Treatment of tracheobronchial lesions by laser photoresection

One hundred eleven patients underwent 205 laser photo-irradiation treatments using a Neodynium YAG laser with a flexible bronchoscope or an open tube for various tracheobronchial conditions, such as obstructing bronchogenic carcinomas, bronchial adenomas, and postintubation tracheal stenosis. The procedure was performed with either local or general anesthesia. Results were especially rewarding with endobronchial tumors. Tracheal stenoses were best treated by a combination of laser surgery and tracheal dilatation. No complication was encountered. Specific indications suggested for laser surgery are resection of inoperable tracheobronchial tumors, correction of tracheal stenosis, removal of surgical sutures, retrieval of tissue-embedded foreign bodies, and cauterization of hemorrhaging endobronchial tissues.

Tracheobronchial transplantation with a stem-cell-seeded bioartificial nanocomposite: a proof-of-concept study

BACKGROUND

Tracheal tumours can be surgically resected but most are an inoperable size at the time of diagnosis; therefore, new therapeutic options are needed. We report the clinical transplantation of the tracheobronchial airway with a stem-cell-seeded bioartificial nanocomposite.

METHODS

A 36-year-old male patient, previously treated with debulking surgery and radiation therapy, presented with recurrent primary cancer of the distal trachea and main bronchi. After complete tumour resection, the airway was replaced with a tailored bioartificial nanocomposite previously seeded with autologous bone-marrow mononuclear cells via a bioreactor for 36 h. Postoperative granulocyte colony-stimulating factor filgrastim (10 μg/kg) and epoetin beta (40,000 UI) were given over 14 days. We undertook flow cytometry, scanning electron microscopy, confocal microscopy epigenetics, multiplex, miRNA, and gene expression analyses.

FINDINGS

We noted an extracellular matrix-like coating and proliferating cells including a CD105+ subpopulation in the scaffold after the reseeding and bioreactor process. There were no major complications, and the patient was asymptomatic and tumour free 5 months after transplantation. The bioartificial nanocomposite has patent anastomoses, lined with a vascularised neomucosa, and was partly covered by nearly healthy epithelium. Postoperatively, we detected a mobilisation of peripheral cells displaying increased mesenchymal stromal cell phenotype, and upregulation of epoetin receptors, antiapoptotic genes, and miR-34 and miR-449 biomarkers. These findings, together with increased levels of regenerative-associated plasma factors, strongly suggest stem-cell homing and cell-mediated wound repair, extracellular matrix remodelling, and neovascularisation of the graft.

INTERPRETATION

Tailor-made bioartificial scaffolds can be used to replace complex airway defects. The bioreactor reseeding process and pharmacological-induced site-specific and graft-specific regeneration and tissue protection are key factors for successful clinical outcome.

FUNDING

European Commission, Knut and Alice Wallenberg Foundation, Swedish Research Council, StratRegen, Vinnova Foundation, Radiumhemmet, Clinigene EU Network of Excellence, Swedish Cancer Society, Centre for Biosciences (The Live Cell imaging Unit), and UCL Business.

Primary tracheal tumors: treatment and results

One hundred ninety-eight patients with primary tracheal tumors were evaluated in 26 years. One hundred forty-seven tumors were excised (74%): 132 (66%) by resection and primary reconstruction, seven by laryngotracheal resection or cervicomediastinal exenteration, and eight by staged procedures. Eleven more were explored. Forty-four squamous cell carcinomas were resected, 60 adenoid cystic, and 43 assorted tumors, benign and malignant. Eighty-two patients underwent tracheal resection with primary reconstruction, and 50 had carinal resection and reconstruction. Surgical mortality for resection with primary reconstruction was 5%, with one death after tracheal and six after carinal repair. Six patients had stenosis after tracheal or carinal resection; all underwent reresection successfully. Nearly all patients with squamous or adenoid cystic carcinoma were irradiated postoperatively. Twenty of 41 survivors of resection of squamous cell carcinoma are living free of disease (some for more than 25 years), 39 of 52 with adenoid cystic carcinoma (up to nearly 19 years), and 35 of 42 with other lesions (5 lost to follow-up). Comparison of length of survival of patients with squamous cell carcinoma and adenoid cystic carcinoma who are alive without disease with those who died with carcinoma supports surgical treatment (usually followed by irradiation). Positive lymph nodes or invasive disease at resection margins appear to have an adverse effect on cure of squamous cell carcinoma; such an effect is not demonstrable with adenoid cystic carcinoma.

