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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00948-9
10.1016/j.ijscr.2024.110167
110167
Case Report
Central airway carcinoid tumor mimicking chronic asthma and necessitating pneumonectomy: A case report
Lisznyai Eric a
Hutchings Hollis a
Debiane Labib b
Okereke Ikenna iokerek1@hfhs.org
a⁎
a Department of Surgery, Henry Ford Health, 2799 West Grand Boulevard, Detroit, MI 48202, United States of America
b Division of Interventional Pulmonology, Henry Ford Health, 2799 West Grand Boulevard, Detroit, MI 48202, United States of America
⁎ Corresponding author at: Department of Surgery, Division Chief, Thoracic Surgery, Henry Ford Health System, 2799 W. Grand Blvd, Detroit, MI 48202, United States of America. iokerek1@hfhs.org
13 8 2024
9 2024
13 8 2024
122 11016728 7 2024
7 8 2024
10 8 2024
© 2024 The Authors. Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Central airway tumors can occasionally be misdiagnosed as a chronic disease. We present a case of a central airway carcinoid tumor that was mistaken as chronic asthma for many years.

Presentation of case

A 29-year-old male bodybuilder presented to our emergency department with shortness of breath and hemoptysis. He was an avid bodybuilder who participated in competitions. He had been diagnosed with asthma for years and used an albuterol inhaler chronically. Computed tomography of the chest showed diffuse opacification of the left hemithorax, multiple air-fluid levels and a 4-cm mass of the proximal left mainstem bronchus with intraluminal calcifications. Bronchoscopy demonstrated a large endobronchial mass, and biopsy was positive for typical carcinoid tumor. Stabilization was achieved with rigid bronchoscopy and partial endobronchial debridement of the tumor to allow some patency to the left lung. After stabilization, he subsequently underwent left pneumonectomy. He recovered well and was discharged home on postoperative day 2. On surveillance 2.5 years after pneumonectomy, he has resumed bodybuilding and has no evidence of recurrent disease.

Discussion

Proximal airway tumors can mimic asthma. Careful management can achieve successful results even in very complex cases. There should be an increased level of suspicion for other diagnoses, especially in young and healthy individuals with asthma that is refractory to medical treatment.

Conclusion

Proximal airway tumors can mimic chronic diseases such as asthma. Other diagnoses should be considered, especially in young and health individuals with asthma symptoms that do not respond to conventional therapies.

Highlights

• Central airway tumors may mimic chronic obstructive lung disease.

• Recommend multidisciplinary approach amongst pulmonology and thoracic surgery.

• Carinoplasty is an effective adjunct in achieving negative surgical margins.

• Pneumonectomy can be both curative and well-tolerated in select patients.

Keywords

Carcinoid
Pneumonectomy
Carinoplasty
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pmc1 Introduction

This work is in line with the SCARE crtieria [1]. Central airway tumors can occasionally be misdiagnosed for chronic conditions. Patients may present with progressively worsening shortness of breath and exercise intolerance [2]. We present a case of a young male bodybuilder previously diagnosed with asthma who was found to have an endobronchial carcinoid tumor and destroyed left lung. He ultimately required pneumonectomy and recovered fully thereafter. We discuss the diagnostic challenges of central airway tumors, specifically in young and otherwise healthy populations.

2 Presentation of case

A 29-year-old bodybuilder presented emergently with shortness of breath and hemoptysis. He was an avid bodybuilder who participated competitively. He had been diagnosed with asthma for years and used an albuterol inhaler chronically. He had never suffered from fever or pneumonia-like symptoms before. His chief symptoms were wheezing and exertional chest tightness. He had a leukocytosis of 12.3 white blood cells per microliter and an elevated creatinine of 1.37 mg per deciliter. Computed tomography showed diffuse opacification of the left hemithorax, multiple air-fluid levels and a 4-cm central mass of the left mainstem bronchus (Fig. 1). The lung parenchyma appeared to be replaced by diffuse cystic changes in both the left upper lobe (Fig. 2) and left lower lobe (Fig. 3). The patient underwent bronchoscopy, which revealed a large endobronchial mass originating at the proximal aspect of the left mainstem bronchus (Fig. 4). The mass obstructed 90 % of the bronchial lumen. Biopsy revealed typical carcinoid tumor.Fig. 1 Computed tomography of chest demonstrating diffuse opacification of the left hemithorax and 4 cm central mass of the left mainstem bronchus.

Fig. 1

Fig. 2 Computed tomography showing extensive cystic changes of left upper lobe.

Fig. 2

Fig. 3 Computed tomography showing extensive cystic changes of left lower lobe.

Fig. 3

Fig. 4 Bronchoscopic image of endobronchial mass originating at the proximal aspect of the left mainstem bronchus.

