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J Thorac Cardiovasc Surg 2008;136:224-225
© 2008 The American Association for Thoracic Surgery

Brief Communication

Recurrent foreign body granuloma with airway obstruction: Is there a role for steroids?

^a Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
^b Department of Surgical Oncology, National Cancer Centre, Singapore

Received for publication November 25, 2007; accepted for publication December 24, 2007.

^_* Address for reprints: Felicia S. W. Teo, MRCP, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore 169608. (Email: felicia.teo.s.w{at}singhealth.com.sg).

Foreign body granuloma is a well-recognized complication of thoracic surgery and is usually managed by removal of the inciting agent. We describe a rare case of recurrent granuloma formation causing significant airway obstruction despite tracheal surgery, airway stenting, and repeated bronchoscopic resections in which the use of systemic steroids eventually led to granuloma regression, obviating the need for further intervention.

Clinical Summary

A 59-year-old man underwent right pneumonectomy for non–small cell lung cancer. Five years later, he presented with progressive dyspnea. Fiberoptic bronchoscopy revealed a nodule over the pneumonectomy stump with 30% occlusion of the left main bronchus. Histology of the resected specimen showed chronic inflammation, and the patient declined further investigations. However, he became dyspneic again 7 months later and acceded to repeat bronchoscopy, which showed a new nodule of similar appearance at the same site. Tracheal resection was performed, with histology suggestive of inflammatory granuloma at the origin of prior suturing. The results of microbiologic tests for tuberculosis were negative.

Over the next 12 months, he experienced repeated episodes of airway obstruction due to recurrent granuloma causing between 30% and 100% airway occlusion ( Figure 1), despite 7 bronchoscopic resections and the adjunctive use of topical mitomycin. As a last resort, a modified inverted Y-shaped silicone stent was deployed by means of rigid bronchoscopy across the carina to cover the suture line. Nonetheless, his symptoms recurred barely a week later, and bronchoscopy revealed extensive granulation tissue over the proximal origin and distal end of the left arm of the Y-stent ( Figure 2, A). After a final attempt at bronchoscopic resection, a trial of systemic steroids was commenced at 0.5 mg · kg^–1 · d^–1 for a month and tapered over 3 months to a maintenance dose of 5 mg every other day. This resulted in significant regression of granulation tissue (Figure 2, B).

View larger version (127K): [in this window] [in a new window]   Figure 1. Recurrence of granuloma at the tracheal suture line, causing ball-valve effect luminal occlusion.

View larger version (78K): [in this window] [in a new window]   Figure 2. Granulation tissue seen over the distal end of the Y-stent at the left bronchial arm 1 week after placement (A) and 3 months after the commencement of steroid treatment (B).

Foreign body granuloma commonly arises at a site of a previous intervention, where foreign material,^1,2 such as buttressing tissue, sutures, staplers, or stents, might provoke a specialized inflammatory response in a predisposed individual.³

The inciting agent might not always be demonstrable in a histologic specimen. In our patient the mere presence of foreign material provoked extensive granulation tissue formation with significant airway obstruction, necessitating repeated interventions. Unfortunately, these interventions in themselves can sometimes perpetuate a cascade of inflammation, healing, and further elaboration of granulation tissue. It is noteworthy that despite their reputation as relatively inert material, silicone stents² have been implicated in the pathogenesis of foreign body granuloma.

Systemic steroids have been widely used to treat immune-mediated granuloma, such as sarcoidosis⁴; their role in managing foreign body granuloma is less well defined. Interestingly, an allergic component to the pathogenesis of foreign body granuloma has been proposed after several authors observed a direct correlation between a positive skin (wheal-and-flare) test response involving intradermal insertion of silk or catgut sutures and the development of granuloma at the surgical site.³ Given this mechanistic similarity, steroids have been used to treat suture granuloma in the thyroid³ and ophthalmic⁵ literature, albeit with variable success. To our knowledge, this is the first report on the successful use of steroids for foreign body granuloma in the airway after thoracic surgery. Although resection remains the cornerstone of management and infection should always be excluded in the first instance, we suggest that systemic steroids be considered as an adjunct in intractable cases of foreign body granuloma.

References

1. Oey IF, Jeyapalan K, Entwisle JJ, Waller DA. Pseudo-tumours of the lung after lung volume reduction surgery. Ann Thorac Surg 2004;77:1094-1096.[Abstract/Free Full Text]
   
2. Dumon JF, Cavaliere S, Diaz-Jimenez JP, et al. Seven year experience with the Dumon prosthesis. J Bronchol 1996;3:6-10.
   
3. Hocwald E, Sichel JY, Dano I, Meir K, Eliashar R. Adverse reaction to surgical sutures in thyroid surgery. Head Neck 2003;25:77-81.[Medline]
   
4. Baughman RP, Lower EE, du Bois RM. Sarcoidosis. Lancet 2003;361:1111-1118.[Medline]
   
5. MacEwen C, Gregson R. Complications of strabismus surgery: how to avoid and manage them. Manual of strabismus surgery. Oxford: Butterworth-Heinemann; 2003. pp. 181.
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Teo, F. S.W. Articles by Thirugnanam, A. Search for Related Content PubMed Articles by Teo, F. S.W. Articles by Thirugnanam, A. Related Collections Lung - cancer Lung - other Trachea and bronchi