Trachea
12 December 2003, copyright (c) 2003, PathologyOutlines.com, LLC
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Primary references, normal anatomy, normal histology
Infectious disorders: adenovirus, cryptosporidium, diphtheria
Non-neoplastic lesions: amyloidosis, mucous membrane plasmacytosis, necrotizing sialometaplasia, post-tracheostomy atypia, rheumatoid nodules, tracheobronchitis, tracheopathia osteoplastica
Tumors: acinic cell carcinoma, adenoid cystic carcinoma, basaloid squamous cell carcinoma, fibromyxoma, fibrous histiocytoma, granular cell tumor, invasive fibrous tumor, MALT lymphoma, mucoepidermoid carcinoma, papilloma/papillomatosis, rhabdomyosarcoma, small cell carcinoma, squamous cell carcinoma
American Journal of Clinical Pathology (AJCP), Jan 1975 to Nov 2003
American Journal of Surgical Pathology (AJSP), Mar 1977 to Nov 2003
Archives of Pathology and Laboratory Medicine (Archives), Jan 1976 to Nov 2003
Human Pathology (Hum Path), Jan 1975 to Oct 2003
Modern Pathology (Mod Path), Jan 1988 to Oct 2003
Rosai, J: Ackerman’s Surgical Pathology (8th Ed); Mosby-Year Book, Inc., 1996
Sternberg, S: Diagnostic Surgical Pathology (3rd Ed); Lippincott Williams & Wilkins, 1999
Please refer to these primary references for more detailed discussions and photographs
Also called windpipe
Cartilaginous and membranous tube, extending from lower larynx at C6 to upper border of T5 vertebrae, where it divides into right and left mainstem bronchi
Flattened posteriorly
11 cm long, 2-2.5 cm in diameter, diameter greater in men than women, adults than children
Anteriorly, contacts thyroid isthmus, inferior thyroid veins, neck muscles, cervical fascia, anterior jugular veins, manubrium sterni, thymus, left innominate vein, aortic arch, innominate and left common carotid arteries, deep cardiac plexus
Posteriorly, contacts esophagus
Right bronchus appears to be a more direct continuation of trachea, and so is the site of most foreign bodies
Supplied by inferior thyroid arteries
Composed of imperfect rings of hyaline cartilage, fibrous tissue, muscular fibers, mucous membranes and glands
Cartilage: 16-20 imperfect rings, with circular cartilaginous defect posterior, and replaced by fibrous tissue and muscular fibers; each cartilage is 4 mm in depth, 1 mm in thickness; are elastic, but may be calcified later in life
Fibrous tissue: thick layer covers outer surface of cartilaginous ring, thin layer covers inner surface; both layers merge at upper and lower margins of cartilaginous rings
Muscular tissue: longitudinal and transverse layers of smooth muscle
Mucus membrane: continuous with laryngeal and bronchial membranes; ciliated columnar epithelium overlying areolar and lymphoid tissue with elastic fibers, blood vessels, nerves, mucous glands
Infectious disorders
Important pathogen in immunocompromised patients, who often have disseminated disease causing death
Associated with ulcerations in larynx and trachea
References: AJCP 2003;120:575
Tracheal dissemination is rare complication of intestinal infection
Case report in 64 year old woman with lymphoma, chronic tracheitis and bronchitis, Archives 1990;114:519
Non-neoplastic lesions
Either diffuse narrowing of airway or solitary / multiple nodules
Symptoms of hemoptysis, atelectasis, obstruction, asthma
15-40% die at mean 9 years after diagnosis from respiratory failure, pulmonary hemorrhage, pneumonia
Does not evolve into systemic amyloidosis
Case report in 49 year old man, Archives 2003;127:e420
Amyloid may be present in lymphocytic interstitial pneumonia, lymphoplasmacytic lymphomas and plasma cell dyscrasias
Treatment: laser therapy or bronchoscopic removal of deposits, radiation therapy, lung transplant
Gross: focal to diffuse nodular thickening of trachea and proximal bronchial walls with patchy mural calcification; also extensive bronchial stenosis, postobstructive pneumonia, atelectasis
Micro: extensive thickening of submucosa due to irregular nodular masses or sheets of amyloid, reduced submucosal glands, calcification or osseous metaplasia of larger airways; variable multinucleated, osteoclast-like giant cells and plasma cells within amyloid; also amyloid deposition within submucosal vessel walls
Positive stains: Congo Red (apple-green birefringence with polarized light)
DD: systemic amyloidosis, light chain deposition disease, pulmonary scar tissue, pulmonary lymphoproliferative disorders, tracheobronchopathia osteochondroplastica (submucosal bony and cartilaginous tissue projects into tracheobronchial lumen, no amyloid)
