Benign endobronchial tumors are rarely seen lung tumors and include approximately 2–5% of all lung tumors, of which only 6% occur endobronchially [
Because endobronchial tumors may cause airway obstruction regardless of their benign or malignant character, removal of the tumor is the first treatment of choice to alleviate respiratory symptoms and to dilate and maintain the airway. Conventionally, these benign tumors have been managed with surgical resection [
The present study is a retrospective cohort study in which we retrospectively reviewed all the patients referred to the interventional pulmonology unit for central airway obstruction between January 2004 and April 2011 and included those who were diagnosed as having endobronchial benign tumors and who underwent endobronchial treatment. All the patients with benign endobronchial tumor were included in the study.
Since the study was a restrospective study, ethical approval was not needed. Argon plasma coagulation (40 Watt, blended mode-continuous flow) was performed using a device manufactured by ERBE Elektromedizine GBMH, (Tubingen, Germany). Standardized protocols for appropriate power selections were used in accordance with the manufacturer’s recommendations.
Cryotherapy was performed using the ERBOKRYO system (Elektromedizine GBMH, Tübingen, Germany). A diode laser operating at a wavelength in 980 nm with 4 to 25 Watt, pulsed mode (Biolitec, Ceralas D 25; Jena, Germany) was used for the endobronchial treatment.
All the patients were intubated by a rigid bronchoscope (Efer Endoscopy, La Ciotat, France) under general anesthesia using standard techniques, and mechanical debridement was performed when necessary.
Clinical and radiological data were accessed using the hospital electronic database and radiological systems. The primary outcomes of the present study were the response to treatment of the patients and the rate of complications of the endobronchial treatment. Respiratory symptoms were evaluated as improved, worsened, or unchanged. In postinterventional clinic patients’ notes, pre- and postinterventional radiological data were evaluated for improvement in the airway lumen. Any complications during or after the endobronchial treatment were recorded. Total procedures for endobronchial treatment, tumor recurrence, and residual rate were also recorded.
The Chi-square test was used to assess the significance of factors influencing the choice of interventional bronchoscopic treatment modality. APC and diode laser was compared from the occurrence of residual tissue by Chi-square analysis. A
A total 44 patients was included in the study. The range of the patients’ ages was between 4 and 86 years (mean, 58 years). There were 33 male (75%) and 11 female (25%) patients in the study population. The locations of the benign tumors were as follows: five of them were located in the trachea (13%); 16 of them were in the right main bronchus (41%); 13 of them were in the left main bronchus (33%); and 5 of them were located at multiple sites (13%). The tumors have obstructed or nearly obstructed the lumen where they were located. Luminal obstruction was between 70% and 100%. Tumor sizes were between 2 mm (left upper lobe apicoposterior segment) and 18 mm (trachea). Patients and their disease characteristics are summarized in Table
Baseline characteristics of patients who had endobronchial treatment.
Characteristics | Values |
---|---|
Age | |
Mean | 59 |
Range | 4–86 |
|
|
Male | 33 (75%) |
|
|
Lesion type | |
Hamartoma | 15 (34.1%) |
Hamartochondroma | 5 (11.4%) |
Hemangioma | 1 (2.3%) |
Mucous gland adenoma | 1 (2.3%) |
Fibroepithelial polyp | 12 (27.3%) |
Papilloma | 3 (6.8%) |
Lipoma | 1 (2.3%) |
Inflammatory pseudopolyp | 2 (4.5%) |
Amyloidosis | 4 (9.1%) |
|
|
Location of endobronchial lesion | |
Trachea | 5 (11%) |
Right main bronchus | 16 (37%) |
Left main bronchus | 13 (30%) |
Multiple sites location | 5 (11%) |
Lobar bronchi | 5 (11%) |
Summary of treatment modalities applied to patients with endobronchial benign tumors.
Diagnosis | Age years (mean) | Gender (male : female) | Number of APC/diode laser/cryo procedures | Additional treatment modalities ( |
---|---|---|---|---|
Hamartoma ( |
55 | 12 : 3 | 5/8/12 | Mechanical debridement (2) |
Hamartochondroma ( |
64 | 3 : 2 | 2/2/4 | Mechanical debridement (2) |
Hemangioma ( |
45 | 1 : 0 | —/1/— | — |
Adenoma ( |
37 | 1 : 0 | 1/—/2 | Mechanical debridement (1) |
Fibroepithelial polyp ( |
58 | 10 : 2 | 4/5/3 | — |
Papilloma ( |
55 | 2 : 1 | 3/2/— | Mechanical debridement (1) |
Lipoma ( |
64 | 1 : 0 | 3/—/— | — |
Inflammatory pseudopolyp ( |
62 | 2 : 0 | 1/4/— | — |
Amyloidosis ( |
71 | 1 : 3 | 3/—/— | Mechanical debridement (2) |
APC, Argon plasma coagulation.
