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Case Presentation: A 37-year-old woman presented with a 2-month history of recurrent hemoptysis and coughing. Her symptoms started 2 months after the delivery of her third child. In total, she endured four episodes of hemoptysis. All pregnancies were induced by intracytoplasmic sperm injections. She lacked a pulmonary or smoking history and had no history of foreign body aspiration or intubation. There was no dyspnea, dysphagia, fever, or chest pain, and the patient did not complain of purulent sputum. She currently did not use medication and was generally in good health., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Study Objectives: To investigate the clinicopathologic features of primary tracheobronchial adenoid cystic carcinoma (ACC), and to examine kit protein (CD117) expression, and a possible correlation between the histologic grade and Ki-67 positivity., Design: Retrospective 10-year study (from 1992 to 2001)., Setting: Referral center for interventional pulmonology., Patients: Fourteen patients referred to our institution for laser resection of tracheal or endobronchial tumors., Interventions: Twelve patients were treated primarily by laser resection via bronchoscopy with subsequent radiation therapy. The remaining two patients had tracheal resection with postoperative radiation and radiation therapy alone., Results: Fourteen patients (5 men and 9 women) had an average age of 44 years at diagnosis (age range, 29 to 57 years). Five of 14 patients were smokers (average smoking history, 28.5 pack-years), 8 were nonsmokers, and the smoking history was unknown in 1 patient. Major symptoms at presentation included cough (57.1%), dyspnea (71.4%), and hoarseness (14.3%). Two patients (14.3%) presented with respiratory failure. Eleven patients (78.6%) had one or more recurrences, and 4 patients (28.6%) had metastases, primarily to the lungs. The average time to either recurrence or metastasis was 4.6 years after the initial diagnosis. Five patients (35.7%), all of whom had recurrences and/or metastasis during the course of their disease, died of their disease (average time, 8.2 years). Thirteen of 13 cases stained for CD117 were positive in the tumor cell cytoplasm with membranous accentuation. Our cases included 8 grade I tumors, 4 grade II tumors, and 2 grade III tumors, which did not correlate with the degree of Ki-67 positivity., Conclusions: Tracheobronchial ACCs in our study were more common in women and nonsmokers who presented with nonspecific respiratory symptoms and followed a clinical course generally comparable to that of tumors in the salivary glands. CD117 expression was present in all cases tested, and Ki-67 stain results did not correlate with the tumor grade.

Objectives: Novel imaging modalities are currently available for the noninvasive evaluation of the tracheobronchial tree. This study was undertaken to compare the diagnostic potentials of conventional CT scanning, super high-resolution CT (SHR-CT) scanning, and virtual bronchoscopy (VB) directly with fiberoptic bronchoscopy (FB) for the detection of tracheobronchial neoplasms., Design: Prospective observer study, in which 44 consecutive patients with thoracic malignancies were evaluated using several diagnostic imaging modalities. Images of the thorax were interpreted by individuals blind to the results of FB for the detection of endoluminal, obstructive, or mucosal lesions., Measurements and Results: Image acquisition and simulation of the tracheobronchial anatomy were created successfully in all patients. Thirty-two patients who underwent both SHR-CT scanning and VB had correlative FBs within 1 month. In all nine patients who had a normal anatomy, SHR-CT scanning and VB accurately correlated with the FB findings. However, CT scanning demonstrated two false-positive obstructive lesions in one patient. Twenty-three patients had a total of 35 abnormal FB findings. The sensitivities of SHR-CT scanning and VB for the detection of endoluminal, obstructive, and mucosal lesions were 90%, 100%, and 16%, respectively. The overall sensitivities and specificities of SHR-CT scanning and VB were 83% and 100%, respectively. In contrast, CT scanning had sensitivities of 50%, 72%, and 0% for the detection of endoluminal, obstructive, and mucosal lesions with an overall sensitivity and specificity of 59%, and 85%, respectively. There was no case in which conventional CT scanning was better at detecting lesions than either SHR-CT scanning or VB., Conclusions: SHR-CT scanning and VB are accurate, noninvasive methods for identifying obstructions and endoluminal lesions within the respiratory tract. Thus, these novel imaging techniques are valuable as complementary modalities to FB, providing information that is useful for the detection and management of airway malignancies.

