Malignant tracheal tumors: a review of current diagnostic and management strategies

Current diagnosis and treatment of salivary gland-type tumors of the lung

Salivary gland-type tumors of the lung are thought to originate from the submucosal exocrine glands of the large airways. Due to their rare occurrence, reports of their study are limited to small-scale or case reports. Therefore, daily clinical practices often require a search for previous reports. In the last 20 years, several genetic rearrangements have been identified, such as MYB::NF1B rearrangements in adenoid cystic carcinoma, CRTC1::MAML2 rearrangements in mucoepidermoid carcinoma, EWSR1::ATF1 rearrangements in hyalinizing clear cell carcinoma and rearrangements of the EWSR1 locus or FUS (TLS) locus in myoepithelioma and myoepithelial carcinoma. These molecular alterations have been useful in diagnosing these tumors, although they have not yet been linked to molecularly targeted therapies. The morphologic, immunophenotypic, and molecular characteristics of these tumors are similar to those of their counterparts of extrapulmonary origin, so clinical and radiologic differential diagnosis is required to distinguish between primary and metastatic disease of other primary sites. However, these molecular alterations can be useful in differentiating them from other primary lung cancer histologic types. The management of these tumors requires broad knowledge of the latest diagnostics, surgery, radiotherapy, bronchoscopic interventions, chemotherapy, immunotherapy as well as therapeutic agents in development, including molecularly targeted agents. This review provides a comprehensive overview of the current diagnosis and treatment of pulmonary salivary gland tumors, with a focus on adenoid cystic carcinoma and mucoepidermoid carcinoma, which are the two most common subtypes.

Adenoid cystic carcinoma of distal trachea: A case report

Key Clinical Message

This case report highlights the rarity of distal tracheal adenoid cystic carcinoma and emphasizes the importance of considering it as a differential diagnosis in patients presenting with sustained dyspnea. Early diagnosis and a multidisciplinary approach involving thoracic surgeons, radiation oncologists, and medical oncologists are crucial for optimal treatment planning and patient outcomes. Further research is warranted to better understand the pathogenesis, molecular characteristics, and optimal management strategies for this rare tracheal malignancy.

Abstract

Adenoid cystic carcinoma (ACC) is an unusual malignant neoplasm that mostly arises in the minor salivary glands. It can also occur in various mucous membrane-lined structures, including the trachea. The treatment of choice is surgery in resectable cases, but radiotherapy and chemotherapy are generally utilized for unresectable cases or palliative treatment. In this study, I report my experience with a case of unresectable ACC occurring in a distal trachea treated with concurrent chemoradiotherapy (CCRT), based on the patient's clinical presentation, diagnostic workup, histopathological findings, treatment modalities, and long-term prognosis.

Extracorporeal membrane oxygenation-facilitated palliative radiotherapy for severe airway obstruction due to lung cancer: A case report

Background

The use of venovenous extracorporeal membrane oxygenation (VV-ECMO), particularly during radiotherapy, for severe malignant central airway obstruction has rarely been reported.

Case Presentation

A 47-year-old female presented to our emergency department with severe respiratory distress. Given her medical history, she was initially diagnosed with asthma. Despite initial treatment, which included intubation, her condition deteriorated, necessitating VV-ECMO. Computed tomography performed following the initiation of VV-ECMO revealed extensive lung cancer involving both bronchial types. Radiotherapy while on VV-ECMO led to a significant reduction in tumor size, allowing for the weaning of ECMO support and successful extubation.

Conclusion

Malignant central airway obstruction is life-threatening. Our case demonstrates the efficacy of combining VV-ECMO with radiotherapy when conventional therapies fail. Further research is necessary to validate and explore this novel approach's implications.

Early extracorporeal membrane oxygenation as bridge for central airway obstruction patients caused by neck and chest tumors to emergency surgery

