Benign Tumors of the Tracheobronchial Tree: CT-Pathologic Correlation

A Rare Case of Tracheal Lipoma in Puerto Rico: Presentation and Management of a Patient With Longstanding Respiratory Complaints

Tracheal lipomas, though exceedingly rare among benign tracheal masses, present unique diagnostic and management challenges due to their unusual clinical course. This case report documents the presentation and surgical management of a 56-year-old male with a tracheal lipoma, a first documented case in Puerto Rico. The patient presented with progressive dyspnea and stridor, initially misdiagnosed and treated as asthma exacerbations. Imaging confirmed a pedunculated tracheal mass, prompting emergency surgical intervention to secure the airway and excise the mass successfully. Histopathological analysis confirmed the mass as a benign tracheal lipoma. This case emphasizes the importance of considering rare tracheal tumors in the differential diagnosis of unexplained respiratory distress and advocates for tailored management strategies informed by comprehensive multidisciplinary approaches.

Imaging of Large Airway Disorders

Large airway disorders encompass a large variety of diseases and pathology, with broad categories including anatomic variants, congenital abnormalities, acquired abnormalities, inflammatory/infiltrative causes, infection, and tumors. The most common diseases in each category are discussed with a focus on the salient imaging findings. Pitfalls to beware of are discussed through the article, and concludes with a general method to approaching large airways pathology that should provide the reader with a basic framework and understanding of this complex topic.

Tracheal hamartoma masquerading as asthma

We present a rare case of a female non-smoker diagnosed with a large benign tracheal chondrohamartoma, masquerading as severe asthma. The patient was in her late 70s and had a history of asthma. She had presented to hospital with multiple episodes of intractable cough, shortness of breath and wheeze in the year prior to diagnosis. She had been managed for asthma for two decades by different physicians in primary care, based on documented airflow obstruction. Given her repeated admissions, the respiratory team was consulted. In view of the persistent cough despite maximal treatment, she was referred for a thoracic high-resolution CT scan which revealed a large intraluminal tracheal polypoid mass. Flexible bronchoscopy was performed and this confirmed the presence of a large pedunculated mass in the distal trachea. The patient subsequently underwent removal of the mass by means of rigid bronchoscopy, laser and electrocautery followed by argon ablation of residual tissue. She made an excellent recovery with full resolution of her respiratory symptoms and normalisation of her pulmonary function tests.

Utility of Virtual Bronchoscopy in Tracheal Tumors

Tracheal tumors are rare neoplasms, most of which are malignant. Conventional bronchoscopy (CB) and biopsy are used in the primary evaluation of these tumors, while Contrast-Enhanced Computed Tomography (CECT) is usually used for assessing extraluminal extension and nodal spread. Virtual bronchoscopy, created by postprocessing the three-dimensional volume data acquired from CECT, attempts to recreate the endoluminal features as seen in CB. The complexity of tracheal surgery necessitates accurate preoperative localization of the lesion and planning. It can assist in evaluation of patients in whom CB cannot be performed and for airway assessment in a preoperative setting. Although it cannot replace CB, it can be resorted to, in specific clinical scenarios. In this pictorial essay, we aim to highlight the technique, role, and clinical utility of Virtual Bronchoscopy (VB) in tracheal tumors.

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.

Tracheal leiomyoma imitating refractory asthma: A case report

INTRODUCTION AND IMPORTANCE

Tracheal leiomyoma is an extremely rare benign tumor. It mostly presents in the third decade of life and mostly affects men. Herein, we describe a patient with tracheal leiomyoma which was treated as asthma for 2 years before definite diagnosis.

CASE PRESENTATION

A 41-year-old female with a history of asthma was referred due to dyspnea and refractory cough. On bronchoscopic examination, a tumoral lesion was found in the distal trachea with near total obstruction and histopathologic examination of the bronchoscopic biopsy was inconclusive. The tumor was surgically resected. On the follow-up bronchoscopic examination, the trachea was normal and symptoms were relieved. Histopathologic results were compatible with Leiomyoma.

CLINICAL DISCUSSION

Airway leiomyoma is commonly misdiagnosed as asthma or bronchitis long before a definitive diagnosis. Fiberoptic bronchoscopy is the modality of choice for direct visualization of intraluminal lesions and tissue sampling. Surgical resection is the gold standard approach. The best surgical approach is not clearly determined to date and both endoscopic procedures and surgical resection have been utilized for treatment in case reports.

