Bronchial

Adenoma*

A Clinicopathologic Charles

Marks,

Among

28 (86

mas chial

Study

M.D.,

patients

percent)

F.C.C.P.;

with were

adenomas

and

bronchial

Malcolm

adenomas,

of the carcinoid

provided

an

a greater

incidence

bronchopulmonary

incidence

A Ithough

of the lesion

tree than

bronchial

nized

in

when

the condition clinically cated that the lesion

for grew

that

might

malignant

as

change

time,

this

benign

which,

low

virtue

level

carcinoma.

The

epithelial be polypoid entiated. or

ducts;

and

as

bronchial 1937,

In

two

final

did

tract,

invalidity strated Williams

and

not

contain and

by

may

MARKS, MARKS

foregut,

that of

first

time

this time, bronchial

At

the

gastrointes-

cells.

subsequently Feyrter,6

as

Louisiana Hospital,

before

survival

treatment.

the

con-

is recorded, Although

patients,

or sleeve

resection

pneu-

lobectomy, of

the

af-

recommended.

The

demonwell State

and

the

essential

of

as by Univer-

Veterans

The

are

with

two

layers, of cell

smaller,

and

while

paler

the

masses

parenchyma

than

This

and

protrusion. that the often lined

lumina

granular cells

may

while

the

acini

material which are less uniform,

than

in

carcinoids,

tumors. mixed

feature indicates tumor develops from

is less septi,

The

secretes

to the

be pro-

seen. The lesion to invade cartilage,

carcinoid

secthe

tongue-like

seen,

frequently

resemblance

and although

irregular

eosinophuic

tumor

a close

The

categorize

surface on extend along

Large be

quite

appearance

acinar

may

are frequently more prone

epidermoid tumor. epidermoid

in

of

bridges.

more

and mitoses vascular and

has

to

cylindromas,

areas

by cellular

is

cylindromas,

translucent likely to

are often full of acidophilic stains with mucicarmine.

and

him

examination demonstrates consists of branching acini,

traversed

carciforegut

and

led

and have a moist They are more wall,

of the

syndrome.

as carcinqids,

carcinoids,

The

part of the

carcinoid

Liebow9 tumors.

to

hindgut.

of bronchial parts

gallbladder)

adenomas

similar firmer tioning.

nature

to the

rise

studies

or

in other

duodenum;

The

that carciof the primi-

is derivatively

those

of giving

bronchial

demonstrated component midgut,

system

( stomach;

with

the

categorized

the

years

in several

Sandler from any

resembles

trusions

the

and

many

foregut,

and

noids

in

it is here

located. for

and arise

embryonic

glands

New Orleans. Read before Pan-American Congress on Diseases of the Chest Lima, Peru, June 1, 1976. Manuscript received May 14; revision accepted July 20 Reprint requests: Dr. Marks, LSU School of Medicine, 1542 Tulane Avenue, New Orleans 70112

316

Hospital, the First

prolonged

of surgical

tracheobronchial

Microscopic cylindroma

differ-

Azzopardi.7

#{176}From the Department of Surgery, sity School of Medicine, Charity Administration

tree,

argentaffine was

and well

types.

view

carcinoids

assertion

Holley,5 and

carcinoid

the

sub-

abundant

adenoma

the

of this by

more

for

and performed

mucoepidermoid

the

mucous

bronchial

distinguished

of bronchial

unlike

the

are usually

Hamperl4

them as cylindroid Hamperl4 expressed carcinoid,

are

tive

bronchial

from

adenomas

varieties

bronchi,

arises of the

and grow-

in

is generally

these

segments

was

Williams noids could

origin,

is a slowly situated

in the absence

monectomy

capable

bronchogenic

lesion

An adenoma

proximal that

adenoma

the

a

designated

of growth,

from

tissues of the proximal or sessile in configuration.

