Pathological and radiological correlation of endobronchial neoplasms: Part I, Benign tumors

Pulmonary Endobronchial Hamartoma Presenting With Post-obstructive Pneumonia

Pulmonary hamartomas (PH) are rare but are the most common benign tumors found in the lungs. They are slow-growing and are usually found incidentally on chest imaging during the sixth decade of life. Approximately 10% of pulmonary hamartomas are endobronchial. Rarely, pulmonary hamartomas can cause a spectrum of pulmonary symptoms depending on their size and location. We present a case of endobronchial hamartoma causing airway obstruction and recurrent post-obstructive pneumonia.

Case report: Bronchoscopic intervention for rare benign airway tumors: a report of 4 cases and literature review

Due to their unique location, airway tumors have a significant impact on patient quality of life and survival. Current research has focused extensively on malignant airway tumors; however, benign airway tumors, especially rare ones, are less understood due to their low incidence. These tumors are often misdiagnosed and mistreated due to diagnostic challenges. Therefore, there is still a lack of consensus on the treatment of some rare benign airway tumors. Our center summarizes the diagnosis and treatment of four rare cases of benign airway stenosis in recent years, highlighting the bronchoscopic manifestations and therapeutic approaches to improve the understanding of these diseases.

Malignant and Benign Tracheobronchial Neoplasms: Comprehensive Review with Radiologic, Bronchoscopic, and Pathologic Correlation

Tracheobronchial neoplasms are much less common than lung parenchymal neoplasms but can be associated with significant morbidity and mortality. They include a broad differential of both malignant and benign entities, extending far beyond more commonly known pathologic conditions such as squamous cell carcinoma and carcinoid tumor. Airway lesions may be incidental findings at imaging or manifest with symptoms related to airway narrowing or mucosal irritation, invasion of adjacent structures, or distant metastatic disease. While there is considerable overlap in clinical manifestation, imaging features, and bronchoscopic appearances, an awareness of potential distinguishing factors may help narrow the differential diagnosis. The authors review the epidemiology, imaging characteristics, typical anatomic distributions, bronchoscopic appearances, and histopathologic findings of a wide range of neoplastic entities involving the tracheobronchial tree. Malignant neoplasms discussed include squamous cell carcinoma, malignant salivary gland tumors (adenoid cystic carcinoma and mucoepidermoid carcinoma), carcinoid tumor, sarcomas, primary tracheobronchial lymphoma, and inflammatory myofibroblastic tumor. Benign neoplasms discussed include hamartoma, chondroma, lipoma, papilloma, amyloidoma, leiomyoma, neurogenic lesions, and benign salivary gland tumors (pleomorphic adenoma and mucous gland adenoma). Familiarity with the range of potential entities and any distinguishing features should prove valuable to thoracic radiologists, pulmonologists, and cardiothoracic surgeons when encountering the myriad of tracheobronchial neoplasms in clinical practice. Attention is paid to any features that may help render a more specific diagnosis before pathologic confirmation. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Clinical, radiological and histopathological profile of patients with endobronchial lesions on fibreoptic bronchoscopy

Various pulmonary diseases, both benign as well as malignant, manifest in the form of endobronchial lesions on bronchoscopy. Malignancy is frequently the provisional diagnosis in the mind of a chest physician undergoing an endobronchial biopsy. Other benign diseases, however, may present similarly on bronchoscopy and computerized tomography (CT) scan. This observational study was conducted to better understand why there is such a wide range of endobronchial lesions with even more diverse radiological and pathological presentations. The research was carried out at the Department of Respiratory Medicine, Himalayan Institute of Medical Science (HIMS), Swami Ram Nagar, Dehradun. Subjects were recruited from HIMS, Dehradun patients over a 12-month period (August 2020 to July 2021). The study included patients (over the age of 18) who had a fibreoptic bronchoscopy and were found to have an endobronchial lesion. After a thorough history, examination, and application of the inclusion and exclusion criteria. 120 patients were enrolled. The majority of patients were between the ages of 56 and 65, with males outnumbering females. The majority of the patients were smokers, and the most common complaint was shortness of breath. Poorly differentiated carcinoma and squamous cell carcinoma were the most common endobronchial lesions in men, while small cell carcinoma was the most common in women. A mass lesion was the most common radiological finding, followed by mediastinal lymphadenopathy, and an exophytic lesion was the most common endobronchial lesion detected in bronchoscopy. We looked at the diseases that cause endobronchial lesions and their clinico-radiological and histopathological profiles. This study clearly demonstrates the importance of studying the histopathological profiles of patients with endobronchial growth, which can mimic malignancy in rare cases.

