A Strategy of Sequential Therapy with a Bronchoscopic Excision and Thoracotomy for Intra- and Extrabronchial Wall Schwannoma: Report of a Case

A 69-year-old woman was admitted with dyspnea on effort and left lung atelectasis on chest X-ray. Fiberoptic bronchoscopy revealed a complete obstruction of the left main bronchus due to a polypoid lesion. This lesion was diagnosed to be a schwannoma arising from the left lower bronchus. Bronchoscopic treatments were performed with electrosurgical snaring and the intratumoral injection of 99.5% ethanol. These treatments were performed once per week for 4 weeks, then were followed with a one-time application of semiconductor laser cautery. These treatments opened the airway and restored the left lung expansion. However, a residual tumor remained at the bifurcation of the left basal bronchus and B6. A cautious follow-up was conducted because schwannoma is a potentially benign tumor. A follow-up bronchoscopic examination at 21 months revealed a regrowth of the residual tumor. A complete resection using a left S6 sleeve segmentectomy was thus performed. The pathologic diagnosis of the tumor was benign schwannoma. There were no complications and no evidence of disease recurrence has been observed after the surgery.     

Papillary adenoma of type 2 pneumocytes

A case of papillary adenoma of type 2 pneumocytes is reported. A 57-year-old man had an unusual coin lesion in the periphery of the right lung without any symptoms. When detected in a mass survey examination, it was approximately 1.5 cm in diameter, well circumscribed, and located in S4, involving the sixth-order bronchus of B4. Light-microscopic examination revealed cuboidal tumor cells arranged in a papillary pattern. Ultrastructurally, the cells had characteristic osmiophilic lamellar bodies. By immunoperoxidase staining, the tumor cells were shown to have intracytoplasmic surfactant apoproteins. The postoperative course was uneventful, and there is no evidence of disease 8 years later.     

Mucoepidermoid carcinoma in a young man treated by bronchoplasty

A 17-year-old man in whom mucoepidermoid carcinoma of the left upper lobe bronchus was successfully treated by bronchoplasty. The patient has been suffered from relapsing respiratory infections over the past 2 years. Bronchoscopic examination revealed a tumor at the orifice of the left upper lobe bronchus. Thus, left upper sleeve lobectomy was carried out. The tumor was 18 x 15 x 14 mm in size and obstructed left upper bronchus with mucoid impaction peripherally. Hystological examination confirmed a diagnosis of low grade malignant mucoepidermoid carcinoma without lymph node metastasis. The patient has been well and free from recurrence for 4 years postoperatively.     

Large bronchial granular cell tumor

We report a 20-year-old woman who underwent complete resection of a granular cell tumor (GCT). On chest computed tomography (CT) scan, a mass with a maximum diameter of 36 mm at the lower bronchus with atelectasis of the right lower lobe was noted. Bronchoscopic examination revealed a whitish mass in the truncus intermedius, and the middle and lower bronchus were unable to be seen. A cytopathological examination of the mass revealed GCT. A right middle and lower lobectomy was performed via a posterolateral thoracotomy. Microscopically, the tumor was composed of polygonal cells with oxyphilic granular cytoplasm and small ovoid nuclei. The cytoplasm of the neoplastic cells was positive for S-100 protein and neuron-specific enolase. The patient’s postoperative course was uneventful, and she was asymptomatic after 4 months. A large bronchial GCT is rare, which is why we report this case.     

A case of tracheal neurilemoma

A 54-year-old woman was admitted to our hospital with a complaint of cough and severe exertional dyspnea. Her pulmonary function was remarkably decline, especially forced expiratory volume in 1 second was 410 ml (28.7%). A chest X-ray film showed an abnormal shadow in the right tracheobronchial portion. Chest CT and MRI scans showed a 38 x 46 mm round tumor in the carina involving the lower trachea and right main bronchus. Bronchoscopic examination revealed a submucosal tumor which obstructed the orfice of the right main bronchus. Pathological examination of tissue obtained by open excisional biopsy revealed a benign neurilemoma. Then we performed a tumor extirpation with tracheal partial resection and the defect of tracheobronchial wall was repaired by direct suture. Postoperative course was uneventful and her pulmonary function was improved. The tracheobronchial neurilemomas are rare. In this report we discuss the therapeutic management of a neurilemoma of the trachea on the basis of 12 domestic cases reviewed.     

