1. Tumor of Trachea and Esophagus

2. Tracheal neoplasm

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

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

5. 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 cm in diameter
Extrathoracic trachea ~ 6-9 cm
Trachea, Anatomy 1
 ประกอบด้วย fibromuscular และ cartilaginous tube มีความยาว 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

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

7. 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

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

9. 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)

10. Primary Tracheal Tumors

11. Primary Tracheal Tumors
Uncommon
Incidence 2 case/million/year
Men = Women
Peak age : 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.

12. 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

13. BENIGN PRIMARY
TRACHEAL TUMORS

14. 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.

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

16. 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.

17. 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

18. 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 %
- associated HPV -11

19. 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

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

21. 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 ”

22. 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

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

24. 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

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

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

27. 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

28. Hemangioma Finding : capillary hemangioma
- Submucosal mass with covered by normal respiratory epithelium
- Site : posterolateral aspect of the subglottic trachea
- smooth , bluish in color , and project into the airway from sessile base

29. Hemangioma Management - Spontaneous regress by 2-3 yr of age
 Close observation is usually advocated
- In symptomatic patient : radiation , steriod , laser ablation

30. Miscellaneous benign primary tumor
Adenomas
Myoepithelial cell tumors
Lipomas
Fibromas
Schwannomas
Neurilemomas
Hemangiomas
Paragangliomas
Fibrous histiocytomas
Neurofibromas
Chrondoblastomas
Benign mucoepidermoid tumors
Angiofibromas
Xanthomas
Myoblastomas
Hamartomas
Glomus tumors
Intratracheal goiters
Chemodectomas
All combined, these tumors represent fewer than 10% of all primary tracheal tumors.

31. Miscellaneous benign primary tumor
Treatment
- surgical excision
- may be successfully managed with endoscopic resection

32. Malignant primary tracheal neoplasms

33. Malignant Primary Tracheal Neoplasms
In adults
The majority of primary tracheal tumors are malignant
Typically, malignant lesions
shorter duration of symptoms than benign lesions
larger in size
irregular surface
75% of all primary malignant tracheal neoplasms are squamous cell carcinoma or adenoid cystic carcinoma

34. Malignant Primary Tracheal Neoplasms
Historically,
more common in men than women
squamous cell histology was most prevalent
Recently,
incidence of squamous cell carcinomas has declined
incidence of adenoid cystic carcinomas has increased
male = female

35. Malignant Primary Tracheal Neoplasms
The most frequent presenting symptoms are
cough (72%)
dyspnea (66%)
hemoptysis (39%)
stridor (39%)
hoarseness (31%)

36. Squamous Cell Carcinoma

37. Squamous Cell Carcinoma
After 1980, incidence is decreased significantly
Men : Women = 2:1
Mean age is 60 years old
Hx of cigarette smoking : 90%
Synchronous or metachronous respiratory tract malignancies occur in 30%
Sputum cytology : 50 % of pts are positive for cancer
When SCCA involve the membranous tracheal wall  Invasion from a primary esophageal tumor should always be considered

38. Squamous Cell Carcinoma
Exophytic growth with ulceration
Aggressive and tend to growth rapidly
Extend longitudinally & circumferentially
Localized or multiple scattered
Often involved at the lateral tracheal wall

39. Squamous Cell Carcinoma
Occur at any level of trachea or carina
Penetrate extraluminal : Adjacent structure may be invade directly

40. Squamous Cell Carcinoma
Metastasize early
Adjacent peritracheal lymph node metastasis
Less common hematogenous metastases
Bone (most often)
Lung
Liver
Adrenal

41. Squamous Cell Carcinoma
Pathology
Nest and sheet of squamous cell with various degree of differentiation
Scant cytoplasm
High nuclear to cytoplasm ratio

42. Squamous Cell Carcinoma
Treatment :
Complete resection
Radiation therapy -> palliate patients with unresectable SCCA
Resectable :
median survival 38 months , 5-year survival rates 39.1%
Unresectable :
median survival 8.8 months , 5-year survival rates 7.3%
Mediastinal LN involvement -> prognostic implication following Sx
5-year survival : negative mediastinal LN 48.4% and positive LN 12.5%

43. Adenoid Cystic Carcinoma

44. Adenoid Cystic Carcinoma
“Cylindromas”
Seen in all age groups
Peak age incidence years old
Usually arise in the trachea or main bronchi
No associated with sex, race, or cigarette smoking

45. Adenoid Cystic Carcinoma
Nonencapsulated, slow-growing, low-grade malignant tumors
Originate from the epithelium of the glands lining the mucosa of the respiratory tract
Perineural, submucosal, and distant metastatic spread
Lymphatic metastases uncommon (13% to 19%)
Hematogenous metastases 44%
Metas occurs most often to lung and bone

46. Adenoid Cystic Carcinoma
Push mediastinal structures aside rather than invade them