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Leiomyoma of the lung
Leiomyoma of the lung A case of asymptomatic pulmonary leiomyoma diagnosed by routine chest radiography and treated by lobectomy is reported. There is no particular clinical pattern that distinguishes this lesion, and diagnosticmaneuvers to identify its nature are generally unrewarding except for biopsy. Resection is the recommended treatment.
Tadeusz Marian Orlowski, M . D . , Krzysztof Stasiak, M .D., and Jerzy Kolodziej, M.D., Wroclaw, Poland
A he benign, primary tumors of the lung, which include hamartoma, fibroma, lipoma, and leiomyoma, are rare. Leiomyomas, which are extremely rare, were first described by Forkel 1 in 1910, and only 51 cases have been reported since that time (Table I). Case report K. J., a 55-year-old woman, was admitted to the clinic with the diagnosis of a tumor of the right lower lobe of the lung detected by routine x-ray examination of the chest (Fig. I). Tomography confirmed the presence of an opaque, sharply outlined, rounded shadow. Results of physical, laboratory, and function examinations were within normal limits. Bronchoscopy showed no tracheal abnormalities. The bronchial pattern was normal except for signs of chronic inflammation. On bronchography, the bronchi filled normally with contrast medium but exhibited signs of incipient bronchitis. A gynecologic examination revealed myomatosis of the uterus. At thoracotomy, a firm, well-circumscribed tumor, 5 cm. in diameter, was found. The lower lobe of the right lung was resected. The postoperative period was uneventful, and the patient was discharged 16 days later. Histopathologic study showed a leiomyoma without malignant features (Fig. 2). Discussion By definition, a leiomyoma is composed of smooth muscle fibers. It occurs most commonly in the uterine corpus but may also be encountered, though less frequently, in the wall of the alimentary tract and in the skin, where it stems from the area of the hair follicle. Theories of origin. There is general agreement that From the Department of Thoracic Surgery, School of Medicine, Institute of Surgery, Wroclaw, Poland. Received for publication Feb. 7, 1978. Accepted for publication April 24, 1978. 0022-5223/78/0276-0257$00.50/0 © 1978 The C. V. Mosby Co.
leiomyomas of the bronchus originate in the smooth muscle fibers of the bronchial wall. The origin of those that are located in the parenchyma, which are in fact more numerous, is more difficult to establish. Many authors 2, 3 feel that tumors in this location stem from the wall of the bronchial arteries. Leiomyomas of the lung are considered by some to represent metastases from uterine myomas. The fact that the tumor occurs twice as often in women (62.7 percent) and that many of these women have uterine myomas (43.4 percent) tends to support this theory. Other and more divergent views have been advanced as reasons for the development of these tumors. Brahdy 4 feels that leiomyomas of the lung may arise in smooth muscle during the process of cicatricial fibrosis of lung tissue, such as occurs in tuberculosis. Clinical presentation. The age of incidence of the collected tumors varies. The youngest patient was 6 years of age, and the oldest was 67. The mean age of all cases is 35 years. In women, the mean age is perhaps 2 years higher than that in men. Approximately one third of the patients were less than 20 years of age. The location of the tumor determines the symptomatology of these lesions. Tumors in peripheral or parenchymal location were asymptomatic in 94 percent of cases. Only routine examinations of the chest made it possible to detect them. In those instances in which the growth originated in the bronchus, all patients had complaints indicative of partial or total occlusion of the affected bronchus. These included cough and expectoration of blood or blood-stained sputum. Radiologic appearance. In the diagnosis of a pulmonary leiomyoma the x-ray examination plays a major role. In most asymptomatic cases the tumor was discovered in the course of periodic examinations. The radiographic appearance of the parenchymal leio-
257
The Journal of Thoracic and Cardiovascular Surgery
2 5 8 Orlowski, Stasiak, Kolodziej
Table I Tumor localization Right lung
Sex Age (yr.)
Authors Forkel' Franco21 Brunn" Brandy4 Sherman and Malone39
Turkington et al10 Williams and Daniel" Freireich et al.7 Pierce et al.34 Hirose and Hennigar24 Galy and Touraine8 Dorken20 Ornatskij32 Brouet3 Lemoine311 Crastnopol and Franklin5 Prochazka et al. 35 Lynn and MacFayden31 Berkheiser and Szypulski13 Rodrigues et al.37 Weil et al. 43 Aakhus and Mylius2 Bielojarcef14 Barre12 Gadrat et al.22 Peleg and Pauzner33 Guida et al.23 Reboul et al.36 Konis and Belsky28 Korobkov et al.29 Lajos and Meckstroth9 Taylor and Miller40 Carpinisan et al.' 8 4
Vinner and Kazak ' Inberg et al. 35 Sweet6 Van Way42 Koczorowski and Plachta26 Blaive16 Dobrota et al. 19 Sabbagh et al.38 Orlowski et al.
