Benign tumors of the lung: a 20-year surgical experience

Endobronchial enchondroma: Unusual bronchial tumor

Bronchial chondromas are very rare pulmonary benign tumors. Despite their rarity, clinicians should be aware of the possibility of endobronchial tumors in patients with unexplained respiratory symptoms. Treatment modalities for the complete excision of the tumor should be initiated to prevent further complications based on the individual tumor situation.

A case of pulmonary sclerosing pneumocytoma diagnosed preoperatively using transbronchial cryobiopsy

Background

The preoperative diagnosis of pulmonary sclerosing pneumocytoma (PSP) is complicated since PSP has several histological structural patterns in the same neoplasm; hence, it is sometimes pathologically misdiagnosed as adenocarcinoma or carcinoid. In recent years, with the prevalence of transbronchial cryobiopsy (TBLC), we are able to obtain larger specimens than previously. However, to date, there have been no reports describing PSP diagnosed using TBLC.

Case reports

A 43-year-old man was referred to our hospital for an abnormal lesion in the left lung discovered on routine health examination. A computed tomography scan of the chest revealed a 14-mm heterogeneous round nodule with surrounding ground-glass opacity in the left lower lobe. The tumor size increased to 18 mm in three weeks, and he developed bloody sputum. TBLC was performed using radial endobronchial ultrasonography and fluoroscopy. An occlusion balloon and prophylactic epinephrine were used to prevent severe bleeding. Histologically, epithelioid cells with solid proliferation, various papillary lesions, and hemosiderin-laden histiocytes were observed. Immunohistochemical staining revealed the histiocytes positive for thyroid transcription factor-1 and vimentin, and the type II pneumocyte-like-cells positive for cytokeratin 7. The tumor was preoperatively diagnosed as a PSP; the patient underwent left basal segmentectomy and consequently, a final diagnosed of PSP was formulated.

Conclusion

We report the first case of PSP preoperatively diagnosed using TBLC. Therefore, cryobiopsy could be beneficial in the preoperative diagnosis of PSP.

Benign Endobronchial Tumors: A Clinicopathologic Review

Purpose: Benign endobronchial tumors are rare entities that can be difficult to diagnose because they often present with non-specific symptoms and vague radiographic findings. The current study reviews the clinical, radiologic and pathologic features, diagnosis, and treatment of patients with benign endobronchial tumors. Methods: We examined the charts of all patients who presented with biopsy-proven benign endobronchial tumors at a tertiary-care academic medical center between 1993 and 2018. Pertinent clinicopathologic and radiologic data were analyzed, with particular attention paid to treatment modalities and mean overall patient survival. Results: A total of 28 cases were identified. The most common benign neoplasm was hamartoma (37%), followed by lipoma (19%), squamous papilloma (11%), pleomorphic adenoma (7%), mucin gland adenoma (7%), papillary adenoma (3%), hemangioma (3%), neurofibroma (3%), leiomyoma (3%), and papillomatosis (3%). Cough (58%), shortness of breath (44%), and hemoptysis (15%) were the most frequent presentations. Most cases demonstrated well-defined submucosal or pedunculated endobronchial lesions with segmental pneumonia or atelectasis on imaging. Histologic diagnosis was obtained by endobronchial resection in 43% of patients, thoracoscopic lobectomy in 36%, endobronchial biopsy in 18%, and thoracoscopic wedge resections in 3%. All procedures were performed with no intraoperative or in-hospital deaths (mean overall survival: 20.2 years). Conclusion: Benign endobronchial tumors typically present as well-defined submucosal and/or pedunculated lesions, and may lead to post-obstructive complications. Endobronchial resection is the preferred strategy for diagnosis and treatment of these tumors.

Intractable cough due to endobronchial chondroma

A 62-year-old man, suffering from bronchial asthma was evaluated due to intractable cough. His dyspnea was controlled but cough remained unresponsive to escalation of asthma management steps. Cough occurred in bouts, especially during night time and was occasionally productive of mucoid sputum. Other than bilateral rhonchi on chest auscultation, remaining systemic examination was unremarkable. CT chest showed a mass lesion in the bronchus intermedius that was confirmed on bronchoscopy and was removed after electrocautery snare excision. Histopathology of the lesion was consistent with endobronchial chondroma. The patient experienced a dramatic resolution of cough post tumor removal. Follow up bronchoscopy after 24 months revealed no tumor recurrence.