We report a case of tracheal adenoma presenting as hemoptysis and reversible airflow obstruction in an ex-smoker. A questionable defect in the tracheal air shadow on a posteroanterior chest radiograph was shown on CT to be a pedunculated, mid-tracheal tumor. Two-stage bronchoscopic laser resection resulted in an apparently normal tracheal mucosa. Results of postresection spirometry were normal.

Background: Bronchoscopy is frequently used to assess invasion of esophageal cancer into the tracheobronchial tree. Prospective studies evaluating the role of bronchoscopy in pretherapeutic staging of esophageal cancer are lacking., Study Objectives: To evaluate the diagnostic utility of fiberoptic bronchoscopy for the assessment of airway involvement by esophageal carcinoma and its resectability., Patients and Methods: In a prospective study, we analyzed 150 bronchoscopies in 116 consecutive patients with potentially operable esophageal carcinoma, and correlated the findings with other staging modalities, intraoperative evaluation, and histopathologic data., Results: One unknown additional bronchial cancer was found. In 32% of bronchoscopies performed in patients with esophageal cancer located above the tracheal bifurcation, some macroscopic abnormality was detected in the trachea and main bronchi, with mobile protrusion of the posterior tracheal wall being the most frequent abnormality (20.7%). When compared with histologic results, normal macroscopic appearance of the trachea and main bronchi had a negative predictive value of 98.5%, but the positive predictive value of all macroscopic abnormalities for the diagnosis of airway involvement was low, particularly after radiation therapy. The overall accuracy of bronchoscopy with multiple brush cytology and biopsy sampling in proving or excluding airway invasion in patients with otherwise operable conditions was 95.8% (95% confidence interval, 88.3 to 99.1%). Bronchoscopy was the sole decisive staging procedure, resulting in exclusion from surgery because of airway invasion, in 9.7% of patients with otherwise potentially operable conditions. The results of bronchoscopy and CT were discordant in 40% of the patients; the specificity and positive predictive value were higher for bronchoscopy than for CT., Conclusions: When performed as the last investigation in the staging workup, bronchoscopy with biopsy and brush cytology is a very accurate procedure in evaluating possible airway invasion of esophageal cancer; macroscopic findings alone are not reliable.

We conducted a review of all the bronchoscopies performed at our institutions for benign tumors from 1980 to 1991 to determine the endoscopic characteristics of these lesions. We reviewed the charts, the endoscopic characteristics from our video records, and finally the pathologic findings of these cases. We tried to identify the effectiveness of laser resections in each group. Of a total of 3,937 patients, 185 (4.7%) were benign tumors. On these patients, 317 procedures were carried out. There were 3 myoblastomas, 53 papillomas, 1 adenoma, 8 chondromas, 4 fibromas, 45 hamartomas, 15 hamartochondromas, 6 lipomas, 19 angiomas, 5 leiomyomas, 4 schwannomas, 1 neurofibroma, and 21 amyloidomas. Results of laser resection were "very good" in 115 (62%) and "good" in 70 (38%). Complications were minimal: two mediastinal emphysemas, one pneumothorax, and one anesthesia-related cardiac arrest leading to the single death in this series. In general, benign tumors of the proximal endobronchial tree responded well to laser resection when their endoscopic appearance is recognized and prognosis known. Even when recurrent, repeated procedures can be performed easily with good results. This series is probably the largest in the world's literature about endoscopic recognition and the role of laser resection in patients presenting with benign endobronchial tumors.