Histologically,

recogsuch

mucosal

rate

neoplasm,

exist

of bron-

first

were

differed

bronchial

circumscribed

right

supervene. of

may

is diagnosed,

bronchoplastic procedures, fected area are generally

patients in the

the first time and inchslowly but emphasized

tumors

adenoma

of female

were subsequentKramer ’ diagnosed

of localization,

of malignancy,

chial dition

described

adenomas

glandular

by

ing,

bronchial

adeno28 bron-

even

were

Muller1

M.D.

of 0.6 percent of institutions. There

the left. Symptoms

lesion at necropsy, similar lesions ly described by Heine.2 In 1930,

At

The

occurring

adenomas

1882,

24

type.

all primary lung tumors seen in our was a slightly greater preponderance and

Marks,

muco-

mucus

and

salivary

gland

that the bronchial

mucomucous

glands. For a long were considered bronchoscopic Goodner

period of time, to be benign excision.

et

al,’#{176} Weiss

bronchial and were

Gradually, and

Ingram,”

adenomas treated by

the

views

Zellos,’2

CHEST, 71: 3, MARCH,

of and 1977

Logan

et

al’3

invasiveness

and

quired

the

as

growth

radical

for

and

a

bronchogenic

more

was

patients Charity

in New

of the

of a

more

indicated.

and

The

was

Age,

and

1973,

a total

were

of

28

diagnosed

at

Administration pathologic

as follows

yr

Hos-

: carcinoid

chial

type,

three

24

patients

(11

one

patient

features

this

abscess.

bronchogenic so that

tumor

bronchial

of primary dicated percent

lung

and

dence

but

to

be

noted tumors.

cases

at these

Naclerio

0.6 and

noted

incidence

the

Price-Thomas16

to the

and

bronchial

infor 8 tract.

found

Burcharth with

be mci-

Axelson’

adenoma

and

its incidence to be 1.2 percent of all primary The apparent gradual reduction in the in-

cidence

of bronchial

reduction

in

carcinomas,

the

rather

to an overall

incidence

actual

of

In

chest in

was

the

chest

Sex

bronchial

several

in

a

study

bronchial

of

that

adenoma

the

occurred

70

cases,

highest in the

of

aged

31 to

group

noted that 62 percent occurred in feMoersch and McDonald’9 noted that

the

age

while

in male

Their

youngest

of

female

patients

the

patient

patients average

was

of 40 cases of bronchial adenoma, half of the patients were over described lasted for

a 16-year-old eight years

was age

15 years

38

was old.

from

the

six months retrospective

1

infec-

of a pulmonary

a dramatic

( five

occurred

the and in

)

to eight

radiologic

the

in one

lesions.

noted

on

a dominant pneumonia

patients.

Weakness,

loss were of symptoms

noted in varied

of

radiologic

of

poorly defined atelectasis patients,

features

a well-defined

as

areas the and

of infiltradominant pulmonary

patient. studies

opacities

diagnosis

was was

presence

in seven

feature

the

percent)

years.

analysis

indicated

that of

( 29

recurrent

three

)

patients

condition Cough

patients, finding

presentation

patients

films.

tumor in 13 patients, tion in nine patients, abscess

of bron-

distal

of pneumonia

and

five

A

( Fig

effects

either

were and

helpful

confirmed

Bronchoscopic

biopsy

in patients the

solid

provided

with nature a posi-

in 26 patients.

Foster-

incidence

40 years and male patients. average

13

18 percent

x-ray

from

tive

indicated

15

eight

initial

ill-defined

Incidences

1941,

Carter18

2

pain, fever, and weight patients. The duration

of the

and

only

Tomographic

adenomas. Age

3

1

episodes

asymptomatic,

feature

percent

Langer’4

accounted respiratory

2 percent.

1

caused

provided in

routine

institutions,

adenoma of the lower

26 patients

0 0 2 4 2

patients.

Interestingly,

were

of primary

represented

Kingsley’5

percent,

described

seen

tumors.

that bronchial of all tumors

Sanders 6.9

were

4,533

adenoma

1 2 4 4 2

or development

Recurrent

series.

of time,

Male

which

bronchiectasis,

in several

Adenoma

period

Female

resulted

obstruction,

tion,

Adenomas

Features

Clinical

classification

tumor,

Clinical

Hemoptysis

During

of Bronchial

10-19

occurred of Bronchial

Incidences

20-20 30-39 40-49 50-59 60-69

percent).