Sclerosing pneumocytoma diagnosed by preoperative endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)

BACKGROUND

Sclerosing pneumocytoma is a rare lung tumor that is usually recognized as a solitary nodule in the lung. Surgical removal is recommended; however, its clinical diagnosis is still an issue because it is difficult to differentiate from lung adenocarcinomas using a tiny sample obtained from biopsy.

CASE PRESENTATION

We report a case of pulmonary sclerosing pneumocytoma located in the upper lobe of the right lung of a 34-year-old woman, which was diagnosed before surgery by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). A 3-cm irregular mass was detected by chest X-ray without any symptoms. She was referred to our hospital after being followed for 10 years in her previous clinic. During this follow-up period, the tumor had grown to 5 cm. We performed the EBUS-TBNA for the diagnosis. The histological findings obtained by EBUS-TBNA consisted of alveolar type 2-like cells that were positive for napsin A and round cells that were positive for vimentin. Based on these immunostaining results, we successfully diagnosed sclerosing pneumocytoma before surgery. Right upper lobectomy was performed, and the pathological diagnosis of the surgical specimen was also confirmed as sclerosing pneumocytoma.

CONCLUSIONS

We herein report a case of sclerosing pneumocytoma, which was clinically diagnosed by EBUS-TBNA and resected surgically.

Pulmonary sclerosing pneumocytoma with mediastinal lymph node metastasis

Pulmonary sclerosing pneumocytoma is a rare tumour with 23 cases reported to have metastasis to lymph nodes, but to date, only 6 had involved mediastinal nodal stations. Our patient was a 40-year-old Asian female with a 2.5 cm nodule in her right lower lobe. Positron-emission tomography suggested no nodal disease; but after resection, the intra-lobular, hilar and subcarinal nodes were all found to be involved. As prognosis of this rare disease is uncertain, we aim to report our findings against available literature and similar cases.

The clinical, radiological, and bronchoscopic findings and outcomes in patients with benign tracheobronchial tumors

PURPOSE

We evaluated the characteristics of and treatment outcomes in patients with benign tracheobronchial tumors.

MATERIALS AND METHODS

We reviewed the records of patients with benign tracheobronchial tumors who underwent bronchoscopic intervention with mechanical removal and Nd: YAG laser cauterization, and evaluated the characteristics and treatment outcomes of 55 patients with hamartomas, leiomyomas, papillomas, typical carcinoids, or schwannomas seen between April 1999 and July 2012.

RESULTS

The most common tumors were hamartoma (n=24), leiomyoma (n=16), papilloma (n=7), typical carcinoid (n=5), and schwannoma (n=3). Forty-one patients (75%) had symptoms. On chest computed tomography, 35 patients (64%) had round or ovoid lesions, accompanied by atelectasis (n=26, 47%) or obstructive pneumonia (n=17, 31%). Fatty components (n=9, 16%) and calcifications (n=7, 13%) were observed only in hamartomas, leiomyomas, and typical carcinoids. At bronchoscopy, the typical findings were categorized according to tumor shape, surface, color, and visible vessels. Fifty (91%) patients underwent complete resection. Forty patients (73%) achieved successful bronchoscopic removal defined as complete resection without complications or recurrence. Recurrences occurred in four papillomas, one leiomyoma, and one typical carcinoid. The proportions of tumor types (p=0.029) differed between the successful and unsuccessful removal groups, and a pedunculated base (p<0.001) and no spontaneous bleeding (p=0.037) were more frequent in the successful removal group.

CONCLUSION

We described clinical, radiological, and typical bronchoscopic findings in patients with benign tracheobronchial tumors; these findings might help to differentiate such tumors. Bronchoscopic intervention was a useful treatment modality, and tumor type, pedunculated base, and vascularity may influence successful tumor removal.

