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At discharge the patient was asymptomatic and chest radiograph showed no abnormalities&#46; Two months later she returned with new onset hemoptysis&#46; Chest radiograph showed a small left side pneumothorax and increased ipsilateral lung volume with a contralateral mediastinum shift&#44; both of which increased with expiration&#46; A chest computed tomography &#40;CT&#41; confirmed these alterations with significantly decreased ipsilateral lung attenuation and showed a 2<span class="elsevierStyleHsp" style=""></span>cm lesion in the left main bronchus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b and c&#41;&#46; Bronchoscopy showed a cherry red polypoid tumor&#44; easily hemorrhagic&#44; causing an almost total obstruction of the left main bronchus&#46; Biopsy of the tumor indicated a typical carcinoid tumor&#46; An octreotide scan revealed uptake solely in the lesion of the left main bronchus and so a sleeve-type surgery was performed with excision of the main bronchus and lobectomy of left upper lobe&#46; Histological examination confirmed a typical carcinoid tumor of the left main bronchus and showed no signs of emphysema or pleural blebs&#46; The post-surgical period was insignificant and the patient was discharged home&#46; Eighteen months after surgery she is asymptomatic&#44; had no new pneumothoraces and her chest CT shows resolution of the mediastinum shift and similar bilateral lung attenuations &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>d&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Bronchial carcinoid tumors are rare accounting for 1&#8211;5&#37; of all lung malignancies<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and usually present with evidence of bronchial obstruction &#40;obstructive pneumonitis or atelectasis&#41;&#44; cough or hemoptysis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The occurrence of a spontaneous pneumothorax as a complication of lung cancer is also rare&#44; comprising only 0&#46;05&#8211;1&#46;4&#37; of all pneumothoraces<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> and occurring in just 0&#46;05&#8211;0&#46;46&#37; of patients with pulmonary malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In the majority &#40;75&#8211;100&#37;&#41; of cases reported in lung cancer patients&#44; spontaneous pneumothorax preceded the diagnosis of lung cancer&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> but there are reports of its occurrence during chemotherapy or radiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> The association between lung cancer and pneumothorax has been reported for most histologic types of lung cancer<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#59; however&#44; it seems there is no previous description of a pneumothorax complicating a bronchial carcinoid tumor or of a bronchial carcinoid tumor presenting with a pneumothorax&#46; The proposed mechanisms for this association have been the appearance of a bronchopleural fistula secondary to necrosis and invasion of the pleura by a peripheral tumor and&#44; less frequently&#44; the rupture of alveoli&#44; emphysematous bullae or subpleural blebs due to hyperinflation of the peripheral airways caused by the tumor acting as a check-valve&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> In the reported case radiology shows hyperinflation of the left lung&#44; leading to contralateral mediastinum shift increasing with expiration&#46; We propose that the polypoid tumor in the left main bronchus functioned as a variable obstruction &#40;check-valve&#41;&#44; leading to an inability to fully exhale the inspired air volume from the left lung&#46; This trapped air in association with the expiratory maneuvers caused an increase in alveolar pressure with rupture of alveoli and formation of a pneumothorax associated with ipsilateral lung hyperinflation&#46; This is also supported by the fact that the patient was a young nonsmoker&#44; with no history of lung disease&#44; had no signs of pleural blebs or emphysema on histologic examination&#44; and that&#44; after removal of the bronchial carcinoid tumor&#44; there was resolution of the ipsilateral hyperinflation and there were no new pneumothoraces&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This is a singular case of a bronchial carcinoid tumor presenting with a recurrent spontaneous pneumothorax explained by a large check-valve mechanism&#46; Also&#44; the reported case strengthens the safe approach in which recurrent pneumothoraces should be considered secondary&#44; and search for a cause should be actively sought&#46;</p></span>"
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Letter to the Editor
Bronchial carcinoid tumor presenting with recurrent pneumothorax
Tumor carcinóide brônquico apresentado com pneumotórax recorrente
R. Reis
Corresponding author
ricardomcreis@gmail.com

Corresponding author.
