Adult Chest Surgery

Chapter 56. Resection of the Carina 

Roughly 90% of all carinal resections are performed for airway neoplasms. The true incidence of primary tracheal tumors is undetermined, but they are extremely rare. In one series of 1744 cancer deaths, only 2 were attributed to tracheal malignancy, whereas in 89,600 autopsies, only four tracheal tumors were found.1 The carinal tumor is a subcategory of tracheal tumors and hence even less common. Most carinal tumors are malignant and are categorized as bronchogenic carcinoma or other airway neoplasms. Bronchogenic carcinomas are, by definition, malignant. Other airway neoplasms may exhibit a wide range of behavior. As shown in Table 56-1, the most common histologies are squamous cell carcinoma (SCC) and adenoid cystic carcinoma (ACC).2 These are the two most common malignant primary tracheal neoplasms. SCC arises primarily in smokers in the sixth and seventh decades. On presentation, the mass is either confined to the trachea or there may be invasion into adjacent mediastinal structures.

Table 56-1. Histologic Types of Carinal Neoplasms from a Single Institution, 1962–1996.

Bronchogenic carcinoma (n = 58)

  Squamous cell carcinoma

42

  Adenocarcinoma

10

  Large cell carcinoma

4

  Small cell carcinoma

1

  Bronchioloalveolar carcinoma

1

Other airway neoplasms (n = 60)

  Adenoid cystic carcinoma

37

  Carcinoid

11

  Mucoepidermoid carcinoma

7

  Malignant fibrosing histiocytoma

2

  Fibrosarcoma

1

  Mixed spindle cell carcinoma

1

  Granular cell tumor

1

 

From Ashiku SK, Mathisen DJ: Carinal resection. In Yang ST, Cameron DE (eds): Current Therapy in Thoracic and Cardiovascular Surgery. St Louis, Mosby, 2004:179.

ACC is an exophytic intratracheal lesion that to a variable extent involves the tracheal wall (Fig. 56-1). Initially, the mass may compress the mediastinal structures without direct invasion. Lymph node metastasis is less common in ACC than in SCC. A characteristic feature of ACC is its proclivity to extend for long distances submucosally and perineurally.

Figure 56-1.

 

Adenoid cystic carcinoma invading through the anterior carinal wall into the mediastinal space and abutting the superior vena cava.

CLINICAL PRESENTATION

Patients with carinal tumors commonly present with symptoms and signs of central airway obstruction. As the diameter of the airway decreases, patients begin to experience worsening dyspnea, often progressing to wheezing and stridor. Dyspnea on exertion occurs when the airway diameter is less than 8 mm, and stridor develops when the airway is less than 5 mm.3 Chest radiographs may demonstrate a mass in the tracheobronchial airway column, but these findings are often subtle and usually missed. Consequently, patients are commonly misdiagnosed with adult-onset asthma, and the true diagnosis is delayed. Diagnosis may be facilitated in patients presenting with postobstructive pneumonia or cough with hemoptysis. Extensive tumors may be heralded by hoarseness, dysphagia, or chest discomfort, suggesting a more diffuse or extensive mediastinal invasion.

DIAGNOSTIC AND STAGING STUDIES

Chest radiographs can appear normal despite significant tracheobronchial obstruction, but careful evaluation often demonstrates the outline of a mass within the airway column. Until recently, carinal tomograms were considered useful for revealing the location and extent of the lesion and permitting assessment of the uninvolved proximal and distal airway. With carinal tomograms, virtually all the essential information was provided in a single view, giving the surgeon an accurate assessment of the extent of the lesion. However, CT scanning has virtually replaced the carinal tomogram. High-speed multidetector helical CT scanners that acquire images combined with powerful three-dimensional image re-formation software now create impressive two- and three-dimensional airway reconstructions (Fig. 56-2). CT scanning also has proved to be critical for evaluating extraluminal extension and enlarged regional mediastinal lymph nodes, detail that conventional tomograms cannot provide (see Fig. 56-2C).

Figure 56-2.

 
 
 

A. Two-dimensional sagittal airway CT reconstruction showing the linear extent of the airway extension. B. Three-dimensional airway CT reconstruction of same carinal neoplasm as viewed by virtual bronchoscopy. C. CT scan of carinal neoplasm with involvement of adjacent peribronchial lymph nodes.

