eMedicine Specialties > Pulmonology > Lung Tumors

Adenoma, Bronchial: Follow-up

Author: Charles W Van Way III, MD, The Ralph Ringo Coffey Professor and Chairman, Department of Surgery, University of Missouri-Kansas City; Chief, Department of Surgery, Truman Medical Center
Coauthor(s): Gerald L Early, MA, MD, BA, FACS, FCCP, Associate Professor, Department of Surgery, University of Missouri-Kansas City
Contributor Information and Disclosures

Updated: Nov 13, 2008

Follow-up

Further Outpatient Care

Chemotherapy and radiotherapy can be instituted if indicated, as discussed in Medical Care.

Transfer

If the endoscopist is not prepared to deal with airway bleeding, biopsy should be deferred until the patient has been sent to an appropriate facility.

Deterrence/Prevention

No preventive regimen has been established. Smoking cessation is always a good thing but has no specific effect on these tumors.

Complications

  • Delayed hemorrhage
  • Bronchial anastomotic leak
  • Coagulopathy
  • Myocardial ischemia
  • Need for persistent mechanical ventilation
  • Mucoepidermoid carcinoma - Known to result in intracranial metastases, even in cases of minimal bronchial wall involvement
  • Carcinoid - Solid organ metastases (eg, to the liver) possible

Prognosis

The overall 5-year patient survival rates for bronchial adenomas are excellent at approximately 96%. Scattered reports describe local recurrences or distant metastases following adequate resection of typical lesions.

Carcinoids 
The slow growth pattern of carcinoids often prolongs the natural history of the disease process. A 5-year patient survival rate of 92% and 10-year survival rate of 88% has been reported for typical carcinoids treated with complete resection and formal mediastinal dissection. These excellent results applied to patients with both N1 and N2 disease, although those with N2 status received adjunctive radiation therapy. In atypical carcinoids, the survival rate is decreased to 60% at 5 years and 49% at 10 years.

Adenoid cystic carcinoma
After resection, the 5-year survival rate is approximately 83% and the disease-free survival rate is 60%. Patients with adenoid cystic carcinoma have an excellent prognosis because the tumor grows slowly and is radiosensitive. The best results are achieved when complete resection is accomplished; however, prolonged patient survival is possible even with incomplete resection.

Mucoepidermoid carcinoma 

The 5-year survival rate is 11.1%. This tumor is known to cause intracranial metastases, even in the presence of minimal bronchial wall involvement. Chemotherapy and radiation are used mainly for palliation.

Patient Education

For excellent patient education resources, visit eMedicine's Procedures Center. In addition, see eMedicine's patient education article Bronchoscopy.

Miscellaneous

Medicolegal Pitfalls

Failure to diagnose 
The most common medicolegal hazard is failure to diagnose. Patients with bronchial adenoma may present with hemoptysis, chronic cough, recurring pneumonia, or simple chest discomfort. While radiographs may show segmental or lobar atelectasis or infiltrate, the tumor itself is rarely large enough to be visible and radiographic findings may be completely normal.

CT scanning should always be performed if the radiograph continues to show atelectasis over a period of 2-3 months.

Definitive diagnosis is made with bronchoscopy. Hemoptysis almost always prompts bronchoscopy, but the general clinician should remember that chronic cough and recurring pneumonia are also indications. No physician should be sued successfully if an honest effort is made to diagnose persisting atelectasis or recurring pneumonia, but that effort should generally include CT scanning and bronchoscopy.

Bleeding 
Bronchoscopic biopsy may lead to bleeding, which can be severe and life threatening. Occasional reports describe spontaneous severe bleeding, or the tumor can bleed following biopsy. Any bleeding in the airway can be life threatening; however, this bleeding can usually be controlled using conservative measures. The availability of argon-beam electrocoagulation in the bronchoscopic suite can be beneficial.

Bleeding following bronchoscopy is the most dangerous pitfall. If the endoscopist is not prepared to deal with airway bleeding, a biopsy should be deferred until the patient has been sent to an appropriate facility.
 
Some surgeons believe the bronchoscopy should always be performed through a straight bronchoscope, but, with current equipment, fiberoptic bronchoscopy is safe. A straight bronchoscope permits better control of a bleeding biopsy site than a flexible bronchoscope, but the fiberoptic bronchoscope allows more complete inspection of all orifices and all segmental branches.

To successfully deal with bleeding, endotracheal intubation should be available and the operator should have the ability to intubate and to use an endotracheal tube to tamponade the bleeding tumor, or at least to block off the bronchus on the bleeding side to permit ventilation through the nonbleeding side. Rigid bronchoscopy should be available within the facility.

Failure to perform a biopsy 
Because of the risk of bleeding, many clinicians have fallen into an associated pitfall, which is a failure to perform a biopsy on anything in the tracheobronchial tree that looks as if it may be a bronchial adenoma. To avoid this, perform the biopsy but be prepared to handle any hemorrhage.