Plasma cell non-neoplastic proliferative disorder
Mean 54 years, range 40-67 years, 2/3 men, 1/3 women
Treatment: unknown (antibiotics, surgery, steroids are unsuccessful)
Gross: cobblestone or warty appearance of larynx, pharynx, palate, lips, mouth, tongue, trachea
Micro: psoriasiform epithelial hyperplasia with dyskeratosis and dense subepithelial plasmacytosis; diffuse but mature plasma cells are polyclonal (i.e. no light chain restriction)
References: AJSP 1994;18:1048
More commonly seen in palate
Due to prolonged intubation
Atypical cells may also occur in bronchi throughout the lungs
May be due to effect of dry air on tracheal mucosa
DD: squamous cell dysplasia/carcinoma in situ
Occasionally seen in patients with rheumatoid arthritis
Due to tracheostomy, other causes
Gross: necrotic ulceration at tracheostomy opening
Micro: erythematous mucosa
Rare disorder in which exophytic osteocartilaginous nodules arise from inner surface of tracheal ring cartilage,
and are connected to one another by fibrous struts, forming an incomplete cylinder of fibro-osteocartilaginous tissue
superficial to the tracheal rings
Tumors
Rare; case report in 54 year old woman, 46 years after childhood thyroid radiation, Archives 1981;105:266
Second most common primary malignancy of trachea after squamous cell carcinoma
Resembles salivary gland tumor
Usually in upper third of trachea
Lengthy clinical course, but poor long term prognosis due to late local recurrences
Case report with placental metastasis, Hum Path 1989;20:193
Micro: cribriform growth pattern of nests of tumor cells with discrete, rounded, “punched-out” gland-like spaces filled with eosinophilic or basophilic material; infiltrative, perineural invasion common
Positive stains: brain derived neurotrophic factor, Hum Path 2002;33:933
Basaloid squamous cell carcinoma
Aggressive and rapidly fatal in upper aerodigestive tract
Micro: basaloid cells associated with dysplastic or neoplastic squamous cells
References: AJCP 1995;104:594
Case report in 59 year old woman with obstructive tumor and asthmatic symptoms, Archives 1985;109:926
Case report of aggressive lesion in 15 year old white girl, AJCP 1978;70:429
Case report at Archives 1987;111:1065
No metastases reported to date, but may recur
Gross: tumors invade to or between plates of cartilage
Micro: proliferating fibroblasts with moderate nuclear pleomorphism, low mitotic activity
References: Hum Path 1989;20:180
Case report of patient with upper airway obstruction, AJSP 1992;16:71
Micro: diffuse infiltrate of small lymphocytes with centrocyte-like features surrounding reactive follicles; plasmacytoid cells and lymphoepithelial lesions present
Positive stains: light chain restriction
Negative stains: CD5, CD10
Case report of oncocytic tumor in 78 year old woman, Archives 1999;123:635
Micro: low grade lesion with primarily oncocytic cells in nests containing dense eosinophilic secretions; oncocytes had abundant granular eosinophilic cytoplasm, central nuclei, small prominent nucleoli; foci of squamous differentiation without atypia in desmoplastic stroma; prominent vascular component; no marked atypia, no necrosis, no mitotic activity, no angiolymphatic invasion
Positive stains: keratin (entire tumor), PTAH and antimitochondrial antibody in oncocytes
Negative stains: neuroendocrine markers, Congo red
DD: carcinoid tumor
Similar to laryngeal lesions
Cases associated with laryngeal lesions have low incidence of malignant transformation
Cases limited to trachea and bronchi usually begin in adults, and have higher incidence of malignant transformation
Case history of 27 year old man with tracheal resection and laryngectomy for invasive tumor extending between cartilages into adjacent soft tissue, AJSP 1980;4:79
Micro: invasive tumor had intracystic papillary structures, epithelium consisted of benign squamous, intermediate and ciliated cells
Case report in 65 year old man with intratracheal polypoid mass, Hum Path 1980;11(5 Suppl):572
Small cell carcinoma
Similar to bronchial tumor
Case report, Archives 1984;108:149
DD: extension from bronchial tumor
Most common primary malignancy of trachea
Usually arises in lower third of trachea
Rapid clinical course, poor prognosis
Treatment: surgical excision with end-to-end anastomosis, radiation therapy
DD: extension of esophageal tumor (Archives 1984;108:983)
End of Trachea Outline