 

When a high degree of obstruction exists, the airway can be reopened endoscopically. Endoscopy palliates the acute symptomology and permits a greater degree of preoperative assessment and preparation, as well as safe delivery of anesthesia. Patients with postobstructive pneumonia in particular do better when the obstruction is relieved, the pneumonia is treated, and the central airways are cleared of purulence in advance of definitive resection and reconstruction (Fig. 56-3D–F). The airways can be cleared with a rigid ventilating bronchoscope under general anesthesia without respiratory paralysis. Using the tip of the bronchoscope as a coring device, the side with the least obstruction is cleared first. Significant bleeding is rarely a problem and can be handled with the usual techniques of rigid bronchoscopic tamponade and the judicious use of topical epinephrine solution or iced saline, clearing the way for unimpeded bronchoscopic examination.4

Figure 56-3.

 
 
 
 
 
 

A-C. Adenoid cystic carcinoma of carina causing a postobstructive pneumonia. D-F. Obstruction relieved by bronchoscopic core-out of tumor enabling effective treatment of the postobstructive pneumonia.

The metastatic workup is similar to that for lung cancer and should include a chest CT scan, brain MRI, and total-body PET scan to assess for extraluminal extension, nodal basins, and distant metastases. Bronchoscopy permits tissue diagnosis and reveals the intraluminal extent of the tumor.

Mediastinoscopy is ideally reserved for the day of resection and is used to assess tumor resectability, to evaluate regional lymph node status, and to begin central airway mobilization. By performing the mediastinoscopy coincident with the planned resection, one can avoid the scarring and decreased mobility associated with a staged approach. Patients with bronchogenic carcinoma and N2 disease should be considered unresectable, and surgery should be performed only in a protocol setting. Patients with ACC may benefit from resection despite nodal involvement.5

ANESTHESIA

Working with an experienced anesthesiology team is essential for successful carinal resection. Placing a patient with a partial airway obstruction under general anesthesia is potentially hazardous. Replacing spontaneous breathing by positive-pressure ventilation creates the risk of converting from a partial to complete obstruction. When problems with maintaining the airway are foreseen, a "breathe down" technique with an inhalation agent is used, and paralytics are given only after the airway is secured. This permits the patient to breathe spontaneously during the induction process, maintaining a favorable respiratory physiology. Once a stable airway has been secured, anesthesia is maintained with total IV anesthesia using short-acting agents such as remifentinil and propafenone. This technique permits immediate extubation at completion of the procedure and maintains continuous anesthesia during periods when inhalational agents are interrupted by the apneic intervals necessary to complete the procedure.

The administration of anesthesia through a rigid bronchoscope during tumor "core out" can be accomplished with either standard volume ventilation or with jet ventilation. Ventilating rigid bronchoscopes do not have balloon cuffs and, by necessity, have an open top to permit the passage of instruments. With standard volume ventilation, there is substantial air leak around the tip of the bronchoscope and out through the partially open top. Even when the instruments are inserted through a rubber diaphragm, the seal is imperfect, and substantial volume is lost. Consequently, a higher gas flow is required to compensate for the loss of effective tidal volume. Assessing the effectiveness of ventilation is performed by observing adequate chest excursions rather than end-tidal CO2 because returning gases leak out from the circuit. With jet ventilation, gas under high pressure is delivered to the source, resulting in higher flow rates and higher effective tidal volumes. The top of the bronchoscope must be left open to permit venting of excess volume/pressure in order to reduce the risk of barotrauma. Both methods are safe and effective in experienced hands. When thermoablative devices are used, special precautions are mandatory to prevent airway fires. We routinely ventilate at low FIO2 combined with periods of apnea to permit the oxygen to disperse before igniting any thermal devices. Clear communication and precise coordination with the anesthesiologist are essential.