CONCLUSION

Usually there is a long interval between onset of clinical symptoms and a definite diagnosis. In the case of refractory signs and symptoms to medical treatment, alternative diagnosis should always be considered.

Differential diagnostic value of 18F-FDG PET/CT in pulmonary carcinoids versus hamartomas

RATIONALE AND OBJECTIVE

To assess the possibility of differentiating pulmonary carcinoids from hamartomas and typical from atypical carcinoids by means of ¹⁸F-FDG PET/CT.

MATERIALS AND METHODS

We retrospectively reviewed 139 patients with pathologically proven pulmonary carcinoids and hamartomas who underwent ¹⁸F-FDG PET/CT before surgical resection. Receiver operating characteristics curves were calculated to determine the potential of SUVmax to discriminate between pulmonary carcinoids and hamartomas, typical and atypical carcinoids. The correlation between SUVmax and tumor size was analyzed by Spearman correlation analysis.

RESULTS

SUVmax was significantly higher in pulmonary carcinoids than in hamartomas (p<0.001), and also higher in atypical carcinoids than in typical carcinoids (p = 0.034). With a SUVmax of 2.0 as a cutoff, the sensitivity, specificity, positive predictive value, and negative predictive value for ¹⁸F-FDG PET/CT to differentiate pulmonary carcinoids from hamartomas were 85.3%, 82.9%, 61.7%, and 94.6%, respectively. The cutoff value of SUVmax for differentiating atypical carcinoids from typical carcinoids was 4.1. The area under the receiver operating characteristics curve of SUVmax was 0.900 for carcinoids and hamartomas, and 0.722 for typical and atypical carcinoids. SUVmax was correlated with maximum tumor size in pulmonary carcinoids (r = 0.658, p <0.001) and in pulmonary hamartomas (r = 0.672, p <0.001).

CONCLUSION

¹⁸F-FDG PET/CT might be a useful tool in the differential diagnosis of carcinoids and hamartomas, and can also distinguish atypical from typical carcinoids. This may facilitate improved selection of patients for surgical resection and radiological follow-up.

[Tracheal lipoma: An exceptional cause of tracheal tumors]

INTRODUCTION

Tracheal tumors are rare, they are most often malignant and can manifest themselves by a non-specific respiratory symptomatology with progressively increasing dyspnea orienting in the first place towards a COPD or even an asthma. Among them, tracheal lipoma is exceptional. Its management is based on removal by rigid bronchoscopy.

OBSERVATION

We report the case of a 73-year-old male patient who presented with non-specific dyspnea that progressively worsened over several months. The EFR showed a flattening of the flow-volume curves, the CT scan showed an anterolateral oval tracheal tumor with fatty density, the bronchial endoscopy showed a tumor lesion with stenosis of about 90% of the airway. Management consisted of a rigid bronchoscopy to delete obtruction with biopsies. Anatomopathology concluded to a tracheal lipoma.

CONCLUSION

Progressively worsening dyspnea, especially if there are signs of inspiratory dyspnea, required a systematic bronchial endoscopy to avoid the possibility of a tracheal tumor.

Does 68Ga-DOTA-NOC-PET/CT impact staging and therapeutic decision making in pulmonary carcinoid tumors?

OBJECTIVE

Purpose of this study was to assess the utility of Ga-DOTA-NOC-PET/computed tomography (CT) (Ga-NOC-PET) in tumor detection, pathological differentiation and baseline staging of pulmonary carcinoids as well as to study its impact on therapeutic decision making.

PATIENTS AND METHODS

Patients who underwent a Ga-NOC-PET for initial evaluation of bronchopulmonary carcinoid tumors from August 2014 to December 2019 were included. Detection rate of Ga-NOC-PET for the primary lesion was calculated by visual estimation of tracer uptake as per Krenning score. SUVmax of typical and atypical carcinoid tumors was measured and difference compared using nonparametric statistical tests. Proportion of patients with distant metastases was also calculated and its impact on intended treatment was assessed.

RESULTS

Imaging, histopathology and treatment details of 119 patients were available for analysis. Majority of tumors had an endobronchial location (74.7%) and showed histopathologic features of typical carcinoid (82.3%). Ga-NOC-PET showed a detection rate/sensitivity of 92.4%. Oncocytic variant on histopathology and smaller tumor size accounted for majority of negative results. Typical carcinoids showed significantly higher SUVmax than atypical tumors (median SUVmax 38.4 vs. 15.7, P = 0.002). Metastases to distant sites outside the thorax were seen in 14 patients (11.7%), primarily in liver and bones changing the intent of treatment from surgery to systemic therapy.

