A 34-year-old male presented to the emergency department (ED) with a chief complaint of hemoptysis. His past medical history (PMH) was notable for recurrent pneumonias. Chest x-ray (CXR) demonstrated a right middle lobe infiltrate. Chest computed tomoghraphy (CT) revealed an endobronchial lesion at the level of the bronchus intermedius. Flexible bronchoscopy was notable for bloody secretions, and a broad-based lesion in the bronchus intermedius is shown in the figure below:
What is the next most appropriate step in management?A. Forceps biopsy
Correct Answer: B
This patient likely has a bronchial carcinoid tumor. Carcinoid tumors of the lung are rare neuroendocrine tumors accounting for less than 1% of all lung tumors. The lung, however, is the second most common presenting site (after the gut) for carcinoid tumor. Typical presenting symptoms include cough, hemoptysis, and/or symptoms of bronchial obstruction. Carcinoid tumors are far more common in the larger airways. The tumors are highly vascular and grow intraluminally as well as extraluminally and are mostly covered by bronchial epithelium. Definitive treatment is with surgical resection, which typically carries an excellent prognosis. Historically there has been concern for massive hemorrhage following forceps biopsy secondary to the highly vascular nature of the tumor . While this complication is actually fairly rare, it is common to sample suspected carcinoid tumors via rigid bronchoscopy, so that any bleeding may be more effectively controlled. Cryobiopsy has also been reported to be preferable to forceps biopsy. IR embolization would not allow for the tissue sampling needed to make the diagnosis of carcinoid. Pulmonary Kaposi sarcoma is characterized by violaceous endobronchial lesions but is typically a late manifestation of HIV and more likely to present with other constitutional symptoms. In addition, the bronchoscopic appearance in this case is far more typical of carcinoid.