Primary tracheal tumours

Primary tumours of the trachea can be benign or malignant and account for fewer than 0.1% of tumours. However, they are a diagnostic and therapeutic challenge. Benign tumours are usually misdiagnosed as asthma or chronic lung disease, and can delay diagnosis for months or years. Because of their rapid growth and onset of haemoptysis, malignant tumours are often diagnosed earlier than benign tumours and patients thus often present with locally advanced disease. Inappropriate treatment is an equally frustrating issue. Modern techniques for tracheal surgery-laryngotracheal, tracheal, or carinal resection-combined with radiotherapy, can be offered curatively with low perioperative risks. Nevertheless, the low numbers of patients undergoing resection and the associated poor survival in epidemiological studies over the past two decades have shown that surgery is rarely considered outside referral centres, with radiotherapy or another form of local treatment (eg, endotracheal stents, debridement, brachytherapy) generally preferred. The liberal use of these other techniques should be avoided because surgery has the potential to cure all patients with benign and low-grade tumours and most patients with malignant primary tracheal tumours, and other techniques are usually palliative at best.

Long-Term Survival After Resection of Primary Adenoid Cystic and Squamous Cell Carcinoma of the Trachea and Carina

BACKGROUND

Tracheal resection for primary carcinoma may extend survival. We evaluated survival after surgical resection or palliative therapy to identify prognostic factors.

METHODS

We conducted a retrospective study of patients diagnosed with primary adenoid cystic carcinoma (ACC) or squamous cell carcinoma (SCC) of the trachea between 1962 and 2002. Laryngotracheal, tracheal, or carinal resection was performed when distant metastasis and invasion of adjacent mediastinal structures were absent and tumor length permitted. Radiotherapy was administered after operation (54 Gy), except in superficial tumors, or as palliation (60 Gy).

RESULTS

Of 270 patients with ACC or SCC (135 each), 191 (71%) were resected. Seventy-nine were not resected due to tumor length (67%), regional extent (24%), distant metastasis (7%), or other reasons (2%). Overall operative mortality was 7.3% (14/191) and improved each decade from 21% to 3%. Tumor in airway margins was present in 40% (17/191) of resected patients (ACC 59% versus SCC 18%) and lymph node metastasis in 19.4% (37/191). Overall 5- and 10-year survival in resected ACC was 52% and 29% (unresectable 33% and 10%) and in resected SCC 39% and 18% (unresectable 7.3% and 4.9%). Multivariate analysis of long-term survival found statistically significant associations with complete resection (p < 0.05), negative airway margins (p < 0.05), and adenoid cystic histology (p < 0.001), but not with tumor length, lymph node status, or type of resection.

CONCLUSIONS

Locoregional, not distant, disease determines resectability in primary tracheal carcinoma. Resection of trachea or carina is associated with long-term survival superior to palliative therapy, particularly for patients with complete resection, negative airway margins, and ACC.

Bronchoscopic management of tracheal lesions using the neodynium yttrium aluminium garnet laser

We report our first clinical trials with the NdYAG laser in the treatment of tracheal and bronchial tumours and stenoses. The beam is carried through a flexible fibre delivering a power of 50 to 90 watts. It can be introduced through the biopsy channel of a standard bronchoscope, or through a fibrescope. Anaesthesia must avoid inflammable gases. In most cases, general anaesthesia was used, and ventilation achieved with a mixture of 50% nitrogen and oxygen, using a modification of the Sanders injector. One hundred and sixty-four cases have been treated in 317 sessions (from one to five sessions per patient). They comprised: 72 cancers, 24 of which had just been diagnosed and had acute respiratory obstruction. In 16, one single session restored the patency of the airway. Forty-eight other cases were recurrent carcinomas after either surgery or radiotherapy, nine of which were caused by cancers of other origin invading the trachea; 21 benign or moderately malignant tumours; 44 iatrogenic stenoses, including 31 narrow ones. Of those 31 cases, 17 had an immediate satisfactory result, but eight recurred; 24 granulomas on bronchial suture lines. There were two deaths not directly related to surgery or anaesthesia. Bleeding was never more than moderate. The main difficulty lies in the critical respiratory condition of the patients, sometimes seen in acute asphyxia, referred to us as a last resort, especially those with carcinomas involving the trachea or main bronchi.

