Ann Thorac Surg 2005;80:2353-2356
© 2005 The Society of Thoracic Surgeons
Case report
A Giant Endobronchial Inflammatory Polyp
brahim Dinçer, MD
a
,
Adalet Demir, MD
a
,
*
,
Hasan Ak
n, MD
a
,
Huseyin Melek, MD
a
,
Sedat Altn, MD
b
a Department of Thoracic Surgery, Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Istanbul, Turkey
b Department of Chest Diseases, Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Istanbul, Turkey
Accepted for publication July 14, 2004.
* Address correspondence to Dr Demir, Yuzyil Mah. Ksla Cad. Yesil Zengibar Sitesi, A-3, Blok D:9 Bagcilar, Istanbul, Turkey (Email: dradalet{at}hotmail.com).
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Abstract
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Bronchial inflammatory polyps are defined as tumor-like lesions. They are usually related to chronic inflammatory processes in the adult. Because they may cause complications, they should be surgically removed. A 55-year-old male patient had been followed for recurrent pulmonary infections for 40 years. His main symptoms were orthopnea and hemoptysis upon admission to our hospital. A chest computerized tomography (CT) revealed bronchiectasis located at the right middle lobe and lower lobe and obstruction of the main bronchus at the level of carina. In bronchoscopy a mobile polypoid pinkish lesion protruding to the trachea was observed. We performed an inferior bilobectomy. The pathological examination revealed an endobronchial fibroepithelial polyp. The presence of a giant endobronchial polyp with chronic respiratory symptoms over an extended period of time and the rarity of information pertaining to these lesions in the literature provoked intrigue and constituted a worthy presentation.
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Introduction
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Although benign endobronchial polyps were described in 1930 by Patterson who termed them as "neoplasms" it is very rarely reported in the literature [1]. Inflammatory polyps in the respiratory system are defined as tumor-like non-neoplastic endobronchial lesions according to the last WHO classification which was published in 1999 [2].
Histopathologically this polyp is fibroinflammatory and is lined with respiratory epithelium with edematous stroma. The etiology remains unclear however it is believed to be related to the chronic inflammatory processes in adults [2–4]. Several chronic inflammatory etiologic factors such as foreign body aspiration, prolonged mechanical ventilation, asthma, chronic sinusitis, chronic smoke inhalation, and mycobacterial infections may potentially be the cause [1, 3, 4]. In patients diagnosed with benign endobronchial lesions, surgery is indicated for postobstructive complications distal to the bronchus as well as for the differential diagnosis of the lesion [5]. In the particular patient that we were attending to, the diagnosis and treatment of a giant endobronchial polyp that had been neglected for years therefore became a large endobronchial tumor that was causing serious obstructive symptoms and irreversible parenchymal changes.
A 55-year-old male patient had been followed for recurrent pulmonary infections for 40 years. The patient presented with a 6-month history of orthopnea, a 3-month history of hemoptysis, and right-sided back pain. He experienced his first pneumonia attack when he was 14 and an endobronchial lesion using bronchoscopy was first recognized at the age of 16. He refused to undergo an offered resectional surgery at that time. He experienced a hemoptysis attack at the age of 30. He also experienced attacks of recurrent infections and received medical treatment several times. Because of the worsening of his symptoms in the last 3 months, he was admitted to our clinic for diagnosis and treatment.
Respiratory sounds decreased at the right side. Other systemic examinations were unremarkable. The erythrocyte sedimentation rate was 65 mm/hour and the leukocyte count was 13.300 cells/µL. The forced vital capacity was 2.23 L (54% of predicted) and the forced expiratory volume in 1 second (FEV1) was 1.5 L (31% of predicted). The partial arterial oxygen pressure (PaO2
) was 55 mm Hg and the carbon dioxide pressure (PaCO2
) was 39.8 mm Hg when the patient was breathing room air. The peripheral blood oxygen saturation was 89%.
A posterolateral chest roentgenogram demonstrated marked deviation of the trachea to the right side of the thorax, marked volume loss in the right hemithorax, and nonhomogenous infiltrations in the right middle and lower zones. A chest computerized tomography (CT) revealed a localized endotracheal mass with a diameter of 25 mm starting from the level of carina in the right main bronchus and protruding into the trachea, nearly total obstruction of the main bronchus, atelectasis in the right middle lobe, and hyperaeration of the left upper lobe. It also indicated cystic bronchiectasis in the right lower and middle lobes (Fig 1A–C).
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Fig 1. Thorax computed tomograph (CT). (A) Computed axial tomographic cross-sections indicating an endobronchial mass nearly obliterating the right main bronchus and a loss of volume in the right lung. (B) Virtual bronchoscopy (coronal) indicating a mass obliterating the right main bronchus that was located from the trachea to the carina with distal atelectasis and changes caused by atelectasis. (C) Sagittal reformatted multislice CT image indicating cystic bronchiectasis in the right lower lobe with similar but less pronounced indications in the right middle lobe.
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Fiber-optic bronchoscopy (FOB) revealed a lobulated, pinkish, mobile polypoid lesion protruding from the trachea, which most likely originated from the lower lobe superior segment. The upper lobe bronchus and its segments were open, the mucosa was edematous and hyperemic, the middle lobe entrance was edematous and narrowed, the lower lobe basal segments were open, the mucosa was edematous, and the carina was widened. The FOB also indicated massive purulent secretion in the bronchial system. Biopsies from the lesion and lavage from the right main bronchus were taken. Examination of the biopsy and lavage samples indicated squamous metaplasia.
