Adult Chest Surgery

Chapter 51. Overview 

Upper airway tumors encompass a wide variety of epithelial and soft tissue neoplasms that are relatively rare and usually malignant. Squamous cell and adenoid cystic carcinoma are the most common. Definitive diagnosis is often delayed because the symptoms associated with upper airway tumors are similar to those of more common pulmonary disorders such as chronic obstructive pulmonary disease. Although less invasive palliative treatment modalities are available, surgical resection with airway reconstruction usually offers the best chance for an excellent long-term prognosis. Figure 51-1 shows the normal upper airway anatomy.

Figure 51-1.

 

Anatomy of the upper airway.

ETIOLOGY

Neoplasms can arise from any of the tissues present in the trachea and main stem bronchi. These tissues include the columnar ciliated mucosa, the submucosa (which contains a significant number of mucus glands), cartilage, and connective tissues. Accordingly, the types of upper airway tumors are numerous (Table 51-1). Tumors are classified as benign or malignant and epithelial or soft tissue in origin. Lesions are evenly distributed throughout the length of the trachea.

Table 51-1. Upper Airway Tumors

 

Benign

Malignant

Epithelial

Papilloma

Mucous gland adenoma

Pleomorphic adenoma

Monomorphic adenoma

Myoepithelioma

Epithelial-myoepithelial tumor

Oncocytoma

Squamous cell carcinoma

Adenoid cystic carcinoma

Carcinoid tumors

Mucoepidermoid carcinoma

Adenocarcinoma

Small cell carcinoma

Combined small cell carcinoma

Large cell carcinoma

Large cell neuroendocrine carcinoma

Acinic cell carcinoma

Malignant salivary gland-type mixed tumors

Pleomorphic carcinoma

Spindle cell carcinoma

Giant cell carcinoma

Carcinosarcoma

Pulmonary blastoma

Soft tissue

Chondroma

Glomus tumor

Hemangioma

Hemangioendothelioma

Granular cell tumor

Hamartoma

Leiomyoma

Lipoma

Neurofibroma

Schwannoma

Chondrosarcoma

Angiosarcoma

Kaposi's sarcoma

Leiomyosarcoma

Rhabdomyosarcoma

Liposarcoma

Fibrosarcoma

Hemangiopericytoma

Malignant fibrous histiocytoma

Neurogenic sarcoma

Osteosarcoma

Synovial sarcoma

Miscellaneous

Inflammatory pseudotumor

Inflammatory myofibroblastic tumor

Malignant lymphoma

Primary pulmonary melanoma

Metastases

 

In adults, most upper airway tumors are malignant.1–3 Extremely rare, their incidence is much lower than carcinomas of the larynx and lung. In fact, upper airway tumors account for less than 0.2% of all respiratory tract malignancies.The malignant epithelial tumors, squamous cell carcinomas, and adenoid cystic carcinomas are the most common primary tracheal malignancies, followed by carcinoid and mucoepidermoid carcinomas.1–3,5–11Benign tumors represent a wide variety of histologic types. The most common are squamous papilloma, pleomorphic adenoma, and benign cartilaginous tumors.3

Squamous Cell Carcinoma

Although squamous cell carcinoma usually occurs in lobar and segmental bronchi, it is the most common neoplasm of the trachea and main stem bronchi.3,7,12 Squamous cell carcinoma of the trachea occurs most commonly in males between the ages of 50 and 70 years and is associated with cigarette smoking.2,3,13 Squamous cell carcinoma has papillary and basaloid variants and usually appears as a well-localized, exophytic, ulcerated lesion. Squamous cell carcinoma also can occur as a focally invasive component of a squamous papilloma. The cancer may spread to regional tracheal lymph nodes and directly into mediastinal structures. Approximately one-third of patients have mediastinal or pulmonary metastasis at the time of diagnosis.5

Adenoid Cystic Carcinoma

Adenoid cystic carcinoma, a salivary gland type, is the second most common primary upper airway malignancy.3,7,12 The mean age for patients with tracheal adenoid cystic carcinoma is 44 years.14 Adenoid cystic carcinoma appears to be unrelated to smoking and is evenly distributed between males and females.3,6,13 These neoplasms, which can have cribriform, tubular, or solid histologic features, generally have a much slower growth pattern and more insidious onset than squamous cell carcinoma. Although histologic pattern is important, prognosis appears to be more a function of disease stage.15

