EVIS X1 Atlas -TXI

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Case : Tumor in the trachea

Kei Morikawa, MD

Division of Respiratory and Infectious Diseases,
Department of Internal Medicine

St. Marianna University School of Medicine

Procedure information

Scope: BF-1TH1200
Location: Upper part of the trachea
Patient information: Male, 78 years old
Medical history: Intubation and tracheostomy were performed 2 years ago due to COVID-19 pneumonia. Chemotherapy was administered to treat mantle cell lymphoma 1 year ago. After complete remission of the lymphoma, PET-CT indicated a suspicion of a tumorous lesion on the right tracheal wall. He was referred to our institution for further examination. He is an ex-smoker who stopped smoking 3 years ago with a history of 27.5 pack-years.

1-1 Upper part of the trachea (WLI)

The upper part of the trachea is constricted, and accompanied by deformation of the tracheal cartilage. Some of the tracheal rings have disappeared due to increased subepithelial vascularity and edematous changes.

1-2 Upper part of the trachea (WLI)

The tracheal rings are disrupted due to flat tumor growth. While the smoothness of the epithelial surface is maintained, increased subepithelial vascularity is conspicuous and varied diameters and irregular distribution of vessels are conspicuous.

1-3 Upper part of the trachea (TXI1)

In the TXI mode, the subepithelial tissue looks faded. Against this faded background, the vascular characteristics and distribution appear clearer.

1-4 Upper part of the trachea (NBI)

The NBI mode increases the visibility of smaller vessels among the increased vascularity.

1-5 Upper part of the trachea (RDI2)

In the RDI mode, the superficial vessels are depicted in shades ranging between red and yellow, facilitating estimation of the depth of the subepithelial vessels.

1-6 Upper part of the trachea (RDI3)

With RDI mode3 the superficial vessels appear in red and the deep vessels appear in green, increasing the visibility of the deep vessels in addition to the superficial vessels.

Case Video

The flat tumor growth in the upper part of the trachea shows a distribution pattern of subepithelial vessels suspected to be malignant and is carefully observed in detail in the NBI, TXI, and RDI modes. The lesion is subsequently biopsied while taking extra care not to cause bleeding.

Pathological Findings

Figure A (HE staining): Tumor foci composed of proliferation of ductal epithelial cells and myoepithelial cells are observed. These feature a mesh-like structure including small cystic parts.
Figure B (p63 immunostaining): p63-positive myoepithelial cells are observed at the periphery of the tumor foci.
Final diagnosis: Adenoid cystic carcinoma

Overall Comment

In this case, abnormal subepithelial vessels that had increased irregularly were observed in detail in the TXI, NBI, and RDI modes. Since the lesion was located below the glottis, evaluation of the vessels in each mode was considered useful for careful selection of a biopsy site to prevent bleeding. The result suggests that the TXI and RDI3 settings, in particular, have the potential to be equivalent or superior to NBI for observation of vessels.

Co-editor:

Dr. Nobuyuki Ohike

Department of Pathology, St. Marianna University School of Medicine

Case 11: Tumor in the bronchus intermedius Case 13: Tumor in the right upper lobe

Content Type

Imaging Atlas