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.

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.

Endobronchial treatment of benign endobronchial neoplasms: Our 10 years of experience

Background

The aim of the study was to assess the safety, efficacy, complications, and long-term outcomes of endobronchial treatment for benign endobronchial tumors.

Methods

A total of 53 patients (39 males, 14 females; mean age: 53.7 years; range, 12 to 83 years) with the diagnosis of benign endobronchial neoplasms in our center between November 2010 and September 2019 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients and treatment outcomes were examined.

Results

Tumors regressed in all patients with argon plasma coagulation, diode laser and electrocautery, which was combined with cryotherapy in some cases. Complications were observed in five (9%) patients. Major complications were atrial fibrillation in two patients and respiratory failure requiring mechanical ventilation in one patient. Minor complications were minimal bleeding in two patients. The response was very good in 39 (74%) patients and good in 12 (23%) patients. There was no significant difference in the residual tissue formation requiring cryotherapy among the endobronchial treatment modalities (p>0.05). The five-year survival rate was 94%. No endobronchial treatment-related mortality was observed in any of the patients.

Conclusion

Endobronchial treatment modalities including diode laser, electrocautery, and argon plasma coagulation combined with or without cryotherapy are effective and safe in the treatment of benign endobronchial tumors.

Mediastinal Masses: 18F-FDG-PET/CT Features Based on the International Thymic Malignancy Interest Group Classification

Imaging plays a key role in the management of mediastinal masses. In an effort to standardize the analysis of the mediastinum, the International Thymic Malignancy Interest Group (ITMIG) has proposed a three compartments-based diagnostic classification, intended for clinicians and radiologists. Several articles have documented its usefulness to guide the diagnosis using cross-sectional imaging. Similarly, fluorine-18-radiolabeled fluorodeoxyglucose positron emission tomography combined to computed tomography (¹⁸F-FDG-PET/CT) can be useful in this setting, either as a first-line diagnostic technique, or in addition to cross-sectional imaging. In this article, which is thought as an aid for nuclear medicine physicians and radiologists, we aim to present, based on the ITMIG classification, the main mediastinal pathologies that can be observed with ¹⁸F-FDG-PET/CT, and the additional diagnostic value that can be expected from this technique. For this purpose, we segmented the mediastinum according to the ITMIG classification, and reviewed the available literature for each of the corresponding organs and/or disease. Given the importance of the clinical context for the interpretation of PET imaging, we presented each of the diseases according to: (1) their suggestive clinical context; (2) the suggestive features on nonenhanced CT (which is the standard in PET imaging); and (3) the typical ¹⁸F-FDG characteristics. The purpose of this article is to depict the main features of the most common mediastinal diseases that can be encountered with ¹⁸F-FDG-PET/CT, and to highlight its diagnostic value in this setting, alone or in combination with other imaging modalities.

Whistling Lipoma: Bronchial Obstruction Caused by a Lipoma

Lipomas are extremely common benign tumors that occur in a variety of locations. However, lipomas in the bronchus are exceptionally rare and account for a very small number of all bronchial tumors. Diagnosis of an endobronchial lipoma can be challenging at times, as they may present with overlapping symptoms of central airway obstruction, pneumonia, or dyspnea.