Central airway obstruction caused by neck and chest tumors is a very dangerous oncological emergency with high mortality. Unfortunately, there is few literature to discuss an effective way for this life-threating condition. Providing effective airway managements, adequate ventilation and emergency surgical interventions are very important. However, traditional airway managements and respiratory support has only limited effect. In our center, using extracorporeal membrane oxygenation (ECMO) as a novel approach to manage patient with central airway obstruction caused by neck and chest tumors has been adopted. We aimed to show the feasibility: using early ECMO to manage difficult airway, provide oxygenation and support surgical procedure for patients with critical airway stenosis caused by neck and chest tumors. We designed a single-center, small sample size retrospective study based on real-world. We identified 3 patients with central airway obstruction caused by neck and chest tumors. ECMO was used to ensure adequate ventilation to emergency surgery. Control group cannot be established. Because traditional manner very likely led to death of such patients. Details of clinical characteristics, ECMO, surgery and survival outcomes were recorded. Acute dyspnea and cyanosis were the most frequent symptoms. All patients (3/3) showed descending arterial partial pressure of oxygen (PaO₂). Computed tomography (CT) revealed severe central airway obstruction caused by neck and chest tumors in all cases (3/3). All patients (3/3) had definite difficult airway. All cases (3/3) received ECMO support and emergency surgical procedure. Venovenous ECMO was the common mode for all cases. 3 patients weaned off ECMO successfully without any ECMO-related complications. Mean duration of ECMO was 3 h (range: 1.5-4.5 h). Under ECMO support, difficult airway management and emergency surgical procedure were finished successfully for all cases (3/3). The mean ICU stay was 3.3 days (range: 1-7 days), and the mean general ward stay was 3.3 days (range: 2-4 days). Pathology demonstrated the tumor dignity for 3 patients including 2 malignant cases and 1 benign case. All patients (3/3) were discharged from hospital successfully. We showed that early ECMO initiation was a safe and feasible approach to manage difficult airway for patients with severe central airway obstruction caused by neck and chest tumors. Meanwhile, early ECMO initiation could ensure security for airway surgical procedure.

Primary tracheal obstruction caused by adenoid cystic carcinoma during pregnancy: A case report

The incidence of malignant tumors diagnosed during pregnancy is increasing, often ascribed to the recently recognized trend that many women are postponing childbirth. Although early diagnosis is optimal for both mothers and fetuses, the diagnosis of malignant tumors during pregnancy is often delayed until an advanced stage, because generalized symptoms of pregnancy and malignancy may overlap, such as shortness of breath, chest or abdominal discomfort. The study patient was 21 years old, and 31 weeks-pregnant when she was diagnosed with primary tracheal adenoid cystic carcinoma (ACC). The patient initially presented with dyspnea and decreased blood oxygen saturation and underwent a cesarean section on the first night of hospitalization, resulting from fetal distress. This case report intended to investigate potential barriers to the timely diagnosis of tracheal ACC and consider optimal management strategies when it is diagnosed during pregnancy.

Primary adenoid cystic carcinoma of the trachea: an elusive diagnosis of chronic dyspnoea

Primary adenoid cystic carcinoma (ACC) of the trachea is a rare entity, with a 5-year survival between 50% and 80% for resectable cases and 30% in case of unresectable disease. We report a case of a primary ACC on a woman in her 70s that presented with a drawn-out history of dyspnoea. She was diagnosed with an unresectable obstructive tumour of the trachea, which required the placement of a Y-shaped stent. The patient underwent concomitant chemoradiotherapy, with partial response, and is still in follow-up, without evidence of disease progression.

Pleomorphic carcinoma of the trachea after chemoradiotherapy for laryngeal cancer

A 66-year-old male patient who had received chemoradiotherapy (CRT) for laryngeal cancer 2 years ago visited a local doctor complaining of dyspnoea and wheezing. CT scan showed narrowing of the trachea caused by a tumour. We intubated the trachea over the tumour using a bronchoscope. A week later, the truncated tracheal tumour obstructed the tracheal tube, compromising the patient’s breathing. We removed the obstructed tube and inserted a new one. We submitted the tissue from the tube to a pathologist. Histopathological diagnosis was pleomorphic carcinoma, a subtype of sarcomatoid carcinoma. The mechanism of epithelial–mesenchymal transition (EMT) occurring after CRT was detected in the tumour. Because he had undergone CRT for laryngeal cancer, surgery was not indicated, and we started radiation therapy. Sarcomatoid carcinomas including pleomorphic carcinoma of the trachea are extremely rare, with few reported cases, and EMT is associated with this histological type and CRT.

Clinical efficacy of treatment for primary tracheal tumors by flexible bronchoscopy: Airway stenosis recanalization and quality of life

The aim of the present study was to evaluate the effectiveness of interventional treatment of primary tracheal tumors through flexible bronchoscopy. The clinical data of 38 patients with primary tracheal tumours who underwent flexible bronchoscopy intervention therapy between January 2011 and January 2017 were retrospectively analyzed. The average time interval from onset of symptoms to the appearance of actual clinical manifestations in the 38 patients ranged from 0 to 60 months, with an average of 8.1±11.6 months and a median of 4.2 months. The rate of misdiagnosis at the first visit was 36.8% (14/38). After interventional treatment, the overall efficiency (complete + partial response) of airway stenosis recanalization in the 38 patients was 89.5%. In 3 patients with benign tumors, the anhelation score was reduced following treatment (1.00±0.77 vs. 3.13±1.21 at the pre-treatment stage; P<0.001). The overall survival rates of the 35 patients at 1, 3 and 5 years were 69.3, 48.7 and 20.3%, respectively. Therefore, flexible bronchoscopic intervention may effectively smoothen the airways of patients and relieve the symptoms of anhelation. Combining radiotherapy and chemotherapy may improve patient prognosis and safety.

Bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation support for advanced cancer metastasis to the central airway: A case report

INTRODUCTION

Dyspnea due to tracheal invasion by malignant tumors is a common oncological emergency that is difficult to manage, and a common cause of death among patients with advanced cancer. Bronchoscopy-guided intervention therapy under conventional ventilation is very risky for patients with severe central airway stenosis. Extracorporeal membrane oxygenation (ECMO) provides strong cardiopulmonary support, but is rarely used in bronchoscopy-guided interventional therapy.

PATIENT CONCERNS

The patient had advanced esophageal cancer with metastases to the trachea and left and right main bronchi. Despite several sessions of radiotherapy, chemotherapy, and bronchoscopy-guided intervention therapy, the tumor in the airway became enlarged, the lumen was severely narrow, and the patient experienced respiratory distress.

DIAGNOSIS

A thoracic computed tomography scan performed at our hospital revealed invasion of the trachea and opening of the left and right main bronchi by the esophageal cancer, blockage of the stent by the tumor, and severe luminal narrowing. An emergency bronchoscopy showed slit-like stenosis of the middle and lower part of the trachea and the left and right main bronchi, and the tumor was highly vascular.

INTERVENTIONS

To reduce the risk of major airway bleeding and asphyxia during bronchoscopy under conventional ventilation, we finally performed argon plasma coagulation with a high frequency electric knife and cryotherapy with ECMO support.

OUTCOMES

We successfully cleared the tumor tissue in the airway under ECMO support. The trachea and left and right main bronchi recovered smoothly, and the patient was soon discharged.

CONCLUSION

ECMO can meet the oxygenation needs during bronchoscopy-guided intervention therapy. For patients with severe central airway obstruction due to malignant tumors, ECMO should be considered if conventional respiratory support cannot guarantee the safety of surgery.

How thoracic surgeon manage tracheal tumors in African country? (Case series)

Introduction

Tracheal tumors are a rare pathological entity whose diagnosis is usually delayed by clinical latency. Surgery, which consists of a tracheal resection-anastomosis with or without reconstructive reconstruction, remains the treatment that ensures the best long-term survival.

Methods

This is a retrospective study about 8 patients admitted in the department of thoracic surgery of Hassan II's university hospital of Fes for tracheal tumors management during 7 years time (December 2010 to December 2017).

Results

There were 6 men and 2 women with an average age of 44.4 years ranged from 17 to 65 years, 4 were smokers. Dyspnea was the main trigger sign. Seven (7) have undergone bronchial fibroscopy diagnostic with a finding of budding process in 5 patients, the middle of the trachea is often concerned in 3 patients, obstructing the lumen of the trachea in almost all patients. The treatment in all patients was surgical with an intubation via the operative field, 4 trachea resection-anastomosis, 4 plasty (Lateral resection with V plasty, Kergin's plasty, Mattey's tracheobronchial anastomosis and widened V-resection to the carina). The most common histological type in our series was Adenoid Cystic Carcinoma in 2 of our patients. For the other patients we have found squamous cell carcinoma (1 case), adenocarcinoma (1 case), atypical carcinoid tumor (1 case), low grade mucoepidermoid carcinoma (1 case), an adenoma pleomorph (1 case) and endotracheal goiter (1 case). The operative follow-up was simple in 7 of our patients, all of whom underwent post-operative fibroscopy within an average of 9 days. Two cases of post-operative recurrent palsy had been observed, all of which had progressed well under treatment. We have noted 2 deaths, including one at day 4 post-operative, and the other died from complications of post-radiation tracheal stenosis. Back to 32 months' average follow-up, we have enregistered a case of a distant relapse by cervical lymph node metastasis in one patient, 5 years after surgery.

Conclusion

Primary tumors of the trachea remain of reserved prognosis with 5-year survival of 57% of all histological types combined. Computed tomodensitometry and tracheobronchial fibroscopy remain the means of reference exploration in the diagnosis and assessment of surgical resectability.

