Primary malignant tumors of the trachea are very uncommon, and can often be confused with asthma or chronic obstructive pulmonary disease (COPD). Tracheal tumors are very rare, with an incidence of less than 0.01%; most are squamous cell carcinomas.1 Very few cases of primary tracheal lymphoma causing central airway obstruction have been described to date.2

A 72-year-old man was admitted with difficulty breathing. The patient had been monitored for a year following a diagnosis of COPD. He had an 80packs/year history of smoking. Physical examination and laboratory tests were normal. On bronchoscopy, a smooth polypoid mass was observed in the middle of the trachea, almost completely occupying the lumen. A diode laser and coring was used to debulk the tumor (Fig. 1a). Pathological examination revealed a B-cell lymphoma.

Fig. 1.

(a and b) Bronchoscopy view before and after the interventions. (c) Immunohistochemical staining of a tracheal tumor showing large B-cell lymphoma.

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The patient received the appropriate chemotherapy, but 20 months after the first intervention he was readmitted to hospital for stridor and dyspnea. The presence of another mass almost completely obstructing the upper third of the trachea was observed (Fig. 1b). Repeat interventional bronchoscopy was performed using a diode laser, and mechanical debulking was performed to completely clear the airway lumen.

Pathological examination revealed a round cell tumor. Immunohistochemical staining showed the presence of diffuse/strong CD20+, scant CD3+ and CD5+, and disseminated CD45+ (Fig. 1c). Macrocytic B-cell lymphoma was therefore diagnosed.

Around two thirds of all primary tracheal tumors are squamous cell carcinomas or adenoid cystic carcinomas. The remaining third are malignant, intermediate or benign lesions.1 Primary hematopoietic malignant diseases of the trachea are very rare, and are observed more commonly in cases of extramedullary plasmocytoma or non-Hodgkin's lymphoma. Asthma and COPD are common erroneous diagnoses.3 In fact our patient had been treated for COPD for one year prior to admission.

The treatment of choice depends on the size of the lesion, and it may be necessary to reconstruct the lumen of the tumor-free trachea. It should be remembered that non-Hodgkin's lymphoma is rarely limited to the trachea in a patient presenting central airway obstruction caused by an endoluminal mass. Airway obstruction can recur in another part of the trachea, despite using appropriate chemotherapy.

Complete emergency resection of a tumor in the trachea can be achieved with rigid bronchoscopy. In this case, the airway obstruction occurred on two occasions 20 months apart. The diagnosis was obtained using an interventional bronchoscopy approach with rapid improvement of the condition and opening of the airway lumen at the time of diagnosis.