the trachea is an uncommon site of primary lung malignancy , then endobronchial origin of malignancy . the primary neoplasm of the trachea is only 2% of all malignancies and representing < 0.1% of cancer death . the tracheal lymphoma is again a very rare presentation , accounting < 3% of all tracheal tumors . endobronchial lymphoma is also a rare presentation , and more common is hodgkin 's lymphoma as compared to non - hodgkin 's lymphoma ( nhl ) . anaplastic large cell lymphoma accounts for 2% of nhl , and its endobronchial presentation is extremely rare . we present a series of two case reports of which one appeared to be endobronchial aspergilloma ( another rare entity ) initially on bronchoscopic biopsy but was proven to be endobronchial anaplastic large cell lymphoma ( ealcl ) on surgical excision and the second one was a case of myelodysplastic syndrome , came with shortness of breath , which was later diagnosed with a case of endotracheal b - cell lymphoma . a 24-year - old male , nonsmoker , presented with a 1-month history of shortness of breath , dry cough , and fever for 2 weeks . on examination , air entry was diminished on the right side of the chest , and breath sounds were absent in infrascapular area on the right side . the patient 's routine blood investigations were within normal limits , but his chest x - ray ( cxr ) showed the right lower lobe ( rll ) collapse and contrast - enhanced computed tomography ( cect ) of the thorax revealed a soft - tissue mass in the right main bronchus with partially opened upper lobe and intermediate bronchus with the collapse of a posterior basal segment of rll [ figure 1 ] . fiberoptic bronchoscopy revealed a yellowish glistening endobronchial mass in the right main bronchus almost totally occluding it [ figure 2 ] . as the cxr and computed tomography ( ct ) had shown only lower lobe collapse , the mass was presumed to be originating from one of the lower lobe segments . the mass could be made to move while taking multiple biopsies proving that it had a stalk . chest x - ray shows the right lower lobe collapse , and computed tomography section shows mass in right main bronchus fiberoptic bronchoscopy shows glistening mass in right main bronchus , and histopathology slide shows anaplastic large cell lymphoma histopathology revealed acute necrotizing inflammation due to aspergillus . in view of the large size of aspergillus mass , thoracotomy with right lower lobectomy and extraction of fungal mass from the right main bronchus was done . histopathology of the mass showed anaplastic large cell lymphoma in the stalk ( positive staining with lca , cd30 , and alk-1 ) [ figure 2 ] , and the head portion of the mass was again found to have aspergillus in necrotic material which was initially reported on bronchoscopic biopsy . a 65-year - old female , nonsmoker , presented with cough , breathlessness , and generalized weakness for 1 month . on examination , the patient was conscious , afebrile ; vitals were stable except oxygen saturation at room air was 91% . on chest auscultation , she was a known case of psoriasis and on ayurvedic medication for the previous 3 years of presenting here . the patient 's routine blood investigations were within normal limit except low hb ( 8.6 g% ) and low total leukocyte count ( 3400/cmm ) due to myelodysplasia . her cxr showed increased bronchovascular markings , but high - resolution computed tomography of the chest showed intratracheal growth and old calcified nodules with peribronchovascular distribution but no intrathoracic lymphadenopathy [ figure 3 ] . two - dimensional echocardiography revealed global hypokinesia with ejection fraction  30% and mild concentric left ventricular hypertrophy . her bronchoscopy showed a large rounded mass lesion just below the vocal cords on the posterior tracheal wall and two small masses on anterior aspect of the vocal cords [ figure 4 ] . furthermore , there were multiple small nodules seen on the mucosa of the trachea till carina . chest x - ray shows prominent bronchovascular marking , and computed tomography section shows growth in the upper trachea fiberoptic bronchoscopy shows multiple intraluminal growths in the upper part of trachea a biopsy was taken from a large mass lesion and histopathology confirmed the lymphoproliferative b - cell lymphoma ( nhl ) with the positivity of cd20 , cd3 , cd138 and limited ck positivity to surface epithelium . the patient was started on standard chemotherapy , and she was kept under close observation in hospital