Endobronchial polyp A case presentation The case of a patient with a benign endobronchial polyp is presented. Early diagnosis will prevent irreversible obstructive lung disease and spare unnecessary pulmonary resection.
Henry F. Sears, M.D., Lawrence L. Michaelis, M.D., George R. Minor, M.D., and Donald E. Sweet, M.D., Charlottesville, Va.
endobronchial polyp is a rarely encountered lesion today. Patterson' first described this pathological entity in five patients in 1930, and in 1932 Jackson and Jackson- included it in their classification of benign endobronchial tumors. By 1940 at least forty cases of this lesion had been reported. Since the introduction of antibiotics, these polyps have been seen much less frequently.>" We herewith present a patient who underwent pneumonectomy for this condition. Awareness of the lesion and careful endoscopy with both fiberoptic and rigid bronchoscopes could probably obviate major resection in most instances.
Case report L. S. (U. Va. No. 68 47 73), a 31-year-old woman, was referred to the University of Virginia Hospital with a 3 year history of multiple episodes of left-sided pneumonia (four or five times per year), each of which responded well to antibiotic therapy. There was no history of smoking, food or pollen allergy, hay fever, or asthma. She had a chronic cough, which was productive of yellow sputum, but had never had hemoptysis. There was a history of rheumatic fever in childhood but no manifestations of myocarditis or valvular disease. On admission to the hospital the patient From the Departments of Surgery and Pathology, University of Virginia School of Medicine, Charlottesville, Va. 22901. Received for publication Feb. 13, 1975. Address for reprints: Henry F. Sears, M.D., Surgery Branch, National Cancer Institute, Bethesda, Md. 20014.
was 3 months' pregnant. Findings on physical examination were unremarkable except for leftsided dullness and decrease in breath sounds. Admission radiograms of the chest showed partial atelectasis of the left lung, predominantly affecting the left lower lobe. The heart and mediastinum were shifted to the left. The air shadow of the right bronchial tree could be seen in its entirety and appeared normal. There was an abrupt termination of the air shadow in the left main-stem bronchus approximately 2 em. from the tracheal bifurcation (Fig. 1, A and B). A lateral radiogram of the chest demonstrated herniation of the right lung across the midline through the anterior mediastinum. Initial bronchoscopy with a rigid scope showed an obstructing mass within the left upper lobe bronchus. The lesion was described as polypoid, smooth, and reddish. The orifice of the left lower lobe bronchus was described as patent. A biopsy of the mass showed bronchial mucosa with squamous metaplasia. It was believed that the bronchoscopic findings were not compatible with the findings on physical examination or the chest radiogram. Because both the physical findings and chest x-ray films suggested obstruction, predominantly of the left lower lobe, a repeat bronchoscopy was performed. The second endoscopic examination demonstrated the same polypoid mass in the left main-stem bronchus, about I cm. from the carina. The conclusion was that the observations made during the first examination were probably in error. The lesion was totally obstructive and had the appearance of a bronchial adenoma. After appropriate preoperative preparation, a left pneumonectomy was performed, with a presumptive diagnosis of bronchial adenoma. Histologic examination demonstrated a benign fibreepithelial polyp arising from within the left upper
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Fig. 1. Preoperative roentgenograms of the chest. A, Posteroanterior projection showing atelectasis, mediastinal shift, and termination of the left main-stem bronchus. B, Left lateral projection demonstrating herniation of right lung through the anterior mediastinum. lobe bronchus and protruding into the left mainstem bronchus. It was freely movable on a long stalk (Figs. 2 to 4). The left lung contained areas of severe focal atelectasis, bronchitis, bronchiolitis, and pneumonia. Postoperatively, the patient did well and was discharged on the seventh postoperative day. Her pregnancy progressed to a normal delivery, and she remains entirely asymptomatic.
Discussion Endobronchial polyps have been included under a variety of names in many reports on benign bronchial tumors. Drennan and Douglas' have classified bronchial papillomas into three categories, each histologically distinct: (1) multiple papillomatosis, (2) inflammatory polyps arising from chronically inflamed bronchial mucosa in patients with a long history of respiratory infections, and (3) solitary bronchial papilloma. This patient's lesion is basically of the second type; a columnar, epitheliumcovered polyp (Figs. 4 and 5). Inflammatory or fibroepithelial polyps may show focal squamous metaplasia (Fig. 5) but, unlike endobronchial papillomas, do not demonstrate the squamous epithelial overgrowth or the varied organoid patterns of bronchial adenoma."
