Primary malignant tumors of the trachea. A radiologic and clinical study

Cough as a Clue: Tracheal Endocarcinoma Unveiled

Tracheal adenocarcinoma (TAC) is a rare malignancy often characterized by significant delays in diagnosis, often attributed to the non-specific nature of symptoms, leading to subsequent challenges in management. The prognosis remains poor, highlighting the need for early detection and multidisciplinary treatment strategies. Surgical resection is recommended for eligible patients, followed by postsurgical irradiation. However, further research is required to give a better perspective on therapeutic interventions and enhance patient outcomes. This paper reports the case of a 50-year-old male, who presented with dyspnea, hemoptysis, and cough. The computed tomography (CT) revealed an intratracheal tissue mass. The cytological examination and immunocytochemistry confirmed the diagnosis of primary adenocarcinoma in the trachea. The treatment involved silicone tracheobronchial Y-stent followed by adjuvant chemotherapy with carboplatin and paclitaxel, and radiotherapy (60 Gray) with good clinical improvement.

Intensity modulated radiation therapy may improve survival for tracheal-bronchial adenoid cystic carcinoma: A retrospective study of 133 cases

PURPOSES

This study aimed to evaluate the role of radiotherapy (RT) and intensity modulated radiation therapy (IMRT) in adjuvant and definitive settings of tracheal-bronchial adenoid cystic carcinoma (TACC) treatment.

MATERIALS/METHODS

TACC patients (n = 133) treated with surgery and/or RT curatively in our institution between January 1^st, 1984 and December 31^st, 2017 were analyzed retrospectively.

RESULTS

Among the 116 patients undergoing surgery, 50 (43.1 %) achieved complete resections and 66 (56.9 %) had positive surgical margins. For patients with positive margins, overall adjuvant RT was correlated with no significantly improved OS (10-year: 58.0 % vs. 47.9 %; P =  0.340) and a slight LRFS benefit (5-year: 81.9 % vs.75.6 %; P =  0.056), but adjuvant IMRT showed significant superiority in both OS (10-year: 82.9 % vs. 47.9 %; P =  0.031) and LRFS (5-year: 100.0 % vs. 75.6 %; P =  0.001) in comparison with no postoperative RT. Multivariate analysis also identified adjuvant IMRT as a significant favorable factor with OS (HR = 0.186, 95 %CI: 0.039-0.883; P =  0.034). For 17 patients receiving definitive RT, IMRT achieved promising 5-year OS of 88.9 % and LRFS of 64.3 %, yet no significant difference from non-IMRT group was reached (P = 0.447 and 0.706). Different therapies presented no significantly different impact on DMFS, whilst DMFS explained more of the OS variances (P < 0.001, R² = 0.480) than LRFS (P < 0.001, R² = 0.323).

CONCLUSION

IMRT could confer greatly improved OS and LRFS in postoperative setting for TACC patients with positive surgical margins. IMRT was also a good therapeutic option for definitive TACC with promising survival and local control.

Predicting Histology of Tracheobronchial Neoplasms: A CT Based Differentiation Model

BACKGROUND

Tracheobronchial (TB) tumors follow same pathological classification as lung neoplasms; however, some entities are known to favor airways. Distinction of pathological types is necessary for suggesting appropriate management strategy.

PURPOSE

To evaluate utility of multidetector CT (MDCT) in differentiation of primary TB tumors; and assess validity of a scoring system based on imaging biomarkers to differentiate tumor types.

METHODS

MDCT features of 45 patients were analyzed for location, shape, calcification, attenuation, parenchymal changes, bronchoceles, extraluminal extension, lymphadenopathy, metastases. The two largest groups were compared with each other and remaining entities using Chi square tests. Six-point scoring system combining the differentiating features was devised and receiver operating characteristic curve analysis performed.

RESULTS

The most frequent type was neuroendocrine tumors (NET) (51.1%), followed by salivary gland tumors (SGT) (20%); including adenoid cystic carcinoma (ACC) (13.3%) and mucoepidermoid carcinoma (MEC) (6.7%). Comparing NETs with other entities as a whole, and independently with SGTs, significant difference was found among location (p = 0.05 and 0.001 respectively), shape (p < 0.001), calcification (p = 0.038 and 0.041 respectively), attenuation (p = 0.001 and 0.019 respectively), bronchoceles (p = 0.013 and 0.010 respectively). Significant difference was found among ACC and MEC in location (p = 0.01) and morphology (p < 0.001). On receiver operating characteristic (ROC) curve analysis of the score, areas under curve for NET, SGT and ACC were 0.913, 0.872 and 0.962 respectively. Suggested cut-off values were >3.5 for carcinoid (sensitivity 70%, specificity 91%), <2.5 for SGT (sensitivity 78%, specificity 75%), <1.5 for ACC (sensitivity 83%, specificity 92%).

CONCLUSION

Use of a scoring system enables maximum diagnostic accuracy in MDCT differentiation of TB tumors.