Diode laser, argon plasma coagulation, and cryotherapy were used as an endobronchial treatment modality in the study patients with endobronchial benign tumors. The patients in the study population underwent 22 procedures with diode laser, 21 procedures with argon plasma laser coagulation, and 21 procedures with cryoptherapy for airway obstruction. Diode laser treatment was the most frequently used endobronchial treatment modality with 19 patients (43%) in the present study. The other endobronchial treatment modalities, and their percentages are presented in Table
Endobronchial treatment modalities of patients with endobronchial benign tumors.
Endobronchial treatment modality | Total number of procedures | Number of patients (%) |
---|---|---|
Diode laser | 22 | 19 (43%) |
Argon plasma coagulation | 21 | 16 (36%) |
Cryotherapy | 21 | 13 (30%) |
Cryotherapy was combined in some cases with immediate effect hot endobronchial treatment modalities.
The response to endobronchial treatment was classified according to the previous study [
(a) Typical bronchoscopic findings of endobronchial hamartoma with smooth surface and rounded mass having a resemblance to normal mucosa (grade I). (b) Bronchoscopic appearance after core-out of the lesion. (c) Application of cryotherapy for the residual lesion.
No recurrence was seen in 5 years follow-up period. In first five years, the fibreoptic bronchoscopy was done yearly for relapse. After five years, it has been cautioned that they should be consulted to interventional pulmonology unit in case of any complaints. It has been performed phone visit for this study to state any complaints or sign of recurrence. Authors could reach to 36 patients via phone call, and they have no sign of relapse. The papilloma patient has been pursued for 4 years with any recurrence bronchoscopically; after that time, he was lost to follow-up.
The present studies of endobronchial treatment of benign tumors can be classified as nonrandomized trials and observational studies including case series, case reports, and retrospective chart reviews in the literature [
(a) Bronchoscopic appearance of tracheal papilloma. (b) Bronchoscopic appearance 1 month after endobronchial treatment.
Endobronchial cryotherapy has been proposed to be less effective as a single therapy of endobronchial benign tumors [
(a) Bronchoscopic appearance of endobronchial mucous adenoma. (b) Bronchoscopic appearance of the tumor during endobronchial treatment. (c) Bronchoscopic appearance 1 month after endobronchial treatment. (d) Bronchoscopic appearance 1 year after endobronchial treatment. (e) Numerous mucus-filled glandular structures throughout the edematous stroma beneath the bronchial epithelium (HE, ×100).
(a) Bronchoscopic appearance of fibroepithelial tumor obstructing left upper lobe superior segment. (b) Bronchoscopic appearance after endobronchial treatment.
The incidence of endobronchial benign tumors particularly in the central airways is low. Endobronchial treatment is an available option for those patients with endobronchial benign tumors but when the possibility of malignancy cannot be excluded, or when there are indications for surgical resection including peripherally located pulmonary organizing pneumonia or bronchiectasis secondary to repeated infection, surgical resection of the lung with the including bronchial tumor, is performed in most of the cases [
Limitations of this study include that this is not a randomized controlled prospective cohort study that is why there is no control group. It would be better to compare patients who underwent surgical procedures for benign endobronchial treatment with patients who underwent only endobronchial treatment for the future studies.
Endobronchial treatment of benign tumors is an effective and safe method that could protect symptomatic patients from an unnecessary invasive surgical procedure. There is a need for randomized prospective studies to define the modality that is most useful for the treatment of endobronchial lesions, particularly for benign endobronchial tumors. Endobronchial treatment having immediate effects with endobronchial debulking concurrently used with cryotherapy may offer an effective method for removing benign endobronchial tumors without any recurrence.
The data used to support the findings of this study are available from the corresponding author upon request.
The abstract has been presented by the authors in 3rd European Congress for Bronchology and Interventional Pulmonology (ECBIP) Congress 2015.
The authors declare that they have no conflicts of interest.
The authors thank Prof. R. W. Guillery from Oxford University for the English correction of the manuscript.