1. Radiographic 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

2. Radiographic evaluation
Features suggest : Benign lesion include
intraluminal tumor with limited spread along the tracheal wall
well-circumscribed lesion, smooth or lobulated appearance
size usually < 2 cm
Features suggest : Malignant tracheal lesion include
irregular surface, extension over variable lengths of trachea
extramural extension into the mediastinum
lesions > 2 cm
circumferential tracheal involvement
enlarged mediastinal lymph nodes

3. Radiographic evaluation
CT scans : Disadvantage
Unreliable for submucosal spread of disease
Adenoid 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

4. Radiographic evaluation
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

5. Pulmonary Function Testing
PFT
Can suggest upper airway obstruction
Findings
Severe reduction in PEFR and FEV1

6. Bronchoscopy
Bronchoscopy represents the mainstay of diagnosis for tracheal tumors
Rigid bronchoscopy
Flexible bronchoscopy
potentially hazardous for biopsy and manipulation of a tracheal tumor
precipitate bleeding or total obstruction

7. Bronchoscopy 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

8. Treatment

9. Treatment Careful assessment of the overall situation
Coexistent medical disorders, esp. cardiopulmonary disease
Pneumonia should be cleared
Stabilized the airway
rigid and flexible bronchoscopic techniques
Important  tracheal tumors once symptomatic can rapidly progress to critical airway obstruction

10. : typically asymptomatic, even with activities
Treatment
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

11. Primary
Malignant tracheal tumors

12. 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

13. Anesthetic Managment

14. Tracheostomy is unwarranted
Anesthetic 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

15. Surgical Management

16. Surgical Management Tracheal resection and primary reconstruction
Release maneuvers
Subglottal resections
Carinal resections

17. Tracheal 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
A low-collar incision
Provides access to the cervical and the upper 2/3 of the intrathoracic trachea
Additional exposure : partial or complete sternotomy

18. Tracheal Resection and Primary Reconstruction
Benign tumors
the dissection is kept immediately adjacent to the trachea
no attempt to identify the RLNs
Malignant tumors
identification and preservation of the RLN
if one RLN is involved with tumor  sacrificed
if sacrifice of both RLN requires
concomitant tracheostomy
subsequent vocal cord-lateralizing procedure
paratracheal nodes are excised

19. Tracheal Resection and Primary Reconstruction
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

20. 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.

21. Tracheal Resection and Primary Reconstruction
Figure Guardian stitch is placed at the end of the operation to maintain neck flexion for the first postoperative week.
To reduce tension on the anastomosis
Cervical flexion is maintained with a heavy (No. 2) monofilament
"guardian" stitch between the chin and the anterior chest wall
Place for ~ 7 days  usually removed after confirmation of anastomotic healing by bronchoscopy

22. Surgical Management Tracheal resection and primary reconstruction
Release maneuvers
Subglottal resections
Carinal resections

23. Release Maneuvers For resections involving the cervical trachea
Neck flexion and dissection along the anterior trachea in the neck and mediastinum
An additional cm of tracheal length
Suprathyroid laryngeal release
Suprahyoid laryngeal release  preferred
lower incidence of swallowing complications postoperatively

24. Surgical Management Tracheal resection and primary reconstruction
Release maneuvers
Subglottal resections
Carinal resections

25. Subglottal Resections
Tumors involve the subglottal region require
Prevent permanent RLN damage and vocal cord injury
Excision 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

26. Surgical Management Tracheal resection and primary reconstruction
Release maneuvers
Subglottal resections
Carinal resections

27. Carinal Resections Tumors involving the carinal
Need for tension-free anastomosis is critical
Tumors involving > 4 cm of tracheal length : preclude resection

28. Carinal Resections 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 trachea
Only with small tumors

29. Carinal Resections 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

30. Adjuvant radiotherapy

31. Adjuvant radiotherapy
Recommended for both SCCA and adenoid cystic CA
Adenoid cystic CA are especially sensitive to radiation therapy
Radiation therapy is usually commenced ~ 4 weeks after surgical resection
use at least 60 Gy of radiation
median survival was 24 months, and 5-year survival was 27%

