role of (68)Ga-DOTATOC positron emission tomography (PET)/CT scan in patients with suspected pulmonary carcinoid tumour and to compare its results with (18)F-fluorodeoxyglucose (FDG) PET/CT scan.

METHODS

In this prospective study, 32 patients (age 34.22 ± 12.03 years; 53.1 % female) with clinical suspicion of bronchopulmonary carcinoid were evaluated with (68)Ga-DOTATOC PET/CT and (18)F-FDG PET/CT. The two imaging modalities were compared, considering the tissue diagnosis as the reference standard.

RESULTS

Based on the reference standard 26 cases were carcinoid tumours [21 typical carcinoids (TC) and 5 atypical carcinoids (AC)] and 6 cases were non-carcinoid tumours. The sensitivity, specificity and accuracy of (68)Ga-DOTATOC PET/CT in the diagnosis of pulmonary carcinoid tumour were 96.15, 100 and 96.87 % respectively, whereas those of (18)F-FDG PET/CT were 78.26, 11.1 and 59.37 % respectively. The maximum standardised uptake value (SUV max) of TC on (68)Ga-DOTATOC PET/CT scan ranged from 3.58 to 55, while that of AC ranged from 1.1 to 32.5. (18)F-FDG PET/CT was true-positive in all cases of AC and false-negative in eight cases of TC (sensitivity for TC 61.9 % and for AC 100 %).

CONCLUSION

(68)Ga-DOTATOC PET/CT is a useful imaging investigation for the evaluation of pulmonary carcinoids. (18)F-FDG PET/CT scan suffers from low sensitivity and specificity in differentiating the pulmonary carcinoids from other tumours.

Thorax: normal and benign pathologic patterns in FDG-PET/CT imaging

This article describes the normal patterns of thoracic (18)F-fluorodeoxyglucose (FDG) biodistribution, and expands on the role of FDG-PET/computed tomography (CT) for the evaluation of patients suffering from a spectrum of benign pathologic conditions that affect the chest. The discussion addresses the applications of FDG-PET/CT imaging in a wide variety of chest-related disorders. Familiarity with the normal thoracic biodistribution of FDG, coupled with knowledge of the potential nonmalignant causes of increased FDG uptake in the chest, is essential to minimize the incidence of incorrect interpretation of FDG-PET images in daily clinical practice.

Tumors and tumorlike conditions of the large airways

OBJECTIVE

Large-airway tumors and tumorlike conditions are uncommon, but a systematic approach aids in narrowing the differential diagnosis. In this article, we describe an approach to dealing with large-airway lesions and discuss their imaging characteristics and clinical presentations.

CONCLUSION

We have found it useful to separate these entities into groups on the basis of the distribution pattern (focal vs diffuse) and location (trachea vs bronchi).

Clinical and Radiological Manifestations of Primary Tracheobronchial Tumours: A Single Centre Experience

Introduction: Tracheobronchial tumours usually cause an airway obstruction and secondary pulmonary infections. Although rare, they are an important differential diagnosis as they may mimic other conditions and diseases. This paper aims to analyse clinical, radiological and histological characteristics of the patients with tracheobronchial tumours diagnosed for a period of 7 years. Materials and Methods: In this retrospective, observational study, we carefully reviewed 65 patients who were diagnosed with tracheal and endobronchial tumours, and performed statistical analysis on the results. Results: Among these 65 patients (36 men and 29 women) with a mean age of 48.8 years (range, 15 to 75), 50 had malignant tumours while 15 had benign ones. The most common symptoms were cough, chest pain and haemoptysis. Cough was a more frequent symptom in patients with benign tumours (P <0.0014). Only 2 patients were asymptomatic. Tumours were predominantly localised in the large airways (46 in large bronchi and 2 in trachea). The most common radiological manifestation of malignant tumours was tumour mass (46%) followed by atelectasis. One third benign tumour caused atelectasis, while tumour mass and consolidation were found in 3 patients each. Computerised tomography revealed endoluminal tumour mass in 29.2% of the cases, which was more frequently found in benign than malignant tumours (47% vs 24%, respectively). On bronchoscopy, tumours were visible in 73% and 70% benign and malignant cases respectively. Conclusion: Tracheobronchial tumours should be ruled as a possible diagnosis in patients with cough, haemoptysis, dyspnoea and chest pain. The imaging techniques and histological examination of the tissue would subsequently lead to correct diagnosis and proper treatment can be administered. Key words: Bronchus, Computerised tomography, Trachea, Tumour, X-ray

[Multidetector computed tomography assessment of the degree of differentiation of bronchial carcinoid tumors]

OBJECTIVE

To define the CT findings for bronchial carcinoid tumors and to determine whether these findings enable these tumors to be classified as typical or atypical.