We present an 82-year-old male with a 40-pack-year history of smoking who presented with recurrent pneumonia and signs of airway obstruction. Imaging studies showed an obstructive lesion. The biopsy sample revealed adipose cells. Eventually, the lesion was successfully resected. The surgical specimen ruled out malignancy and confirmed the diagnosis of lipoma.

Timely identification and differentiating a malignant lesion from benign lesions, like lipoma, is crucial to management.

Rare case of bronchoscopic debulking of endobronchial leiomyoma

An endobronchial leiomyoma is a rare benign tumour of lung. It occurs from the smooth muscle of tracheobronchial tree or within lung parenchyma. It presents less than 2% of all benign lung tumours. We present a case report of a 39-year-old male, ex-smoker, with no family history of malignancies, presenting with cough and dyspnoea for 7 months with no symptomatic relief. CAT scan thorax showed well-defined oblong soft tissue mass lesion 24.2 mm × 15.4 mm in right major bronchus compromising central lumen. Flexible bronchoscopy revealed an endobronchial mass at right major bronchus. Patient underwent rigid bronchoscopy with endobronchial mass excision with an electrocautery snare and cryoprobe in the same seating. Complete debulking of tumour was achieved and histopathology report was suggestive of leiomyoma. Prompt investigations and intervention can give favourable outcomes in cases of endobronchial tumours.

Incidental endobronchial hamartoma in a patient with enchondroma

Hamartomas are the most common type of benign tumours of the lung, constituting a small portion of all lung neoplasms. Hamartomas are rare benign tumours composed of multiple mesenchymal cell lines. Two clinical types have been defined according to the location: intraparenchymal and endobronchial, more frequently the former. We present a case of endobronchial hamartoma causing significant blockage of the right middle lobe. The finding was incidental on a CT scan of the chest done for staging purposes for a large mixed lytic and sclerotic lesion that was found within the proximal-mid portion of the tibial diaphysis. The endobronchial lesion was removed by hot electrocautery snare during bronchoscopy and identified as a hamartoma. Argon plasma coagulation was applied to the lesion's base afterwards and the patient was to follow-up in 3 months for a repeat CT scan.

Endobronchial Myxoma: An Uncommon Entity

A 31-year-old woman presented with progressive breathlessness since 1 year. Flexible bronchoscopy revealed a vascular tumor completely occluding the right main bronchus. A diagnosis of primary endobronchial myxoma was made. Tumor debulking was performed using rigid bronchoscopy. This enabled right lower lobectomy. A literature search yielded 12 cases of primary pulmonary myxoma, and only 2 previous reports of endobronchial myxoma. Most tumors were incidentally detected and were cured surgically. Endobronchial myxomas are rare and are usually asymptomatic. Treatment involves surgical excision. Rigid bronchoscopy serves as a bridge to surgery and can reduce the extent of surgery.

A rare case of bronchial elastosis: An unusual presentation of an unexpandable lung

Endobronchial obstruction is a known cause of an unexpandable lung. Endobronchial lesions are usually malignant, however benign cause like hemartoma, lipoma, amyloidosis and neuroendocrine tumors are known. We, hereby present the rare cause of bronchial elastosis presenting as right lower lobe lung collapse.

Endobronchial hamartoma; a rare structural cause of chronic cough

Pulmonary hamartomas are rare benign tumors consisting of multiple mesenchymal cell lines like cartilage, bone and fat. We discuss an interesting case of a 53-year-old male patient, who was referred to our clinic for persistent cough. Chest X-ray revealed a left suprahilar density associated with plate like atelectasis, which on chest CT was found to be a densely calcified nodule, causing narrowing of the left upper lobe (LUL) bronchus with calcified bilateral hilar lymph nodes. A bronchoscopy revealed a smooth endobronchial mass with calcification, which was removed. Histopathology revealed pulmonary hamartoma.

