CASE REPORTS. Inflammatory Polyp of the Bronchus. V. K. Saini, M.S., and P. L. Wahi, M.D.

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1 CASE REPORTS V. K. Saini, M.S., and P. L. Wahi, M.D. I n 1932 Jackson and Jackson [l] first reported a number of clinical cases under the title Benign Tumors of the Trachea and Bronchi with Especial Reference to Tumor-Like Formations of Inflammatory Origin. In 1934 Peroni [3] discussed the various theories on the pathogenesis of these endobronchial tumors and likened them to common polyps of the nose and nasal sinuses. It was not clear if their etiology was neoplastic or inflammatory. This type of endobronchial tumor is a relatively rare benign growth. SPlek et al. [4] described two such cases in 1958, and recently Peleg and Pauzner [2] reported one more case. A 45-year-old man was admitted to the Postgraduate Institute Hospital in Chandigarh with the complaints of productive cough for six years and hemoptysis for 2 weeks. Six years previously he had had bronchopneumonia. Since that time he persistently coughed up mucopurulent fluid; this symptom was increased by lying on his left side. Two weeks before admission he coughed up dark blood during one day. On examination his trachea was markedly deviated to the right. There was retraction of the right hemithorax, which moved less than the left. Dullness and decreased breath sounds were noted on the right. A chest x-ray (Fig. 1) showed marked shifting of the trachea and mediastinum to the right and narrowed right intercostal spaces. Some pleural effusion or pleural thickening was suspected at the right base. At bronchoscopy a growth was found projecting into the right main-stem bronchus. Biopsy of the mass showed normal mucosa with papillary hyperplasia. Repeated examination of sputum for malignant cells was negative. At operation the pleura was found to be densely scarred and mobilization of the lung in the extrapleural plane resulted in considerable loss of blood. Because a limited amount of blood was available, the chest cavity was packed with sponges and closed. A week later the patient was reoperated, and a pneumonectomy was From the Postgraduate Institute of Medical Education and Research, Chandigarh, India. Our thanks to Prof. B. K. Aikat and Dr. B. N. Datta for the pathology data. Accepted for publication Sept. 11, VOL. 5, NO. 2, FEB.,

2 SAINI AND WAHI FIG. 1. Anteroposterior x-ray of the chest showing shift of mediastinum to the right and opacity at the base. performed. The lung was solid with an opaque, thick, shaggy pleural covering. In the right main-stem bronchus there was a polypoid growth 1.5 cm. in diameter which was attached with a 3 mm. stalk to the bronchial wall (Fig. 2). The polyp was soft, lobulated, and grey in color. The bronchial lumen contained exudate and necrotic material. The lung showed bronchiectatic changes. Cavities varying from 0.5 cm. to 5 cm. in diameter were seen near the hilum; they contained purulent and necrotic material. FIG. 2. The polypoidal growth found in the right bronchus. 142 THE ANNALS OF THORACIC SURGERY

3 CASE REPORT: A FIG. 3. (A) Low-power view of the polyp showing thin, atrophied epithelium and inflammatory tissue. (B) High-power view of the lining epithelium of the polyp showing squamous metaplasia. B On microscopic examination the stalk was found to contain a large number of mucous glands which were continuous with the normal mucous glands of the bronchus. The polyp was edematous, loosely-packed inflammatory tissue and contained a few scattered glands (Fig. 3A). The surface of this growth was lined with tall columnar cells of respiratory epithelium, which at places showed welldeveloped squamous metaplasia (Fig. 3B). The glands in their depths appeared to be invaginations of the lining epithelium. The picture was exactly similar to that seen in an inflammatory nasal polyp and was compatible with the diagnosis of inflammatory bronchial polyp. The section from the pleura showed organized inflammatory exudate and areas of dense collagenous scarring. The lung showed VOL. 5, NO. 2, FEB.,

4 SAINI AND WAHI acute pneumonia and abscess formation besides bronchiectasis of the major bronchial branches. The patient made an uneventful recovery and is well 3 years after operation. DISCUSSION An endobronchial growth producing pulmonary atelectasis will most often be considered as bronchial carcinoma unless proved otherwise. In the present case, however, the long history could be considered against this possibility. Bronchial adenoma is another important lesion and cannot be differentiated unless histological details are available. The microscopic findings in the type of endobronchial lesion under review suggest that this is not a neoplastic process but a localized hyperplastic inflammation. Bronchial polyps are more or less reddish, fleshy, velvety tumors with prominent superficial vessels, and this appearance explains the frequent occurrence of hemoptysis as a major symptom. These tumors are often pedunculated, but at times they are sessile. They are characteristically located in the main bronchi or in their principal branches close to their origin or bifurcation. On microscopic examination the covering epithelium is well preserved and continues uninterrupted with the epithelium of the normal bronchial wall. The lining epithelium can be columnar, though at places it is stratified. The stroma can consist predominantly of fibrous connective tissue or thin collagenous fibers with a good deal of edema and variable amounts of inflammatory cells and degrees of vascularity. Some bronchial polyps are composed of edematous connective tissue with large blood vessels and lymphatics showing evidence of stasis. At times these large, dilated blood vessels resemble cavernous angioma. These three types of bronchial polyps have counterparts in polyp of the larynx, often called fibroma; chronic inflammatory polyp of the ethmoid and maxillary antrum; and angioma or fibroangioma of the larynx, respectively. The question whether these endobronchial polyps are secondary to the chronic suppurative process in the lung or whether the latter is the consequence of endobronchial obstruction produced by the polyp is debatable, but on the basis of general principles regulating the pulmonary pathology, it is more likely that the bronchiectasis and suppurative lung disease that is often associated with this bronchial lesion is secondary to obstruction. SUMMARY A rare case of inflammatory polyp of the bronchus causing bronchial obstruction and chronic suppuration of six years duration is reported. 144 THE ANNALS QF THORACIC SURGERY

5 CASE REPORT: REFERENCES Jackson, C., and Jackson, C. L. Benign tumors of the trachea and bronchi with especial reference to tumor-like formations of inflammatory origin. J.A.M.A. 99:1747, Peleg, H., and Pawner, Y. Benign tumors of the lung. Dis. Chest 47:179, Peroni, A. Inflammatory tumors of the bronchi. Arch. Otolaryng. 19: 1, Sdlek, J., Pazderka, S., and ZPk, F. Solitary bronchial polyps of inflammatory origin. J. Thorac. Surg. 35:807, EDITORIAL COMMENT In retrospect, endoscopic removal of the polyp may have made medical treatment or decortication and less than pneumonectomy possible.-r. K. H. VOL. 5, NO. 2, FEB.,