Clinical Review & Education
Clinical Problem Solving | ENDOSCOPY
Tracheal Mass Patricia Purcell, MD; Tanya Meyer, MD; Clint Allen, MD
A
B
C
Figure. A, Sagittal computed tomographic image of midtracheal mass. B, Image from in-office flexible bronchoscopy. C, Image from operative rigid endoscopy.
A woman in her 50s presented to the emergency department (ER) with a 3-month history of progressive dyspnea with exertion and 6 weeks of gradually worsening stridor. She had been treated empirically for adult-onset asthma with bronchodilators without Video at improvement. Pertinent medijamaotolaryngology.com cal history included cutaneous melanoma of the left shoulder 4 years previously. The lesion was treated with wide excision, axillary lymph node dissection, and systemic interferon. Following treatment, she had undergone annual surveillance with positron emission tomography (PET). Her most recent negative result from a PET scan was 9 months prior to presentation. On physical examination, the patient displayed stable
jamaotolaryngology.com
vital signs, with oxygen saturation greater than 95% on room air. She was able to speak in full sentences and did not display any neck or chest retractions with breathing, but she did have audible biphasic stridor. No clinically significant cervical or axial lymphadenopathy was present. Computed tomography, performed in the ER, revealed an intraluminal posterior tracheal wall mass (Figure, A). Awake flexible bronchoscopy performed under local anesthesia alone in the clinic revealed a purple, pedunculated mass that was mobile with respiration and obstructed 90% of the mid-tracheal airway (Figure, B, and Video). The patient underwent urgent endoscopic subtotal resection of the lesion in the operating room with immediate relief of her respiratory symptoms (Figure, C). What is your diagnosis?
(Reprinted) JAMA Otolaryngology–Head & Neck Surgery March 2015 Volume 141, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 05/20/2015
291
Clinical Review & Education Clinical Problem Solving
Diagnosis Malignant melanoma metastatic to the trachea
Discussion Intraluminal tracheal masses present diagnostic and treatment challenges. The decision was made to initially evaluate the patient’s lesion via awake transnasal flexible bronchoscopy in the otolaryngology clinic, despite the presence of biphasic stridor, given her overall stability (stable saturation, low work of breathing). Following nasal topical anesthesia and decongestant application, the patient’s larynx and trachea were topically anesthetized via nebulization of 3 mL of 4% topical lidocaine. This technique is safe, well tolerated, and provides topical anesthesia sufficient to examine the tracheal airway with the patient maintaining spontaneous respiration.1 With the distal-chip flexible laryngoscope passed through the vocal cords, the tracheal mass was easily visualized (Video). The differential diagnosis at the time of clinical examination included metastatic melanoma, based on the patient’s medical history, but also adenoid cystic carcinoma, which is the second most common primary tracheal malignant neoplasm and can often have a “cluster of grapes” appearance.2 Given the patient’s medical history and the lesion’s appearance, squamous cell carcinoma was low on the list of differential diagnoses. After discussion with the patient, the recommendation was made to proceed to the operating room for biopsy and surgical debulking of the lesion. While biopsies would have been possible in the clinic, the degree of tracheal obstruction present, need for adequate tissue biopsy specimens for pathologic analysis, and risk of bleeding were factors considered. Following discussion with our colleagues on the anesthesia service, surgery was performed with the patient spontaneously ventilating. While use of paralytic or agents that suppress respiration may have allowed for easier laryngoscopy and access to the tracheal lesion, the risk of not being able to adequately ventilate the patient using techniques such as supralesional jet ventilation or an endotracheal tube was deemed too great. ARTICLE INFORMATION
Section Editor: Albert L. Merati, MD.
Author Affiliations: Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle (Purcell, Meyer, Allen); Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Bethesda, Maryland (Allen).
Published Online: January 2, 2015. doi:10.1001/jamaoto.2014.3328.
Corresponding Author: Clint Allen, MD, Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, 6420 Rockledge Dr, Ste 4920, Bethesda, MD 20817 ([email protected]).