63 56 11 18 22 54 41 11 57 8 61 24 43 27 15 31 42 12 17 35 45
F
+ + + + + + + + + + +
+ + +
27 5 43
+ + +
19 38 21 7 31 20 53 6 63 36 22 54 43 13 48 32 18 54 46 21 48 33
+
+
63 65 67 49 55
+ + + +
+ +
+ + + + + + +
M
RUL
RML ML
RLL
Left lung Main bronchus
LUL
LLL
+ +
+ + +
+ +
+ +
+
+ + + +
+ +
+
+ +
+ +
+
+ + + + +
+ + + + +
+
+ + + +
+ +
+ +
+ + + + +
+
Legend: RUL, RML, RLL, Right upper, middle, and lower lobes. LUL, LLL, Left upper and lower lobes.
Main bronchus
Leiomyoma of lung
259
Treatment Lobectomy
Pneumonectomy
Bronchoscopy
+ + + +
+ +
+ + + + + + + + + +
+ + +
+ +
Fig. 1. Tomogram showing opaque, sharply outlined, round shadow. myoma is that of a rounded shadow. This appearance in no way permits any conclusion as the etiology of the tumor. There are no peculiarities which distinguish a peripheral leiomyoma of the lung from other benign, malignant, or metastatic processes. A possibly important morphologic feature of some diagnostic value is calcification. Most authors stress that the presence of calcification within rounded shadows in the x-ray film militates against malignancy. Crastnopol and Franklin5 and Sweet,6 however, have reported on the presence of calcification within these benign tumors. In the parenchymal or peripheral location, the appearance of the rounded lesion is a clear indication for surgical intervention. The clinical picture is different in those tumors that are situated within the bronchus. Radiologically, the neoplastic process can be masked because the sequelae of atelectasis or an inflammatory process caused by narrowing or occlusion of the bronchus are to be expected. Treatment. The treatment of choice consists in the removal of the tumor. The extent of the operation depends on the location of the lesion. Peripherally located tumors require a less radical procedure, whereas those stemming from the bronchus may occasionally necessi-
2 60
Orlowski, Stasiak,
The Journal of Thoracic and Cardiovascular Surgery
Kolodziej
tive et isole'es des poumones et des branches. J Franc Med Chir Thorac 9: 330, 1955 9 Lajos TZ, Meckstroth CV: Pedunculated leiomyoma of the lung. Chest 52: 114, 1967 10 Turkington SI, Scott GA, Smiley TB: Leiomyoma of the bronchus. Thorax 5: 138, 1950 11 Williams RB Jr, Daniel RA Jr: Leiomyoma of the lung. J THORAC SURG 19: 806,
1950
12 Barre E: Tumeur bronchiqe a cellules fusiformes apparemment benigne. Branches 12: 386, 1962 13 Berkheiser SW, Szypulski JT: Leiomyoma of intermediate bronchial origin. J THORAC CARDIOVASC SURG
14 15 16 17
38: 398, 1959 Bielojarcef F: Sluczaj dobrokaczestwiennoj opucholi liekkogo u rebionka. Chirurgie 6: 120, 1962 Blaikley JB: Metastasizing fibromyoma. J Obstet Gynecol 80: 856, 1973 Blaive B: Intrathoracic leiomyomas. Mars Med 109: 683, 1972 Brunn H: Two interesting benign lung tumors of contradictory histopathology. J THORAC SURG 9: 119, 1939
Fig. 2. Photomicrographs of the tumor. Top, Oblique course of the ciliary epithelium. Bottom, A fragment of benign tumor with slender nuclei without signs of atypia. tate total resection of the lung. 3, 7 _ u Lobectomy was carried out in 53 percent of the cases. It seems very likely that in many instances of partial and total resection of the lung, a less radical operation such as segmentectomy or sleeve resection might have been performed if the histologic diagnosis had been known prior to the completion of the surgical procedure.
