radiographic evaluation ct scan : advantage suggest the histologic type of the tumor the presence of...

Radiographic evaluationRadiographic evaluation

CT scan : Advantage

Suggest the histologic type of the tumor• The presence of fat and calcification within a tracheal

mass : pathognomonic of a hamartoma• Marked enhancement of a tracheal lesion after IV contrast

: suggests carcinoid tumor

Provide clues to the benign or malignant nature of a tracheal tumor


Features suggest : Benign lesion includeintraluminal tumor with limited spread along the tracheal wallwell-circumscribed lesion, smooth or lobulated appearancesize usually < 2 cm

Features suggest : Malignant tracheal lesion includeirregular surface, extension over variable lengths of tracheaextramural extension into the mediastinumlesions > 2 cmcircumferential tracheal involvementenlarged mediastinal lymph nodes


CT scans : Disadvantage

Unreliable for submucosal spread of diseaseAdenoid cystic carcinoma submucosal spread tend to grow slowly and push mediastinal structures away

rather than invade them loss of fat planes between the tumor and mediastinal

structures


MRI

• MRI offers some advantage over CT when

• vascular or cardiac invasion is suspected and to

• determine whether a lesion has a pedicle or broad-based

attachment

Pulmonary Function TestingPulmonary Function TestingPFT

Can suggest upper airway obstruction

Findings • Severe reduction in PEFR and FEV1

BronchoscopyBronchoscopy

Bronchoscopy represents the mainstay of diagnosis for tracheal tumors

Rigid bronchoscopyFlexible bronchoscopy

potentially hazardous for biopsy and manipulation of a tracheal tumorprecipitate bleeding or total obstruction

BronchoscopyBronchoscopy

Rigid bronchoscope

Pts with large proximal tracheal tumors

Subtotal obstruction Ventilation can be maintained Used to dilate and core-out the malignant lesion

providing stabilization of the airway

Tumor bleeding : rarely a problem Bronchoscope used to apply pressure to the site Cautery or laser treatment

TreatmentTreatment

Careful assessment of the overall situationCoexistent medical disorders, esp. cardiopulmonary diseasePneumonia should be cleared Stabilized the airway

rigid and flexible bronchoscopic techniques

Important tracheal tumors once symptomatic can rapidly progress to critical airway obstruction

TreatmentTreatment

Tracheal lumen ~ 8 mm Exertional dyspnea Worsens rapidly with any further decrease in diameter

Tracheal lumen ≤ 5 mm Stridor present at rest

Tracheal lumen > 10 mm : typically asymptomatic, even with activities

TreatmentTreatment

Primary Malignant tracheal tumors

Primary Malignant Tracheal Tumor

Primary Malignant Tracheal Tumor

The majority of adult tracheal tumors are malignant

The best therapy -> surgical excision with circumferential tracheal resection and primary end-to-end reconstruction

Limitations to resectability include invasion of critical mediastinal structures involvement of such an extensive length of trachea that reconstruction would be impossible

If metastatic is detected in superior mediastinal nodes -> combination chemoradiotherapy

Anesthetic ManagmentAnesthetic Managment

Before surgical resection of tracheal tumors

Flexible and rigid bronchoscope techniques are used to

stabilize the airway

Tracheostomy is unwarranted Stomal placement may interfere subsequently with ideal

positioning of the tracheal anastomosis

Intubation

Anesthetic ManagmentAnesthetic Managment

Surgical ManagementSurgical Management

Tracheal resection and primary reconstructionRelease maneuversSubglottal resectionsCarinal resections


Tracheal Resection and Primary ReconstructionTracheal Resection and Primary Reconstruction

A low-collar incision : cervical and upper 2/3 of intrathoracic trachea

Tumors of the distal third of the trachea : right posterolateral thoracotomy

Carina is involved : a median sternotomy


Benign tumors the dissection is kept immediately adjacent to the trachea no attempt to identify the RLNs

Malignant tumorsidentification and preservation of the RLN if one RLN is involved with tumor sacrificedif sacrifice of both RLN requiresconcomitant tracheostomy subsequent vocal cord-lateralizing procedure

paratracheal nodes are excised


Resection margins should be assessed by intraoperative frozen section

During resection -> prevent anastomotic tension

~ ½ of the trachea can be resected : primary anastomosis

(but advanced patient age and prior mediastinal radiation)

Before complete division and resection stay sutures at proximal and distal ends to assist alignment and gauge tension

A, A tumor of the upper trachea has been excised, and the proximal and distal ends of the trachea are mobilized. Interrupted simple sutures are placed with the knots on the outside. Ventilation is accomplished initially across the field with intubation of the distal airway. Subsequently, as the anastomosis nears completion, the endotracheal tube is advanced across the anastomosis

B, A tumor of the distal trachea is excised, and ventilation is maintained by selective intubation of the left mainstem bronchus across the field. After suture placement, the endotracheal tube is advanced across the anastomosis and into the left mainstem bronchus. The completed anastomosis is wrapped with a pleural flap.


