Use of endotracheal stent for hemostasis of a bleeding glomus tumor.
Samuel G, Chrissian A, and Diaz-Mendoza J. Use of endotracheal stent for hemostasis of a bleeding glomus tumor. Am J Respir Crit Care Med 2018; 197.
Am J Respir Crit Care Med
Introduction Glomus tumor is a rare benign neoplasm, commonly present in the dermis but cases have been reported at the gastrointestinal and respiratory tracts. We present a case of a tracheal glomus tumor that developed persistent bleeding after bronchoscopic mechanical debulking/biopsy, that required placement of endobronchial stent for hemostasis. Case A 52 year-old, nonsmoker, female presented with dry persistent cough and shortness of breath. CT scan showed a lower tracheal tumor measuring 1.5 cm. Bronchoscopy revealed an endotracheal tumor at the distal third of the trachea. Endobronchial biopsy at outside hospital was non-diagnostic and patient was referred to our service for diagnosis. Rigid bronchoscopy revealed an endotracheal sessile tumor, causing 60% obstruction of the tracheal lumen. Mechanical debulking was performed with the apple-coring technique. Debulking of 80% of the tumor was achieved, however it was complicated by persistent bleeding from the mass. Mechanical compression at the base of the tumor using the bronchoscope temporarily controlled the bleeding. A 16mm balloon was inflated for tamponading with partial results. It was decided to deploy an endobronchial stent to achieve permanent hemostasis. A self-expanding metal stent 18×60mm (Aero Merit Medical, Utah, USA) was deployed to cover the bed of the tumor completely, which caused an immediate and sustained hemostasis. Pathology report showed a Glomus tumor with benign features. Two weeks later the stent was removed and the patient was referred for surgical evaluation. Discussion Glomus tumor is a rare, benign neoplasm with male: female ratio of 7:1. Grossly it is a pink vascular nodule. Histologically, it is composed of glomus cells with prominent vascular and smooth muscle components. Preoperative linear Doppler ultrasonography should be done to specify the size, depth and anatomic criteria. Transthoracic segmental resection with primary reconstruction is the treatment of choice yet bronchoscopic resection has been used to relieve obstruction prior to the definitive operation. Submucosal invasion is common so bronchoscopic resection should be reserved for the surgical high risk population given the risk of recurrence. Criteria for malignancy include deep location and a size >2, or atypical mitotic figures, or high nuclear grade and >5 mitotic figures per HPF. Our case illustrates a Glomus tumor that was partially resected with minimal invasion using rigid bronchoscopy, post resection bleeding was successfully managed by placing a stent that successfully achieved hemostasis. Conclusion Self-expanding metal stent could be used to achieve hemostasis for bleeding endotracheal tumors, like Glomus tumors.