REFERENCES 1 Forkel W: Ein Fall von Fibroleiomyom der Lunge, Z Krebsforsch 8: 390, 1910 2 Aakhus T, Mylius EA: Leiomyoma of the lung. Acta Chir Scand 124: 372, 1962 3 Brouet G: Leiomyome bronchique chez une fillette 12 ans exerese chirurgicale guerison. J Franc Med Chir Thorac 22: 589, 1968 4 Brahdy L: Leiomyoma of the Lung. Am Rev Respir Dis 43: 429, 1941 5 Crastnopol P, Franklin WD: Fibroleiomyoma of the lung. Ann Surg 145: 128, 1957 6 Sweet RS: Pulmonary leiomyoma. Am J Roentgenol Radium Ther Nucl Med 107: 823, 1969 7 Freireich K, Bloomberg A, Langs EW: Primary bronchogenic leiomyoma. Chest 19: 354, 1951 8 Galy P, Touraine RG: Les tumeures conjonctives primi-
18 Carpinisan C, Coman C, Cubolteanu F: Contributions to the study of pulmonary leiomyoma. J Franc Med Chir Thorac 22: 589, 1968 19 Dobrota S, Motil E, Chovanova T, et al: Problematika benignych mezenchymalnych na'dorov plu'cneobvyklych rozmerov. Bratisl Lek Listy 59: 488, 1973 20 Dorken N: Pedunculated fibroma and leiomyoma of the lung. J Int Coll Surg 25: 241, 1956 21 Franco EE: Sopra uno rarissimo voluminoso leiomioma del pulmone. Tumori 15: 27, 1929 22 Gadrat J, Laporte J, Dambrin P, et al: On pulmonary leiomyoma. J Franc Med Chir Thorac 19: 5, 1965 23 Guida PM, Fulcher T, Moore SW: Leiomyoma of the lung. J THORAC CARDIOVASC SURG 49: 1058,
1965
24 Hirose FM, Hennigar GR: Intrabronchial leiomyoma. J THORAC SURG 29: 502,
1955
25 Inberg MV, Sutinen S, Tala E: Leiomyoma of the lung and intercostal space. Scand J Thorac Cardiovasc Surg 3: 52, 1969 26 Koczorowski T, Plachta H: -Lagodny nowotwdr oskrzela jako przyczyna nawracajjcego zapalenia pluc i op}ucnej. Wiad Lek 25: 2233, 1972 27 Kofodziej J, Orlowski TM, Stasiak K, et al: Przypadek rzadkiego nowotworu pluca. Wiad Lek 29: 2211, 1976 28 Konis E, Belsky R: Metastasizing leiomyoma of the uterus. Obstet Gynecol 27: 442, 1966 29 Korobkov ES, Komissarenko BT, Kozyrev IUS: Angiomatoznaia leiomioma legkogo. Grudn Khir 9: 114, 1967 30 Lemoine J: Deux cas de tumeurs bronchiques rares. J Franc Med Chir Thorac 11: 355, 1957 31 Lynn RB, MacFayden DJ: Solitary primary leiomyoma of the lung. Can J Surg 2: 93, 1958 32 Omatskij W: Myoma liegkogo. VoprOnkol 6: 343, 1958 33 Peleg H, Pauzner Y: Benign tumors of the lung. Chest 47: 179, 1965
Volume 76 Number 2 August, 1978
34 Pierce WF, Alznauer RL, Rolle C: Leiomyoma of the lung. Arch Pathol Lab Med 58: 443, 1954 35 Prochazka VJ, Fingerland A, Mydlil F: Intrabronchiales Leiomyom. Thoraxchirurgie 5: 17, 1957 36 Reboul AR, Longefait H, Corolleur JR: Un syndrome du lobe moyen d'etiologie rare. Mars Med 102: 197, 1965 37 Rodrigues WM, de Mello JB, de Arruda RM, de Almeida AM, Zerbini E: Leiomioma do pulmao. Rev Asoc Med Bras 5: 244, 1959 38 Sabbagh AH, O'Hare JE, Fritz JM: Pulmonary leiomyoma. Ariz Med 31: 359, 1974 39 Sherman RS, Malone BH: A roentgen study of smooth
Leiomyoma
of lung
261
muscle tumors primary in the lung. Radiology 54: 507, 1950 40 Taylor TL, Miller DR: Leiomyoma of the bronchus. J THORAC GARDIOVASC SURG 57: 284,
1969
41 Vinner MG, Kazak TI: Pulmonary leiomyoma. Vopr Onkol 10: 118, 1964 42 Van Way CW: Leiomyoma of the lower respiratory tract. Ann Thorac Surg 6: 273, 1968 43 Weil J, Renault P, de Saint Florent G, Delaviere P: Tumeur bronchique rare, leiomyome a cellule granuleuses. J Franc Med Chir Thorac 15: 657, 1961
Tadeusz Marian Orlowski, M . D . , Krzysztof Stasiak, M .D., and Jerzy Kolodziej, M.D., Wroclaw, Poland
