Endobronchial endometriosis presenting as central-type lung cancer: a case report
© Yu et al.; licensee BioMed Central Ltd. 2013
Received: 25 February 2013
Accepted: 26 March 2013
Published: 3 April 2013
A 45-year-old female patient was referred to our hospital for complaining of dyspnea and coughing in the past four months. The computed tomography scanning demonstrated a central lesion in the upper lobe of the left lung close to the hilar, and the subsequent bronchoscopy revealed a polypoid lesion of the distal of the left main bronchus. This patient was diagnosed clinically as “possibly central-type lung cancer”. However, the pathologic result of the surgically excised polypoid lesion was endobronchial endometriosis.
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Endometriosis is defined as the presence of endometrial tissue, including endometrial glands and stroma, in the body areas out of the uterus. Endometriosis foci are usually located in the pelvis and abdomen, and rarely in the thorax. Moreover, the thoracic endometriosis commonly affects the lung parenchyma, pleura, and diaphragm, and the prominent clinical manifestations are recurrent hemoptysis, pneumothorax, hemothorax, and asymptomatic pulmonary nodules [1, 2]. We herein report a rare case of endobronchial endometriosis presenting as central-type lung cancer.
Materials and methods
The resected specimens were fixed with 10% neutral-buffered formalin and embedded in paraffin blocks. Tissue blocks were cut into 4-μm slides, deparaffinized in xylene, rehydrated with graded alcohols, and immunostained with the following antibodies: cytokeratin (CK, AE1/AE3), thyroid transcription factor 1 (TTF-1, 8G7G3/1), ER (SP1), CD10 (56C6), and Ki67 (MIB-1) (MaiXin, China). Sections were then stained with a streptavidin-peroxidase system (KIT-9720, Ultrasensitive TM S-P, MaiXin, China). The chromogen used was diaminobenzidine tetrahydrochloride substrate (DAB kit, MaiXin, China). All the samples were slightly counterstained with hematoxylin, dehydrated, and mounted. For the negative controls, each sample was incubated with PBS instead of the primary antibody as above described.
The occurrence of endometriosis in areas other than the abdomen and pelvis is uncommon, even rare in the thorax. Thoracic endometriosis is usually located in the lung parenchyma, pleura, and diaphragm. The endometriosis of the bronchus is extremely rare. To our knowledge, there were only five cases of thoracic endometriosis reported to occur in the bronchus previously [2–6]. The typical clinical manifestations of thoracic endometriosis include pneumothorax (72%), hemoptysis (14%), or hemothorax (12%) coincident with menstrual bleeding, and only 2% cases were presented as pulmonary nodules [7, 8]. Moreover, catamenial hemoptysis was documented in all the five patients with endobronchial endometriosis [2–6], suggesting that patients with tracheal endometriosis are prone to hemoptysis. However, in our case, the patient only showed dyspnea and coughing without hemoptysis, and the case history gave no other valuable information.
The CT scanning and bronchoscopy, which have been considered to be valuable in diagnosing thorax endometriosis, both have a yield in this extremely rare condition. It was reported that asymptomatic pulmonary nodules was documented in only 2% patients with thoracic endometriosis . While of the 5 cases with tracheal endometriosis, no patient presented as pulmonary nodules [2–6]. In our case, CT scanning detected a round-like lesion in the upper lobe of the left lung close to the hilar. The bronchoscopy revealed that there was a polypoid lesion in the distal of the left main bronchus. Accordingly, the clinical diagnosis was considered as “possibly central-type lung cancer”. Though the bronchoscopic biopsy was performed, the result was of little value in precluding neoplasm of the lung. Therefore, surgical treatment was imperative.
On pathology sections, endometrial glands and stromal cells were found under the bronchial epithelium. Furthermore, the immunohistochemistry was performed to confirm the diagnosis. The immunohistochemical results revealed that all the epithelium and the glands were positive for CK, while the stromal cells were negative. All the epithelium and glandular structures which were positive for CK showed no atypia. The alveolar epithelial cells were positive for TTF-1. The ectopic glands showed positive staining for ER, and the stromal cells were positive for both ER and CD10. Taken together, the possibility of pulmonary tumors exhibiting atypical microscopic changes could be ruled out [9, 10], and the diagnosis of this case is endobronchial endometriosis.
Reports of endobronchial endometriosis are extremely rare. Diagnosis of etiology remains challenging due to the absence of specific clinical characteristics, especially when the features of CT scanning and bronchoscopy could not exclude the possibility of central-type lung cancer. In this condition, to make a right diagnosis can only depend on pathological examination. Endobronchial endometriosis had to be considered in the differential diagnosis of “central-type lung cancer”, particularly in patients with known endometriosis.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in Chief of this Journal.
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