To determine the diagnostic utility of fiberoptic bronchoscopy (FB) in the evaluation of patients with newly diagnosed esophageal carcinoma (EC) and whether FB findings impact therapy and survival, we retrospectively reviewed 2,832 FB records (1984 through 1992). Twenty-two cases were identified in which FB was performed to evaluate pulmonary involvement in patients with newly diagnosed EC. Two cases were eliminated due to data unavailability. Seventeen of 20 patients had no pulmonary symptoms and most of them (15/17) had normal chest radiographs. All three patients with pulmonary symptoms (cough, hemoptysis, dyspnea) had significant radiographic abnormalities. In the asymptomatic group, FB findings were normal in nine, showed extrinsic compression of the trachea and/or bronchi in seven, and demonstrated a submucosal tumor nodule in one. The pathologic diagnosis of malignant airway involvement was not made in any asymptomatic patient. In the three symptomatic patients, extensive endobronchial abnormalities were present. Therapy with surgery, radiation, and/or chemotherapy did not differ among patients with extrinsic compression compared to patients with normal FB. Average survival in the patients with normal endobronchial anatomy was 20.5 months, in the group with extrinsic compression 12.2 months, and in the group with marked endobronchial abnormalities, less than 1 month. Statistical analysis of our findings suggest that FB is a low-yield procedure in the evaluation of patients with EC unless pulmonary symptoms of cough and/or hemoptysis or chest radiographic abnormalities are present.

A patient with a previously unsuspected intrathoracic tracheal malignancy presented with symptoms suggestive of asthma and an unusual pattern seen by conventional PFTs. Reduced expiratory flows with a large difference between FVC and SVC, normal inspiratory flows and high MVV/FEV1 were found. Body plethysmography using normal and panting efforts with increasing tidal volume and flow helped define the lesion as a variable intrathoracic obstruction and document its regression after palliative therapy.

A patient with primary carcinoma of the trachea is described. The diagnosis was established physiologically by employing maximal expiratory flow-volume loops obtained while the patient was breathing air and a mixture of helium and oxygen.

Thirteen adult patients underwent palliative Nd-YAG laser treatment for relief of severe dyspnea due to malignant endotracheal obstruction. Three of the 13 patients had underlying chronic airflow obstruction (CAO) due to diffuse obstructive pulmonary disease. Despite dyspnea, cough, wheezing, stridor and/or hemoptysis, the diagnosis was delayed because of a normal chest roentgenogram in eight patients and nondiagnostic pulmonary function studies (including maximal expiratory and inspiratory flow-volume loops) in all three patients with CAO and in four of ten patients without CAO. The location of the tumor was extrathoracic in two patients, including one with CAO; intrathoracic in seven patients, including two with CAO; and combined extra- and intrathoracic in four. Tracheal diameter increased from 3.5 +/- 1.0 mm before, and to 9.8 +/- 2.0 mm after single or multiple laser treatments. Increased patency of the trachea after laser surgery was associated with improvement in expiratory and/or inspiratory flow rates and with symptomatic relief in all patients which persisted for 14.1 +/- 8.7 months (range four to 48 months). These results indicate that severe symptomatic narrowing of the extra- and/or intrathoracic trachea to a diameter of 2 to 5 mm may not be detected by conventional chest radiography or even by sensitive physiologic tests, especially in patients with underlying CAO. The resultant delay in diagnosis defers possible relief of disabling symptoms with palliative therapy, including Nd-YAG laser photocoagulation.

Papillomas are rare tumors of the respiratory tract, which are usually considered benign. We studied a male patient with adult onset of squamous papillomatosis involving both the trachea and the bronchi, with malignant degeneration. When we obtained specimens bronchoscopically, only the bronchial lesions showed carcinomatous changes. Thoracotomy demonstrated carcinoma in the tracheal lesion as well. We conclude that transbronchoscopic biopsy may be inadequate in the evaluation of papillomatosis.

Mucoepidermoid carcinoma of the trachea is rare. Its occurence in a 14-year-old boy is reported here. This case illustrates the typical course of tracheal tumors with clinical manifestations of cough, wheezing, and hemoptysis, the intially reported normal chest roentgenogram, and the common failure to diagnose tracheal tumor for several months. Early use of tomographic studies and bronchoscopic examination in any person with recent onset of airway obstruction unresponsive to bronchodilator therapy is recommended.

This report describes a patient with acute airways obstruction and respiratory failure secondary to a large endotracheal metastasis from a primary ovarian carcinoma first detected seven years previously. Associated airflow obstruction due to mucus impaction contributed significantly to the development of respiratory failure. The tumor responded to radiotherapy, and radiologic evidence for tracheal obstruction was no longer present five months after irradiation.