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Ann Thorac Surg 1997;64:1429-1432
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Surgical Management of Tracheal Tumors

Department of Thoracic Surgery, Tel Aviv University Sackler School of Medicine, Tel Aviv, and E. Wolfson Medical Center, Holon, Israel

Accepted for publication April 7, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Resection of tracheal tumors is particularly challenging when the neoplasm involves the carina or is located in close proximity. We reviewed our experience with 22 tracheal resections for tumor.

Methods. In this retrospective review, adenoid cystic carcinoma was diagnosed in 13 patients, squamous cell carcinoma in 5, typical carcinoid in 2, and leiomyoma and benign fibrous histiocytoma, in 1 each. There were 19 segmental resections with direct anastomosis, and 3 complex resections in which the carina was involved.

Results. One patient with tumor in the trachea and left main bronchus underwent resection through simultaneous bilateral thoracotomy and died. During 2 to 17 years of follow-up, 2 patients died of unrelated disease, 2 died of metastases, and 1 is receiving radiotherapy for recurrence. Sixteen patients are well and free of tumor.

Conclusions. Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively with preservation of lung parenchyma. Options for treatment of neoplasms involving trachea and left bronchus should include resection of the neoplasm in two stages, thus minimizing trauma of each operation.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
See also page 1432.

Management of tumors of the trachea and carina depend in a large measure on their location and extent. This series summarizes our experience based on 22 resections of primary neoplasms of the upper tracheobronchial tree.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Between 1975 and 1994, 22 patients with primary neoplasms of the proximal tracheobronchial tree were treated by resection. There were 13 men and 9 women, ranging in age from 26 to 76 years.

The trachea was involved in all instances. The neoplasm extended into the left bronchus in one patient and invaded the carina and the right bronchus in one. In one patient the tumor arose from the right tracheal wall between the origin of an anomalous tracheal bronchus and the right main bronchus.

Symptoms and signs of airway obstruction were present in 15 patients, hemoptysis in 5, cough in 4, hoarseness in 4, sore throat in 1, and dysphagia in 1.

In preoperative evaluation, chest roentgenograms and pulmonary function tests were routine. Until 1980 we used linear tomography, which was performed in 7 patients. As of 1981, computed tomography became available, and was used in the remaining 15 patients. Contrast tracheobronchography with propyliodone (Dionosil, Glaxo, UK) was performed in 8 patients. All patients had bronchoscopy and biopsy, with histologic diagnosis of adenoid cystic carcinoma in 13 patients, squamous cell carcinoma in 5, typical carcinoid (KCC-I) in 2, leiomyoma in 1, and benign fibrous histiocytoma in 1.

All patients were treated by resection. Microscopic examination of all resected specimens by frozen-tissue section confirmed that all resections were complete.

A tracheal segment from 2 cm to 5 cm in length was resected, with primary end-to-end anastomosis in 19 operations. One of these, a 29-year-old woman who was 32-weeks pregnant, was hospitalized because of adenoid cystic carcinoma of the trachea, causing dyspnea. Our suggestion that resection should be preceded by induction of labor with the trachea intubated was rejected by the obstetrician in charge. Resection of the tracheal segment with the tumor was followed by delivery 2 hours later. One patient underwent right sleeve pneumonectomy. Two other patients will be described in detail.

After resection, 10 of the patients with adenoid cystic carcinoma and all 5 patients with squamous cell carcinoma received a course of radiotherapy.

Patient 1
A 39-year-old man complained of cough with expectoration of bloodstained sputum for 6 months and was treated by his family physician with antibiotics. The chest roentgenogram appeared normal. At bronchoscopy a smooth, round mass 1 cm in diameter was seen at the distal end of the trachea, arising from the right tracheal wall and obstructing the view of the right main bronchus. A right-sided anomalous tracheal bronchus originated just above the neoplasm. The carina and the left-sided bronchial tree appeared normal. Biopsy sample revealed KCC-I typical carcinoid. Contrast tracheography confirmed the bronchoscopic findings (Fig 1). At right posterolateral thoracotomy, the lower trachea, carina, and proximal right main bronchus were dissected, while carefully protecting the pulmonary artery. A wedge of the trachea between the anomalous right upper lobe bronchus and the origin of the right main bronchus was resected and the edges of the trachea were anastomosed (Fig 2). From the moment of sectioning the trachea, the anesthetist's tube was passed into the left bronchus for ventilation of the left lung. The postoperative course was uneventful. Seventeen years later the patient remains well.

