When Airway Tells a Tale through the Bronchoscopic Lens Revealing Tracheobronchopathia Osteochondroplastica
Document Type
Conference Proceeding
Publication Date
2025
Publication Title
American Journal of Respiratory and Critical Care Medicine
Abstract
Introduction:TracheobronchopathiaOsteochondroplastica(TPO) is an uncommon airway condition characterized by submucosal cartilaginous and osseous nodules projecting into the tracheobronchial tree. Despite its first description in the 19th century, the rarity of this clinical entity often leads to the underreporting on radiographic imaging. We present a case of TPO discovered incidentally during the endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for cancer staging.
Case Description: A 63-year-old woman with nephrotic syndrome status-post renal transplant on cyclosporine and oxygen-dependent severe COPD (GOLD class E) presented with acute dyspnea. Non-contrasted computed tomography (CT) chest revealed a 2.5 cm RUL nodular opacity, multiple solid nodules, and extensive mediastinal lymphadenopathy. Due to AKI (creatinine of 2.91 mg/dL), a lung perfusion scan was performed instead of contrast CT suggestive of pulmonary embolism. Following anticoagulation and clinical stabilization, a video bronchoscopy was performed, revealing the characteristic TPO findings of submucosal cartilaginous nodules with "cobblestone" appearance in the trachea and bilateral bronchi, sparing the posterior tracheal wall. Further, the EBUS-TBNA of station 2R paratracheal mass confirmed a poorly differentiated non-small cell carcinoma. Subsequent staging revealed extensive brain and liver metastases. The patient opted for hospice care and subsequently passed away.
Discussion: This case highlights several important aspects of TPO: (1) the diagnostic advantage of the bronchoscopic visualization over radiographic imaging, and (2) its occurrence in the setting of multiple comorbidities- malignancy, chronic obstructive airway disease and immunosuppression- raising questions about its potential correlation. The existing literature suggests links between TPO and increased bone morphogenetic protein-2 (BMP-2) expression playing a crucial role in its pathogenesis. However, it remains uncertain whether the presence of TPO in chronic inflammatory states is coincidental or indicative of an interplay between molecular interactions during a chronic inflammatory state causing the upper airway architectural distortions. A routine biopsy of TPO lesions poses technical challenges related to nodules hardness and is generally not recommended. However forgoing the biopsy may lead to missed diagnosis of coexisting conditions, such as tracheobronchial amyloidosis (TPA) and metastatic occult malignancies. This case highlights the importance of bronchoscopic evaluation in detecting TPO, often overlooked in radiographic assessments; and it adds to the limited literature describing TPO in immunocompromised individuals with concurrent malignancy. Systematic documentation of such cases is crucial for advancing our understanding of TPO and the future development of the evidence-based guidelines for its management.
Volume
211
First Page
A4855
Recommended Citation
Smith Z, Faizee F, Alnabulsi Z, Heal K, Kaplan PV. When airway tells a tale through the bronchoscopic lens revealing tracheobronchopathia osteochondroplastica. Am J Respir Crit Care Med. 2025;211: A4855. doi: 10.1164/ajrccm.2025.211.Abstracts.A4855
DOI
10.1164/ajrccm.2025.211.Abstracts.A4855
Comments
The American Thoracic Society (ATS) International Conference, May 16-21, 2025, San Francisco, CA.