Adenoid cystic carcinoma growth patterns are either nodular, infiltrative (in which the tumors grow submucosally without producing a distinct mass), or of mixed nodular and infiltrative type.6,16 Tumors can spread along the airways and involve a long length of trachea by submucosal and perineural spread without involving adjacent mediastinal structures.14 The microscopic level of invasion often exceeds that which is grossly apparent. Negative resection margins can be difficult to achieve, although long-term disease control has been reported with positive surgical margins.2,14 Tumors also can spread radially into adjacent parenchyma and lymph nodes. These tumors tend to displace rather than invade mediastinal structures.16 Approximately 10% of adenoid cystic carcinomas metastasize to regional lymph nodes.3,11,13 When these tumors metastasize, they locate predominantly in the lung, bone, and liver. Patients can have extended survival despite the presence of pulmonary metastases, which tend to progress very slowly.1,14

Carcinoid Tumors

Carcinoid tumors are malignant neuroendocrine tumors that make up to 4% of all primary lung tumors.17,18 Although most bronchial carcinoid tumors arise in lobar bronchi or the lung periphery, 10% originate in the main stem bronchi.19 Carcinoid tumors appear as fleshy, highly vascular masses. Typical carcinoid tumors are low-grade malignancies with no necrosis and fewer than 2 mitoses per 2 mm2. Typical carcinoids occur equally in men and women, most commonly around age 50, and are not associated with smoking or any other toxic exposure.Hilar and mediastinal lymph node metastases occur in 5–10% of patients but are not necessarily associated with poor survival.20 Atypical carcinoids, which comprise approximately 10–20% of all carcinoids, have 2-10 mitoses per 2 mm2 or a foci of coagulative necrosis. The atypical carcinoids are consistently associated with smoking and 30–75% incidence of lymph node metastases.20 Most pulmonary carcinoid tumors, typical and atypical combined, present with obstructive-type symptoms. Carcinoid syndrome symptoms are uncommon with pulmonary carcinoid tumors.

Salivary Gland-Type Tumors

Salivary gland-type tumors, other than adenoid cystic carcinoma, also can arise from the mixed submucosal seromucinous glands and ducts. These tumors are found in the trachea and main stem bronchi but occur much more frequently in lobar bronchi.Patients usually present with wheezing or hemoptysis caused by airway tumor growth. Tracheobronchial salivary gland-type tumors are histologically indistinguishable from those arising in the major salivary glands. Benign tumors include mucous gland adenomas, pleomorphic adenomas (also known as benign mixed tumors), oncocytoma, monomorphic adenomas, myoepitheliomas, and epithelial-myoepithelial tumors. Malignant salivary gland-type carcinomas, in addition to adenoid cystic carcinoma described earlier, include low- and high-grade mucoepidermoid carcinoma, acinic cell carcinoma, and salivary gland-type mixed tumors. Other rare salivary gland-type carcinomas that can occur in endobronchial locations are pleomorphic carcinoma, spindle cell carcinoma, giant cell carcinoma, carcinosarcoma, and pulmonary blastoma.

Other Epithelial Neoplasms

Papillomas are benign tracheobronchial epithelial tumors composed of connective tissue with an overlying epithelial surface. Tracheobronchial papillomas generally have an exophytic growth pattern, and their appearance, endoscopically and grossly, resembles a sessile cauliflower-like mass occupying the airway lumen.21 Papillomas are subclassified as squamous cell, glandular, or mixed depending on the type of epithelial lining contained in the tumor.Squamous cell papillomas, by far the most common type, are associated with human papillomavirus types 6 and 11 and can be either solitary or multiple (squamous papillomatosis).21,22 The epithelium in these tumors can become dysplastic and progress to carcinoma.

Endobronchial Carcinomas

Although most pulmonary adenocarcinomas are peripheral and involve the larger airways secondarily, endobronchial adenocarcinomas that are histologically distinct from the salivary gland-type tumors do exist.23 These polypoid lesions have a similar prognosis to the more common peripheral adenocarcinomas.Similarly, one can encounter endobronchial small cell, combined small cell, large cell, and large cell neuroendocrine carcinomas. Combined small cell carcinoma is defined as a small cell carcinoma with an additional component of any non-small cell carcinoma histologic type. Large cell carcinoma lacks squamous or glandular differentiation and small cell carcinoma cytologic features; large cell neuroendocrine carcinoma is a variant of large cell carcinoma with neuroendocrine differentiation.

