Endobronchial Lipoma

Endobronchial Lipoma

8 Jensen KG, Schiodt T : Growth conditions of the lung. Thorax 13:133, 1958 9 Sagel 55, Ablow RC: Hamartoma: On occasion a rapidly growing tumor of th...

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8 Jensen KG, Schiodt T : Growth conditions of the lung. Thorax 13:133, 1958 9 Sagel 55, Ablow RC: Hamartoma: On occasion a rapidly growing tumor of the lung. Radiology 91:971,1968 10 Hayward RH, Carabasi RJ: Malignant hamartoma of the lung: Fact or fiction? J Thorac Cardiovasc Surg 53:457, 1967

Endobronchial Lipoma* Dson E. Schraufnagel. M.D.;]. E. Morin, M.D.; andN.S. Wang, M.D.

An endobronchial lipoma has been studied with Baht, and tn.......... *ctroIl ~ ad the Uterature bas been rel'iew" EndobroadaIaI lipoma Is a type of hamartoma uaiqae GIlly ba _ _ of Its specific adult-type fat cell and its location. Of 49 endobronc:1aiaI Upo..... eiPt aye beeR reported In obeIe peno-. TIae neoplasm appears to propapte lit its peripberal zone tbroacb continuous iDcorponadoII . . , . . . of &JoI-Ies of fat In the spindle-sb8ped prec8I'IOI' cells. AItbougb beDJp paImonary taIIIon about 3 pen:eat and endobroDcbial Upomas only about 0.1 perceIIt of all piliIIIOIIIII'Y tumon, benign etIdoIwoadIiIII tmDon may cause unneceaary morbidity and mortality if aot pr0p-

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Benign endobronchial tumors are much less common than malignant ones1 ,s but assume greater importance than their frequency because if they are not diagnosed and treated properly, they cause significant morbidity and mortality. Endobronchial lipomas are rare tmnors for which lobectomy is still being performed in over half of the cases." We believe that the tumor can usually be removed bronchoscopically or by bronchotomy and that only rarely is pulmonary resection necessary.

CASEREI'oRT A 50-year-old man was admitted to the Royal Victoria Hospital, Montreal, for investigation of an abnormal chest xray film. He was asymptomatic. Approximately 1~ months prior to his admission, the patient had a transient episode of a cough productive of white sputum and rhinorrhea. for which the chest x-ray film was taken. He did not smoke and used DO medication. On physical examination the patient was 180 em (5 ft 10 in) tall and weighed 145.5 kg (321 Ib). The vital signs were normal. There were decreased fremitus and breath sounds over the left posterior upper portion of the thorax. Except for obesity the findings from the remainder of the examination were normal. Automated analysis of blood chemical constituents (SMA12 ), serologic data, and hematologic values were all normal, except for a fasting blood glucose level of 138 mg/l00 mI. -From the Department of Pathology and the Divisions of Respiratory Medicine and of Qardiovascolar and Thoracic 5ursery, the Pathology Institute and the Royal Victoria H0spital, McGill University, Montreal. ~u:d~ in part by the Medical Besearch Council of

Reprint reqfl6St8: Dr. Schroufnagel, Royal Victorla HospUal, 687 Pine Aoenue, WBIt, Montreal. QueIHtc. Ctlllllda

CHEST, 75: I, JANUARY, 1979

FlcURB 1. Tomogram of hilum of left lung, showing obstruction of proximal portion of left upper lobar bronchus. The results of urinalysis, cultures of sputum, and cytologic studies were also normal. The arterial oxygen pressure was 59 mm Hg, the arterial carbon dioxide tension was 44 mm Hg, the arterial pH was 7.4, and the bicarbonate level was 9:1 mEq/L. The electrocardiogram was normal. The chest x-ray film showed left upper lobe collapse and mediastinal shift to the left. Tomographic studies of the left bilum showed an obstructing mass at the proximal portion of the left upper lobe bronchus (F"Ig 1) Pulmonary function tests showed a mild restrictive impairment consistent with the patient's obesity (Table 1) .

Table I--PulmolUll'Y' Funcdon Data

PulmoD8I'Y volumes Expiratory reserve volume, L Vital capacity, L Functional residual capacity, L Residual volume, L Total lung capacity, L Expiratory flow rates Forced expiratory volume at 1 second, L/min Forced vital capacity, L/min Maximal midexpiratory flow, L/min

Actual

Predicted

0.33 3.84 2.46 2.13 5.97

4.49 3.89 2.30 6.80

2.57 3.80 2.25

3.44 4.49 3.52

1.59

dDGBROIiCHIAl UPOIIA 91

the center of the tumor was formed by adult-type fat cells and the peripheral zone by spindle cells and coDagen fibers. With the scarming electron microscope the lipid content in the fat oeD was dissolved, and the cut surface of the tumor appeued lilce a honeycomb, with the size of the cells decreasiDg from the center of the tumor toward the relatively flbrosed periphery (Fig 2). The transmission electron micr0scope showed spindle-shaped cells in the peripheral zone of the tumor, with many cytoplasmic fibrils and smaller droplets of fat (Fig3). DISCUSSION

FIctmE 2. By scarming electron microscopic enmJDlitioD, en-

dobronchiallipoma appears hooeyoombed; cellsin peripheral fibrous zones 8le smaller than those in central mass (X 120). Through the fiberoptic bronchOlOlJP8 a smooth yellow tumor was seen obstruCting the inltia1 portion of the left upper lobe bronchus. A bronchial adenoma was suspec:bld, but a biopsy was not taken because of the possibility of a hemorrhage. A left thoracotomy was perfonned; the left upper lobe bronchus was opeDed, and a tumor attached posteriorly to the bronchial muscosa was completely excised. Frozen sections of the tumor revealed benign fatty cells. The postoperative course was UDeventfuL Pothologic Fmdi~

