Endobronchial Polypoid Tumor

Abstract

CASE REPORT A 55-year-old man presented with a 6-month history of malaise and cough associated with intermittent fevers, night sweats, and a weight loss of 7 kilograms. He had increased dyspnea with exertion for a year and associated wheezing. Medical history was unremarkable except for active cigarette use, a 70–pack-year history of smoking, and chronic obstructive pulmonary disease. Physical examination was significant for clubbing and diminished breath sounds with mild bilateral expiratory wheezes. Chest radiograph revealed a 1.5-cm nodule in the superior segment of the right lower lobe, a 3.5-cm mass in the right hilum, and bilateral hyperinflation consistent with chronic obstructive pulmonary disease. Chest computed tomography revealed a 2-cm right lower lobe nodule, a large right hilar mass, and mediastinal adenopathy involving right paratracheal and subcarinal regions. On flexible bronchoscopy, a large white mobile endobronchial polypoid lesion extended along the medial wall of the bronchus intermedius (Fig. 1). The distal end was fixed in the right middle lobe. The main and secondary carina appeared to be widened. Pathologic examination of the mass and transbronchial needle aspiration biopsy of the right upper lobe secondary carina was positive for squamous cell carcinoma. Two weeks after bronchoscopy, the patient had a sudden onset of choking and expectorated a piece of tissue measuring 6 cm × 2 cm (Fig. 2). Histologic examination revealed a poorly differentiated squamous cell carcinoma. Mediastinoscopy confirmed mediastinal involvement and stage T3N2M0 disease. He received palliative radiation therapy. Subsequently, he developed progressive right lung collapse and died of respiratory failure 6 weeks later.FIG. 1.: Large mobile endobronchial polypoid lesion.FIG. 2.: Expectorated piece of tissue.DISCUSSION Endobronchial polypoid neoplasms form a small, distinct group of pulmonary neoplasms that invade and metastasize late. 1 Endobronchial polypoid squamous cell carcinoma is rarely reported. Sherwin et al. described only two cases of endobronchial polypoid tumors in a series of 85 resectable lung cancers. 2 In both cases, the endobronchial tumors were less than 2 cm in diameter. Endobronchial polypoid squamous carcinoma was reported to have a frequency of 2% (34 cases) over a 35-year period with a 5-year survival of 62.5%. 3 These tumors were presumed to carry a favorable prognosis. The differential diagnosis of any endobronchial tumor-like lesion is broad, ranging from benign to malignant processes. Benign endobronchial lesions include inflammatory polyps and papillomas as well as a variety of benign tumors. 4,5 Of the neoplastic category, bronchogenic carcinomas are the most common, but soft tissue tumors and metastatic disease from other organs, such as thymoma, thyroid carcinoma, lymphoma, and renal cell carcinoma have been described. 6–9 Treatment of benign or malignant endobronchial lesions may involve surgical resection or local treatment. When curative resection is not possible, endoscopic and local therapy are effective strategies for palliation. Cryotherapy, electrocautery, brachytherapy, and laser therapy can be applied using rigid or flexible bronchoscopy. 10 These modalities may be combined with conventional chemotherapy, external beam radiotherapy, and surgical resection. 11–12 In contrast to historically described cases, our patient presented with endobronchial polypoid squamous cell carcinoma with a large tumor size, mediastinal involvement, and rapidly progressive clinical course. Our observations underscore the value of flexible bronchoscopy and address limitations in staging. Endobronchial polypoid squamous carcinoma may represent a spectrum of bronchogenic carcinomas that includes tumors exhibiting less aggressive behavior as well as those following a more aggressive course as was seen in this case.