Incidence

Sex

Total

to

Veterans

1-Age

>70

( 86 percent) ; cylindroid, ) ; and mucoepidermoid

percent

rate

development

adenomas

Orleans.

adenomas

patients

(3

1948

bronchial

Hospital

pital

as

MATERIAL

period,

with

re-

a slower

carcinoma,

approach

the

spread

Despite

Table

local

adenomas

gradual

CLINICAL

During

that

metastatic

tumors.

than

operative

stressed

of bronchial

malignant

metastases

they

potential

categorization

potentially

of

prevailed

years,

42 years. In a study

Zellos’2 50 years

found that of age. He

patient whose symptoms before the diagnosis had

had been

established. In the

present

indicated 13,

a ratio

a slight

average of the

age male

series, of female

preponderance of the patients

CHEST, 71: 3, MARCH,

the

age

and

to male

sex

of female

female was 1977

patients 54 years

incidences

pati&nts was

( Table

of 15 to

patients. 45 years 1).

The and

1. “Coin lesion” be bronchial carcinoid.

FIGun

visualized

radiographically

proved

BRONCHIAL ADENOMA

to

311

Cytologic aid

examination

in this

series

were reported for the presence patients,

six

viding

bronchial

carried

vided

in

two

evidence

of the

Nineteen pulmonary tribution

axillary node biopsy in carcinoid tumor proof the

nine

lesion.

in the in the

right

left.

was

and

lobectomy

in eight.

performed

in seven

the

tumors

were

lobar

dis-

performed

in nine

Bronchoscopic patients,

examined

been

and

at

performed

of the bronchial

biopsy

alone

in four

cases

autopsy.

in

a bronchial

eight

with

years

carcinoid

cylindroid

earlier.

had

of

endocrine

pa-

live

One

patients.

This

One

from

a bronchial

the

died

as in-

nodes,

eight

of

other

all

the

normal

spread

adrenal

from

as well

were

at

indicate

a

glands,

bones,

and

bronchopul-

mediastinal in one case, was found.

for patient

had

of pro-

the

Two

clinical

a

obstruction had active with

de-

patients

evidence

who

underwent

lymph

nodes

did

with

not

2-Distribution

Location Upper lobe Middle lobe or lingula Lower lobe Main-stem bronchus Total

MARKS, MARKS

was

of

lymph

surnodes

underwent

immediate

of Bronchial

in three affect

to the who

in the

posi-

found

materially

extension

carcinoid died

resection,

for

Adenoma.s

Right

Left

8 4

6 1

one

spread

(5

patient years

20

operative

is a residual

bronchial

and

and to

death

clinical

the

Nine

low

order

Two

years;

of

two

these

and

( 16

one

patients

and one survived exploration. Two

(5

tient

only

may

of

the

Cause

ten pneu-

a lobectomy.

Three

five

and

ten

lobectomy,

after refusing surgical percent ) survived be-

one of these patients had a refused surgery. One paa previous

pneumonectomy,

year. extend

over

many

years

is diagnosed, but in the surgery, the radiologic had

notable

been

known

for

patients

who

died

death

occurred

three exis-

up

to

15

progression.

of Death

Analysis

one

the

of

eight

postoperative

monectomy

in 1951.

after right myocardial

lower lobectomy, infarction. One

after

by

undergone

symptoms

lesion

without

had slow

for

treated

between

( 10

after one

the condition who refused

tence

that

),

less than

before patients years

years

and five years; and the other

percent

survived

seven patients

per-

of the lesion.

had had

(47

group, four four patients

survived were

group

for

and one patient exemplifies the

survived

this

survived

in this

percent)

patient

the of 19

pneumonec-

of malignancy

patients

percent)

of

tween one lobectomy,

( 16

case

and

group

)

percent a previous

after

carcinoid.

patients

patients

right postopera-

the there

One

Not

finding

patient

pneumonectomy Table

liver,

excludes

monectomy,

with

evidence

carcinoid.

carcinoids

to the

vival.

