Bronchoscopic management of endobronchial hamartomas using “hot and cold” therapies – Initial experience in two patients

Abstract

Pulmonary hamartomas are the most common benign tumours of the lung and are often detected incidentally. Endobronchial hamartomas, though rare, can cause significant symptoms such as dyspnoea, haemoptysis, and recurrent respiratory infections due to bronchial obstruction. This report describes the successful bronchoscopic management of symptomatic endobronchial hamartomas in two young Indian males aged 29 and 34 years. Both cases were diagnosed based on radiological and histopathological findings. The first patient underwent eight sessions of electrocautery fulguration using a flexible bronchoscope, while the second was treated with six sessions of cryotherapy delivered through a flexible bronchoscope guided cryoprobe. All procedures were carried out under conscious sedation via nasal insertion of the flexible bronchoscope, with no requirement for rigid bronchoscopy or general anaesthesia. Both patients showed marked symptomatic improvement and near-complete resolution of endobronchial lesions. Follow-up bronchoscopies at 18 and 12 months, respectively, revealed no recurrence, and no procedure-related complications were observed. These cases highlight the safety, efficacy, and minimally invasive nature of flexible bronchoscopic techniques such as electrocautery and cryoablation in managing endobronchial hamartomas, particularly in settings where surgical options may be limited.

INTRODUCTION

Pulmonary hamartomas are the most prevalent benign tumours, of the lung, often discovered incidentally through imaging studies.[1] They are composed of a heterogeneous mixture of mesenchymal and epithelial tissues. While many patients remain asymptomatic, patients with endobronchial hamartomas experience significant symptoms such as dyspnoea, recurrent respiratory infections, and haemoptysis, which can adversely affect their quality of life and respiratory function.[2]

Traditionally, surgical resection has been the standard approach for managing symptomatic pulmonary hamartomas;[3] however, in recent years, advancements in bronchoscopic techniques have offered promising alternatives for the management of endobronchial hamartomas.[4] Bronchoscopic interventions, utilising modalities such as electrocautery (referred to as “Hot” techniques) and cryoablation (termed as “Cold” techniques), have emerged as effective minimally invasive strategies.

We herein report our initial experience involving two young Indian males who presented with symptomatic endobronchial hamartomas. Utilising bronchoscopic interventions, we employed electrocautery and cryoablation techniques to manage their conditions effectively. Our experience highlights the potential of these minimally invasive approaches as viable alternatives to surgical resection.

Case 1: A 29-year-old male with no notable medical history presented with fever, dry cough, and atypical left-sided chest pain of 5 days duration. On examination, decreased breath sounds were noted in the left hemithorax. Hematological and biochemical parameters were within normal limits. Initial chest radiography displayed consolidation in the left upper and middle zones. A follow-up computed tomography (CT) scan of the chest identified a soft tissue lesion in the left main bronchus [Figure 1a, white arrow and arrowhead]. Bronchoscopy revealed a sessile globular mass of 0.5 cm in size, located in the distal left main bronchus, which completely obstructed the left upper lobe bronchus and nearly occluded the left lower lobe bronchus [Figure 2]. Bronchoscopic endobronchial biopsy demonstrated respiratory epithelium overlying a stroma with mixed inflammatory infiltrates and fragments of mature cartilage, consistent with a diagnosis of pulmonary hamartoma [Figure 3]. Due to the terminal position of the lesion, the institutional tumour board recommended surgical resection with a high likelihood of lobectomy. Given the benign nature of the lesion and the young age of the individual, it was decided to undertake bronchoscopic endobronchial fulguration of the tumour. The patient underwent eight sessions of therapeutic bronchoscopy using the Olympus BF-1TH190TM flexible bronchoscope, introduced via the intranasal route under conscious sedation. Electrocautery fulguration was performed in each session using the CAUDRA D450V1 electrocautery unit, with the probe introduced through the working channel of the flexible bronchoscope. The procedures were conducted at 3-day intervals under conscious sedation, employing intravenous midazolam and fentanyl to ensure patient comfort and procedural safety. A follow-up bronchoscopy 7 days after the final intervention revealed a near-complete resolution of the obstructive lesion [Figures 1b and 4]. The patient has been under follow-up for the past 18 months and has undergone 02 check bronchoscopies, which have been normal.