292
On the chance that the lesion needed to be urgently bypassed for ventilation, multiple different microlaryngoscopy endotracheal tubes as well as rigid Holinger ventilating bronchoscopes were immediately available. The patient’s laryngoscopic access turned out to be straightforward with a Lindholm laryngoscope. After exposing the lesion with a rigid endoscope, biopsies were performed, and the lesion was debrided with a microdebrider, taking care not to damage the posterior tracheal wall. Strict hemostasis was maintained with suction and epinephrine-soaked pledgets. Alternative options for mass removal included use of a fiber-based laser for debulking, but we felt the debrider offered the ability to reestablish a patent airway more quickly. Stenting of the airway was not considered. After biopsies, tumor debulking, and hemostasis, the patient was allowed to awaken and was found to have complete resolution of her dyspnea. She was observed overnight in the ICU and discharged home on postoperative day 2 without complication. Surgical pathologic results confirmed the diagnosis of melanoma metastatic to the tracheal mucosa. Melanoma is an aggressive malignant neoplasm with a greater tendency to metastasize compared with other skin cancers.3 However, less than 1% of patients with melanoma develop upper aerodigestive tract metastases.4 Metastatic tracheal melanoma is especially rare, with about 10 published case reports.5 For patients found to have metastatic lesions of the aerodigestive tract, treatments aim to preserve voice, swallow, and airway as much as possible if curative treatments are deemed unlikely.3 Following multidisciplinary tumor board discussion, our patient underwent postoperative radiation to the site of lesion; however, she developed widely metastatic disease within 6 months. To date, she has not required repeated surgical debulking of her tracheal metastasis. Although this patient’s overall prognosis is guarded, she seems to have experienced durable symptomatic relief with surgical debulking and adjuvant radiotherapy of her tracheal metastasis. This case highlights the need for otolaryngologists to aware of the risk of airway metastasis in patients with a history of melanoma.
Conflict of Interest Disclosures: None reported. REFERENCES 1. Verma SP, Smith ME, Dailey SH. Transnasal tracheoscopy. Laryngoscope. 2012;122(6):1326-1330. 2. Webb BD, Walsh GL, Roberts DB, Sturgis EM. Primary tracheal malignant neoplasms: the University of Texas MD Anderson Cancer Center experience. J Am Coll Surg. 2006;202(2):237-246.
3. Mifsud M, Padhya TA. Metastatic melanoma to the upper aerodigestive tract: a systematic review of the literature. Laryngoscope. 2014;124(5):1143-1149. 4. Henderson LT, Robbins KT, Weitzner S. Upper aerodigestive tract metastases in disseminated malignant melanoma. Arch Otolaryngol Head Neck Surg. 1986;112(6):659-663. 5. Shelton T, Cambron S, Seltzer M, Siegel A. Tracheal metastasis from melanoma detected with 18F-FDG PET/CT. Clin Nucl Med. 2013;38(10):815-817.
JAMA Otolaryngology–Head & Neck Surgery March 2015 Volume 141, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 05/20/2015
jamaotolaryngology.com
Clinical Problem Solving | ENDOSCOPY
Tracheal Mass Patricia Purcell, MD; Tanya Meyer, MD; Clint Allen, MD
A
B
C
Figure. A, Sagittal computed tomographic image of midtracheal mass. B, Image from in-office flexible bronchoscopy. C, Image from operative rigid endoscopy.
A woman in her 50s presented to the emergency department (ER) with a 3-month history of progressive dyspnea with exertion and 6 weeks of gradually worsening stridor. She had been treated empirically for adult-onset asthma with bronchodilators without Video at improvement. Pertinent medijamaotolaryngology.com cal history included cutaneous melanoma of the left shoulder 4 years previously. The lesion was treated with wide excision, axillary lymph node dissection, and systemic interferon. Following treatment, she had undergone annual surveillance with positron emission tomography (PET). Her most recent negative result from a PET scan was 9 months prior to presentation. On physical examination, the patient displayed stable
jamaotolaryngology.com
vital signs, with oxygen saturation greater than 95% on room air. She was able to speak in full sentences and did not display any neck or chest retractions with breathing, but she did have audible biphasic stridor. No clinically significant cervical or axial lymphadenopathy was present. Computed tomography, performed in the ER, revealed an intraluminal posterior tracheal wall mass (Figure, A). Awake flexible bronchoscopy performed under local anesthesia alone in the clinic revealed a purple, pedunculated mass that was mobile with respiration and obstructed 90% of the mid-tracheal airway (Figure, B, and Video). The patient underwent urgent endoscopic subtotal resection of the lesion in the operating room with immediate relief of her respiratory symptoms (Figure, C). What is your diagnosis?
