Anesthetic management of thyroid carcinoma invading the upper tracheal segment: A case report

INTRODUCTION AND IMPORTANCE

Intratracheal tumors account for approximately 0.2 % of respiratory tumors, including primary and secondary tumors. Secondary tumors of the upper trachea are most commonly derived from advanced thyroid cancer. Surgical resection is currently the general curative modality for thyroid cancer with tracheal invasion. Patients with tracheal tumors invading and protruding into the lumen may have reduced oxygen reserve capacity, leading to a shorter safe window for general anesthesia induction. Establishing an appropriate artificial airway is essential to ensure intraoperative safety for these patients. Here, we report a case of tracheal tumor caused by differentiated papillary thyroid carcinoma invading the upper segment of the trachea and the non-conventional approach used for intraoperative airway management without traditional endotracheal intubation.

PRESENTATION OF CASE

A 59-year-old female presented with bilateral neck masses and hemoptysis. The CT scan revealed suspicious malignant thyroid nodules, and tracheoscopy showed an approximately 50 % obstruction of the tracheal lumen. The patient's physical examination and biochemical examination showed no significant abnormalities. Based on imaging studies and pre-anesthetic assessment, a multidisciplinary team decided against performing endotracheal intubation in the patient due to the risk of tumor bleeding during the procedure. Instead, they opted for a modified endotracheal tube and the insertion of a laryngeal mask airway (LMA). The anesthesia induction and maintenance proceeded smoothly, with stable intraoperative hemodynamics. The tumor was successfully resected and tracheal anastomosis was performed without any complications.

CLINICAL DISCUSSION

The strategy adroitly evades the risk of bleeding and dislodgement due to tumor contact during the intubation process. In this case report, the anesthetic highlight is the employment of a reverse insertion technique for endotracheal intubation, facilitated by a sterile suction catheter and complemented by an innovative modification to the tracheal tube.

CONCLUSION

For patients with thyroid cancer invading the upper segment of the trachea, and in whom rapid induction anesthesia is anticipated not to cause tumor collapse, the use of laryngeal mask airway combined with modified tracheal tube mechanical ventilation is both safe and feasible.

Pulmonary Adenoid Cystic Carcinoma Mimicking Asthma-Like Symptoms: A Case Report and Literature Review

Introduction

Pulmonary adenoid cystic carcinoma (PACC) is a rare, low-grade malignant salivary gland-type tumor characterized by a dormant onset and slow progression, often leading to misdiagnosis. Due to its rarity, limited cases have been reported in the literature. This report aimed to enhance clinicians' understanding of this infrequent disease.

Case Presentation

We present the case of a 41-year-old female patient diagnosed with PACC. Our report provides a comprehensive analysis of the patient's imaging, pathology, and treatment, with a particular focus on immunohistochemical results. Importantly, we emphasize the significance of considering foreign bodies and tumors in the bronchus when encountering asthma-like symptoms unresponsive to conventional treatments. Due to the uncertain etiology and pathophysiology of PACC, there are currently no established guidelines for chemotherapy and radiotherapy.

Conclusion

PACC predominantly manifests as bronchial lesions without significant clinical heterogeneity. Therefore, it is crucial to consider foreign bodies and tumors in the bronchus when dealing with asthma-like symptoms, especially in patients without chronic lung disease who do not respond to anti-infective, antispasmodic, and antiasthmatic treatments. Additionally, meticulous examination of lesions is essential for timely diagnosis and intervention, ultimately improving patient survival rates.

[The first allogenic tracheal transplantation in humans 45 years ago : Procedure, course, and outcome]

In November/December 1978, the first successful tracheal transplantation in humans was performed at the University ENT Clinic in Cologne by the then senior physicians Kurt G. Rose (later chief physician in Dortmund) and Klaus Sesterhenn (later chief physician in Duisburg). Director of the clinic at that time was Prof. Dr. Dr. Fritz Wustrow [10]. The immunological foundations and preliminary work were laid by Sesterhenn in the context of a total of 338 tracheal transplants in Lewis rats in the 1970s (details in the text). The first successful tracheal transplantation was performed on 18 November 1978 in a, then 19-year-old patient who had previously had a motorcycle accident. The donor organ was explanted in the University Hospital Essen and transplanted about 160 min later in the Cologne University ENT Clinic, first into a pocket of the right sternocleidomastoid muscle. The definitive transplantation took place on 06 December 1978. In the article, the circumstances at that time and the perioperative course in the Cologne University ENT Clinic are described by an eyewitness. The former patient is still well and without complications after more than four decades.

