Tumor of Trachea and Esophagus

Tracheal neoplasm

Overview Tracheal anatomy Primary tracheal tumors Benign primary tracheal tumors Malignant primary tracheal neoplasms Secondary tracheal tumors

Anatomy: Trachea Trachea เป็นอวัยวะที่อยู่แนวกลางตัว ยกเว้นส่วนปลายที่จะเอียงไปทางด้านขวา จะมีรอยเว้า 2 แห่ง เนื่องจากมีรอยกดของ aortic arch ทางด้านซ้าย และ arch of azygos veinทางด้านขวา Trachea wall ประกอบด้วย horseshoe-shaped cartilages 20-22 อัน เชื่อมติดกันด้านหลังด้วย thick fibromuscular membrane เส้นผ่าศูนย์กลาง 19.5 ม.ม ในผู้ชาย และ 17.5 ม.ม ในผู้หญิง

Anatomy: Trachea Fibromuscular tube Support by cartilagenous rings Lower border of cricoid cartilage – top of the carina spur Average length 11 cm (10-13 cm) Adult trachea 2-2.5 cm in diameter Extrathoracic trachea ~ 6-9 cm Trachea, Anatomy 1  ประกอบด้วย fibromuscular และ cartilaginous tube มีความยาว 10 - 12 เซนติเมตร เริ่มต้นจาก cricoid cartilage ในคอจนถึง bifurcation ที่เรียก tracheal carina Trachea เป็นอวัยวะที่อยู่แนวกลางตัว ยกเว้นส่วนปลายที่จะเอียงไปทางด้านขวา จะมีรอยเว้า 2 แห่ง เนื่องจากมีรอยกดของ aortic arch ทางด้านซ้าย และ arch of azygos veinทางด้านขวา Trachea เมื่อเข้ามาในส่วนของทรวงอกได้ประมาณ 6-9 ซ.ม จะแบ่งออกเป็น Bronchi 2 อัน Right main bronchus จะยาวประมาณ 2.2 ซ.ม และ Left main bronchus จะยาวประมาณ 5 ซ.ม Right main bronchus จะมีเส้น ผ่าศูนย์กลาง 15.3 ม.ม และ Left main bronchus จะยาวมีเส้นผ่าศูนย์กลาง 13 ม.ม

C shaped with posterior membranous wall connecting the arms of the “C” Mucosa : a ciliated pseudostratified columnar epithelium

Anatomy: Blood supply to trachea Branches of inferior thyroid artery supply the upper trachea Branches of bronchial artery supply the lower trachea Branches arrive the trachea via lateral pedicles

Tumor of trachea Tracheal tumor 2 type - primary tracheal tumor - secondary tracheal tumor

Tracheal resection with end to end anastomosis Tracheal mobilization maneuvers Extreme flexion of the neck (1-6 cm) Incising the annular ligament (1-2 cm) Suprahyoid or infrahyoid release of the upper laryngotracheal unit (2.5-5 cm) Blunt dissection and mobilization of the lower tracheal segment (0.5-1 cm) All combinations yields 4-6 cm (~ patient age and range of neck motion)

Primary Tracheal Tumors

Primary Tracheal Tumors Uncommon Incidence 2 case/million/year Men = Women Peak age : 50- 59 yr Risk factor : Smoking In adults : Malignant >80% In children : Benign > 90 % Most frequent : proximal and distal 1/3 of trachea Originate from any layer in tracheal wall Classified : - Epithelial tumors - Mesenchymal tumors Primary tumor can originate from any layer in the tracheal wall Cummings, 5 th ed.

Classification of Tracheal Tumors Epithelial Neoplasms Benign Squamous cell papilloma Papillomatosis Pleomorphic adenoma Malignant Squamous cell carcinoma Adenoid cystic carcinoma Carcinoid Mucoepidermoid carcinoma Adenocarcinoma Small-cell undifferentiated carcinoma Secondary malignancy Invasion by adjacent malignancy Metastases Nonneoplastic tumors Tracheobronchopathia osteochondroplastica Amyloidosis Inflammatory pseudotumor Mesenchymal Neoplasms Benign Fibroma Hemangioma Granular cell tumor Schwannoma Neurofibroma Fibrous histiocytoma Pseudosarcoma Hemangioendothelioma Leiomyoma Chondroma Chondroblastoma Lipoma Malignant Leiomyosarcoma Chondrosarcoma Paraganglioma Spindle-cell sarcoma Lymphoma Malignant fibrous histiocytoma Rhabdomyosarcoma

BENIGN PRIMARY TRACHEAL TUMORS

Benign primary tracheal tumors Uncommon in adult Usually smooth, well circumscribe, round, soft, and small < 2 cm Chest CT Not extend through the tracheal wall May presence of calcium within the lesion  benign histology Cummings, 5 th ed.

Benign primary tracheal tumors Squamous papilloma Granular cell tumor Chondroma Leiomyoma Hemangioma

Squamous Papilloma Superficial, sessile or papillary masses consisting of a connective tissue core covered by squamous epithelium Adult : rare : associate with heavy smoking Children : most common tracheal neoplasm Cause : HPV 6, 11 Cummings, 5 th ed.

Squamous Papilloma Cause : transmitted from mother to fetus during childbirth Frequent recurs and difficult to completely eradicate Usually regresses spontaneously after puberty Major lesion occur isolated to the larynx (90-95%) - 11% occur in the trachea in addition to the larynx - 1.2 % isolated to the trachea

Squamous Papilloma Treatment : similar laryngeal papilloma - recent : CO2 laser : Adjuvant treatment with α-interferon Malignant transformation to SCCA or Verrucous CA - incidence of malignant degeneration 1.6-4.0 % - associated HPV -11

Granular cell tumor Neurogenic in origin , from schwann cell No sex predilection Children : rare 50% of granular cell occur in the head and neck region - 10 % in the larynx - rare : in the cervical trachea

Granular cell tumor 20% Multicentric tumor, more aggressive Finding : Non-encapsulated, : tend to invade locally Malignant degeneration 1-2% (never report in children)

Granular cell tumor Management : surgery - Tumor size < 8 mm : “ Bronchoscopic resection ” - Tumor size > 8 mm  high likelihood of full-thickness wall involvement  recurrent after bronchoscopic removal “ Segmental tracheal resection ”

Chondroma Most common benign mesenchymal tracheal tumor Cartilaginous origin Most common site - internal aspect of the posterior cricoid lamina Hard , smooth , broad-based and covered by intact mucosa Radiography : 75% found calcification, not distinguish from chondrosarcoma

Chondroma Management : - surgery  segmental tracheal resection - endoscopic resection  for palliation but leads to recurrence

Leiomyoma Origin : smooth muscle of tracheal wall , typically from the membranous portion of the lower third of the trachea Finding : Smooth contoured , polypoid mass and usually have a broad base

Leiomyoma Management : surgery - segmental tracheal resection - incomplete resection  local recurrence

Hemangioma Hemangioma of the airway occur in adults and children - cavernous hemangiomas develop in the larynx - capillary hemangioma originate in subglottic area

Hemangioma Tracheal Hemangioma  occur more often in young children and most common obstructive subglottic mass Asymptomatic at birth, but most will cause stridor within the first 6 months of life Cutaneous hemangioma 50% of patient