|Year : 2016 | Volume
| Issue : 6 | Page : 744-746
A case of solitary pulmonary nodule (large pulmonary chondroid hamartoma)
Sanuveda Rajasekhar1, Rashmi Patnayak1, Pavan Kumar Gururaj Kale2, Abha Chandra3, Amitabh Jena4
1 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
3 Department of Cardio Thoracic Surgery, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
4 Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Web Publication||16-Nov-2016|
Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Chondroid hamartomas are rare benign tumors of the lung which show predominantly cartilage. Usually, they are small, solitary, and asymptomatic lesions. They are detected incidentally on chest X-ray or at the time of autopsy. Occasionally, large pulmonary hamartomas are encountered. We present a case of a 60-year-old male patient with a 6-month history of cough. His X-ray and computed tomography (CT) scan of the chest revealed a well-defined soft-tissue density lesion with popcorn calcification measuring 6.5 cm × 4.8 cm in the left lung upper lobe. A presumptive diagnosis of chondroid hamartoma was made in CT-guided percutaneous biopsy. A posterolateral thoracotomy and left upper lobectomy were done. There was a spherical gray-white firm mass noted in the resected lobectomy specimen. Postoperative histopathological examination confirmed the diagnosis of pulmonary chondroid hamartoma. This is an additional case of large chondroid hamartoma.
Keywords: Benign lung tumor, chondroid hamartoma, pulmonary tumor, solitary pulmonary nodule
|How to cite this article:|
Rajasekhar S, Patnayak R, Kale PG, Chandra A, Jena A. A case of solitary pulmonary nodule (large pulmonary chondroid hamartoma). Med J DY Patil Univ 2016;9:744-6
|How to cite this URL:|
Rajasekhar S, Patnayak R, Kale PG, Chandra A, Jena A. A case of solitary pulmonary nodule (large pulmonary chondroid hamartoma). Med J DY Patil Univ [serial online] 2016 [cited 2021 Jan 23];9:744-6. Available from: https://www.mjdrdypu.org/text.asp?2016/9/6/744/194203
| Introduction|| |
Hamartomas are disorganized masses composed of tissue elements which are normally found at that particular site. They usually present as single, round nodules with distinct boundaries.  The estimated incidence of pulmonary hamartoma is 0.025-0.32%.  Solitary pulmonary hamartoma is usually seen in males, whereas multiple pulmonary hamartomas predominate in females.  Most patients with pulmonary hamartoma are asymptomatic.  A peripheral, small hamartoma with no atypical features does not need any surgical intervention. However, in atypical cases, or in cases of endobronchial hamartomas causing complications, surgical resection is essential. 
When chondroid tissue predominates in the composition of the hamartoma, it is called as chondroid hamartoma.  Chondroid hamartomas are rare benign lesions of the lung. They are usually small, solitary, peripherally located, and asymptomatic lesions. They are detected incidentally on chest X-ray or at the time of autopsy. Sometimes, they may be large. 
Here, we present a case of peripherally located large, solitary, pulmonary chondroid hamartoma in the left lung upper lobe.
| Case Report|| |
A 60-year-old male came with complaints of cough without expectoration for the last 6 months and slight difficulty in breathing for 1 month. He was a chronic smoker and a known hypertensive on treatment. There was no history of fever, chest pain, loss of weight, loss of appetite, tuberculosis, and diabetes. Routine examination findings were within normal limits. Respiratory system examination revealed bilateral wheeze and occasional crepitations. Other systemic examination was unremarkable. Chest X-ray showed a mass in the left lung upper lobe [Figure 1]a. Chest computed tomography (CT) scan showed left lung upper lobe mass lesion measuring 6.5 cm × 4.8 cm with calcifications [Figure 1]b. A CT-guided biopsy was done which showed only fragments of cartilage. Histopathologically, a possibility of chondroid hamartoma was considered. The patient underwent left posterolateral thoracostomy and left upper lobectomy.
|Figure 1: (a) Chest X-ray showing a mass lesion in the left lung upper lobe. (b) Plain axial computed tomography of chest showing well-defined soft-tissue density lesion with calcifications measuring 6.5 cm × 4.8 cm in the left lung upper lobe|
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Grossly, the left upper lobectomy specimen measured 17 cm × 11 cm × 4 cm. There was a well-defined spherical gray-white mass measuring 6 cm × 4.5 cm × 3.5 cm, located in the posteromedial region. The external surface was bosselated. Cut section of the mass was firm, gray-white, glistening with areas of hemorrhages [Figure 2]. Microscopically, the lesion was well circumscribed and showed predominantly benign chondrocytes arranged in lobules, separated by fibrous septae [Figure 3]a and b. Intervening areas between these lobules revealed slit-like spaces lined by respiratory type of epithelium. Foci of calcifications and mature adipose tissue were also seen. Normal looking lung parenchyma with carbon-laden macrophages was appreciated peripherally. The tumor exhibited no cytological atypia, increased mitotic activity, and/or necrosis. The final histopathology was reported as chondroid hamartoma. Postoperatively, the patient improved symptomatically. He was discharged 7 days after the surgery without any major complication.
