1. Carcinoid tumors

2. Develop from the argyrophillic Kulchitsky’s cells that are present in the airway mucosa Neuroendocrine tumor categorized Grade I : typical carcinoid Grade II : atypical carcinoid Grade III : small or large cell undifferentitated neuroendocrine carcinoma

3. Carcinoid tumors Typical carcinoid (>atypical carcinoids 10 times) Slow growth Infrequent metastasize Atypical carcinoid Aggressive behavior Characteristic malignant histologic features (Nuclear abnormalities, Mitotic activity, Necrosis) At the time of diagnosis : LN or distant metastases Small cell of the trachea Rare Unresectable at diagnosis

4. Diagnosis Histologic comfirmation Bronchoscopy with bx : obtain tissue Tendency to bleeding Rigid bronchoscope : Prefer in operative room Appearance describe as “mulberry-like” Polypoid intraluminal Smooth, pink cut surface Carcinoid tumors

5. Treatment Tracheal carcinoids w/o mediastinal LN involvement  Surgical resection Aggressive atypical carcinoids  Response to CMT and RT Small cell CA of the trachea  extreamly poor prognosis  Combined chemotherapy and radiation Carcinoid tumors

6. Mucoepidermoid carcinoma

7. Derived from minor salivary gland tissue of the proximal tracheobronchial tree Bronchoscopy appear : pink, polypoid masses  Can be confused with a carcinoid tumor Cummings, 4 th ed.

8. Mucoepidermoid carcinoma Classified as low or high grade based on Mitotic acitvity Level of necrosis Nuclear pleomorphism

9. Mucoepidermoid carcinoma Low-grade tumors : behave in a benign fashion High-grade tumors : progress rapidly Treatment : surgical resection 5-year survival 100% ; completely resected tumor no patients surviving 5 years ; unresectable tumors

10. Secondary Tracheal Tumors

11. Arise either from : Direct extension from the primary tumor more common most common from tumors of the lung, esophagus, thyroid, mediastinum, and head and neck only lung and thyroid have any chance for cure with sx resection Metastatic spread to the airways renal cell carcinoma, sarcomas, breast cancer, and colon cancer rarely tumors of the uterus, testes, and adrenal incurable and treated palliatively Secondary Tracheal Tumors

12. CA thyroid involve trachea Optimal surgical management -> controversial Some favor -> thyroidectomy + shaving the tumor off the trachea 5-year survival rate 78% ; complete resection 44% ; incompletely resection Secondary Tracheal Tumors

13. CA lung invade trachea aggressive tracheal and carinal resections in patients without mediastinal lymph node involvement CA esophagus, mediastinal, H&N invade trachea not considered for surgical resection (poor outcome) palliative (radiotherapy, chemotherapy, stents, and other endoscopic techniques) Secondary Tracheal Tumors

14. DIAGNOSISDIAGNOSIS

15. Often not diagnosed until months or years after the onset of symptoms Lumen of the airway narrowed ~75% -> produce symptoms (most common symptom : exertional dyspnea; other : stridor, wheezing,cough, difficulty clearing secretions, recurrent pneumonia, hemoptysis, and hoarseness) Initial symptoms often mimic as asthma or chronic bronchitis Symptoms & Signs

16. Physical Examination Unrevealing Significant narrowing of the airway Stridor, wheezing, bronchial breath sounds Increased accessory muscle use Signs of obstructive pneumonia Subtle alteration in the timber of the voice

17. Radiographic evaluation Findings (PA & lateral CXR )  presence of a mass  narrowing  distortion or disruption of the tracheal air column CXR

18. CT SCAN Excellent for assess mediastinal tumor extension and nodal or metastatic disease Radiographic evaluation