318

patient

concurrently

a bronchial

17 patients

extension

In

nodes

were treated by lobectomy, refused surgery. This last

adenoma

of Metastases

In the

disease.

lymph

as

than

years.

abnormalities.

Incidence

well

who

lymph

cent) survived 10 to 20 years, and patients underwent pneumonectomy,

for carcinoma

histologic

tuberculosis

bronchial

the

lymph nodes; axillary nodes

cases,

tomy

were proce-

recent

mastectomy

carcinoma after prostatectomy of the neck of the bladder. One

velopment

as

patients. longer

Although

several

static

fibrocaseous

of

was

fibro-

bronchial carat autopsy.

in a patient

mediastinal

for the

Three

successful

breast

the

onset

nodes

advanced

metastases,

specimens,

growth

with

patient

undergone

after

resected

autopsy

Disease

One

years

was

of widespread of

lymph

with a malignant being confirmed

occurrence

If one

patients

tients.

had

effects

monary ipsilateral

2.

operations or sleeve resections in this series of patients, these

Associated

third

the

the

associated

Survival

was

have

The

brain,

broncho-

The

with

tuberculosis the condition

predilection

in Table

Pneumonectomy

dures

caseous cinoid,

to

patient

pathologic examination. The patterns of hematogenous

Procedures

bronchoplastic not performed

Metastasis

in the

volvement

Adenomas

is represented

Surgical

biopsy

providing

nature

period.

found

pro-

node

without

occurred and

tree

performed,

Scalene

metastatic

tumors

five

findings

of sputum, except in one patient. In

patients

of Bronchial

diagnostic

negative

was

yield.

information. An with a malignant

Distribution

provide

and

washing

negative out

diagnostic one patient

not

in all examinations of atypical cells

a totally

was

did

of patients,

the

diagnosis

confirmed

and Death

5

2

propriate.

2

0

hemorrhage

19

9

tasis.

after

One

patient

survived

death patient

of malignant surgery was craniotomy

had

indicated after

being due to a died eight years

carcinoid been

pneu-

16 months

had

been

deemed

attributable

to

for

a cerebral

mapcerebral metas-

CHEST, 71: 3, MARCH,

1977

2. Smooth globular proximal bronchus.

carcinoid

FIGURE

into

One

patient

years

after

died surgical

of

of

coronary

artery

cure

of

condition.

the

tient died from arteriosclerotic the bronchial carcinoid was at

autopsy.

One

caseous carcinoid

disease,

24

One

pa-

heart disease, and incidential finding

an

died

patient

protruding

of

advanced

fibro-

tuberculosis, and a concomitant bronchial was confirmed at autopsy. Death due

myocardial

infarction

months

after

noid,

and

mobile

occurred

in

pneumonectomy

one

patient

accident

chial

bronchus

one

for

died

19 years

as the after

patient

to

nine

bronchial

carci-

result

of an

auto-

lobectomy

for

bron-

carcinoid.

The

bronchial protrudes

or

complete adenomas

partial bronchial and

nine

tumors

preponderance

sented struction

sema,

Fu;ullE

4

)

is

into

.

and

3.

in the

carcinoid lead to

( Fig

smooth

( Fig

occlusion were found were

on

left

globular

bronchus, 2 the

Nineteen

).

right

bronchial

tumors

was

with

with

also

associated

wheezing,

bronchospasm

bronchiectasis

adenoma.

CHEST, 71: 3, MARCH, 1977

due

may

to

obstructing

This repre-

group. The bronchial the development of

localized

side,

tree.

3 ) or recurrent pneumonia, development of a pulmonary

Dyspnea

Distal

a

a proximal

of right-sided

the may

in

bronchiectasis tlw SUl)seqUCIlt

( Fig

carcinoid

that

Although ical

obdistal with abscess emphy-

hemoptysis

feature

of

scopid

examination

mucous

membrane

lesion the

bronchus,

may

I)e

vary

from

lobulated covered In

the

extrabronchial endobronchial

small.