Nd:YAG laser bronchoscopy. A five-year experience with 1,396 applications in 1,000 patients

We treated 1,000 patients with the Nd:YAG laser. The rigid bronchoscope was used in 1,280 (92 percent) of the treatments, with patients almost always under general anesthesia; 116 (8 percent) treatments were performed with the flexible fiberoptic bronchoscope alone, with the use of local anesthesia. In almost all cases of benign tumors and in many carcinoid tumors, the treatment was curative. In genuine nonmalignant tracheal stenoses, laser therapy was curative in 34 out of 81 cases. In malignant tumors, the laser improved airway gauge 92 percent of the time. Cumulative survival was 50 percent (+/- 3 percent) at six months and 26 percent (+/- 3 percent) at one year. Following palliative laser therapy, eight patients with bronchogenic carcinoma appearing to be inoperable did have surgery and ten underwent less extensive surgery than expected. Results confirm the usefulness and safety of this relatively new method in the treatment of obstructive lesions of the tracheobronchial tree.

Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective study. The French Society of Cardiovascular Surgery

To determine long-term survival and prognostic factors, 208 patients with primary tracheal tumors were evaluated in a retrospective multicenter study including 26 centers. Ninety-four patients had squamous cell carcinoma, four had adenocarcinoma, 65 had adenoid cystic carcinoma, and 45 patients had miscellaneous tumors. The following resections were performed: tracheal resection with primary anastomosis, 165; carinal resection, 24; and laryngotracheal resection, 19. Postoperative mortality rate was 10.5% and correlated with the length of the resection, the need for a laryngeal release, the type of resection, and the histologic type of the cancer. Fifty-nine percent of patients with tracheal cancer and 43% of patients with adenoid cystic carcinomas had postoperative radiotherapy. The 5- and 10-year survivals, respectively, were 73% and 57% for adenoid cystic carcinomas and 47% and 36% for tracheal cancers (p < 0.05). Among patients with tracheal cancers, survival was significantly longer for those with complete resections than for those with incomplete resections. On the other hand, the presence of positive lymph nodes did not seem to decrease survival. Postoperative radiotherapy increased survival only in the case of incompletely resected tracheal cancers. Long-term prognosis was worsened by the occurrence of second primary malignancies in patients with tracheal cancers and by the occurrence of late pulmonary metastases in patients with adenoid cystic carcinomas.

Circumferential resection and reconstruction of the mediastinal and cervical trachea

Images

The surgical management of laryngotracheal invasion by well-differentiated papillary thyroid carcinoma

OBJECTIVES

To determine prognostic factors for survival in patients with invasive well-differentiated thyroid carcinoma, specifically examining laryngotracheal invasion as an independent prognostic factor, and to compare types of surgical resection to determine treatment efficacy.

DESIGN

Retrospective review of patients with papillary invasive well-differentiated thyroid carcinoma surgically treated over 45 years.

SETTING

Academic tertiary care medical center.

PATIENTS

A total of 292 patients with invasive well-differentiated thyroid carcinoma were surgically treated between 1940 and 1995. Informed consent was obtained from all patients. Extent and location of tumor invasion were determined. Invasion of larynx and/or trachea occurred in 124 patients (41%). Patterns of invasion and techniques of surgical resection were evaluated.

INTERVENTION

Types of surgical resection performed: complete tumor removal (n = 34), "shave" excision (n = 75), and incomplete tumor excision (n = 15).

MAIN OUTCOME MEASURES

Cox regression analysis was used to determine significance of prognostic factors for survival; Kaplan-Meier curves were used to evaluate survival. A P value of less than .05 was statistically significant.

RESULTS

Patterns of invasion by thyroid carcinoma included direct spread through laryngeal framework into paraglottic space or spread from involved lymph nodes. Laryngotracheal invasion was a significant, independent, prognostic factor for survival (P < .05). Significance was reached when types of resection were compared for all patients (P < .05) as well as for those with laryngotracheal invasion alone (P < .001).

CONCLUSIONS

Laryngotracheal invasion was a significant independent prognostic factor for survival (P < .05). When types of surgical resection were compared, the survival rates of patients who underwent shave excision were not different from those of patients who underwent radical tumor resection if gross tumor did not remain (P > .05). Tumors with minimal invasion may be treated by shaving tumor from the aerodigestive tract. Gross intraluminal involvement should be resected completely to prevent complications.

