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T ase Presentation Dr Shah: A 63-year-old man with a 5-pack-year smoking history presented to ur institution for management of progressive dyspnea. He was diagnosed with ronchial asthma yet had not responded to inhaled -agonists or oral steroids. His ast surgical history was significant for cervical laminectomy 9 years ago and left ye vitrectomy 1 year ago. His medical history was significant for adult-onset diabetes ellitus, hypertension, and hyperlipidemia. He also had remote exposure to tuberculosis nd 2 episodes of pneumonia over the past 24 months. Physical examination revealed xpiratory, as well as inspiratory, stridor throughout both lung fields without rales or onchi. Baseline laboratory tests were significant for a blood glucose level of 210 mg/dL, blood urea nitrogen level of 50 mg/dL, and a creatinine level of 2.4 mg/dL. Forced xpiratory volume in 1 second, forced vital capacity, forced expiratory volume in second/forced vital capacity, and diffusion capacity, were 20%, 86%, 70.3%, and 4% of predicted values, respectively. Resting oxygen saturation was normal. Configration of the flow-volume loop was suggestive of variable intrathoracic upper airway bstruction, with reduction in peak expiratory flow to 22% of predicted value. Dr Karnak: Dr Shah, could you please describe the radiographic and chest omputed tomographic (CT) findings? Dr Shah: The chest radiograph showed a 2 2.5–cm opacity projected over the istal trachea on the frontal view; the lateral view was unremarkable. The nonconrast axial CT image at the level just above the carina (Figure 1) and th tructed midline sagittal and coronal image (Figure 2) in soft tissue windows demon trated a lobulated transmural solid mass involving the distal anterior tracheal wall .5 cm proximal to the carina. The 3.2 2.2 3.2–cm extraluminal pretracheal omponent was coarsely calcified, whereas the 2.2 2.3 1.6–cm endobronchial omponents predominantly exhibited soft tissue density, with only a thin rim of alcification at its interface with the distal anterior tracheal wall. There was nearotal occlusion of the distal trachea. The differential diagnosis included primary racheal neoplasm (eg, squamous cell carcinoma, adenoid cystic carcinoma, bronhial adenoma, and carcinoid tumor) or metastasis (breast cancer, renal cell carcioma, colon carcinoma, or melanoma). Tracheal chondroma and paratracheal nerve heath tumor were believed to be less likely possibilities, given their lower incidence. Dr Shah: Drs Mehta and Karnak, could you describe the bronchoscopic examnation and intervention? Dr Karnak: Flexible bronchoscopy revealed a lobulated, smooth, exophytic ass located approximately 2 cm above the carina and producing 80% obstruction f the tracheal lumen. When the bronchoscope was negotiated beyond the obstrucion, there was no evidence of distal disease. Dr Mehta: By using an electrocautery snare through the flexible bronchoscope fter achievement of general anesthesia, the endobronchial portion of the tumor was esected (Figure 3).

Clinical-pathologic conference in general thoracic surgery: A malignant peripheral nerve sheath tumor of the trachea