SQUAMOUS CELL CARCINOMA OF THE TRACHEA
PAUL J. BRESLICH 1
(From Thc Henry Baird FaviU Lcrborafoty and Medieat S m i a "A" of St. Luke's
Hospital, Chimgo, ZUinoie)
An examination of the literature dealing with carcinoma of
the trachea discloses that this condition ie frequently not
diagnosed during life and that the trachea is rarely the site of a
primary carcinoma. Bilz (1)) tabulated the results of 700
postmortem examinations i.n the Pathological Institute of the
University of Jena of patients with carcinoma, but did not find a
carcinoma of the trachea. Fraenkel (2) discovered seven in
5,063 examinations made at the Pathological Institute of the
University of Hamburg. Broman (3) in 1924 collected 57
reports of carcinoma of the trachea and added a detailed description of one found by H. G. Wells among 545 malignant growths
examined at the Cook County Hospital and University of
Chicago. Many of these reports are rather incomplete because
they were based upon tisauea removed surgically, and only about
three-fourths of the papers listed in Broman's account include a
complete statement of the symptoms, physical findings, and
results of a postmortem examination.
Carcinomas of the trachea are found almost twice as frequently
in men as in women and most of them occur within the age
limits of 30 to 70 years. Usually the tumor arises in the lower
third of the membranous portion of the trachea jut above the
bifurcation, but it sometimes begins in the upper third. Carcinomas in the middle third and cartilaginous portion of the
trachea are uncommon. The tumors are well localized, and
very rarely encircle the lumen, and do not extend widely into the
lining of the trachea. The projection of the growth into the
lumen sometimes results in considerable obstruction. In most
patients treated surgically for carcinoma of the trachea me1
The John Jay Borland Fellow in Medioine.
144
tastases were not noted at the time of operation and many of the
postmortem reports state that metastases were not found.
When metastases occur they are usually in the peritracheal,
cervical, and tracheobronchial lymph nodes. The tissues in
which they are less often found are, in the order of frequency,
the lungs, liver, supra-clavicular and axillary lymph nodes, and
the esophagus. They are also known to occur in the spleen,
pancreas, kidney, and skeleton. Because of their location in
the membranous portion of the trachea, the carcinomas occaaionally grow posteriorly and bulge into the esophagus. The lining
of the esophagus, however, is rarely ulcerated. Tumor metastases occur in the large lymph channels which drain the trachea.
Here they may injure the recurrent laryngeal nerves which lie
close by and cause paralysis of the vocal cords.
Histologically a large number of the tracheal carcinomas consist of cylindrical, glandular, or basal cells. Squamous cell
carcinomas are rare. hlany of the tumors have been diagnosed
medullary carcinomas, but the microscopic description of these
has been so brief that a more exact classification of the new
growth is not possible.
The symptoms of carcinoma of the trachea are usually similar
to those of chronic tracheal obstruction. Commonly there are
attacks of dyspnoea resembling asthma, and hoarseness. When
the attacks are sevel'e there may be marked cyanosis, and death
results from suffocation. The dyspnoea is independent of
physical exertion and is of the expiratory type. Most patients
have a chronic cough with an abundant bronchial secretion,
occasionally stained with blood. Cachexia and marked loss of
weight are not often noted, probably because the duration of the
disease is short. Most of the patients examined postmortem
have died within a year of the onset of the symptoms.
The clinical diagnosis of carcinoma of the trachea usually is
not made until the tumor is seen by tracheoscopy. The vocal
cords may be paralyzed, and when metastases occur the cervical
lymph nodes are enlarged. In one instance reported by Simmel
(4) the most marked complaint was dysphagia. In this patient
the carcinoma metastases in the esophagus were seen in the
10
146
PAUL J. BRESLICH
esophagoscopic examination. There are no constant physical
findings in the chest or lungs. I n the patient reported by
Broman an X-ray examination of the thorax disclosed a tumor
of the mediastinum.
G. S., a white man, aged 60 years, was admitted to the medical
service of Dr. N. C. Gilbert at St. Luke's Hospital on July 8,
1928. For two days he had complained of great difficulty in
breathing. He had never had any serious illnesses, but six
months before his admission to the hospital he began to have
attacks of " asthma " occurring with increasing frequency, usually
a t night. He had a persistent productive cough, was hortrse,
and barely able to speak louder than in whispers. He also
complained of pain in the upper part of the chest on both sides.
