Airway Leiomyoma: Imaging Findings and Histopathologic Comparisons in 13 Patients

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.

A hint for abnormal thoracic shadow: look behind the heart

Can you diagnose this woman with a history of uterine fibroids in the previous year and a recent finding of intrathoracic mass on chest radiography? https://bit.ly/44mQ9Jj.

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.

Pulmonary leiomyoma with iceberg tumor growth pattern: A case report

Pulmonary leiomyoma is a rare disease, accounting for ~2% of cases of benign lung tumors. Pulmonary leiomyomas can be classified as tracheobronchial or pulmonary parenchymal, or as having an iceberg growth pattern, wherein the tumor extends into both the bronchial and pulmonary cavities. In the present report, a 41-year-old man complaining of sputum and discomfort during swallowing was referred to the National Center for Global Health and Medicine, because of an abnormal shadow on chest radiography and computed tomography (CT). Since the follow-up CT showed that the tumor in the third right lung segment had increased and progressed along the intra-bronchus over time, thoracoscopic right upper lobectomy was performed and leiomyoma was pathologically diagnosed. After resection, the symptoms of airway irritation improved. Since respiratory symptoms and radiographical findings are nonspecific with tracheobronchial and pulmonary parenchymal types of pulmonary leiomyoma, the identification of symptoms and determination of the extent of the lesion are necessary for treatment. In cases of iceberg growth pattern, in which the tumor extends into both the bronchial and pulmonary cavities, surgical resection should be considered.

Endobronchial Leiomyoma: A case report with cryoprobe extraction and review of literature

Large airway tumors are uncommon, accounting for about 0.6% of all pulmonary tumors [[1], [2], [3]]. The majority of these tumors (80–90%) are malignant, represented primarily by squamous cell carcinoma and adenoid cystic carcinoma [2,4]. Benign central airway tumors are less common and are generally comprised of hamartomas and papillomas. Tracheobronchial leiomyomas are exceedingly rare, representing only about 0.6% of all benign lung neoplasms [3]. We report here on a case of primary endobronchial leiomyoma without uterine involvement treated successfully with cryoresection with excellent outcome.

Smooth Muscle Conditions of the Chest: A Clinical, Radiologic, and Pathologic Review

Smooth muscle conditions of the chest have diverse clinical and imaging manifestations and may involve nearly every thoracic structure. Differentiation among these conditions requires the integration of clinical, radiologic, and histopathologic data. Histologic examination in conjunction with immunohistochemistry is essential for differentiation from other spindle cell neoplastic mimics. Familiarity with these entities will ensure the inclusion of smooth muscle conditions in the differential diagnosis of thoracic soft tissue lesions and potentially guide the clinician in appropriate management. We review the clinical, imaging, and histopathologic features of thoracic smooth muscle-related conditions organized by the anatomic structures affected.

Leiomioma pulmonar primario

El leiomioma primario de pulmón es un tumor benigno raro, de origen mesodérmico, que representa aproximadamente el 2 % de todos los tumores benignos de pulmón. Desde que fue descrito por primera vez por Forkel en 1910, se han reportado al menos 150 casos en la literatura. Se hace una revisión del tema a propósito del caso de una mujer posmenopáusica oligosintomática, con hallazgo de una lesión pulmonar sólida, asociada a una malformación vascular, en quien la biopsia inicial reportó un tumor fusocelular, por lo que fue llevada a lobectomía superior del pulmón derecho y cuyo diagnóstico patológico definitivo fue leiomioma pulmonar primario. Este caso se presenta por su baja incidencia y la poca literatura sobre este tipo de lesiones tumorales benignas.

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.

A Rare Case of Tracheal Leiomyoma: Role of Digital Tomosynthesis in Diagnosis and Treatment

Tracheal leiomyoma is a rare benign tumor, which is composed of transformed cells of mesenchymal origin. We describe a case in which digital tomosynthesis was useful to evaluate a tracheal tumor that was overlooked on initial chest radiographs.

Endobronchial Smooth Muscle Tumors: A Series of Five Cases Highlighting Pitfalls in Diagnosis

Background

Primary endobronchial smooth muscle tumors (SMTs), which are extremely rare, include endobronchial leiomyomas and leiomyosarcomas. Clinically, SMTs present with signs and symptoms of bronchial obstruction, and lack specific radiological findings. Thus, histopathological examination is required for accurate diagnosis as well as for tumor grading. We examined the histomorphological and immunohistochemical features of endobronchial SMTs and highlighted pitfalls in diagnosis, particularly when using small biopsies.

Methods

Cases of primary endobronchial SMTs diagnosed at our Institute over the last 6 years (2012–2017) were retrieved from the departmental archives. Histopathological features and immunohistochemistry performed for establishing the diagnosis were reviewed.