Anesthesia for carinal resection is administered through an extralong armored endotracheal tube. Its flexibility permits bronchoscopic placement into one of the main stem bronchi. After transecting the airway, the orotracheal tube is pulled back into the trachea, and intermittent ventilation is performed with sterile cross-field equipment. The orotracheal tube is again advanced after the anastomosis is complete (Fig. 56-4). Jet ventilation on occasion can be useful, for example, when the left main bronchus is surgically foreshortened such that it will not accommodate an endotracheal balloon cuff. The small caliber of the tubing and lack of balloon cuff reduce clutter in the operative field and provide better exposure for suture placement. However, high-velocity airflow coupled with an open airway provides a vehicle for blood and airway secretions to mix and spray into the lungs and the operative field. This has the potential to increase the risk of both pleural and pneumonic infections. Additionally, the anesthesiology team must be proficient with the techniques of high-frequency jet ventilation. Excessive jet ventilation without time for passive exhalation results in hyperexpansion injury to the lung parenchyma. Conversely, inadequate jet ventilation results in a slow reduction in functional residual capacity because there is no mechanism to provide the positive end-expiratory pressure necessary to prevent alveolar collapse. The risk of adult respiratory distress syndrome (ARDS) is also greater with jet ventilation.6Cardiopulmonary bypass generally is not helpful and introduces unnecessary risks, although a rare circumstance may arise where it is required.

Figure 56-4.

 

Technique of cross-table ventilation with the left mainstem bronchus intubated from the operative field (A) until the anastomosis is nearly complete, when the endotracheal tube (B) is advanced by the anesthesiologist.

OPERATIVE TECHNIQUE

Mediastinoscopy is performed on the day of the proposed surgery not only to assess nodal status and resectability but also to facilitate resection and reconstruction by mobilizing the pretracheal plane while visualizing the recurrent laryngeal nerve. Scarring of the pretracheal plane from prior mediastinoscopy limits airway mobility, complicates the reconstruction, and increases the likelihood of injury to the left recurrent laryngeal nerve. Scar tissue also may be difficult to distinguish from tumor.

Choice of operative approach depends on the type of carinal resection, as well as on personal preference. Carinal resection alone or with right pneumonectomy can be performed comfortably through either a right thoracotomy or median sternotomy. Both approaches have their proponents.7,8 We prefer the right thoracotomy approach. Carinal resection with left pneumonectomy presents a unique challenge and is discussed later.

A standard right posterolateral thoracotomy in the fourth interspace creates excellent exposure of the carina and permits most resections to proceed through a single incision. Tumors that extend down the left main bronchus, precluding carinal reconstruction after complete resection, are approached with either median sternotomy, bilateral thoracotomy, or extended clamshell incision because each of these incisions permits sleeve pneumonectomy.

Once the right lung has been collapsed and retracted anteriorly, the pleura overlying the carina is incised, and the carina is exposed. The azygos vein is divided to facilitate exposure. The carina should be freed circumferentially by dissecting on the airway and avoiding the left recurrent laryngeal nerve. Dissection should be kept to a minimum, and skeletonization of the airway should be limited to the diseased segment (Fig. 56-5). Likewise, a balance must be struck between achieving adequate lymphadenectomy and maintaining the tracheobronchial blood supply. Tapes are placed around the trachea and both main stem bronchi. The inferior pulmonary ligament is released to permit greater mobility of the right lung while the equipment for cross-field sterile ventilation is prepared. The order of dividing the airway structures varies, but the trachea is commonly divided first. Preoperative bronchoscopic assessment by the surgeon directs the tracheal division just proximal to the tumor. An adequate margin then can be taken under direct visualization in the form of a complete ring and sent separately to pathology for intraoperative frozen section. The endotracheal tube then is removed to permit division of both main stem bronchi under direct endobronchial visualization. Adequate margins are taken of both distal bronchi and sent separately for frozen section. Only the left mainstem bronchus is reintubated, usually across the field, maintaining collapse of the right lung.

Figure 56-5.

 

Airway dissection is limited to the airway to be resected.

 

If mediastinoscopy is not performed, airway mobilization should be accomplished in the anterior plane up to the neck proximally and down the left mainstem bronchus distally. Additional airway mobility can be obtained by hilar release. This technique involves a U-shaped incision in the pericardium below the inferior pulmonary vein (Fig. 56-6).

Figure 56-6.

 

Hilar mobilization is performed by releasing the inferior pulmonary ligament and making a semicircular incision around the inferior pulmonary vein. More extensive circumferential incision is accomplished by extending the incision around the entire hilum along the dotted line. The pleura attached to the right mainstem bronchus posteriorly should be left intact to provide collateral blood supply to the anastomosis.