Endoscopic relief of malignant airway obstruction

The ability to manage acute airway obstruction can be life-saving. Airway relief should be expeditious and immediate, with low morbidity and mortality. It should not interfere with future definitive therapy. In patients with terminal malignancy, it should be economical in cost and should minimize hospitalization. We used biopsy forceps and the rigid bronchoscope to "core out" 56 patients with obstructing airway neoplasms. The location of the obstruction was trachea in 16 patients, carina in 24, main bronchi in 8, and distal airway in 8. Improvement in the airway was accomplished in 90% of patients. A single bronchoscopy was sufficient in 96%. Nineteen complications occurred in 11 patients: pneumonia in 5, bleeding in 3, pneumothorax in 2, hypoxia/hypercarbia in 2, arrhythmias in 6, and laryngeal edema in 1. There were four deaths within 2 weeks of core-out related to respiratory failure. Further therapy consisted of resection in 28.6% (tracheal in 9, carinal in 3, pulmonary in 4), irradiation alone or in combination with chemotherapy in 60.7%, and no therapy in 10.7%. Palliation of symptoms and establishment of an airway in acute obstruction is the goal. Survival depends on the effectiveness of the proposed treatment. We find this time-honored method superior to use of the laser.

Carinal reconstruction

Thirty-six carinal resections were performed: 23 for primary neoplasms of the airways, 5 for bronchogenic neoplasms, and 8 for inflammatory lesions. In 31 cases, primary reconstruction was done. Eleven reconstructions were performed without pulmonary resection; in 5, right upper lobectomy was also done, in 9 pneumonectomy, and 6 patients had had a prior left pneumonectomy. Five staged reconstructions were attempted. The mode of reconstruction depended on the precise location and extent of the lesion. Bronchial anastomoses to the side and end of the trachea or to the end of the trachea and to the side of a bronchus predominated. Four deaths occurred among the 31 patients who had primary reconstruction (13%). Two patients with anastomotic stenoses had successful reexcision. Attempts at staged reconstruction failed.

Benign tumors of the tracheobronchial tree. Endoscopic characteristics and role of laser resection

We conducted a review of all the bronchoscopies performed at our institutions for benign tumors from 1980 to 1991 to determine the endoscopic characteristics of these lesions. We reviewed the charts, the endoscopic characteristics from our video records, and finally the pathologic findings of these cases. We tried to identify the effectiveness of laser resections in each group. Of a total of 3,937 patients, 185 (4.7%) were benign tumors. On these patients, 317 procedures were carried out. There were 3 myoblastomas, 53 papillomas, 1 adenoma, 8 chondromas, 4 fibromas, 45 hamartomas, 15 hamartochondromas, 6 lipomas, 19 angiomas, 5 leiomyomas, 4 schwannomas, 1 neurofibroma, and 21 amyloidomas. Results of laser resection were "very good" in 115 (62%) and "good" in 70 (38%). Complications were minimal: two mediastinal emphysemas, one pneumothorax, and one anesthesia-related cardiac arrest leading to the single death in this series. In general, benign tumors of the proximal endobronchial tree responded well to laser resection when their endoscopic appearance is recognized and prognosis known. Even when recurrent, repeated procedures can be performed easily with good results. This series is probably the largest in the world's literature about endoscopic recognition and the role of laser resection in patients presenting with benign endobronchial tumors.

Resectional management of thyroid carcinoma invading the airway

Fifty-two patients had thyroid carcinoma invading the airway. Thirty-four underwent resection; 18 were male and 16 female. Age ranged from 17 to 79 years. Twenty-seven had resection with airway reconstruction (1 wedge excision, 10 sleeve tracheal resections, 6 tracheal resections with a portion of the cricoid cartilage, and 10 complex laryngotracheoplastic resections). Seven required cervicomediastinal exenteration with mediastinal tracheostomy; 3 of these had esophagectomy with colon interposition. Nineteen tumors were papillary, 6 follicular, 4 mixed papillary and follicular, 1 squamous, 2 undifferentiated giant cell, 1 anaplastic spindle cell carcinoma, and 1 carcinosarcoma. Three postoperative deaths occurred. Thirteen of the 31 survivors died of cancer from 1/4 to 10 1/4 years postoperatively (average, 4.4 years). Four died of other diseases. Fourteen are alive from 1/12 to 14 1/3 years postoperatively (average, 5.3 years). Only 2 patients had airway recurrence. Resection of the airway invaded by thyroid malignancy in the absence of extensive metastases offers prolonged palliation, avoids suffocation due to bleeding or obstruction, and may produce cure. Airway reconstruction should be performed whenever technically feasible.

Microdebrider versus CO2 laser removal of recurrent respiratory papillomas: a prospective analysis

OBJECTIVE

To compare postoperative patient discomfort, voice quality, and procedure time and cost for removal of recurrent respiratory papillomas using the microdebrider versus the CO2 laser.