Bronchial lipoma treated by surgical resection; report of a case

We report a case of bronchial lipoma, which relapsed after endoscopic treatment, and was treated by surgical resection. An abnormal shadow on chest X-ray was noted at the annual medical checkup of a 44-year-old man. Chest computed tomography (CT) demonstrated a tumor in the right basal bronchus and linear opacity on the peripheral side of that tumor. Bronchoscopic examination demonstrated a smooth polipoid tumor occluding the right basal lobe bronchus. Bronchoscopic biopsy specimens were not sufficient for histological diagnosis. We performed endobronchial resection of the tumor using electrosurgical snare, but 2 months after endoscopic treatment, the tumor relapsed. We therefore performed right S(9+10) segmentectomy. The tumor was 11 x 9mm in size and the histological diagnosis was an endobronchial lipoma. More than 4 years after resection, the patient is alive without recurrence.     

A case of leiomyoma of the intermediate bronchus

Leiomyoma of the trachea and bronchus is a rare tumor. Only 45 cases have been reported in the Japanese literature. We report here a case of leiomyoma of the intermediate bronchus which was successfully operated on. A 45-year-old man suffered from a repeated episode of pneumonia in the right lower lobe. Bronchoscopy revealed a polypoid mass on the intermediate bronchus. The diagnosis of leiomyoma was made by bronchoscopic biopsy. Sleeve resection of the intermediate bronchus including the tumor and end-to-end anastomosis was performed. His postoperative course was uneventful and bronchoscopic findings showed clear healing of the anastomotic site. The resected specimen contained a tumor with smooth surface having protrusion into the bronchial lumen with 6 x 5 x 4 mm in size. The final pathological diagnosis was leiomyoma of the intermediate bronchus with no evidence of malignancy.     

A surgical case of giant mediastinal neurilemmoma]

A 45-year-old male was admitted to Nagoya University Hospital with dyspnea. He was examined by chest X-ray, CT, MRI, and bronchofiberscope. The chest X-ray showed a large abnormal shadow in the right lung field. A large tumor mass pressing the right lung occupied a half of thoracic cavity on a chest CT and MRI. Bronchofiberscopic findings showed a stenosis of the right intermediate bronchus. The clinical diagnosis was posterior mediastinal tumor. He underwent a posterolateral thoracotomy and the tumor was removed smoothly. The size of resected specimen was 15 x 13 x 11 cm. Histopathological examination of the specimen revealed a mediastinal neurilemmoma. He has been well for 4 months postoperatively.     

Leiomyoma of the lung: a case report

An asymptomatic 43-year-old female was admitted to the Hospital because of an abnormal nodule in the left lung field on screening chest X-ray. Chest CT showed a tumor shadow mass (4 x 3 cm) in the left lower lobe. Bronchofiberscopy revealed an endobronchial polypoid mass obstructing the lower lobe bronchus at the orifice of left B10. Lt lower lobectomy was performed. Histopathological examination of the specimen showed the tumor (4.5 x 3.6 x 3.6 cm) developing not only within the tracheal lumen, but also in the lung tissue. Because immunohistochemical staining for desmin and alpha-smooth muscle actin was positive, we diagnosed leiomyoma. As MRI revealed multiple uterine masses after operation, we discussed the diagnostic problems in the relation to metastasizing leiomyoma of the uterus.     

A case of adenoid cystic carcinoma of the left main bronchus, which was performed carinal resection and reconstruction while the aortic arch is pulled down

A 55-year-old woman, who had treated as bronchial asthma for eight months, was admitted to our hospital. Chest CT scan showed a mass in the left main bronchus. Bronchoscopic examination revealed a tumor obstructing the left main bronchus and invading the left lower portion of the trachea. The pathologic diagnosis was adenoid cystic carcinoma. Primary resection of the left main bronchus and the carina with the objective and one-stoma-type carinal reconstruction were performed by the left thoracotomy. We pulled down the aortic arch to obtain an operative field, and carried out the operative procedure at the upper side of the aortic arch. As the resection margin contained residual tumor, the postoperative irradiation (50 Gy) was added.     

A case of collision tumor involving the mouth of the left lower lobe bronchus treated by left lower sleeve lobectomy]

A 72-year-old man was admitted because of hemoptysis. Further examination revealed adenocarcinoma involving the orifice of the left lower lobe bronchus. We performed left sleeve lower lobectomy and the postoperative pathologic examination revealed a collision tumor comprising adenocarcinoma and squamous cell carcinoma.     

