Glomus tumors (GT) of the airways are extremely rare and their biological behavior seems to be benign.1 Surgical treatment is the most frequently cited intervention,2 however an endoscopic approach can also be an option in the management of respiratory airway involvement. The authors describe two clinical cases of GT in the large airways treated with endoscopic techniques.
The first patient was a 60-year-old Caucasian non-smoker male admitted to the emergency department with complaints of cough and low-volume hemoptysis. Chest tomography (CT) showed left lower lobe atelectasis (Fig. 1). Flexible bronchoscopy revealed a clot occluding the left lower lobe. Prompt rigid bronchoscopy was performed and showed a highly vascular lesion arising from the antero-medial wall of the entrance of the left lower lobe with almost total occlusion. This lesion was removed mechanically with forceps, showing patency of all the segmental bronchus of the left lower lobe. The histopathological findings presented a monotonous population of round-to-polygonal cells containing round nuclei and eosinophilic cytoplasm, without necrosis. The neoplasia was highly vascularized with a mitotic count of 10 mitosis per 10 high-power fields (HPF) (Fig. 2). Immunohistochemical staining was positive for vimentin, actin and a pericellular pattern for type IV collagen, in the absence of epithelial, neuroendocrine and melanoma markers, being suggestive of a GT. An 18fluorodeoxyglucose positron emission tomography (18FDG-PET) scan and further investigation was negative for an extra-pulmonary origin. Due to patient co-morbidities, a minimally invasive treatment was preferred. The patient was submitted to three sessions of endobronchial laser photocoagulation with neodymium:yttrium aluminum garnet (Nd-YAG) equipment.
(A and B) Chest tomography in the patient no. 1. (A) Image at diagnosis revealed left lower lobe atelectasis (blue arrow). (B) Image after treatment with laser photocoagulation revealing no abnormalities. (C and D) Chest tomography in the patient no. 2 (C) Image at diagnosis showed a lesion in the posterior-lateral wall of the trachea (blue arrow). (D) Image after endoscopic treatment with no abnormalities.
After 42 months of follow-up, the patient is asymptomatic with no endobronchial lesions and no signs of relapse.
The second patient was a 59-year-old male, Caucasian, former smoker, referred to the Pulmonology outpatient clinic because of chronic nonproductive cough and recent intense dyspnea. A chest CT showed a lesion in the posterior-lateral wall of the trachea (Fig. 1) and a flexible bronchoscopy revealed an endotracheal soft-tissue mass in the posterior wall, occupying almost all the tracheal lumen. Prompt rigid bronchoscopy with laser photocoagulation was then performed with opening of 50% of the tracheal lumen. The histological evaluation showed monotonous population of round to fusiform cells, in nests and surrounding vessels, with low atypia, and no necrosis or mitotic activity (Fig. 2). Immunohistochemical study was similar to that described in the first patient, and a GT was the final diagnosis. After staging, there was no evidence of other extra-tracheal lesions. The patient was submitted to another 3 sessions of diode laser equipment. After 38 months of follow-up, the patient is asymptomatic with endotracheal full response.
GT are uncommonly found in the trachea and in the main bronchus.3 To the best of our knowledge, only 50 cases of a GT in the respiratory tract have been reported.4,5 Our report describes two new cases occurring in the large airways.
GT are usually benign and the prognosis is generally good with only very rare reported cases of local recurrence.3 Considering the rarity of these tumors in the large airways and the rarity of malignant potential, the best approach and treatment is debateable from a clinical point of view. In the two cases described in this report, an endobronchial approach with laser photocoagulation was performed.
Surgical treatment is considered the treatment of the choice in GT arising in large airways.4,6 Nevertheless, endoscopic resection combined with laser ablation has been described in 10 patients2,3 with no recurrence in the follow-up period. In the two cases described in this manuscript, an endoscopic approach was performed with no recurrence after a mean follow-up time of 40 months. The benign behavior of these tumors and the reported excellent outcomes of the endoscopic resection with laser ablation in these two patients, lead us to believe that this approach should always be considered in the treatment of a GT of the airways, causing less morbidity and mortality than the surgical intervention.Conflicts of interest
The authors have no conflicts of interest to disclose.