TRACHEAL LIPOMA CAUSING NEAR COMPLETE OBSTRUCTION: A MULTI-MODAL TECHNIQUE FOR MANAGEMENT

Abstract

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tracheal lipomas are a rare cause of major airway obstruction and account only for 0.1% to 0.5% of all lung tumors (1). Management of these has involved flexible or rigid bronchoscopy guided resection (1,2). Here we report a multi-modal approach to resection of a tracheal lipoma causing 80% obstruction of the distal trachea. CASE PRESENTATION: A 70-year-old male with 40 pack year cigarette smoking history and chronic obstructive pulmonary disease (COPD), had presented with progressively worsening dyspnea and wheezing. He had been using his prescribed budesonide/formoterol inhaler without significant relief. A CT-Chest without contrast showed a lesion in the distal trachea. An endobronchial tumor was suspected and evaluation with rigid bronchoscopy was planned. He was first intubated in an atraumatic fashion with the 12mm rigid bronchoscope. A vascular appearing polypoid tumor was protruding from the posterior membrane of the trachea and obstructed 80% of the lumen. Endobronchial ultrasound (EBUS) was used to examine the tumor further and it appeared solid without significant vascularity within the lesion. Rigid forceps were used for biopsy and the specimen was sent for frozen section analysis. Then electrocautery snare was used to remove the largest component of the tumor. Subsequently, Nd:YAG laser was used while holding ventilation to destroy the base of the tumor and left a crater like appearance. This was done with the intention to facilitate healing of the mucosa. The final pathology was consistent with a benign tracheal lipoma. DISCUSSION: Tracheal lipomas are 1.4–13.0% of benign tumors of the lung (1). Multiple cases in the literature report use of electrocautery or endobronchial lasers (1,2). Our approach involved using EBUS, which allowed us to examine the lesion to assess its margins and vascularity. Hemorrhage could prove to be fatal in a patient with high risk obstructive lesion. This method allowed a safe excision without significant bleeding. Furthermore, use of Nd:YAG laser achieved superior destruction of the tumor base which allowed for better healing of the mucosa. We do recommend using the laser at a low energy setting to avoid rare complications such as fire when used in high fat content lesions. A surveillance bronchoscopy 5 months following the procedure showed a completely healed posterior tracheal membrane with no evidence of recurrence. CONCLUSIONS: Combined use of rigid bronchoscopy, EBUS and Nd:YAG laser as a multi-modal approach to maximize safety while minimizing chances of recurrence should be considered. Reference #1: Stevic R, Milenkovic B. Tracheobronchial tumors. J Thorac Dis. 2016;8(11):3401-3413. doi:10.21037/jtd.2016.11.24 Reference #2: Pollefliet C, Peters K, Janssens A, et al. Endobronchial lipomas: rare benign lung tumors, two case reports. J Thorac Oncol. 2009;4(5):658-660. doi:10.1097/JTO.0b013e31819c9a59 DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response No relevant relationships by Sisir Akkineni, source=Web Response No relevant relationships by Sixto Arias, source=Web Response No relevant relationships by Jose Garcia Blanco, source=Web Response