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J Thorac Cardiovasc Surg 2007;134:1080-1081
© 2007 The American Association for Thoracic Surgery

Brief Communication

Fibroepithelial polyps: Preoperative diagnosis may avoid thoracotomy

Christopher T. Wartmann, MDa,b, Denise Fernandez, BAb, Raja M. Flores, MDb,*

a Department of Surgery, Northwestern University, Chicago, Ill
b Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.

Received for publication April 23, 2007; accepted for publication May 30, 2007.

* Address for reprints: Raja M. Flores, MD, Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10021. (Email: floresr{at}mskcc.org).


Figure 1
Dr Wartmann


We present the case of a 32-year-old man who presented with an indeterminate obstructing lung lesion thought to be malignant. Thoracotomy revealed the lesion to be a benign fibroepithelial polyp of the bronchus. Had this diagnosis been entertained preoperatively, thoracotomy might have been avoided.

Clinical Summary

This construction worker with a medical history consisting of smoking 1 pack of cigarettes per day for 16 years presented to his general practitioner and was treated for asthma and recurrent pneumonia. A chest radiograph taken at this time showed minimal lower lobe subsegmental atelectatic changes along with a mild degree of perihilar pulmonary vascular congestion. A chest computed tomographic (CT) scan demonstrated a 3-cm mass occluding the left mainstem bronchus, extending into the left upper and lower lobe bronchi (Figure 1). A positron emission CT scan illustrated no lymphadenopathy, and no fluorodeoxyglucose accumulation was seen in the left endobronchial lesion.


Figure 1
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  		Figure 1. Computed tomographic scan demonstrating occlusion of the left mainstem bronchus.

 
The patient underwent rigid bronchoscopic scanning, where the lesion within the left mainstem bronchus was identified. The lesion side underwent biopsy multiple times; pathology showed benign squamous mucosa with extensive submucosal fibrosis and mild chronic inflammation, with no tumor seen. An attempt was made at coring out this lesion. However, in lieu of radiographic evaluation and demarcation, it was deemed unsafe to remove at this time because of the potential for pulmonary artery invasion; therefore aggressive coring out by means of rigid bronchoscopy could result in significant hemorrhage. Thus thoracotomy was scheduled because of fear of a missed malignant diagnosis caused by the lesion’s extensive nature and to avoid potential hemorrhage caused by performing aggressive rigid bronchoscopy. A left posterolateral thoracotomy was performed, and the lung was inspected without any evidence of parenchymal lesions. A bronchotomy was made in the orifice of the left upper lobe bronchus. A significant amount of endobronchial lesion was removed in a piecemeal fashion. This was a lobulated, multiseptated, fleshy lesion slightly larger than a golf ball that continued down into the left upper and lower lobes (Figure 2). On closer inspection, the lesion was adherent to a segmental bronchus down in the left lower lobe by a single stalk; a frozen section was determined to be benign. The area from which the lesion was excised underwent laser ablation. Final pathologic analysis revealed a benign fibroepithelial polyp. The patient has no complaints and is doing well on 3-year follow-up. Surveillance bronchoscopy and CT scanning demonstrate no evidence of recurrent disease.


Figure 2
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  		Figure 2. Gross photo of the mass.

 
Discussion

Inflammatory polyps are solitary benign endobronchial lesions with stromal configurations consisting of well-formed fibrous connective tissue with or without inflammatory cell infiltration.1Go Many believe that these lesions are more inflammatory than truly neoplastic in nature, which is supported by the fact that several reports show that these polyps are seen much less frequently since the introduction of antibiotics.1Go However, the cause of fibroepithelial polyps of the bronchus remains unclear. More importantly, these lesions can be mistaken as either malignant lesions or those with an indeterminate histopathologic diagnosis. For example, in a case report by Dincer and colleagues,2Go a large obstructing endobronchial polyp was treated with a bilobectomy to alleviate the respiratory symptoms and provide a definitive diagnosis. The authors believe that although these lesions are rare, it is important to educate the thoracic surgeon on the existence of bronchial fibroepithelial polyps to avoid unnecessary thoracotomies or lung resection for a benign lesion that could possibly be treated with endobronchial methods alone. Furthermore, although few reports exist in the modern literature concerning these lesions, there are common presenting symptoms that should be noted. Multiple reports, including this one,1-3Go assert that patients who were later found to have benign endobronchial lesions all presented with asthma, pleuritic chest pain, and a history of recurrent pneumonia.

In summary, had the possible diagnosis of benign bronchial fibroepithelial polyps been considered, greater efforts would have been made to identify its stalk and core out the lesion in a piecemeal fashion by means of laser ablation through a rigid bronchoscopy, negating the need for a thoracotomy to both determine the nature of the lesion and to relieve the obstruction.

References

  1. Gamblin TC, Farmer LA, Dean RJ, Bradley RA, Dalton ML. Tracheal polyp. Ann Thorac Surg 2002;73:1286-1287.[Abstract/Free Full Text]
  2. Dincer I, Demir A, Akin H, Melek H, Altin S. A giant endobronchial inflammatory polyp. Ann Thorac Surg 2005;80:2353-2356.[Abstract/Free Full Text]
  3. Schnader J, Harrell J, Mathur P, Joseph C, Koduri J, Kvale P. Clinical conference on management dilemmas: bronchiectasis and endobronchial polyps. Chest 2002;121:637-643.[Medline]



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