Non-Neural (S-100 Negative) Bronchial Granular Cell Tumor Causing Acute Respiratory Failure.

Introduction: Endobronchial granular cell tumors are uncommon in the pediatric population. Case report: A 9-year-old female presented with respiratory failure due to an endobronchial tumor. After debulking and diagnosis, she underwent thoracotomy with right upper lobe resection and bronchoplasty. Pathology demonstrated an endobronchial S-100 negative granular cell tumor, which to our knowledge, is the first such report in the literature. Conclusion: Endobronchial granular cell tumors may cause obstructive respiratory failure, are amenable to surgery, and may be S-100 negative.

Factors affecting survival in patients with endobronchial malignant mass after flexible Bronchoscopic cryotherapy: a cohort study.

BACKGROUND: Malignant endobronchial mass (MEM) has poor prognosis, cryotherapy is reportedly to diagnose MEM, however, the therapeutic role of cryotherapy impacts on survival has not be well addressed. METHODS: Cohort data on post-cryotherapy MEM patients in a university-affiliated hospital between 2007 and 2012 were evaluated. Factors that impact survival of these subjects were analyzed using multivariate regression analysis. RESULTS: During study period, 67 patients (47 males), with median age was 63 years (range, 50-77 and median performance status of 2 (inter-quartile range [IQR], 2-3). Twenty-five had primary lung squamous cell carcinoma, 14 primary had lung adenocarcinoma, seven had metastatic colon adenocarcinoma, four had sarcoma, four had non-small cell lung cancer, four had small cell lung cancer, three had large cell carcinoma, two had lymphoma, one had muco-epidermoid carcinoma, two had esophageal squamous cell carcinoma, and one had metastatic renal cell carcinoma. MEM were observed as follows: 15 at the trachea, 14 at the left main bronchus, 12 at the right main bronchus, 12 at the right upper lobe bronchus, five at the right intermediate bronchus, three at the right lower lobe bronchus, three at the left upper lobe bronchus, two at the left lower lobe bronchus, and one at the right middle lobe bronchus Post-cryotherapy complications included minor bleeding (n = 14) and need for multiple procedures (n = 12); outcomes were relief of symptoms (n = 56), improved performance status (n = 49) and ability to receive chemotherapy (n = 43). After controlling for other variables, performance status improved after cryotherapy (odds ratio [OR] 3.7; p = 0.03; 95% confidence interval [CI] 1.2~10.7) and ability to receive chemotherapy (OR 4.3; p = 0.02; 95% CI 1.4~13.7) remained significant survival factor. Patients who received chemotherapy and cryotherapy had better survival than patients who received only cryotherapy (median, 472 vs. 169 days; log-rank test, p = 0.02; HR 0.37; 95% CI 0.16-0.89). CONCLUSION: Cryotherapy could be useful management of MEM by flexible bronchoscopy. The performance status after cryotherapy improved and caused further chemotherapy possible for the study patients and thereby, improved survival. However, the mechanism in detail of cryotherapy improve survival should be explored in the future.

A rare case of an endobronchial mass due to Neurospora intermedia.

The ascomycete filamentous fungus Neurospora intermedia is commonly used in the food industry and considered nonpathogenic to humans. This study characterizes four N. intermedia isolates recovered from three patients. The first patient had a mediastinal germ cell tumor with multiple metastases. N. intermedia was recovered from his endotracheal aspirate and from the endobronchial mass obtained by bronchoscopic forceps biopsy. Histopathology of the biopsy tissue revealed necrotic tissue mixed with septate fungal hyphae with right-angle branching. An endobronchial mass caused by N. intermedia was thus diagnosed. Another two N. intermedia isolates were recovered from the endotracheal aspirates of two critically ill patients. In vitro, N. intermedia grows rapidly and forms orange, conidiating colonies composed of septate hyphae. Two isolates from the first patient belong to mating type a; the other two isolates belong to mating type A. Coculture of isolates of opposite mating types yielded dark ascomata containing ascospores, supporting that N. intermedia is a heterothallic fungus. N. intermedia isolates cross-reacted with the Aspergillus galactomannan antigen assay and were susceptible to amphotericin B and voriconazole. In conclusion, this report describes the first human infection (endobronchial mass) caused by N. intermedia, highlighting its potential to invade the human respiratory tract.

