Ann Thorac Surg 2001;71:366-368
© 2001 The Society of Thoracic Surgeons
Case report
Successful treatment of mucoepidermoid carcinoma of the carina
Fengshi Chen, MDa,
Akitoshi Tatsumi, MDa,
Yoshihiro Miyamoto, MDb
a Department of General Thoracic Surgery, Kochi Municipal Hospital, Kochi, Japan
b Department of General Thoracic Surgery, National Himeji Hospital, Hyogo, Japan
Accepted for publication March 15, 2000.
Address reprint requests to Dr Chen, Department of General Thoracic and Cardiovascular Surgery, Shizuoka City Hospital, 10-93, Outemachi, Shizuoka 420-8630, Japan
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Abstract
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We successfully treated a 33-year-old man with mucoepidermoid carcinoma at the carina. Through preoperative spiral computed tomography with multiplanar and three-dimensional reconstructions, the lesion extended along the right main bronchus across the orifice of the right upper lobe. He underwent a carinal resection plus right upper lobectomy and reconstruction of the carina. He shows neither anastomotic complication nor recurrence of disease 1 year after surgery. Spiral computed tomography was used to evaluate the preoperative and postoperative state of the central airway.
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Introduction
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Mucoepidermoid lung tumors are uncommon, representing 0.2% of all lung tumors and 1% to 5% of bronchial adenomas. They can be divided into low grade and high grade on the basis of histological criteria. The most important factors in the prognosis include histological grading and the ability to achieve a complete surgical resection [1].
A 33-year-old man, who had a history of asthma-like attacks after hard physical exercise for about 1 year, presented with hemoptysis in December 1998. Routine laboratory studies including pulmonary function tests were normal. A chest radiograph was initially interpreted as normal, but in retrospect it showed a mass at the carina. A flexible bronchoscopy demonstrated a broad-based, sessile, large polyp at the carina, protruding into the lumen of the right main bronchus. Through a transbronchial biopsy, the tumor was found to be a mucoepidermoid carcinoma of low grade. Computed tomography (CT) revealed a 4 x 3 x 3 cm circular mass at the carina, which extended along the right main bronchus. There was no mediastinal lymphadenopathy or obvious findings of bronchial invasion. Spiral CT with multiplanar and three-dimensional reconstructions predicted the tumor extended just across the orifice of the right upper lobe (Fig 1). After further workup, there was no evidence of any metastatic lesion.
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Fig 1. Spiral computed tomography (CT) with three-dimensional reconstructions showed that the tumor extended just across the orifice of the right upper lobe. (LMB = left main bronchus; RUB = right upper lobe bronchus.)
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The patient eventually underwent a carinal resection plus right upper lobectomy, followed by a reconstruction of the carina. Through a right thoracotomy, the azygous vein was transected and a paratracheal and subcarinal lymph node dissection was performed. After vessels of the right upper lobe were sutured and transected, the left main bronchus was transected three rings below the carina. The left main bronchus was intubated across the operative field with a sterile endotracheal tube to maintain ventilation. The trachea was transected three rings above the carina. The bronchus intermedius was transected below the take off of the upper lobe bronchus. The carina, including the tumor and the right upper lobe, was extirpated with adequate margins. The trachea and left main bronchus were anastomosed primarily. Three-fourths of the anastomosis was accomplished, and one-fourth remained to be done. The right pulmonary ligament was divided, and a U-shaped incision was made in the pericardium beneath the inferior pulmonary vein for the mobilization. The remaining tracheal opening was trimmed so that it might be a proper stoma for the secondary end-to-side anastomosis. The bronchus intermedius was reimplanted into the tracheal opening. Simple interrupted anastomotic sutures of absorbable material were placed. The fifth intercostal muscle was used to wrap the anastomotic site. Carinal reconstruction was accomplished in this way (Fig 2).
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Fig 2. The schema of carinal resection and reconstruction. The left main bronchus, the trachea, and the bronchus intermedius were transected at the black lines. One-fourth of the primary end-to-end anastomosis remained to be done, and the remaining lumen was trimmed so that it might be a proper stoma for the secondary end-to-side anastomosis. The bronchus intermedius was reimplanted into the stoma.
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Pathological examination showed the tumor did not invade beyond the cartilage plates. There was no lymph node involvement. His postoperative course was free from complications, and he returned to work within 1 month after surgery. He remains free of tumor and anastomotic complications except some narrowing at the end-to-side anastomosis on follow-up bronchoscopy and spiral CT at 6 months (Fig 3). He shows no symptoms 1 year after surgery.
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Fig 3. Follow-up spiral computed tomography (CT) with three-dimensional reconstructions showed no critical anastomotic stenosis.