Pulmonary actinomycosis and tracheal squamous cell carcinoma: A rare simultaneous presentation of both in a single patient

A 57-year-old male with schizophrenia and a 37 pack-year smoking history presented with cough productive of purulent sputum associated with hemoptysis and worsening shortness of breath. Computed tomography (CT) scan revealed multiple masses in the right upper and lower lobes with a small distal tracheal mass and significant mediastinal lymphadenopathy. CT guided biopsy of the largest lung mass in the right lower lobe confirmed a diagnosis of pulmonary actinomycosis. The patient received appropriate antibiotic therapy for four weeks, but his condition did not improve. A repeat CT scan showed worsening of the right lung consolidation with increasing occlusion of the trachea. Bronchoscopy was performed which revealed a friable necrotic mass occupying 70% of the tracheal lumen. Histopathology showed squamous cell carcinoma of the trachea likely of primary origin. Unfortunately, the patient was not a candidate for any surgical intervention or oncologic treatment, and he died few days later. This patient had a rare simultaneous presentation of both pulmonary actinomycosis and tracheal squamous cell carcinoma. To the best of our knowledge, this is the first reported case of simultaneous diagnosis of both conditions in the same patient. This case illustrates the importance of looking for an alternative diagnosis in patients with actinomycosis who do not respond well to appropriate therapy.

The role of endoscopic ultrasound in the staging of tracheal neoplasm: a brief review

Our case report shows the complexity of dealing with tracheal tumors, highlighting the importance of the method used for staging. In this report, endoscopic ultrasound (EUS) was crucial to identify the involvement of the esophageal muscular propria in a tracheal tumor and change the surgical planning of the case. Staging this kind of tumor represents a challenge for physicians. There is no evidence in the literature on which methods represent the gold standard for T staging.

Intraluminal tracheal lipoma as a rare cause of dyspnoea in a dog

Background

Tracheal tumors are rarely diagnosed in veterinary medicine and the majority of tracheal neoplasia reported in adult dogs are malignant. Intratracheal lipoma has not been previously reported in the veterinary literature.

Case presentation

A 7-year-old Briard dog was evaluated for inspiratory dyspnoea and an inspiratory wheeze. Cervical radiographs and tracheoscopic examination revealed an intratracheal mass that was surgically removed. The dog has been asymptomatic after the surgery.

Conclusions

Based on histopathology, the mass was diagnosed as lipoma. To the authors‘ knowledge, this is the first published report of an intratracheal lipoma in the veterinary literature.

A 44-year-old man with hemoptysis

A 44-year-old man with background history of diffuse cutaneous systemic sclerosis and dilated cardiomyopathy receiving immunosuppressive medications, presented with a 2-month history of cough and streaky hemoptysis. Clinicoradiological features were consistent with an endotracheal mass. Subsequently, the patient developed nodular skin lesions and the tracheal mass increased in size causing central airway obstruction. This clinicopathologic conference discusses the clinical and radiological differential diagnoses of such a clinical presentation and their management options.

Central airway obstruction caused by adenoid cystic carcinoma in pregnancy: a case report and review of the literature

Malignancy complicates one in a thousand pregnancies. The most frequently diagnosed of these are breast, cervical, melanoma, ovarian, and haematological neoplasms. Tumours of respiratory origin are very uncommon during pregnancy. We present a case of tracheal adenoid cystic carcinoma (ACC), a rare type of primary airway tumour, diagnosed in a pregnant woman. To our knowledge, this is the third reported case of tracheal ACC complicating pregnancy. We discuss potential barriers to timely diagnosis of malignancies during pregnancy and consider optimal management strategies, taking into account the potential harm to the mother and foetus in a field with a limited evidence base.

Overview of malignant tracheal tumors

Malignant airway tumors present particular challenges for surgeons, namely: to distinguish symptoms from those of the more frequent benign airway diseases; to separate metastatic disease from the uncommon primary tumors; and to consider curative resection in appropriate candidates. Here, we present a critical review of tracheal malignant obstruction, focusing on the evaluation of a patient with malignant airway tumor, patient selection for resection and the predictors of long-term survival. The new development in primary tracheal tumors is an old story, that of making physicians aware that resection rates in epidemiologic studies remain low, mainly because opportunities for resection are missed.

Marital status is an independent prognostic factor for tracheal cancer patients: an analysis of the SEER database

BACKGROUND

Although marital status is an independent prognostic factor in many cancers, its prognostic impact on tracheal cancer has not yet been determined. The goal of this study was to examine the relationship between marital status and survival in patients with tracheal cancer.