for a few days because of risk of complete tracheal obstruction by tumor mass . after a few weeks , her check bronchoscopy was done to evaluate the mass which revealed regression of the mass with patent trachea . a 24-year - old male , nonsmoker , presented with a 1-month history of shortness of breath , dry cough , and fever for 2 weeks . on examination , air entry was diminished on the right side of the chest , and breath sounds were absent in infrascapular area on the right side . the patient 's routine blood investigations were within normal limits , but his chest x - ray ( cxr ) showed the right lower lobe ( rll ) collapse and contrast - enhanced computed tomography ( cect ) of the thorax revealed a soft - tissue mass in the right main bronchus with partially opened upper lobe and intermediate bronchus with the collapse of a posterior basal segment of rll [ figure 1 ] . fiberoptic bronchoscopy revealed a yellowish glistening endobronchial mass in the right main bronchus almost totally occluding it [ figure 2 ] . as the cxr and computed tomography ( ct ) had shown only lower lobe collapse , the mass was presumed to be originating from one of the lower lobe segments . the mass could be made to move while taking multiple biopsies proving that it had a stalk . chest x - ray shows the right lower lobe collapse , and computed tomography section shows mass in right main bronchus fiberoptic bronchoscopy shows glistening mass in right main bronchus , and histopathology slide shows anaplastic large cell lymphoma histopathology revealed acute necrotizing inflammation due to aspergillus . in view of the large size of aspergillus mass , thoracotomy with right lower lobectomy and extraction of fungal mass from the right main bronchus was done . histopathology of the mass showed anaplastic large cell lymphoma in the stalk ( positive staining with lca , cd30 , and alk-1 ) [ figure 2 ] , and the head portion of the mass was again found to have aspergillus in necrotic material which was initially reported on bronchoscopic biopsy . a 65-year - old female , nonsmoker , presented with cough , breathlessness , and generalized weakness for 1 month . on examination , the patient was conscious , afebrile ; vitals were stable except oxygen saturation at room air was 91% . on chest auscultation , she was a known case of psoriasis and on ayurvedic medication for the previous 3 years of presenting here . the patient 's routine blood investigations were within normal limit except low hb ( 8.6 g% ) and low total leukocyte count ( 3400/cmm ) due to myelodysplasia . her cxr showed increased bronchovascular markings , but high - resolution computed tomography of the chest showed intratracheal growth and old calcified nodules with peribronchovascular distribution but no intrathoracic lymphadenopathy [ figure 3 ] . two - dimensional echocardiography revealed global hypokinesia with ejection fraction  30% and mild concentric left ventricular hypertrophy . her bronchoscopy showed a large rounded mass lesion just below the vocal cords on the posterior tracheal wall and two small masses on anterior aspect of the vocal cords [ figure 4 ] . furthermore , there were multiple small nodules seen on the mucosa of the trachea till carina . chest x - ray shows prominent bronchovascular marking , and computed tomography section shows growth in the upper trachea fiberoptic bronchoscopy shows multiple intraluminal growths in the upper part of trachea a biopsy was taken from a large mass lesion and histopathology confirmed the lymphoproliferative b - cell lymphoma ( nhl ) with the positivity of cd20 , cd3 , cd138 and limited ck positivity to surface epithelium . the patient was started on standard chemotherapy , and she was kept under close observation in hospital for a few days because of risk of complete tracheal obstruction by tumor mass . after a few weeks , her check bronchoscopy was done to evaluate the mass which revealed regression of the mass with patent trachea . the majorities of tracheal tumors are malignant and mostly are metastases from other sites such as lung , thyroid , esophagus , or larynx . the primary tracheal tumor is uncommon , and lymphoma of tracheal or endobronchial origin is a rare instance . the nhl of tracheobronchial tree is less common than hodgkin 's lymphoma . primary tracheal nhl accounts for only 0.23% of all tracheal tumors . the most comprehensive review of the literature identified only 28 primary tracheal lymphomas from 1973 to 2000 . extranodal lymphoma itself is not