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Ann Thorac Surg 2002;73:310-312
© 2002 The Society of Thoracic Surgeons

Case report

Tracheobronchoplasty for resection of lung cancer arising from a tracheal bronchus

Masaaki Sato, MDa, Seiki Hasegawa, MD, PhD*a, Tsuyoshi Shoji, MDa, Hiromi Wada, MD, PhDa

a Department of Thoracic Surgery, Kyoto University Hospital, Kyoto, Japan

Accepted for publication March 14, 2001.

* Address reprint requests to Dr Hasegawa, Department of Thoracic Surgery, Kyoto University Hospital, 53 Kawara-cho, Kyoto 606-8397, Japan
e-mail: seikiha{at}kuhp.kyoto-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Tracheal bronchus is a rare anomoly wherein a bronchus arises directly from the trachea and supplies the right upper lobe. We had a case of lung cancer arising from a tracheal bronchus with invasion into the trachea. Tracheobronchoplasty was needed for complete resection of the tumor. Because of the anatomical characteristics of the tracheal bronchus, special surgical techniques for resection of the neoplasm were needed.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Tracheal bronchus is a rare abnormal bronchus that directly comes off from the trachea and supplies to the right upper lobe. Tracheal bronchus is usually asymptomatic. However, when a malignant tumor arises from a tracheal bronchus and invades into the trachea, special consideration is necessary for surgical resection and tracheobronchial reconstruction.

A 61-year-old man was referred to our hospital for the evaluation of a right upper lung mass. A chest radiograph showed consolidation at the right upper lung field. Chest computed tomography (CT) demonstrated right upper lobe atelectasis and an ectopic opening of the right upper bronchus on the right lateral wall of the trachea: a tracheal bronchus (Fig 1). No evidence of mediastinal lymphoadenopathy was demonstrated. Fiberoptic bronchoscopy revealed a tracheal bronchus arising approximately 1.0 cm above the carina and its complete obstruction by a tumor. The right upper bronchus coming off the right main bronchus was not found. The tracheal bronchus was found to supply the entire right upper lobe. Tumor invasion into the right tracheal wall proximal to the tracheal bronchus was suspected. Bronchoscopic washing cytologic examination demonstrated squamous cell carcinoma. Systemic examination demonstrated no evidence of metastasis. Though the clinical stage was IIIB, the tumor was localized and considered completely resectable.



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  		Fig 1. Chest CT demonstrated ectopic opening of the right upper lobe bronchus from the trachea: tracheal bronchus. Atelectasis of the right upper lobe due to tumor arising from the tracheal bronchus is also noted.

 
A right posterolateral thoracotomy was done. A pedicled latissmus dorsalis muscle flap was prepared for wrapping tracheobronchial anastomosis to be made. The right upper pulmonary arteries and veins were ligated and dissected. The anterior wall of the trachea was vertically incised from a point 10 mm above the tumor invasion to the carina. Vertical incision was made both on the cartilageous and membranous portion of the trachea. Oblique incision on the trunchus intermedius was made about one cartilageous ring below the carina (Fig 2A). Clear frozen section margin was confirmed. Then, end-to-side tracheobronchial anastomosis was made. The discrepancy in diameter was adjusted by stretching the membranous portion of the trunchus intermedius (Fig 2B). The anastomosis was wrapped with a pedicled lattismus dorsalis muscle flap. Radical disection of mediastinal and hilar lymph nodes was performed. Postsurgical pathologic stage was T4N0M0 (stage IIIB).



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  		Fig 2. (A) Removal of the tracheal bronchus with wedge-like resection of the trachea. (B) Reconstruction of the carina using tracheobronchial end-to-side anastomosis.

 
A series of postoperative observations on the tracheobronchial anastomosis by flexible bronchoscopy did not show stenosis, separation, or other complications. The patient is well with no evidence of recurrence 20 months after the operation.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Tracheal bronchus is an aberrant bronchus that arises most often from the right lateral wall of the trachea [1]. Its incidence ranges between 0.1% and 0.6% [1, 2]. This anomaly is usually diagnosed incidentally during bronchoscopy or bronchography. Abnormal branching of the tracheobronchial tree is believed to be the result of a teratogenic event that occurs before the end of the second month of gestation [1]. Although tracheal bronchus is most commonly asymptomatic, if drainage is impaired, bronchiectasis, cystic change, or emphysema can develop because of stenosis of the origin of the ectopic bronchus [3].

