Tracheal Pleomorphic Adenoma With Severe Airway Obstruction

Abstract

Pleomorphic adenoma of the trachea is a rare benign tumor, often challenging to diagnose due to nonspecific symptoms. We report a case of a 72-year-old female with a 10-year history of presumed bronchial asthma, presenting with persistent dyspnea. Preoperative assessment for breast cancer surgery revealed severe obstructive ventilatory impairment. Further investigation with chest CT and bronchoscopy identified an intratracheal nodule, which was successfully resected using electrocautery and cryotherapy via rigid bronchoscopy. Pathological examination confirmed pleomorphic adenoma. Following the intervention, the patient's lung function significantly improved, enabling the planned breast cancer surgery. This case highlights the importance of considering rare tracheal tumors in the differential diagnosis of refractory respiratory symptoms. A review of 11 cases of tracheal pleomorphic adenomas managed by bronchial intervention showed various endoscopic resection techniques, with electrosurgical snaring and argon plasma coagulation being the most common. Our case illustrates the effectiveness of bronchial intervention in managing tracheal tumors with severe airway obstruction and emphasizes the need for thorough preoperative assessment and heightened suspicion for rare tracheal tumors in persistent, treatment-resistant respiratory symptoms.

Keywords: airway obstruction; bronchoscopy; interventional bronchoscopy; pleomorphic adenoma; tracheal tumor.

Figure 1. Chest images of the patient

(A) Chest X-ray showing no apparent abnormalities in the lung fields or mediastinum. (B) Axial chest CT image showing an intratracheal tumor (black arrow).

Figure 2. Bronchoscopic images of the step-by-step resection of the tracheal tumor

(A) Pre-treatment view of the polypoid tracheal tumor with a smooth, vascularized surface obstructing a significant portion of the airway lumen. (B) Application of argon plasma coagulation (APC). (C) Cryoablation is done with a cryoprobe in contact with the tumor tissue. (D) Tumor resection using an electrosurgical snare, which is looped around the base of the tumor. (E) View of the trachea immediately after tumor resection, showing the residual base of the tumor and the newly opened airway lumen. (F) Retrieval of tumor fragments using the cryoprobe. (G) Additional tumor retrieval using the snare to remove any remaining fragments. (H) After resection.

Figure 3. Histopathological findings of the resected tracheal tumor

(A) Fragment of removed tumor. The tumor was large and had a slippery surface, so it was removed in sections. (B,C) Hematoxylin and eosin (H&E) staining showing. (B) The surface of this polypoid lesion is covered by nonneoplastic ciliated columnar epithelial cells. (C) The tumor consists of gland-forming epithelial cells, showing a double layer with basal cells, and spindle- or stellate-shaped cells with abundant myxoid or chondroid stroma. These tumor cells are irregularly admixed with each other. No apparent cellular atypism is noted.

Figure 4. Pulmonary function and images before and after tracheal tumor removal

(A) Pre-treatment flow-volume curve showing severe obstruction, with a flattened expiratory limb indicative of fixed upper airway obstruction. (B) Post-treatment flow-volume curve demonstrating significant improvement in airflow, with a more normal curve shape and increased peak expiratory flow rate. (C) Pre-treatment and (D) four months after treatment of chest CT images. The large tumor obstructing most of the trachea (black arrow) was removed (black triangle).