INTRODUCTION: Granular cell tumor (GCT) of the bronchus is an uncommon benign tumor that can cause complications due to obstruction of the airways. We report the first case of bronchial GCT treated successfully with argon plasma coagulation (APC), without evidence of its recurrence 3 months later.
CASE PRESENTATION: A 54-year-old man, former smoker, and with history of hypertension, spontaneous pneumothorax in distant past, hepatitis C related cirrhosis of the liver, portal hypertension with esophageal varices and status post banding was evaluated for intermittent mild hemoptysis, of 1 year duration. Physical examination revealed normal nasal mucosa without any evidence of bleeding. There was no cervical lymphadenopathy. Examination of the chest revealed broncho-vesicular breath sounds in all lung fields, without presence of any crackles or wheezing. The cardiovascular examination revealed normal S1, S2, and regular rhythm. There was no peripheral edema. The prothrombin time (10.6 seconds) and platelet count (142 thousand/mm3) were normal. Pulmonary function testing revealed normal forced vital capacity of 6.01 L (113% predicted) and forced expiratory volume in 1 second of 4.13 (98% predicted). High resolution computed tomography of the chest revealed oval thickening (11.5mm × 7.8mm) of the inferior wall of the bronchus intermedius suggestive of a growth. Fiberoptic bronchoscopy revealed a small, variegated, non-bleeding lesion in the inferior aspect of the bronchus intermedius. This was located proximal to the right superior basal segment take-off and at the base of the accessory segment without causing its occlusion. Differential diagnoses included bronchial carcinoid, mucoepidermoid tumor, chondroid hamartoma, bronchogenic carcinoma etc. Histopathology of the tumor biopsies revealed polygonal cells with granular eosinophilic cytoplasm and uniform appearing hyperchromatic, centrally originating nuclei consistent with GCT. Immunohistochemistry was positive for S-100. Since, the patient was symptomatic and no other source of bleeding was identified, decision was made to achieve endobronchial resection. Endobronchial resection of the tumor was performed, in 2 sittings, using ERBE USA Inc. APC system with argon flow rate of 2 L/minute to achieve adequate tumor destruction and coagulation. A follow up bronchoscopy 3 months later did not reveal recurrence of tumor. The patient's hemoptysis resolved completely.
DISCUSSIONS: GCT of the tracheobronchial tree is uncommon and believed to be Schwann cell origin. Immunohistochemistry is crucial in the diagnosis. There is no consensus with regards to effective treatment modality for GCT's of the airways. A recent review of all the registered cases of GCT's in the Dutch Network and National Database for Pathology suggests very benign course of the disease1. The authors favor endobronchial therapy. Daniel et. al.2, in their review of the literature, found that all tumors removed bronchoscopically whose diameter was ≥ 1 cm recurred. However, none of the patients died because of the tumor recurrence. Full thickness involvement of the tracheal wall correlated with tumor size, and likely explained their recurrence. Surgical morbidity and mortality must be weighed before making a decision for treatment. APC provides a controlled, limited penetration into the tissue and good control of bleeding. APC is suitable for treating bronchial segments, taking off at acute angles, as argon flows quite flexibly around bends and corners. Also, it is cheaper, portable, and safely used with flexible bronchoscope.
CONCLUSION: Granular cell tumor of the bronchus is a benign tumor and endobronchial resection with argon plasma coagulation is an effective new treatment modality. Follow up bronchoscopy for tumor recurrence is recommended.
DISCLOSURE: Ashutosh Sachdeva, No Financial Disclosure Information; No Product/Research Disclosure Information