Muco-Epidermoid Tumor of the Bronchus

Transcription

1 Muco-Epidermoid Tumor of the Bronchus CHARLES V. MECKSTROTH, MD., F.C.C.P., HORACE B. DAVIDSON, M.D. and GEORGE O. KRESS, MD., F.C.C.P. Columbus, ome- As the techniques of pulmonary resection became known and applied, the results of the removal of various pulmonary tumors were compared. The difference in the five-year survival rates of patients with bronchogenic carcinoma and bronchial adenomas was apparent. Geipel, Kramer, Wessler and Rabin made notable contributions in this work. M I O However, it was not until 1937 that the differences between the two types of bronchial adenomas were clearly brought forth by Hamperl.' The more common variety, the carcinoid adenoma, was first reported by Muller in These are generally benign and comprise 90 per cent of most series of bronchial adenomas. The less common variety, the cylindroid type, was first described by Heschl in These lesions account for the remaining 10 per cent and have been more descriptively named adenoid cystic carcinoma. The similarity between this latter type of bronchial adenoma and the counterpart in the salivary and lacrimal glands was sufficient to warrant the name "cylindroma." The term "cylindroma" was first used by Billroth' in 1859 to describe a tumor of the orbit and it has been applied to lesions histologically similar in the breast and in the mucous membrane of the mouth and pharynx. FIGURE la FIGURE Ib FIGURE la: Bronchogram shows distortion of right lower lobe bronchi. The lobulated mass can be seen lying on the right diaphragm. FIGURE Ib: Spot film confirms lumen to be obstructed distal to the superior segment oriftce. -From the Departments or Surgery, Pa.thology, and Medicine, Ohio State University Medical Center and Mount Carmel Hospital. 652

2 Vol. 40 MUCO-EPIDERMOID TUMOR OR BRONCHUS 653 It has recently become apparent that included in the cylindromatous classification is a separate type of tumor distinguished both on the basis of histologic differences and on probable clinical course. This type, a muco-epidermoid tumor, was first separated by Smetana of the Armed Forces Institute of Pathology and reported by Liebow in 1952.'The term "muco-epidermoid tumor" is in accordance with the muco-epidermoid tumors of the salivary gland described by Stewart, Foote, and Becker." Two cases were described. Grossly these lesions were pedunculated polypoid endobronchial masses which occluded the lumen to varying extent. Microscopically these tumors are covered with metaplastic squamous epithelium. The body of the tumor is composed of a mixture of well differentiated mucous producing cells and sheets of squamous epithelium. Occasionally minimal invasion of local structures is seen. Four additional cases have been reported by Payne, Ellis, Woomer, and Moersch in their report of 1959.' They stressed the fact that symptoms are on the basis of bronchial obstruction and that surgical resection is the only chance for cure. Two of their cases were treated conservatively and died, two weeks and four years respectively after diagnosis. Two underwent pneumonectomy with survivals of at least ten and eight years Because of the location of the lesion, a resection of lesser extent was not feasible. These same authors listed a seventh case of mucoepidermoid tumor mentioned in a personal communication from Liebow. FIGURE 2a : lobe. Muco-epidermoid adenoma obstructing basal segments of right lower

3 654 MECKSTROTH, DAVIDSON AND KRESS Dec We would like to present an additional case of muco-epidermoid tumor which produced symptoms of a similar nature, namely bronchial obstruction with distal pulmonary suppuration. Case History This 76 year-old white man entered Mount Carmel Hospital in February of 1959 with the chief complaint of intermittent hemoptysis of 12 months' duration. The first episode was minimal in severity. but one month before admission he coughed over a pint of blood during a two-day period. There had been no hoarseness or arthralgia. His past history was noncontributory. He had worked as a carpenter for 27 years. but had been retired for two years. There had been no weight loss noted over the past months or years. Cough, productive of yellow-white sputum began one and one-half years previously. Physical examination showed essentially normal findings. Keratotic lesions were present on the face. No lymphadenopathy was found. Breath sounds were decreased over the entire chest area. No cardiac murmur was heard. Routine laboratory tests were within limits of normal. He could climb a flight of stairs without becoming too short of breath. Roentgenograms showed a peripheral lobulated mass in the base of the right lower lobe, in close continuity to the diaphragm. This resembled a solitary lesion and the diagnosis of bronchogenic carcinoma was entertained. Bronchography delineated a bronchial block of the anterior and medial basal segments with an irregularity of the proximal lobar segmental bronchus (Fig. 1). Bronchoscopy showed suggestion of a tumor. but the biopsy obtained was not diagnostic. With the pre-operative diagnosis of peripheral bronchogenic carcinoma or granulomatous lesion. exploratory thoracotomy was carried out on March The area of destroyed lung involved at least the anterior and medial basal segments. and no characteristic tumor tissue was felt for peripheral biopsy. Right lower lobectomy was carried out. and the tumor was visualized upon examination of the resected specimen. Due to the location and polypoid nature of the lesion and because of his age and moderate pulmonary disabwty, a more radical procedure was not warranted. His postoperative course was uneventful. and he was discharged ten days later. He has survived over two and one-half years without evidence of recurrence or metastases. FIGURE 2b: Diagramatic outline of tumor with location in bronchus.