Soft Tissue Neoplasms

The fibroconnective tissues of the trachea and bronchi, which include cartilage, smooth muscle cells, fibroblasts, adipocytes, nerves, lymphatics, and blood vessels, all can give rise to a variety of benign and malignant soft tissue tumors. These tumors are rarer than primary epithelial malignancies of the airway. Hamartoma, the most common benign lung tumor, is a mesenchymal neoplasm that contains adipose tissue, fibrous tissue, and cartilage. These tumors occur mostly in the lung parenchyma, although approximately 10% present in an endobronchial location.Chondromas and chondrosarcomas arise in the cartilaginous rings of the large bronchi or trachea. Glomus tumors are lesions with smooth muscle features that arise from the posterior membranous trachea. Granular cell tumors are polypoid endobronchial lesions that can invade peribronchial structures.

Vascular tumors such as hemangiomas, hemangioendotheliomas, angiosarcomas, and Kaposi's sarcoma occur rarely. Similarly, primary pulmonary leiomyomas, leiomyosarcomas, rhabdomyosarcomas, lipomas, liposarcomas, and osteosarcomas are rare tumors that have been found endobronchially. Other sarcomas, such as fibrosarcoma, hemangiopericytoma, malignant fibrous histiocytoma, and synovial sarcoma, have been reported but occur primarily in the lung periphery.Nerve sheath tumors such as neuorofibroma, schwannoma, and neurogenic sarcoma also can occur endotracheally, although these lesions are found far more often in the posterior mediastinum.6

Miscellaneous Tumors

Inflammatory pseudotumor and inflammatory myofibroblastic tumors are lesions composed of a spectrum of fibroblastic or myofibroblastic proliferations with a varying infiltrate of inflammatory cells that can occur as endobronchial and endotracheal masses as well as in the lung parenchyma.The airways also can be involved with lymphoma, either from disseminated disease from a nodal lymphoma or from a primary pulmonary lymphoma arising in bronchial-associated lymphoid tissue. Melanoma, whether in the form of metastatic disease or much more uncommonly a primary pulmonary melanoma, can occur in a similar manner. Thyroid and laryngeal carcinomas can involve the upper trachea by direct extension. Tracheal and main stem bronchi invasion also can result from metastasis from other primary malignancies, including primary pulmonary adenocarcinomas, malignant mesothelioma, and breast, colon, and renal cell adenocarcinomas.

CLINICAL PRESENTATION

Patients with upper airway neoplasms typically present with slowly progressive respiratory symptoms such as dyspnea, cough, hemoptysis, wheezing, stridor, excessive secretions, and recurrent pneumonia6,9,10,13 (Table 51-2). The rate of progression of symptoms tends to be slower with benign tumors and adenoid cystic carcinoma and more rapid with bronchogenic cancers. Because tracheal neoplasms tend to be slow growing, symptoms owing to upper airway obstruction, irritation, or ulceration can continue for months or even years. Acute life-threatening airway emergencies secondary to near-complete airway occlusion are uncommon but can occur. Symptoms related to involvement of adjacent structures, such as hoarseness and dysphagia, are generally less frequent but also can occur. The peak incidence range of the more common upper airway neoplasms is between the ages of 40 and 60 years. Tumors other than squamous cell carcinoma and adenoid cystic carcinoma have a scattered age distribution but tend to occur more commonly in young adults.4

Table 51-2. Symptoms of Upper Airway Neoplasms

Cough

Dyspnea

Recurrent pneumonia

Hemoptysis

Wheezing

Stridor

Excessive secretions

Hoarseness

Dysphagia

Acute respiratory difficulty

 

The more common pulmonary conditions, including pneumonia, asthma, and chronic obstructive pulmonary disease, are usually suspected on initial presentation. Medical treatments often are attempted for a period of time for presumed parenchymal disease before a tracheal tumor is correctly diagnosed, especially because most patients have a normal initial chest x-ray report. A high index of suspicion therefore is needed to diagnose tracheal neoplasms at an early stage. Any patient with adult-onset asthma, and especially any patient with unilateral wheezing on physical examination, should be suspected immediately of having an upper airway tumor. Diagnoses usually are made more rapidly when patients have hemoptysis, which is most common with squamous cell carcinoma, because bronchoscopy generally will be performed even with a normal chest x-ray.13 Tumors often are locally advanced at the time of diagnosis owing to the slow progression of symptoms. Patients with a short duration of symptoms thus are more likely to be resectable.