A virtual bronchoscopic examination rendered from thorax CT data was performed to evaluate the localization and distal border of the lesion. The vegetating lobulated mass lesion was observed to almost totally obstruct the right main bronchus proximal to the level of carina. Two-dimensional multiplanar reformation images indicated cystic bronchiectasis in the right lower lobe. To terminate the respiratory symptoms and provide a definitive diagnosis, we performed bronchotomy at the level of intermediate bronchus by right posterolateral thoracotomy. The anticipated endobronchial lesion originated from the middle lobe bronchus protruding into the trachea was a polypoid tumor measuring 10 cm in length. There was no invasion of the bronchial wall (Fig 2A). The polyp was removed from the intermediate bronchus. Right middle and lower lobes were observed as diffusely bronchiectatic and fibrotic. We performed a lower bilobectomy. There were no complications in the postoperative period. The postoperative pathologic examination revealed that the tumor was a 10 x 2 x 2 cm fibroepithelial polyp with focal stromal calcification (Figs 2, 3). There was also generalized fibrosis in the parenchyma, interstitial pneumonia, bronchiectasis, chronic bronchitis, and bronchiolitis of the middle and lower lobes. The patient has been in favorable health for 10 months.
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Fig 2. Polyp positioned in the medial subsegment of the middle lobe with a handle indicating a yellowish-white smooth bright surface.
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Fig 3. Polyp lined with respiratory epithelium that displays a lipofibrotamous stroma with focal calcification and mononuclear inflammatory cells (magnification = 10 x 10).
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Comment
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Inflammatory polyps are solitary benign endobronchial lesions with stromal configurations consisting of well-formed fibrous connective tissue with or without inflammatory cell infiltration. These polyps are covered with stratified squamous epithelium or normal bronchial mucosa [2, 6]. The silent nature of benign endobrochial lesions often leads to delayed diagnosis [1, 5]. Secondary diseases that develop because of localization of the intrabronchial lesion, such as chronic bronchitis and bronchiectasis, may produce clinical symptoms that mimic bronchial asthma, foreign body aspiration, thermal inhalational injury, smoke injury or inhalation, and chronic bronchial infection [1, 3, 5]. In addition endobronchial pathology should be sought for patients diagnosed with recurrent pulmonary infection. For this reason a bronchoscopy ought to be performed.
The etiology regarding this polyp still remains obscure, but it has been speculated that the polyp could be a reactive process to a foreign body. The right side was the locus of aspirated foreign bodies 56% of the time and the right lower lobe was a common location (28%) for a foreign body to become lodged in the airway [1]. Our patient had experienced chronic respiratory symptoms and bronchiectasis in the right middle and lower lobes since 14 years of age, although a history of foreign body aspiration was absent.
Benign lung tumors and tumor-like lesions may be localized endobronchially or can be observed in the pulmonary parenchyma. The most noteworthy complication is the risk of infectious complications that occur distal to the lesion in patients with endobronchial tumors. An additional problem is the difficulty in distinguishing this lesion from bronchogenic carcinoma [1, 5, 7]. Differential diagnosis in patients exhibiting an endobronchial lesion suggesting malignancy should be taken into consideration. Because of these reasons, all lesions, even if known to be benign, should be excised.
There are four possible management approaches that may be taken for a patient diagnosed with a benign inflammatory polyp. The first would be a simple observation. However to simply observe such a patient implies that the biopsy specimen was judged to be adequate by the pathologist and for the pathologist to state unequivocally that the polyp is benign and not of a more ominous process. The second approach may require a rigid bronchoscopy with biopsy using larger cup forceps; the polyp may end up being removed endoscopically in the process. Endoscopic removal of a polyp can often be performed with the mechanical energy of the bronchoscope and forceps, particularly if a rigid bronchoscope is used. The removal of the polyp by endoscopic means could be facilitated by the use of a laser or by electrocautery, but a polyp this small would seldom require more than large-cup forceps for it to be completely resected with a bronchoscope. The third suggestion is to simply observe such a patient and would be predicated on clinical circumstances in which there were no associated symptoms of chronic or recurring infection. Inflammatory polyps have been attributed to inhalation injuries and therapy with systemic or aerosolized corticosteroids has been reported to induce the regression of such polyps. The fourth approach proposes that if symptoms of chronic but localized infection cannot be adequately controlled by the use of steroid and/or antibiotic therapy, surgical resection of the affected lobe would likely relieve the symptoms and result in the removal of the offending polyp [1].
In the surgical treatment of endobronchial benign lesions, tissue-sparing techniques must be accomplished [5, 7]. Minimal possible parenchymal resection should be performed. For this reason, primarily, the excision of the bronchial part, where the lesion takes its origin (bronchoplasty), should be tried first. The most frequent indication for bronchoplastic resection is the presence of a lesion in the main bronchus or lobar bronchus [5–7]. However irreversible pathologic changes should be investigated preoperatively because additional pulmonary resection might be indicated. During the operation bronchotomy is performed and secretions are removed to observe the expansibility of the underlying lung. Also any nodularity or bronchiectatic changes should be sought by palpation. If the lung lost its ability to expand or if any fibrotic or bronchiectatic changes occurred, a parenchymal resection is to be performed. In the patient we treated, the middle and lower lobes were totally bronchiectatic and were not capable of expansion with ventilation. Because of the secondary abovementioned changes the resection had to be performed.
In conclusion patients experiencing recurrent lung infections and symptoms caused by bronchial irritation may exhibit extremely large benign endobronchial lesions. Early diagnosis and treatment is essential to rule out malignancy and to avoid parenchymal resection, which might become necessary because of secondary changes.
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References
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Abstract
Introduction
