Endobronchial lipoma a rare cause of pleural empyema: a case report.

Abstract

Benign neoplasm of the endobronchial tree is quite rare, while endobronchial lipoma is extremely rare. The irreversible pulmonary damage is due to progressive bronchial obstruction; even so, pleural empyema is exceptionally encountered in a case of endobronchial lipoma. We report a case of a 47-year-old man who had left lung pneumonia with hemoptysis. The chest computed tomography showed cystic bronchiectasis with pleural effusion, Flexible bronchoscopy revealed a round tumor on the left main bronchus.

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Case report
Endobronchial lipoma a rare cause of pleural empyema:
a case report
Yassine Ouadnouni1*, Mohammed Bouchikh1, Salma Bekarsabein2,
Abdellah Achir1, Mohammed Smahi1, Yassine Msougar1, Najat Mahassini2
and Abdellatif Benosman1
Open Access
Addresses:1Department of Thoracic Surgery, Ibn Sina University Hospital, Rabat, Morocco
2Department of Anatomical Pathology, Ibn Sina University Hospital, Rabat, Morocco
Email: YO* - ouadnouni2@yahoo.fr; MB - bouchikh_mohammed@yahoo.fr; SB - salma_bekar@yahoo.fr; AA - abdachir@yahoo.fr;
MS - smct71@yahoo.com; YM - msougar@hotmail.com; NM - najat_mahassini@yahoo.fr; AB - abenos@menara.ma
*Corresponding author
Received: 3 March 2009Accepted: 25 June 2009Published: 21 July 2009
Cases Journal 2009, 2:6377doi: 10.4076/1757-1626-2-6377
This article is available from: http://casesjournal.com/casesjournal/article/view/6377
© 2009 Ouadnouni et al; licensee Cases Network Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Benign neoplasm of the endobronchial tree is quite rare, while endobronchial lipoma is extremely
rare. The irreversible pulmonary damage is due to progressive bronchial obstruction; even so, pleural
empyema is exceptionally encountered in a case of endobronchial lipoma. We report a case of a
47-year-old man who had left lung pneumonia with hemoptysis. The chest computed tomography
showed cystic bronchiectasis with pleural effusion, Flexible bronchoscopy revealed a round tumor on
the left main bronchus.
Introduction
Endobronchial lipoma is an uncommon benign tumor,
127 cases have been reported till now. The late diagnosis
of benign neoplasms can lead to irreversible pulmonary
damage. We report the case of endobronchial lipoma
complicated by chronic cystic bronchiectasis and pleural
empyema.
Case presentation
A46-year-oldmanAfricanoriginandMoroccannationality
who had been treated for a pulmonary tuberculosis in his
childhood. He was a heavy smoker (25 pack-years). The
patientsufferedformanyyearsfromchronicbronchitisand
chronic left-side pneumonia, treated each time with
amoxicillin-clavulanic acid. He was admitted in the
emergency department with a temperature of 39°C,
sputum production, hemoptysis and pleuritic chest pain.
Duringtheclinicalexamination,thepatientwastachypneic
atrest;auscultationrevealeddecreasedbreathingsoundsat
theleftlung’sbase.Bloodtestsshowedanelevatedwhitecell
count(18500cells/μL).Chestradiographshowedatelectasis
of the left lung and pleural effusion. A chest computed
tomography(CT)scanshowedmultiplecysticcavitiesinthe
left lung, the volume within was diminished with encysted
pleurisy (Figures 1, 2). Flexible bronchoscopy revealed a
round tumor completely filling the lumen of the left main
bronchus, and the biopsy of the neoplasm revealed lipidic
cells. Several cytobacteriologic examinations of the sputum
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did not reveal any malignant cells or Koch’s bacillus, and
culture of the sputum turned out to be negative. Preopera-
tively, the diagnosis of endobronchial lipoma associated to
chroniccysticbronchiectasiscomplicatedbypleuraleffusion
was suggested. A left posterolateral thoracotomy was
performed; a pleural pocket was opened, bringing out a
purulent fluid. Cutting the left main bronchus revealed a
smooth and yellow tumor. Because of the irreversible
damage to the left lung, a pneumonectomy was performed.
Macroscopicexaminationoftheresectedspecimenshoweda
sessile mass measuring 1.5 cm, attached to the bronchial
mucosa, and cystic bronchiectasis. Microscopically, the
endobronchial tumor mainly contains a mature fatty tissue
surrounded by respiratory epithelium; whereas the sub-
mucosa contains a moderate number of chronic inflamma-
tory cells. Consequently, the tumor was diagnosed as an
endobronchial lipoma (Figure 3). In the pleural fluid, a
Streptococcus pneumoniae was detected; it proved to be
sensitive to amoxicillin-clavulanic acid. The patient had an
uncomplicated postoperative course, he was discharged
9 days after the operation, and was asymptomatic after
36-month follow-up.
Discussion
Lipoma is a benign mesenchymal neoplasm of fat which is
most common in the subcutis. In the usual type, it looks
like mature fat, surrounded by a delicate capsule. It is
extremely rare in the bronchus. The fat cells were located in
