Presentation
Ten year history of resection and adjuvant chemoradiation for multifocal bronchial neuroendocrine carcinoma. Absence of disease for nearly five years followed by two months of persistent non-productive cough, shortness of breath, and exercise intolerance.
Patient Data
Chest X-ray:
The tracheobronchial air column fades out near the carina.
Otherwise normal heart and mediastinum.
Clear lungs and pleural spaces.
A CT scan of the chest 4 months after the initial PET-CT scan revealed the carinal mass to measure 2.6 cm x 2.6 cm. The tumor involved the distal posterior trachea, causing luminal compression of the main stem bronchi. The left bronchial lumen (2-3 mm) was more occluded than the right (4-5 mm).
Bronchial artery embolization
Diagnostic angiography was performed in the aortic arch, demonstrating multiple intercostal arteries. In searching for a bronchial artery, multiple selected arteries branching from the thoracic aorta demonstrated an intercostal course. An artery branching from the thoracic aorta was seen to course along the carina and supply branches of the upper and lower airways in the right lung. A microcatheter system was introduced into the selected right bronchial artery for super-selective angiography. Tumor blushes with contrast were observed overlying the carina, with at least two feeding vessels arising from the main right bronchial artery. Post-embolization angiography demonstrates successful occlusion of the vessel feeding the mass. Residual flow is visible in the left lower bronchial artery.
Case Discussion
The patient presented in this case had a ten year history of multiple resections and adjuvant chemoradiation for multifocal bronchial neuroendocrine carcinoma. Initially she presented with a two month history of non-productive cough, shortness of breath, and exercise intolerance. FDG PET-CT scan revealed a 1.5 x 1.5 cm mass in the posterior distal trachea. Four months later the patient had acutely progressed to dyspnea with persistent small-volume hemoptysis. CT chest revealed the carinal mass had grown to 2.6 x 2.6 cm and was obstructing the right and left main stem bronchi. It was believed that the bronchial arteries were involved as they are isolated as the most frequent source of bleeding in hemoptysis 1. Bronchial artery embolization (BAE) was performed and the patient experienced resolution of hemoptysis following the procedure.
Embolization of bronchial arteries is minimally invasive and can elicit immediate cessation of hemoptysis in 70–90% of patients 1,2-5. Pulmonary malignancy, as in this patient, is more likely to result in recurrent hemoptysis, poor immediate and long-term outcomes, and higher rates of mortality 5,6. Should re-bleeding occur, repeat embolization is both safe and efficacious in most patients 7.
The major airways are important check areas on CXR especially in someone presenting with dyspnea, cough or stridor. In a patient with hemoptysis and such critical narrowing of the airways at the carina, recognition of the abnormality on CXR could be life-saving.
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