The technique of endoscopic airway tumor treatment

More than half of primary lung cancers are not resectable at diagnosis and 40% of deaths may be secondary to loco-regional disease. Many of these patients suffer from symptoms related to airways obstruction. Indications for therapeutic endoscopic treatment are palliation of dyspnea and other obstructive symptoms in advanced cancerous lesions and cure of early lung cancer. Bronchoscopic management is also indicated for all those patients suffering from benign or minimally invasive neoplasm who are not suitable for surgery due to their clinical conditions. Clinicians should select cases, evaluating tumor features (size, location) and patient characteristics (age, lung function impairment) to choose the most appropriate endoscopic technique. Laser therapy, electrocautery, cryotherapy and stenting are well-described techniques for the palliation of symptoms due to airway involvement and local treatment of endobronchial lesions. Newer technologies, with an established role in clinical practice, are endobronchial ultrasound (EBUS), autofluorescence bronchoscopy (AFB), and narrow band imaging (NBI). Other techniques, such as endobronchial intra-tumoral chemotherapy (EITC), EBUS-guided-transbronchial needle injection or bronchoscopy-guided radiofrequency ablation (RFA), are in development for the use within the airways. These endobronchial interventions are important adjuncts in the multimodality management of lung cancer and should become standard considerations in the management of patients with advanced lung cancer, benign or otherwise not approachable central airway lesions. We aimed at revising several endobronchial treatment modalities that can augment standard antitumor therapies for advanced lung cancer, including rigid and flexible bronchoscopy, laser therapy, endobronchial prosthesis, and photodynamic therapy (PDT).

The Different Clinical Aspects of Pediatric Primary Airway Tumors in the Larynx, Trachea, and Bronchi

Primary airway tumors are rare in children and no literature reviewed their characteristics each location. We evaluate the clinical characteristics and outcomes of Korean children with primary airway tumors, from the larynx to bronchi. A retrospective chart review of children with primary tumors of the larynx, trachea, and bronchi at Asan Medical Center from January 2000 to July 2016 was conducted. Nineteen children were diagnosed with primary airway tumors of the larynx (47.4%), trachea (10.5%), and bronchi (42.1%). Median follow-up duration was 2.8 years and there were recurrences in 21.1%. Laryngeal tumors were associated with a younger median age at onset (2 months) and diagnosis (4 months), and most were relatively small (median size = 5.3 mm) and symptomatic. Tracheal and bronchial tumors were found in older children (age at onset and diagnosis > 11 years) and large (> 15.0 mm). Most (75%) patients with bronchial tumors were asymptomatic and all the patients with tracheal tumors were symptomatic. This study suggests that we should consider different the locations in primary airway tumor based on the age at onset and diagnosis, initial symptoms or signs, and size of tumor.

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.

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.

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.

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.

Computed tomography correlation of airway disease with bronchoscopy--part II: tracheal neoplasms

This pictorial essay illustrates, describes, and correlates computed tomographic findings of tracheal neoplasms with fiberoptic bronchoscopy findings. Corresponding computed tomography (CT) and bronchoscopy findings of common primary tracheal neoplasms; squamous cell papilloma, papillomatosis, squamous cell carcinoma, adenoid cystic adenoma, non-Hodgkin׳s lymphoma, and a secondary malignant neoplasm of the trachea; and renal cell carcinoma were correlated.

Surgical approaches of endobronchial neoplasms

Endobronchial tumors are a rare entity that presents with different pathological findings. The interventional pulmonologist, but also the thoracic surgeon have at their disposal the same techniques for diagnosis, however; the two modalities differentiate in the treatment approach. Diagnosis evaluation should include lymph node evaluation. Minimal invasive techniques under local or general anesthesia are usually preferred by the interventional pulmonologists, whereas in the surgical approach of the thoracic surgeons the general anesthesia is necessary. A more extensive surgical approach either lobotomy or pneumonectomy should be performed in cases with positive intrapulmonary lymph nodes. Carinal reconstruction should be performed skillfully to get a negative proximal margin whenever needed. In the current manuscript we will present the methods of patient evaluation and surgical techniques for the management of these lesions.

