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Leiomyoma of Trachea presenting as Bronchial Asthma

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Leiomyoma of Trachea presenting as Bronchial Asthma

    PULMON Volume 3; No.2 (May-August) 2001 Case Report

     Leiomyoma of Trachea presenting as Bronchial Asthma

    Ramachandran PV, Rauf CP*, Della Harigovind, Neelakandhan KS**

    KHRWS Imageology Centre & Chest Hospital,* Calicut and

    SCTIMST**, Thiruvananthapuram

Key Words: Tracheal Neoplasm, Fixed Airway Obstruction, Leiomyoma

Abstract:

     Tracheal tumors are often overlooked as a cause of pulmonary symptoms until they reach and advanced state. They often present with cough and wheeze, mimicking bronchial asthma. Most tracheal tumors in adults are cancerous (80% to 90%). Benign tracheal tumors are rare in adult patients. A case history of a 52 year old lady is presented with a rare tracheal leiomyoma. She was treated as having bronchial asthma initially. The possibility of the presence of an upper airway obstruction was not raised until the stridor was noted and the flow-volume loop testing suggested the former. A simple investigation like a plain lateral view X-ray of soft tissues of neck revealed a intratracheal mass. Bronchoscopy and helical computed tomography with multiplanar reconstructions and virtual endoscopy confirmed the diagnosis of upper airway obstruction caused by a tracheal tumor. Surgical resection and end-end anastomosis was performed.

Case Report:

     A 52-year old lady presented with complaints of repeated attacks of cough and shortness of breath for last three years. She was diagnosed to have asthma and was on bronchodilators and steroids almost regularly. In addition, during exacerbation of dyspnoea she was treated with nebulized salbutamol. These exacerbations used to occur at variable intervals. She has history of dry cough and occasional haemoptysis for the last three years. There is no history of chest pain, nasal symptoms or change in the voice. She has never smoked.

     Patient was moderately built and nourished. Head, Eye & ENT examination were normal. During physical examination she was found to have stridor. Examination of the respiratory system showed generalized wheezing and low pitched inspiratory rhonchi were noted. Other systems were normal.

     Haemogram, urinalysis and biochemical investigations were normal. PFT showed evidence of fixed upper airway obstruction. Chest X-ray was within normal limits. Lateral view X-ray of soft tissue neck (Fig.1) showed a well defined nodular soft tissue mass within the trachea at T1 level. Plain and contrast enhanced helical CT scans with coronal and sagittal reconstructions (Fig.2,3 & 4) revealed a well-defined mildly enhancing soft tissue mass arising from the anterolateral wall of extrathoracic trachea ndthinvolving 2 to 4 rings. Slightly mobile nature of the mass was revealed by the

    successive helical CT images. Virtual endoscopy further confirmed the site of attachment of the mass (Fig.5,6). Intrathoracic trachea and its further divisions were normal.

     Patient was referred to SCTIMST, Trivandrum for surgical management. A smooth 2x1cm mass found arising from the mucosal aspect of second to fourth tracheal rings, producing subtotal obstruction of tracheal lumen. The involved segment of trachea was resected and continuity reestablished by end to end anastomosis of the tracheal stumps. Patient had an uneventful post operative recovery. Histopathology of the lesion was reported as leiomyoma.

Discussion:

     Though many different tracheal tumours have been reported, both benign and 1,2malignant, primary tracheal neoplasia is rare. Tumours of the larynx and lungs are 3respectively 75 and 180 times more frequent than tumours of trachea. Tracheal tumours

    include both primary epithelial and mesenchymal neoplasms and secondary neoplasia either due to metastases or more commonly direct tracheal invasions by adjacent mediastinal neoplasms, especially carcinomas arising from the lung, thyroid and oesophagus. Though primary tracheal neoplasia itself is very rare, squamous cell 4carcinoma and adenoid cystic carcinoma together account for upto 86% of cases. The

    former most often occur in middle aged male smokers. The latter, arising from the tracheobronchial mucous glands, previously classified along with carcinoid tumours as adenomas, represent low grade malignant tumours and show a marked propensity for focal, especially submucosal invasion. Rare malignant tracheal lesions have been 5-10reported, primary as well as metastatic. Literature is also rich with reports of benign

    tumours of varied histology, the highest number reported being benign pleomorphic 1213,14adenomas. Most of the remaining are single case reports. Mesenchymal primary 15-19neoplasm of trachea are still rare. We could find only 2 reports of leiomyoma of 20,2122trachea, and one leiomyosarcoma in literature, though a Japanese report indexed for 21Medline counts 18 cases of leiomyoma reported worldwide and 2 reports of leiomyosarcoma, including their case. No known association exists between tracheal tumours other than squamous cell Ca and cigarette smoking, nor is there any predilection 24for any sex. Lesions like intratracheal ectopic thyroids also will come in differential 29diagnosis of fixed upper airway obstructions, though the former has often been noted to

    occur in association with goiter in the thyroid gland.

     Diagnosis of tracheal tumours are often elusive as they masquerade as bronchial 19,26asthma and chronic bronchitis. reinforcing the age-old adage that “not all that

    wheezes is asthma”. The common symptoms include wheezing, cough, dyspnoea and haemoptysis and thus mimic asthma. The temporary responses to bronchodilators and steroids further delay the diagnosis. PFT and a soft tissue neck lateral X-ray give the first 27,28clues. Helical CT with reconstructions and virtual endoscopy completes the anatomic

    data set necessary for surgical planning. Virtual endoscopy is recent development in post processing techniques for cross sectional images. Unlike conventional 3D constructions, the images obtained are given a perspective which, when highly magnified, creates the impression of a true endoscopic image.

     Most commonly performed treatment is resection and end to end anastomosis. Palliative therapies such as external beam radiation, endoluminal brachytherapy,

bronchoscopic laser resection and endoprosthetic stenting are also tried for malignant 29tumours. Endoscopic ND-YAG laser ablation has been reported as primary treatment as 30well as prior adjuvant to tracheal resection.

Figure Legends:

    Figure 1 : X-ray soft tissue neck lateral view showing the intratracheal tumour

     2 : Axial CT image showing the lesion from anterolateral wall of trachea

     3 : Sagittal reconstruction showing the lesion

     4 : Coronal reconstruction showing the lesion

     5 : Virtual endoscopy images showing the tumour

     6 : Virtual endoscopy images showing the tumour

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