Laurence Cunningham, D.O.;([unkeyab...

Laurence Cunningham, D.O.;([unkeyable]) Gary Wendell, M.D.;([unkeyable]) Leonard Berkowitz, M.D.;([unkeyable]) Edward s Schulman, M.D., F.C.C.P.;([unkeyable]) and Robert Promisloff, carry into effect F.C.C.P.([unkeyable])

Granular lonely dwelling myoblastomas of the trachea and right upper lobe bronchus were discovered incidentally during therapeutic bronchoscopy Because of their propensity of cause airway compromise and distal atelectasis, ablation of the couple lesions was undertaken. This is the first reported case of bipolar cautery of GCM end a flexible fiberoptic bronchoscope. Small tumor size and lack of atelectasis permitted utilization of this technique. Long-term follow-up is necessary to compare this therapy with other nonresectional therapies.

Granular enclosed space myoblastomas (GCM), first described at Abrikossoff in 1926,[1] are Schwann enclosed space tumors of the skin, breast, subcutaneous tissue, tongue, and rarely, the tracheobronchial tree Classified as benign tumors, in the lung they near as a solitary pulmonary nodule, large obstructing endobronchial masses, or greatest in number commonly, as incidentally discovered small endobronchial lesions.[2] The clinical recognition of this lesion is important for brace reasons: resection must be performed for prevention or treatment of distal atelectasis and suppuration, and also to differntiate the observ lesion from bronchogenic carcinoma. generally received treatment modalities include sleeve resection, lobectomy, pneumonectomy, external beam irradiation, and radon se implantation. Curettage, electrocoagulation and laser therapy have been utilized by means of the rigid bronchoscope as alternative, nonresectional therapies. We describe the first case of multifocal (tracheal and right upper lobe bronchial) GCM ablated with bipolar cautery by the and of the flexible fiberoptic bronchoscope.

CASE REPORT

A 61-year-old black man was intubated nasotracheally after sustaining multiple rib fractures in a motor vehicle accident. forward admission, diffuse wheezing and bilateral anterior chest wall tendernes were observ Chest x-ray film demonstrated hyperinflation, left upper lobe bulla, bilateral rib fractures, right lower lobe density consistent with pulmonary contrusion, and left lower lobe atelectesis. Therapeutic bronchoscopy was performed. Unexpectedly lesions forward the anterior wall of the trachea and a mass lesion of the right upper lobe bronchus were affaired Cytologic brushings and washings yielded squamous metaplasia and reactive bronchial cells

Because of pertain to for an endobronchial malignancy, repeat bronchoscopy was performed five days later. Nodular pink lesions were rest on the anterior wall of the trachea (Fig 1) A separate white-to-gray granular polypoid lesion was noted in succession the anterior wall of the right upper lobe bronchus, partially occluding the anterior section of the lobe. Individually, tracheal lesions measured 05 to 10 mm; the right upper lobe lesion approximately 6 mm The bronchial mucosa surrounding all lesions appeared indurated. Endoscopic biopsies of the couple lesions were reported as GCM (Fig 2)

across the ensuing six days, the patient's clinical condition improved and a third bronchoscopy was performed just prior to extubation for tumor ablation. Each lesion was repeatedly cauterized with 2 s bursts of 30 watts utilizing a bipolar electrode a whole (BICAP, Pulmonary Therapeutic System, Microvasive Inc, Milford, MA) by means of a flexible fiberoptic bronchoscope (Pentax Inc, Orangeburg, NY) Following the operation no tumor was visible--the trachea, the right upper lobe bronchus and anterior section of the right upper lobe were widely patent. No other bronchoscopic follow-up was obtained prior to hospital discharge.

DISCUSSION

formerly believed to be of skeletal muscle origin, often controversy has existed over the histogenesis of GCM Electron microscopic evidence has indicated that this lesion is derived from neural enclosed spaces of the Schwann cell line.[3] Grossly GCM range from several millimeters to 65 cm in size, can be white or pink, nodular or polypoid, and vary from submucosal irregularities to obstructing masses.[4] These tumors rarely invade the pulmonary parenchyma, if it were not that may extend into the peribronchial tissues. Cytologically, it is associated with bronchial squamous metaplasia, and upon biopsy, it displays closely packed, large, granular acidophilic solitary abode; squalids with small oval to rotund nuclei, as seen in Figure 2

Female sex fifth decade of life and black race are the greatest in number frequently cited demographic factors for the exhibition of GCM.[2,5] As of 1986 sole ten tracheal and 45 bronchial GCM have been described; the oldest patient with a tracheal lesion was 56 years old[6] Along with being the oldest described patient with tracheal GCM our case also exhibited an additional bronchial tumor. although multicentric tumors located in the skin, breast, tongue, and subcutaneous tissue are well described, multifocal tracheobronchial GCM are distinctly unusual. Ostermiller et al described a 7 percent incidence of multiple endobronchial occurences[7]