Introduction

Endo bronchial leiomyoma are very rare benign tumours. They account for about 2% of benign tumours of the lower respiratory tract.₁ They are thought to arise from the smooth muscle of the bronchus.₂ Surgical resection is the main stay of treatment for such tumours though literature has revealed treatment by endoscopic resection or laser treatment. Lung resection has been the treatment of choice from most cases reported in the past. We report one such case where the tumour which was completely occluding the left upper lobe at its origin close to the left main bronchus. The tumour was removed by performing a sleeve lobectomy of the left upper lobe along with a cuff of the left main stem where the bronchus arose. To our knowledge we are not aware of such an extensive resection of the tumour preserving the lung parenchyma that has been mentioned in the literature before.

Case Report

A 36 year old man of Indian origin presented with history of fever, dyspnoea and generalized malaise. Initial chest X-ray (Fig 1 A) revealed collapse of left upper zone of lung. He was empirically treated with antibiotic with which his symptoms have improved. A CT scan thorax (Fig 1 B) appeared to show a soft tissue mass arising from the left upper lobe bronchus. This was confirmed at bronchoscopy which revealed a soft tissue mass in the left upper lobe bronchus. A biopsy taken at that time showed the possibility of tumour to be of smooth muscle origin.

Figure 1

Figure 1a: Chest X-ray at initial presentation before surgery

Figure 2

Figure 1b: Chest X-ray on follow-up at 2 years show no evidence of recurrence

The tumour was approached through a left postero-lateral thoracotomy. The left upper lobe bronchus was opened and the tumour was noted. The tumour along with a cuff of the bronchial tissue was excised. The two ends of the bronchus where reattached with the help of Vicryl 4/0 sutures in an interrupted fashion (Fig 1 C). The patient had an uneventful postoperative period. The gross specimen revealed an endobronchial tumour arising from the bronchial wall and almost completely obliterating its lumen (Fig 1 D, E).

Figure 3

Figure 1c: CT scan showing endobronchial tumour in the left upper lobe bronchus

Figure 4

Figure 1d: Lung post resection of the lobectomy

Figure 5

Figure 1e: Resected tumour macroscopic cross-section

Histopathology showed the tumour to be made up of intertwined fascicles of what appear to be smooth muscle cells with ill defined cell margins, eosinophilic cytoplasm and elongated, cigar-shaped and oval clear nuclei. The tumour was covered by slightly hyperplastic columnar epithelium, supported by thickened basement membrane. The resection margins were clear off the tumor. These findings were consistent with endobronchial leiomyoma. The patient was followed up at 2 year after surgery. He appears to be clinically symptom free and repeat bronchoscopy revealed no recurrence of tumor. Chest X-ray at 2 years follow-up (Fig 1 F) showed no radiological evidence of recurrence.

Figure 6

Figure 1f: Resected specimen with the left upper lobe bronchus

Discussion

Bronchial leiomyomas are benign tumours which predominantly occur in the fourth decade of life with female preponderance.₃ Patients with this condition usually present with symptoms such as cough, hemoptysis, dyspnoea and malaise. Chest X-ray shows evidence of pneumonitis because of infection due to stasis of secretion distal to obstructed bronchus. CT scan will help to define the location of the tumours in the bronchus. Bronchosopy is greatly helpful in locating the exact site of the tumor and to obtain histopathological diagnosis. A pre-operative histological diagnosis would certainly help in planning the site and resection of the tumor rather than radical resection of the lung. Transthoracic approaches including, lung resection, bronchotomy and bronchoplastic₄ procedures if involved the main bronchus have been mentioned in the past. Bronchoscopic resection is feasible in selected cases where the tumour is small and pedunculated.(₅,₆,₇) Successful removal with Neodymium-yttrium aluminum garnet laser have been reported.(₈,⁹) There is always a concern of incomplete resection and recurrence in those patients who underwent endoscopic resection. Our report shows that a pre-operative diagnosis of benign leiomyoma which involved the left upper lobe bronchus close to the left main stem greatly helped in the planning for bronchoplastic procedure. Bronchoplasty procedure of a tumour isolated to the lobar bronchus has been mentioned in the past. In our report the sleeve of left upper lobe was removed flush to the left main bronchus and the remaining left upper lobe bronchus was anastomosed to the left main bronchus. Bronchoplasty procedures are technically demanding with significant postoperative complication. But in a unit such as ours where bronchoplasty procedures are performed regularly it can be carried out safely with no morbidity and mortality.

Correspondence to

Mr B K Somani, Flat 23, Foresterhill Court, Aberdeen AB25 2WA Tel: 01224681895 /07813651051 Email: bhaskarsomani@yahoo.com Fax: 0122450726