ENDOBRONCHIAL HAMARTOMA: A MISDIAGNOSIS OF COPD

Abstract

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hamartomas are benign tumors composed of various mesenchymal cells including cartilage, connective tissue, bone and fat. Pulmonary hamartomas constitute about 8% of all benign lung neoplasms and have an incidence of 0.025-0.32%. They typically occur peripherally involving the lung parenchyma and rarely occur as endobronchial tumors. Here, we present a case of endobronchial hamartoma presenting as dyspnea and chronic cough. CASE PRESENTATION: A 61-year-old male non-smoker presented for 6 months of chronic productive cough. His chest x-ray was unremarkable. Pulmonary function testing was notable for mild obstruction with a forced expiratory volume in one second (FEV1) of 84.9%, forced vital capacity (FVC) of 102.1%, FEV1/FVC ratio of 63.74% and normal DLCO without bronchodilator response. He was initially diagnosed with chronic obstructive pulmonary disease (COPD) and prescribed a daily steroid inhaler and as needed short acting bronchodilator. Despite compliance with his inhalers, he continued to have persistent cough and was referred to a pulmonologist. A computed tomography scan of the chest showed two endobronchial soft tissue lesions in the right bronchus intermedius nearly occluding the bronchus intermedius. Diagnostic bronchoscopy showed a lobulated, mobile endobronchial mass obstructing approximately 85% of the lumen. Endobronchial biopsies returned as fragments of mature hyaline cartilage with adipose tissue and benign bronchial epithelium compatible with pulmonary hamartoma. He underwent rigid bronchoscopy and tumor resection with laser cautery to the base by thoracic surgery. Pathology confirmed the diagnosis of pulmonary hamartoma. After resection, he had improvement of his dyspnea and cough. DISCUSSION: Endobronchial hamartomas account for only 10% of pulmonary hamartomas. Most pulmonary hamartomas are asymptomatic as they typically involve the parenchyma. Endobronchial hamartomas most commonly present as post obstructive pneumonia or hemoptysis. Less frequently, non-specific pulmonary symptoms such as cough, wheezing, and/or dyspnea can be the presenting sign and can lead to a misdiagnosis of asthma or COPD. CONCLUSIONS: Although endobronchial tumors are common, endobronchial hamartomas are very rare. Most endobronchial lesions are malignant. Endobronchial hamartomas are typically slow growing and therefore often incidentally discovered on chest imaging. In some cases, they may be poorly or not visualized on chest radiograph. Patients with nonspecific pulmonary symptoms who fail standard management with an unremarkable chest radiograph should prompt further detailed chest imaging to rule out structural causes such as endobronchial hamartomas. The gold standard for management of symptomatic endobronchial hamartomas is rigid bronchoscopy with resection and laser therapy. REFERENCE #1: Cosío, Broja et al. "Endobronchial Hamartoma.” Chest. Vol. 122;1 (2002): 202-205. REFERENCE #2: Ahmed, Saman et al. "Endobronchial hamartoma; a rare structural cause of chronic cough.” Respiratory medicine case reports. Vol. 22 (2017): 224-227. REFERENCE #3: Stevic, Ruza, and Branislava Milenkovic. "Tracheobronchial tumors.” Journal of thoracic disease vol. 8,11 (2016): 3401-3413. DISCLOSURES: No relevant relationships by Kathy Chan, source=Web Response No relevant relationships by George Moran, source=Web Response No relevant relationships by Sudhir Rajan, source=Web Response No relevant relationships by Eduardo Solbes, source=Web Response