DIAGNOSIS AND STAGING

The evaluation of patients with tracheal tumors typically starts with a chest x-ray. Tracheal narrowing, postobstructive atelectasis or pneumonia, or abnormal calcification on chest x-ray can suggest the presence of a tracheal tumor. Fewer than half of tracheal tumors are identified by an initial chest radiograph, which, as mentioned earlier, often leads to a delay in diagnosis. Pulmonary function tests are often used to evaluate the presenting symptoms, and flow-volume loops can indicate upper airway obstruction with plateauing of the inspiratory or expiratory phase in the presence of an upper airway neoplasm. An obstructive pattern with no response to bronchodilators suggests a fixed upper airway obstruction. Pulmonary function tests are also useful for preoperative evaluation and to predict postoperative lung function. Laboratory tests are not helpful in the diagnosis of tracheal tumors.

CT scan of the chest and endoscopic airway evaluation by bronchoscopy should be initiated early in the evaluation of any patient suspected of having an upper airway lesion. Chest CT scanning is capable of demonstrating a tracheal mass, local tumor extent such as mediastinal involvement either by enlarged lymph nodes or by direct tumor extension into adjacent structures, and distant disease spread. Although chest CT scanning historically was thought to identify great vessel invasion, it did not reliably predict tumor length or esophageal invasion. Helical CT scanning is the preferred method for assessing both tumor growth and longitudinal extent along the tracheal or bronchial wall.16

Bronchoscopy is essential to confirm the diagnosis and extent of intraluminal involvement. It is used for precise measurement and biopsy to define the margins of the lesion. This information is essential for planning the surgical resection because tumor length is a key component in determining resectability. Endobronchial ultrasound also can be performed during bronchoscopy to further evaluate local tumor extent. Endobronchial ultrasound gives visualization of the airway wall to evaluate for tumor invasion into surrounding structures, as well as peritracheal and peribronchial lymph nodes.24,25 Flexible bronchoscopy is used primarily to evaluate tracheal tumors and to obtain biopsy. However, flexible bronchoscopy is ineffective for establishing airway control, and rigid bronchoscopy should be used to establish a patent airway in patients with life-threatening conditions such as significant upper airway obstruction or massive hemoptysis. Tracheotomy may complicate any subsequent resection attempt and should be avoided whenever possible for acute airway emergencies. As discussed below, local treatment of tracheal tumors can be performed during both flexible and rigid bronchoscopy as both palliative and curative efforts. Caution is required, however, because bronchoscopic manipulation of airway tumors can lead to complete airway compromise. Biopsy is also contraindicated if the tumor appears to be highly vascular.

Further staging workup should be initiated as needed if a malignant lesion is diagnosed. Laryngoscopy is performed if the tumor involves the subglottic airway or if there is vocal cord dysfunction. Other studies to evaluate regional and distant metastases can include head CT scanning, brain MRI, bone scanning, and positron-emission tomography (PET) scanning. Mediastinoscopy is used to stage bronchogenic carcinoma and also can be useful for direct evaluation of extraluminal spread. As described earlier, mediastinoscopy should be done at the time of planned resection.8

SURGICAL TREATMENT OPTIONS

The optimal therapy for upper airway tumors is airway surgical resection and reconstruction. The underlying goal is to preserve as much lung tissue as possible. Excessive longitudinal extent that precludes safe reconstruction, macroscopic mediastinal nodal metastases, and distant metastases are the key elements that make upper airway cancers unresectable. Direct invasion of mediastinal structures, such as the aorta and the esophagus, precludes resection if the involved mediastinal structure cannot be repaired primarily. Unfortunately, early diagnosis is uncommon owing to the lack of early symptoms and because regional spread beyond the trachea often has occurred by the time of detection. The true percentage of unresectable upper airway cancers is unknown. The reported resectability rates vary from 9% to 74%.2,26,27 Advances in tracheal mobilization likely have increased the number of resectable tumors, and all reasonable surgical candidates should have operative exploration if resectability is in question. Patients expected to require chronic postoperative mechanical ventilation have significant morbidity and mortality and should not undergo attempted resection.A useful guide for resectability is the predicted postoperative forced expiratory volume in 1 second, with a minimum value of 800 mL denoting a suitable candidate for surgery.