Fig. 4

Interventional pulmonology and thoracic surgery coordinated multidisciplinary discussions. To improve respiratory function before definitive surgery, interventional pulmonology performed rigid bronchoscopy and debulking of the tumor to establish left mainstem patency. The patient improved clinically. One week later, he underwent a left thoracotomy and exploration. During the surgery, attempts were made to dissect the hilum first to determine what extent of parenchymal resection would be necessary. The tumor did not extend outside the airway into the peribronchial tissues. Both the upper and lower lobes had extensive parenchymal necrosis, however. Salvage of the lung was not possible and left pneumonectomy was required to resect all the destroyed lung parenchyma. Intraoperative frozen section analysis was initially positive for tumor at the bronchial stump margin. As such, carinoplasty was required to achieve negative margins. Carinal repair was buttressed with a thick pericardial fat pad. Estimated blood loss was 400 ml. Final pathology demonstrated a pathologic T2aN0M0 typical carcinoid tumor with neuroendocrine features and negative margins. Pathologic review of the specimen showed that the lung parenchyma had been replaced by cystic changes, bronchiolectasia and extensive necrosis of both lobes. All lymph nodes were negative for malignancy.

The postoperative course was uncomplicated. Chest tube was removed on postoperative day one. The patient was discharged to home on postoperative day two. Computed tomography surveillance imaging showed no disease recurrence at thirty months after surgery. Thirty months after surgery, he is in good health and has resumed bodybuilding.

3 Discussion

Diagnosis of central airway tumors in the young and healthy population can be challenging. Due to its proximal location in the airway, symptoms can be misdiagnosed as benign airway diseases including asthma and chronic obstructive pulmonary disease [3]. There should be a high degree of suspicion about a central tumor if chest imaging reveals atelectatic changes or mediastinal shift suggesting pulmonary collapse. In these instances, computed tomography followed by bronchoscopy is indicated. Patients who are young and relatively fit may have delayed presentation, as their contralateral lung reserve may be excellent. Early diagnosis may help to limit the extent of intervention needed to remove the tumor.

Bronchoscopy can be used for diagnostic and therapeutic purposes [4]. A variety of techniques, including cryotherapy, laser and argon plasma coagulation have been demonstrated as safe and effective means for resection [5]. Endobronchial stenting is an option for palliative treatment in patients who are not surgical candidates. Definitive surgical resection is ideal, however, if patients can tolerate airway and/or pulmonary resection. In our patient, the tumor's location in the airway would have allowed for salvage of the lower lobe with direct anastomosis of the lower lobe bronchus to the carina. This airway reconstruction was technically possible and considered during the surgery. But the destruction of the lung parenchyma of both lobes mandated pneumonectomy. There was no viable lung, given the advanced nature of the necrotic changes throughout both lobes. Our patient was very healthy and could tolerate pneumonectomy, as his left lung likely contributed very little to his overall pulmonary function. Furthermore, our patient was a very active bodybuilder and had excellent right-sided pulmonary function.

Two other cases of central airway carcinoid misdiagnosed as asthma have been reported. In one case, a 61-year-old female presented with shortness of breath and cough [6]. Although pulmonary function testing was consistent with asthma, she did not respond well to inhaler treatment. Eventually bronchoscopy revealed tracheal carcinoid tumor that was excised endobronchially. In another case, a 46-year-old female presented with poorly controlled asthma symptoms for years despite being on maximal anti-asthmatic inhaled therapy. Computed tomography scan revealed a pedunculated endotracheal lesion that obstructed 90 % of the trachea. This was subsequently resected via bronchoscopy. Final pathology was consistent with atypical carcinoid tumor [7]. Our case is the first reported case in which pneumonectomy was performed to cure disease and relieve asthma-like symptoms.

It is important to have strong multidisciplinary collaboration in such cases. In our case, the surgery team and interventional pulmonology teams coordinated care on the day of patient admission. Rigid bronchoscopy was performed to attempt to establish patency of the left lung, since the patient had presented to the emergency room with respiratory insufficiency. Given the expected extent of surgery, improving respiratory function before surgery was anticipated to improve postoperative recovery and the ability to tolerate a complex surgical procedure. Unfortunately, the left lung parenchyma was destroyed and patency of the mainstem bronchus did not lead to improved aeration. Given the excellent pulmonary reserve of the patient, however, he tolerated pneumonectomy without difficulty and was discharged to home after only 2 days.

4 Conclusion

Central airway obstruction can be the great mimicker and presents an important challenge in diagnosis and work up. Subtle abnormalities on chest x-ray should be pursued with more sensitive imaging modalities. In athletically fit patients, there should be a much lower threshold to investigate mild forms of dyspnea with imaging, as these patients may not develop severe symptoms until they have severe progression of disease from the tumor. Multidisciplinary planning is crucial early in the treatment course. Bronchoscopic evaluation is an important initial intervention. Clinicians should consider less common diagnoses in patients not responding to conventional asthma treatment.

Consent

Consent was obtained directly from the patient.

Ethical approval

The report was given an exemption from ethics approval by the Henry Ford Health Institutional Review Board. Exemption was given due to the nature of the manuscript as a case report. Patient consent was obtained prior to writing this case report.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Author contribution

EL, HH, LB and IO contributed to the writing and editing of the manuscript. LB and IO contributed to the clinical care reported in the manuscript.

Guarantor

Ikenna Okereke, M.D.

Research registration number

N/A.

Conflict of interest statement

All authors declare no conflicts of interest.
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