Results

Five cases of SMTs occurring in endobronchial locations were identified. These included three cases of leiomyoma, and two cases of leiomyosarcoma. The age distribution of patients ranged from 13 to 65 years. Leiomyomas showed more consistent staining with smooth muscle markers (smooth muscle actin, desmin, and smooth muscle myosin heavy chain), while tumors of higher grade showed variable, focal staining, leading to erroneous diagnosis, especially on small biopsies.

Conclusions

The diagnosis of endobronchial SMTs relies on histopathological examination, for both confirmation of smooth muscle lineage and determination of the malignant potential of the lesion. Appropriate immunohistochemical panels including more than one marker of smooth muscle differentiation are extremely valuable for differential diagnosis from morphological mimics, which is necessary for instituting appropriate management.

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.

Tracheal leiomyoma resected with endobronchial electrocautery snare

Tracheobronchial leiomyoma is a rare benign tumor, which comprises about 2% of benign tumors of the lower respiratory tract. Bronchoscopic intervention is a minimally invasive treatment, but incomplete resection or recurrence has been reported. We report a case of a 76-year-old woman with a tracheal tumor of 14 mm in diameter incidentally detected on chest computed tomography. Bronchoscopic examination revealed a smooth polypoid tumor which pedunculated from the left side of the cartilaginous tracheal wall. An endobronchial electrocautery snare with flexible bronchoscope was successfully used under general anesthesia and with intubation. The resected specimen was pathologically consistent with leiomyoma. Bronchoscopic intervention can yield successful treatment of pedunculated tracheobronchial leiomyomas, although surgical resection should also be considered in cases of broad-based or iceberg-type leiomyomas because of the risk of incomplete resection or recurrence.

Diagnostic Value of Multidetector CT and Its Multiplanar Reformation, Volume Rendering and Virtual Bronchoscopy Postprocessing Techniques for Primary Trachea and Main Bronchus Tumors

Purpose

To evaluate the diagnostic value of multidetector CT (MDCT) and its multiplanar reformation (MPR), volume rendering (VR) and virtual bronchoscopy (VB) postprocessing techniques for primary trachea and main bronchus tumors.

Methods

Detection results of 31 primary trachea and main bronchus tumors with MDCT and its MPR, VR and VB postprocessing techniques, were analyzed retrospectively with regard to tumor locations, tumor morphologies, extramural invasions of tumors, longitudinal involvements of tumors, morphologies and extents of luminal stenoses, distances between main bronchus tumors and trachea carinae, and internal features of tumors. The detection results were compared with that of surgery and pathology.

Results

Detection results with MDCT and its MPR, VR and VB were consistent with that of surgery and pathology, included tumor locations (tracheae, n = 19; right main bronchi, n = 6; left main bronchi, n = 6), tumor morphologies (endoluminal nodes with narrow bases, n = 2; endoluminal nodes with wide bases, n = 13; both intraluminal and extraluminal masses, n = 16), extramural invasions of tumors (brokethrough only serous membrane, n = 1; 4.0 mm—56.0 mm, n = 14; no clear border with right atelectasis, n = 1), longitudinal involvements of tumors (3.0 mm, n = 1; 5.0 mm—68.0 mm, n = 29; whole right main bronchus wall and trachea carina, n = 1), morphologies of luminal stenoses (irregular, n = 26; circular, n = 3; eccentric, n = 1; conical, n = 1) and extents (mild, n = 5; moderate, n = 7; severe, n = 19), distances between main bronchus tumors and trachea carinae (16.0 mm, n = 1; invaded trachea carina, n = 1; >20.0 mm, n = 10), and internal features of tumors (fairly homogeneous densities with rather obvious enhancements, n = 26; homogeneous density with obvious enhancement, n = 1; homogeneous density without obvious enhancement, n = 1; not enough homogeneous density with obvious enhancement, n = 1; punctate calcification with obvious enhancement, n = 1; low density without obvious enhancement, n = 1).

Conclusion

MDCT and its MPR, VR and VB images have respective advantages and disadvantages. Their combination could complement to each other to accurately detect locations, natures (benignancy, malignancy or low malignancy), and quantities (extramural invasions, longitudinal involvements, extents of luminal stenoses, distances between main bronchus tumors and trachea carinae) of primary trachea and main bronchus tumors with crucial information for surgical treatment, are highly useful diagnostic methods for primary trachea and main bronchus tumors.

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

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

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.

Thoracic Castleman disease: computed tomography and clinical findings

AIM

The objective of this study was to evaluate the clinicoradiological findings of thoracic Castleman disease.

METHODS

The study included 34 patients (22 male and 12 female patients; mean age, 32 [SD, 18.1] years) with thoracic Castleman disease. Clinicoradiological findings of the 34 patients were analyzed. Regarding computed tomography findings, lesion number, location, degree of enhancement (moderate, >20 Hounsfield units than back muscle enhancement; high, >40 Hounsfield units), and associated findings were recorded.

