A 55-year-old African man with a past medical history of hypertension presented to Parkland Memorial Hospital with a chief complaint of a worsening productive cough that was recurring for the past year. Cough was described as intermittent with occasional yellow sputum production and associated with shortness of breath and chest pain. He denied voice hoarseness, hemoptysis, melanoptysis, and wheezing. Patient also noted 5-pound weight loss over the past 2-3 months, but denied fever, chills, or night sweats. Patient was a recent immigrant from Nigeria where he worked as a mechanic and had a remote smoking history of ~1 pack/year in the early 1990s. He had no personal history tuberculosis nor he had known tuberculosis contacts. He had no personal or family history of cancer and he denied sick contacts. His surgical history was non-contributory. On physical exam he was afebrile with a regular respiratory rate and no adventitious lung sounds where noted. The patient had been seen for the same complaint at an outside primary care clinic two weeks prior and a chest X ray revealed a mild tracheal deviation to the right (Fig. 1A).
A computed tomography (CT) of the chest with contrast was obtained (Fig. 1B & C) and it was notable for a 1.9 cm mass in the right mainstem bronchus with associated right lower lobe consolidation and bronchiectasis. Pulmonology was consulted and management options were discussed. The patient was ultimately recommended to undergo bronchoscopy for airway examination, biopsy of endobronchial lesion, and potential therapeutic intervention.
Bronchoscopy showed a 90% obstructing mass in the proximal right mainstem bronchus and bronchus intermedius. The mass was large and circumferential, endobronchial, exophytic, and polypoid (Fig. 2A). The mass was too large to pass the therapeutic bronchoscope for assessment of the distal airways. The lesion was pretreated with epinephrine and cold saline. The tumor was then excised piecemeal using an electrocautery snare, forceps and suction. Tumor coagulation was performed using APC for hemostasis. Finally, balloon dilation was performed in the right mainstem bronchus and bronchus intermedius (Fig. 2B). The excised tissue was sent for histopathologic examination.
Microscopic evaluation (Fig. 3) showed an infiltrating gland-forming neoplasm with two cell components: eosinophilic ducts, tightly coupled with a surrounding layer of myoepithelial cells with clear cytoplasm. Immunostains (Fig. 3) highlighted the two cell components, as the ducts were positive for AE1/AE3 and CD117 while the myoepithelial cells stained for SOX10, S100, p40 and p63.SMA was negative. The findings were diagnostic for epithelial-myoepithelial carcinoma. The tumor was interpreted as intermediate-grade on the basis of increased nuclear atypia and an elevated mitotic rate.
Patient was discharged from the hospital with scheduled outpatient visits for monitoring of the carcinoma by pulmonology and thoracic surgery. He, unfortunately, was lost to follow up.
Radiological Findings. [A] posterior-anterior plain chest film obtained 2 weeks prior to presentation with tracheal deviation to the right and hilar fullness. [B] Chest CT scan with contrast with axial view with right mainstem obstructing endobronchial mass (yellow arrow) [C] Coronal reconstruction with right mainstem endobronchial mass (yellow arrow) with evidence of post obstructive bronchiectasis. (For interpretation of the references to colour in this figure legend, the reader is referred to the Web version of this article. ).