A rare phenomenon, primary pulmonary smooth muscle tumor and its management.

Smooth muscle tumors of uncertain malignant potential, the borderline tumors arising from the smooth muscle cells, usually grow slowly and do not fulfill the diagnostic criteria of leiomyosarcoma and its variants, but may behave in a malignant manner. A 15-year-old female patient with an endobronchial mass in the left main bronchus on thoracic computed tomography underwent thoracotomy and tracheobronchoplasty with a wide and safe margin. Histopathological evaluation revealed a smooth muscle tumor of uncertain malignant potential. There were no complications related to the operation during the hospital stay. At six months of surgery, there were no symptoms or signs suggesting any recurrence in her follow-up. In conclusion, In conclusion, pulmonary leiomyomas may rarely present as an endobronchial mass and may mimic asthma by causing respiratory symptoms developing as attacks due to displacement of the mass within the lumen.

An Unusual Pulmonary Aspergillus Infection: Endobronchial Aspergilloma.

Endobronchial aspergilloma (EBA) is an extremely rare presentation of pulmonary involvement of Aspergillus. It is a noninvasive form of pulmonary aspergillosis where the fungus overgrows and colonizes the bronchial lumen. The patient may present with chronic cough, dyspnea, hemoptysis, or wheezing. The diagnosis is usually incidental when bronchoscopy is performed to evaluate the cause of hemoptysis or radiological abnormalities. Here, we report a case of a middle-aged female who presented with hemoptysis and right middle lobe collapse and was subsequently diagnosed to have EBA on bronchoscopy with endobronchial biopsy. Although EBA is rare, it should be considered as a differential in the evaluation of endobronchial mass lesions.

Carcinoid Tumor Presenting as Hemoptysis and Elevated Diaphragm.

A bronchial carcinoid tumor is a rare pulmonary neuroendocrine tumor. This report describes a case where a patient experienced multiple episodes of hemoptysis and dyspnea on exertion over the course of five months. An initial chest X-ray showed an elevated right hemidiaphragm with atelectasis, and a follow-up chest computed tomography (CT) scan was ordered to further assess this finding. The CT revealed a tumor occluding 90% of the right main stem bronchus lumen. A bronchoscopy with biopsy was then performed, confirming the diagnosis of a pulmonary carcinoid tumor. The patient underwent surgical resection of the tumor, a right upper lobe sleeve lobectomy, and a mediastinal lymph node dissection, resulting in full eradication of the tumor. This case highlights the need for physicians to maintain a broad differential when evaluating a patient with hemoptysis and an elevated diaphragm.

Pulmonary artery aneurysm protruding into the bronchus as an endobronchial mass: A case report.

BACKGROUND: Pulmonary artery (PA) aneurysms are usually diagnosed radiographically and present as small or large lesions resembling inflammation or a neoplasm on chest radiography. It has rarely been reported as an endobronchial mass. CASE SUMMARY: We report the case of a 64-year-old man who presented with recurrent hemoptysis. Bronchoscopy revealed a tumorous protrusion blocking the right middle lobe bronchus, which was confirmed to be a PA aneurysm using endobronchial ultrasound bronchoscopy and computed tomography angiography. CONCLUSION: Although endobronchial PA aneurysms are rare, bronchoscopists need to add this lesion to the list of endobronchial masses for which a biopsy is to be assiduously avoided.

Endobronchial mucormycosis: A rare clinical entity diagnosed by endobronchial cryobiopsy.

Mucormycosis is a rare fungal infection caused by fungi of the order Mucorales. The rhino-cerebral form of mucormycosis is most commonly seen in patients with diabetes mellitus, whereas pulmonary mucormycosis is a rare manifestation in patients with hematological malignancy and transplant recipients. We report a case of a 40-year-old male, with history of poorly controlled diabetes, who presented to the emergency room with a one-week history of hemoptysis. Computed Tomography (CT) of the chest was concerning for a lung mass or abscess. Flexible bronchoscopy revealed an endobronchial lesion that was biopsied with a cryoprobe. Histopathologic examination showed non-septate right-angle branching hyphae, typical of mucormycosis. He underwent surgical resection of the right middle and lower lobes and treatment with antimycotic agents with a complete recovery. This case highlights the importance of early histopathological diagnosis of pulmonary mucormycosis in preventing a fatal outcome.

