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A middle-aged Chinese woman presented to the emergency department with stridor and acute type 2 respiratory failure. She had previously declined surgery for a multinodular goiter diagnosed on ultrasound. Flexible nasoendoscopy showed normal vocal cords and lateral tracheal bulge, presumably from extrinsic compression by the goiter. She was intubated (Figure 1) and underwent emergent total thyroidectomy to relieve the upper airway obstruction. Intraoperatively, a tumor with features of follicular dendritic cell sarcoma (FDCS) was found, displacing the thyroid and extending retrosternally (Figures 2A-2E). Postoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography revealed positron emission tomography-avid mediastinal lymph nodes (Figure 3), and the patient was referred for evaluation. Bronchoscopy incidentally showed a polypoidal tracheal tumor 4 cm below the vocal cords, causing 40% obstruction, which was resected with an electrosurgical snare. Tracheal biopsy revealed metastatic FDCS (Figures 4A-4C). Despite chemoradiotherapy, the patient presented 8 months later with near-total airway obstruction...