Intrabronchial leiomyoma treated with endoscopic resection; report of a case

A 63-year-old female presented with an abnormal shadow on a chest X-ray. A serial chest computed tomography (CT) showed ground-glass attenuation, which measured 2 cm on S1+2 of the left lung. When bronchofiberscopy was performed to make a diagnosis, a tumor with a smooth surface was revealed which obstructed the right middle bronchus. Leiomyoma was thus diagnosed. At first, a wide wedge resection of left lung tumor was performed. Secondly, a bronchus tumor was successively removed using a high frequency snare and a laser by a bronchofiberscopy. Her postoperative course was uneventful. Leiomyoma of the bronchus is rare benign tumor. This report describes the performance of a resection using bronchofiberscopy with good results.     

Carinal resection and reconstruction for recurrent lung cancer

A patient with a recurrent tumor in the trachea adjacent to the right main bronchus was treated by surgical resection 19 months after undergoing surgery for the primary cancer. The patient had previously undergone right upper lobectomy for T1N0M0 stage I squamous cell carcinoma. A carinal resection was performed which included 4 rings of the trachea, 2 rings of the righ main bronchus, and 1 ring of the left main bronchus. Reconstruction consisted of an end-to-end anastomosis of the trachea and left main bronchus, and an end-to-side anastomosis of the right and left main bronchi. The postoperative course was uneventful, and at present the patient is healthy 12 months following reoperation.     

A case of invasive thymoma with endobronchial growth.

We report a rare case of invasive thymoma with endobronchial growth in a 69- year-old woman. Chest CT revealed an ill-defined mass with a calcified lesion in the anterior mediastinum and coin lesion in the bilateral lung fields. An endobronchial polypoid tumor in the right B3 bronchus was found by bronchoscopic examination. A biopsy specimen obtained from the polypoid tumor suggested thymoma. After radiotherapy combined with chemotherapy, thymothymectomy combined with right upper lobectomy through median sternotomy was performed. The surgical specimen revealed that the tumor extended nodularly, not only into the pulmonary parenchyma but also into the bronchial lumen. We performed an added chemotherapy for lung metastasis, and partial resection of lung with video-assisted thoracoscopic surgery (VATS) was done. Now she is alive and disease-free.     

Successful treatment of bronchial mucoepidermoid carcinoma by bronchoplasty

A 63-year-old man who was pointed out abnormal shadow on chest X-ray admitted to our hospital. Chest computed tomography (CT) showed a tumor originated from right upper bronchus and grew into right main bronchus. The tumor was diagnosed as mucoepidermoid carcinoma by bronchoscopic biopsy. Fluorodeoxyglucose positron emission tomography (FDG-PET) showed abnormal uptake localized at the tumor. The standardized uptake values of the tumor 60 minutes after injection were 2.86, and 120 minutes after injection, it increased to 3.97. Right upper lobectomy with bronchoplasty by deep wedge resection of right main bronchus at the orifice of right upper bronchus and lymphadenectomy was performed. Pathological diagnosis was high-grade mucoepidermoid carcinoma without lymph nodes metastasis which was compatible with FDG-PET. Postoperative course was uneventful.     

Endobronchial fibroleiomyomatous hamartoma: a diagnostic pitfall

A 46 year-old man was found to have a polypoidal growth in the lumen of the right main bronchus. Fiberoptic bronchoscope-guided biopsy of the mass on two occasions showed acute-on-chronic inflammation. The origin of the polyp was the right upper lobe bronchus; and upper lobectomy with adequate resection margin was done. Histopathology examination of the polyp showed features compatible with benign fibroleiomyomatous hamartoma. True fibroleiomyomatous hamartoma arising primarily in the lung is rare and presents as a pulmonary parenchymal lesion. the endobronchial variant of this tumor is extremely uncommon and not well documented in the literature. A preoperative diagnosis is difficult, and a high index of suspicion is required for diagnosing this benign neoplasm.     