Although this entity is called a benign tumor, it is more likely inflammatory than neoplastic and, as in any bronchial process, is capable of causing airway obstruction. In 1932 Jackson and Jackson" postulated that endobronchial polyps were in some way caused by infection. Although they admitted that no infective agent had been identified which had a specific tendency to induce these tumorlike formations, they believed these masses were comparable to the granulomas seen bronchoscopically in tuberculosis, syphilis, actinomycosis, and blastomycosis. They believed that any bronchial inflammatory condition was capable of inducing a nodule which could assume a tumorlike appearance on gross examination. The motion of the bronchus was also felt to contribute to polyp development. Histologically, areas of these polyps resemble a chronic inflammatory reaction (Fig. 5). This fact prompted Peroni," when discussing their pathogenesis, to liken them to the common polyps of the nose and nasal sinuses. Such lesions consist of loose connective tissue covered by normal respiratory epithelium. However, the bronchial polyp does not contain a large number
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of eosinophils, nor does it develop in atopic patients or in those with asthma. Previous respiratory infections, as had been experienced by this patient, have been described by others . However, whether the polyp is a result of the infection, or in fact causes it, remains unproved. Definitive diagnosis of these lesions, as with any other rare clinical occurrence, is usually made by the pathologist. The symptoms which may prompt a patient to seek medical attention are the secondary manifestations of bronchial obstruction. Prior to these later obstructive symptoms , the only clue to the presence of a bronchial polyp, or any partially obstructive mass, might be wheezing and frequent respiratory infections. Recurrent pneumonia, atelectasis, cough, and, occasionally , hemoptysis or dyspnea may prompt the patient's referral to the surgeon. Bronchoscopically, the polyp appears as a reddish, velvety smooth mass with prominent superficial vessels, which partially or completely occludes the bronchial lumen . There have been a few reports of endoscopic resections of this lesion, but only one was found in the recent literature." 8 . ~ . 1 7 Unfortunately, the gross characteristics of the polyp are so similar to certain bronchial adenomas that concern about uncontrollable bleeding may prevent the endoscopist from obtaining enough tissue for conclusive diagnosis. Kahn and Amer" described a patient who was followed for 3 years after bronchoscopic removal of a polyp. No recurrence was noted, and gratifying return to normal pulmonary drainage and function was documented. The possibility of endobronchial polypectomy places a premium on early diagnosis, since the resultant obstruction of the bronchial tree caused by ' a neglected polyp can lead to the loss (by secondary infection) of otherwise salvageable pulmonary parenchyma. In retrospect, the change in position of the obstructing mass in this patient should have alerted us to the fact that it was based on a long pedicle. Even if bronchoscopic resection could not have been performed, bronchotomy and ex-
Fig. 2. Resected left lung with the bronchial tree opened to show the polyp.
Fig. 3. Gross appearance of endobronchial pol yp, the stalk of which is shown arising from the carina between the anterior and apicoposterior segments of the left upper lobe .
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Fig. 4. Low-power photomicrograph show s fibroepithelial polyp, lined with bronchial mucosa, arising from a fairly normal-appearing endobronchial wall. The latter contains focal areas of chronic inflammation in the submucosa. Note the numerous bronchial glands throughout the polyp. (Original magnification x6.5.)
cision of the polyp might have spared the patient a pneumonectomy. As in this case, polyps in the bronchus can be mistaken for bronchial adenomas or cancer and can result in needless pulmonary resection; yet neglecting the obstruction or failing to make an early diagnosis of an obstructing lesion can just as surely destroy pulmonary parenchyma. A high index of suspicion and careful endoscopic examination with manipulation of the lesion will lead to the early diagnosis of this rare malady. Resections , either through the broncho-
Thoracic and Cardiovascular Surgery
Fig. 5. Photomicrograph (xl l G) shows the pseudostratified, tall columnar, respiratory epithelial mucosa covering the pol yp. Squamous metaplasia is noted in the crypt and was seen in the base of other glands. The submucosal stroma is loose, edematous, and infilt rated with numerous plasma cells. The stalk of the polyp has a more fibromuscular-appearing stroma. (Original magnification x llO.)
scope or with thoracotomy and bronchotomy, may minimize loss of lung tissue, unless it is irreversibly damaged by obstructive pneumonitis. REFERENCES
3 4 5
Patterson, E. J.: Benign Bronchial Neoplasms, Arch. OtolaryngoI. 12: 739, 1930. Jackson, C. , and Jackson, C. L. : Benign Tu mors of the Trache a and Bronchi With Especial Reference to Tumorlike Format ions of Inflammatory Origins, J. A. M. A. 99: 1747, 1932. Saini, U. K., and Wahi, P. L.: Inflammatory Polyp of the Bronchus, Ann . Thorac. Surg , 5: 141, 1968. Salek, J., Pazderka, S., and Zak, F.: Solitary Bronchial Polyps of Inflammatory Origin, J. Thorac. Surg. 35: 807 , 1958. Pele g, R., and Pauzner, Y . : Benign Tumors of the Lung, Chest. 47: 179,1965.
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6 Miller, D. R.: Benign Tumors of the Lung and Tracheobronchial Tree, Ann. Thorac. Surg, 6: 542, 1969. 7 Drennan, J. M., and Douglas, A. C.: Solitary Papillomata of a Bronchus, J. Clin. PathoI. 18: 401, 1965. 8 Peroni, A: Inflammatory Tumors of the Bronchi, Arch. Otolaryngol. 19: 1, 1934. 9 Kahn, B., and Amer, N. S.: Multiple Bronchial Polyps, Chest 57: 279, 1970. 10 Miller, R. D.: Benign Tumors of the Lung and Tracheobronchial Tree, Ann. Thorac. Surg. 8: 52, 1964. 11 Jackson, D. A, and Hatch, H. B.: Solitary Benign Squamous Papilloma of the Bronchus: Report of Two Cases, Am. Rev. Resp. Dis. 97: 699, 1968.
12 Laubscher, F. A: Solitary Squamous Cell Papillomata of Bronchial Origin, Am. J. Clin. Pathol. 52: 599, 1969. 13 Stien, V.: Papillomatosis of the Trachea and Lung, Arch. Pathol. 68: 968, 1959. 14 Langston, H. T.: Benign Endobronchial Tumors, Int. Abstr. Surg. 91: 521, 1950. 15 Orton, H. B.: Papilloma of the Bronchus, Ann. Otol. Rhinol. Laryngol. 41: 933, 1932. 16 Jackson, C., and Jackson, C. L.: Benign Tumors and Tumorlike Conditions of the Tracheobronchial Tree, Am. J. Surg. 42: 275, 1938. 17 Ashby, D. J. 8., Danino, E. A, and Davies, H. D.: Bronchial Polyps, Thorax 18: 45, 1963.