 

If required, the pericardium can be incised 360 degrees around the hilum for maximal mobility. In this event, the vascular and lymphatic pedicle to the mainstem bronchus is preserved and left behind the pericardium. Left-sided hilar release can only be accomplished easily through a median sternotomy by opening the pericardium anteriorly, through bilateral thoracotomies, or through an extended clamshell incision. As with most airway surgery, neck flexion is helpful. Laryngeal release has not been shown to produce meaningful mobility at the level of the carina.1

Placement of 2-0 Vicryl lateral traction sutures in the trachea and both bronchi permits easy handling of these structures during the reconstruction phase. The optimal mode of carinal reconstruction depends largely on the extent of the resection. In the series reported by Mitchell (n = 135), 15 different modes of reconstruction were used. The three most common methods, arranged in order of frequency, were (1) end-to-end anastomosis of the trachea to the left mainstem bronchus with reimplantation of the right mainstem bronchus into the trachea, (2) end-to-end anastomosis of the trachea to the right mainstem bronchus with reimplantation of the left mainstem bronchus into the bronchus intermedius, and (3) anastomosis of the trachea to the reapproximated left and right main stem bronchi creating a neocarina9 (Fig. 56-7).

Figure 56-7.

 

A. The most common carinal reconstruction consisting of end-to-end anastomosis of the trachea to the left mainstem bronchus with reimplantation of the right mainstem bronchus into the trachea. B. The next most common carinal reconstruction involving an end-to-end anastomosis of the trachea to the right mainstem bronchus with reimplantation of the left mainstem bronchus into the bronchus intermedius. C. Anastomosis of the trachea to a reapproximated left and right main stem bronchi creating a neocarina with the left mainstem bronchus anastomosed to the trachea and right mainstem bronchus.

 

The neocarina method is the simplest. However, it can only be used for cases that involve limited resection of the distal trachea and left main bronchus because the aortic arch limits the cephalad movement of the neocarina (Fig. 56-8). For this reason, end-to-end anastomosis of the trachea to the left mainstem bronchus with reimplantation of the right mainstem bronchus into the trachea is more common (Fig. 56-9). A right hilar release maneuver facilitates this procedure. More extensive resections require end-to-end anastomosis of the trachea to the right mainstem bronchus with reimplantation of the left mainstem bronchus into the bronchus intermedius. This technique obviates the need for extensive left mainstem bronchus mobility. If there is extensive endobronchial involvement, excessive lung destruction, or invasion of hilar vessels, carinal (sleeve) pneumonectomy is required.

Figure 56-8.

 
 

Example of a tumor requiring minimal resection of the left mainstem bronchus, creating a neocarina type of reconstruction. A. Preoperative imaging. B. Postoperative imaging.

 

Figure 56-9.

 
 
 

A. Adenoid cystic carcinoma with submucosal extension beyond the carina. B. Carinal reconstruction requiring end-to-end anastomosis of the trachea to the left mainstem bronchus with reimplantation of the right into the trachea (postoperative image). C. Technique for right main bronchus implantation into the side of the trachea.

 

The anastomosis is fashioned with interrupted simple 4-0 Vicryl sutures placed with knots tied outside the lumen (Fig. 56-10). Once reconstructed, the anastomoses are tested for air tightness to 40 mm Hg. All suture lines are wrapped circumferentially with pedicled flaps of pericardial fat or a broad-based pleural flap. In high-risk patients, especially those who have undergone prior radiotherapy, an intercostal flap stripped of all periosteum or an omentum pedicle is used. These flaps not only buttress the anastomoses but also separate them from the hilar vessels, helping to prevent bronchovascular fistulas.

Figure 56-10.

 

Interrupted polyglycolic acid suture placement with knots on the outside of the airway.

Carinal resection with left pneumonectomy is rarely required and presents a unique and difficult challenge. The long length of the left mainstem bronchus permits most carinal tumors to be resected with sufficient left mainstem bronchus remaining for a tension-free anastomosis. However, on rare occasion, a tumor extends distally from the carina to involve a large portion of the left mainstem bronchus. In this circumstance, an extended left bronchial airway resection would leave the left lung without sufficient left mainstem bronchus to reach around the undersurface of the aortic arch for a tension-free anastomosis. Thus the left lung cannot be salvaged, and a concomitant left pneumonectomy is required.