Pleomorphic adenoma of the trachea: A case report

INTRODUCTION AND IMPORTANCE

Although pleomorphic adenoma is the most common type of parotid gland tumor, its occurrence in the trachea is rare. Here, we describe a successfully resected pleomorphic adenoma of the trachea in a woman with severe respiratory failure that had been preoperatively misdiagnosed as asthma.

CASE PRESENTATION

A 69-year-old woman presented to the emergency department with symptoms of worsening dyspnea and subsequent loss of consciousness. She had a history of progressively worsening wheezing and stridor over the course of 2-years and had been diagnosed with asthma. Arterial blood gas sample analysis indicated type II respiratory failure. A chest computed tomographic scan revealed a tumor in the trachea, which was almost completely obstructing the lower tracheal lumen. The tumor was located just above the carina. To alleviate airway constriction and achieve complete resection, carinal resection with reconstruction was performed. The postoperative diagnosis was pleomorphic adenoma of the trachea.

CLINICAL DISCUSSION

Pleomorphic adenoma is a rare tracheal tumor that may present with obstructive airway symptoms that mimic asthma.

CONCLUSION

Tracheal tumors should be considered in patients with chronic respiratory symptoms that do not improve with medication.

Tracheostomy and venovenous extracorporeal membrane oxygenation for difficult airway patient with carinal melanoma: A case report and literature review

BACKGROUND

Anesthesia for tracheal tumor resection is challenging, particularly in patients with a difficult upper airway. We report a case of a difficult upper airway with a metastatic tracheal tumor causing near-total left bronchial obstruction and requiring emergency tracheostomy and venovenous extracorporeal membrane oxygenation (VV-ECMO) support for rigid bronchoscopy-assisted tumor resection.

CASE SUMMARY

A 41-year-old man with a history of right retromolar melanoma treated by tumor excision and myocutaneous flap reconstruction developed progressive dyspnea on exertion and syncope episodes. Chest computed tomography revealed a 3.0-cm tracheal mass at the carinal level, causing 90% tracheal lumen obstruction. Flexible bronchoscopy revealed a pigmented tracheal mass at the carinal level causing critical carinal obstruction. Because of aggravated symptoms, emergency rigid bronchoscopy for tumor resection and tracheal stenting were planned with standby VV-ECMO. Due to limited mouth opening, tracheostomy was necessary for rigid bronchoscopy access. While transferring the patient to the operating table, sudden desaturation occurred and awake fiberoptic nasotracheal intubation was performed for ventilation support. Femoral and internal jugular vein were catheterized to facilitate possible VV-ECMO deployment. During tracheostomy, progressive desaturation developed and VV-ECMO was instituted immediately. After tumor resection and tracheal stenting, VV-ECMO was weaned smoothly, and the patient was sent for intensive postoperative care. Two days later, he was transferred to the ward for palliative immunotherapy and subsequently discharged uneventfully.

CONCLUSION

In a difficult airway patient with severe airway obstruction, emergency tracheostomy for rigid bronchoscopy access and standby VV-ECMO can be life-saving, and ECMO can be weaned smoothly after tumor excision. During anesthesia for patients with tracheal tumors causing critical airway obstruction, spontaneous ventilation should be maintained at least initially, and ECMO deployment should be prepared for high-risk patients, such as those with obstructive symptoms, obstructed tracheal lumen > 50%, or distal trachea location.

Treatment of primary tracheal schwannoma with endoscopic resection: A case report

BACKGROUND

Schwannoma is a benign tumor originating from the peripheral nerve sheath. The clinical symptoms of tracheal schwannoma depend on the location of the tumor, and the most common clinical symptoms are cough and hemoptysis. The most effective treatment for benign tumors is complete resection of the primary lesion at an early stage. Our experience has demonstrated that primary tracheal schwannoma can be safely excised with a high-frequency electric knife in a minimally invasive manner.

CASE SUMMARY

We report a 61-year-old asymptomatic woman who underwent chest computed tomography (CT), which accidentally found an intraluminal tracheal mass without enlarged lymph nodes. Then, the patient underwent bronchoscopy, which found that the tracheal mass originated from the left wall of the upper trachea, was less than 1.5 cm in size, immovable, smooth and 4 cm away from the vocal cord, resulting in partial upper respiratory tract obstruction. Treatment was performed using an endoscopic resection for en bloc removal of the tracheal mass. The diagnosis was primary tracheal schwannoma. A follow-up was performed after endoscopic surgery, and bronchoscopy and thoracic CT were used to monitor whether there was a recurrence. At present, there is no evidence of recurrence, and the patient had a good quality of life. Endoscopic resection may be effective and safe in the treatment of primary tracheal schwannoma.