Solitary tracheal B-cell lymphoma in an adult alpaca (Vicugna pacos)

BACKGROUND

This report describes a case of solitary tracheal lymphoma in a 14-year-old alpaca mare.

CASE PRESENTATION

The alpaca was referred for dyspnea and inspiratory noise. The clinical examination included complete blood cell count, blood chemistry, endoscopy, ultrasound, radiographs, and computed tomography (CT). A solitary tracheal intraluminal and juxtatracheal lymphoma was diagnosed by fine needle aspiration (FNA). The owner requested euthanasia due to the uncertain prognosis. At postmortem examination, the presence of solitary lymphoma without involvement of other organs was confirmed. Immunohistochemical analysis confirmed a B-cell origin.

CONCLUSIONS

Although multicentric lymphoma is the most commonly described neoplasia affecting South American camelids (SAC), solitary forms of the disease may occur.

Tracheolaryngeal Squamous Cell Carcinoma with Extensive Mucosal Spread Without Metastasis in a Female

Tracheal tumors remain one of the most interesting and challenging respiratory tumors. Usually, with the more invasive histologic subtypes, cancer has already invaded surrounding structures at the time of diagnosis. We present an unusual case of primary tracheal squamous cell carcinoma with an extensive mucosal spread at the time of diagnosis without any invasion of surrounding organs or distant metastasis. We discuss the unique features and our treatment approach to this unusual presentation. We also discuss the various epidemiologic, diagnostic and treatment aspects of upper airways tumors of the hypopharynx, larynx, and trachea that can help patients achieve more favorable outcomes.

Successful treatment of tracheal lymphoma in a Siamese cat

CASE SUMMARY

An 8-year-old female spayed Siamese indoor cat presented with a 3 week history of inspiratory dyspnoea, stridor and open-mouth breathing after exercise. Laryngoscopy, tracheoscopy, bronchoscopy and retroflexed nasopharyngoscopy were performed, and identified a multilobulated intraluminal mass within the trachea. Brush cytology was performed on the mass but was inconclusive in providing a definitive diagnosis. A CT scan of the neck failed to identify an obvious intraluminal mass and was negative to contrast uptake. Surgery was performed and seven rings of the trachea were removed to enable the complete excision of the mass. Histopathology of the excised mass was consistent with B cell lymphoma. After surgery, chemotherapy treatment was started. At the time of writing, 20 months since diagnosis, the cat remained clinically well, with no clinical signs or recurrence of macroscopic disease on endoscopic evaluation.

RELEVANCE AND NOVEL INFORMATION

Upper airway endoscopy was considered to be an essential diagnostic tool in this case presenting with signs of upper respiratory dyspnoea. Moreover, combined surgery and chemotherapy were considered effective treatments and positively affected the long-term prognosis of this patient.

Tracheobronchial tumors

Tumors of trachea and bronchi are uncommon and can occur in the form of benign or low- and high-grade malignant tumors. Although tracheobronchial tumors (TBTs) represent only 0.6% of all pulmonary tumors, they are clinically significant. Delays in diagnosis of these tumors commonly occur because the signs and symptoms caused by these tumors are nonspecific and chest radiographs are often considered unremarkable. Therefore, novel radiological techniques and better access to flexible bronchoscopy enable detection of larger number of TBT. The purpose of this article is to provide a review of tracheal and bronchial tumors and discuss significant aspects of the different TBT with focus on clinical manifestations and diagnostic procedures.

Tracheal cancer - treatment results, prognostic factors and incidence of other neoplasms

Background

Tracheal cancers (TC) are rare and treatment results that are reported are typically not satisfactory. The purpose of this research was assessment of the results of treatment of TC patients, identification of potential additional surgery candidates, evaluation of prognostic factors, and assessment of the occurrence of other malignancies.

Patients and methods

The Regional Cancer Database and the Hospital Database were searched for patients with tracheal neoplasms. Fifty-eight of 418 patients identified initially, met the inclusion criteria (primary TC with confirmed histology and complete treatment records). Standard statistical tests were used.

Results

Squamous cell carcinoma (SCC; 63.8%) and adenoid cystic carcinoma (ACC; 15.5%) were the most commonly diagnosed histological types of TC. Radiotherapy was delivered in 48 cases, surgery or endoscopic resection in 20, and chemotherapy in 14. TC was diagnosed as a second cancer in 10 patients, in 1 patient it occurred prior to the lung cancer, and in 1 was diagnosed simultaneously. During the median follow-up of 12.7 months, 85.5% of the patients died because of the disease. Local recurrence occurred in 17% cases. In univariate analysis, patients with ACC had statistically better five-year overall survival (77.8%) than those diagnosed with SCC (8.4%, p = 0.0001). Radiotherapy, performance status and haemoptysis were factors significantly influencing overall survival (OS) in the multivariate analysis. Among patients who were not treated surgically, 15–26% were found to constitute additional surgery candidates, depending on the selection criteria.