The

cut

soft

the

necrosis

neoplasm to

or frankly capsule

( Fig

surface 5). It

is

reaction

contrast

in carcinoids

bron-

defined.

fibrous in

may

a tan-colored

malignant

is poorly

unusual,

features

the beyond

component the

sumor

a desmoplastic is

of these

of

intact

component

with its parenchymal of connective tissue

invasive

that

intestinal

surface

a pale-pink

an

extends

if the

din-

broncho-

Although

it generally

and

initial

discloses

ulceration.

even

more

only mass,

generally

without

carcinoid,

quency

the

large,

noteworthy tissue

be

and pneumonic carcinoid.

endobronchial

firm lesion I)y a capsule

the

chial

atelectasis bronchial

may

the

is endobronchial,

is quite

DiscussioN tumor

FIGURE 4. Chest x-ray film showing consolidation due to underlying

to

of the

or

the

fre-

gastro-

tract.

Although

most

clinical

course

FIGURE

5. Gross

bronchial with

carcinoids

prolonged

survival,

have even

a benign in

the

occur.

bronchial

bronchial

appearance

of cut

surface

of intraluminal

adenoma.

BRONCHIAL ADENOMA

319

absence

of extirpative

occasion with and

surgery,

transgress

local invasiveness, hematogenous

metastasis

to

the

resected

specimens, to the

signs

and

of associated

When

the

Although

they

do occur,

in nature.

Pollard

to bone

resulting

from

the

tumors,

in our

tin! removal of a posterior lesion to be metastatic the

At

primary

ciated

sites

glands, and

axila.

of the

was

The

lesion

of

be

of

evident

noids series,

of the gastrointestinal one patient initially

prostatic

and

its

a two-year

concomitant bronchial

in the

or coexis-

with the

carci-

present adenoma

12 years after radical of the breast. In the secfor

obstruction

of

histologic

of in

the

evidence

treated years

demonstrated hilar present

note.

in This

one

a

of

routine

a rounded

region.

Acid-fast

MARKS, MARKS

the

sputum,

x-ray

and

this

white

man

had

of

left upper tracheobronchial,

lobe

bronchus thoracic,

liver

and

both

adrenal

glands.

and chest

in bacilli

bronchoscopic

der BronchialerHalle, Germany,

Kramer

R:

Adenoma

of

bronchus.

Ann

Otol

Rhinol

Anat)

332:25,

Williams

ED,

Azzopardi

carcinoid

syndrome.

ED,

Lancet

1959 JG:

Tumors

of

the

lung

Thorax 15:30, 1960 Sandler M : The classification 1:238,

and

the

of carcinoid

1963

9 Liebow AA : Tumors of the lower respiratory tract. In Atlas of Tumor Pathology ( section 5, fascicle 17 ) . Washington, DC, Armed Forces Institute of Pathology, 1952 10 Goodner JT, Berg JW, Watson WL: The non-benign nature of bronchial carcinoids and cylindromas. Cancer 14:539, 1961 11 Weiss L, Ingram M : Adenoinatoid bronchial tumors. 14:161,

1961

12 Zellos 5: Bronchial adenoma. Thorax 17:61, 1962 13 Logan WD Jr, Sehdeva J, Hatcher CR, et al: Tracheobronchial adenomas. Am Surg 36:359, 1970 14 Naclerio EA, Langer L: Adenoma of the bronchus. Am J Surg7S:532, 1948 15 Sanders CR, Kingsley JW: Bronchial adenoma. N Engl J Med 239:459, 1948 16 Price-Thomas C: Benign tumours of the lung. Lancet 1:1, 1954 17

Burcharth

F,

Axelson

C :

27:442, 1972 18 Foster-Carter 1941

AF:

19 Moersch

MacDonald

20

developed

alcohol-fast and

of the to the

included a malignant

Ueher eine prim#{228}re gestielte BronchialgeVerh Dtsch Ges Pathol 22:293, 1927

tumors.

