Multiple pulmonary hamartomas; a case report and review of the literature

Death Related to a Congenital Vascular Anomaly of Pulmonary Hamartoma Type: Malpractice or Tragic Fatality?

In forensic pathology, apparently straightforward cases can often hide rarities that, if not correctly interpreted, can alter the results of the entire investigation, leading to misinterpretations. This occurs when the investigation is conducted to assess medical malpractice. An unexpected death, with no known apparent cause, is often linked to an underlying disease process of unclear etiological origin whose nature can, unfortunately, be properly investigated only post-mortem. This presentation shows a case study, in which it was possible to reconduct the death of a patient to a natural pathology and not to medical treatment. Here, the authors illustrate a case with a hamartoma developed in chronic inflammatory conditions (bronchiectasis) that was difficult to differentiate from lung cancer due to the inability to perform specific instrumental examinations. The hamartoma, usually benign and identifiable by standard instrumental investigations, in this case, led to the patient's death precisely during the execution of a bronchoscopy. However, in the absence of a certain cause of death, public opinion unanimously attributes a patient's disease to medical error. Indeed, a routine practice such as bronchoscopy should not cause death and consequently, the doctor must have made a mistake. Fortunately, the autopsy not only demonstrated the origin of the bleeding but also unveiled the reason for this, as rare congenital lung disease. Fate, one might say.

Clinical, Radiologic, and Pathologic Characteristics of Pulmonary Hamartomas With Uncommon Presentation

OBJECTIVES

To investigate the clinicopathologic and radiologic features of pulmonary hamartomas (PHs) with uncommon clinical presentation.

METHODS

A retrospective clinicopathologic and radiologic review was performed for patients diagnosed (1999-2019) with multiple hamartomas, lesions arising adjacent to a coexisting pulmonary malignancy, and tumors with predominantly extrapulmonary localization.

RESULTS

Of 979 patients diagnosed with PHs, 6 (0.6%) had multiple hamartomas, 4 (0.4%) had hamartomas adjacent to lung adenocarcinoma, and 2 (0.2%) had large mediastinal masses. Patients with multiple lesions had a median age of 65 years and mean tumor size of 0.9 cm; 1 patient had 3 hamartomas, and 5 patients had 2. Lesions next to adenocarcinomas had a mean size of 1.4 cm, and affected patients had a median age of 69 years. Predominantly mediastinal PHs, diagnosed in a 63-year-old woman and a 68-year-old man, measured 4.1 to 6 cm and were connected to the lung. All lesions were solid on imaging with absence of definitive fat or calcification, concerning for granuloma or malignancy. All cases had typical histology of PH, although one of the mediastinal tumors had an unusual amount of epithelial hyperplasia.

CONCLUSIONS

PHs can be clinically and radiologically challenging to diagnose. Histopathologic examination of biopsies and resection specimens is diagnostically crucial in this setting.

Multiple benign lung tumors

Multiple benign pulmonary nodules are rare and are from a variety of etiologies. Infectious causes, such as histoplasmosis, tuberculosis, or parasitic infections, usually require biopsy for confirmation. An interesting entity, benign metastasizing leiomyoma, is rare but occurs from a low-grade leiomyoma that most commonly spreads from the uterus.

Diagnosis and staging of "other bronchial tumors"

Unusual bronchial tumors represent 4% to 6% of all lung tumors. These lesions include hamartomas, bronchial carcinoids, adenoid cystic carcinoma, mucoepidermoid carcinoma, and other more rare tumors. In the majority of patients these lesions are diagnosed using transthoracic FNA and different bronchoscopic biopsy techniques such as bronchial lavage, bronchial brushing, endobronchial biopsy, transbronchial biopsy, and transbronchial needle aspiration. Thoracoscopic wedge biopsy is diagnostic in the remainder of cases. Occasionally, because of tumor location, thoracoscopically-guided FNA or thoracoscopic ultrasound are helpful in obtaining a diagnosis. Staging of these lesions is assessed after proper resection; however, mediastinoscopy should be performed if preoperative mediastinal adenopathy is appreciated.