RESULTS

Of 34 patients, hyaline-vascular type (HVT) was found in 27 patients (79%), plasma cell type (PCT) in 5 patients (15%), and mixed type (6%) in 2 patients. In HVTs (n = 27), lesions were found, in decreasing order, in the lower neck (n = 9, 33%), pulmonary hilum (n = 6, 22%), and the upper paratracheal area (n = 4, 15%). Ten (37%) of 27 HVT patients had symptoms, whereas all (100%) with PCT had generalized symptoms. In 26 (96%) of 27 HVT patients, disease was unicentric, whereas it was multicentric in all PCT patients. Moderate to high degree of lesion enhancement was seen in 22 (92%) of 24 HVT patients and 4 (80%) of 5 PCT patients. Feeding vessels or draining veins were identified in 12 (44%) of 27 HVT patients and 2 (40%) of 5 PCT patients. The diseases were cured with surgical removal in HVT, whereas they showed variable prognosis in PCT.

CONCLUSIONS

Irrespective of subtypes, Castleman disease is characterized radiologically by unicentric or multicentric enhancing lymph node enlargement; in HVT, they show good prognosis after surgical treatment, but in PCT, they show variable prognosis.

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

Bronchial leiomyoma in a chemical warfare victim-a causative agent or an incidental finding: A case report

INTRODUCTION

Bronchial leiomyoma is one of the rarest benign tumors of the lower respiratory system, compromising less than 2% of reported benign pulmonary tumors. Chemical warfare is a known cause of chronic pulmonary diseases in soldiers who survives of the chemical wars. Most of these patients are chronically under treatment by respiratory drugs and acute exacerbations of their symptoms prompt for investigations for diagnosis of a new complication in these patients.

PRESENTATION OF CASE

In this case report we present a 43 y/o male chemical warfare victim who was under treatment for his respiratory disease for near 20 years but at last bronchial leiomyoma was diagnosed as the cause of exacerbation of his symptoms. He was undergone right thoracotomy and sleeve resection of left main bronchus. Severe adhesions plus lymphadenitis in the mediastinum might be due to the effects of prior inflammatory process.

DISCUSSION

Because of rarity of this tumor, bronchial leiomyoma in this patient may be the result of previous exposure to nitrogen mustard but the exact relationship remained to be confirmed.

CONCLUSION

Although the association between chemical warfare and lung neoplasias has not been well understood, it is the first time that a bronchial leiomyoma is reported in a nitrogen mustard survivor.

Primary leiomyoma of the trachea, bronchus, and pulmonary parenchyma--a single-institutional experience

OBJECTIVE

Primary leiomyoma of the respiratory tract is a rare disease. Based on our experience, we investigated its clinical characteristics and outcomes of treatment.

METHODS

Between 1997 and 2008, 16 patients in our institution (nine male, seven female) were found to have primary leiomyoma of the respiratory tract. The median patient age was 46.5 years (range 17-66 years). The tumor was located in the trachea in four patients, in the carina and main bronchus in four, in the bronchus intermedius in four, in the lobar or segmental bronchus in two, and in the lung parenchyma in two.

RESULTS

Tumor removal through bronchoscopic intervention using Nd-YAG (neodymium-yttrium-aluminum-garnet) laser cauterization was attempted in 11 patients; it failed in two with wide-based tumors. Surgical resection was performed in seven patients. Operative procedures included tracheal resection and end-to-end anastomosis (n=3), lobectomy (n=3), and bilobectomy (n=1). There were no in-hospital mortalities. During a median follow-up duration of 43.2 months, one patient who underwent bronchoscopic removal had recurrence, for which segmental resection of the trachea and main bronchus with carinal reconstruction was performed.

CONCLUSIONS

Bronchoscopic intervention can offer successful control of primary leiomyoma of the main airway stem; however, in cases of a wide-based tumor, bronchoscopic intervention can result in incomplete resection or recurrence. Surgical complete resection can yield satisfactory outcomes in patients with primary leiomyoma occurring in the respiratory tract.

Video-assisted lobectomy for endobronchial leiomyoma

Endobronchial leiomyomas are rare tumours arising from the smooth muscle on the bronchial tree. We describe a patient with a six-month history of chest infections, who was treated surgically with a video-assisted thoracic surgery (VATS) lobectomy. The pathology revealed an endobronchial leiomyoma that coexisted with postobstructive pulmonary non-necrotising granulomas.

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.

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.

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.

Integrated PET/CT of salivary gland type carcinoma of the lung in 12 patients

OBJECTIVE

The purpose of our study was to show the integrated 18F-FDG PET/CT findings of salivary gland type carcinomas of the lung.

CONCLUSION

Salivary gland type carcinomas of the lung appear as airway tumors with variable CT morphologies and show different patterns and extents of FDG uptake on PET images according to their grades of differentiation.