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Comment
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Mucoepidermoid lung tumors are rare tumors that arise from bronchial glands. Whether they are malignant or benign has been argued since they were first described in 1952 [2, 3]. Heitmiller and colleagues [1] demonstrated they can be divided into low grade and high grade on the basis of histological criteria. Prognosis is mostly dependent on histological grading and the ability to achieve a complete surgical resection. Surgical resection is recommended unless there is distant metastasis or clearly unresectable margins. Conservative lung-sparing procedures, especially bronchoplastic techniques, are needed for lesions in central locations. In this sense, the present case was suitable for surgical treatment. If disease processes at the carina also involve lobar orifices, like the present case, resection can be accomplished, including contiguous resection of the affected lobe, to prevent both positive resection margins and anastomotic complications.
Mucoepidermoid lung tumors generally produce symptoms of upper airway irritation such as coughing, hemoptysis, wheezing, or postobstructive pneumonia. Younger patients are often felt to be asthmatic, as in the present case, and are followed up with or without medical therapy. In these cases, it is only when symptoms persist despite medical therapy that further workup discloses a tumor in the upper airway.
Techniques for carinal resection and reconstruction still remain a tremendous challenge for surgeons. The potential for morbidity and mortality is still high. Techniques to prevent anastomotic complications are to reduce tension and preserve blood supply. Mitchell and coworkers [4] reported that patients undergoing carinal plus lobar resection had a rate of anastomotic morbidity as high as carinal pneumonectomy. This was due to problems at the end-to-side secondary anastomosis. If reimplantation is performed, they suggest that either the bronchus intermedius or right lower lobe bronchus should be placed into the side of the left main bronchus and not into the trachea.
We tried another carinoplasty procedure, which was proposed by Miyamoto [5], as shown on Figure 2. This technique might alleviate tension at both the first and second anastomotic sites. In this option, there is no need to suture the right side of the end-to-end anastomosis, where the greatest tension is located. In addition, there is no need to make a new stoma in the tracheal or bronchial wall; this may better preserve the blood supply to the anastomotic sites. In selected cases, such as a case which needs a long resection of the carina, this procedure may be useful. In the present case, we needed a long resection of the carina including a resection of the right upper lobe due to the tumor extension. If we found it impossible to do this procedure at the second anastomosis even after the mobilization of the hilum, we planned to complete the closure of the one-fourth remaining tracheal anastomosis and to reimplant the bronchus intermidius to a new stoma in the left main bronchus.
Improvements in technology now allow CT scanning to provide various images for airway visualization. As far as diseases involving central airways, the transverse extent of disease and relationship to adjacent structures are better shown on usual transverse CT sections, but the longitudinal extent of the tumor is better demonstrated on the multiplanar reconstruction and three-dimensional images [6]. In the present case, preoperative spiral CT accurately predicted the extent of the tumor; in contrast, bronchoscopic observation could not evaluate the state of the airway distal to the tumor, especially at the right main bronchus. We also evaluated the postoperative state of the anastomotic site with spiral CT. In addition to the preoperative evaluation, spiral CT was thought to be useful as one of the postoperative routine follow-up measurements. Although the patient has no subjective symptoms, we plan to follow carefully from now on the anastomotic site, which is slightly narrowed.
In conclusion, we treated a man with mucoepidermoid carcinoma of low grade at the carina successfully with surgical resection and a novel reconstruction. Spiral CT was useful for evaluating the state of the central airway both preoperatively and postoperatively.
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References
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Heitmiller R.F., Mathisen D.J., Ferry J.A., Mark E.J., Grillo H.C. Mucoepidermoid lung tumors. Ann Thorac Surg 1989;47:394-399.[Abstract]
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Smetana H.F., Iverson L., Swan L.L. Bronchogenic carcinoma. Analysis of 100 autopsy cases. Milit Surg 1952;3:335-351.
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Liebow AA. Tumors of the lower respiratory tract. In: Atlas of tumor pathology. Washington, DC: Armed Forces Institute of Pathology, 1952:26–53.
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Mitchell J.D., Mathisen D.J., Wright C.D., et al. Clinical experience with carinal resection. J Thorac Cardiovasc Surg 1999;117:39-53.[Abstract/Free Full Text]
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Miyamoto Y. Carinal reconstruction of lung cancer [in Japanese]. In: Hitomi S, Wada H, eds. The practice in chest surgery: learning from 130 cases (Kokyukigega-no-Jissai). Kyoto: Kinpodo, 1994:24–6.
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LoCicero J., Costello P., Campos C.T., et al. Spiral CT with multiplanar and three-dimensional reconstructions accurately predicts tracheobronchial pathology. Ann Thorac Surg 1996;62:811-817.[Abstract/Free Full Text]
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Abstract
Introduction