Impacted gutkha presenting as an intrabronchial mass lesion leading to post-obstructive pneumonia.

A 66-year-old man presented with a chief complaint of difficulty breathing and productive cough. CT scan of the chest revealed an endobronchial mass with associated "tree-in-bud" opacities. A bronchoscopic biopsy of the mass was performed due to clinical suspicion of malignancy. Microscopic examination revealed inflamed endobronchial mucosa, granulation tissue and abundant fragments of uncharacterized organic material, compatible with aspiration. Detailed history revealed a history of chewing "gutkha", a form of smokeless tobacco comprising a mixture of betel nut and other condiments. Microscopic sections of a betel nut and the "gutkha mix" processed subsequently in the histology laboratory were found to be similar to the organic material found in the mass. Thus, a diagnosis of impacted betel nut mixture leading to post-obstructive pneumonia was rendered.

The importance in early identification of a herpetic endobronchial mass.

We present a case of a 78 year old female that required intubation for hypercapnic, hypoxic respiratory failure, found to have an obstructing mass in the right main stem bronchus positive for Herpes Simplex (HSV) I and II on biopsy and immunohistochemistry (IHC). Herpetic endobronchial masses are described rarely, and having them on the differential when investigating endobronchial masses can promote prompt treatment and decrease unnecessary investigations. Our goals in highlighting this report include incidence of HSV pneumonia [7], the need to include it as part of the differential diagnosis in working up endobronchial masses, especially in intubated patients, and the various modalities of treatment.

Endobronchial masses encountered on fine-needle aspiration biopsy: a focus on unusual entities.

Fine-needle aspiration biopsy (FNAB) is a useful technique in the evaluation of central lung tumors which is commonly encountered in clinical cytology practice. Some of these tumors may show endobronchial, polypoid growth which is readily apparent to the endoscopist. Pulmonary salivary gland-type tumors and carcinoid tumors are overall uncommon in the lung, but these tumors tend to occur centrally and show endobronchial involvement. The prognosis of these tumors is generally better than that of small cell or non-small cell carcinomas of the lung and more conservative surgical resection is often indicated. The identification of salient cytological features and a high index of suspicion when considering the differential diagnosis of a central lung tumor is essential to accurate diagnosis. This review focuses on cytological clues as well as ancillary techniques that may be useful to the practicing cytopathologist.

A unique case report of endobronchial cryptococcosis and review of the literature.

Cryptococcosis is an infection caused by the yeast-like fungus Cryptococcus neoformans. Pulmonary cryptococcosis is typically identified as a single mass or as multiple nodules, while endobronchial lesions are quite rare. Here we report an uncommon case of pulmonary cryptococcosis presenting as endobronchial lesion in an immunocompetent patient. A 49-year-old male patient complained of intermittent cough with hemoptysis for two years. Computerized tomography of the chest showed a filling defect in the basal segment of the right lower lobe bronchus. A flexible bronchoscopic examination revealed a white smooth-surfaced polypoid lesion completely occluding the medial basal segment of the right lower lobe bronchus. The diagnosis was confirmed by bronchial biopsy under bronchoscopy, and the histopathologic findings showed the organisms were Cryptococcal neoformans. The patient was treated with fluconazole at a dose of 400 mg daily. The endobronchial lesion was found rapidly diminished after 18 days of therapy, and disappeared after 6.5 months of therapy by repeated fiberoptic bronchoscopy. Then the patient continued fluconazole for another 2.5 months. During the total 16 months' follow-up visits, the patient repeated CT scanning for five times, the results of which were all normal. The patient's symptoms disappeared as well, and now he is still under follow-up. This case highlights the fact that pulmonary cryptococcosis can present as endobronchial lesions even in immunocompetent subjects, mimicking lung tumor. Pathological confirmation is important to establish the definite diagnosis.