CONCLUSION

Primary tracheal schwannoma is a very rare benign tumor. In this case, we cured it by complete endoscopic resection.

Video-assisted thoracoscopic tracheal resection with only endobronchial intubation

We report a case of video-assisted thoracoscopic surgery (VATS) tracheal resection and running suture anastomosis with only endobronchial intubation in a patient with adenoid cystic carcinoma (ACC). The tumor extended 3.2 × 1.9 cm in the distal trachea, and the distance to carina was 2 cm. Running suture anastomosis around the endobronchial tube was performed. No cross-field intubation was needed. The postoperative course was good and no complication occurred. VATS tracheal resection and running suture anastomosis with only endobronchial intubation is a feasible option for patients with distal tracheal tumor.

Low-grade tracheal adenocarcinoma with ETV6::NTRK3 fusion: unique morphology akin to subsets of sinonasal low-grade non-intestinal-type adenocarcinoma

The prevalence of NTRK fusions in non-small cell carcinoma (NSCLC) is only approximately 0.2%, most of which harbor NTRK1 fusions. NSCLCs with NTRK3 fusions are extremely rare. Herein, we report a case of low-grade tracheal adenocarcinoma in a 64-year-old woman. Histologically, areas of complicated tubule-papillary or cribriform patterns constituted a major component of the tumor and comprised cuboidal to columnar epithelial tumor cells with pale eosinophilic cytoplasm and cytoplasmic mucin, similar to subsets of sinonasal low-grade non-intestinal-type adenocarcinomas. Immunohistochemically, the tumor was positive for MUC5AC and MUC4 and showed nuclear expression of the pan-Trk antibody. ETV6::NTRK3 was identified by reverse transcription-polymerase chain reaction using formalin-fixed paraffin-embedded tissues. To the best of our knowledge, this is the first case of low-grade tracheal adenocarcinoma with ETV6::NTRK3 fusion. Our case illustrates that low-grade adenocarcinomas with ETV6::NTRK3 fusion may exist throughout the respiratory tract.

Tracheal myoepithelioma resected by using rigid bronchoscopy: a case report and review of the literature

Background

Endotracheal tumors are rare in the respiratory system. Myoepitheliomas are benign tumors, which are rarely reported in the respiratory system. Herein, we report a rare case of endotracheal myoepithelioma, which was resected by rigid bronchoscopy.

Case presentation

A 36-year-old man, presenting with chest pain, dyspnea, stridor, and hemoptysis, was referred to our center with radiological features of near-total tracheal obstruction due to mass. Fiberoptic bronchoscopy with argon plasma coagulation and rigid bronchoscopy with grasper forceps was utilized to resect the mass. Pathological evaluation of the mass demonstrated myoepithelioma. The patient was discharged in good condition. Now, after 6 months, the patient is symptom-free with no evidence of tumor recurrence or re-growth.

Conclusions

Despite being extremely rare, myoepithelioma should be considered a possible differential diagnosis for endotracheal tumors. Fiberoptic and rigid bronchoscopy management is an effective method for the resection of endotracheal tumors.

High-Grade Neuroendocrine Carcinoma Within a Tracheal Polyp: A Case Report

Introduction

Primary carcinomas of the trachea are rare, with a reported annual incidence of one in a million. We present a case of a previously undescribed polypoid high-grade neuroendocrine carcinoma of the trachea. Resection of the carcinoma revealed only superficial invasion of the mucosa and without evidence of local or distant metastatic disease. Histologically, the tumor had high-grade features with necrosis and a high mitotic index.

Methods

Characterization of this rare neuroendocrine carcinoma of the trachea was performed by immunohistochemistry and whole-genome sequencing.

Results

Immunohistochemistry result was positive for neuroendocrine markers, p16 and an elevated Ki-67. Whole-genome sequencing of the lesion was performed and revealed a very unusual and very distinct mutational signature without relationship to other relevant neuroendocrine carcinomas. Neither known driver nor targetable mutations were found by whole-genome sequencing. Analysis of the sequence of numerous viral elements of human papillomavirus-18 suggests that the pathogenesis of the lesion is related to viral integration. The patient developed distal recurrence, which progressed to widespread pulmonary dissemination, presumably through aerogenous spread of disease.

Conclusions

This is the first characterization of this type of tracheal tumor, including genomic findings, pathogenesis, and natural history.

