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Tracheal Bronchus With Metachronous Tumor

Monteiro, Regina MD*; Gonçalves, Ivone MD*; Parente, Bárbara MD*; Moura e Sá, João MD

Journal of Bronchology & Interventional Pulmonology: October 2012 - Volume 19 - Issue 4 - p 343–344
doi: 10.1097/LBR.0b013e31826c64d4
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Tracheal bronchus, a bronchus arising from the lateral wall of the trachea, is a rare congenital anomaly. It is usually asymptomatic but symptoms could occur with relatively poor local drainage. There are a few cases of lung cancer within the tracheal bronchus reported in the literature; however, none of them were reported to be metachronous. A metachronous tumor is a second primary malignancy diagnosed >6 months after the diagnosis of the index tumor. We present a case of a squamous cell carcinoma originating in a tracheal bronchus of a 53-year-old patient previously diagnosed with a supraglottic malignancy.

*Pulmonology Department

Respiratory Endoscopy Unit, Pulmonology Department, Hospital Center of Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal

Disclosure: There is no conflict of interest or other disclosures.

Reprints: Regina Monteiro, MD, Serviço de Pneumologia, Centro Hospitalar Vila Nova de Gaia/Espinho, Unidade 1, Rua Conceição Fernandes s/n, Vila Nova de Gaia 4434-502, Portugal (e-mail: caixadaregina@gmail.com).

Received May 6, 2012

Accepted July 17, 2012

Tracheal bronchus is an abnormal bronchial branch, arising directly from the lateral wall of the trachea. They can be located at any point but are generally found within 2 cm above the carina, in the right lateral wall.1–4 Tracheal bronchi are rare congenital anomalies with a prevalence of 0.1% to 2% in the bronchographic and bronchoscopic studies. These bronchi are described as “supernumerary” when they coexist with a normal branching of the upper lobe bronchus and as “displaced” when 1 branch of the upper lobe is missing. The displaced type is more frequent.3,4

These aberrant bronchi are usually asymptomatic, but symptoms may occur in approximately 25% of the patients,3 mainly as a result of relatively poor local drainage. There are some important implications, particularly during endotracheal intubation when the endotracheal tube may occlude the lumen of the tracheal bronchus or an inadvertent intubation of the anomalous lobe takes place. In the literature, these aberrant bronchi have been described with presenting manifestations as recurrent local infections, persistent cough, stridor, or hemoptysis.3–5 Tumor development in tracheal bronchi is known with a few cases reported in the literature.1–3,5–7 To our knowledge, this is the first case of a metachronous tumor involving a tracheal bronchus.

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CASE REPORT

A 53-year-old man, with smoking history of 60 pack years (1.5 packs of cigarettes every day for 40 y) and alcohol abuse, was referred to otorhinolaryngology assessment for odynophagia and dysphonia since the beginning of 2010. A diagnosis of squamous cell carcinoma of the right pyriform sinus was made in April 2010. The patient was submitted to hemilaryngectomy and the histologic examination revealed the lesion to be a T2N0Mx tumor.

A chest computerized tomography scan performed in January 2011 (Fig. 1) for hemoptysis revealed a 5.3-cm mass involving the right upper lobe and the latter being ventilated by a tracheal bronchus. Signs of mediastinal invasion were present and multiple smaller nodules were also scattered in both the lung fields. A flexible bronchoscopy performed in February 2011 revealed a displaced tracheal bronchus in the right lateral wall of the trachea above the carina (B1). The remaining right upper lobe (B2+B3) presented edema of the mucosa. The bronchial lavage performed in the tracheal bronchus was diagnostic of squamous cell carcinoma (stage IV); however, no endobronchial lesion involving the tracheal bronchus was noticed at this stage.

FIGURE 1

FIGURE 1

Given the stage of the supraglottic tumor (stage II), the absence of local recurrence and existence of a tumor mass on the right upper lobe significantly larger than the other lung lesions, it was assumed to be a second primary of the lung origin. The patient completed 6 cycles of carboplatin and gemcitabina in June 2011 with local disease control until October 2011. In November 2011, a repeat bronchoscopy (Fig. 2) was performed for hemoptysis that revealed near-total obstruction of the tracheal bronchus with a pedunculated tumor mass, which was eventually diagnosed as a squamous cell carcinoma.

FIGURE 2

FIGURE 2

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DISCUSSION

The differential diagnosis between lung metastases of the larynx tumor and a second primary tumor is not clear, whether they have the same histologic type and there are multiple pulmonary lesions.

A metachronous tumor is a second primary diagnosed >6 months after the diagnosis of the index tumor.8 Second primary malignancies are a particular problem for head and neck cancer patients. The reported overall incidence, which is higher in smokers and alcohol abusers, ranges between 5% and 30%.9

In contrast, the incidence of distant metastases in subjects with head and neck squamous cell carcinoma is relatively low, 5% in patients with locoregional control.10

Although there is a lack of evidence to establish whether a tracheal bronchus is more susceptible to malignant neoplasias, there are 14 cases of lung cancer associated with tracheal bronchi in the literature.1–3,5–7 Our case is the first case reported in Portugal and, to our knowledge, the first case of a metachronous tumor in a tracheal bronchus.

Our case highlights the fact that the bronchoscopist needs to be aware of endobronchial anomalies and their implications.

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REFERENCES

1. Sen S, Senturk E, Pabusçu E, et al. Upper lobectomy for lung cancer with true tracheal bronchus: a unique presentation. Arch Bronconeumol. 2010;46:332–334
2. Kuo CW, Lee YC, Perng RP. Tracheal bronchus associated with lung cancer: a case report. Chest. 1999;116:1125–1127
3. Findik S. Tracheal bronchus in the adult population. J Bronchol Intervent Pulmonol. 2011;2:149–153
4. Ghaye B, Szapiro D, Fanchamps JM, et al. Congenital bronchial abnormalities revisited. Radiographics. 2001;21:105–119
5. Bou-Khalil P, Aboussouan L, Mehta A. Tracheal bronchus. J Bronchol. 1996;3:134–135
6. Liu HC, Hsu WH, Huang MH. Squamous cell carcinoma of the right upper lung congenital tracheal bronchus. Zhonghua Yi Xue Za Zhi (Taipei). 2000;63:424–428
7. Navarro F, Lorenzo J, Cicero R. Bronchogenic carcinoma in a tracheal bronchus. J Bronchol. 1999;6:58–59
8. Vaamonde P, Martín C, Rio M, et al. Second primary malignancies in patients with cancer of the head and neck. Otolaryngol Head Neck Surg. 2003;129:65–70
9. Léon X, Quer M, Diez S, et al. Second neoplasm in patients with head and neck cancer. Head Neck. 1999;21:204–210
10. Léon X, Quer M, Orús C, et al. Distant metastases in head and neck patients who achieved loco-regional control. Head Neck. 2000;22:680–686
Keywords:

tracheal bronchus; lung cancer; metachronous tumor

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