MATERIAL AND METHODS

We reviewed the chest CT studies performed between 1 January 2001 and 31 December 2009 in patients at our hospital diagnosed with bronchial carcinoid tumors. The sample consisted of 52 patients (23 women and 29 men) with a mean age of 47 years (range 11-77 years). The 52 cases were classified as typical or atypical on the basis of the following radiological findings: size, location, focality, type of growth, calcifications, signs secondary to bronchial obstruction, and the presence of significant lymph node enlargement or metastases. These findings were then compared with the histological findings.

RESULTS

Typical carcinoid tumors were the most prevalent (46 cases). The variables associated with atypical tumors were: male sex, advanced age at onset, and size >3cm. The accuracy of CT in classifying atypical tumors correctly increased with the number of variables indicative of atypical carcinoid tumors. A negative result for atypical nature made it possible to rule out an atypical carcinoid tumor in 95% of the cases.

CONCLUSION

CT is useful for defining and characterizing carcinoid tumors into typical or atypical, although a precise formula for differentiating between the two types remains to be defined.

Usefulness of FDG PET/CT in determining benign from malignant endobronchial obstruction

OBJECTIVE

To evaluate the usefulness of FDG PET/CT to differentiate malignant endobronchial lesions with distal atelectasis from benign bronchial stenosis.

METHODS

This retrospective study reviewed 84 patients who underwent contrast-enhanced chest CT and then PET/CT and had histological (n = 81) or follow-up imaging (n = 3) confirmation. Two chest radiologists reviewed initial chest CT and determined endobronchial lesions to be malignant or benign. Two nuclear medicine physicians reviewed PET/CT for FDG uptake at the obstruction site and measured SUV. Malignancy was considered when increased FDG uptake was seen in the obstruction site, regardless of FDG within the atelectatic lung.

RESULTS

The sensitivity, specificity and accuracy of chest CT was 95%, 48% and 84%, compared with 95%, 91% and 94% for PET/CT. Benign obstructive lesions showed statistically lower FDG uptake than malignant obstructions (benign SUV 2.5 ± 0.84; malignant SUV 11.8 ± 5.95, p < 0.001). ROC analysis showed an SUV cut-off value of 3.4 with highest sensitivity of 94% and specificity of 91%.

CONCLUSION

Increased FDG PET/CT uptake at the obstruction site indicates a high probability of malignancy, while benign lesions show low FDG uptake. Careful evaluation of FDG uptake pattern at the obstruction site is helpful in the differentiation between benign and malignant endobronchial lesions.

Endobronchial fibroleiomyomatous hamartoma: a diagnostic pitfall

A 46 year-old man was found to have a polypoidal growth in the lumen of the right main bronchus. Fiberoptic bronchoscope-guided biopsy of the mass on two occasions showed acute-on-chronic inflammation. The origin of the polyp was the right upper lobe bronchus; and upper lobectomy with adequate resection margin was done. Histopathology examination of the polyp showed features compatible with benign fibroleiomyomatous hamartoma. True fibroleiomyomatous hamartoma arising primarily in the lung is rare and presents as a pulmonary parenchymal lesion. the endobronchial variant of this tumor is extremely uncommon and not well documented in the literature. A preoperative diagnosis is difficult, and a high index of suspicion is required for diagnosing this benign neoplasm.

MDCT of trachea and main bronchi

Tracheobronchial imaging has undergone a major revolution since the advent of MDCT. The improved spatial and temporal resolution not only allows reformatting images that enhance the comprehension of disease before bronchoscopy or surgery, it has introduced newer techniques such as dynamic expiratory imaging to evaluate for tracheomalacia, which can be a subtle, but a confounding entity for patients and clinician alike. Tracheobronchial diseases can be arbitrarily divided into those that cause focal and diffuse narrowing and widening. Such groupings can help develop a practical approach in evaluating diseases of the central airways.

MDCT of trachea and main bronchi

Tracheobronchial imaging has undergone a major revolution. The improved spatial and temporal resolution has introduced newer techniques such as dynamic expiratory imaging to evaluate for tracheomalacia. This article describes these techniques.