, L. Nascimento, A. Fernandes
Pneumonology Service, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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At discharge the patient was asymptomatic and chest radiograph showed no abnormalities&#46; Two months later she returned with new onset hemoptysis&#46; Chest radiograph showed a small left side pneumothorax and increased ipsilateral lung volume with a contralateral mediastinum shift&#44; both of which increased with expiration&#46; A chest computed tomography &#40;CT&#41; confirmed these alterations with significantly decreased ipsilateral lung attenuation and showed a 2<span class="elsevierStyleHsp" style=""></span>cm lesion in the left main bronchus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b and c&#41;&#46; Bronchoscopy showed a cherry red polypoid tumor&#44; easily hemorrhagic&#44; causing an almost total obstruction of the left main bronchus&#46; Biopsy of the tumor indicated a typical carcinoid tumor&#46; An octreotide scan revealed uptake solely in the lesion of the left main bronchus and so a sleeve-type surgery was performed with excision of the main bronchus and lobectomy of left upper lobe&#46; Histological examination confirmed a typical carcinoid tumor of the left main bronchus and showed no signs of emphysema or pleural blebs&#46; The post-surgical period was insignificant and the patient was discharged home&#46; Eighteen months after surgery she is asymptomatic&#44; had no new pneumothoraces and her chest CT shows resolution of the mediastinum shift and similar bilateral lung attenuations &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>d&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Bronchial carcinoid tumors are rare accounting for 1&#8211;5&#37; of all lung malignancies<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and usually present with evidence of bronchial obstruction &#40;obstructive pneumonitis or atelectasis&#41;&#44; cough or hemoptysis&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The occurrence of a spontaneous pneumothorax as a complication of lung cancer is also rare&#44; comprising only 0&#46;05&#8211;1&#46;4&#37; of all pneumothoraces<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a> and occurring in just 0&#46;05&#8211;0&#46;46&#37; of patients with pulmonary malignancy&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In the majority &#40;75&#8211;100&#37;&#41; of cases reported in lung cancer patients&#44; spontaneous pneumothorax preceded the diagnosis of lung cancer&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;5</span></a> but there are reports of its occurrence during chemotherapy or radiotherapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> The association between lung cancer and pneumothorax has been reported for most histologic types of lung cancer<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#59; however&#44; it seems there is no previous description of a pneumothorax complicating a bronchial carcinoid tumor or of a bronchial carcinoid tumor presenting with a pneumothorax&#46; The proposed mechanisms for this association have been the appearance of a bronchopleural fistula secondary to necrosis and invasion of the pleura by a peripheral tumor and&#44; less frequently&#44; the rupture of alveoli&#44; emphysematous bullae or subpleural blebs due to hyperinflation of the peripheral airways caused by the tumor acting as a check-valve&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> In the reported case radiology shows hyperinflation of the left lung&#44; leading to contralateral mediastinum shift increasing with expiration&#46; We propose that the polypoid tumor in the left main bronchus functioned as a variable obstruction &#40;check-valve&#41;&#44; leading to an inability to fully exhale the inspired air volume from the left lung&#46; This trapped air in association with the expiratory maneuvers caused an increase in alveolar pressure with rupture of alveoli and formation of a pneumothorax associated with ipsilateral lung hyperinflation&#46; This is also supported by the fact that the patient was a young nonsmoker&#44; with no history of lung disease&#44; had no signs of pleural blebs or emphysema on histologic examination&#44; and that&#44; after removal of the bronchial carcinoid tumor&#44; there was resolution of the ipsilateral hyperinflation and there were no new pneumothoraces&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This is a singular case of a bronchial carcinoid tumor presenting with a recurrent spontaneous pneumothorax explained by a large check-valve mechanism&#46; Also&#44; the reported case strengthens the safe approach in which recurrent pneumothoraces should be considered secondary&#44; and search for a cause should be actively sought&#46;</p></span>"
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ISSN: 08732159
Original language: English
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