32. Palliative Treatment of Unresectable
Malignant Tracheal Tumors

33. Therapeutic Bronchoscopy
Endoscopic procedures including
Dilatation
Mechanical débridement
Laser vaporization
PDT
Cryotherapy
Brachytherapy
Stenting

34. Therapeutic Bronchoscopy
Extrinsic compression
Only stenting can provide palliation
Mechanical débridement, laser vaporization, PDT, cryotherapy, and brachytherapy are contraindicated
For endotracheal lesions
The optimal choice : depends on the individual tumor's characteristics
Rigid 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

35. Endoscopic technique

36. Therapeutic Bronchoscopy
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

37. Complications

38. Complications
Regnard and colleagues : 4 factors that were significantly associated with the development of postoperative complications
Increasing length of resection
The need for laryngeal release
Laryngotracheal or carinal resection
Squamous cell histology

39. Complications Common problems after tracheal surgery include
Atelectasis
Retained secretions
Pneumonia
Swallowing dysfunction with aspiration
Wound infections
Anastomotic dehiscence
Tracheal-innominate or tracheal-pulmonary artery fistula

40. Complications 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

41. Summary

42. Summary Primary tracheal tumors are rare
In adults, most tumors are malignant
More than 80% of malignant tracheal tumors are either SCCA or adenoid cystic CA
Tracheal tumors are best managed by resection with end-to-end anastomosis
Great care should be taken to avoid excessive tension on the anastomosis by
limiting the extent of the resection
cervical flexion
appropriate release procedures

43. Summary
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 tumors
Medically unfit for an operation
Unresectable tumors
Metastatic disease

44. Summary
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

45. Tumors of the Esophagus

46. Benign Esophageal Tumors and Cysts
Benign tumors are rare (< 1 %)
Classified in two groups
Mucosal
Extramucosal (intramural)
More useful classification:
60% of benign neoplasms are leiomyomas
20% are cysts
5% are polyps
Others (< 2%)

47. Leiomyomas Most common benign tumor of the esophagus Intramural
Age years
Male ~ Female
80% occur in the middle and lower third of the esophagus, they are rare in the cervical region
Obstruction and regurgitation may occur in large lesions
Bleeding is a more common symptom of the malignant form of the tumor : leiomyosarcoma

48. Esophageal Cysts Arise as diverticula of the embryonic foregut
¾ of this cyst present in childhood
Over 60% are located along the right side of the esophagus
Are often associated with vertebral anomalies (ex: spina bifida)
60% present in the first year of life with either respiratory or esophageal symptoms
Cyst found in the upper third of the esophagus present in infancy while lower third lesions present later in childhood

49. 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

50. Malignant Tumors of the Esophagus

51. Cancer

52. Malignant Tumors of the Esophagus
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

53. Malignant Tumors of the Esophagus
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

54. Malignant Tumors of the Esophagus
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

55. Clinical 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

56. Diagnosis Barium swallow Esophagoscopy Esophageal biopsy
Brushings for cytologic evaluation

57. Barium

58. Cancer : Apple Core Appearance

59. CT scan

60. 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

61. TMN Classification for Staging
The esophagus is first divided into four segments
Cervical
Upper thoracic
Middle thoracic
Lower

62. Current AJCC 2002 staging

63. Treatment
Surgical resection is the standard treatment for early esophageal cancer ie Stages I, II and most cases of III
5-years survival rate
% - stage I
% - stage IIA
% - stage IIB

64. Systemic Disorders that Cause Dysphagia
Stroke – present in up to 47%
Amyotrophic Lateral Sclerosis
Parkinson’s Disease
Multiple Sclerosis
Muscular Dystrophy
Myasthenia Gravis

65. Autoimmune Disorders Systemic Sclerosis Systemic Lupus Erythematosis
Dermatomyosits
Mixed Connective Tissue Disease
Mucosal Pemphigoid, Epidermolysis Bulosa
Sjogren’s Syndrome (xerostomia)
Rheumatoid Arthritis (cricoarytenoid joint fixation)

66. Aging Dysphagia is present in 2% in age > 65 yr. Poor dentition
Loss of tongue connective tissue
Increased pharyngeal transit time

67. Thank you for your attention