Prognosis generally depends on tumor histology, stage, and overall patient status.11,28–31 Patients with complete resection of benign or low-grade tracheal tumors are likely to have recurrence-free long-term survival. The overall prognosis for malignant lesions historically is poor, with a median survival of 6 months and a 10–20% 2-year survival.28 Overall survival after tracheal tumor resection is 36–79% at 5 years and 27–57% at 10 years. Surgical resection is associated with 5-year survival rates of 13–50% for squamous cell carcinoma and 52–80% for adenoid cystic carcinoma.13,14,28,31,32

Positive lymph nodes and positive resection margins are much worse prognostic factors for squamous cell carcinoma than for adenoid cystic carcinoma.2,14 After resection, typical carcinoid tumors have 5- and 10-year survival rates of 95% and 90%, respectively, whereas atypical carcinoids have a worse prognosis, with 5- and 10-year survival rates of 61% and 35%, respectively.Median survival rates in patients with unresectable malignant tumors who are treated primarily with radiation ranges from 6 to 31 months, and the 5-year survival rate is 8–27%.27–30

Operative mortality generally depends on both the physiologic impact of the procedure and the length of the airway resection and has improved dramatically over time as surgical judgment and techniques have been refined. Overall operative mortality is 5-10% and is expected to be lowest in centers where tracheal surgery is performed commonly.2,13,14 Operative mortality after tracheal resection has been reported to be as low as 1%, with a 12-15% mortality after carinal resection.2,31 Predominant predictors of operative death after carinal resection include postoperative mechanical ventilation, length of resected airway, and development of anastomotic complications.Anastomotic complications have been observed in 17% of patients undergoing carinal resection and almost always result in death or require surgical reintervention.Early anastomotic complications include necrosis. Late anastomotic complications include stenosis and formation of excessive granulation tissue. Other relatively common complications after resection include atrial arrhythmias and pneumonia.

Illustrated techniques for surgical management of upper airways cancers are presented in Chapters 54, 55, 56, 57, and 58. Endoscopic management is covered in Chapter 59.

NONSURGICAL MANAGEMENT

Treatment modalities for patients with unresectable tumors or for those who cannot tolerate or refuse surgery include external-beam radiation therapy and several bronchoscope-based tumor ablation techniques. Chemotherapy generally is not useful for treating upper airway neoplasms, although it is used often in combination with radiation for bronchogenic tumors. Bronchoscopic destructive techniques include mechanical debridement, laser treatment, cryotherapy, brachytherapy, airway stent placement, photodynamic therapy, and argon plasma coagulation. These nonsurgical treatments generally are designed to ensure airway patency and are performed either for palliation alone or with curative intent depending on the modality. Tumor resectability ideally should be determined before instituting any of these treatment modalities because they can preclude future safe resection. Preoperative radiation in particular may compromise anastomotic healing and make subsequent resection riskier. These techniques may be used, if necessary, to stabilize a patient's airway. They also permit better preoperative preparation and staging, including local downstaging of tumor, permitting subsequent resection.26 Nonsurgical treatments for patients with acute airway compromise and patients who are not candidates for surgical resection are broadly categorized as curative or palliative. Modalities used with curative intent include external-beam radiation therapy, brachytherapy, and photodynamic therapy. Bronchoscopic techniques used for palliation include endobronchial debridement or mechanical core out using a rigid bronchoscopy, laser treatment, cryotherapy, argon plasma coagulation, and airway stent placement.

Curative Intent

External-beam radiation may be used postoperatively to prevent local disease recurrence, especially with positive or close margins. Resection combined with postoperative radiation results in the best local tumor control rate.33 Radiation also has a use for inoperable patients either for palliation or with curative intent. Adenoid cystic carcinoma appears to be more radiosensitive than squamous cell carcinoma. Higher-dose radiation (>60 Gy) is needed for prolonged local control and long-term survival but is also associated with more complications.27,28,30 Common acute complications are cough and dysphagia, although tracheal necrosis also has been reported.27Late complications include radiation pneumonitis, tracheoesophageal fistula, and esophageal stricture.28,30,33

Brachytherapy involves the implantation or temporary placement of radioactive material in the airway to deliver relatively high-dose radiation to the tumor and immediately adjacent tissue with minimal dose to surrounding structures.34 Brachytherapy may be used as a primary treatment, to improve local control after either resection or external-beam therapy, and for recurrent tumors, especially those already treated with primary radiation therapy.27–29 A catheter is placed using the flexible bronchoscope with fluoroscopic guidance and secured in place. Dummy seeds with radiopaque markers are used to confirm proper catheter position. Radioactive seeds containing a high-dose-rate source, such as a high activity iridium-192 radioisotope, then are implanted into the catheter. Most patients are treated with one to six fractions over several days to weeks on an outpatient basis. Endobronchial brachytherapy is generally well tolerated, although late complications can include radiation bronchitis, stenosis, and massive hemoptysis owing to bronchovascular fistula.