|Figure 2: Cut section of the firm mass is gray-white with areas of hemorrhages and adherent to adjacent normal looking lung parenchyma|
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|Figure 3: (a) Lung alveoli with lesion of chondroid hamartoma showing islands of mature cartilage (H and E, ×100). (b) Chondroid hamartoma showing islands of cartilage and spaces lined by pseudostratified ciliated columnar epithelium (H and E, ×100)|
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| Discussion|| |
Hamartomas are benign lesions composed of disorganized mixture of epithelial and mesenchymal elements, especially cartilage. Previously, it was thought as a developmental abnormality; however, nowadays, it is considered as a benign mesenchymal neoplasm.  Cytogenetic analysis of pulmonary hamartomas showed abnormal karyotype and revealed recombinations between chromosomal bands 6p21 and 14q24, which supported the theory that a hamartoma may be considered as a true neoplasm. 
Pulmonary chondroid hamartoma is a subtype of pulmonary hamartoma. It is defined as tumor with predominance of chondroid tissue.  It occurs in only 1% of pulmonary hamartomas.  Most of the chondroid hamartomas are solitary and well circumscribed. The maximum size ranges from 1 to 4 cm, with an average of 2 cm. Occasional large ones are reported.  A few may be multiple.  Depending upon their location in the lung, pulmonary chondroid hamartomas are classified as peripheral parenchymal type and central endobronchial type. Peripheral type of chondroid hamartoma accounts for over 90% of all chondroid hamartomas. They take origin from small bronchi and are generally asymptomatic. In contrast, the endobronchial type arises from large bronchi, is less frequent, and is often associated with symptoms of obstruction. 
In Indian literature, a few cases of pulmonary hamartoma are reported. ,,,
These lesions are slow growing. Recurrence and transformation to malignancy are extremely unusual events in chondroid hamartomas. 
Imageologically, in chest X-ray, smooth well-circumscribed mass with lobulated or bosselated margins, associated with calcifications is present. Chondroid hamartomas account for 7-14% of pulmonary coin lesions.  Calcifications are often present in a diffuse or popcorn distribution (popcorn calcification).  In the CT scan of chest, well-defined sharply marginated lesion showing multiple intralesional hyperdense areas are noted. Alternating areas of fat and calcifications may be seen. The presence of fat density in a peripheral, solitary lesion is strongly suggestive of benign hamartoma. Transthoracic fine-needle aspiration cytology can be used to diagnose hamartomas.  In our case, the CT-guided biopsy showed only cartilage. The biopsy report was concluded as hamartoma taking into account the CT findings.
Histopathology of chondroid hamartoma shows predominance of islands of mature cartilage admixed with fat, fibromyxoid stroma, and slit-like spaces lined by respiratory type of epithelium. In the endobronchial type of chondroid hamartoma, greater proportion of fat and less epithelial-lined spaces are noted. The differential diagnosis of chondroid hamartomas includes bronchopulmonary chondroma, pleuropulmonary blastoma, and chondrosarcoma. In bronchopulmonary chondroma, the mixture of mesenchymal elements present in chondroid hamartoma is not seen. It consists predominantly of cartilage without cleft-like spaces lined by respiratory epithelium. It lies in continuation with the bronchial cartilage. Pleuropulmonary blastomas are mainly neoplasms of children. In pleuropulmonary blastomas, adjacent to the epithelial lining, a cambium layer of embryogenic mesenchyme is seen. The cartilage, fat, and muscle present in pleuropulmonary blastoma are immature whereas in chondroid hamartomas, mature tissue is seen.  Chondroid hamartomas lack the cytological atypia exhibited by chondrosarcomas.
Immunohistochemically, some of the spindle cells of hamartoma have features of myoepithelial cells. They exhibit actin and S-100 protein immunopositivity. Furthermore, there may be expression of estrogen receptor, progesterone receptor, and androgen receptor (in male patients), in most of the myoepithelial-like cells. 
Management of pulmonary hamartomas needs to be individualized according to tumor size, anatomical distribution, growth rate, and performance status of the patient. Only follow-up may be sufficient for small (<2.5 cm), slow-growing, asymptomatic lesions. For endobronchial, huge, and fast-growing lesions, tumor resection is preferred. Surgical enucleation, wedge resection, and lobectomy are the usual modes of treatment. , Bronchoscopic removal for endobronchial lesions and video-assisted thoracoscopic removal for peripheral lesions have less morbidity, less surgical complications, and shorter hospital stay when compared to traditional thoracotomy. 
| Conclusion|| |
Pulmonary chondroid hamartoma can present as pulmonary nodule, can be solitary or multiple. Although they can be diagnosed radiologically, at times they need to be confirmed by percutaneous/endobronchial biopsies and can be completely cured by surgical removal.
This is an additional case of large solitary pulmonary chondroid hamartoma.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]