Endobronchial fibrous histiocytoma treatment malignant fibrous histiocytoma case report of an unusual presentation and palliative flexible bronchoscopic resection respiratory care

A 61-year-old man presented to our clinic for shortness of breath fibrous histiocytoma treatment and chest discomfort. Six months before presentation, he was diagnosed with stage 4 lung cancer at a fibrous histiocytoma treatment different clinic, due to an endobronchial mass and pleural effusion shown on fibrous histiocytoma treatment his computed tomography (CT) scan. However, neither bronchoscopy nor diagnostic thoracentesis was performed. He had received only symptomatic treatment, including pain control, medications for cough and sputum, and supplemental oxygen. A medical interview revealed a history of schizophrenia for 10 fibrous histiocytoma treatment years, but he was not on medications. He was a 40-pack-year smoker and a serious alcohol abuser.

Physical examination revealed decreased breath sounds on the right lower fibrous histiocytoma treatment lung field, and pretibial pitting edema. Chest x-ray showed atelectasis of the right lower lobe, with pleural effusion. A CT scan revealed a mass in the bronchus intermedius, pleural effusion, and pulmonary thromboembolism ( fig. 1). Echocardiography showed dilated cardiomyopathy, with a 17% ejection fraction and an intracardiac thrombus. He refused further evaluation for the endobronchial mass and pleural fibrous histiocytoma treatment effusion. Clinical diagnoses of lung cancer and alcoholic cardiomyopathy were made. A cardiologist prescribed diuretics, an angiotensin converting enzyme inhibitor, digitalis, and warfarin for his heart problems. Three months later, a follow-up chest radiograph showed decreased pleural effusion. Bronchoscopy was performed, and a polypoid mass was found in the bronchus intermedius fibrous histiocytoma treatment ( fig. 2). The pathology report for the bronchoscopic biopsy was non-specific granulation. A diagnostic thoracentesis revealed transudate fluid, without malignant cells. We therefore felt that he may have been misdiagnosed with fibrous histiocytoma treatment lung cancer, so considered surgical resection of the endobronchial mass. However, we decided to observe the mass without surgical resection, because substantial operative risk was estimated.

Two years later the sputum became more purulent and his fibrous histiocytoma treatment dyspnea worsened. Chest x-ray showed an obstructive collapse of the lower lobe of fibrous histiocytoma treatment the right lung. A follow-up CT scan showed complete resorption of the previously noticed fibrous histiocytoma treatment thromboembolism. However, the mass completely obstructed the bronchial lumen at the level fibrous histiocytoma treatment of the bronchus intermedius (see fig. 1).

We performed another bronchoscopy and found that a mass obstructed fibrous histiocytoma treatment the lumen of the bronchus intermedius ( fig. 2). Curative operation was not an option because of his cardiac fibrous histiocytoma treatment problems, so we introduced a gastrointestinal polypectomy snare into the channel fibrous histiocytoma treatment of the flexible bronchoscope and performed a palliative partial mass fibrous histiocytoma treatment resection. During the procedure a mild sedation was achieved using midazolam. The procedure was done without any complications. After the procedure the right lower lobe bronchus was patent, with only a small stalk of the tumor remaining. The pathology specimen consisted of a polypoid mass measuring 3.0 × 1.5 × 1.5 cm. On multiple sections, the mass occupied most of the specimen and revealed multinodular fibrous histiocytoma treatment gray white cut surfaces with focal necrosis. Microscopically it showed a storiform pattern with bizarre anaplastic tumor fibrous histiocytoma treatment cells arranged haphazardly in sheets ( fig. 3). An extreme degree of pleomorphism and occasional multinucleation were noted. There was a focus of necrosis on the surface. The resection margin was free of the malignant tumor. Immunohistochemical stain revealed positive smooth-muscle actin, vimentin, and CD68. Desmin and cytokeratin were negative. The diagnosis was storiform-pleomorphic MFH. A fludeoxyglucose positron emission tomography scan revealed no evidence of fibrous histiocytoma treatment distant metastasis. The mediastinal lymph nodes were not changed in size, compared to previous CT scan, and did not show notable fluorodeoxyglucose uptake.

Most cases of primary MFH of the lung present as fibrous histiocytoma treatment a peripheral lung mass. 1– 3 although a study reported that 33% of patients who received combination chemotherapy showed partial response, MFH is usually resistant to chemotherapy or radiotherapy. 3, 5 A previous study revealed a 5-year survival rate of 58% and a 10-year survival rate of 38%. 6 surgical resection is the best treatment option when the fibrous histiocytoma treatment disease is limited. 5, 7 A few cases of MFH arising from the pleura fibrous histiocytoma treatment and diaphragm have shown aggressive clinical features. 8, 9 however, the bronchus and trachea are extremely rare sites for MFH, and to our knowledge, there are only 10 cases reported in the literature. 1, 10– 17 judging from these reports, it seems that endobronchial MFH shows relatively favorable clinical features, compared to MFH of other sites. Our patient has survived for more than 3 years without fibrous histiocytoma treatment distant metastasis or parenchymal invasion, which is a very unusual presentation. Surgical resection is the treatment of choice whenever possible, but we performed a palliative resection using flexible bronchoscopy, because substantial operative risk was expected.

A recent report presented 3 cases of endobronchial tumors treated fibrous histiocytoma treatment by flexible bronchoscopy with a polypectomy snare followed by electrocauterization. 19 they used the same technique as we did in fibrous histiocytoma treatment the present case, but their cases were benign tumors. In another report, vinod et al used external beam radiotherapy to achieve local fibrous histiocytoma treatment control. 15 conforti et al used yttrium-aluminum-garnet laser for a case of benign histiocytoma. 20 however, benign histiocytoma is a different disease entity from MFH, in that benign histiocytoma shows rare mitosis and no cellular fibrous histiocytoma treatment atypia in histology, and has very low local recurrence rate and metastasis rate. 21, 22 argon plasma coagulation 23 and cryotherapy 24 were also fibrous histiocytoma treatment used in other reports. Although we do not know which modality is the best fibrous histiocytoma treatment for endobronchial MFH, interventional bronchoscopy can be a reasonable alternative choice when surgery fibrous histiocytoma treatment is not an option.

Primary MFH of the lung is very rare, and MFH of the bronchus is extremely rare. In this case of MFH confined to the bronchus, the patient has survived more than 3 years without distant fibrous histiocytoma treatment metastasis or parenchymal invasion. A palliative bronchoscopic resection using a polypectomy snare was performed fibrous histiocytoma treatment successfully under mild sedation, and provided sufficient symptom control for 10 months.

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