View larger version (110K): [in this window] [in a new window]   Fig 1. . Tracheobronchogram of patient 1. The tumor grew from the right tracheal wall and nearly obstructed the flow of the contrast medium into the right bronchus. The anomalous bronchus supplies the right upper lobe.

View larger version (14K): [in this window] [in a new window]   Fig 2. . Schematic drawing of extent of resection and reconstruction in patient 1.

View larger version (94K): [in this window] [in a new window]   Fig 3. . Tracheobronchogram of patient 2. The tumor extends along the left main bronchus almost to its bifurcation. Trickling of contrast medium is barely allowed.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

Of the 5 patients with squamous cell carcinoma, 1 died after 7 years, 6 months of chronic renal failure without tumor recurrence, 1 is surviving 3 years 4 months with local recurrence and is receiving radiotherapy, and 3 patients are surviving from 5 years to 11 years without tumor recurrence. This last group included the patient with right sleeve pneumonectomy; at 11 years, he is the longest survivor in the squamous cell carcinoma group.

Both patients with carcinoid are living without recurrence 17 years and 8 years after resection, the patient with benign fibrous histocytoma survives 5 years without recurrence, and the patient with leiomyoma survives 2 years 4 months without recurrence. Thus, a total of 16 patients remain alive and free of tumor, with follow-up ranging from 2 years 4 months to 17 years after resection.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Delays in diagnosis of tracheal tumors occur commonly because the large lumen of the trachea prevents early occlusion. Belsey [1] determined that 75% of the tracheal lumen must be occluded before symptoms occur. In addition, nonspecific respiratory symptoms are easily confused with other pulmonary diseases. Several of our patients were treated by their family physicians for supposed infection or asthma, with delay of their clinical workup. Some of our patients were so managed for up to 6 months before their eventual referral to our center. At that time, bronchoscopy with biopsy resulted in prompt diagnosis without exception. This emphasizes the importance of early evaluation of every symptomatic patient.

In virtually all primary tracheal tumors, complete resection with primary reconstruction of the airways offers the best chance of cure. The basic techniques and approaches to tracheal operations have been determined mainly through the pioneering work of Grillo [2], Pearson and associates [3], and Perelman and Koroleva [4]. A transverse cervical incision is satisfactory for tumors restricted to the cervical trachea. A right posterolateral thoracotomy is excellent for lesions located in the lower half of the trachea, including the carina and proximal bronchi. The combination of a cervical incision with median sternotomy provides access to the entire length of the trachea. The extent of tracheal resection must be determined before the operation. In this respect, bronchoscopy and contrast tracheograms were invaluable in our experience. Contrast tracheograms are obsolete now and were replaced with magnetic resonance imaging and spiral computed tomography. These techniques were not available at the time of this study [5–7].

While dissecting the trachea, one must take utmost care to preserve tracheal circulation and avoid tension at the anastomosis [8]. In extensive resections, tension on the suture line must be avoided. This is often achieved by mobilization of the larynx [9, 10], and freeing the lung at the hilum by incising pleural and pericardial attachments of the hilar structures and division of the inferior pulmonary ligament [11–13]. In addition, we routinely maintain flexion of the neck postoperatively for 1 week by passing heavy silk suture through the chin and skin overlying the sternum. With this policy, we did not have any anastomotic complications.

According to Grillo and Mathisen [14], resection of malignant tumors should be followed by full-dose irradiation of the mediastinum. Pearson and associates [15] achieved good results by using preoperative irradiation intended at ablation of microscopic foci, which otherwise could remain after resection. In this series, preoperative irradiation was not used. All patients with squamous cell carcinoma and 10 of 13 patients with adenoid cystic carcinoma were irradiated postoperatively. Of the 3 patients who did not receive radiotherapy, 2 had development of metastases and died. It is evident that they should have been irradiated. Since then, it has been our routine to give a full course of radiotherapy after resection of malignant tumors.