CONCLUSION

Ga-NOC-PET detects asymptomatic distant metastatic disease in a sizeable number of patients (11.7%) with pulmonary carcinoid and thus contribute to clinical management by precluding futile surgeries. It shows a high sensitivity for tumor detection and can help differentiate between typical and atypical carcinoid variants by virtue of their variable tracer uptake. PET/CT using Ga-labeled DOTA peptides should be an integral part of diagnostic workup of patients with lung carcinoid.

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.

CT Findings of Central Airway Lesions Causing Airway Stenosis-Visualization and Quantification: A Pictorial Essay

The tracheobronchial tree is a system of airways that allows the passage of air to aerate the lungs and entire body. Several pathological conditions can affect this anatomical region. Multidetector CT (MDCT) helps identify and characterize various large airway diseases. Post-processing tools, such as virtual bronchoscopy and automatic lung analysis, can help enhance the performance of imaging studies. In this pictorial essay review, we provide imaging findings of various bronchial lesions manifested as wall thickening and endoluminal nodules on conventional MDCT and advanced image visualization and analysis.

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.

A Rare Case of Endobronchial Metastasis in a Case of Carcinoma Tongue

Cancer of the tongue and other parts of the oral cavity are a leading cause of death in the worldwide population. The common sites of metastasis from oral cavity cancers are lung and bone. Endobronchial metastasis of an extra-thoracic malignancy is a rare phenomenon and such metastases from a malignancy of the tongue are almost unheard of. We present a case of carcinoma oral cavity with subsite tongue that after radical therapy of local site had an unusual site of distant metastasis in the right main bronchus, along with metastases to the lung parenchyma and right third rib.

Intraluminal tracheal lipoma as a rare cause of dyspnoea in a dog

Background

Tracheal tumors are rarely diagnosed in veterinary medicine and the majority of tracheal neoplasia reported in adult dogs are malignant. Intratracheal lipoma has not been previously reported in the veterinary literature.

Case presentation

A 7-year-old Briard dog was evaluated for inspiratory dyspnoea and an inspiratory wheeze. Cervical radiographs and tracheoscopic examination revealed an intratracheal mass that was surgically removed. The dog has been asymptomatic after the surgery.

Conclusions

Based on histopathology, the mass was diagnosed as lipoma. To the authors‘ knowledge, this is the first published report of an intratracheal lipoma in the veterinary literature.

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.

18F-FDG PET/CT Diagnosis of Bronchopulmonary Carcinoids Versus Pulmonary Hamartomas

PURPOSE

Radiological characterization of pulmonary tumors may be difficult and invasive. Needle biopsy may produce false-negative results. 18F-FDG PET/CT is an established noninvasive procedure for lung tumor characterization and staging. This study was aimed at differentiating bronchopulmonary carcinoids from hamartomas and typical from atypical bronchopulmonary carcinoids by means of 18F-FDG PET/CT.

PATIENTS AND METHODS

In a retrospective analysis of 118 patients, with surgically resected pulmonary carcinoid tumors and hamartomas, 87 of those selected had also undergone 18F-FDG PET/CT preoperatively and constituted the study population. To better assess the tracer accumulation, especially in small lesions, the 18F-FDG uptake (SUV) in the tumors was corrected for partial volume effect by applying recovery coefficients corresponding to the respective various specific tumor volumes, as extrapolated from those obtained from experiments in a NEMA phantom.

RESULTS

The SUVmax was higher in the pulmonary carcinoids (mean, 3.9) than in the hamartomas (mean, 1.4; P ≤ 0.00001) and higher in the subgroup of peripheral carcinoids than in hamartomas (P ≤ 0.00001). The SUVmax was similar for the atypical and typical carcinoids, 5.0 and 3.8, respectively, because of the large variation in the data (P = 0.11).

CONCLUSIONS

Using PET measurements of the 18F-FDG uptake (SUVmax) in the tumors, corrected for partial volume effects, it was possible to differentiate the carcinoids from the hamartomas, but the clinically more aggressive atypical carcinoids could not be differentiated from the typical carcinoids.

