Endobronchial lipoma: two cases and review of the literature D.W. COCKCROFT,* B SC, MD; G.M. COPLAND,t MB, CH B, FRCP[C]; R.E. DONEVAN,t MD, CM, M SC, FRCPIICI, FACP; R.H. GOURLAY4 MD, CM, M SC, FACS, FRCS[C]

Endobronchial lipoma is a benign tumour of the large bronchi occurring in middle-aged men. To the 38 successfully treated cases in the English literature a further 2 are added. The symptoms are those of obstructive pneumonitis mimicking bronchogenic carcinoma, and the result of delayed therapy may be bronchiectasis. Treatment includes local resection through a bronchoscope or a bronchotomy incision, or removal, if necessary, of the obstructed lobe or lung at thoracotomy. Smoking may be important in the pathogenesis of this tumour. Le lipome endobronchique est une tumeur b6nigne des grosses bronches que l'on rencontre chez les hommes d'Ige moyen. Aux 38 cas trait6s avec succ&s signal6s dans Ia litt6rature anglaise, 2 nouveaux cas sont ajout6s. Les symptOmes sont ceux d'une pneumonie obstructive ayant les apparences d'un carcinome bronchogene, et un d6lai de traitement peut entrainer une bronchiectasie. Le traitement comprend Ia resection locale au moyen d'un bronchoscope ou par bronchotomle ou, si n6cessaire, l'ablation & Ia thoracotomie du lobe ou du poumon obstrud. L'usage du tabac peut jouer un r8le important dans Ia pathogen&se de cette tumeur. Lipomas are common benign neoplasms, most often subcutaneous. In a recent review of 388 simple lipomas it was found that only 8 (2.1%) were within the viscera;i visceral lipomas frequently simulate malignant tumours, which are more common in these locations. Lipomas within the lung are rare. We have found case reports of only 38 successfully treated endobronchial lipomas in the English literature.'. There are, in addition, only five reportSi4.ao4a of peripheral lipomas of the lung. From the respiratory service, department of medicine and the department of surgery, St. Paul's Hospital, Vancouver *BC Christmas Seal Fellow in respiratory medicine tCodirector, respiratory unit, St. Paul's Hospital; clinical associate professor of medicine, University of British Columbia, Vancouver .Chief, department of surgery, St. Paul's Hospital; clinical professor of surgery, University of British Columbia, Vancouver Reprint requests to Dr. G.M Copland, Respiratory unit, St. Paul's Hospital, 1081 Burrard St. Vancouver, BC V6Z 1Y6

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Endobronchial lipomas are believed to arise from fat that is normally present in the bronchial tree, both in the fibrous tissue external to the cartilage plates and, to a lesser extent, in the interstitial tissue of the submucosa.9'15 Fat in the bronchial wall tends to diminish as the bronchi branch, and is virtually absent beyond the level at which the cartilage disappears.9 This probably explains the rarity of peripheral pulmonary lipomas. Some believe that chronic inflammation may be important in the pathogenesis of these tumours.33 In this paper we present two cases of endobronchial lipomas and review the other 38 successfully treated cases in the English literature. Case reports Case 1 A 48-year old male pulpmill worker was admitted to St. Paul's Hospital on Mar. 27, 1973. He had smoked 20 cigarettes per day for 20 years and had recovered uneventfully from right upper lobe pneumonia in 1968. A chest radiograph taken 1 year prior to admission had shown a density in the right upper lobe, and, because the tuberculin skin test was positive, isoniazid therapy had been given for 1 year. Eight weeks prior to admission a persistent cough productive of purulent sputum developed; bloodstreaking was occasionally noted. During this time he lost 4.5 kg in weight. He was afebrile, looked healthy and was in no distress. The trachea was deviated to the right. Breath sounds were decreased and bronchial breathing was heard over the right upper lobe. Results, of the remainder of the physical examination were within normal limits. Chest radiograph (Fig. 1) showed loss of volume of the right upper lobe with tracheal deviation to the right. Tomograms of the right upper lobe and hilum (Fig. 2) demonstrated a mass, 3 cm in diameter, obstructing the right upper lobe

FIG. 1-Case 1. Partial right upper lobe collapse.

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bronchus. Bronchoscopic examination on Apr. 2 revealed a tumour obstructing the right upper lobe bronchus. Biopsy showed normal bronchial mucosa; cytology demonstrated class II cells (some atypical). Because of the strong suspicion of malignant disease a right pneumonectomy was performed on Apr. 4. A polypoid tumour, 1.8 x 1.3 x 1.2 cm (Fig. 3), arising 2 cm distal to the origin of the right upper lobe bronchus, was shown histologically to be a lipoma with overlying normal bronchial mucosa. Organizing pneumonia with some bronchiectasis was noted in the lung distal to the lipoma. Postoperatively paroxysmal atrial tachycardia, pulmonary edema and staphylococcal empyema developed. These complications were successfully treated and the patient was discharged 4 weeks after the operation. Since then he has remained well. Case 2 A 44-year-old male labourer was admitted to St. Paul's Hospital on July 3, 1973 for investigation of hemoptysis. He had smoked 20 to 40 cigarettes per day for 30 years and had a 10-year history of wheezing, exertional dyspnea and a cough productive of one-half cup (112 ml) of sputum, frequently purulent, per day. He