For tracheal anastomosis, we currently use absorbable sutures of Polyglactin 910 (Vicryl; Ethicon, Somerville, NJ). Number 00 chromic was used in our early experience. Nonabsorbable sutures often cause granuloma and may have to be removed at bronchoscopy [8]. Under specific circumstances, considerable technical difficulties can be encountered because of local anatomic conditions. In one of our patients (patient 1) (see Figs 1, 2), the tumor arose from the right tracheal wall, between the anomalous tracheal bronchus supplying the right upper lobe and the origin of the right main bronchus. The operation could have been relatively easy, had we decided to sacrifice the right upper lobe and resect it together with a full circumference of the involved tracheal segment. The difficulty of resection was compounded by our decision to save the upper lobe, necessitating simultaneous protection of the anomalous bronchus and of the pulmonary artery, with constant retraction of the artery. Saving the upper lobe was achieved as a result of sectioning the trachea close to the neoplasm. Because this was a typical carcinoid, type KCC-I, this kind of conservative resection was justified [16]. The patient is well 17 years after the operation. More difficult to handle was the tumor that involved the lower trachea and the entire left main bronchus (patient 2) (see Fig 3). Curative operation required resection of the lower trachea with the carina and the left lung, and anastomosis of the right main-stem bronchus to the trachea. Right-sided thoracotomy would enable performance of tracheo–right bronchial anastomosis with relative ease, but at the same time would negate resection of the left lung. The same anastomosis through a left-sided approach (needed for left pneumonectomy) is rarely possible and then exceedingly difficult [17]. We have chosen simultaneous bilateral thoracotomy with ventilation of the transected right bronchus across the operative field. This enabled all technical requirements of the procedure, but imposed a great amount of trauma on the patient. In addition to the trauma of bilateral thoracotomy, the access to the carina with the patient in the supine position was cumbersome and required constant, sometimes forceful retraction of the right lung, eventually contributing to the adult respiratory distress syndrome and death.

Experience with this patient brings to mind other treatment options that could be used in this anatomic situation. The use of extracorporeal circulation would be helpful by obviating the need for ventilation of the right lung and rendering the anastomosis easier to perform [18]. However, anticoagulation necessary for the extracorporeal circulation would markedly increase the risk of hemorrhage from the manipulation of the lung. The same effect could be achieved without cardiopulmonary bypass by using the jet (Venturi) ventilation system. With this technique, the velocity of oxygen jet flow sucks ambient air into the bronchus [19]. El-Baz and associates [20] preferred high-frequency positive-pressure ventilation through a small endobronchial catheter. In our opinion, either the Venturi or high-frequency positive-pressure ventilation could be used, directing the flow into the left lung by placing a small-caliber catheter in the left bronchus alongside the tumor. The tracheo–right bronchial anastomosis could thus be performed without hindrance caused by the presence of a tube. Only after completion of the anastomosis would the left lung be resected.

As a final option, left pneumonectomy could be performed first, dividing the left main bronchus close to the carina, deliberately cutting through neoplastic tissue and closing the bronchial stump temporarily. After several days (1 week seems the optimal time), resection of the carina with the remaining neoplastic tissue (lower trachea and the left bronchial stump) would be performed through a right thoracotomy. The trauma of simultaneous bilateral thoracotomy would thus be divided into two operations, each one of a much lesser magnitude. We suggested this option as our choice at the Centenary Congress of the Polish Surgical Association in Krakow, Poland, on September 18, 1989. The idea was discussed, and a short time later, this method was used successfully in Poland (H. Olechnowicz, personal communication, 1990).

A special problem in timing the operation can arise occasionally, as exemplified by our pregnant patient. In retrospect, it is our conviction that we should have insisted on inducing labor first, and after delivery, operate on the trachea. At 32 weeks of gestation, the baby would not be endangered.

In summary, we reviewed retrospectively experience with resection of 22 tumors of the upper tracheobronchial tree. There were 19 segmental resections with direct anastomosis and 3 complex resections in which the carina was involved. Complete resection of all neoplastic tissue is mandatory, but benign and low-grade malignant tumors should be resected conservatively, with preservation of all salvable lung parenchyma. One patient with tumor extending from the trachea into and along the entire left bronchus underwent resection through simultaneous bilateral thoracotomy and died. In retrospect, we believe that a less traumatic resection in two stages could have resulted in cure.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Weissberg, Dept of Surgery, E. Wolfson Medical Center, Holon 58100, Israel.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dov Weissberg Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Refaely, Y. Articles by Weissberg, D. Search for Related Content PubMed PubMed Citation Articles by Refaely, Y. Articles by Weissberg, D. Related Collections Related Article