自发性荧光支气管镜在中心型肺癌诊断中的价值

目的 探讨自发性荧光支气管镜(AFB)在中心型肺癌病人气道检查中的应用价值.方法 2009年9月至2010年3月29例中心型肺癌病人施行了30次AFB和普通白光支气管镜(WLB)检查.其中男23例,女6例;年龄62.2岁.病变位于气管3例,右主支气管1例,右肺上叶9例,右侧中间段支气管1例,右肺中叶1例,右肺下叶4例,左主支气管1例,左肺上叶9例(10次).初诊病例21例,肺癌术后复查8例.采用局部麻醉+静脉持续药物维持的无痛支气管镜检查技术,经口置人荧光支气管镜,先在普通白光状态下全面检查气道,再切换至荧光状态对气道重新检查,对全部可疑病变部位进行活检组织学病理检查.结果 全部病人检查过程顺利,无死亡病例及严重并发症发生.共取活检100处,恶性病变39处,非恶性病变61处.全组中AFB无漏诊,WLB漏诊30处,其中12处为恶性病变,漏诊率30.8%.AFB和WLB对恶性病变诊断的敏感性分别为100%和69.2%.21例初诊病例中,AFB无漏诊,WLB漏诊了23处,其中9处为恶性病变;8例术后常规复查者,AFB无漏诊,WLB漏诊了7处,其中3处为恶性病变.结论 AFB在中心型肺癌病例中可以更准确判断气道内肿瘤侵犯范围,更灵敏发现气道内多发病变,更敏感发现气道内复发病变.

Abstract：

Objective To evaluate the value of autofluorescence bronchoscope (AFB) in airway examination in central type lung cancer. Methods From Sep 2009 to Mar 2010 ,29 patients ( 23 men , 6 women , median age 62.2 years , range from 34 to 81 years) underwent AFB procedure. There were 3 lesions located at trachea, 1 at right main bronchus, 9 at right upper lobe, 1 at right median bronchus, 1 at right middle lobe, 4 at right lower lobe, 1 at left main bronchus, 9 at left upper lobe.There were 21 preliminary diagnostic cases and 8 postoperative surveillance cases. All procedure was performed under combination of local anaesthesia and general anaesthesia. All patients underwent white light bronchoscopy followed by AFB procedure.All of the suspicious abnormal sites were recorded and biopsied for pathological examination. Results All procedures were safely performed without death or serious complications. 100 specimens were obtained for pathologic examination. Malignant lesion was diagnosed in 39 and non-malignancy in61. All malignant sites were detected by AFB, however WLB missed 12 sites.The sensitivity of AFB and WLB for malignancy were 100% and 69.2%, respectively. In 21 preliminary diagnostic cases,AFB detected all malignancy sites, but WLB missed 23 sites, in which 9 were malignant sites. In 8 rechecked patients, AFB detected all malignancy sites, but WLB missed 7 sites, in which 3 were malignant sites. Conclusion Autofluorescence bronchoscopy could be more accurate in judging the extent of the tumor invasion, more sensitive in finding multiple lesions in airway, more sensitive in detecting early cancer recurrence in postoperative surveillance patients.     

Invasive thymoma with endobronchial polypoid growth

A rare case of invasive thymoma with endobronchial polypoid growth is presented. A 68-year-old woman presented with coughing and sputum. The chest X-ray and computed tomography (CT) findings demonstrated a large mass with a calcified lesion in the left hilar region. A bronchoscopic examination showed a polypoid tumor in the left B³b bronchus. The tumor was surgically resected and revealed a unique polypoid endobronchial extension. This tumor was pathologically diagnosed to be invasive thymoma.     

A case of ascending aortic aneurysm with intrathoracic goiter

A case of the successful operation for ascending aortic aneurysm and intrathoracic goiter was described. A 71-year-old woman was admitted to our hospital for the treatment of ascending aortic aneurysm disclosed by the examination in another hospital. Preoperative chest CT showed ascending aortic aneurysm as large as 8 cm in diameter, and an upper mediastinal tumor compressing the main bronchus. The tumor was continuous with the right lobe of the thyroid. The excision of the tumor was performed through median sternotomy with cervical collar incison. After that, the replacement of the ascending aorta was carried out under cardiopulmonary bypass and hypothermic circulatory arrest. The histological examination of the resected specimen revealed adenomatous goiter without malignancy.     

Pleomorphic Carcinoma of the Lung with Mediastinal Extension Following Malignant Lymphoma: Report of a Case

In following up a patient with non-Hodgkin's lymphoma, we encountered a case of pulmonary pleomorphic carcinoma with mediastinal direct invasion. A 65-year-old man with hemoptysis was found to have an abnormal shadow in the right upper lung field. A 6.4 × 4.8-cm tumor adjacent to the upper mediastinum occupied the right anterior segment of the upper lobe (S3) and invaded the superior vena cava (SVC). The serum level of neuron-specific enolase was elevated to 11.9 ng/ml. A specimen from a transbronchial lung biopsy of the right B3b bronchus revealed giant tumor cells. A right upper lobectomy with SVC reconstruction was performed. The resected tumor was diagnosed as a pulmonary pleomorphic carcinoma with a large component of giant and spindle cells, and it is considered to be a rare histologic type.