Conclusions

The diagnostic workup should be focused on the identification of TC patients suitable for invasive treatment and radiotherapy. Respiratory system cancer survivors can be considered a risk group for tracheal cancer. Radiotherapy constitutes an important part of the treatment of patients with TC.

Young man with dyspnoea for 6 months; presenting with subacute tracheal obstruction due to leiomyoma

Tracheal leiomyoma is a rare benign tumour with less than a 100 cases reported in the literature. We report a case of leiomyoma initially presenting and being treated as asthma until it lead to life-threatening tracheal obstruction, requiring immediate surgical intervention.

Anesthetic management for bronchoscopy and debulking of obstructing intratracheal tumor

Primary tracheal tumors comprise a rare group of benign and malignant tumors. Bronchoscopy is required for diagnosis and staging of tracheal neoplasms as well as debulking of the tumor. The management of anesthesia for rigid bronchoscopy in a patient with tracheal neoplasm presents with many challenges to the anesthetist. We present anesthetic management of an 18-year-old female who presented with orthopnea. Computed tomography scan of the thorax revealed a polypoidal lesion in the trachea proximal to carina and consolidation in the right middle lobe. The patient was scheduled for rigid bronchoscopy and debulking of the tumor. Case was successfully managed by providing positive pressure ventilation and oxygenation during rigid bronchoscopy using manual ventilation through the side port of the rigid bronchoscope. The procedure was uneventful, and patient improved symptomatically in the immediate postoperative period. The successful management of this case demonstrates the airway management in a patient with tracheal tumor for rigid bronchoscopy.

Computed Tomography Virtual Bronchoscopy: Normal Variants, Pitfalls, and Spectrum of Common and Rare Pathology

A broad spectrum of pathologies that involve the laryngotracheobronchial airway and imaging plays a crucial role in evaluating these abnormalities. Computed tomography with virtual bronchoscopy has been found to be very helpful in defining the location, extent, and nature of these lesions, and is increasingly being used even in patients with contraindications for fiberoptic bronchoscopy and laryngoscopy. Ionizing radiation, associated with virtual bronchoscopy, can be minimized by using low-dose multidetector computed tomography and hybrid iterative reconstruction techniques. Furthermore, retrospectively generated virtual bronchoscopy from a routinely acquired computed tomography data set eliminates additional cost and radiation. In the future, virtual bronchoscopy assisted with advanced navigational techniques will broaden the diagnostic and therapeutic landscape. This article presents the characteristic features of common and rare laryngotracheobronchial pathologies seen with virtual bronchoscopy.

Airway compromise due to adenoid cystic carcinoma obstructing the distal trachea: a review of current management and clinical trials

An 84-year-old man presented with a 2-month history of intermittent stridor and worsening difficulty in breathing. Chest X-ray and flexible nasendoscopy were unremarkable but following further deterioration a CT scan revealed an obstructing lesion in the distal trachea. Bronchoscopy revealed an infiltrative tumour arising 3 cm above the carina causing 90% obstruction. The mass was biopsied and surgically debrided to leave a patent airway. Histological analysis revealed a diagnosis of adenoid cystic carcinoma. Transthoracic surgical resection was unsuccessful and the patient continues to be effectively managed with periodic bronchoscopic debulking and radiotherapy. This case highlights the diagnostic and therapeutic dilemmas posed by distal tracheal lesions and the need for specialist input for effective management.

Primary malignant melanoma of the trachea: A case report

Primary cancer of the trachea is rare and accounts for only 0.1–0.4% of all newly diagnosed respiratory tract cancers, worldwide. In the present study, a case of primary tracheal malignant melanoma, a particularly rare type of cancer, is reported. A 68-year-old male presented with a cough and bloody sputum. A chest computed tomography scan revealed a 25×20×15-mm tracheal tumor, located immediately above the carina, which reduced the cross-sectional area of the trachea by ~90%. Histopathological analysis of biopsy specimens determined a diagnosis of malignant melanoma. The patient was treated with argon plasma coagulation and chemoradiotherapy, which restored airway patency, however, metastasis was detected in the lungs. The patient refused further treatment and received palliative care. Subsequently, the patient succumbed to the disease within four months. Thus, although primary malignant melanoma of the trachea is extremeley rare, the possibility should be considered during diagnosis.

[Squamous cell carcinoma of the trachea: imaging lymph node mapping]

The anatomy of the trachea lymphatics is poorly understood and the only researches date back to more than one century. Tracheal tumors are very rare, miscellaneous and variously lymphophilic. The cancers of the trachea have no TNM and their lymph node metastases are little studied despite their poor prognosis. We observed 2 cases of squamous cell carcinoma, one in the cervical and the other in the intrathoracic trachea. TDM-3D reformats demonstrated metastatic lymph nodes of the right para-tracheal lymph node chain (2R and 4R) in both patients and in the cervical lymph nodes (right recurrent nerve lymph node chain) in the patient with cervical tumor. Right location of the mediastinal metastases may be explained by the anatomy of the lymph node chain drainage of the lung segments, the right para-tracheal chain being the only one to regularly possess lymph nodes at that level. The right recurrent nerve lymph node metastases of the cervical tumor are explained by common lymph drainage of the cervical trachea towards larynx lymph centres. Besides lymph node metastases, cancers prognosis may also depends on its location in the trachea. Thus, the tracheal tumors are complex and constitute quite as many orphan tumors. Multicentric studies are mandatory to better understand their behavior. Means provided by new imaging techniques might permit establishing a veritable TNM lymph node mapping of these tumors.