To reduce tension on the anastomosisCervical flexion is maintained with a heavy (No. 2) monofilament"guardian" stitch between the chin and the anterior chest wallPlace for ~ 7 days usually removed after confirmation of anastomotic healing by bronchoscopy

Release ManeuversRelease Maneuvers

For resections involving the cervical tracheaNeck flexion and dissection along the anterior trachea in the neck and mediastinumAn additional 2 - 3 cm of tracheal length • Suprathyroid laryngeal release • Suprahyoid laryngeal release preferred

– lower incidence of swallowing complications postoperatively

Tumors involve the subglottal region require Prevent permanent RLN damage and vocal cord injuryExcision of the anterior cricoid arch and the posterior cricoid plate leaving its perichondrium Primary thyrotracheal anastomosis

usually within 1 cm of the inferior border of the vocal cords

Subglottal ResectionsSubglottal Resections

Carinal ResectionsCarinal Resections

Tumors involving the carinal

• Need for tension-free

anastomosis is critical

• Tumors involving > 4 cm of

tracheal length : preclude

resection


The simplest technique for reconstruction Involves approximating the medial walls of the right and left mainstem bronchi to fashion a new carina and then anastomosing to distal tracheaOnly with small tumors


More commonly

the trachea is anastomosed end-

to-end to one of the mainstem

bronchi

the other mainstem bronchus is

sutured into the lateral wall of the

trachea above the first

anastomosis

Adjuvant radiotherapyAdjuvant radiotherapy

Adjuvant radiotherapyAdjuvant radiotherapy

Recommended for both SCCA and adenoid cystic CAAdenoid cystic CA are especially sensitive to radiation therapyRadiation therapy is usually commenced ~ 4 weeks after surgical resectionuse at least 60 Gy of radiationmedian survival was 24 months, and 5-year survival was 27%

Palliative Treatment of Unresectable Malignant Tracheal Tumors

Therapeutic BronchoscopyTherapeutic Bronchoscopy

Endoscopic procedures including DilatationMechanical débridementLaser vaporizationPDTCryotherapyBrachytherapyStenting


Extrinsic compressionOnly stenting can provide palliation Mechanical débridement, laser vaporization, PDT, cryotherapy, and brachytherapy are contraindicated

For endotracheal lesionsThe optimal choice : depends on the individual tumor's characteristicsRigid bronchoscope can remove large tumor that obstruction• by running the scope against the wall of the trachea and

slicing off the tumor “coring-out” or mechanical débridement

Endoscopic techniqueEndoscopic technique

Bleeding controlled

compression by the rigid bronchoscope

• (+/- epinephrine-soaked sponges)

Laser vaporization

• performed through a flexible bronchoscope

• combination with rigid bronchoscope

• the most frequently used laser Nd:YAG


ComplicationsComplications


Regnard and colleagues : 4 factors that were significantly

associated with the development of postoperative complications

1. Increasing length of resection

2. The need for laryngeal release

3. Laryngotracheal or carinal resection

4. Squamous cell histology

Common problems after tracheal surgery includeAtelectasisRetained secretionsPneumoniaSwallowing dysfunction with aspirationWound infectionsAnastomotic dehiscenceTracheal-innominate or tracheal-pulmonary artery fistula


Late complications include

Granulation tissue or stenosis at the anastomosis

• often be extracted endoscopic with a bx forcep

Stenosis at the anastomosis

• Endoscopic techniques including dilation and T-tube

placement


SummarySummary

SummarySummary

Primary tracheal tumors are rareIn adults, most tumors are malignantMore than 80% of malignant tracheal tumors are either SCCA or adenoid cystic CA Tracheal tumors are best managed by resection with end-to-end anastomosisGreat care should be taken to avoid excessive tension on the anastomosis by

limiting the extent of the resection cervical flexionappropriate release procedures

Adjuvant radiotherapy is probably of benefit after resection of SCCA and adenoid cystic CA

Particularly in those with positive resection margins

Primary management for malignant tracheal tumorsMedically unfit for an operationUnresectable tumors Metastatic disease

SummarySummary

Overall, the 5-year survival rate adenoid cystic CA 73% is much greater than for those with SCCA 47%

