Radiographic evaluation

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. Treatment • Tracheal lumen ~8 mm • Exertionaldyspnea • 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 resectabilityinclude • 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. 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

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  intraoperativefrozen 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 • 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 2 - 3 cm of tracheal length • Suprathyroidlaryngeal release • Suprahyoidlaryngeal 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 SCCAand 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 bxforcep • 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 SCCAor 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 20-50 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