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
We would like to acknowledge the contributions of Dr. Ellis Salloum, MD, who was a coauthor on the original version of this article.
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Further Reading
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
Follow-up: Adenoma, Bronchial