INTRODUCTION: A 70 year old African American woman with history of smoking presented with worsening of asthma associated with productive cough and hemoptysis of 3 days duration.
CASE PRESENTATION: Her medications included Fluticasone/Salmeterol, bronchodilators and Omalizumab. On examination, she was not in distress. Blood Pressure was 125/80 mmHg; heart rate, 68/min; respiratory rate, 22/min; temperature, 98 F and SaO2 of 98% on room air. Auscultation revealed scattered wheezes more prominent on the right lung field. Computed tomography images of the chest are shown. Flexible bronchoscopy revealed a polypoid lesion arising from the right bronchus intermedius close to secondary carina occluding 90% of the bronchial lumen. Multiple biopsies and bronchial brushings were negative for carcinoma. Bronchoalveolar lavage and cultures were negative for acid fast bacilli and fungi. Pathologic specimen of the excised mass, by rigid bronchoscopy, is shown.
DISCUSSION: Benign polypoid lesions are uncommon findings and present a diagnostic dilemma. Fibroepithelial polyp of the tracheobronchial tree is a slow-growing tumor but can produce obstructive complications such as chronic bronchitis and bronchiectasis, recurrent pneumonia. Benign tracheobronchial tumors represent 1.9% of pulmonary tumors. Fibroepithelial polyps are rare with unclear etiology. The most accepted hypothesis is chronic inflammation due to factors such as foreign body aspiration, prolonged mechanical ventilation, asthma, smoke inhalation and mycobacterial infections. Histopathologically they are fibro-inflammatory and lined with respiratory epithelium with edematous stroma. Inflammatory polyps are solitary benign endobronchial lesions with stromal configurations consisting of well-formed fibrous connective tissue with or without inflammation and covered with stratified squamous epithelium or normal bronchial mucosa. The silent nature of these lesions often leads to a delayed diagnosis. Diagnosis is essential to rule out malignancy and avoid parenchymal resection. Fiber-optic bronchoscopy is the procedure of choice to diagnose clinically-suspected endobronchial lesions but excisional biopsy by rigid bronchoscopy is required for definitive diagnosis and to exclude bronchogenic carcinoma. Occasionally surgical excision is required. Treatment is eradication of the lesion in order to relieve complications secondary to airway obstruction and conserve functioning lung parenchyma. For localized endobronchial lesions without extraluminal extension, endoscopic treatment modalities like bronchoscopic curettage, Nd-YAG laser, electrocautery and cryosurgery are available which avoid the morbidity and mortality associated with thoracotomy and pulmonary resection. The choice between these endobronchial therapies varies from center to center depending on the equipment available and the preferences and experience of the physician. Surgical resection is required when the lesion has extended beyond the bronchial lumen and there is a high likelihood of recurrence. Proximal lesions which cannot be excised by endoscopy require surgical excision of involved bronchus with brochoplasty to avoid resection of functional lung parenchyma. In the surgical treatment, tissue-sparing techniques with minimally possible parenchymal resection should be performed. For this reason, 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. Our patient underwent rigid bronchoscopy. The pedunculated polypoid mass was removed. On six-month follow up, there was a marked improvement in asthma symptoms with fewer exacerbations and the use of inhaled bronchodilators and corticosteroids had declined substantially.
CONCLUSIONS: Benign Fibroepithelioma is rare and difficult to distinguish from malignant lesion based on endobronchial appearance. Flexible Fiber-optic bronchoscopy with small tissue samples is insufficient to diagnose fibroepithelioma. Rigid bronchoscopy with excision is required to avoid sampling error, exclude malignancy and confirm fibroepithelioma. Majority of patients can be treated with therapeutic endoscopic procedures like laser, elctrocautery or mechanical excision. Rarely, conservative surgical excision of fibroepithelioma along with bronchus and bronchoplasty with preservation of functioning lung parenchyma may be required.
Reference #1 Leiro-Fernandez et al J Bronchol Intervent Pulmonol _ Volume 17, Number 1, January 2010 56-58 58 | J Bronchol Intervent Pulmonol 2010;17:56-58
Reference #2 Ushiki A, Yasou M, Tanabe T, et al. A rare case of a tracheal polyp treated by endobronchial resection. Intern Med. 2008;47:1723-1726.
Reference #3 Strachan P, Multz AS, Esposito MJ, et al. Bronchoscopic image: benign bronchial polyp. J Bronchol. 2007; 14:111-112.
DISCLOSURE: The following authors have nothing to disclose: Saleem Shahzad, Manoj Suryanarayanan, Sasikanth Nallagatla, Vishal Verma, Viswanath Vasudevan, Farhad Arjomand, Rana Ali, Scott Reminick
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