FIG. 2-Case 1. Tomogram of right upper lobe and hiluml well demarcated hamour within right upper lobe bronchus.

first noted pink sputum 8 weeks prior to admission, and 6 weeks before admission there was bright red blood in the sputum for 3 days. He looked healthy and was in no distress. Bilateral medium-pitched rhonchi were heard throughout the chest and were louder on the left. Results of the remainder of the physical examination were within normal limits. Chest radiography showed complete collapse of the right middle and lower lobes; tomography showed a nodular mass in the right intermediate stem bronchus (Fig. 4). At bronchoscopy a firm round white tumour was seen protruding to the carina. Biopsy revealed the tumour to be a lipoma. On July 13 an encapsulated lipoma, 2.4 x 1.8 x 1.2 cm (Figs. 5 and 6), was removed from the right intermediate bronchus through a bronchotomy incision. The overlying mucosa of the lipoma showed squamous metaplasia. Recovery was uncomplicated. Four months after discharge the patients' respiratory symptoms were unchanged and the collapsed lobes had not re-expanded. He then underwent right middle and right lower lobectomy. Severe bronchiectasis and septal fibrosis were found in the atelectatic lobes. The patient was discharged after an uneventful recovery. Discussion

A summary of the 40 reported cases of endobronchial lipoma is given in Table I. The mean age was 51.5 years and 90% of the patients were male. The tumours occurred with greater frequency on the left (23 cases) than on the right (15 cases) and two were within the trachea. The lipoma in our second case is the first to be reported in the right intermediate bronchus. The usual size of an endobronchial Jipoma is between 1 and 3 cm in largest diameter. The tumours are most often pedunculated, with a narrow stalk, but there are two reports13'14 of dumbbell-shaped tumours, with por-

FIG. 3-Case 1. Specimen from right pueninonectomy: polypold tumour arising In right upper lobe bronchus.

tions on either side of the bronchial cartilage. Endobronchial lipomas are covered with epithelium, which either is normal respiratory mucosa or may show squamous metaplasia. In all but one case (no. 33) there were symptoms and signs attributable to the lipoma, usually for 1 to 2 years, but occasionally for 10 or more years. Most often these were the result of persistent or intermittent large bronchus obstruction, and included cough, sputum production, wheeze, chest pain, fever, hemoptysis, atelectasis and recurrent pneumonia. In one case (no. 32) there was a positional wheeze, and in another (no. 3), clubbing. Treatment of these tumours has been divided between local resection of the lesion and resection of the lipoma and distal lung tissue. Fifteen lipomas were resected and two others were coagulated at bronchoscopy. Three were removed through bronchotomy incisions. Twenty were treated primarily by pulmonary resection - 14 by lobectomy and 6 by pneumonectomy. Several reports mentioned persistent pulmonary suppuration following removal of an endobronchial lipoma, and in two cases (nos. 19 and 40) subsequent lobectomy became necessary for the treatment of localized bronchiectasis in the distal lung. Chronic inflammation may be an etiologic factor.33 Of the 40 cases reviewed above the smoking habits were recorded in only 9 (nos. 9, 22, 31 to 33 and 37 to 40). Eight of the nine patients were moderate to heavy smok-

ers and most had symptoms of chronic bronchitis, which may have been confused with the symptoms caused by the lipoma. In addition, in three cases of endobronchial lipomas recently reported in the French literature (two treated bronchoscopically and one discovered at autopsy) all the patients smoked 40 to 50 cigarettes per day.3' There is also one case (no. 31) of a lipoma developing in a patient who had had tuberculosis 20 years before. Thus, there is reason to suspect that chronic inflammation antedated the appearance

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of the endobronchial lipoma in 9 of the 40 cases. In most of the other cases this could not be assessed. Since most patients present with symptoms of major bronchial obstruction and most appear to be middle-aged men who smoke, the most common concern in the differential diagnosis of an endobronchial lipoma is bronchogenic carcinoma. In at least two instances (cases 20 and 39) a pneumonectomy was performed because of a preoperative diagnosis of carcinoma. References 1. LiN JJ, LIN F: Two entities in angiolipoma. Cancer 34: 720. 1974 2. KERNAN JD: Three unusual endoscopic cases. Laryngoscope 37: 62, 1927 3. MYERSON MC: Benign neoplasms of the bronchus. Report of case of fibrolipoma of left main bronchus removed through bronchoscope. Am J Med Sci 176: 720. 1928 4. Idem: Benign neoplasms of the bronchus. Report of case of bronchoscopic removal of fibrolipoma from left main bronchus. Arch Otolaryngol 9: 376, 1929 5. WassLast H, RABIN CB: Benign tumors of the bronchus. Am J Med Sc! 183: 164, 1932 6. JACKSON C, JACKSON CL: Benign tumors of the trachea and bronchi, with especial reference to tumor-like formations of inflammatory origin. JAMA 99: 1747, 1932 7. MCGLADE TH: Fibro-lipoma of the bronchus: report of a case. Ann Otol Rhino! Laryngol