the peribronchial and occasionally the submucosal tissue
of large bronchus, with a reported incidence between only
0.1 and 0.5% in all lung tumors. The tumors are more
frequent in middle-age men; some authors claim that
smoking and obesity are significant risk factors for
endobronchial lipoma [1]. Most cases reported in the
literature, emphasize that the tumors occurred on the right
side, and the most frequent were located in the first three
subdivisions. In the present case, endobronchial lipoma
was located in the left main bronchus and seal off the
lumen completely.
Endobronchial lipomas produce a round or oval mass
with smooth-surface, yellowish, and covered by respira-
tory epithelium. The tumor causes respiratory symptoms
due to partial or total obstruction of bronchus and
secondary lung destruction. Common symptoms include
a persistent cough, sputum production, dyspnea, chest
pain, recurrent fever and pneumonia. Hemoptysis is
uncommon, related to the avascular nature of lipomas,
but can occur as a result of postobstructive infection [2].
Figure 1. Computed tomography (CT) scan showing multiple
cystic cavities in the left lung.
Figure 2. Computed tomography (CT) scan showing pleural
pocket.
Figure 3. Photomicrograph showing mature fat cells
surrounded by respiratory epithelium and the submucosa
contained a moderate number of chronic inflammatory cells
(hematoxylin-eosin stain x10).
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For asymptomatic patients, the chest radiography hardly
shows obvious signs of intrabronchial mass (enlarged
hilar). However, it exhibits clear indirect signs (parenchy-
matous consolidation, bronchiectasis). Other less frequent
radiography observed a pleural effusion. Our patient
presented atelectasis of the left lung and pleural effusion;
a bacteriologic examination has detected the presence of
Streptococcuspneumoniae.Pleuralempyemaassociatedto
theendobronchiallipomawasonlyrecordedinthreecases,
and this is the fourth English-language case reported [1].
In 1982, Sommer et al reported the first case of a lipoma
identified by CT, the tumor is often a homogeneous mass
with fat density (from -70 HU to -140 HU) and no
enhancing contrast [3].
The diagnosis may be suggested by endoscopic aspects,but
bronchoscopic biopsy frequently does not confirm it.
Simmersetalreportedthatchronicobstructivepneumonia
may induce sufficient nuclear atypia to suggest malignancy
in endobronchial brush cytology of this tumor [4].
The exhaustive review by Muraoka et al shows that a
correct preoperative diagnosis is possible only in 31% of
64 patients and that a thoracotomy is mandatory in 74%
of patients, pulmonary resection was performed for 36
patients [2]. Surgical treatment, including pulmonary
resection, has been often indicated: first, when there still
a doubt about the diagnosis even with all the techniques,
then, when a malignant tumor or a peripheral lung
destruction is associated.
These tumors can be removed by bronchoscopy; in 1981,
Dumon et al reported the first case of endoscopic resection
for endobronchial lipoma [5].
Conclusions
Endobronchial lipoma is a rare entity that can cause
irreversible damages to lung parenchyma, unless the
diagnosis and treatment are carried out in time. The
conservative method such as bronchoscopic removal is
recommended, otherwise, surgery is an alternative option
for the undetermined benign or parenchyma destruction.
Abbreviations
CT, Computed tomography; HU, Hounsfield unit.
Consent
Written informed consent was obtained from the patient
for publication of this case report, photographic and
radiographic images. A copy of the written consent is
available for review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
YO drafted the manuscript, MB performed the case
management, drafted the manuscript, SB participated in
the patient's management, AA participated in the patient’s
management, MS participated in the patient's manage-
ment, YM participated in the patient’s management, NM
participated in the patient’s management and AB corrected
the manuscript. All authors read and approved the final
manuscript.
References
1. Casanova Espinosa A, Cisneros Serrano C, Giron Moreno RM,
Olivera MJ, Moreno Balsalobre R, Zamora García E: Pleural
Empyema Associated With Endobronchial Lipoma. Arch
Bronconeumol 2005, 41:172-174.
2.Muraoka M, Oka T, Akamine S, Nagayasu T, Iseki M, Suyama N,
Ayabe H: Endobronchial lipoma: Review of 64 cases reported
in Japan. Chest 2003, 123:293-296.
3.Simmers TA, Jie C, Sie B: Endobronchial lipoma posing as
carcinoma. Neth J Med 1997, 51:143-145.
4.Sommer B, Walter P, Remberger K: Bronchial lipoma: Diagnosis
by computer tomography. Rofo 1982, 136:595-596.
5.Dumon JF: Lipoma of the ventral segment of the right upper
lobe: Laser photoresection by fiberoscopy under local
anesthesia. Nouv Presse Med 1981, 10:177.
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