Adenoid cystic carcinoma in the bronchus behaves more aggressively than its tracheal counterpart

BACKGROUND

Primary airway adenoid cystic carcinomas (ACCs) are rare neoplasms and challenging to resect completely. The objective of the current study was to evaluate clinical and pathologic features and indicate prognostic factors based on different tumor locations in the airway.

METHODS

From March 2001 to April 2012, 82 consecutively operated patients were enrolled in this study with pathologically confirmed airway adenoid cystic carcinomas in the Shanghai Chest Hospital. Clinical and pathologic data were retrospectively reviewed. Survival analysis was performed using the Kaplan-Meier and log-rank tests. Multivariate analysis was performed using the Cox regression model.

RESULTS

The ACCs originating from the bronchus were associated with older age (p = 0.021), had fewer positive margins (44.8% vs 84.9%, p < 0.001), and more involved lymph nodes (55.2% vs 14.3%, p = 0.002) than their tracheal counterparts. The overall survival after resection of all ACCs was 90.6% at 5 years and 56.4% at 10 years. Five and 10-year disease-free survival was 66.9% and 11.2%, respectively. Multivariate analysis indentified only dyspnea as a presenting symptom to predict tracheal disease-free survival (hazard ratio = 0.062, 95% confidence interval = 0.005 to 0.785, p = 0.032). Bronchial ACCs had worse disease-free survival than tumors of tracheal origin (p = 0.001).

CONCLUSIONS

Adenoid cystic carcinoma in the bronchus behaves more aggressively than its tracheal counterpart. Only dyspnea as a presenting symptom predicts better disease-free survival after resection of tracheal ACCs.

Small-cell cancer presenting as a tracheal polyp: a case report and review of the literature

Primary tracheal tumors are rare. Malignant tracheal polyps constitute the majority, with very few case reports of small-cell cancer in the literature. Staging of these tumors follows the lung cancer TNM staging system, with little evidence-based guidance for their management. We report a case of small-cell cancer presenting as a tracheal polyp and review the related literature.

Rare tracheal tumors and lesions initially diagnosed as isolated differentiated thyroid cancers

BACKGROUND

Thyroid carcinoma with tracheal invasion is uncommon; however, this is significantly more prevalent than primary tracheal tumors. Rare tracheal tumors at the level of the thyroid can be misinterpreted as invasive thyroid cancer upon initial diagnosis. We present a series of tumors within the tracheal wall that were initially misdiagnosed as isolated, but aggressive, thyroid cancer, and later diagnosed to be different histopathologic entities.

METHODS

The series consisted of four women and five men, all but two age 60 or older, who were initially diagnosed with tracheal invasion from differentiated thyroid carcinoma (DTC). Eight had obstructive airway symptoms and one experienced gagging and choking sensations. Preoperatively, the patients underwent fine-needle aspiration (FNA) and imaging studies. A complete resection of the involved airway in combination with the thyroid gland was performed in all patients.

RESULTS

In this series of patients, the final diagnosis was tracheal stenosis, recurrent laryngeal nerve schwannoma, papillary thyroid carcinoma (PTC) with benign intratracheal thyroid tissue, adenoid cystic carcinoma, and squamous cell carcinoma, each in one patient. Two patients had a tracheal chondrosarcoma, and two patients had collision tumors (PTC with laryngeal squamous cell carcinoma). All patients were misunderstood preoperatively as having isolated DTC with aggressive involvement of the trachea. An accurate diagnosis in these cases was difficult due to misleading FNA readings, thought due to the FNA needle passing through the thyroid before reaching the trachea or a tumor that abuts both structures on imaging. Primary tracheal tumors and a nontumorous lesion, as well as benign thyroidal masses, mimicked invasive thyroid carcinoma in this preoperative setting.

CONCLUSIONS

Various entities other than thyroid cancer can masquerade as invasive thyroid cancer. In patients with an FNA showing thyroid tissue or suggesting PTC, but also have obstructive or other airway symptoms, physician awareness is needed to consider the distinct possibility of a primary tracheal lesion. Obtaining the correct preoperative diagnosis is essential for accurate surgical planning for patients with tracheal tumors.

Surgical management of malignant tumors of the trachea: report of two cases and review of literature

Malignant neoplasms occurring from the trachea are extremely rare. Therefore, their clinical characteristics and surgical results have not been thoroughly discussed. These tumors are often misdiagnosed and treated as bronchial asthma or chronic obstructive pulmonary disease. It is critically important to probe the cause-effect relationship between the medical presentations and the clinical diagnosis. In this report, two cases of tracheal malignancy suffering from dyspnea due to obstruction of the proximal trachea are described, and a review of the literature is presented.