An unexpected cause of hemoptysis: endobronchial lipomatous hamartoma

Hamartomas are the most common benign tumors of the lung. Endobnronchial hamartomas are even rarer and infrequently causes hemoptysis. We report a case of endobronchial hamartoma that was originating from a segment bronchus and invisible in chest X-ray. A 63-year-old man was admitted to hospital with hemoptysis. A CT scan revealed endobronchial mass obstructing anterior bronchus of the right lower lob of the right lung. It wasn’t radiographically presented. Flexible bronchoscopy detected a polypoid mass (1.5x1.0 cm) that arising from the posterior wall of the anterior segment of right lower lob. Histopathologic examination revealed lipoumatous hamartoma. It was resected with an electro-surgical snare. Cryotherapy was applied to residual lesion on surface of the bronchus. The patient was successfully recovered. In conclusion, lipoumatous hamartoma may presented as rare cause of hemoptysis. Endoscopic treatment is safe and currently modality used for select cases.

Bronchial leiomyoma, a case report and review of literature

A 44 year old male former smoker from Ecuador presented with productive cough for 3 weeks, positive tuberculin skin test, 40 lbs weight loss and right lower lobe collapse. He denied wheezing or hemoptysis. He was treated with antibiotics and ruled out for tuberculosis with negative sputum smear. Bronchoscopy showed an endobronchial lesion at the distal end of bronchus intermedius as cause of the collapse. Endobronchial biopsy of the lesion revealed an endobronchial leiomyoma, a rare cause of endobronchial tumor. The patient underwent bilobectomy as definite therapy for the leiomyoma due to its large size and possible extra-luminal extension, which made it not amenable to bronchoscopic resection or bronchoplasty. Differential diagnoses of endobronchial lesions are discussed along with clinical, radiographic, pathologic characteristics and various treatment modalities for endobronchial leiomyomas.

[Endobronchial hamartochondroma]

INTRODUCTION

Endobronchial hamartochondroma is a form of rare benign tumour. Compared to those that occur in the lung parenchyma, the endobronchial form can potentially be managed by relatively conservative treatment involving per-endoscopic resection.

COMMENT

A 61-year-old patient had a dry cough and chest pain for 3 months. Their clinical examination was normal, but thoracic CT scan showed lingular collapse. Bronchoscopy revealed the presence of a multilobar tumour occluding the orifice of the lingula bronchus. Bronchial biopsies were consistent with the diagnosis of a hamartochondroma. Before the destruction of any of the left upper lobe parenchyma, the tumor was resected surgically and the patient had an uneventful postoperative course.

CONCLUSION

Endobronchial hamartochondroma support must be rapid to avoid irreversible parenchymal consequences downstream obstruction involving an often mutilating surgery. Essentially endoscopic treatment should be the most conservative possible.

Primary lung and large airway neoplasms in children: current imaging evaluation with multidetector computed tomography

Multidetector computed tomography (MDCT) offers an important noninvasive imaging modality for confirmation and further characterization of primary lung and large airway neoplasms encountered in pediatric patients. Children represent a unique challenge in imaging, not only because of unique patient factors (eg, inability to follow instructions, motion, need for sedation) but because of the technical factors that must be optimized to reduce radiation dose. This article reviews an MDCT imaging algorithm, up-to-date imaging techniques, and clinical applications of MDCT for evaluating benign and malignant primary neoplasms of lung and large airway in infants and children.

Bronchial schwannomas: clinicopathologic analysis of 7 cases

BACKGROUND

It has long been recognized that bronchial schwannomas are extremely rare. As such, diagnosing tumors in this extraordinary location can sometimes be problematic.

METHODS

We reviewed seven cases of bronchoscopically or surgically resected endobronchial schwannomas and evaluated their clinical and pathologic features.