Management for tumors involving the trachea secondarily is general palliative

Aggressive tracheal resection for invasive thyroid carcinoma and bronchogenic carcinoma offers a chance for cure

SummarySummary

Tumors of the EsophagusTumors of the Esophagus

Benign Esophageal Tumors and CystsBenign Esophageal Tumors and Cysts

Benign tumors are rare (< 1 %)Classified in two groups

MucosalExtramucosal (intramural)

More useful classification:60% of benign neoplasms are leiomyomas20% are cysts5% are polypsOthers (< 2%)

LeiomyomasLeiomyomas

Most common benign tumor of the esophagusIntramuralAge 20-50 years Male ~ Female80% occur in the middle and lower third of the esophagus, they are rare in the cervical regionObstruction and regurgitation may occur in large lesionsBleeding is a more common symptom of the malignant form of the tumor : leiomyosarcoma

Esophageal CystsEsophageal Cysts

Arise as diverticula of the embryonic foregut¾ of this cyst present in childhoodOver 60% are located along the right side of the esophagusAre often associated with vertebral anomalies (ex: spina bifida)60% present in the first year of life with either respiratory or esophageal symptomsCyst found in the upper third of the esophagus present in infancy while lower third lesions present later in childhood

Pedunculated Intraluminal Tumors (Polyps)Pedunculated Intraluminal Tumors (Polyps)

Benign polyps are rare

Usually occur in older men and may cause intermittent

dysphagia

Are sometimes easily missed with barium swallow and

esophagoscopy

Malignant Tumors of the EsophagusMalignant Tumors of the Esophagus

CancerCancer


Usually are in advanced stages at the time of diagnosis

(involving the muscular wall and extending into adjacent

tissues)

Alcohol consumption and cigarette smoking seem to be

the most consistent risk factors

95% of all esophageal cancers is esophageal squamous cell carcinoma Male : female = 5:1

Squamous cell esophageal cancer occurs most often in the upper and midthoracic segments

Squamous cell esophageal cancer occurs least frequently in the cervical esophagus and


Adenocarcinoma constitute approximate 8% of primary esophageal cancers

Most often occur in the distal third of the esophagus in the 6th decade of life.

Male to female ratio is 3:1

Patients with Barrett’s metaplasia are 40 times more likely to develop adenocarcinoma

These tumors are aggressive as well


Clinical PresentationClinical Presentation

Dysphagia is the presenting complaint in 80-90% of patients with esophageal carcinoma

Early symptoms are sometimes nonspecific retrosternal discomfort or indigestion

As the tumor enlarges, dysphagia becomes more progressive

Later symptoms include weight loss, odynophagia, chest pain and hematemesis

DiagnosisDiagnosis

Barium swallow

Esophagoscopy

Esophageal biopsy

Brushings for cytologic evaluation

BariumBarium

Cancer : Apple Core AppearanceCancer : Apple Core Appearance

CT scanCT scan

Staging of Tumors Staging of Tumors

Endoscopic ultrasound-to define the depth of invasion and presence of paraesophageal lymph nodes

Chest x-ray ± abnormal findings

CT scan (most widely used and now standard radiographic means of staging)

Bronchoscopy for tumors which are proximal to the trachea

TMN Classification for StagingTMN Classification for Staging

The esophagus is first divided into four segments

Cervical

Upper thoracic

Middle thoracic

Lower

Current AJCC 2002 stagingCurrent AJCC 2002 staging

TreatmentTreatment

Surgical resection is the standard treatment for early esophageal cancer ie Stages I, II and most cases of III

5-years survival rate30 - 50 % - stage I 15 - 30 % - stage IIA 5 - 15 % - stage IIB

Systemic Disorders that Cause DysphagiaSystemic Disorders that Cause Dysphagia

Stroke – present in up to 47%

Amyotrophic Lateral Sclerosis

Parkinson’s Disease

Multiple Sclerosis

Muscular Dystrophy

Myasthenia Gravis

Autoimmune DisordersAutoimmune Disorders

Systemic SclerosisSystemic Lupus ErythematosisDermatomyositsMixed Connective Tissue DiseaseMucosal Pemphigoid, Epidermolysis BulosaSjogren’s Syndrome (xerostomia)Rheumatoid Arthritis (cricoarytenoid joint fixation)

AgingAging

Dysphagia is present in 2% in age > 65 yr.Poor dentitionLoss of tongue connective tissueIncreased pharyngeal transit time

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radiographic evaluation ct scan : advantage suggest the histologic type of the tumor the presence of...

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