Rigid bronchoscopic management of acute respiratory failure in a 30-year-old woman

A 30-year-old woman presented with a history of progressive shortness of breath, cough, and hoarseness. Stridor was audible on examination. Chest X-ray showed normal lung fields and contrast-enhanced computed tomography thorax showed lower tracheal occlusion with endoluminal growth. Diagnostic flexible bronchoscopy demonstrated multiple whitish glistening nodules over both vocal cords and lower tracheal occlusion by whitish nodular growth. In view of critical central airway obstruction, rigid bronchoscopy and excision of the lower tracheal growth were performed. Histopathological examination of the excised specimen demonstrated features of squamous papillomas. A diagnosis of respiratory papillomatosis was established. On follow-up surveillance bronchoscopy, there was a gradual spontaneous regression of the residual lesions, and the patient remains currently asymptomatic 1 year since the procedure.

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.

Young man with dyspnoea for 6 months; presenting with subacute tracheal obstruction due to leiomyoma

Tracheal leiomyoma is a rare benign tumour with less than a 100 cases reported in the literature. We report a case of leiomyoma initially presenting and being treated as asthma until it lead to life-threatening tracheal obstruction, requiring immediate surgical intervention.

Delayed diagnosis of endobronchial mucoepidermoid carcinoma in a 29-year-old male

Mucoepidermoid carcinoma (MEC) is an uncommon primary lung tumor. It usually involves large airways and presents clinically and radiologically with nonspecific features. Because of nonspecific presentation diagnosis is frequently delayed. We report the case of a 29-year-old male patient wherein a clinico-radiological consideration of tuberculosis (TB) led to a prolonged treatment with anti-TB medications without response. Flexible bronchoscopic biopsy confirmed the diagnosis of MEC following that the patient underwent curative surgical resection.

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.

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.

Endoscopic treatment of primary benign central airway tumors: Results from a large consecutive case series and decision making flow chart to address bronchoscopic excision

BACKGROUND

Benign tracheo-bronchial neoplasms are rare, but potentially dangerous conditions with life threatening consequences. Tumor removal should be pursued by methods minimizing the procedural stress. The role of endoscopic treatment, as an alternative to open surgery, remains controversial.

OBJECTIVES

report the twelve-years endoscopic experience in Rome, Italy. Fifty-seven benign tracheo-bronchial tumors were diagnosed and 130 tracheo-bronchial resections by rigid bronchoscopy performed.

METHODS

we identified histotypes associated with higher recurrence rate and assessed their relationship with gender, age and tracheo-bronchial location. We provided data on safety and complications and suggested a decision making flow chart to address the patients to endoscopic resection.

RESULTS

complete eradication after a single procedure without recurrence at 2 years was obtained in 63.1% of cases (36/57). Need of a second intervention within few months but no further recurrence at follow up was seen in a further 8.8% (5/57). Histotypes associated with recurrence were papillomas and inflammatory polyp. Seven patients (12.3%) were addressed to surgery because of multiple recurrence. Ten patients (17.5%) were lost at follow up. In case of recurrence, the bronchial biopsy was always repeated and no malignant transformation was observed. No major complications, pneumothorax or pneumomediastinum occurred.

CONCLUSIONS

endoscopic treatment of benign tracheo bronchial tumors is safe and effective, provided that the procedure is carefully and systematically planned. The rate of eradication is satisfactory and the incidence of complications negligible. This will encourage this approach as first line treatment especially in patients, frequently elderly people, having increased surgical risk due to concomitant respiratory failure or major comorbidities.

Two cases of glomus tumor arising in large airway: well organized radiologic, macroscopic and microscopic findings

Glomus tumors of the lung are rare benign neoplasm, originating from modified smooth muscle cells. The patients are usually presented with no or non-specific symptoms such as cough, dyspnea or hemoptysis. Although surgical treatment is considered as the treatment of choice, the endobronchial therapy can be applied to the patients who are unfit for surgical excision. Herein, we describe two rare cases of glomus tumor originated at large airway (trachea and main bronchus) without respiratory symptoms and review their characteristic radiologic, macroscopic and pathological features.

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.

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).

Is 68Ga-DOTATATE the answer in lung carcinoid? : Case report and review of literature

Carcinoid tumors are rich in somatostatin receptors and show high uptake of radiotracer on octreotide scintigraphy. 68Ga-DOTATATE could be of great help at initial staging and during follow-up of these patients. We describe a patient with avid 68Ga-DOTATATE and poor F18-FDG uptake.

Endobronchial schwannoma treated by rigid bronchoscopy with argon plasma coagulation

Primary endobronchial schwannomas are extremely rare tumors that originate from Schwann cells. We report a case of primary endobronchial schwannoma. A 44-year-old woman, without respiratory symptoms, was presented with a nodule in the left main bronchus on her chest computed tomography scan. The nodule was removed by a rigid bronchoscopy with argon plasma coagulation. Biopsy confirmed the diagnosis of schwannoma. There was no recurrence during her 4-month follow-up.