4 Vol. 40 MUCO-EPIDERMOID TUMOR OR BRONCHUS 655 Gross and Microscopic Study Gross: The specimen consisted of a resected right lower lobe of lung (Fig. 2). Upon opening the bronchi, a pedunculated solid tumor nodule was found, attached to the main stem bronchus at a point about 1 em. from the line of resection. The tumor nodule itself measured 18 mm. in its greatest dimension. It rather effectively occluded most of the bronchi supplying the lower lobe. These were tremendously dilated and in some points they were at least 2 cm. in diameter. The lumen was filled with a thick greyish mucoid material. The lung tissue distal to the tumor was somewhat atelectatic but otherwise not remarkable. The surface of the tumor nodule was relatively smooth. It had a pink-tan color corresponding to that of the bronchial mucosa. On section, in addition to the mass of tumor lying within the lumen, there was evidence of extension of tumor through the wall of the bronchus for a distance of 5 to 6 rnm. Microscopic: Sections showed a tumor apparently arising in the wall of the bronchus. It was circumscribed, but not entirely encapsulated. In one area it seemed to extend through a cartilage of the bronchus and in this local area it was invasive. It was composed of two types of cells with some intermediate stages (Fig. 3). There were well-defined mucus-secreting columnar epithelial cells in acini. There were solid masses of prickle cells such as are found in stratified squamous epithelium. The tumor appeared to arise from the glands in the wall of the bronchus. There was prominent intimal thickening of the wall of one artery caught in a section. These findings are reasonably characteristic of a tumor which occurs in salivary glands and at the base of the tongue. Diagnosis: Muco-epidermoid tumor. Discussion Recent studies of patients treated either conservatively or with pulmonary resection for cylindroid adenoma (adenoid Cystic carcinoma) of the bronchus have suggested the advisability of separating into a distinct group those rare tumors showing both FIGURE 3a FIGURE 3b FIGURE 3a : Low power magnification showing almost equal amounts of mucous producing cells and epithelial elements. FIGURE 3b: High power view of the lighter cytoplasm of the mucous-producing cells and the darker cytoplasm of the epithelial cells.

5 656 MECKSTROTH. DAVIDSON AND KRESS Dec FIGURE 3c FIGURE 3d FIGURE 3c: High power view of the lighter cytoplasm of the mucous producing cells and the darker cytoplasm of the epithelial cells. FIGURE 3d : Low power field of section stained with the periodic acid-schiff (PAS ) reaction of McManus for staining of mucin. squamous differentiation and mucus production. These have been termed mucoepidermoid tumors. Clinically. they have failed to show local or distant metastases and produce symptoms by bronchial block with distal pulmonary suppuration. Microscopically, they are characterized by the presence of almost equal amounts of mucous cells and squamous epithelium. Involvement of the cartilage or neuro-vascular structures is minimal or nonexistent. Pulmonary resection appears to have produced a permanent cure in the small number of patients who have undergone this type of treatment. REFERENCES 1 Billroth, T.: "Beobach tungen trber Geschwillste der Bpetcheldrtlsen," Arch. Path. Anat., 17:357, Geipel, P.: "Zur Kenntnis der Gutartigen Bronchialtumoren," Frankfurt, Ztschr. Path., 42:516, Hamperl, H.: "Uber Gutartige Bronchialtumoren (Cylindrome und Carcinoide)," Arch. Path. Anat., 300:46, Hesch!, H.: "Ueber ein Cylindrom der Lunge," Wien. Med. Wchnschr., 27:385, Kramer, R.: "Adenoma of the Bronchus," Ann. atol., Rhin., and LaT1/ng., 39:689, Liebow, A. A.: "Tumors of the Lower Respiratory Tract in Armed Forces Institute of Pathology," Atlas of Tumor Pathology, Section V, Fascicle 17, pp , Washington, D. C., National Research Council, Muller, H.: "Quoted by Engelbreth-Holm, J.: "Beni gn Bronchial Adenomas," Acta Chir. Scandinav., 90:383, Payne, W. S., Ellis, F. H., Woolner, L. B., and Moersch, H. J.: "The Surgical Treatment of Cylindroma (Adenoid Cystic Carcinoma) and Muco-epidermoid Tumors of the Bronchus," J. Thor. and Cardiov. Surg., 38:709, Stewart, F. W., Foote, F. W., and Becker, W. F.: "Muco-epidcrmoid Tumors of Salivary Glands," Ann. Surg., 122:820, Wessler, H., and Rabin, C. B.: "Benign Tumors of the Bronchus," Am. J. M. sc., 183:164,1932.