British Journal of Radiology (2007) 80, e91-e93
© 2007 British Institute of Radiology
doi: 10.1259/bjr/25631438
Calcified endobronchial leiomyoma
S M Ko, MD
1
S B Han, MD
2
S K Lee, MD
1
S K Woo, MD
1
M J Kim, MD
1
D Y Keum, MD
3 and
Y N Kang, MD
4
1 Department of Radiology, 2 Internal Medicine, 3 Thoracic Surgery, 4 Pathology, Dongsan Medical Center, Keimyung University College of Medicine, 194 Dongsan-dong, Jung-gu, Daegu 700-712, Korea
Correspondence: Dr Sung Min Ko, Department of Radiology, Dengsan Medical Centre, Keimyurg University College of Medicine, 194 Dongsan-dong, Jung-gu, Daegu, 700-712, Republic of Korea. E-mail: ksm9723{at}yahoo.co.kr
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Abstract
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We report a case of calcified endobronchial leiomyoma in the left main bronchus. Leiomyoma of the airways is a rare benign tumour, usually described as a solitary lesion and located in the membranous portion of the lower third of the trachea and rarely in the bronchi. Chest CT showed a well-defined, calcified, polypoid endobronchial mass with a broad stalk in the left main bronchus.
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Introduction
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Benign neoplasms comprise less than 10% of tumours involving the trachea and main stem bronchi [1]. Most of them are found in children, in whom squamous cell papilloma is the most common. Leiomyoma of the airways is a rare benign tumour, usually described as a solitary lesion and located in the membranous portion of the lower third of the trachea and rarely in the bronchi [2–5]. To our knowledge, a calcified endobronchial leiomyoma has not been reported in the English literature. Herein, we report a case of calcified endobronchial leiomyoma in the left main bronchus with radiological, bronchoscopic and microscopic findings.
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Case report
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A 65-year-old man was admitted to our hospital complaining of cough, sputum and intermittent fever for 3 weeks. He was formerly a heavy smoker (60 packs per year). His medical history was marked by diabetes mellitus, chronic obstructive pulmonary disease and angina pectoris. Physical examination was not remarkable. Pulmonary function test showed moderate obstructive ventilatory defect and mild response to bronchodilator. A posteroanterior chest radiograph showed emphysema and multifocal scarring with small nodules in both lungs, indicating fibronodular tuberculosis (Figure 1a
). Chest CT (SCT-7800TX; Shimadzu, Japan) was performed to exclude reactivated tuberculosis and lung cancer. Unenhanced axial CT scan (3 mm collimation) obtained at the level of the carina showed a well-defined, popcorn-like, calcified, polypoid endobronchial mass with a broad stalk in the left main bronchus (Figure 1b). Contrast-enhanced CT scan was performed the next day using 16 slice multidetector row CT (Sensation 16; Siemens, Erlangen, Germany) with the following protocol: 1.5 mm collimation, pitch 1, reconstruction interval 1 mm, 120 kV, 150 mAs, gantry rotation time 500 ms. Multiplanar coronal reconstruction imaging demonstrated a well enhancing polypoid mass without extraluminal involvement (not shown). Flexible bronchoscopy (Figure 1c) and virtual bronchoscopy (Figure 1d) revealed a polypoid endobronchial mass with smooth surface in the left main bronchus near the carina which obstructed the lumen of the airways. Microscopic examination of the biopsy specimen demonstrated proliferation of neoplastic spindle cells with squamous metaplasia of the bronchial mucosal epithelium (Figure 1e). Immunochemical staining for desmin and smooth muscle actin was positive. This tumour was thus diagnosed to be leiomyoma of the bronchus.
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Figure 1. (a) Chest radiograph shows emphysema and multifocal scarring with small nodules in both lungs and a subtle nodular opacity in the left main bronchus (arrow). (b) Unenhanced axial CT at the level of the carina shows a well-defined, popcorn-like, calcified, polypoid endobronchial mass with a broad stalk in the left main bronchus. (c) Flexible and (d) virtual bronchoscopy shows polypoid endobronchial mass with smooth, well-limited surface in the left main bronchus near the carina which obstructed the lumen of the left main bronchus. (e) Microscopic examination of the biopsy specimen shows proliferation of neoplastic spindle cells with squamous metaplasia of the bronchial mucosal epithelium (haematoxylin–eosin, original magnification x 40).
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The patient was not in good enough general condition to be treated by sleeve bronchoplasty of the tumour in our hospital, so he was transferred to another university hospital where he underwent endoscopic laser removal. The pathologic diagnosis of the resected tumour specimens was the same as ours. Following the operation, the patient made an entirely uneventful recovery.
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Discussion
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Endobronchial leiomyomas are extremely rare even though smooth muscle is normally found in conducting and transitional airways [6]. Most of the endobronchial leiomyomas occur in the middle aged with a mean age of 39.1 years for the 85 cases reported in the literature [5]. These tumours most commonly occur in the membranous portion of the lower third of the trachea and rarely in the bronchi thus causing wheeze, cough, dyspnoea, atelectasis and pneumonia because of partial or total obstruction of the affected airways. Grossly, they are fleshy, polypoid, broad-based and more or less completely fill the lumen of the airways. Microscopic exam demonstrates a well-demarcated spindle cell tumour with positive staining for desmin and smooth muscle actin on immunochemistry [3, 5, 6].
A specific diagnosis of a leiomyoma usually cannot be made by imaging alone. This is because most benign endobronchial tumours produce non-specific focal masses in the wall of the airways except for fat-containing tumours such as lipoma and hamartoma and calcium-containing tumours such as cartilaginous and hamartomatous tumours [7, 8]. A calcified endobronchial leiomyoma has not previously been reported in the English literature. Cartilaginous tumours, ossifying endobronchial carcinoid, calcified endobronchial hamartoma or heterotopic ossification in endobronchial metastases of gastrointestinal adenocarcinoma should be considered in cases of a calcified endobronchial tumour being evident.
Central airway tumours are often overlooked on chest radiographs despite the presence of sessile or pedunculated soft tissue nodules within the trachea or bronchi [7], as in the present case. The CT appearances of the tracheal leiomyomas have been described as similar to most other benign tracheal tumours; a well-marginated, homogeneous, smooth or lobulated mass with homogeneous enhancement confined within the endotracheal lumen [3, 7–9]. 3D reconstruction of the high resolution spiral CT images and virtual bronchoscopy clearly present the extent of intraluminal and extraluminal involvement by allowing visualization from multiple angles thus providing significant implications in planning surgical resection [10].
Provided that the tumours can be adequately excised, the prognosis is good. Treatment of endobronchial leiomyomas is diverse according to the location, size and width of the base of the lesions. If complete resection is possible, simple bronchoscopic removal is preferable. For most lesions arising from the main stem bronchus or proximal part of the lobar bronchus, bronchoplasty or bronchotomy without lung resection is widely used. Parenchymal resection should be done only for the end stage infection or solitary parenchymal nodule [5, 11].
In conclusion, a calcified endobronchial leiomyoma showed a well-defined, popcorn-like, calcified, polypoid endobronchial mass with a broad stalk in the left main bronchus on the chest CT, and demonstrates another rare cause to be added to the differential diagnosis of calcified endobronchial tumours.
Received for publication March 24, 2005.
Revision received June 8, 2005.
Accepted for publication June 27, 2005.
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References
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Abstract
Introduction