On physical examination the chest expansion was normal but
there was some dullness on percussion over the right upper lobe
of the lung. The tactile fremitus was everywhere decreased
FIG.1. SECTION
OF CARCINOMA
OF
THY
TRACHEA
( X 135).
and the breath sounds were harsh. Expiration required greater
effort than inspiration. Otherwise the physical examination
disclosed nothing unusual. Because of the severe dyspnoea it
was thought that there might be a foreign body in the trachea
and an X-ray examination of the chest was ma& by Dr. E. L.
Jenkinson. There was a bilateral emphysema of the lungs with
a few dilated bronchioles in both lower lobes, but the trachea was
considered normal. Attempts to relieve the severe dyspnoea by
ephedrine, atropine, and morphine were unsuccessful. The
patient rapidly lost strength and died on July 10, 1928.
The postmortem examination (Edwin F. Hirsch) was started
shortly after death. The essential findings were: Primary
carcinoma of the lining of the trachea with almost complete
occlusion of the lumen; metastatic carcinoma of the mucosa of
the esophagus; carcinoma invasion, displacement, and compression of the esophagus; acute vesicular emphysema of the.lungs ;
chronic muco-purulent tracheitis and bronchitis; etc.
The body of this man was 168 crns. long and weighed 117
pounds. When the sternum was removed and the chest opened
much of the right pleural space was obliterated by fibrous adhesions. The lungs were voluminous, markedly distended with
air, and with the thorax open the anterior margins overlapped.
The left lung weighed 260 grams, and the right 360 grams. The
surfaces made by cutting the lungs were gray-pink tissue mottled
ten per cent with regions of carbon pigment and covered with a
scanty pink frothy fluid. ,4 purulent exudate was expressed
from the bronchi of the lower lobe of the right lung. The lungs
were crepitant and there were no regions of consolidation. I n
eviscerating the chest a tumor mass in the posterior portion of
the trachea a t the level of the clavicles was divided. Further
examination demonstrated an oval mass of friable, gray-pink,
granular tissue projecting from the left side of the posterior
wall of the trachea. It began 2 crns. above the bifurcation and
extended upward 3.5 cms. Its width was 2 cms. and it projected about 1 cm. into the lumen, which was narrowed to a slit
a few millimeters wide and 1 cm. long. The surface of the tumor
was nodular and ulcerated. Both main bronchi were filled with
a purulent yellow secretion, but their lining was in normal pinkgray longitudinal folds. Excepting in the region of the tumor
the lining of the trachea was gray and smooth. The lymph
148
PAUL J. BRESLICH
nodes at the bifurcation of the trachea were small and markedly
pigmented with carbon. The peritracheal and deep cervical
lymph nodes were not enlarged. The tumor mass extended
backward and upward to the prevertebral fascia, displacing the
esophagus 2 crns. to the left of the trachea. N7hen the esophagus
was opened from behind, the mass bulged into the lumen in a
region 3 crns. long and 2 crns. wide. The mucosa over it was
gray and smooth. Three centimeters below this was a nodule in
the mucosa 2.5 crns. in diameter and 1.5 crns. thick. The surface of the mucosa here also was unbroken and smooth. There
were no other changes of the lining of the esophagus and no
ulceration of the lining of the larynx or of the tissues a t the base
of the tongue. The surfaces made by cutting the tumor mass
and the nodule in the lining of the esophagus were firm, opaque,
white tissue marked with yellow in narrow lines. The tracheal
cartilages on the left side behind were buried in the tumor mass
and were unchanged. There were no metastases in any of the
other tissues of the trunk and abdomen.
Sections for microscopic examination were prepared by the
paraffin method. They were stained with henlatoxylin and
eosin and phosphotungstic acid-hematoxylin. In the tissues of
the tumor mass in the trachea was a dense fibrous stroma which
supported solid branching cords and masses of epithelial cells.