Multiple pulmonary chondrohamartomas in trachea, bronchi and lung parenchyma. Review of the literature

Multiple pulmonary chondromatous hamartomas (MPCH) are rare, and MPCH with tracheal involvement have not been, to the best of our knowledge, reported before. Furthermore, there is no agreement in the literature about the origin of these tumours. We report a case of MPCH involving trachea, bronchi and lung parenchyma, incidentally found at the autopsy of a 88-year-old woman who died of acute myocardial infarction, and we review the literature about MPCH. We conclude that there appear to be two different types of multiple pulmonary chondromatous hamartomas; those presented in young patients often linked to gastric leiomyoblastomas and catecholamine-producing paragangliomas (Carney syndrome) with high mortality, and those presented in elderly patients, which seems to be compatible with life.

Pulmonary hamartomas

OBJECTIVE

To analyze the clinical and pathologic features of biopsy-proven pulmonary hamartomas at a tertiary referral center.

DESIGN

We retrospectively reviewed institutional data on pulmonary hamartomas for a 17-year study period.

MATERIAL AND METHODS

The Mayo Clinic computerized medical records database was searched for patients who had biopsy, excision, or autopsy diagnosis of pulmonary hamartomas from 1976 through 1992. Medical records and all available histologic sections were reviewed.

RESULTS

Of the 215 patients with histologically confirmed pulmonary hamartoma, 141 were men and 74 were women (approximately a 2:1 ratio). Two hundred eight patients were asymptomatic, 54 of whom were undergoing assessment for a comorbid disease process. Only four patients had new onset of respiratory symptoms. The peak incidence of occurrence was in the seventh decade of life. The mean size of the hamartomas were 1.5 cm (range, 0.2 to 6.0); no lobe was predominantly involved. Most hamartomas were resected by simple or wedge excision. Sixty-three patients (29.3%) had a concurrent neoplasm (most commonly, lung carcinoma). Follow-up ranged from 2 to 192 months (mean, 61). Eight postoperative deaths occurred. No recurrent pulmonary hamartomas developed. In one patient, lung carcinoma developed 33 months after excision of a hamartoma. In a second patient, sputum cytologic findings were abnormal 9 years later. A third patient had biopsy-proven adenocarcinoma metastatic to bone and an indeterminate lung nodule 2 years after resection of a pulmonary hamartoma.

CONCLUSIONS

Pulmonary hamartomas are benign lung neoplasms that, in our referral population occurred most commonly in asymptomatic older men. A substantial number of our patients had concurrent neoplasms; however, many had been referred for cancer treatment. We found no evidence of either a malignant transformation or an unexplained association with other lung neoplasms.

Benign metastasizing leiomyoma

The cases of 2 patients with benign metastasizing leiomyofibroma are reviewed. Although extremely rare both in our experience and in the literature, benign metastasizing leiomyofibroma is an important differential diagnosis in young women seen with multiple lung nodules. Our patients underwent staged thoracotomies for diagnosis and treatment, and have experienced no evidence of recurrence over a six-year period.

Atypical lipomatous hamartoma of the lung

An unusual lipomatous tumour discovered accidentally in the right middle lobe of a 34-year old woman is described. The tumour was associated with an intrapulmonary typical chondromatous hamartoma in the same lobe but separate from the first lesion. The lipomatous tumour was primarily an intrapulmonary lipoma but in a few of the numerous sections made minute islands of cartilage and bone were discovered along with a few epithelial-lined clefts. These justify the diagnosis of a lipomatous hamartoma. Dispersed among the mature fat cells were a few immature cells with atypical nuclei. Cellular atypia in predominantly lipomatous hamartomas has not previously been reported. As the occurrence of atypical lipoblast-like cells might lead to an erroneous diagnosis of liposarcoma, this case is thought worthy of reporting.

Benign tumors of the lung and bronchus

Benign tumors of the lung and bronchus are a heterogeneous group of lesions that usually present as asymptomatic, solitary, peripheral lung nodules or, less commonly, as endobronchial lesions causing obstructive symptoms. All endobronchial lesions should be removed surgically to alleviate symptoms and to prevent destruction of distal lung tissue. Parenchymal lesions may present challenging problems in clinical diagnosis and management. Most patients will ultimately require thoracotomy for histologic confirmation of benignity. It is probable that newer diagnostic procedures will allow a more accurate nonoperative diagnosis in certain patients in the near future. At the present time, expeditious limited thoracotomy affords a safe, rapid, and effective treatment for patients with a benign tumor of the lung or bronchus.