(Reprinted) JAMA Otolaryngology–Head & Neck Surgery March 2015 Volume 141, Number 3
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 05/20/2015
291
Clinical Review & Education Clinical Problem Solving
Diagnosis Malignant melanoma metastatic to the trachea
Discussion Intraluminal tracheal masses present diagnostic and treatment challenges. The decision was made to initially evaluate the patient’s lesion via awake transnasal flexible bronchoscopy in the otolaryngology clinic, despite the presence of biphasic stridor, given her overall stability (stable saturation, low work of breathing). Following nasal topical anesthesia and decongestant application, the patient’s larynx and trachea were topically anesthetized via nebulization of 3 mL of 4% topical lidocaine. This technique is safe, well tolerated, and provides topical anesthesia sufficient to examine the tracheal airway with the patient maintaining spontaneous respiration.1 With the distal-chip flexible laryngoscope passed through the vocal cords, the tracheal mass was easily visualized (Video). The differential diagnosis at the time of clinical examination included metastatic melanoma, based on the patient’s medical history, but also adenoid cystic carcinoma, which is the second most common primary tracheal malignant neoplasm and can often have a “cluster of grapes” appearance.2 Given the patient’s medical history and the lesion’s appearance, squamous cell carcinoma was low on the list of differential diagnoses. After discussion with the patient, the recommendation was made to proceed to the operating room for biopsy and surgical debulking of the lesion. While biopsies would have been possible in the clinic, the degree of tracheal obstruction present, need for adequate tissue biopsy specimens for pathologic analysis, and risk of bleeding were factors considered. Following discussion with our colleagues on the anesthesia service, surgery was performed with the patient spontaneously ventilating. While use of paralytic or agents that suppress respiration may have allowed for easier laryngoscopy and access to the tracheal lesion, the risk of not being able to adequately ventilate the patient using techniques such as supralesional jet ventilation or an endotracheal tube was deemed too great. ARTICLE INFORMATION
Section Editor: Albert L. Merati, MD.
Author Affiliations: Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle (Purcell, Meyer, Allen); Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, Bethesda, Maryland (Allen).
Published Online: January 2, 2015. doi:10.1001/jamaoto.2014.3328.
Corresponding Author: Clint Allen, MD, Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins School of Medicine, 6420 Rockledge Dr, Ste 4920, Bethesda, MD 20817 ([email protected]).
292
On the chance that the lesion needed to be urgently bypassed for ventilation, multiple different microlaryngoscopy endotracheal tubes as well as rigid Holinger ventilating bronchoscopes were immediately available. The patient’s laryngoscopic access turned out to be straightforward with a Lindholm laryngoscope. After exposing the lesion with a rigid endoscope, biopsies were performed, and the lesion was debrided with a microdebrider, taking care not to damage the posterior tracheal wall. Strict hemostasis was maintained with suction and epinephrine-soaked pledgets. Alternative options for mass removal included use of a fiber-based laser for debulking, but we felt the debrider offered the ability to reestablish a patent airway more quickly. Stenting of the airway was not considered. After biopsies, tumor debulking, and hemostasis, the patient was allowed to awaken and was found to have complete resolution of her dyspnea. She was observed overnight in the ICU and discharged home on postoperative day 2 without complication. Surgical pathologic results confirmed the diagnosis of melanoma metastatic to the tracheal mucosa. Melanoma is an aggressive malignant neoplasm with a greater tendency to metastasize compared with other skin cancers.3 However, less than 1% of patients with melanoma develop upper aerodigestive tract metastases.4 Metastatic tracheal melanoma is especially rare, with about 10 published case reports.5 For patients found to have metastatic lesions of the aerodigestive tract, treatments aim to preserve voice, swallow, and airway as much as possible if curative treatments are deemed unlikely.3 Following multidisciplinary tumor board discussion, our patient underwent postoperative radiation to the site of lesion; however, she developed widely metastatic disease within 6 months. To date, she has not required repeated surgical debulking of her tracheal metastasis. Although this patient’s overall prognosis is guarded, she seems to have experienced durable symptomatic relief with surgical debulking and adjuvant radiotherapy of her tracheal metastasis. This case highlights the need for otolaryngologists to aware of the risk of airway metastasis in patients with a history of melanoma.
Conflict of Interest Disclosures: None reported. REFERENCES 1. Verma SP, Smith ME, Dailey SH. Transnasal tracheoscopy. Laryngoscope. 2012;122(6):1326-1330. 2. Webb BD, Walsh GL, Roberts DB, Sturgis EM. Primary tracheal malignant neoplasms: the University of Texas MD Anderson Cancer Center experience. J Am Coll Surg. 2006;202(2):237-246.
3. Mifsud M, Padhya TA. Metastatic melanoma to the upper aerodigestive tract: a systematic review of the literature. Laryngoscope. 2014;124(5):1143-1149. 4. Henderson LT, Robbins KT, Weitzner S. Upper aerodigestive tract metastases in disseminated malignant melanoma. Arch Otolaryngol Head Neck Surg. 1986;112(6):659-663. 5. Shelton T, Cambron S, Seltzer M, Siegel A. Tracheal metastasis from melanoma detected with 18F-FDG PET/CT. Clin Nucl Med. 2013;38(10):815-817.
JAMA Otolaryngology–Head & Neck Surgery March 2015 Volume 141, Number 3 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archotol.jamanetwork.com/ by a Nanyang Technological University User on 05/20/2015
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