48: 240, 1939 8. VINsON PP. PEMBLETON WE: Lipoma of left main bronchus. Report of a case, and report of literature. Arch Otolaryngol 35: 868, 1942 9. WATTS CF, CLAGETT OT, McDONALD JR: Lipoma of the bronchus: discussion of benign neoplasms and report of a case of endobronchial lipoma. J Thorac Surg 15: 132, 1946 10. WHALEN EJ: Lipoma of the bronchus. Ann Otol Rhinol Laryngol 56: 811, 1947 11. LELL WA: Report of a case of fibrolipoma of right main bronchus: bronchoscopic removal. Ann Otol Rhinol Laryngol 58: 1124, 1949 12. SOM ML, FEUERSThIN SS: Endoscopic removal of lipoma of the bronchus; report of 2 cases. Arch Otolaryngol 54: 341, 1951 13. CARLISLE JC, LEAkY WV, McDONALD JR: Endobronchial lipoma: report of a case. Mayo Clan Proc 26: 103, 1951 14. TOUROFF ASW, SELEY GP: Lipoma of the bronchus and the lung; report of 2 unusual cases. Ann Surg 134: 244, 1951 15. BEATON AH, HEATLY CA: Fat in the tracheo-bronchial tree with report of a case of true lipoma of the bronchus. Ann Otol Rhinol Laryngol 61: 1206, 1952 16. BREWIN EG: A case of lipoma of the bronchus treated by transpleural bronchotomy. Br J Surg 40: 282, 1952 17. SMART J: Intra-thoracic and intra-bronchial lipomata. Br J Dis Chest 47: 26, 1953 18. MCCALL RE, HARRISON W: Intrabronchial lipoma; a case report. J Thorac Surg 29: 317, 1955

of the literature. Can J Surg 2: 192, 1959 22. TAHERI SA, CARSEluIY DM, Ross CA: Lipoma of the bronchus. NY J Med 60: 3310, 1960 23. CALDAROLA VT, HARRISON EQ .nt, CLAGOETr OT, Ct al: Benign tumors and tumor-like

conditions of the trachea and bronchi. Trans Am Bronchoesoph Assoc 44: 46, 1964 24. STAUB EW, BARKER WL, LANOsTON HT: Intrathoracic fatty tumors. Dis Chest 47: 308,

1965

25. JASLoKOW VR, RuBNITz ME: Endobronchial lipoma. Report of a case and review of the literature. ill Med 1 129: 57, 1966 26. CRUTCHER RR, WALTUCH TL, GHO5H AK:

Bronchial lipoma; report of a case and literature review. I Thorac Cardiovasc Surg 55: 422, 1968 27. RAM5EY HE, OSTER W, FOREMAN S: Endobronchial lipoma. A review of the literature and report of an unusual case. Ann Otol

Rhinol Laryngol 78: 1281, 1969

28. JENSEN MS. PETERSEN AH: Bronchial lipoma: three cases and review of the literature.

Scand I Thorac Cardiovasc Surg 4: 131, 1970 29. BELLIN HJ, LIasHrrz HI, PATCHEPSEY AS:

19. OCHSNER S, LEJEUNE FE, OCHSNER A: Lipoma of the bronchus; report of a case. J

Bronchial lipoma; report of two cases showing chrondriotic metaplasia. Arch Pathol 92: 20, 1971 30. SHAPIRO R, CARTER MG: Peripheral lipoma of the lung; report of a case. Am Rev Tuberc 69: 1042, 1954 31. PLACHTA A, HERSHEY H: Lipoma of the lung. Review of the literature and report of a case. Am Rev Resp Dis 86: 912, 1962 32. JONES EL, KUCEY JJ, TAYLOR AB: Intrapul. monary lipoma associated with multiple pulmonary hamartomas. Br I Surg 60: 75, 1973

Lipomas of the bronchus. A presentation of two cases and an analysis of the literature.

33. SPENCER H: Pathology of the lung, London, Pergamon, 1968, p 901 34. FEltLrro A, DIBONsTo L, SLvEsmI F: A

Thorac Surg 33: 371, 1957 20. HUTCHESON JB, Assse WM, PAULSON DL:

J Thorac Surg 35: 638, 1958 21. NANSON EM, HILLIARD IM: Endobronchial lipoma; presentation of a case and review

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propos du lipome bronchique, consid6rations et suggestions critiques & l'aide de trois observations. Poumon Coeur 28: 435, 1972

Endobronchial lipoma: two cases and review of the literature.

Endobronchial lipoma: two cases and review of the literature D.W. COCKCROFT,* B SC, MD; G.M. COPLAND,t MB, CH B, FRCP[C]; R.E. DONEVAN,t MD, CM, M SC,...
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