A 27 year old nurse was admitted with a left sided chest infection. She had stopped smoking 5 years previously after being treated for asthma with recurrent chest infections for a period of five years. She reported no other medical problems and was able to work satisfactorily between exacerbations of her lung disease.

 

Chest radiograph showed a typical lobar consolidation with volume loss in the left upper lobe. CT scan confirmed the lobar consolidation with pleural inflammatory changes and hilar node enlargement but demonstrated no tumour mass nor mediastinal lymphadenopathy. Flexible bronchoscopy revealed a smooth polypoid mass approximately 5 mm in diameter at the bifurcation of the left main bronchus producing a ball-valve obstruction of the left upper lobe. Bronchial biopsy was accompanied by profuse bleeding which settled spontaneously. It was reported as being suggestive of small cell carcinoma but with substantial crush artefact.

 

The considerably anxious patient with her nursing background then underwent rigid bronchoscopy under general anaesthetic. The whole polyp was excised with the biopsy forceps. The resultant bleeding was easily controlled using an Adrenaline soaked pledget. Histology on this occasion showed a carcinoid tumour with no recognised features of malignancy.

 

A plaque of recurrent tumour was found on repeat bronchoscopy 3 months later. This was ablated with laser on two occasions. Repeat CT scan 6 months after the initial diagnosis showed extra-luminal tumour around the distal left main bronchus. Resection was advised and the patient admitted for preoperative subcutaneous somatostatin.

 

At thoracotomy there were abundant inflammatory pleural adhesions to the upper lobe and fleshy hilar nodes. The lung parenchyma had recovered well from the infective episodes. A cylinder of distal left main bronchus including the orifices of both the upper and lower lobes was resected. Both lobar bronchi were re-implanted onto the residual left main bronchus one centimetre from the carina, thus preserving all lung tissue.

 

The patient made an uncomplicated recovery from surgery. The “asthmatic” symptoms disappeared. Three years after resection she remains well with no limitation of exercise tolerance and check bronchoscopy has shown no tumour recurrence nor cicatrisation of the bronchial anastomoses.