The cells along the outer margin of the cords were cuboidal or
columnar with a moderate amount of finely granular cytoplasm
and round or oval vesicular nuclei containing coarse chromatin
granules. Centrally in the epithelial masses the cells were
spindle-shaped and arranged in a mosaic. These had a light
blue or faintly pink cytoplasm with oval nuclei. There were
also large spindle cells with clear or foamy pink cytoplasm and
small faint irregular nuclei arranged in concentric layers suggesting epithelial pearls. The fibrous tissue strolna was markedly
infiltrated with plasma cells, lymphocytes, eosinophil leucocytes,
and contained many thin-walled capillaries. The tracheal
surface of the tumor was covered by a stratified squamous
epithelium, the outer layer of which consisted of long flat cells
with pink cytoplasm and thin elongated black nuclei. A few
crypts in the tumor extending inward from the tracheal surface
were lined by colunmar ciliated epithelium which became lower
a t the mouths of the crypts and was continuous with the surface
stratified squamous epithelium.
Where the tumor bulged into the esophagus it was covered by
regular stratified squamous epithelium, unbroken except in one
place less than 1mm. in diameter. The muscularis of the esophagus was invaded by tumor tissue and at the edge of the carcinoma mass it merged with the indefinite fibrous capsule which
enclosed the tumor. There was some ossification of the tracheal
cartilages and the tumor tissue had invaded and partially destroyed them. The nodule in the esophagus consisted of tissue
like that in the main tumor mass. The lining of the trachea was
transitional columnar ciliated epithelium. There was a chronic
inflammation of the submucosa but no other noteworthy change.
In several sections of tracheobronchial lymph nodes there were
no changes excepting a marked carbon pigmentation.
Squamous cell carcinomas of the trachea were thought by
Reiche ( 5 ) , Nager (G), and ~ a l a n dand RScFarland (7) to have
their origin in rests of embryonic esophageal epithelium included
in the tissues of the trachea at the time i t separated from the
ventral portion of the esophagus. However, Krompecher (8),
who studied the basal and squamous cell carcinomas which occur
in structures lined by columnar epithelium, believed that these
tumors originate from proliferations of the basal cells. According t o him these undifferentiated cells are morphologically
similar to the basal cells of stratified epithelium and are distributed irregularly on the basement membrane of the mucosa between the cylindrical cells. Normally they divide and differentiate into columnar epithelium to replace the lining cells which
are injured or desquamated, but under certain conditions they
may differentiate into transitional or stratified squamous epithelium, or give rise to basal or squamous cell carcinomas.
Krompecher's views are supported by several others. Thus in
the tracheas of rabbits with acute inflammations, Kawamura (9)
observed a metaplasia of columnar ciliated to transitional
epithelium. Goldzieher (10) noted that considerable portions
150
PAUL J. BRESLICH
of the bronchi of a patient who had died of diphtheria were lined
by a wide layer of basal epithelium which in some places was
covered with cylindrical cells and in other places with squamous
epithelium. In his opinion these unusual changes resulted from a
further differentiation of the proliferated basal cells into cylindrical or squamous epithelium. Teutschlaender (1 1) observed
that the bronchi of certain rats after bronchopneumonia were
lined by transitional or stratified squamous, or even hornified
squamous epithelium, and traced the development of these
changes step by step from a hyperplasia of the basal cells. The
three squamous cell carcinomas of the lung described by Siegmund (12) developed in bronchiectatic cavities. The singlelayered cylindrical epithelial lining of the dilated bronchi was
transformed into a many-layered basal cell or transitional epithelium from which he thought the tumors originated. Finally,
in the basal cell carcinoma of the trachea reported by hfeyenburg (13) there were regions of stratified squamous epithelium
and also places consisting of columnar and columnar ciliated
cells. He thought that probably this tumor originated in the
basal cells which in some places had differentiated further to
columnar or to stratified squamous epithelium. Hart and
Mayer (14) accept Krompecher's explanation of the origin of
squamous cell carcinonin in the trachea. However, these authors
state that these malignant growths may also arise in the epithelium of tracheoesophageal fistulae and in isolated nests or
cysts of squamous epithelium.
Carcinoma of the trachea occurs so rarely that it is frequently
not considered in a patient who has symptoms of obstruction of
the larger air passages. The tumor described in my report was
demonstrated by the postmortem examination as were many
other trache:~lcarcinomas reported in the literature. It was a
squamous cell carcinoma of which there are about seven in the
57 instances of carcinoma of the trachea reviewed by Broman.
SUMMARY
In a patient. with symptoms of marked obstruction of the
large nir passages, a carcinoma of the trachea was demonst.rated
by the postmortem examination. Histologically the tumor was
a squamoue cell tumor.
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3. BROMAN,
J. R.: Primary carcinoma of the trachea with report of a case nnd review
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