Tracheal lymphoma presenting with acute airway obstruction diagnosed with transbronchial needle aspiration (TBNA)/rigid bronchoscopy and managed acutely with mechanical debulking and neodymium yttrium aluminum garnet (ND:YAG) laser resection

Introduction: Primary tracheal lymphoma is an uncommon disease of the lower respiratory tract that can rarely present as an acute airway obstruction. The diagnosis and management of such a presentation are not well defined, but may include flexible or rigid bronchoscopy, YAG laser resection, stent placement, tracheostomy and emergency radiation and chemotherapy. We describe such a case that was uniquely diagnosed and managed at our institution utilizing the technique of TBNA/Rigid bronchoscopy with mechanical debulking and YAG laser. Case Presentation: A 71-year old woman was admitted to the Coronary Care Unit with progressive shortness of breath and palpitations. Her symptoms started 2 days prior to admission with shortness of breath. She did not experience any symptoms of cough, chest pain, fevers, chills, orthopnea or leg swelling. She had no significant past medical history, no smoking history and only occasional alcohol consumption. Her appetite was poor and she admitted significant weight loss (more than 20 lb. in the previous 6 months). Shortly after admission, the patient became more short of breath necessitating endotracheal intubation that had to be performed using a fibreoptic laryngoscope because of the difficulty in advancing the endotracheal tube. An endotracheal mass was identified during intubation with narrowing of the tracheal lumen causing more than 90% occlusion. A size 6 French endotracheal tube was advanced past the mass so that the tip was just above the carina. Chest X-ray showed a right suprahilar mass. A CAT scan of the chest demonstrated an endotracheal mass causing severe narrowing of the tracheal lumen with enlarged pretracheal/retrocaval lymph nodes that could not be separated from the endotracheal mass. The patient was taken to the Operating Room the next day and under general anesthesia, a rigid bronchoscope was placed alongside the endotracheal tube and used to enter the trachea to the level of the cuff of the endotracheal tube. A fibreoptic flexible bronchoscope was introduced through the rigid bronchoscope and the cuff of the endotracheal tube was deflated facilitating passage of the flexible bronchoscope. Approximately 3 cm above the carina, a large intraluminal soft mass with smooth surface was seen abutting the tube on the right side. The tracheal lumen was being held open by the endotracheal tube. Using a 22 gauge WANG needle (Mill-Rose Laboratories), a needle aspiration of the mass was done with minimal bleeding. Considering the avascular appearance of the mass and the minimal bleeding noted using the WANG needle, bite biopsies utilizing a rigid biopsy forceps were performed. No significant bleeding was noted. Specimens were sent for cytology, frozen section and surgical pathology. Partial mechanical debulking of the mass utilizing rigid/flexible biopsy forceps was done alternating with YAG laser photoresection of the mass. The endotracheal tube was then withdrawn and using a cup forceps large pieces of the tumor were removed. This was done until the lumen was flushed with the tracheal wall. It was elected to keep the patient intubated for a day with the cuff fully inflated compressing the tumor site to be sure no hemorrhage would occur. A repeat bronchoscopy on the following day demonstrated a widely patent trachea without any bleeding or edema and the patient was successfully extubated. Cytological and pathological specimens confirmed a diagnosis of B cell non-Hodgkin's lymphoma. The patient underwent chemotherapy with good response and is well 4 months after the procedure. Discussion: This is a unique case of primary tracheal lymphoma presenting with acute airway obstruction. The difficulty in obtaining a diagnosis while maintaining a safe airway made us use the endotracheal tube as a temporary stent until the partial debulking of the mass was done. The use of the bronchoscopic needle initially to obtain a specimen from the mass with minimal bleeding allowed us to feel more comfortable and be aggressive in the subsequent debulking of the mass. Conclusion: We believe that rigid bronchoscopy and other interventional bronchoscopic procedures are underutilized in the management of acute airway obstruction due to large endotracheal/endobronchial lesions. Aggressive management of acute airway obstruction secondary to such etiologies utilizing interventional bronchoscopic procedures is safe and should be pursued when indicated.