Pulmonary hamartoma: Cytological study of a case and literature review

Pulmonary hamartomas are the most common but rare benign tumor-like lesions of the lung arising from the embryonic rest. They are more common in males and in aged. Majority are asymptomatic and seen as coin lesions with popcorn calcification in the chest radiograph. Fine needle aspiration cytology (FNAC) helps to diagnose and distinguish them from the cancerous lesions of the lung. The cytological material is characterized by fibromyxoid stroma, cartilage, bronchial cells, adipose tissue and bone. Bronchial cells with reactive atypia may be a source of false-positive result. Symptomatic cases need surgical intervention such as enucleation or segmental resection. We report a case of a 74-year-old male who had a lung mass that did not progress over 4-year on chest radiograph. The CT-guided FNAC smears showed benign bronchial epithelial cells, fibro-myxoid spindle cell stroma and fat spaces that aided the diagnosis of pulmonary hamartoma avoiding surgical intervention.

Fine-Needle Aspiration of Pulmonary Hamartoma: A Common Source of False-Positive Diagnoses in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

Context.—We use data from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology to evaluate the accuracy of fine-needle aspiration (FNA) biopsy for diagnosing pulmonary hamartoma (PH).

Objective.—To use the performance characteristics of the PH cases in the Nongynecologic Cytology Program to determine the accuracy of FNA for identifying these lesions and to determine potential sources of interpretative errors.

Design.—A retrospective review of the College of American Pathologists Nongynecologic Cytology cumulative data from 1997 to 2003 was performed to identify the overall accuracy of FNA for diagnosing PH and to determine the most common interpretative pitfalls. The slides from each of the cases of PH in the Nongynecologic Cytology Program were then reviewed in an effort to identify the cytologic characteristics that contributed to the poor performance of these cases.

Results.—A total of 766 participant responses for 19 PH FNA specimens were reviewed. The specificity of FNA for making the correct general reference interpretation of benign was 78%. The false-positive rate was 22%, with the most common false-positive diagnoses being carcinoid tumor, adenocarcinoma, and small cell carcinoma. The overall accuracy for making the correct specific reference diagnosis of PH was 26%. Microscopic review of the individual cases revealed possible explanations for some of the interpretative errors and the most frequent false-positive interpretations.

Conclusions.—Cytologists should be aware of the potential false-positive interpretations that can occur in FNAs of PH and the potential reasons for these inaccuracies in order to minimize clinically significant diagnostic errors.

Chromosomal aberrations, profiles of expression of growth-related markers including galectins and environmental hazards in relation to the incidence of chondroid pulmonary hamartomas

This prospective study includes 103 cases of chondroid pulmonary hamartomas, resected over a period of nearly six years. Genes encoding proteins of the high motility group (HMGI-C, (Y), chromosomes 12q15 and 6p21) were analyzed cytogenetically. Furthermore, we examined the expression of growth-regulatory markers, including galectins-1, -3, -8, heparin-binding lectin (HBL), calcyclin (S100A6) and macrophage migration inhibitory factor (MIF), as well as that of Ki-67 (MIB-1). Syntactic structure analysis was applied to automated classification of stained histological slides and for the detection of topological properties in hamartomas and disease-free lung. These data were set in relation to clinical features, including environmental hazards, smoking habit, and the occurrence of heart-lung disease. Men and women contributed to the study in 61 and 42 cases, respectively. Smoking was frequent (75% men and 54% women), with a mean tobacco consumption of 36 pack years. Aberrations affecting exclusively the HMGI-C gene and the HGMI(Y) gene were seen in 46 cases (44.7%) and in 22 cases (21.3%), respectively. Both genes were affected in only one case. Abnormalities most frequently occurred in chromosomal bands 6p12 and 12q14. Genetic aberrations were significantly increased in men exposed to environmental (occupational) risk factors, excluding smoking (p < 0.05), and in tumors larger than average hamartomas. There were significant differences in staining profiles, particularly for calcyclin and MIF. The mean proliferation index was Nv = 9.9 +/- 6.4%; structural entropy was similar in all markers applied. Owing to their remarkably high values (from 142 to 148), these data were in contrast to a low current of entropy seen in most markers applied. The staining profile identified several markers that delimited cell positivity from normal parenchymal cells. These results contribute to the definition of biochemical characteristics in hamartomas and can be useful for distinguishing them from chronic degenerative disorders.