Benign fibroepithelial endobronchial polyps are rare among all benign endobronchial lesions and comprise <2% of all pulmonary tumors. There have been only a handful of case reports on fibroepithelial polyp in the literature. We report a case of a 39-year-old man with a fibroepithelial polyp arising from the right upper lobe (RUL) bronchus and extending into the main stem bronchus, which was successfully removed using an electrocautery snare.
A 39-year-old man, active smoker with a 27-pack-year history, who worked as a telephone and a cable installer, was referred for further evaluation of an RUL endobronchial mass detected on a computed tomography scan of the chest (Fig. 1).
He presented with dyspnea of 2-month duration. A chest auscultation revealed vesicular breathing sounds without any wheeze. Chest x-ray revealed RUL pneumonia, and he was treated with antibiotics for over 2 months with no relief from his symptoms. Flexible bronchoscopy–aided endobronchial biopsy from the RUL lesion, at an outside institution was reported to exhibit extensive immature squamous metaplasia. Rigid bronchoscopy under general anesthesia was performed at our institute to facilitate diagnostic and therapeutic maneuvers. Bronchoscopy demonstrated a pedunculated smooth glossy polyp arising from the RUL bronchus extending into the right main stem bronchus causing its partial obstruction (Fig. 2A). Rapid-on-site cytologic evaluation of an endobronchial needle aspiration was negative for a malignancy. The polyp was noted to arise from the posterior wall of the RUL bronchus, and an electrocautery snare was used to remove the endobronchial polyp in toto (Fig. 2B). Endobronchial ultrasound–guided transbronchial needle aspiration of station 4R lymph node was negative for malignancy. Histopathologic examination reported a 2-cm polyp with a fibrovascular core lined by a single layer of squamous epithelium—a diagnostic for fibroepithelial polyp. A repeat bronchoscopy performed 6 months later demonstrated a healed tumor bed site without any evidence of recurrence.
Fibroepithelial polyps are common benign lesions involving the skin, uterus, ureter, and neck; however, it is rare in the tracheobronchial tree with very few cases reported in the literature.1–7 The etiology is unclear, but it was thought to be due to inflammation or infection, especially among smokers and in patients with asthma or chronic obstructive pulmonary disease.1
It may be asymptomatic but may present with a myriad of symptoms including shortness of breath, monophonic wheezing, cough, dyspnea, and hemoptysis or obstructing features like pneumonia, pneumonitis, and atelectasis.
Removal of the entire tumor serves as the best diagnostic approach, as washing is usually negative because of the normal bronchial mucosa lining the polyp.6,7 Fine-needle aspirations are most often negative, and forceps biopsy may be challenging because of the smooth surface and respiratory motion.
Histologically, the polyp consists of a lining of squamous epithelium or bronchial mucosa with a fibrovascular stroma with some inflammatory cells. This histologic finding can be confused with solitary papilloma of the airways, mostly affecting the vocal cords and trachea. Squamous papilloma demonstrates papillary architecture with proliferation of well-differentiated squamous epithelium with associated keratinized debris covering a connective tissue stalk, although majority are positive for human papilloma virus.
There is no consensus on the best modality for diagnosis and treatment of fibroepithelial polyps. Over the last decade, improved bronchoscopic skills and technology have aided in avoiding surgery. Removal of the polyp with electrocautery snare not only helps in the diagnosis but also serves as a superior treatment modality with or without argon plasma coagulation and laser treatment of the base of the polyp.2,5,7 Recurrence is rare.7
Fibroepithelial polyp is a rare benign endobronchial tumor that usually arises from the trachea and the main stem bronchi. It should be included in the differential diagnosis of all endobronchial lesions, especially in active smokers and among patients with chronic obstructive pulmonary disease. It can be diagnosed and treated with interventional endobronchial modalities. In our opinion, the most effective modality is removal of the polyp with an electrosurgical snare. Awareness regarding this rare lesion and its endobronchial management could aid in accurately establishing the diagnosis and avoid invasive surgical interventions.
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