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Unusual presentation of small cell carcinoma with diffuse tracheal wall thickening leading to delayed diagnosis
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  1. Anil Ananthaneni1 and
  2. Kavitha Beedupalli2
  1. 1Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
  2. 2Hematology/Oncology, Feist-Weiller Cancer Center, Shreveport, Louisiana, USA
  1. Correspondence to Dr Anil Ananthaneni; aan005{at}lsuhs.edu

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Description

We present a man in his early 60s who initially was noted to have diffuse mural thickening of the distal trachea on a CT scan performed at an outside hospital. Further investigations to evaluate the incidental finding were not performed as alternate non-neoplastic diagnoses were considered. Six months later, patient presented to our hospital with hemoptysis, unintentional weight loss of over 30 pounds, hoarseness of voice and on repeat CT was noted to have endobronchial lesions in the main stem bronchus as well.

Given alarming symptoms and CT scan findings, he underwent bronchoscopy with biopsy. Pathology confirmed high grade neuroendocrine carcinoma. Immunohistochemistry characteristics included CD56 and synaptophysin cytoplasmic/membranous positivity, Ki-67 index of 60% and absence of chromogranin and TTF-1 reactivity. No other tumour markers are available. Fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan showed increased uptake along the distal trachea and proximal bronchus, right lung nodule and nodes in the chest. Routine labs were unremarkable. No intracranial metastases were noted on MRI of the brain. Given limited stage disease, plan was made for concurrent cisplatin/etoposide with radiation. Repeat imaging is unavailable at the time of submission of this manuscript.

CT/PET combined figure (figure 1) shows unusual diffuse non-calcified peritracheal and peribronchial pattern of small cell cancer growth. Although nodular tracheal metastasis of primary non-small cell carcinoma with a predilection for upper trachea1 and nodular small cell cancer tracheal metastasis2 have been described, our patient presented with diffuse lower tracheal wall thickening from primary small cell carcinoma. While tomographic differentials of diffuse tracheal wall thickening without posterior wall involvement is broad and includes sarcoidosis, amyloidosis, tuberculosis, paracoccidioidomycosis, rhinoscleroma, granulomatosis with polyangiitis, lymphomas and even inflammatory bowel disease,3 4 bronchoscopic evaluation is indicated to narrow the differentials5 especially to rule out high grade malignancy as timely diagnosis and treatment will have a great impact on outcomes.

Figure 1

CT/positron emission tomography showing diffuse non-calcified distal tracheal and proximal bronchial wall thickening.

Learning points

  • Diffuse non-calcified tracheal wall thickening needs inclusion of aggressive cancers in the differentials.

  • In addition to tomographic evaluation, bronchoscopic correlation would strongly be indicated to narrow the differentials.

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References

Footnotes

  • Twitter @Ananth_MD

  • Contributors The drafting of the article was done by AA and KB. Critical review was done by KB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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