Results
A 71-year-old female initially presented in January of 2017 to an outpatient clinic in Memphis, TN, with a base of tongue mass. Her past medical history included hypertension (HTN), transient ischemic attach (TIA), acute cerebrovascular accident (CVA), acute respiratory failure with hypoxia, obesity, history of breast cancer, mixed hyperlipidemia, shortness of breath (SOB), depression with anxiety, and a 50-year history of tobacco use. Family history included HTN in her deceased mother, a heart attack in her deceased father, and diabetes in her brother. There was no family history of cancer. She had no history of drug or alcohol use.
In March of 2017, she then presented to her PCP with upper respiratory infection (URI) symptoms, including cough, congestion, and sore throat. On April 6, 2017, she was admitted to Baptist East with stridor and shortness of breath (SOB). She had a CT performed, which showed a 2.4 x 2.1 x 2.2 cm enhancing polypoid mass at the base of tongue with some downward mass effect on the epiglottis. Just above the sternal notch and 5 cm inferior to the vocal cords, there was also a 10 x 17 x 14 mm polypoid lesion, causing moderate stenosis of the trachea (Figure 2). The patient then had a biopsy of the tracheal mass and received a tracheostomy. Pathology from the trachea showed squamous cell carcinoma. On April 7, she underwent a direct laryngoscopy and biopsy. The biopsy of the base of tongue was negative for malignancy.
The patient then had a PET scan on April 20, which showed increased FDG activity in the base of tongue (L>R) and around the tracheostomy site. She then underwent resection of her lingual tonsils on May 8, 2017. On August 1, she then underwent a tracheal resection procedure. Pathology of the trachea showed squamous cell carcinoma with negative margins.
She was lost to follow-up until 2020, when she presented to the same hospital with stridor. She no longer had the tracheotomy tube at that time and had been doing well by all accounts since 2017. According to the patient, she was eating an oral diet and had not coughed up any blood since 2017. In January 2020, she was scheduled for laryngoscopy and bronchoscopy with possible dilation and biopsy. However, repeat imaging showed a 3 x 2 cm tracheal mass with possible esophageal involvement. The tracheal lumen was also significantly narrowed. It was decided that intubation could not be performed due to the size of the mass. Therefore, cardiothoracic surgery was consulted to assist with cardiopulmonary bypass.
The patient was brought to the operating room on January 15, 2020, and placed supine on the operating table. Veno-venous ECMO oxygenation was performed. The patient was then prepped and draped for laryngoscopy and bronchoscopy. The laryngoscope was placed in the oral cavity and a tooth block was used to protect dentition. The laryngoscope was suspended using a Lewy arm and advanced to view the larynx. A zero-degree telescope was then placed through the true vocal cords (Figure 3). The large tracheal mass was visualized and several biopsies were taken with cup forceps (Figure 4). The mass seemed to originate from the left posterolateral wall of the trachea. The micro-debrider was then placed in the trachea and used to suction the mass into the central lumen of the trachea, away from the lateral wall. The mass was debrided using the micro-debrider. Ninety percent of the mass was removed, Afterwards, Afrin-soaked pledges were used to provide hemostasis. Upon re-examination, the trachea was widely patent (Figure 5). The laryngoscope and telescope were then removed, and the patient was turned over to anesthesia. She was intubated orally and transferred to the ICU. On postoperative day 1, she was extubated. She had no stridor and no respiratory complaints.
Final pathology showed high grade weakly keratinizing SCC with variable koilocytosis. Immunohistochemistry for p16 showed diffuse strong nuclear and cytoplasmic positive staining confirming HPV origin. The PD-L1 for Keytruda (Pembrolizumab) was positive with a combined positive score (CPS) of 15, representing the number of PD-L1staining cells divided by the total number of variable tumor cells and then multiplied by 100. The PD-L1 for Opdivo was also positive.
Cisplatin chemotherapy and concomitant radiation were begun on February 5. CT performed on February 5 no longer showed a tracheal mass. PET showed multifocal increased FDG activity along the left posterior wall of the trachea just below the level of the thyroid gland and near the tracheal esophagus, concerning for neoplastic activity. There was also increased activity in the rectal cavity, concerning for neoplasia. Following completion of chemotherapy and radiation for her tracheal tumor, the patient then underwent a colonoscopy and polypectomy. Final GI pathology from the nearby cecum showed colonic mucosa with benign, prominent submucosal lymphoid aggregate. There was no presence of adenoma or malignancy. Final pathology results from the rectum showed fragments of hyperplastic polyps with mucosal prolapse features, but no adenomas or malignancy.
Results of a post-treatment PET-CT were negative, except for some uptake in the rectal area, which proved more likely due to the previous polypectomy.
Provided good findings during her June 3, 2020, bronchoscopy, PEG tube removal can be considered.