There is no single optimal incision to approach a carinal resection with a left pneumonectomy. The carina is best approached via a right thoracotomy or median sternotomy, whereas a left pneumonectomy is best approached via a left thoracotomy. Both single-incision approaches, left thoracotomy and median sternotomy, involve compromises in exposure. Through a left thoracotomy, the aortic arch limits access to the carina, making resection and reconstruction technically difficult and only possible when the carinal resection is limited. If the carinal resection is extended into the distal trachea, then safe resection and reconstruction are not possible through the left chest. Through a median sternotomy, access to the left hilar structures is limited, increasing the difficulty of the pneumonectomy. However, resections extending into the distal trachea are possible. Staged bilateral thoracotomies or bilateral thoracotomies that extend across the sternum at the fourth intercostal level (clamshell incision) are less technically demanding for the surgeon but are physiologically more burdensome for the patient. Recent technical advances ultimately may improve the exposure and reduce the morbidity associated with carinal resection with left pneumonectomy. For example, thoracoscopic resection techniques have been used to limit the morbidity of a staged approach using a minimally invasive left pneumonectomy after right thoracotomy for carinal resection and airway reconstruction. New suction retractors created for "off pump" coronary artery bypass surgery can be used via median sternotomy to lift the apex of the beating heart, permitting excellent exposure to the left hilar structures, particularly the left inferior pulmonary vein. Regardless of the approach used, carinal resection with left pneumonectomy remains a challenging operation with high morbidity and mortality.

When the disease is too extensive for resection, tumor core-out with or without expandable covered stents is often helpful. External beam radiotherapy and brachytherapy remain the standard palliative treatment.

POSTOPERATIVE ISSUES

The primary goals of intraoperative and postoperative care are promotion of anastomotic healing and maintenance of good pulmonary toilet. Ideally, patients should be extubated in the OR. The need for postoperative ventilation is a relative contraindication to carinal resection because it is a strong predictor of postoperative mortality.9 Patients with marginal lung function need to be managed carefully during the operation to prevent the need for postoperative ventilation. During the procedure, secretions and blood are cleared to keep them from running distally into the lungs, and it is important to avoid volume overload. Postoperatively, fluids are minimized, and patients are supplied with humidity by face mask to facilitate clearance of secretions. Most patients are able to clear the airway by coughing. Frequently, therapeutic flexible bronchoscopy is used to suction secretions under direct vision. Cervical flexion is maintained for 5–7 days with a chin-to-chest suture, after which time the patient is advised not to extend the neck for another week. Before removing the chin-to-chest suture, we routinely examine the anastomosis with flexible bronchoscopy to ensure normal healing. Oral alimentation is begun cautiously in the first few postoperative days. If there is any concern for injury to the left recurrent laryngeal nerve, a speech and swallowing evaluation, with or without video swallow, is obtained before oral feeding is initiated.

COMPLICATIONS

Few centers have reported a significant experience with carinal resection, and in those that have, the reported experience has been gathered from over several decades. The two largest series are by Mitchell and colleagues (n = 135) and Porhanov and colleagues (n = 231).6,9

In the series of Mitchell and colleagues,9 the overall mortality for all types of carinal resections over a 32-year period was 12.5%. Mortality in the initial 67 patients was 16.1%. However, the rate dropped to 9% for the last 67 patients as techniques and perioperative care evolved and outcomes improved. Overall morbidity was 39%. The two major complications were anastomotic complications and ARDS. Anastomotic complications occurred in 17% of patients. Early complications included necrosis, separation, and mucosal slough. Late complications were stenosis, excessive granulation tissue, and recurrent postobstructive pneumonia. Most of these sequelae required intervention. Anastomotic complications were associated with a 44% mortality rate. ARDS occurred in 10% of patients, usually occurring after carinal pneumonectomies, and was associated with a 90% mortality rate.9 The etiology of postpneumonectomy ARDS is unclear but may result from intraoperative overhydration and lung overinflations. These conditions can induce lung injury and interstitial edema in lungs that already have a disrupted lymphatic drainage system. Major postoperative complications were higher after carinal pneumonectomy than after carinal resection alone, with 30.8% mortality for left carinal pneumonectomy and 15.9% mortality for right carinal pneumonectomy. Complications associated with carinal pneumonectomy accounted for most of the postoperative deaths.9