A he benign, primary tumors of the lung, which include hamartoma, fibroma, lipoma, and leiomyoma, are rare. Leiomyomas, which are extremely rare, were first described by Forkel 1 in 1910, and only 51 cases have been reported since that time (Table I). Case report K. J., a 55-year-old woman, was admitted to the clinic with the diagnosis of a tumor of the right lower lobe of the lung detected by routine x-ray examination of the chest (Fig. I). Tomography confirmed the presence of an opaque, sharply outlined, rounded shadow. Results of physical, laboratory, and function examinations were within normal limits. Bronchoscopy showed no tracheal abnormalities. The bronchial pattern was normal except for signs of chronic inflammation. On bronchography, the bronchi filled normally with contrast medium but exhibited signs of incipient bronchitis. A gynecologic examination revealed myomatosis of the uterus. At thoracotomy, a firm, well-circumscribed tumor, 5 cm. in diameter, was found. The lower lobe of the right lung was resected. The postoperative period was uneventful, and the patient was discharged 16 days later. Histopathologic study showed a leiomyoma without malignant features (Fig. 2). Discussion By definition, a leiomyoma is composed of smooth muscle fibers. It occurs most commonly in the uterine corpus but may also be encountered, though less frequently, in the wall of the alimentary tract and in the skin, where it stems from the area of the hair follicle. Theories of origin. There is general agreement that From the Department of Thoracic Surgery, School of Medicine, Institute of Surgery, Wroclaw, Poland. Received for publication Feb. 7, 1978. Accepted for publication April 24, 1978. 0022-5223/78/0276-0257$00.50/0 © 1978 The C. V. Mosby Co.
leiomyomas of the bronchus originate in the smooth muscle fibers of the bronchial wall. The origin of those that are located in the parenchyma, which are in fact more numerous, is more difficult to establish. Many authors 2, 3 feel that tumors in this location stem from the wall of the bronchial arteries. Leiomyomas of the lung are considered by some to represent metastases from uterine myomas. The fact that the tumor occurs twice as often in women (62.7 percent) and that many of these women have uterine myomas (43.4 percent) tends to support this theory. Other and more divergent views have been advanced as reasons for the development of these tumors. Brahdy 4 feels that leiomyomas of the lung may arise in smooth muscle during the process of cicatricial fibrosis of lung tissue, such as occurs in tuberculosis. Clinical presentation. The age of incidence of the collected tumors varies. The youngest patient was 6 years of age, and the oldest was 67. The mean age of all cases is 35 years. In women, the mean age is perhaps 2 years higher than that in men. Approximately one third of the patients were less than 20 years of age. The location of the tumor determines the symptomatology of these lesions. Tumors in peripheral or parenchymal location were asymptomatic in 94 percent of cases. Only routine examinations of the chest made it possible to detect them. In those instances in which the growth originated in the bronchus, all patients had complaints indicative of partial or total occlusion of the affected bronchus. These included cough and expectoration of blood or blood-stained sputum. Radiologic appearance. In the diagnosis of a pulmonary leiomyoma the x-ray examination plays a major role. In most asymptomatic cases the tumor was discovered in the course of periodic examinations. The radiographic appearance of the parenchymal leio-
257
The Journal of Thoracic and Cardiovascular Surgery
2 5 8 Orlowski, Stasiak, Kolodziej
Table I Tumor localization Right lung
Sex Age (yr.)
Authors Forkel' Franco21 Brunn" Brandy4 Sherman and Malone39
Turkington et al10 Williams and Daniel" Freireich et al.7 Pierce et al.34 Hirose and Hennigar24 Galy and Touraine8 Dorken20 Ornatskij32 Brouet3 Lemoine311 Crastnopol and Franklin5 Prochazka et al. 35 Lynn and MacFayden31 Berkheiser and Szypulski13 Rodrigues et al.37 Weil et al. 43 Aakhus and Mylius2 Bielojarcef14 Barre12 Gadrat et al.22 Peleg and Pauzner33 Guida et al.23 Reboul et al.36 Konis and Belsky28 Korobkov et al.29 Lajos and Meckstroth9 Taylor and Miller40 Carpinisan et al.' 8 4
Vinner and Kazak ' Inberg et al. 35 Sweet6 Van Way42 Koczorowski and Plachta26 Blaive16 Dobrota et al. 19 Sabbagh et al.38 Orlowski et al.