Clinical and Radiological Manifestations of Primary Tracheobronchial Tumours: A Single Centre Experience

Introduction: Tracheobronchial tumours usually cause an airway obstruction and secondary pulmonary infections. Although rare, they are an important differential diagnosis as they may mimic other conditions and diseases. This paper aims to analyse clinical, radiological and histological characteristics of the patients with tracheobronchial tumours diagnosed for a period of 7 years. Materials and Methods: In this retrospective, observational study, we carefully reviewed 65 patients who were diagnosed with tracheal and endobronchial tumours, and performed statistical analysis on the results. Results: Among these 65 patients (36 men and 29 women) with a mean age of 48.8 years (range, 15 to 75), 50 had malignant tumours while 15 had benign ones. The most common symptoms were cough, chest pain and haemoptysis. Cough was a more frequent symptom in patients with benign tumours (P <0.0014). Only 2 patients were asymptomatic. Tumours were predominantly localised in the large airways (46 in large bronchi and 2 in trachea). The most common radiological manifestation of malignant tumours was tumour mass (46%) followed by atelectasis. One third benign tumour caused atelectasis, while tumour mass and consolidation were found in 3 patients each. Computerised tomography revealed endoluminal tumour mass in 29.2% of the cases, which was more frequently found in benign than malignant tumours (47% vs 24%, respectively). On bronchoscopy, tumours were visible in 73% and 70% benign and malignant cases respectively. Conclusion: Tracheobronchial tumours should be ruled as a possible diagnosis in patients with cough, haemoptysis, dyspnoea and chest pain. The imaging techniques and histological examination of the tissue would subsequently lead to correct diagnosis and proper treatment can be administered. Key words: Bronchus, Computerised tomography, Trachea, Tumour, X-ray

The use of radiation therapy appears to improve outcome in patients with malignant primary tracheal tumors: a SEER-based analysis

PURPOSE

To conduct a matched pair analysis assessing the impact of radiotherapy (RT) in patients with resectable and unresectable primary malignant tracheal tumors using Surveillance, Epidemiology and End Results (SEER) database.

PATIENTS AND METHODS

The SEER registry was used to identify every patient (or "case") who received RT between 1988 and 2007 for primary malignant tracheal tumors, and to search for corresponding "controls" (not treated with RT), with the same prognostic and treatment factors (surgery on the trachea, disease extension, histology, and gender). Overall survival (OS) was calculated with the Kaplan-Meier methods. Results of OS and cumulative incidence of death from tracheal cancer in the cases and controls, and in various subsets, were compared using log-rank and Gray's tests.

RESULTS

Two hundred fifty-eight patients who received RT were identified, and 78 of these had appropriate matched controls identified, forming the basis of this analysis. In the 78 (+RT) cases, the median follow-up was 60 months (range, 10-192) in the survivors vs. 55 months (range, 2-187) in the controls (no-RT group). Patients in RT group had significantly better OS, and a lower cumulative incidence of death from tracheal cancer than no-RT patients (p < 0.05). Treatment with radiation was associated with improved survival in patients with squamous cell histology [p < 0.0001], regional disease extension [p = 0.030], or those that did not undergo resection [p = 0.038]. There were four deaths in RT group and three in no-RT group attributed to cardiac and respiratory causes.

CONCLUSION

Our data suggest a survival benefit for the use of RT broadly for all patients with tracheal cancer. Nevertheless, the retrospective nature of this observational study limits its interpretation.

Incidentally discovered primary malignant melanoma of the trachea

Primary malignant melanoma of the trachea is extremely rare. We report here the first case of primary tracheal malignant melanoma in the asymptomatic stage. Incidentally, this 73-year-old man was found to have a flat tumor at the upper trachea on chest computed tomography scans. The tumor was surgically resected with end-to-end anastomosis and was diagnosed to be primary malignant melanoma of the trachea. Four months after the surgical resection, cervical lymph node metastasis was found. Despite the resection of metastatic lymph nodes and six courses of chemotherapy, he died of cachexia approximately two years after the discovery of the tracheal tumor.

Primary adenoid cystic carcinoma of trachea presenting as midline neck swelling and mimicking thyroid tumor: A case report and review of literature

We report an extremely rare case of primary adenoid cystic carcinoma (ACC) trachea presenting as midline swelling neck and mimicking thyroid tumor. A 44-year-old female presented with painless midline swelling neck without any respiratory complaints, hoarseness of voice or dysphagia etc. Fine needle aspiration cytology (FNAC) from swelling reveal features of papillary carcinoma thyroid. Subsequently the operative findings, bronchoscopy and histological diagnosis of excised mass, along with review of FNAC, revealed features of ACC of trachea with exra tracheal extension anteriorly into the soft tissue neck, without actual invasion of the thyroid gland. The world literature on extension of an ACC arising in the laryngotracheal complex to thyroid or soft tissue neck and clinical manifestation as a thyroid nodule or mass is reviewed. The cytological differential diagnosis of ACC and CT findings are also briefly discussed.