Tracheal bronchi are classified as apical or lobar, depending on whether the apical segment or the entire right upper lobe is supplied, respectively [1]. In addition, depending on the total number of bronchi that supply the right upper lobe, tracheal bronchi are further classified as displaced or supernumerary [1]. The variant of our patient was classified as displaced lobar bronchus; that is, the tracheal bronchus trifurcated into the regular branches of the right upper lobe bronchus and there was no actual right upper lobe bronchus coming off the right main stem bronchus.

Several cases of lung cancer arising from tracheal bronchus have been reported [4, 5]. In three reported cases, usual right upper lobectomy was chosen as a treatment option [4–6]. In another report, upper sleeve lobectomy was performed for its apical-type tracheal bronchus [7]. In our patient, the tumor invaded beyond the inlet of the tracheal bronchus into the trachea, and the tracheobronchial plastic procedure was needed. To our knowledge, no cases of partial tracheal resection and tracheobronchoplasty performed for tracheal bronchus have been reported.

According to the latest TNM classification [8], our patient was preoperatively staged as T4N0M0 (stage IIIB). The T category was T4 because of the involvement of the trachea. No mediastinal lymphoadenopathy was found on chest CT and mediastinoscopic examination was not performed.

In our facility, the 5-year survivals of patients with p-stage IIIB and IV disease were almost 0%, except for patients with p-stage IIIB pT4N0–1 disease (the 5-year survivals were 43.3%) [9, 10]. Operation for T4 disease is considered only when preoperative evaluations indicate that complete resection can be achieved.

Surgical option for tumor arising from a tracheal bronchus with invasion into the trachea is similar to that for trachegenic neoplasm because the tracheal bronchus comes off directly from the trachea. In our patient, the tracheal bronchus was located about 1.0 cm above the carina. This distance was too short for tracheal resection and after tracheal end-to-end anastomosis, preserving the carina intact. Complete carinal resection and carinal reconstruction was another option. However, this would necessitate another anastomosis (left main bronchus to the trachea), requiring a deeper operating field and making the operation complex. More extension of the tumor could have required this method. We chose end-to-side tracheobronchial anastomosis as simple and sufficient reconstruction with the least anastomotic tension.

The tracheobronchial anastomosis was covered with a pedicled latissimus dorsi muscle flap in order to prevent bronchopleural or bronchovascular fistula. No complications occurred at the site of anastomosis.

Because of the anatomical variations of tracheal bronchus, surgical resection necessitates preoperative evaluation of the tracheobronchial branching through bronchoscopy and chest CT. In our patient, preoperative chest CT and flexible bronchoscopy demonstrated the displaced lobar bronchus with no other bronchi supplying the right upper lobe, which contributed to operation planning and its smooth completion. As with usual sleeve lobectomy or carinal resection, careful bronchoscopic evaluation to determine the extent of involvement was also mandatory.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Barat M., Konrad H.R. Tracheal bronchus. Am J Otolaryngol 1987;8:118-122.[Medline]
  2. Moriya H., Kato H., Togawa T. Small cell lung cancer arising in an abnormal bronchus. Jpn J Chest Dis 1985;44:1035-1039.
  3. Marks C. The ectopic tracheal bronchus: management of a child by excision and segmental pulmonary resection. Dis Chest 1966;50:652-654.
  4. Kim J., Park C., Kim H., Lee K.S. Surgical resection of lung cancer originating in a tracheal bronchus. Ann Thorac Surg 1998;66:944-946.[Abstract/Free Full Text]
  5. Kuo C.W., Lee Y.C., Perng R.P. Tracheal bronchus associated with lung cancer: a case report. Chest 1999;116:1125-1127.[Abstract/Free Full Text]
  6. Liu H.C., Hsu W.H., Huang M.H. Squamous cell carcinoma of the right upper lung congenital tracheal bronchus. Chung Hua I Hsueh Tsa Chih (Taipei) 2000;63:424-428.
  7. Okubo K., Ueno Y., Isobe J., et al. Upper sleeve lobectomy for lung cancer with tracheal bronchus. J Thorac Cardiovasc Surg 2000;120:1011-1012.[Free Full Text]
  8. UICC: TNM Classification of Malignant Tumors, 5th ed. New York: Wiley-Liss, 1997.
  9. Tanaka F., Yanagihara K., Ohtake Y., et al. Time trends and survival after surgery for p-stage IIIa, pN2 non-small cell lung cancer (NSCLC). Eur J Cardiothorac Surg 1997;12:372-379.[Abstract]
  10. Wada H., Tanaka F., Yanagihara K., et al. Time trends and survival after operation for primary lung cancer from 1976 through 1990. J Thorac Cardiovasc Surg 1996;112:349-355.[Abstract/Free Full Text]



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