A 52 year old, previously fit and well gentleman presented to hospital with progressive shortness of breath and significant stridor over a five month period. He also described the feeling of needing to cough but being unable to expectorate. He gave no history of haemoptysis or weight loss.
He was a never smoker who gave no personal or contact history of tuberculosis, no significant occupational exposures and no history of asthma or atopy, although his GP had treated his progressive dyspnoea as asthma with inhaled bronchodilators to no effect. He had no other significant past medical history or drug history.
Computed Tomography (CT) of the Thorax (Fig. 1) demonstrated a twelve millimetre, partially obstructive, pedunculated mass lesion in the trachea just distal to the larynx at the level of C7 which was then confirmed on rigid bronchoscopy. A staging CT showed no metastatic disease or lymphadenopathy.
Biopsy specimens obtained following laser ablation were initially non-diagnostic but were felt to represent low grade tumour derived from an accessory gland in the mucosa. Specialist expert input was sought from pathologists in the Royal Brompton Hospital, London. Their report described fibrovascular stroma infiltrated by an epithelial tumour comprising of solid islands and tubular aggregates of mild to focally moderately pleomorphic epithelial cells. The epithelial cells showed irregular infiltration. In areas of tubular architecture, a focal dual layer was noted, with the inner layer staining for cytokeratines and the outer layer staining for S100 and smooth muscle actin. There was also an associated moderate non-specific chronic inflammatory cell infiltrate.
Given the morphology, the specimens were classified as an epithelial-myoepithelial carcinoma.
Management options were discussed at the regional lung cancer multidisciplinary team meeting involving respiratory, thoracic and oncology specialist teams and the decision was made to proceed with rigid bronchoscopy and laser ablation therapy.
A Nd-YAG laser was used with the fibre passed through a fibreoptic bronchoscope which was then passed through a rigid bronchoscope, the latter being required to control the airway. Initial biopsies were fragmented meaning that margins could not be adequately assessed and so further laser ablation therapy was undertaken in an attempt to ensure satisfactory removal of the entire lesion.
Positron Emission Tomography (PET-CT) demonstrated no abnormal active uptake at the original site of the lesion, or at any distant metastatic or nodal site, and the decision was made for follow up with surveillance CT and bronchoscopy initially after 3 months.