Primary tracheal non-Hodgkin lymphoma: case report with an emphasis on computed tomography findings

A 24-year-old male presented with productive cough associated with fever, dyspnea, and hoarseness. A chest radiograph showed nonhomogeneous air-space consolidations, mainly in the middle and inferior zones of both lungs, with cavitations and peribronchial thickening. The computed tomography scan demonstrated irregular, lobulated narrowing of the trachea, and parenchymal consolidations containing air bronchogram, peribronchial thickening, and cavitations. Afterward, the patient was referred for a bronchoscopy with a biopsy of the tracheal mucosa. The samples were submitted to immunohistochemical analysis and revealed a diagnosis of diffuse large B-cell non-Hodgkin lymphoma of the trachea. A culture of bronchoalveolar lavage fluid revealed Pseudomonas aeruginosa. Antibiotic treatment was proposed as a first treatment. The patient did not receive intensive chemotherapy because of his comorbid conditions and died 2 months later.

[Tracheal stenosis due to non-Hodgkin's lymphoma of the exceptionaly rare location]

A case of tracheobronchiale stenosis due to non-Hodgkin's lymphoma (mantle cell lymphoma) of the exceptionaly rare location, in 75 old woman is described. After the restoration of airways patency and stent implantation dyspnea was removed.

A primary tracheal carcinoid tumor masquerading as chronic obstructive pulmonary disease

Primary tumors of the trachea are rare and can be missed because of the paucity of symptoms and findings and the difficulty in detecting them with chest radiographs. A 31-year-old male patient was admitted with complaints of shortness of breath, coughing, phlegm, and blood in the sputum. He stated that he was being treated for chronic obstructive pulmonary disease. Fiberoptic bronchoscopy revealed a vegetative mass with a wide base on the posterolateral wall of the distal one-third of the trachea. Postoperative histopathological examination revealed a typical carcinoid tumor. In patients with an unexplained cough, dyspnea, infrequent hemoptysis, and normal pulmonary imaging findings, tracheal carcinoma should be suspected. In such cases, early thoracic computed tomography and bronchoscopic examination can provide a rapid diagnosis and treatment options and prevent a false diagnosis.

Incidence and Treatment of Tracheal Cancer: A Nationwide Study in The Netherlands

BACKGROUND

The aim of this study was to assess the incidence, characteristics, treatment, and survival of patients with tracheal malignancies in the Netherlands.

METHODS

All cases of tracheal cancer entered into the database of the Netherlands Cancer Registry in the period 1989-2002 were selected. Data on histological type, age at time of diagnosis, treatment, and survival were analyzed retrospectively.

RESULTS

The annual incidence was 0.142 per 100,000 inhabitants (308 cases, of which 15 were found incidentally at autopsy). Of these, 72% were men. In 52.9%, the histological type was squamous cell carcinoma and in only 7.1% adenoid cystic carcinoma (ACC). Mean age at time of diagnosis was 64.3 years. Of the 293 patients diagnosed while alive, 34 patients underwent surgical resection (11.6%), 156 patients received radiotherapy (53.2%), and 103 patients neither (35.4%). Median survival of all 293 patients was 10 months (mean 28 months) with 1-year, 5-year, and 10-year survival rates of 43%, 15%, and 6%, respectively. The prognosis of patients with ACC was significantly better. The 5-year survival rate in patients who underwent surgical resection was 51%, and the 10-year survival rate in these patients was 33%.

CONCLUSION

The prognosis of patients with a tracheal malignancy is usually poor. Surgical treatment, however, can lead to good survival rates; still, this is currently only used in selected patients, even though it would seem to be possible in more cases in view of the technical advances in the field of tracheal surgery. Centralizing the care and treatment of tracheal cancers and implementing a more assertive attitude towards this disease could make surgery accessible to a larger number of patients. Data from the literature show that this would lead to better survival in patients with a tracheal malignancy.

Primary Intratracheal Lymphosarcoma in Four Cats

Four cats presented with clinical signs suggestive of respiratory disease, including dyspnea, wheezing, cyanosis, inspiratory stridor, coughing, and gagging. Radiographs revealed intratracheal masses. Bronchoscopy allowed for lesion localization and collection of samples for cytopathological and histopathological evaluation, which confirmed a diagnosis of lymphosarcoma. Cats treated with systemic chemotherapy or radiation were able to achieve complete remission and long-term resolution of clinical signs.

Epithelial and soft tissue tumors of the tracheobronchial tree

This article provides a broad overview of tumors that can involve the tracheobronchial tree. For the most part, the clinical, radiographic, and endoscopic presentation of these rare tumors does not differ significantly from the more common tumors of the lung. Appropriate classification of many tracheobronchial tumors ultimately requires complete sampling and a thorough microscopic evaluation. The introduction of ancillary diagnostic techniques such as immunohistochemistry and molecular analysis will continue to refine tumor classification.

