CT demonstration of an ossifying bronchial carcinoid simulating broncholithiasis

Abstract

A 58-year-old man with long-standing chronic lymphocytic leukemia presented with hemoptysis of 48 hr duration. Medical history was significant only for recurrent episodes of pneumonia. Physical examination revealed diminished breathing sounds over the right lower lobe. Laboratory findings included a hematocrit of 43%, which dropped to 34% within 12 hr after admission, and a platelet count of 20,000. Chest radiographs showed a homogeneous opacification of the right middle and lower lobe consistent with atebectasis. There was no evidence of a discernible endobronchial lesion (Fig. 1A). The patient underwent flexible fiber-optic bronchoscopy, and a large blood clot was discovered in the bronchus intermedius. The bleeding stopped after platelet transfusions. Three days later, followup bronchoscopy revealed a rock-hard, pearly white intraluminal mass almost completely obstructing the bronchus intermedius. A CT scan, obtained after the second bronchoscopy, showed complete atelectasis of the right lower lobe and partial atelectasis of the right middle lobe. Several 1to 2-cm noncalcified lymph nodes were seen in the mediastinum. A densely calcified 1 .5-cm mass was identified at approximately 1 cm proximal to the bifurcation of the right middle and lower lobe bronchus and was initially interpreted as a broncholith (Fig. 1B). Subsequently, however, a magnified bonewindow-setting view of the calcified mass revealed heterogeneous calcifications (Fig. 1C). At thoracotomy, the patient was found to have an endobronchial mass filling the bronchus intermedius approximately 1 cm proximal to the bifurcation of the right middle and lower lobes. A right middle and right lower lobectomy and a biopsy of several enlarged mediastinal and hilar lymph nodes were performed. The resected specimen contained a 1 .5-cm calcified endobronchial mass at the bifurcation of the bronchus intermedius (Fig. 10). The distal lung parenchyma showed patchy areas of consolidation and hemorrhage. Microscopically, the tumor was a typical carcinoid tumor. An unusual feature, however, was the presence of extensive stromal ossification comprising irregularly shaped spicules of calcified lamellar bone (Fig. 1E). The enlarged lymph nodes contained a diffuse infiltrate of small lymphocytes consistent with nodal involvement by