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Location, Location, Location: An Uncommon Problem in a Common Place
March 2014, Vol 145, No. 3_MeetingAbstracts Pulmonary Procedures | March 2014
Location, Location, Location: An Uncommon Problem in a Common Place Matthew Hammar, DO; Jan Silverman, MD; Yulin Liu, MD; Susan Mucha, MD; Mark Lega, MD Allegheny General Hospital, Pittsburgh, PA
Chest. 2014;145(3_MeetingAbstracts):471A. doi:10.1378/chest.1823658
Abstract SESSION TITLE: Bronchology Case Report Posters SESSION TYPE: Case Report Poster PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary hamartomas (PH) are a benign growth usually containing fat, cartilage and respiratory epithelium. They are the most common benign lung tumor with an incidence from 0.025% to 0.32% based on autopsy series studies. The vast majority of PH are located in the lung parenchyma. The largest case series consisting of 215 patients with PH reported only 3 endobronchial hamartomas (1.4%). We report an endobronchial hamartoma causing post-obstructive pneumonia and hemoptysis. CASE PRESENTATION: A 68-year-old Caucasian male with a history of tobacco dependence and atrial fibrillation on aspirin therapy presented with hemoptysis. The patient complained of coughing episodes associated with pleuritic chest pain for the past 24 hours. Although his presenting complaint was hemoptysis, the patient admitted to an initial symptom of dyspnea on exertion over the past several weeks. CXR revealed a retrocardiac infiltrate. Chest CT demonstrated a left mainstem endobronchial lesion suspicious for bronchogenic carcinoma with a post-obstructive pneumonia. A large flesh colored, polypoid endobronchial mass was seen in the left mainstem bronchus. Multiple endobronchial biopsies, fine needle aspirates and cytologic brushings were taken. Real-time bedside pathology review was nondiagnostic prompting extra sampling. The final pathology assessment reported only benign respiratory mucosa. Accordingly, thoracic surgery removed the mass via rigid
bronchoscopy. Histologic examination revealed an endobronchial hamartoma. DISCUSSION: Although PHs are the most common benign lung tumor, the incidence is reported <0.33%. Most PHs are located in the lung parenchyma. Endobronchial variants only account for 1.4% of all PHs. Our high volume tertiary care center has seen only 12 endobronchial PHs since 2000. Parenchymal PHs are generally asymptomatic incidentally discovered “coin lesions”. Whereas, endobronchial hamartomas are likely to cause symptoms based on their size and location. Obstruction of the bronchial lumen may cause cough, pleural pain, bronchospasm and post-obstructive pneumonia. Hemoptysis may also be present but has only been described in the setting of post-obstructive infection. Diagnosis with traditional fiberoptic bronchoscopy is challenging and usually does not yield a diagnosis. One small case series reported only 2 of 7 endobronchial hamartomas were diagnosed with the flexible bronchoscope because of the “extreme hardness” of the tumor. CONCLUSIONS: Bronchoscopists should be aware that endobronchial hamartomas should be included in the differential diagnosis of an endobronchial mass. An endobronchial hamartoma may be accessible with a fiberoptic bronchoscope, but the likelihood of a tissue and cytologic diagnosis is low secondary to the submucosal location and density of the tumor. Reference #1: Borro, J., Moya, J., Botella, J., Padilla, J., Canto, A., Paris, F. Endobronchial hamartoma, report of 7 cases. Scand J Thor Cardiovasc Surg 1989; 23:285-287. Reference #2: Cosio, B., Villena, V., Echave-Sustaeta, J., Miguel, E., Alfaro, J., Hernandez, L., Sotelo, T. Endobronchial hamartoma. CHEST 2002; 122:202-205. Reference #3: Gjevre, J., Myers, J., Prakash, U. Pulmonary hamartomas. Mayo Clin Proc 1996; 71(1):14-20. DISCLOSURE: The following authors have nothing to disclose: Matthew Hammar, Jan Silverman, Yulin Liu, Susan Mucha, Mark Lega No Product/Research Disclosure Information
