PULMONARY HAMARTOMA PRESENTING AS CENTRAL AIRWAY OBSTRUCTION

Abstract

SESSION TITLE: Medical Student/Resident Procedures SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Pulmonary hamartoma (PHM) is the most common benign tumor of the lung with a population incidence of 0.25% (1). Most PHM are intraparenchymal with only 10% being endobronchial (1). We report a case of endobronchial hamartoma presenting as left main stem (LMS) obstruction treated successfully with combination of snare electrocautery, cryotherapy debulking, and argon plasma coagulation (APC). CASE PRESENTATION: A 52-year old woman, never smoker, with history of cough-variant asthma presented with intermittent wheezing and dyspnea on exertion, presumed to be recurrent episodes of acute bronchitis or asthma. She failed a course of antibiotics and initiation of inhaled corticosteroids with beta 2 agonist therapy. Computed tomography (CT) of the chest demonstrated an ovoid mass predominantly in the left upper lobe bronchus (LUL) with partial extension to LMS and post obstructive collapse of the lingula (fig. 1). Hypoperfusion of the left lung was also evident. Bronchoscopy revealed obstruction of LMS bronchus by an endobronchial lesion (fig. 2). Complete excision of the lesion was performed using combination of snare electrocautery, cryotherapy debulking, and APC destruction of the tumor base, noted to be at the bifurcation of apico-posterior segment of the LUL. Histopathology revealed benign cartilage interspersed with a fibrovascular stroma and scattered bronchial glands, consistent with PHM (fig.3). The patient’s symptoms improved significantly following the intervention. She remains symptom-free on a 3-month follow up. DISCUSSION: Hamartomas are disorganized tumor masses composed of various tissues including fat, epithelium, cartilage, and fibrous stroma. PHMs are usually slow growing and most patients are asymptomatic. Classified as either intraparenchymal or endobronchial, the symptoms depend largely on the location of the tumor; small peripheral intraparenchymal tumors often remain asymptomatic for many years, however, endobronchial hamartomas may present as recurrent bronchitis due to post-obstructive inflammation, as did our patient. Chest radiograph may not reveal collapse despite significant obstruction due to air-trapping as a result of ball-valve phenomenon; however, CT chest is diagnostic. Additionally, hypo-perfusion of the under-ventilated lung may be observed due to perfusion shift to better aerated lung.Given their minimal potential for malignant transformation, PHMs are usually managed conservatively. Tumor debulking utilizing multimodal endoscopic ablative techniques, as in our patient, is the preferred modality in patients with symptomatic endobronchial disease (2). CONCLUSIONS: Endobronchial PHM, although a rare entity, should be considered in the differential diagnosis of patients presenting with chronic cough and/or wheezing. CT allows identification of the location and size of the lesion and bronchoscopic excision using multi-modality approach is therapeutic. Reference #1: 1. Ahmed S, Arshad A, Mador MJ. Endobronchial hamartoma; a rare structural cause of chronic cough. Respiratory medicine case reports. 2017;22:224-7. Reference #2: 2. Bilaceroglu S. Endobronchial Ablative Therapies. Clin Chest Med. 2018;39(1):139-48. DISCLOSURES: No relevant relationships by DIVYANSH BAJAJ, source=Web Response No relevant relationships by Rydhwana Hossain, source=Web Response No relevant relationships by Or Kalchiem-Dekel, source=Web Response No relevant relationships by Akshay Kohli, source=Web Response stock holder relationship with Opko Health, Inc Please note: $20001 - $100000 Added 03/02/2018 by Matthew Paparo, source=Web Response, value=dividends Audience for a educational course relationship with Pinnacle Biologics Please note: $1-$1000 Added 03/02/2018 by Matthew Paparo, source=Web Response, value=Honoraria No relevant relationships by Lynette Parker, source=Web Response No relevant relationships by Edward Pickering, source=Web Response No relevant relationships by Ashutosh Sachdeva, source=Web Response