Porhanov and colleagues reported a similar experience in 2002.6 Their overall mortality for all types of carinal resections over a 23-year period was 16%. Overall morbidity was 35.6%. Again, the two major types of complications were related to problems with the anastomosis and ARDS. Anastomotic complications occurred in 25.1% of patients. Dehiscence occurred in 9.1% of patients, all of whom died. Anastomotic complications were associated with a 36% mortality rate. ARDS occurred in 4.7% of patients and was associated with 81% mortality. Again, complications associated with carinal pneumonectomy accounted for most of the postoperative deaths.6

ADJUVANT THERAPY

The low incidence of carinal malignancies and their variable histology preclude the ability to make definitive statements about the merits of postoperative radiotherapy and chemotherapy. In the study reported by Regnard and colleagues, 70 of 143 patients with SCC, adenocarcinoma, and ACC were treated with radiotherapy postoperatively, whereas 4 of 143 patients were treated with combined chemoradiation postoperatively.10 There was no survival benefit in patients with negative operative margins, whereas a significant benefit was found for patients with positive surgical margins. No survival benefit was detected for patients with positive lymph nodes treated with postoperative radiotherapy.10 However, centers with the most experience have recommended the routine use of postoperative radiotherapy in all patients with a resected ACC and bronchogenic carinal neoplasms regardless of margin or lymph node status.11,12 The rationale for this approach is based on the inherently close margins accepted in carinal resections. A compromise is always made between the desire for negative margins and the necessity of achieving a tension-free anastomosis. The role of chemotherapy is even less well understood, and no evidence-based consensus can be derived.

PROGNOSIS

Carinal neoplasms are a rare and heterogeneous group, which limits the ability to determine prognostic factors for all histologies. However, limited prognostic data are available for bronchogenic carcinoma as a group and separately for ACC.

The three largest series for which 5-year survival data are available for resected bronchogenic carcinoma of the carina were reported, respectively, by Dartevelle and Macchiarini in 1996 (n = 60),13 Mitchell and colleagues in 2001 (n = 60),12 and Porhanov and colleagues in 2002 (n = 101).6 In these series, overall 5-year survival for resected patients was 43%, 42%, and 25%, respectively. The lower overall survival in the series by Porhanov and colleagues partly reflects the inclusion of bronchogenic carcinoma with N2 nodes invasive into the carina. Separated from the overall group, the N2 group had only 2.6% 5-year survival. In the series reported by Mitchell and colleagues, 57% presented with N0 disease, 25% had N1 disease, and 18% had N2/N3 disease. Lymph node status strongly influenced survival. The 5-year survival of N0, N1, and N2/N3 patients was 51%, 32%, and 12%, respectively (see Fig. 56-3). Microscopically positive margins did not affect survival. Isolated carinal resection resulted in a more favorable prognosis than more extensive resections, with a 5-year survival of 51%.6,12,13

SCC comprises the majority of bronchogenic carcinomas of the carina. In a recent series, Gaissert and colleagues compared the long-term oncologic outcome of patients with SCC of the trachea and carina.5 Of 135 patients (90 resected, 45 unresected), 5-year survival was 39.1% in the resected group versus 7.3% in the unresected group. Despite the higher mortality observed in the carinal resection group, overall long-term survival was not significantly different from that of the tracheal resection group. Positive nodal disease markedly reduced survival. There were few microscopically positive margins in the resected SCC patients. Thus, despite an adverse absolute effect on survival, the findings did not reach statistical significance. In a European multicenter retrospective series, Regnard and colleagues reported similar results in 94 patients with resected tracheal and carinal SCC. Survival was 47% at 5 years and 36% at 10 years.10

The long-term survival data for resected ACC of the carina has not been as well defined partly because of its proclivity for late recurrence. The published experience of all tracheal ACCs, which includes those involving the carina, suggests a much more favorable prognosis than bronchogenic carcinomas. In the recent series, Gaissert and colleagues reported the long-term outcome of 135 patients with ACC of the trachea and carina as a group. The 5-year survival was 52.4% for the 101 resected patients and 33.3% for the 34 unresected patients.5