Tracheal cancer in Denmark: a nationwide study

OBJECTIVE

Most published series on tracheal cancer reflect single institution experiences. We used the nationwide Danish Cancer Registry to report on characteristics and treatment of tracheal cancers in Denmark.

METHODS

One hundred and nine cases of primary tracheal cancers were extracted from the registry in the period 1978-1995. The clinical data, histological distribution and treatment modalities were analyzed. The cancers were staged in four groups (stage I-IV) according to size, location and spread.

RESULTS

Seventeen cases were diagnosed at autopsy. Ninety-two cases were diagnosed in vivo and 84% of these within 3 months after the first consultation. Sixty-three percent of the cancers were squamous cell carcinomas and only 7% were adenoid cystic carcinomas. The disease was at stage I in 21%, stage II in 23%, stage III in 6% and stage IV in 50%. The majority of the patients received radiotherapy as single treatment. Only nine patients were offered surgery (six were resected and three were found inoperable). The overall survival rates for cases diagnosed in vivo were 1-year 32%, 2-year 20% and 5-year 13%. For the resected patients the 5- and 15-year survival rates were 50%.

CONCLUSIONS

Tracheal cancers were rare and adenoid cystic carcinomas not as frequent as generally believed. Surgery was rarely offered. A resectability rate of only 10% is not adequately explained by selection bias and indicates a nihilistic attitude based on ignorance about surgical treatment of tracheal cancers. A more dedicated and aggressive approach with centralized workup and radical treatment is strongly recommended.

Successful resection of endotracheal papillary adenocarcinoma by endoscopic electrosurgery using a new snare: report of a case

We report herein the rare case of a patient with endotracheal papillary adenocarcinoma of the goblet cell type. The tumor existed in the upper trachea, obstructing 95% of the airway, and prompt palliation was required. Endotracheal polypectomy was successfully performed in this patient using electrosurgery with a new snare designed for the respiratory tract. The procedure took only a few minutes and the dyspnea was relieved promptly without any complications. The alternative techniques for palliation of bronchial stenosis are also discussed.

Role of radiation therapy in the treatment of primary tracheal carcinoma

PURPOSE

The objective of this work is to investigate the role of radiation therapy in the treatment of primary tracheal carcinoma.

METHODS AND MATERIALS

From 1963 to 1993, 106 patients presenting with a tracheal carcinoma received a radiation course as part of their treatment in three institutions. Eighty-four patients were treated with megavoltage radiation only, receiving doses ranging from 30 to 70 Gy, with a median dose of 56 Gy. Five patients received high-dose-rate (HDR) brachytherapy, five patients underwent a surgical procedure, and eight received chemotherapy.

RESULTS

With a mean follow-up of 141 months, the overall 1-, 2-, and 5-year survival rates are 46%, 21%, and 8%, respectively. Prognostic factors included tumor size (less than 3 cm), performance status, and total radiation dose: the 5-year survival rate dropped from 12% for patients receiving doses greater than 56 Gy to 5% for lower doses. Performance status and radiation doses are the only independent significant factors in multivariate analysis; these results must however be analyzed with precaution in this retrospective study.

CONCLUSIONS

Radiation is a good alternative to surgery for primary tracheal cancer. A review of the literature and our current results allow us to recommend a radiation dose greater than 60 Gy for primary irradiation. Collaborative studies are warranted to (1) determine the optimal radiation dose for definitive irradiation, (2) define the potential role of radiation after complete and partial surgery, (3) determine the role and optimal treatment scheme for HDR brachytherapy, (4) describe and record the late effects, (5) establish the potential benefit of chemoradiation.

Primary malignant melanoma of the trachea

Only three primary malignant melanomas have been identified among large series of tracheal resections. Pertinent clinical and histopathologic features of these rare malignancies, however, have rarely been presented. We present the case of a young woman who underwent tracheal resection for a primary malignant melanoma with clinical and histopathologic verification.

Management of Tracheal Neoplasms

Patients with tracheal involvement from primary or secondary neoplasms usually present with relatively nonspecific symptoms of cough, wheeze, and shortness of breath. Prompt diagnosis often requires a high index of suspicion. Tomography or computed tomography of the chest will often confirm the presence of a tracheal lesion. A detailed rigid bronchoscopic assessment by an experienced thoracic surgeon is essential for establishing the extent of tracheal involvement. Although advanced tumor stage often precludes surgical resection, the application of current operative techniques allows a significant number of tracheal tumors to be completely excised and primarily reconstructed. Adjuvant radiotherapy is often employed with surgical resection to improve local control and enhance the potential for cure.

