Linear probe 19-gauge endobronchial ultrasound diagnosis of a benign chondroid hamartoma

Abstract

We report a case of a 68-year-old gentleman, found to have a right hilar soft tissue mass whilst undergoing CT staging for prostate cancer. MRI imaging showed a heterogeneous, enhancing solid mass without evidence of fat content. A linear probe endobronchial ultrasoundguided transbronchial needle aspiration was performed using a 19G needle. This confirmed the diagnosis of a benign chondroid hamartoma, avoiding the need for more invasive surgical biopsy. Case ReportA 68-year-old gentleman with a recent diagnosis of prostate cancer was referred to the lung cancer multi-disciplinary team meeting by the uro-oncology team following a CT staging scan. The patient had no respiratory symptoms or prior respiratory history. The CT scan showed a well-defined soft tissue mass (2.9 x 2.9 x 3.3 cm) in the right lower lobe, adjacent to the posterior wall of the bronchus intermedius (Figure 1). There was no evidence of axillary, supraclavicular or mediastinal lymphadenopathy and no evidence of abdominopelvic disease elsewhere.The diagnosis of prostate cancer had been made on the basis of a raised prostate specific antigen (PSA) of 136 ug/l and a positive prostate biopsy showing grade 2 moderately differentiated adenocarcinoma. Skeletal scintigraphy showed no evidence of skeletal metastases.CT imaging raised the possibility that the lesion could be cystic in nature, and so a magnetic resonance imaging (MRI) scan of the thorax was arranged to further elucidate the structure of the lesion (Figure 2). This showed a heterogenous enhancing solid mass without evidence of fat content. It was felt that this could represent a carcinoid tumour or a metastatic lesion from prostatic carcinoma.The patient started neo-adjuvant hormonal therapy and a linear probe endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS TBNA) was performed as previously described [1]. The linear probe EBUS showed a 24mm heterogenous lesion arising from the posterior aspect of the right main bronchus, with areas of high density within a low echoic mass (Figure 3). Six biopsies were taken using an Olympus 19G needle (Olympus ViziShot, NA-U402SX-4019, Olympus KeyMed, UK), ranging from 4-10 mm in size. These samples comprised several cores of hyaline cartilage (Figure 4), together with strips of respiratory epithelium and mucus-containing macrophages. Additional adipose tissue, fibrotic stroma and oedematous stroma covered by cuboidal epithelium with bland morphology were present in the sample ( Figure 5). This combination of features was consistent with sampling of a benign chondroid hamartoma.The patient went on to have high dose rate brachytherapy and external beam radiotherapy for the prostate cancer, and continues on hormonal therapy. This PSA is now normal at 0.8 ug/l. A follow-up CT scan performed at an interval of 6 months showed no change in the size of the nodule. He remains under expectant review in the respiratory clinic and is asymptomatic from the chondroid hamartoma. Further surveillance imaging and clinical assessment is plann...

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