Author(s)
Steven G Hoshal, MD
Peter C Wickwire, MD
Regina F Gandour-Edwards, MD
Prabhu Rajappa, MD
Daniel J Cates, MD
Affiliation(s)
University of California Davis, CA Veteran's Affairs Northern California Healthcare System, CA;
Abstract:
Objective: Tracheal tumors can present as life-threatening airway emergencies. Renal cell carcinoma (RCC) metastasis to the trachea is exceedingly rare with few reported cases in the literature. Anti-PD1 immunotherapy for metastatic RCC may be complicated by hyper-progression secondary to a robust immunologic response. The authors present a case of metastatic RCC presenting as a rapidly enlarging endotracheal mass due to hyper-progression on anti-PD1 immunotherapy. Treatment challenges associated with this rare entity are discussed.
Methods: Presenting symptoms, endoscopic exam findings, radiographic images, histopathologic slides, and treatment outcomes are reviewed.
Results: A 68-year-old male with a history of metastatic renal cell carcinoma undergoing anti-PD1 immunotherapy was found to have an incidental tracheal mass on surveillance imaging (CT Chest). Office bronchoscopy demonstrated an exophytic endotracheal mass. Over four weeks the tumor underwent rapid enlargement requiring urgent surgery and a total of three endoscopic interventions over eleven days. The primary surgery included endoscopic Nd:YAG laser and cryo-ablation with tumor debulking and use of advanced airway support techniques. At last outpatient visit the patient was breathing comfortably without stridor and with minimal residual disease. Despite the tracheal metastasis hyper-progression, his systemic disease burden has responded well to anti-PD1 therapy.
Conclusion: Tracheal involvement by metastatic renal cell carcinoma is rare. Tumor hyper-progression on anti-PD1 therapy is a poorly understood immunologic phenomenon that can result in life-threatening circumstances. Awareness of this clinical entity is important for the airway surgeon and treatment may require urgent intervention and tools outside the typical armamentarium of the Otolaryngologist.