Solitary fibrous tumor of the trachea: a case report

We experienced a surgical case of a rare primary tracheal tumor. A 77-year-old woman visited a local clinic with chief complaints of coughing, wheezing, and discomfort in the throat. Computed tomography revealed a mass measuring approximately 1.5 cm in the mediastinal trachea, extending from the membranous portion of the trachea to the esophagus. Bronchofibroscopy showed a flat, smooth-surfaced, round mass arising from the membranous portion. Surgery was performed because of the possibility of airway obstruction and suffocation. Sleeve resection of five tracheal rings was performed via median sternotomy and interrupted suture was performed using 3-0 absorbable suture material. The postoperative course was favorable and there has been no evidence of recurrence. The pathological diagnosis was solitary fibrous tumor. A primary solitary fibrous tumor of the trachea is extremely rare. Here, we report this disease with a literature review.

Non-circumferential membranous resection of the trachea for paraganglioma: A case report

INTRODUCTION

Paraganglioma is a rare neuroendocrine tumor and may sometimes be located in the membranous part of the trachea.

PRESENTATION OF CASE

We report the case of a 52-year-old man presenting a paraganglioma just above the carina with obstructive symptoms. The patient successfully underwent a non-circumferential tracheal membranous resection, followed by latissimus dorsi muscle flap repair, under peripheral extra-corporeal membrane oxygenation (ECMO).

DISCUSSION

Complex carinal resection can be avoided for tracheal membranous tumors and replaced with non-circumferential resection and direct reconstruction with a muscle flap. In addition, ECMO support may be used for airway resection and reconstruction.

CONCLUSION

Tracheal membranous tumors can be managed without circumferential resection or direct anastomosis.

Primary tracheal hyalinizing clear cell carcinoma

Hyalinizing clear cell carcinomas (HCCC), now referred to as clear cell carcinomas (CCC) by the World Health Organization (WHO), are rare tumors usually arising from the salivary glands of the head and neck. We present the first case of a CCC originating from the trachea. A 66 year-old woman with history of hypertension, former smoker, presented to the emergency department reporting worsening shortness of breath. Computed chest tomography revealed a polypoid mass arising from the left posterior-lateral wall of the trachea. The patient developed worsening respiratory failure requiring mechanical ventilation. Bronchoscopy was completed which relieved a malignant airway obstruction and pathology revealed nests of cells with monomorphic nuclei and clear cytoplasm set in a hyalinized stroma. Using break apart probe fluorescence in situ hybridization testing the tissue revealed the presence of a recurring translocation of the Ewing sarcoma (EWSR1) gene, confirming the diagnosis. CCC is a rare primary airway tumor. CCC was first reported to originate in the lung in 2015. We present the first case of CCC arising from the trachea.

Low-grade chondrosarcoma of the cricoid cartilage: a case report and review of the literature

We report the case of a 60-year-old man with a 12-day history of vomiting whenever he had a meal. Computed tomography revealed a calcified mass in the right cricoid cartilage with intraluminal and extraluminal extension. The patient underwent surgical resection of the trachea with end-to-end anastomosis. Pathological examination of the surgical specimen showed a low-grade chondrosarcoma. Eighteen months after surgery, the patient is alive and disease-free.

Video-assisted thoracoscopic surgery resection and reconstruction of thoracic trachea in the management of a tracheal neoplasm

Intratracheal tumor is a rare tumor, accounting for only 2% of upper respiratory tract neoplasms. Its symptoms are similar to those of head and neck cancers, including coughing up blood, sore throat, and airway obstruction. The diagnosis of this disease is often based on the findings of fibrobronchoscopy or computed tomography (CT). Surgery remains the treatment of choice for tracheal tumor. In patients with benign neoplasms or if the tumors have limited involvement, fibrobronchoscopic resection of the tumor can be performed. For malignant tumors, however, radical resection is required. In the past, open incision is used during the surgery for tumors located in thoracic trachea. Along with advances in video-assisted thoracoscopic surgery (VATS) minimally invasive techniques and devices, VATS resection and reconstruction of the trachea can achieve the radical resection of the tumor and meanwhile dramatically reduce the injury to the patients. In this article we describe the application of VATS resection and reconstruction of trachea in the management of a tracheal neoplasm.

Totally robotic-assisted non-circumferential tracheal resection and anastomosis for leiomyoma in an elderly female

We describe a novel technique of totally robotic-assisted non-circumferential tracheal resection and running anastomosis with coverage of anastomosis with anterior mediastinal fat flap. A 71-year-old female presented with cough and CT scan revealed a mass at the intra-thoracic trachea. A complete robotic-assisted tracheal resection and anastomosis was performed. The postoperative course was uneventful. The final pathologic examination confirmed the diagnosis of primary tracheal leiomyoma.