Location, Location, Location: An Uncommon Problem in a Common Place Matthew Hammar, DO; Jan Silverman, MD; Yulin Liu, MD; Susan Mucha, MD; Mark Lega, MD Allegheny General Hospital, Pittsburgh, PA
Chest. 2014;145(3_MeetingAbstracts):471A. doi:10.1378/chest.1823658
Abstract SESSION TITLE: Bronchology Case Report Posters SESSION TYPE: Case Report Poster PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary hamartomas (PH) are a benign growth usually containing fat, cartilage and respiratory epithelium. They are the most common benign lung tumor with an incidence from 0.025% to 0.32% based on autopsy series studies. The vast majority of PH are located in the lung parenchyma. The largest case series consisting of 215 patients with PH reported only 3 endobronchial hamartomas (1.4%). We report an endobronchial hamartoma causing post-obstructive pneumonia and hemoptysis. CASE PRESENTATION: A 68-year-old Caucasian male with a history of tobacco dependence and atrial fibrillation on aspirin therapy presented with hemoptysis. The patient complained of coughing episodes associated with pleuritic chest pain for the past 24 hours. Although his presenting complaint was hemoptysis, the patient admitted to an initial symptom of dyspnea on exertion over the past several weeks. CXR revealed a retrocardiac infiltrate. Chest CT demonstrated a left mainstem endobronchial lesion suspicious for bronchogenic carcinoma with a post-obstructive pneumonia. A large flesh colored, polypoid endobronchial mass was seen in the left mainstem bronchus. Multiple endobronchial biopsies, fine needle aspirates and cytologic brushings were taken. Real-time bedside pathology review was nondiagnostic prompting extra sampling. The final pathology assessment reported only benign respiratory mucosa. Accordingly, thoracic surgery removed the mass via rigid
bronchoscopy. Histologic examination revealed an endobronchial hamartoma. DISCUSSION: Although PHs are the most common benign lung tumor, the incidence is reported <0.33%. Most PHs are located in the lung parenchyma. Endobronchial variants only account for 1.4% of all PHs. Our high volume tertiary care center has seen only 12 endobronchial PHs since 2000. Parenchymal PHs are generally asymptomatic incidentally discovered “coin lesions”. Whereas, endobronchial hamartomas are likely to cause symptoms based on their size and location. Obstruction of the bronchial lumen may cause cough, pleural pain, bronchospasm and post-obstructive pneumonia. Hemoptysis may also be present but has only been described in the setting of post-obstructive infection. Diagnosis with traditional fiberoptic bronchoscopy is challenging and usually does not yield a diagnosis. One small case series reported only 2 of 7 endobronchial hamartomas were diagnosed with the flexible bronchoscope because of the “extreme hardness” of the tumor. CONCLUSIONS: Bronchoscopists should be aware that endobronchial hamartomas should be included in the differential diagnosis of an endobronchial mass. An endobronchial hamartoma may be accessible with a fiberoptic bronchoscope, but the likelihood of a tissue and cytologic diagnosis is low secondary to the submucosal location and density of the tumor. Reference #1: Borro, J., Moya, J., Botella, J., Padilla, J., Canto, A., Paris, F. Endobronchial hamartoma, report of 7 cases. Scand J Thor Cardiovasc Surg 1989; 23:285-287. Reference #2: Cosio, B., Villena, V., Echave-Sustaeta, J., Miguel, E., Alfaro, J., Hernandez, L., Sotelo, T. Endobronchial hamartoma. CHEST 2002; 122:202-205. Reference #3: Gjevre, J., Myers, J., Prakash, U. Pulmonary hamartomas. Mayo Clin Proc 1996; 71(1):14-20. DISCLOSURE: The following authors have nothing to disclose: Matthew Hammar, Jan Silverman, Yulin Liu, Susan Mucha, Mark Lega No Product/Research Disclosure Information