63 56 11 18 22 54 41 11 57 8 61 24 43 27 15 31 42 12 17 35 45
F
+ + + + + + + + + + +
+ + +
27 5 43
+ + +
19 38 21 7 31 20 53 6 63 36 22 54 43 13 48 32 18 54 46 21 48 33
+
+
63 65 67 49 55
+ + + +
+ +
+ + + + + + +
M
RUL
RML ML
RLL
Left lung Main bronchus
LUL
LLL
+ +
+ + +
+ +
+ +
+
+ + + +
+ +
+
+ +
+ +
+
+ + + + +
+ + + + +
+
+ + + +
+ +
+ +
+ + + + +
+
Legend: RUL, RML, RLL, Right upper, middle, and lower lobes. LUL, LLL, Left upper and lower lobes.
Main bronchus
Leiomyoma of lung
259
Treatment Lobectomy
Pneumonectomy
Bronchoscopy
+ + + +
+ +
+ + + + + + + + + +
+ + +
+ +
Fig. 1. Tomogram showing opaque, sharply outlined, round shadow. myoma is that of a rounded shadow. This appearance in no way permits any conclusion as the etiology of the tumor. There are no peculiarities which distinguish a peripheral leiomyoma of the lung from other benign, malignant, or metastatic processes. A possibly important morphologic feature of some diagnostic value is calcification. Most authors stress that the presence of calcification within rounded shadows in the x-ray film militates against malignancy. Crastnopol and Franklin5 and Sweet,6 however, have reported on the presence of calcification within these benign tumors. In the parenchymal or peripheral location, the appearance of the rounded lesion is a clear indication for surgical intervention. The clinical picture is different in those tumors that are situated within the bronchus. Radiologically, the neoplastic process can be masked because the sequelae of atelectasis or an inflammatory process caused by narrowing or occlusion of the bronchus are to be expected. Treatment. The treatment of choice consists in the removal of the tumor. The extent of the operation depends on the location of the lesion. Peripherally located tumors require a less radical procedure, whereas those stemming from the bronchus may occasionally necessi-
2 60
Orlowski, Stasiak,
The Journal of Thoracic and Cardiovascular Surgery
Kolodziej
tive et isole'es des poumones et des branches. J Franc Med Chir Thorac 9: 330, 1955 9 Lajos TZ, Meckstroth CV: Pedunculated leiomyoma of the lung. Chest 52: 114, 1967 10 Turkington SI, Scott GA, Smiley TB: Leiomyoma of the bronchus. Thorax 5: 138, 1950 11 Williams RB Jr, Daniel RA Jr: Leiomyoma of the lung. J THORAC SURG 19: 806,
1950
12 Barre E: Tumeur bronchiqe a cellules fusiformes apparemment benigne. Branches 12: 386, 1962 13 Berkheiser SW, Szypulski JT: Leiomyoma of intermediate bronchial origin. J THORAC CARDIOVASC SURG
14 15 16 17
38: 398, 1959 Bielojarcef F: Sluczaj dobrokaczestwiennoj opucholi liekkogo u rebionka. Chirurgie 6: 120, 1962 Blaikley JB: Metastasizing fibromyoma. J Obstet Gynecol 80: 856, 1973 Blaive B: Intrathoracic leiomyomas. Mars Med 109: 683, 1972 Brunn H: Two interesting benign lung tumors of contradictory histopathology. J THORAC SURG 9: 119, 1939
Fig. 2. Photomicrographs of the tumor. Top, Oblique course of the ciliary epithelium. Bottom, A fragment of benign tumor with slender nuclei without signs of atypia. tate total resection of the lung. 3, 7 _ u Lobectomy was carried out in 53 percent of the cases. It seems very likely that in many instances of partial and total resection of the lung, a less radical operation such as segmentectomy or sleeve resection might have been performed if the histologic diagnosis had been known prior to the completion of the surgical procedure.
