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LOBULAR CAPILLARY HEMANGIOMA OF THE TRACHEA: THE SECOND CASE

Henry Ford Hospital, Detroit, MI

INTRODUCTION: A benign lesion, also known as pyogenic granuloma, lobular capillary hemangioma (LCH) is relatively common as a cutaneous and mucosal lesion. Previous reports of LCH within the larynx and trachea have been reviewed and since determined to be granulation tissue with a prior history of airway trauma. There is only one reported case in the literature of LCH in the trachea, and here we present the second.

CASE PRESENTATION: This is a 62 year old gentleman who presented with 3 months of hemoptysis, despite antimicrobials. This persisted despite discontinuation of his anticoagulation, which he takes for a history of multiple pulmonary emboli. For this, he had an inferior vena caval filter placed years ago and it was never removed. He has well controlled asthma with no history of exacerbations requiring mechanical ventilation. He smoked as a teenager and does drink alcohol. He suffers from post-traumatic stress disorder since the Vietnam War, at which time he did suffer from a gunshot to his right lower extremity and subsequently had a below-knee amputation. Physical exam was unremarkable. A CT of the chest was performed and noted a tracheal lesion. Flexible bronchoscopy revealed the same as the source of the patient's hemoptysis. The patient was referred to our service for further management.He was taken to the operating room for rigid bronchoscopy. The lesion was noted at the 9 o'clock position in the distal trachea. Due to active bleeding, the lesion was photocoagulated with Nd:YAG laser. At this point, rigid forceps were used to debulk the lesion. The base of the lesion was photodessicated.Pathologic review revealed subepithelial capillary proliferation in a lobular architecture. No micro-organisms were noted.

DISCUSSIONS: LCH is a benign vascular lesion of the skin and upper respiratory mucosa. It is prone to ulceration and bleeding. Pain is an uncommon symptom. These lesions are more common in children and young adults. Growth will be maximal over a period of a few weeks. The definitive pathophysiologic mechanism is unknown. Hormonal changes during pregnancy, viral infections, Bartonella infection, trauma, pre-existing arteriovenous malformations have all been considered culprits.Lesions early in development appear to be histologically similar to granulation tissue. There is a background of a mixed inflammatory infiltrate within an edematous stroma. The prominent finding is that of numerous capillaries and venules in a radial pattern. As the lesion matures, the stroma becomes fibromyxoid and there is less inflammatory infiltrate. The stroma separates the lesion into lobules. The surface may re-epithelialize initial surface erosion or ulceration. Regressing lesions will fibrose. Differential diagnosis includes granulation tissue, angioendothelioma, angiosarcoma, tufted hemangioma, and intravascular angiomatosis.Lesions previously described as LCH within the larynx and trachea have now been declared to be granulation tissue due to clinical history and pathologic findings. Granulation tissue can often be found within the airway lumen after endotracheal intubation, tracheostomy, trauma, mucosal biopsies or tracheal fistulae. The tracheal lesion in our patient presented as recurrent hemoptysis. Flexible bronchoscopy was performed after a complete non-invasive work-up did not reveal an etiology. The patient was referred to our service for rigid bronchoscopy and further management. Nd:YAG photocoagulation and mechanical debulking with rigid forceps removed the lesion as a single specimen.

CONCLUSION: Lobular capillary hemangioma is an uncommon finding in the trachea. It may be an explanation for recurrent hemoptysis. This benign lesion can be easily removed bronchoscopically.

DISCLOSURE: Mohit Chawla, None.

REFERENCES:

1. Fechner RE, Cooper PH, Mills SE. Pyogenic granuloma of the larynx and trachea. A causal and pathologic misnomer for granulation tissue. Arch Otolaryngol1981; 107 :30 –32[Abstract/Free Full Text]
2. Irani S, Brack T, Pfaltz M, et al. Tracheal lobular capillary hemangioma: a rare cause of recurrent hemoptysis. Chest2003; 123 :2148 –2149[Medline]