Massive hemorrhage after inspection bronchoscopy for carcinoid tumor

Abstract

Carcinoid tumor is a neuroendocrine tumor that can arise in the bronchial tree and can be hypervascular. Here we describe a case of bronchial carcinoid tumor in a 34-year-old previously healthy male who presented with hemoptysis and right lung mass. Inspection bronchoscopy revealed bronchus intermedius endobronchial lesion and was complicated by urgent intubation and placement of endobronchial blocker for massive hemorrhage. Subsequent angiography with embolization of the bronchial artery supplying the mass resulted in control of bleeding. While massive hemorrhage has been described with biopsy of bronchial carcinoid tumor, this case suggests that careful planning for inspection bronchoscopy is needed when carcinoid tumor is suspected.

Keywords: CT, computed tomography; Carcinoid tumor; Hemoptysis; Hemorrhage.

Fig. 1

Posteroanterior radiograph of the chest showing a mass like opacity in the medial aspect of the right lower lung (arrow), silhouetting the right heart border, likely located in the medial segment of the right middle lobe.

Fig. 2

Noncontract computed tomography of the chest at the level of bronchus intermedius, showing a mass (circle) with large dystrophic calcification (black arrow) and an area of cystic appearing lesion more anteriorly (blue arrow), which is likely a bronchocele associated with the mass.

Fig. 3

Right mainstem bronchus-endobronchial large, smooth, friable mass occluding bronchus intermedius.

Fig. 4

Reconstructed contrast enhanced CT of the chest in oblique coronal Maximal Intensity Projection (MIP) at the area of the tumor, showing the mass in the right bronchus intermedius with dystrophic calcification (circle). The bronchial artery supplying the mass is visible (blue arrow). Black arrow points to bronchial blocker placed for massive hemorrhage and displaced into the left bronchial tree.

Fig. 5

Digital subtraction catheter angiographic image at the site of the tumor demonstrates the bronchial artery supplying the mass (arrow). Faint blushing of contrast is seen at the site of the tumor, in keeping with hypervascular nature of the tumor.

Fig. 6

Gross photo of right middle lobe and right lower lobe with poorly demarcated, firm yellow-white mass (black circle) expanding the right mainstem bronchus (black arrow).

Fig. 7

Hematoxylin and Eosin; Typical Carcinoid Tumor (200×). Small, polygonal neoplastic cells with granular, pale eosinophilic cytoplasm. Nuclei are round with open, “salt and pepper” chromatin. Mitotic figures are absent. Inset (400×); Finely stippled, “salt and pepper” chromatin (black arrow) without nuclear atypia or mitotic activity.