The Medscape Medical Malpractice and Legal Issues Resource Center may be of interest.

Special Concerns

  • Future and controversies - Tumorlet etiology
    • Hyperplastic proliferation of neuroendocrine cells, rather than neoplasms, as proposed by Cutz1
    • True neoplasm, because D'Agati et al2 have reported peribronchial nodal metastases
    • Diffuse form as possible etiology of small airway obliterative disease as proposed by Aguayo et al3
 
Acknowledgments

We would like to acknowledge the contributions of Dr. Ellis Salloum, MD, who was a coauthor on the original version of this article.



More on Adenoma, Bronchial

Overview: Adenoma, Bronchial
Differential Diagnoses & Workup: Adenoma, Bronchial
Treatment & Medication: Adenoma, Bronchial
Follow-up: Adenoma, Bronchial
References
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References

  1. Cutz E. Neuroendocrine cells of the lung. An overview of morphologic characteristics and development. Exp Lung Res. Nov 1982;3(3-4):185-208. [Medline].

  2. D'Agati VD, Perzin KH. Carcinoid tumorlets of the lung with metastasis to a peribronchial lymph node. Report of a case and review of the literature. Cancer. May 15 1985;55(10):2472-6. [Medline].

  3. Aguayo SM, Miller YE, Waldron JA Jr, Bogin RM, Sunday ME, Staton GW Jr, et al. Brief report: idiopathic diffuse hyperplasia of pulmonary neuroendocrine cells and airways disease. N Engl J Med. Oct 29 1992;327(18):1285-8. [Medline].

  4. Dagostino RS, Ponn RB. Adenoid Cystic Carcinoma and Other Primary Salivery Gland-Type Tumors of the Lung. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:1768-77.

  5. Darling G, Ginsberg RJ. Carcinoid Tumors. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:1753-67.

  6. Faber LP. Sleeve Lobectomy. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:458-69.

  7. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, et al. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest. Jun 2001;119(6):1647-51. [Medline].

  8. Goldberg M, Patchefsky AS. Uncommon Tumors of the Tracheobronchial Tree: Diagnosis and Management. Chest Surg Clin North Amer. 2003;13:1-174.

  9. Kirshbom PM, Harpole DH Jr. Bronchial Gland Tumors. In: Pearson FG, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC, eds. Thoracic Surgery. 2nd ed. New York, NY: Churchill Livingstone; 2002:763-71.

  10. Litzky L. Epithelial and soft tissue tumors of the tracheobronchial tree. Chest Surg Clin N Am. Feb 2003;13(1):1-40. [Medline].

  11. Parsons RB, Milestone BN, Adler LP. Radiographic assessment of airway tumors. Chest Surg Clin N Am. Feb 2003;13(1):63-77, v-vi. [Medline].

  12. Scott WJ. Surgical treatment of other bronchial tumors. Chest Surg Clin N Am. Feb 2003;13(1):111-28. [Medline].

  13. Warren WH, Faber LP. Bronchoscopic Evaluation of the Lungs and Tracheobronchial Tree. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:284-98.

  14. Watanabe Y. Tracheal Sleeve Pneumonectomy. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:486-95.

  15. Whyte RI, Ferguson MK. Preoperative Preparation of Patients for Thoracic Surgery. Thor Surg Clin. 2005;15:185-322.

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Further Reading

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Keywords

bronchial adenoma, endobronchial neuroendocrine tumor, Kulchitsky tumor, bronchial carcinoid, bronchial gland tumor, mucous gland carcinoma, mucous gland adenomas, mucoepidermoid carcinoma, adenoid cystic carcinoma, cylindromas, small cell undifferentiated carcinoma, malignant lung neoplasms, lung tumor, lung cancer, lung malignancy

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Contributor Information and Disclosures

Author

Charles W Van Way III, MD, The Ralph Ringo Coffey Professor and Chairman, Department of Surgery, University of Missouri-Kansas City; Chief, Department of Surgery, Truman Medical Center
Charles W Van Way III, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physician Executives, American College of Surgeons, American Medical Association, American Medical Informatics Association, American Society for Clinical Nutrition, American Society for Nutritional Sciences, American Society for Parenteral and Enteral Nutrition, American Surgical Association, Association of Military Surgeons of the US, Central Surgical Association, Missouri State Medical Association, Shock Society, and Southwestern Surgical Congress
Disclosure: Sanofi-Aventis Grant/research funds Local PI

Coauthor(s)

Gerald L Early, MA, MD, BA, FACS, FCCP, Associate Professor, Department of Surgery, University of Missouri-Kansas City
Gerald L Early, MA, MD, BA, FACS, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American College of Surgeons, American Medical Association, Society of Critical Care Medicine, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Michael Peterson, MD, Chief of Medicine, Vice-Chair of Medicine, University of California at San Francisco; Endowed Professor of Medicine, University of California at San Francisco-Fresno
Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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