RESULTS

The present study included five female and two male patients, with ages ranging from 16 to 81 years (mean age, 44.9 years). The clinical presentation varied according to tumor size and location. Patients with more centrally (trachea or main bronchus) located tumors experienced respiratory symptoms (80%) more often than patients with more peripherally (lobar or segmental bronchus) located tumors (0%). Histologically, the tumors were composed of spindle cells that stained with S100 protein. Some of the tumors showed typical Antoni A areas with Verocay body formation. Five of six patients (83.3%) underwent complete tumor removal by rigid bronchoscopy.

CONCLUSIONS

Pathologists should consider endobronchial schwannoma in the differential diagnosis of a spindle cell tumor involving the bronchus. Additionally, our results showed that rigid bronchoscopy is an effective tool for tumor removal in endobronchial schwannoma patients.

Small cell lung cancer with endobronchial growth: A case report

The current study presents a rare case of small cell lung cancer (SCLC) with endobronchial growth in a 68-year-old male. Chest CT scans revealed an ill-defined mass in the upper lobe of the right lung, with ipsilateral mediastinial lymph node swelling. An endobronchial polypoid tumor in the right B3 bronchus was located by bronchoscopic examination. The analysis of a biopsy specimen obtained from the tumor resulted in a diagnosis of SCLC. Although extremely rare, this case highlights the importance of considering a diagnosis of SCLC in patients presenting with a pulmonary tumor adjacent to the bronchus, with an endobronchial polypoid lesion.

Successful surgical resection of leiomyoma obstructing the trachea

We report a case of 51-year-old woman with a severely airway-obstructing leiomyoma who underwent successful tracheal resection. A preoperative tumor biopsy was avoided not to cause any risk of suffocation. At surgery, an endotracheal intubation distal to the tumor was achieved with a bronchoscopic guidance. A segmental resection of the trachea with a primary end-to-end anastomosis was performed via a half-splitting median sternotomy. Negative surgical margins for tumor were confirmed intraoperatively. Final pathological diagnosis was a primary tracheal leiomyoma. Definitive surgical resection is a treatment of choice for such airway-obstructing, wide-based leiomyoma. Although a bronchoscopic removal of the tumor is an alternative choice, the risks of suffocation, positive surgical margins, and perforation of the trachea need to be carefully discussed if it is considered.

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.

Tumors in the tracheobronchial tree: CT and FDG PET features

A variety of tumors, including primary malignant tumors, secondary malignant tumors, and benign tumors, can occur in the tracheobronchial tree. Primary malignant tumors commonly originate from the surface epithelium or the salivary glands, whereas most benign tumors arise from the mesenchymal tissue. At computed tomography (CT), primary malignant tumors manifest as a polypoid lesion, a focal sessile lesion, eccentric narrowing of the airway lumen, or circumferential wall thickening. At fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET), most squamous cell carcinomas show high uptake, whereas adenoid cystic carcinoma and mucoepidermoid carcinoma show variable uptake depending on the grade of differentiation. High-grade malignancies tend to show high and homogeneous uptake. Carcinoid tumors commonly show intense enhancement at contrast material-enhanced CT, which can be helpful in making the diagnosis, and usually have lower uptake at FDG PET than would be expected for a malignant tumor. Secondary malignant tumors occur as a result of either hematogenous metastasis or direct invasion by a malignancy from an adjacent structure. Their CT manifestations are similar to those of primary malignant tumors, with uptake at FDG PET depending primarily on the metabolic activity and degree of differentiation of the primary tumor. Among the benign tumors, hamartoma and lipoma can show characteristic CT findings such as "popcorn" calcification or internal fat. However, CT findings in most benign tumors are nonspecific. At FDG PET, benign tumors usually show little or no uptake and can be differentiated from malignant tumors. Knowledge of the characteristic CT and FDG PET findings of tracheobronchial tumors can aid in diagnosis and treatment planning.

Clinical characteristics and efficacy of bronchoscopic intervention for tracheobronchial leiomyoma

BACKGROUND AND OBJECTIVE

This study reports the clinical characteristics, efficacy and safety of bronchoscopic treatment of patients with tracheobronchial leiomyoma.