[Malignant tracheal tumors--surgical experiences in 6 patients with primary malignancies of the trachea. Current diagnosis and therapy]

In a retrospective study six patients with malignant tumours of the trachea located distal to the cricoid and proximal to the carina tracheae were operated on during the period of December 1983 to July 1995 in the Department of Thoracic Surgery in Hannover (Heidehaus). Histopathological examination revealed two adenoid cystic carcinomas, two squamous cell carcinomas, one mucoepidermoid carcinoma, and one low-grade sarcoma. Laser bronchoscopic resection was performed in one patient and tracheotomy one other avoid imminent asphyxia. Physical examination mainly showed a range of symptoms such as stridor and dyspnoea; spirography showed increased airway resistance, and X-ray of the trachea was important in the diagnostic process. The tracheal tumours were diagnosed by histopathological examination of excised material obtained by bronchoscopy. Three patients underwent resection and primary reconstruction of the trachea, with a length of resection between 2.0 and 3.5 cm and end-to-end anastomosis. Endotracheal afterloading was necessary in the case of one female patient with tumour infiltration of the proximal end of the upper trachea. Neoadjuvant irradiation was followed by resection of the whole trachea and implantation of a tracheal prosthesis (Neville) in the case of a patient with extensive endo- and extraluminal tumour infiltration. An extensive recurrence led to the death of this patient 5 months after the surgical intervention. Because of the distal location, resection of the tracheal bifurcation was necessary in two patients, in one combined with a pneumonectomy on the right side. Stenosis of the main bronchus and development of granuloma made stent implantation unavoidable. Dislocation of the stents and recurrent pneumonia caused the patients deaths 74 days and 18 months postoperatively. On follow up 17, 93, and 120 months postoperatively none of the other patients had recurrences. Current diagnostic and therapeutic options for malignant tracheal tumours are discussed.

Lung cancer

BACKGROUND

Lung cancer is the most common cause of cancer death in the United States, and its incidence has been rising for at least 50 years. Shifts in histologic type and differences in sex and race distribution have accompanied the increased incidence of lung malignancies.

METHODS

Population-based data regarding lung cancer reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for the 15-year period 1973-1987 were analyzed.

RESULTS

Results indicate that from 1973-1977 to 1983-1987, the age-adjusted rates of lung cancer increased by 30%, with the gain markedly greater in women (70%) than in men (17%). The largest percentage increases in age-adjusted rates were observed for small cell carcinoma and adenocarcinoma (approximately 60% each), with a more modest change for squamous cell carcinoma (+ 14%). For squamous cell carcinoma, the age-adjusted rates increased substantially for black (65%) and white (70%) women and only slightly for black men (10%), whereas it decreased slightly in recent years for white men.

CONCLUSIONS

In recent years, adenocarcinoma has replaced squamous cell carcinoma as the most frequent histologic subtype for all sexes and races combined. These shifts in histologic types by sex and race may be related to differences in exposure to tobacco products, dietary factors, environmental or occupational carcinogens, and host characteristics. Increased use of transbronchial and needle biopsy may have also influenced these trends to some extent. Over the study period, 5-year relative survival rate did not change appreciably for lung cancer, suggesting that therapeutic advances have had little effect.

Treatment of primary squamous cell carcinoma of the trachea: the role of radiation therapy

Eleven patients with SCC of the trachea were treated (ten primarily, one postoperatively) with megavolt irradiation (four in combination with brachytherapy). A median survival of 31 and a median disease free survival of 7.5 months was observed. Factors favourable for survival were the achievement of complete remission, the absence of mediastinal lymphnode involvement, and the use of additional brachytherapy.

Primary tumours of the trachea: analysis of clinical features and treatment results

Primary tracheal tumours are extremely rare and present with widely variant clinical and histological features. Treatment methods vary considerably, and few studies have sought to provide adequate guidelines. A retrospective analysis was carried out of all patients treated in our unit between 1965 and 1990. Our experience deals almost exclusively with high tracheal tumours involving the adjacent subglottic region. Squamous carcinoma (SCC) and adenoid cystic carcinoma (ACC) were the commonest subtypes, and presented with dyspnoea and hoarseness as the most frequent symptoms. ACCs occurred commonly in young individuals, presented insidiously, and ran a long, and often, unpredictable course. Endoscopic evaluation revealed the majority of the lesions to be bulky and obstructive in nature. Primary surgery with adjuvant radical radiotherapy, when indicated, appeared to provide optimal results. Debulking surgery followed by radiotherapy provided effective and lasting control in two cases of ACC. Other malignant subtypes behaved aggressively and progressed uncontrolled.

Risk factors involved in stomal recurrence following laryngectomy

Stomal recurrence after surgery for laryngeal tumours is an extremely serious complication, with a dismal prognosis despite aggressive surgical therapy or high-dose irradiation. Data from 209 patients who underwent total laryngectomy for cancers of the larynx and hypopharynx were retrieved from the registry of the Department of Otorhinolaryngology at the Hospital 'Virgen de las Nieves' of Granada. Stomal recurrence developed in 8.1 per cent of them (17 cases). We analysed several parameters from each case: first, those parameters significantly associated with stomal recurrence were detected, and secondly, a logistic regression analysis was done. Three factors were found independently related to stomal recurrence: T-staging, site of the primary tumour and prior tracheostomy. Together with a review of the literature, we discuss our findings and a proposal for management of the high risk patient.