Positive margins after resection adversely affected survival, resulting in a similar 5-year survival as in unresected patients. However, after 15 years, the survival curves separated further, with 14.5% alive in the resected with positive margins group versus no survivors in the unresected group. Unlike SCC, nodal status did not adversely affect survival in patients with ACC.5 Similarly, Regnard and colleagues reporting on 65 ACC's demonstrated a 5-year survival of 73% and 10-year survival of 57%.10 Lymph node status was not shown to affect survival. Positive margins did appear to adversely affect survival, but because of low numbers of patients, it did not reach statistical significance.10

SUMMARY

Most carinal resections are performed for SCC or ACC. Diagnosis and assessment of resectability are accomplished with bronchoscopy and CT reformatted in two and three dimensions. Patients are assessed for metastatic disease with MRI of the brain and total-body PET scans. Mediastinoscopy is used to assess for regionally advanced disease and for airway mobilization. Regionally advanced disease should be considered unresectable unless performed in a protocol setting. Rigid bronchoscopy and carinal resection create a unique requirement for the delivery of anesthesia, demanding an experienced and collaborative team. Most carinal resections can be approached through either a right thoracotomy or a median sternotomy and should have low operative mortality. Carinal resection with left pneumonectomy presents a special operative challenge and results in a high risk of operative mortality. Several methods of airway reconstruction are available, and the selection depends on the extent of airway involvement. In properly selected patients, oncologic outcomes are good, with ACC having a more favorable prognosis than SCC. Postoperative radiotherapy should be considered for all resected patients regardless of histology or the status of margins. No evidence-based consensus can be derived for the role of chemotherapy.

EDITOR'S COMMENT

Carinal pneumonectomy is a complex and rare procedure that should be performed by experienced surgeons in centers of excellence. Careful preoperative evaluation is required to ascertain the oncological rationale for this procedure. Attention should be paid to avoid over-hydration or lung inflation in the perioperative period.

–RB

REFERENCES

1. Grillo H: Primary tracheal neoplasm. In Grillo H (ed): Surgery of Trachea and Bronchi. London, BC Decker, 2004:208.

2. Ashiku S, Mathisen D: Carinal resection. In Yang ST, Cameron DE (eds): Current Therapy in Thoracic and Cardiovascular Surgery. St Louis, Mosby, 2004.

3. Hollingsworth HM: Wheezing and stridor. Clin Chest Med 8:231–40, 1987.[PubMed: 3304813]

4. Mathisen DJ, Grillo HC: Endoscopic relief of malignant airway obstruction. Ann Thorac Surg 48:469–73; discussion 473–5, 1989. 

5. Gaissert HA, Grillo HC, Shadmehr MB, et al: Long-term survival after resection of primary adenoid cystic and squamous cell carcinoma of the trachea and carina. Ann Thorac Surg 78:1889–96; discussion 1896–7, 2004. 

6. Porhanov VA, Poliakov IS, Selvaschuk AP, et al: Indications and results of sleeve carinal resection. Eur J Cardiothorac Surg 22:685–94, 2002.[PubMed: 12414031]

7. Pearson FG, Todd TR, Cooper JD: Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg 88:511–8, 1984.[PubMed: 6090818]

8. Grillo HC: Carinal reconstruction. Ann Thorac Surg 34:356–73, 1982.[PubMed: 7138104]

9. Mitchell JD, Mathisen DJ, Wright CD, et al: Clinical experience with carinal resection. J Thorac Cardiovasc Surg 117:39–52; discussion 52–3, 1999. 

10. Regnard JF, Fourquier P, Levasseur P: Results and prognostic factors in resections of primary tracheal tumors: A multicenter retrospective study. The French Society of Cardiovascular Surgery. J Thorac Cardiovasc Surg 111:808–13; discussion 813–4, 1996. 

11. Grillo HC, Mathisen DJ: Primary tracheal tumors: Treatment and results. Ann Thorac Surg 49:69–77, 1990.[PubMed: 2153371]

12. Mitchell JD, Mathisen DJ, Wright CD, et al: Resection for bronchogenic carcinoma involving the carina: Long-term results and effect of nodal status on outcome. J Thorac Cardiovasc Surg 121:465–71, 2001.[PubMed: 11241081]

13. Dartevelle P, Macchiarini P: Carinal resection for bronchogenic cancer. Semin Thorac Cardiovasc Surg 8:414–25, 1996.[PubMed: 8899929]



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