uncommon , but patients with extranodal lymphoma only have a 3.6% rate of tracheobronchial involvement . the first case of endobronchial nhl was described in 1955 by dawe et al . in an autopsy study of 55 patients of nhl , none of the cases showed endobronchial lymphoma . in another autopsy study , only one patient had endobronchial lesion out of 93 patients with pulmonary lymphoma . our both patients found to have nhl which is less common than hodgkin 's lymphoma , and one patient has anaplastic large cell type of hodgkin 's lymphoma which is again rare . the median age of patients with primary tracheal lymphoma is 44 years , with a range of 481 years . the clinical presentations of primary tumors of the trachea are usually insidious in onset , with signs and symptoms of upper airway obstruction . in a series of 329 patients with primary tracheal malignancies , dyspnea was the most frequent symptom ( 71% ) followed by cough ( 40% ) , hemoptysis ( 34% ) , asthma ( 19.5% ) , and stridor ( 17.5% ) . although hemoptysis is uncommon in tracheal lymphoma because of its submucosal involvement of the tracheal wall , blood - tinged sputum can occur in endobronchial lymphoma . the less common symptoms are hoarseness of voice and dysphagia , due to involvement of adjacent structures , but rarely , the patient can also present with acute respiratory distress due to compromised airways . retention of secretions may lead to symptoms of persistent cough , wheezing , or stridor . the plain cxr sometimes appears normal , and the diagnosis is usually delayed or misinterpreted as asthma . the diagnosis may also be delayed in adults because of the large functional reserve of the tracheal lumen , which often requires at least 5075% occlusion before symptoms present . the ct scan of the chest is the most useful method to assess tracheal or endobronchial tumors radiologically because it allows assessment of tumor extent and relationship to adjacent structures . ct scan can also demonstrate coexisting mediastinal or hilar lymphadenopathy though in our both cases ct of the chest did not reveal any mediastinal or hilar lymphadenopathy . the treatment of tracheal lymphoma includes chemotherapy , radiotherapy , or surgery alone or in combination . radiotherapy alone is a standard treatment for stage i to ii gastric and nongastric mucosa - associated lymphoid tissue lymphomas . in patients with symptomatic tracheal stenosis , temporary stenting followed by chemotherapy , radiotherapy , or both has been suggested . the treatment of choice for endobronchial lymphoma is chemotherapy though our patient was undergoing surgical removal of the mass due to its large size and initial diagnosis of endobronchial aspergilloma . ealcl requires surgical treatment only when they cause respiratory embarrassment due to obstruction , and it is mainly stenting or laser removal through the rigid bronchoscope . our case represents a rare ealcl whose head was covered with aspergillus probably from inhaled environmental exposure . the treatment and prognosis of tracheobronchial lymphoma depend on the histopathologic subtype and extent of tumor in surrounding tissues . the overall outcome of tracheobronchial lymphoma is favorable though patients with tracheal cancers had a poorer prognosis compared with lung cancer . we conclude that lymphoma of tracheobronchial tree is a rare tumor and non - hodgkin 's type of lymphoma is a very rare presentation . patients of tracheal lymphoma are more symptomatic and have acute presentation because of compromised conduit access to the lungs . diagnosis was confirmed by biopsy and histopathologic examination and had a favorable response to chemotherapy and/or surgery .
the tracheobronchial origin of non - hodgkin 's lymphoma ( nhl ) is a very rare presentation , and there are only a few case reports of primary tracheal or endobronchial nhl . 
 we have two cases of primary tracheobronchial nhl ; one case was incidentally diagnosed as anaplastic large cell lymphoma of endobronchial origin when a comprehensive workup and surgery were carried out for an endobronchial aspergilloma which was actually sitting on top of lymphoma . 
 the second patient was a case of myelodysplastic syndrome who presented with acute respiratory distress ; on thorough workup , he was found to have endotracheal b - cell lymphoma . 
 both cases were responding well with standard chemotherapy . 
 the mortality in these kinds of patients is due to disease progression or airway compromise and treatment complications .