We present a case of endobronchial hamartoma, which was resected and ablated with loop electrocautry and Argon Plasma Coagulation using therapeutic fiberoptic bronchoscopy.
A 55-year-old white male with a 30 pack-year smoking history was referred to pulmonary clinic after failing two cycles of antibiotic treatment for a right upper lobe “pneumonia”. The patient denied dyspnea, chest pain, sputum production, hemoptysis, weight loss or night sweats. He worked as a salesperson in an auto shop, and denied any occupational or environment exposure to allergens, irritants or toxins. Chest radiograph after the two courses of antibiotics showed a persistent triangular infiltrate in the right upper lobe, extending to the hilum suggesting an obstructive lesion. CT of the chest showed an endobronchial density, mucus plug vs. mass, in the right upper lobe anterior segmental bronchus with post-obstructive atelectasis.A fiberoptic bronchoscopy was performed which demonstrated a pedunculated, spindle shaped, occluding mass protruding from the right upper lobe orifice into the right main bronchus. No nodularities or ulcerations were noted. Endobronchial biopsies indicated a benign papillomatous growth. The patient underwent a repeat fiberoptic bronchoscopy, during which a heated loop electrocautry was used to remove the mass. It was found to originate from the anterior segment of the right upper lobe. Argon Plasma Coagulation (APC) was then used to cauterize the remaining base. Pathological examination of the mass indicated it was a benign hamartoma.Two additional therapeutic bronchoscopies, using APC, were performed to further open the anterior segment of the right upper lobe. This objective has been only partially achieved thus far and additional bronchoscopies are planned to completely open the airway.
Hamartomas are the most common form of benign lung tumors, with an incidence ranging between 0.025% and 0.32%. However, endobronchial hamartomas (EH) are a very rare entity. In the largest review series, only 1.4% of hamartomas had an endobronchial location, the remainder being located within the lung parenchyma. Whereas patients with intra-pulmonary hamartomas are usually symptom-free, those with EH typically are symptomatic, and therefore, require treatment. EH are generally broad-based lobulated nodules, resulting in symptoms of airway obstruction. Cough, hemoptysis, dyspnea, and post obstructive pneumonia are the main clinical features. Histologically, the tumors consist of varying combinations of benign elements including cartilage, connective tissue, fat, and smooth muscle. Most tumors grow slowly (average of 3 mm/year) during follow up.Different treatment modalities are available for the management of EH. Surgical resection (wedge resection, lobectomy and in extreme case, pneumonectomy) has been recommended for these patients, but carries the surgical risks inherent to a thoracotomy. When completely resected, pulmonary hamartomas rarely recur. Less invasive, bronchoscopic techniques have been used, allowing the preservation of normal lung parenchyma. These are performed with flexible or rigid bronchoscopy, typically using a ND-YAG laser and forceps. To our knowledge, this is the first report of the use of APC as a treatment modality in this type of benign endobronchial tumor.
Endobronchial hamartoma remains a rare entity. Patients are frequently symptomatic, due to airway obstruction. The benign nature of the lesion makes surgical resection, with its risks and potential complications, less appealing. The use of endoscopic techniques, including Argon Plasma Coagulation, should be considered in the appropriate setting. The long term outcome after endoscopic resection remains to be determined.
Tanveer Ahmed, None.