INTRODUCTION: Fibroepithelial polyps of the lower respiratory tract are extremely rare with only a few reported cases(1). Surgical resection was typically used to make the diagnosis(2). We report a case of a patient with a fibroepithelial polyp diagnosed and treated by endobronchial resection after the benign nature of the lesion was suspected during bronchoscopic airway evaluation.
CASE PRESENTATION: A 68-year-old man presented to the emergency department with a one month history of retrosternal chest pain after eating. Initial imaging revealed a nodule in the lower esophagus which on biopsy proved to be squamous cell carcinoma. A chest CT done for staging purposes incidentally showed atelectasis of the right upper lobe and an endobronchial lesion in the right upper lobe bronchus. The patient denied cough, dyspnea, wheezing, hemoptysis or fever. He also denied receiving antibiotics for pneumonia in the past. Of note, he smoked half a pack of cigarettes per day for thirty years, and quit several weeks prior to presentation. On physical examination his vital signs were within normal limits. Chest examination showed normal percussion note and vesicular breath sounds bilaterally. Bronchoscopy showed a lobulated polyp with a glossy surface causing incomplete obstruction of the right upper lobe bronchus. With manipulation, the stalk of the polyp was noticed to be originating from the posterior wall of the anterior segment of right upper lobe bronchus. Multiple biopsies taken from the polyp showed benign respiratory mucosa. He subsequently underwent repeat bronchoscopy and the entire polyp was removed by using an electrocautery snare. After removal, the remaining stalk was cauterized with an electrocautery probe. Histopathological examination showed a polypoid lesion lined by benign metaplastic squamous epithelium. The stroma was composed of fibromyxoid connective tissue with vascular congestion, few inflammatory cells and a prominent adipocytic component. This was consistent with the diagnosis of fibroepithelial polyp.
DISCUSSIONS: Tumors in the tracheobronchial tree are typically malignant. While common in locations outside the lungs, fibroepithelial polyps are extremely rare benign tracheobronchial tumors. Although their etiology remains unclear, it is thought to be related to a chronic inflammatory process. Histopathologically these polyps consist of normal bronchial respiratory epithelium covering a fibrovascular stroma with scattered lymphocytes. Depending on their size and location, fibroepithelial polyps may be asymptomatic or cause wheezing, cough, dyspnea, or rarely hemoptysis. Partial or complete obstruction of the tracheobronchial tree can lead to recurrent pneumonia, bronchiectasis, and atelectasis. Radiologic imaging may identify these lesions with a soft tissue density in the tracheobronchial tree, or there may be indirect evidence of obstruction like distal atelectasis, bronchiectasis and ipsilateral volume loss. Endobronchially, they have a lobulated appearance with a glossy surface. With manipulation, a stalk arising out of the tracheobronchial wall can usually be identified. Endobronchial biopsy via flexible bronchoscope in most cases is non-diagnostic. However, complete endobronchial resection is usually possible and can yield definitive diagnosis and prompt relief of symptoms.
CONCLUSION: Even though fibroepithelial polyps are exceedingly rare endobronchial lesions, a high clinical suspicion in the right context may help avoid unnecessary surgery. Diagnosis and relief of symptoms can be obtained by flexible bronchoscopy and the appropriate instruments.
DISCLOSURE: Puncho Gurung, No Financial Disclosure Information; No Product/Research Disclosure Information