HJ,

Pollard cinoid

21

Bronchial

A, Grainger

adenomas.

Thorax

Q J Med

adenoma. JR:

RG,

bronchial

syndrome.

Toomey

FB,

gastrointestinal

Bronchial

10:139,

adenoma.

JAMA

reference

Radiol

19:221,

0 : An unusual associated

2: 1084, B:

case the

of car-

1962

Osteoblastic

bronchial

with

bone

carcinoids.

metastasis Am

in

J Roent-

1960

BM : Three

ticular

Fleming adenoma

Lancet

Felson and

genol83:709, 22 Thomas

Bronchial

1950

metastasizing

is had

the

J:

142:299,

series

in 1948,

film

mass

3

pulmoa malignant

in

tuberculosis

that in

with

patient

56-year-old

for pulmonary later,

fibrocaseous

association

carcinoid of

left

advanced

and

At autopsy

schwulst.

Cancer

carci-

frequent

tract. In had a bronchial

disclosed

tuberculosis

worthy

380

thorax

years,

in patients

prostatectomy

bronchial

were

adrenal diagnosis

over

tuberculosis

HL: Zur Entstehungsgeschichte ungen ( inaugural dissertation).

8 Williams

asso-

of the

1 Muller weiter 1882 2 Heine

7

of

time,

from

findings

lymph nodes, as well as spread to the lungs and pleura. Metastases were also

in the

( Pathol

par-

nature

in the

eight

with

carcinoma

bladder

with

nodes

associated disease

contrasted

presence

nary

the

and case.

carcinoma.

The

been two

that

noted

been

cylindroid type) for carcinoma

of the

the

noted

At this

lymph

had

may

patient,

and

mixed blastic in only one

to radiotherapy

tence

neck

tract

the

type.

pathologic

upper

genol83:709, 1960 4 Hamperl H: Ueber gutartige Bronchialtumoren (Cylindrome und Carcinoide ). Virchow’s Arch ( Pathol Anat) 300:46, 1937 5 Holley SW: Bronchial adenoma. Milit Surg 99:528, 1946 6 Feyrter F: Ueber das Bronchuscarcinoid. Virchow’s Arch

of metastases

of survival

noid

ond

of

primary

later,

confirmed.

duration

period was noteworthy. The infrequency synchronous malignant

(of the mastectomy

days

and

to respond

patterns

craniotomy

were

pleura,

bronchial

failure

two

of metastases

bones,

of

Felson12

fossa tumor confirmed the from a malignant bronchial

autopsy lesion

with

from

Thomas22

series,

of

presence

of 17 cases

in 14 cases, purely lytic

fibrocaseous

carcinoid

left

a malignant

REFERENCES

case

and

gastrointestinal

carcinoid

patient

carcinoid.

the

Toomey osteoblastic

the

of the

it to be

rare,

associated

lesions

the lesions were blastic lytic in two cases, and In one

an unusual

lesions.

present

disclosed

of the

later,

abdominal and left

right

brain, are

adenoma

months

carcinoid tumor with metastases

sites

a lesion

Biopsy

osteoblastic

noted

and

the

bone

generally

adenoma

In a review

advanced

glands,

of the

both

in three

two

and

adrenal

carcinoid tree.

bronchial

had

dem nstrated

bronchus.

nodes, series,

spread

occur,

to

examination lobe

spread.

similarity

in

bronchial

on

as manifesting

does

are

syndrome

metastatic tumors

case,

metastases they

osteoblastic the

found

as well

liver,

bronchial

carcinoid

noted

was

et al20 reported

metastasizing numerous

of lymph present

one

spread

are

does barriers,

the

hematogenous

bones.

when

the

in

nodes,

hematogenous

of predilection and

nodes

axillary

tumor

restrictive

infiltration spread. In

lymph

occurred

the

normal

its

unusual to

osteoblastic

carcinoid bone

tumors metastases.

with

parClin

1968

CHEST, 71: 3, MARCH, 1977