Intrathoracic ganglioneuroma presenting as an endobronchial mass.

Peripheral nerve sheath tumors (PNST) are exceedingly rare, especially outside of the posterior mediastinum. These tumors represent less than 1% of pulmonary tumors. Very few pulmonary PNSTs are ganglioneuromas. We present a case of a ganglioneuroma presenting as an endobronchial mass. CASE PRESENTATION: An 80 year old male was seen in pulmonary clinic for routine cancer screening. He had a 60-pack year smoking history. CT evaluation noted a 1cm right lower lobe endobronchial lesion. This lesion was present since 2012 and had slightly increased in size since that time from 8mm (Figure 1). The lesion was further assessed using virtual bronchoscopy (Figure 2). Bronchoscopy revealed an obstructing lesion, which was completely excised with the snare (Figure 3). Pathology revealed well-circumscribed tumor consisting of nests and trabeculae of round/polygonal cells with granular eosinophilic and basophilic cytoplasm. The tumor was chromogranin, synaptophysin, S-100, pancytokeratin, SOX10, and TTF-1 positive, consistent with a ganglioneuroma. DISCUSSION: Aside from a solitary article regarding 75 patient samples (which included only one ganglioneuroma) only a small number of intrathoracic PNSTs have been reported. Only a single case report of an endobronchial ganglioneuroma has been reported. Each of these lesions were benign, and detected on routine imaging evaluations. CONCLUSIONS: An intrapulmonary endobronchial location for a PNST is an exceedingly rare presentation of an already uncommon pathology.

A novel presentation of Mycobacterium avium complex in a recipient of a lung transplant: a case report.

BACKGROUND: Lung transplantation remains an important potential therapeutic option for end-stage lung disease. It can improve quality of life and in some cases be a life-lengthening therapy. Despite the possible benefits, there are also many potential complications following transplantation. Here we describe a novel presentation of nontuberculous mycobacterium manifesting as an endobronchial mass developing 4 years after lung transplantation. CASE PRESENTATION: A 66-year-old African-American woman presented with progressive dyspnea, cough, and persistent wheezing of 2 months' duration. She had a distant history of breast cancer and received bilateral lung transplantation due to end-stage pulmonary fibrosis 4 years prior to her current presentation. She denied fevers, but did endorse night sweats. She had diffuse expiratory wheezing on auscultation. Chest computed tomography imaging showed an endobronchial soft tissue lesion nearly occluding the left mainstem bronchus, which was concerning for endobronchial carcinoma. Rigid bronchoscopy demonstrated a fibrinous mass protruding into the left mainstem proximal to the anastomosis. A pathology report noted fragments of partially necrotic granulation tissue in addition to scant fragments of focally ulcerated bronchial mucosa. Both the tissue culture and bronchial wash stained positively for acid-fast bacilli and grew Mycobacterium avium complex. CONCLUSIONS: Nontuberculous mycobacterium pulmonary disease is common post lung transplant and risk factors are related to immunosuppression and history of structural lung disease. Mycobacterium avium complex presenting as an endobronchial lesion in a patient post lung transplant is a novel presentation.

Mucoepidermoid carcinoma of the airways in a young adult male.

Mucoepidermoid carcinoma (MEC) of the airways is a rare entity most often found in young patients. We present a case of a 23 year old patient with symptoms of pneumonia, which progresses to a pulmonary abscess within a week. Diagnostic work-up reveals an endobronchial obstruction by a pedunculated low grade MEC. A literature review is provided and radiological appearances are described.

Pulmonary cryptococcosis: An unusual presentation.

Cryptococcal infection of the lung is usually asymptomatic in immunocompetent hosts. Symptomatic cryptococcal lung infection presenting as an endobronchial mass lesion in an immunocompetent host is rare. We report our experience with an immunocompetent young patient presenting with an endobronchial mass lesion caused by cryptococcal infection. This male patient presented with left sided collapse, consolidation on computed tomography scanning, and was found to have a polypoid lesion in the left main bronchus. The diagnosis was confirmed by bronchial biopsy and the patient responded well to parenteral antifungal therapy. The case report is followed by a review of pulmonary cryptococcosis including clinical features, diagnosis, and treatment.