Photodynamic therapy is used with both curative intent and for palliation to destroy airway tumor while maintaining the structural integrity of surrounding tissues.35 A photosensitizing drug containing hematoporphyrin is administered and accumulates in malignant tissue. The subsequent exposure to activating light from a nonthermal laser generates reactive oxygen species that destroy the tumor by a combination of effects, including direct cell kill, destruction of tumor neovascularization, and the resulting immunologic response.36,37 Photodynamic therapy generally is administered using flexible bronchoscopy under local anesthesia, with cleanup bronchoscopy a few days later to remove the resulting necrotic tissue.

Palliation

Upper airway obstruction secondary to tumor can be relieved by several other bronchoscopic techniques.36 Tumors can be debrided mechanically by means of rigid bronchoscopy, although this technique can be limited by bleeding. Laser treatment, cryotherapy, and argon plasma coagulation can be administered using flexible or rigid bronchoscopy to cause tumor ablation by means of necrosis, permitting subsequent safer mechanical debridement. Although these techniques are used mostly for palliative purposes in patients who are not surgical candidates, tumor debulking also may permit future resection or limit the extent of a future parenchymal resection in selected patients.38–40

Tracheobronchial stents also can be used to provide effective and durable palliation in patients with large-airway obstructions caused by intraluminal tumors.41 Stents maintain airway patency before or during surgical or radiation treatment or after other endoscopic treatments.40 The choice of stent, either nonexpandable silicone or expandable metal, is determined by the anatomy of the lesion and the preference of the placing physician. Silicone stents are inexpensive, can be repositioned and removed easily, initiate little tissue reactivity, and are associated with minimal tumor ingrowth. However, silicone stents require rigid bronchoscopy and general anesthesia for delivery and have the potential for dislodgment, migration, and plugging owing to secretions. Expandable metal stents can be delivered more easily using flexible bronchoscopy with local anesthesia and fluoroscopy. Metal stents exhibit better airway conformation and less potential for migration but are also essentially permanent. Metal stents covered with a layer of silicone or polyethylene should be used when the airway mucosa is not intact to prevent recurrent airway obstruction caused by ingrowth of tumor into the stent.

CURRENT CHALLENGES

Lack of a suitable graft or conduit to reconstruct or replace the native trachea is a problem that has plagued surgeons from the inception of tracheal surgery. It is the only thoracic structure for which a suitable replacement has not been found. Conduits readily used for esophageal surgery such as colon, jejunum, or Dacron graft are too malleable to substitute for the rigid but flexible native organ. Using current methods, only about half the trachea (5 cm) can be resected and still deliver a durable, tension-free anastomosis. Disease that extends to and involves resection of the carina is even more difficult to resect. Since upper airway tumors are rare, slow growing, and initially frequently mistaken for other more common pulmonary disorders, diagnosis is often delayed, and submucosal spread of tumor often exceeds the limits of resectability. Age is another factor that limits accessibility to the lesion. Consequently, meticulous technique (see Chaps. 54, 55, 56, 57, and 58) has evolved to stretch the limits of tracheal resection.

FUTURE DIRECTIONS

A number of studies have been conducted in animal models (e.g., sheep and pig) using vascular grafts toward the goal of finding a suitable substitute for tracheal and carinal reconstructions.42 In humans, reports describing the use of aortic autograft for long tracheal reconstruction have yielded promising results.43 Preceding studies in animal models have demonstrated the aortic allograft to have several unique properties that would render it a suitable alternative for long tracheal replacement.44 It is less immunogenic than other vascular grafts, accounting for the lack of acute or chronic rejection, and it precludes the necessity of long-term immunosuppression, an important factor in survival and quality of life. The graft also appears to be sufficiently rigid to substitute for the native trachea. Most notably, however, it has a demonstrated ability for long-term tracheal regeneration, complete with a stable, viable respiratory endothelial lining. Although it is premature to conclude that aortic allograft will prove to be a suitable reproducible technique for long tracheal reconstruction, the results are promising and bear further scrutiny.

EDITOR'S COMMENT

Malignant tumors that involve trachea are often unresectable. This is the case particularly for squamous cell carcinoma. Even in cases where the radiographic studies suggest that the tumor can be removed, the patient and the surgeon must be prepared for the possibility that exploration will reveal that the tumor has infiltrated adjacent tissues, including blood vessels, and resection will have to be aborted. Another tumor that commonly involves trachea is thyroid cancer, which invades the trachea by direct extension. If technically possible, this tumor should be excised en bloc with the thyroid, and a tracheal reconstruction should be performed.

–RB

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