Twenty-two years old female presented with a complaint of intermittent productive cough with bloody sputum of 3 weeks' duration associated with wheezing, low grade intermittent fever and loss of appetite. She had frequent similar complaints for the last 10 years for which she visited different hospitals and was given salbutamol puff and antibiotics for the diagnosis of bronchial asthma with acute exacerbation. She had no contact history with known pulmonary tuberculosis patients and have never smoked cigarettes. she has no history of drug allergy, self or family history of relevant medical or surgical illness. On presentation her vital signs were in the normal range. She had scattered wheeze over her right posterior lower third lung field. Otherwise, there was no remarkable finding on other systems evaluation.
Her complete blood count, renal function test and serum electrolytes were in the normal range. Chest computerized tomography (Chest CT) showed 5.6 cm x 4.4 cm enhancing, lobulated, soft tissue mass in the lower lobe of the right lung. The mass has endoluminal extension to bronchus intermedius and the lower lobe of the right lung has marked collapse due to bronchial obstruction (Fig. 1). Bronchoscopic evaluation revealed red, fleshy and fragile right bronchus intermedius mass, and tissue biopsy from the mass showed organoid growth pattern of monomorphic small cells with paper chromatin, inconspicuous nucleoli surrounded by delicate vessels with diagnostic impression of typical carcinoid tumor. Abdominal ultrasound examination didn't reveal evidence of liver secondary.
With an impression of right lung lower lobe typical carcinoid tumor, the patient was operated through right posterolateral thoracotomy after getting informed written consent. The intraoperative finding was an 8 cm x 6 cm firm lower lobe mass involving bronchus intermedius (Fig. 2, Fig. 3). There were multiple enlarged mediastinal lymph nodes involving stations 8, 9 and 11. With these findings right lung bi-lobectomy (middle and lower lobe) with mediastinal lymphadenectomy of station 8, 9 and 11 was done and we left right tube thoracostomy.
Post procedure, she was transferred to intensive care unit and put on oxygen support as well as epidural analgesics. Subsequently, she had smooth recovery and was transferred to surgical ward. The chest tube output was insignificant and minor bubbling decreased gradually. Control chest x ray taken on her 5th post op day showed well expanded right upper lobe with no evidence of pneumothorax for which the chest tube was removed.
Histopathologic study of the excised mass showed lobulated tissue consisting of organoid and trabecular growth pattern with scattered pseudoglandular pattern. The cells are uniform round with salt and paper chromatin pattern. There was no evidence of mitosis and necrosis the final diagnosis being typical bronchopulmonary carcinoid tumor (Fig. 4, Fig. 5). The mediastinal lymph nodes were free of metastatic deposits.
Subsequently, the patient showed a remarkable improvement and was discharged from the hospital in a stable condition.
Chest CT scan showing enhancing, lobulated right lung lower lobe soft tissue mass encasing bronchus intermedius.