Figure 1.

Computerized tomography (CT) Chest showing soft tissue attenuating lesion in left main bronchus (a) white arrow and arrowhead) and clearing of the lesion post procedure (b) white arrow)

Figure 2.

Fibre optic bronchoscopy showed globular growth in distal part of left main bronchus completely occluding left upper lobe bronchus and near totally occluding left lower lobe bronchus

Figure 3.

Tissue bit lined by respiratory epithelium with underlying stroma showing mixed inflammatory infiltrate and multiple fragments of mature cartilage -Pulmonary Hamartoma

Figure 4.

Fibre optic bronchoscopy showing clearing of globular growth in distal part of left main bronchus after intervention

Case 2: A 34-year-old male, a reformed smoker with no significant comorbidities, presented with a single episode of hemoptysis, characterised by 4–5 drops of blood in sputum, occurring in the early morning. Physical examination revealed decreased breath sounds in the right hemithorax. Hematological and biochemical parameters were within normal limits. Initial chest radiography indicated patchy consolidation in the peripheral region of the right lung. Subsequent CT of the chest revealed a well-defined, lobulated mass in the right peri-hilar region [Figure 5, white arrow]. Bronchoscopy was performed, which identified a sessile endobronchial lesion of 0.5 cm in the right lower lobe bronchus, originating from the superior segment, leading to complete obstruction of the segmental bronchus [Figure 6]. Histopathological analysis of the biopsied tissue confirmed the diagnosis of pulmonary hamartoma, characterised by the presence of benign cartilage, fibrovascular stroma, and respiratory epithelium [Figure 7].

Figure 5.

CT Chest showing well defined lobulated shaped, solid mass lesion in the right peri hilar location (a-white arrow). Resolution of the lesion on repeat imaging post intervention (b-white arrow)

Figure 6.

Fibre optic bronchoscopy showing endobronchial lesion in right lower lobe bronchus, superior segment causing near complete obstruction of the segmental bronchus

Figure 7.

Tissue bit showing benign cartilage with a fibrovascular stroma and respiratory epithelium-Pulmonary Hamartoma

The patient underwent a total of six therapeutic bronchoscopic sessions using the Olympus BF-1TH190TM flexible bronchoscope, introduced via the intranasal route under conscious sedation. The flexible bronchoscope served as a conduit for cryotherapy delivery, allowing the introduction of a cryoprobe through its working channel. The cryoprobe, connected to the ERBECRYO-2 cryotherapy unit, was used to perform targeted ‘freeze-thaw’ cycles on the endobronchial tumour. Each cycle lasted approximately 1–2 minutes, and the procedures were conducted under conscious sedation using intravenous midazolam and fentanyl. Notably, endotracheal intubation, laryngeal mask airway (LMA), or rigid bronchoscopy was not required. The use of the flexible bronchoscope enabled precise visualisation and controlled application of therapy, with each session lasting approximately 30 minutes. Follow-up bronchoscopy performed 7 days after the last intervention demonstrated near-complete resolution of the endobronchial lesion [Figure 8]. The patient has been under follow-up for the past 12 months and has undergone 02 check bronchoscopies, which have been normal.

Figure 8.

Fibre optic bronchoscopy showing resolution of the endobronchial lesion in right lower lobe bronchus, superior segment bronchus

DISCUSSION

The word ‘hamartomas’ is derived from the Greek word hamartia, which means erroneous or faulty. Hamartomas are the most common type of benign lung tumour, often found incidentally in lung imaging.[1] The incidence of endobronchial hamartomas varies widely in reports, ranging from 1.6% to 20%.[5,6] Composed of a heterogeneous mixture of mesenchymal and epithelial tissues, these tumours frequently localise within the endobronchial tree, leading to a spectrum of clinical manifestations.[7] While many patients remain asymptomatic, some experience significant symptoms such as dyspnoea, recurrent respiratory infections, and haemoptysis, which can adversely affect their quality of life and respiratory function.[5] Traditionally, surgical resection has been the standard approach for managing symptomatic pulmonary hamartomas,[3,8] effectively alleviating symptoms and providing definitive treatment. However, surgical interventions can pose substantial risks, which can include complications from general anaesthesia, prolonged recovery times, and the potential for significant morbidity associated with thoracotomy or video-assisted thoracoscopic surgery.[8]