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

Role of (68)Ga-DOTATOC PET/CT in the evaluation of primary pulmonary carcinoids

BACKGROUND/AIMS

Although carcinoid tumors usually have good prognosis, early and specific diagnosis is important. Computed tomography and magnetic resonance imaging do not provide findings that are specific for carcinoids, and somatostatin receptor scintigraphy suffers from low spatial resolution. 18-Fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) has limited sensitivity for carcinoids due to low uptake of the marker. A PET/CT system that uses the somatostatin receptor-based PET tracer 1,4,7,10-tetraazacyclododecane-N(I),N(II),N(III),N(IIII)-tetraacetic acid (D)-Phe(1)-thy(3)-octreotide ((68)Ga-DOTATOC) has also been used in the evaluation of carcinoids, although information regarding its use for the detection of primary pulmonary carcinoids is limited. Thus, we investigated the value of (68)Ga-DOTATOC PET/CT for the diagnosis of primary pulmonary carcinoid tumors.

METHODS

This was a retrospective analysis of patients with primary pulmonary tumors who underwent (68)Ga-DOTATOC PET/CT. All the patients had a histopathologic diagnosis of carcinoid. The rate of detection of primary pulmonary carcinoid tumors using (68)Ga-DOTATOC PET/CT was assessed.

RESULTS

Twenty patients were diagnosed as having carcinoid, and 19 tumors showed significant uptake on (68)Ga-DOTATOC (detection rate, 95%). The maximal standardized uptake value (SUV(max)) ranged from 1.1 to 66, with a median value of 21.6. In one patient, (68)Ga-DOTATOC PET/CT revealed additional lesions.

CONCLUSIONS

Our results demonstrate that (68)Ga-DOTATOC PET/CT is useful in the evaluation of primary pulmonary carcinoids and should be included in the diagnostic work-up of these patients.

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.

Update on multidetector computed tomography imaging of the airways

Recent advances in multidetector computed tomography (MDCT) technology have transformed the imaging evaluation of the trachea and bronchi. Multiplanar 2-dimensional and 3-dimensional volume reconstruction techniques, including external rendering and virtual bronchoscopy, can be generated in mere minutes, thereby complementing conventional axial CT imaging in the depiction of various central airway disease processes including airway stenoses, central airway neoplasms, and congenital airway disorders. Paired inspiratory and dynamic expiratory MDCT imaging, along with newer cine CT imaging methods, have enhanced the assessment of tracheobronchomalacia in both adults and the pediatric population. In addition, MDCT imaging plays an essential complementary role to conventional bronchoscopy, facilitating planning and guidance of bronchoscopic interventions, and providing a noninvasive method for postprocedural surveillance.

Imaging of tumors of the trachea and central bronchi

Tumors of the trachea and central bronchi can be benign or malignant. Clinical presentation may be confusing, particularly in benign tumors that can be misdiagnosed as asthma or chronic bronchitis. Chest radiography has many limitations and is often considered unremarkable in patients with tumors of the central airways; therefore, multidetector CT (MDCT) has become the most useful noninvasive method for diagnosing and assessing the central airways. The purpose of this article is to provide a review of imaging of the tumors of the trachea and central bronchi. We emphasize the crucial role of MDCT and postprocessing techniques in assessing neoplasms of the central airways.

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.

Imaging of tumors of the trachea and central bronchi

Tumors of the trachea and central bronchi can be benign or malignant. Clinical presentation may be confusing, particularly in benign tumors that can be misdiagnosed as asthma or chronic bronchitis. Chest radiography has many limitations and is often considered unremarkable in patients with tumors of the central airways; therefore, multidetector CT (MDCT) has become the most useful noninvasive method for diagnosing and assessing the central airways. The purpose of this article is to provide a review of imaging of the tumors of the trachea and central bronchi. We emphasize the crucial role of MDCT and postprocessing techniques in assessing neoplasms of the central airways.

A case of endobronchial lipoma mimicking bronchial asthma

Endobronchial lipoma is a rare neoplasm of the tracheobronchial tree and it may cause irreversible pulmonary damage due to recurrent pneumonia. Rarely, it may mimic bronchial asthma. We present a 53-year-old woman with an endobronchial lipoma, which had been treated as a bronchial asthma for four years. She also had developed recurrent pneumonia three times.

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.

[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.