The excised tumor was sliced into sections 1 to 2 rom thick and was fixed with 2 percent glutaraldehyde in a 0.1 M sodium cacodylate buffered solution. Alternate sections were processed routinely for light, scanning, and traIllD'lJiaioD e1ectron microscopic examination. The tumor was round, with a diameter of 2.0 em and a glistening yellow center. On light-microscopic xamination

Broochiallipomas make up about 0.1 percent of aD pulmonary tumors and about 13 percent of benign tumors (Table 2).1,2,4,6 The mean age of patients at diagnosis is 52 years. and the male-female ratio is 45:7.The usual subcutaneous lipomas are also more common in male subjects. Most patients initially had cough (85 percent). production of sputum (60 percent). and pain in the chest and fever (44 percent). Some had late occurring hemoptysis. and some patients were asymptomatic. Severe dyspnea was reported in three cases of obstruction of a large airway. a The most common signs were recurrent infections and atelectasis. The chest x-ray film usually showed obstruction of a large airway. with distal collapse or consolidation. Even though bordered by air. the roentgenographic shadow of a tumor with fat density was never seen. unless the tumor extended into the pulmonary parenchyma," No complication has been reported following bronchoscopic biopsy in cases of bronchial lipoma; however. when complete removal of a tumor with extrabronchial extension was attempted by rigid bronchoscopic techniques, mediastinitis has occurred, apparently from a perforation. r The problem is that a lipoma is bronchoscopically indistinguishable from a bronchial adenoma. and bleed-

F'Icum!: 3. Varied sims of lipid droplets (L) are seen in cellular processes of connective tissue cells adjacent to capillary with red blood cells. Lipid droplets show tendency to fuse with each other (arrow) (uranium acetare and lead citrate. original magnification X 5.500).

II SCHRAUfIIACEl. ..... WAIlS

CHEST. 75: 1, JANUARY, 1979

Time

Reference

Horamyi et al 4 Caldarola et all Pelag and Paumerl Jensen and Peterson'

Location Budapest

Span, yr

Malignant Hamartoma Lipoma Adenoma--

Other Benign

Total

13

NR

13

3

NR

44

2,759t

Rochester, Minn

30

NR

7

6

NR

50

NR

Tel Hashomer, Israe1

10

230

10

2

18

4

2M

Copenhagen

15

3,418

55

3

19

7

3,502

Mayo Clinic,

-NR, Not specifically reported. -*Considered as maUgnant tumors. tReported as consecutive pulmonary resections, not as total number of tumors.

ing often occurs during the bronchoscopic biopsy and removal of bronchial adenomas. Rarely, this may be fatal; 8 however, most adenomas, as well as all visible bronchial tumors, are subjected to biopsy, and most authors favor this approach.•,10 In case of parabronchial extension, excessive bleeding, or other difBculties, the tumor should be removed by bronchotomy during a thoracotomy. A frozen section should be done before pulmonary resection. Endobronchial lipoma arises from the fat cells normally found in the peribronchial and, occasionally, the submucosal tissue of the large bronchi. Fat is also present in two-thirds of the hamartomas, half of the chondromas, and in other benign tumors in the Iung.11 A hamartoma is an exaggerated proliferation of celluIar types that are normally present in an organ. Endobronchial lipoma fits this definition and is unique only because of its specific cellular type and location. The patient was obese; his ratio of weight over height was 5.3 standard deviations above the North American norm. 1 2 In the reported cases of endobronchial lipoma, eight patients were obese; in the other 41 cases, no statements about body weight were made. In certain conditions, common subcutaneous lipomas are associated with obesity, and this could also be related to the development of endobronchial lipoma. ACKNOWLEDGMENT: We thank Ms. Monique Charbonneau and Ms. J. Kroon-Vandor for excellent technical assistance.

CHEST, 75: 1, JANUARY, 1979

1lEFERENCBS 1 Caldarola VT, Harrison EG, Clagett OT, et al: Benign tumors and tumor-like conditions of the trachea and bronchi. Trans Am Bronchoesoph Assoc 44:49-69,1964 2 Pelag H, Pauzner Y: Benign tumors of the lung. Dis Chest 47:179-186, 1~ 3 MacArthur CGC, Cheung OLe, Spiro SG: EndobronchiaI lipoma: A review with four cases. Br I Dis Chest 71:93-100, Ur17 4 Horanyi I, Borlay B, Molnar I: Endobronchiales lipom. Thoruchirurgie 8:573-578,1961 5 Ienson MS, Peterson AR: Bronchial lipoma. Scand I Thome Cardiovasc Surg 4: 131-134, 1970 6 Madewell JE, Feigan DS: Benign tumors of the lung. Semin Roentgenol12:175-186, 1977 7 Whalen EJ: Lipoma of the bronchus. Ann Otol 56:811818,1947 8 Batson JF, Gale jW, Hickey RC: Bronchial adenoma. Arch Surg 92:623-630, 1966 9 Lawson RM. Ramanathan L, Hurley G, et al: Bronchial adenoma: Review of an IS-year experience at the Brompton Hospital. Thoru 31 :245-253, 1976 10 Suratt PM. Smiddy IF, Gruber B: Deaths and complicatiODS associated with fiberoptic bronchoscopy. Chest 69: 747-751, 1976 11 Beaton AR, Heatly CA: Fat in the tracheobronchial tree with report of a case of true lipoma of the bronchus. Ann 0t0161:1206-1215,1952 12 Womersley J. Durnin JVGA: A comparison of the skinfold method with extent of "overweight" and various weigbtheight relationships in the assessment of obesity. Br I Nutr 38:271-284, 1977

ENDOBRONCHIAL UPO. •