METHODS

A retrospective study of 10 patients with tracheobronchial leiomyoma who underwent bronchoscopic intervention between 2000 and 2007 at a single centre, documenting the clinical characteristics, treatment method and outcomes.

RESULTS

Seven men and three women were studied. The median age at diagnosis was 47 years (range 17-66). The most frequent symptoms were cough (n = 5) and dyspnoea (n = 4). The lesions were in the trachea in two patients, the right bronchi in six, and the left bronchi in two. On chest CT, the most frequent findings were a tracheobronchial mass without parenchymal lesion (n = 7). The tumours were removed by neodymium-yttrium-aluminum-garnet laser treatment by rigid bronchoscopy under general anaesthesia (n = 9) and with flexible bronchoscopy under local (n = 1) anaesthesia. Two patients eventually underwent surgical resection because of late tumour recurrence at 16 months, after the bronchoscopic intervention, in one patient, and incomplete removal by bronchoscopic intervention in another patient. In eight of ten patients who were successfully treated by the bronchoscopic intervention, the clinical outcome was good during the median follow-up period of 24.5 months. There were no procedure-related mortalities or late complications.

CONCLUSIONS

Patients with a tracheobronchial leiomyoma usually present with non-specific respiratory symptoms and an endobronchial mass without parenchymal lesions. Bronchoscopic intervention is a safe and effective technique for the treatment of patients with a tracheobronchial leiomyoma.

[Endobronchial lipoma: imaging findings. A case report]

Endobronchial lipoma is a rare benign bronchial tumour. A search should be carried out on submillimetre MDCT scan slices in patients presenting segmental or lobar collapse or recurrent pulmonary infection in the same bronchial territories. The authors report MDCT and MR imaging in a patient with endobronchial lipoma discovered on an MDCT scan.

Airway Leiomyoma: Imaging Findings and Histopathologic Comparisons in 13 Patients

OBJECTIVE

The aim of our study was to review retrospectively the imaging findings on tracheobronchial leiomyoma and to compare them with the pathologic findings.

CONCLUSION

Leiomyoma of the respiratory tract is located in the bronchi in two thirds of patients and in the trachea in one third. The tumor most commonly manifests on CT scans as a homogeneously enhancing airway tumor with intraluminal growth. In approximately 15% of patients, the tumor has an iceberg appearance.

Benign Tumors of the Tracheobronchial Tree: CT-Pathologic Correlation

OBJECTIVE

The purpose of this essay is to illustrate the CT findings of variable benign tumors of the tracheobronchial tree and to correlate the CT and pathologic findings in 17 patients.

CONCLUSION

The tracheal tumors were eccentric, well-defined, polypoid masses in all cases. The endobronchial tumors were masses confined within the bronchus in all cases, and atelectasis or pneumonia of the distal parenchyma was frequently associated. Of the six hamartomas, one was a fatty mass, and two were nodules with calcification. The others were soft-tissue-density nodules. The lipomas manifested as fat density on CT scans in both cases. The other benign tumors were low-attenuating, soft-tissue-density masses without characteristic findings on CT scans.

Pathological-radiological correlations: pathological and radiological correlation of endobronchial neoplasms: part II, malignant tumors

The majority of lung neoplasms are malignant. Many of these are central and have an associated endobronchial component. Most such neoplasms are of surface epithelial origin; however, neoplasms of submucosal gland, mesenchymal, and lymphoreticular origin may also demonstrate an endobronchial component. Because of their endobronchial location and associated symptoms, these patients often present at an earlier stage than purely parenchymal lung malignancies. The radiographic features in such cases may be similar to those associated with benign endobronchial tumors; however, there are certain radiological signs that are more suggestive of a malignant process. Despite these circumstances, conservative management such as endoscopic excision are inappropriate in most instances. The clinicopathologic and radiological features of these lesions are detailed.