RESULTS

Compared with unmarried patients (42.67%), married patients (57.33%) had better 5-year OS (25.64% vs. 35.89%, p = 0.009) and 5-year TCSS (44.58% vs. 58.75%, p = 0.004). Results of multivariate analysis indicated that marital status is an independent prognostic factor, with married patients showing better OS (hazard ratio [HR] = 0.78, 95% confidence interval [CI] 0.64-0.95, p = 0.015) and TCSS (HR = 0.70, 95% CI 0.54-0.91, p = 0.008). In addition, subgroup analysis suggested that marital status plays a more important role in the TCSS of patients with non-low-grade malignant tumors (HR = 0.71, 95% CI 0.53-0.93, p = 0.015).

METHODS

We extracted 600 cases from the Surveillance, Epidemiology, and End Results (SEER) database. Variables were compared by Pearson chi-squared test, t-test, log-rank test, and multivariate Cox regression analysis. Overall survival (OS) and tracheal cancer-specific survival (TCSS) were compared between subgroups with different pathologic features and tumor stages.

CONCLUSIONS

Marital status is an independent prognostic factor for survival in patients with tracheal cancer. For that reason, additional social support may be needed for unmarried patients, especially those with non-low-grade malignant tumors.

The technique of endoscopic airway tumor treatment

More than half of primary lung cancers are not resectable at diagnosis and 40% of deaths may be secondary to loco-regional disease. Many of these patients suffer from symptoms related to airways obstruction. Indications for therapeutic endoscopic treatment are palliation of dyspnea and other obstructive symptoms in advanced cancerous lesions and cure of early lung cancer. Bronchoscopic management is also indicated for all those patients suffering from benign or minimally invasive neoplasm who are not suitable for surgery due to their clinical conditions. Clinicians should select cases, evaluating tumor features (size, location) and patient characteristics (age, lung function impairment) to choose the most appropriate endoscopic technique. Laser therapy, electrocautery, cryotherapy and stenting are well-described techniques for the palliation of symptoms due to airway involvement and local treatment of endobronchial lesions. Newer technologies, with an established role in clinical practice, are endobronchial ultrasound (EBUS), autofluorescence bronchoscopy (AFB), and narrow band imaging (NBI). Other techniques, such as endobronchial intra-tumoral chemotherapy (EITC), EBUS-guided-transbronchial needle injection or bronchoscopy-guided radiofrequency ablation (RFA), are in development for the use within the airways. These endobronchial interventions are important adjuncts in the multimodality management of lung cancer and should become standard considerations in the management of patients with advanced lung cancer, benign or otherwise not approachable central airway lesions. We aimed at revising several endobronchial treatment modalities that can augment standard antitumor therapies for advanced lung cancer, including rigid and flexible bronchoscopy, laser therapy, endobronchial prosthesis, and photodynamic therapy (PDT).

Central airway tumors: interventional bronchoscopy in diagnosis and management

The diagnosis of central airway tumors is usually challenging because of the vague presentations. Advances in visualization technology in bronchoscopy aid early detection of bronchial lesion. Cryotechnology has great impact on endobronchial lesion sampling and provides better diagnostic yield. Airway tumor involvements result in significant alteration in life quality and lead to poor life expectancy. Timely and efficiently use ablation techniques by heat or cold energy provide symptoms relief for central airway obstruction. Prostheses implantation is effective in maintaining airway patency after ablative procedure or external compression. Combined interventional bronchoscopy modalities and other adjunctive therapies have improvement in quality of life and further benefit in survival. This review aims to provide a diagnostic approach to central airway tumors and an overview of currently available techniques of interventional bronchoscopy in managing symptomatic central airway obstruction.

Tracheal resection and reconstruction for malignant disease

Malignant tracheal neoplasms are rare diseases, mostly represented by squamous cell carcinoma (SCC) and adenoid cystic carcinoma (ACC). Symptoms presentation is often misleading and diagnosis may be delayed for months or years, so clinical suspicion plays a fundamental role. Corner stones in the diagnostic pathway are represented by rigid endoscopy and computed tomography (CT) scan, necessary to correctly stage the patients and identify the optimal surgical candidate. When appropriate, surgical resection and reconstruction is still the best opportunity to achieve a long-term survival with a good quality of life, but this kind of surgery is always a very challenging procedure and a wide experience with an in-depth knowledge of every technical detail, from selection of patient, to choice of surgical approach to reconstruction techniques, are needed and recommended.