In recent years, advancements in bronchoscopic techniques have offered promising alternatives for the management of endobronchial hamartomas. Bronchoscopic interventions, utilising modalities such as electrocautery (referred to as “Hot” techniques) and cryoablation (termed as “Cold” techniques), have emerged as effective minimally invasive strategies.[9] These approaches allow for targeted treatment of the hamartomas while preserving surrounding healthy lung tissue and minimising patient recovery time. Studies have demonstrated that electrocautery can effectively reduce tumour size and alleviate obstructive symptoms, while cryoablation offers the benefits of localised destruction of tumour tissue with minimal thermal injury to adjacent structures.[9]

Two cases, aged 26 and 32 years, presented with symptomatic endobronchial hamartomas, one in the left lower lobe bronchus just below the secondary carina and the other in the superior segment bronchus of the right lower lobe. Initially recommended for surgical resection by the institute tumour board, both cases were considered for flexible bronchoscopic interventions. Case 1 underwent electrocautery fulguration, while case 2 received cryoablation. Each case underwent eight bronchoscopies, spaced 3 to 5 days apart under conscious sedation, until complete resolution. Follow-up periods of 18 and 12 months, respectively, ensured the absence of recurrence.

Both cases achieved resolution without the need for major surgeries, showcasing the promise of this approach in preserving lung function and minimising morbidity associated with traditional resection methods. The unique aspect of these cases lies in the use of a flexible bronchoscope to perform therapeutic interventions, with all procedures conducted under appropriate precautions and clinical monitoring. Electrocautery, employed in these cases, is a highly effective tool that ensures immediate coagulation, thereby minimising the risk of bleeding. Cryotherapy on the other hand induces tissue destruction through repeated freeze-thaw cycles, leading to cellular autolysis with minimal associated inflammation. These cases highlight the practical utility of managing endobronchial tumours via a flexible bronchoscope, demonstrating that such interventions can be safely and effectively performed without the need for rigid bronchoscopy in appropriately selected patients.

The utilisation of flexible bronchoscopic hot and cold therapies demonstrates significant potential in managing symptomatic endobronchial hamartomas in young males, as seen in the above cases and endorsed in various other studies.[9,10,11] This approach not only addresses the lesions effectively but also mitigates the risks and complications associated with invasive resection. The relevance of this approach is particularly significant in developing countries, where access to highly specialised thoracic surgery is limited, and less invasive techniques offer a practical and cost-effective alternative to traditional resection methods.[11]

A direct comparison between the two therapeutic modalities was not undertaken in this study. The variation in the number of treatment sessions primarily reflected differences in lesion size, location, and anatomical accessibility. Cryotherapy induces cellular autolysis with minimal associated inflammation. In contrast, ‘hot’ modalities such as electrocautery tend to cause more pronounced inflammatory responses due to coagulative necrosis. While both approaches have demonstrated clinical utility, further prospective studies are warranted to systematically evaluate and compare their relative safety, efficacy, and long-term outcomes.

The prognosis for endobronchial hamartomas is generally favourable, although the recurrence rate after bronchoscopic resection is about 10%.[12] There is no established consensus on the optimal follow-up schedule. Long-term monitoring typically shows no signs of malignant transformation in most cases.[13] In the above cases, follow-up bronchoscopy and chest CT at 18 and 12 months revealed no recurrence. Observation through follow-up CT scans is planned to monitor for potential recurrence. Our experience highlights the potential of these minimally invasive approaches as viable alternatives to surgical resection.

CONCLUSION

Bronchoscopic interventions—such as electrocautery and cryoablation—performed through a flexible bronchoscope without the need for rigid bronchoscopy, represent effective, minimally invasive alternatives to surgical resection for symptomatic endobronchial hamartomas. These techniques offer reliable symptom relief, preserve lung function, and significantly reduce procedural morbidity, making them particularly suitable for young patients. Moreover, their utility is especially relevant in resource-limited settings, where access to advanced thoracic surgical care is constrained, thereby offering a practical and cost-effective therapeutic solution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.