REFERENCES 1 Forkel W: Ein Fall von Fibroleiomyom der Lunge, Z Krebsforsch 8: 390, 1910 2 Aakhus T, Mylius EA: Leiomyoma of the lung. Acta Chir Scand 124: 372, 1962 3 Brouet G: Leiomyome bronchique chez une fillette 12 ans exerese chirurgicale guerison. J Franc Med Chir Thorac 22: 589, 1968 4 Brahdy L: Leiomyoma of the Lung. Am Rev Respir Dis 43: 429, 1941 5 Crastnopol P, Franklin WD: Fibroleiomyoma of the lung. Ann Surg 145: 128, 1957 6 Sweet RS: Pulmonary leiomyoma. Am J Roentgenol Radium Ther Nucl Med 107: 823, 1969 7 Freireich K, Bloomberg A, Langs EW: Primary bronchogenic leiomyoma. Chest 19: 354, 1951 8 Galy P, Touraine RG: Les tumeures conjonctives primi-
18 Carpinisan C, Coman C, Cubolteanu F: Contributions to the study of pulmonary leiomyoma. J Franc Med Chir Thorac 22: 589, 1968 19 Dobrota S, Motil E, Chovanova T, et al: Problematika benignych mezenchymalnych na'dorov plu'cneobvyklych rozmerov. Bratisl Lek Listy 59: 488, 1973 20 Dorken N: Pedunculated fibroma and leiomyoma of the lung. J Int Coll Surg 25: 241, 1956 21 Franco EE: Sopra uno rarissimo voluminoso leiomioma del pulmone. Tumori 15: 27, 1929 22 Gadrat J, Laporte J, Dambrin P, et al: On pulmonary leiomyoma. J Franc Med Chir Thorac 19: 5, 1965 23 Guida PM, Fulcher T, Moore SW: Leiomyoma of the lung. J THORAC CARDIOVASC SURG 49: 1058,
1965
24 Hirose FM, Hennigar GR: Intrabronchial leiomyoma. J THORAC SURG 29: 502,
1955
25 Inberg MV, Sutinen S, Tala E: Leiomyoma of the lung and intercostal space. Scand J Thorac Cardiovasc Surg 3: 52, 1969 26 Koczorowski T, Plachta H: -Lagodny nowotwdr oskrzela jako przyczyna nawracajjcego zapalenia pluc i op}ucnej. Wiad Lek 25: 2233, 1972 27 Kofodziej J, Orlowski TM, Stasiak K, et al: Przypadek rzadkiego nowotworu pluca. Wiad Lek 29: 2211, 1976 28 Konis E, Belsky R: Metastasizing leiomyoma of the uterus. Obstet Gynecol 27: 442, 1966 29 Korobkov ES, Komissarenko BT, Kozyrev IUS: Angiomatoznaia leiomioma legkogo. Grudn Khir 9: 114, 1967 30 Lemoine J: Deux cas de tumeurs bronchiques rares. J Franc Med Chir Thorac 11: 355, 1957 31 Lynn RB, MacFayden DJ: Solitary primary leiomyoma of the lung. Can J Surg 2: 93, 1958 32 Omatskij W: Myoma liegkogo. VoprOnkol 6: 343, 1958 33 Peleg H, Pauzner Y: Benign tumors of the lung. Chest 47: 179, 1965
Volume 76 Number 2 August, 1978
34 Pierce WF, Alznauer RL, Rolle C: Leiomyoma of the lung. Arch Pathol Lab Med 58: 443, 1954 35 Prochazka VJ, Fingerland A, Mydlil F: Intrabronchiales Leiomyom. Thoraxchirurgie 5: 17, 1957 36 Reboul AR, Longefait H, Corolleur JR: Un syndrome du lobe moyen d'etiologie rare. Mars Med 102: 197, 1965 37 Rodrigues WM, de Mello JB, de Arruda RM, de Almeida AM, Zerbini E: Leiomioma do pulmao. Rev Asoc Med Bras 5: 244, 1959 38 Sabbagh AH, O'Hare JE, Fritz JM: Pulmonary leiomyoma. Ariz Med 31: 359, 1974 39 Sherman RS, Malone BH: A roentgen study of smooth
Leiomyoma
of lung
261
muscle tumors primary in the lung. Radiology 54: 507, 1950 40 Taylor TL, Miller DR: Leiomyoma of the bronchus. J THORAC GARDIOVASC SURG 57: 284,
1969
41 Vinner MG, Kazak TI: Pulmonary leiomyoma. Vopr Onkol 10: 118, 1964 42 Van Way CW: Leiomyoma of the lower respiratory tract. Ann Thorac Surg 6: 273, 1968 43 Weil J, Renault P, de Saint Florent G, Delaviere P: Tumeur bronchique rare, leiomyome a cellule granuleuses. J Franc Med Chir Thorac 15: 657, 1961