Plexiform schwannoma involving the trachea and recurrent laryngeal nerve: a case report

Plexiform schwannoma is an infrequent variant of schwannoma characterized grossly and microscopically by multi-nodular growth. Although plexiform schwannoma has such growth patterns, it is a benign tumor as well as a conventional schwannoma. It rarely infiltrates adjacent organs or arises from the organ itself. In this report, we describe a case in which plexiform schwannoma involved the tracheal wall and left recurrent laryngeal nerve to a great extent. As it was expected to be difficult to achieve complete resection even if the longer tracheal resection were performed, we preserved the trachea and resected as much of the tumor as possible. This report is thought to be the first to describe plexiform schwannoma infiltrating or growing from the trachea. Although the treatment decisions we made might be controversial, we believed we could make an accurate diagnosis and adequate treatment decision through surgery.

Tracheal epithelial-myoepithelial carcinoma associated with sarcoid-like reaction: A case report

Epithelial-myoepithelial carcinomas are rare tumors that primarily originate in the salivary glands but have also been found in the tracheobronchial tree. We report the first case of epithelial-myoepithelial carcinoma associated with sarcoidosis. A 61 year old Hispanic man presented with altered mental status and hypercalcemia. Imaging revealed diffuse intra-thoracic and intra-abdominal lymphadenopathy. A diagnostic bronchoscopy was performed where an incidental tracheal nodule was discovered and biopsied. Pathology was consistent with epithelial-myoepithelial carcinoma. Lymph node biopsy demonstrated non-caseating granulomas consistent with sarcoidosis. Patient underwent tracheal resection of the primary tumor with primary tracheal reconstruction. Hypercalcemia subsequently normalized with clinical improvement. Repeat CT imaging demonstrated complete resolution of lymphadenopathy. Our findings are suggestive of a possible paraneoplastic sarcoid-like reaction to the epithelial-myoepithelial carcinoma with associated lymphadenopathy and symptomatic hypercalcemia.

Temporary transection of innominate vein in surgery of midtracheal tumor

In this case, a patient presented with a large primary midtracheal tumor posterior to the innominate vein and brachiocephalic artery. The left innominate vein (LIV) was temporarily transected to attain proper access to the tumor. After complete removal of the tumor, the vessel was reanastomosed. The operation was uneventful, and the patient recovered well. Temporary transection of the LIV appears to be a reasonable alternative to surgical resection in such a large cross-border midtracheal tumor.

Endoscopic treatment of tracheal stenosis

For all cases of tracheal obstructions surgery should be considered first. Interventional endoscopic procedures can provide immediate relief. Intraluminally growing tumors can be resected with laser, argon-plasma coagulation, an electrosurgical knife or cryo-probe. Photodynamic therapy of smaller tracheal tumors can be curative. Narrowing from intramural tumor growth or wall destruction requires internal splinting with an airway stent. Scar strictures can be dilated with balloons but the biotrauma may stimulate new scarring. In benign strictures and malacias, tracheal stents should only be placed if all other methods are exhausted. Complications including stent migration, mucostasis, halitosis and granulation tissue development must be considered. Most important for a good outcome is a multidisciplinary approach.

Tracheal metastasis from rectal cancer: a case report and review of the literature

The trachea is an uncommon site of metastasis from colorectal carcinoma. A few cases have been reported in the literature, but these focused mostly on the clinical aspects without detailing radiologic and histologic findings. The authors describe a 70-year-old woman who was diagnosed with tracheal metastasis from a primary rectal cancer. We present the contrast-enhanced chest computed temography (CT), including volume-rendered image, as well as bronchoscopic findings.

Pleomorphic adenoma originating from the trachea showing the appearance of a follicular tumor of the thyroid on ultrasonography. J Med Ultrason (2001). 2010;37:27-30. [PMID: 27277607 DOI: 10.1007/s10396-009-0245-z]

Pleomorphic adenoma (PA) is the most common tumor of the salivary gland. This report presents a case of a PA originating from the trachea that looked like a thyroid neoplasm on ultrasonography, showing a well-circumscribed, hypovascular, solid, and hypoechoic tumor within the thyroid. The tumor was resected with the right lobe of the thyroid and the first tracheal ring, which revealed a PA impacted within the thyroid. PAs originating outside of the salivary glands are rare, and there have been no reports of PAs arising from the lateral side of the trachea. This report describes the first reported, and unique, case of this type of tumor.