STUDY DESIGN

A randomized prospective study comparing children undergoing excision of recurrent respiratory papillomas by CO2 laser versus excision by microdebrider.

METHODS

For the 6-month study, patients for whom removal of recurrent respiratory papillomas was indicated were randomly assigned by birth year to microdebrider or CO2 laser therapy. Disease severity was scored as the sum of ratings of 1+ (minimal), 2+ (moderate), or 3+ (severe) for involvement of 27 areas of the aerodigestive tract by direct microlaryngoscopy immediately before treatment. Parents scored patient discomfort and improvement in voice quality 24 hours after surgery, using a 5-point (0 = no pain; 4 = worst pain) and a 10-point (1 = minimal change; 10 = significant improvement) scale, respectively.

RESULTS

Nineteen patients ranging in age from 2.5 to 20 years underwent 32 procedures in all. Groups did not differ significantly in age, sex, or severity of disease. For disease of equivalent severity, microdebrider treatment was associated with equivalent 24-hour-postoperative pain scores, greater improvement in voice quality, shorter procedure times, and lower overall procedure cost.

CONCLUSIONS

Immediate postoperative results indicate that the microdebrider may be as safe as and, at some institutions, might be more cost-effective than the CO2 laser for removal of recurrent respiratory papillomas.

Laser therapy in 100 tracheobronchial tumours

One hundred patients with tracheobronchial tumours were treated with the neodymium YAG (yttrium-aluminium-garnet) or argon laser for symptoms of airways obstruction caused by tumour (59 cases), complete collapse of a lung (17 cases), or recurrent haemoptysis (24 cases). Seventy four of them had relapsed or failed to respond to radiotherapy or chemotherapy and all were inoperable. Objective improvement in results of lung function tests or haemoptysis diary charts was seen in 37 patients with airways obstruction (63%), five (29%) with collapsed lung, and 14 (58%) with haemoptysis. Overall, 68 patients had symptomatic benefit and there was objective improvement in 56. Two deaths occurred in 288 treatment sessions both occurring as a result of asphyxia from minor haemorrhage in patients with advanced cylindromas and critical narrowing of the trachea or single remaining bronchus. In suitable patients with intraluminal tumour laser phototherapy is a valuable addition to conventional treatment.

Segmental Laryngotracheal and Tracheal Resection for Invasive Thyroid Carcinoma

BACKGROUND

Laryngotracheal invasion worsens prognosis in patients with thyroid carcinoma. The extent of resection is controversial.

METHODS

We performed a retrospective study of patients with thyroid carcinoma and invasion of the larynx or trachea between 1964 and 2005.

RESULTS

Eighty-two patients, mean age 64 years and 50% female, underwent segmental airway resection. Differentiated carcinoma was present in 76% (62 of 82 patients), prior tracheal "shave" procedures in 40% (33 of 82 patients), transmural invasion in 58% (48 of 82 patients), and preoperative vocal cord paralysis in 35% (29 of 82 patients). There were 29 tracheal and 40 laryngotracheal resections (reconstruction group: 69 patients); 5 underwent laryngectomy, 7 cervical exenteration, and 1 tracheal resection after exenteration (salvage group: 13 patients). Operative mortality was 1.2% (1 of 82 patients) and anastomotic dehiscence 4.3% (3 of 69 patients). Tracheostomy was permanent in 4.3% (3 of 69 patients). Mean follow-up was 6.1 years. After reconstruction, mean survival was 9.4 years and 10-year survival was 40%; after salvage, these were 5.6 years and 15%, respectively. In differentiated carcinoma, thyroidectomy, immediate shave procedure, and delayed (mean, 67 months) resection of airway recurrence in 15 patients resulted in overall and disease-free survival of 13.1 and 5.1 years, respectively, compared with 17.9 and 14.6 years, respectively, after thyroidectomy and early airway resection in 11 patients. Airway symptoms, metastases at presentation, recurrent disease, and salvage operation were associated with decreased survival; airway resection early after thyroidectomy, complete resection, and well-differentiated tumors were associated with improved prognosis.

CONCLUSIONS

Segmental airway resection for invasive thyroid cancer is safe, preserves the voice, and relieves airway obstruction. Complete resection of laryngeal and tracheal invasion during or early after thyroidectomy is associated with improved survival.

Reconstruction of the trachea. Experience in 100 consecutive cases

Grillo, H. C. (1973).Thorax, 28, 667-679. Reconstruction of the trachea. Experience in 100 consecutive cases. Anatomic mobilization of the trachea permits resection of one-half or more with primary anastomosis. An anterior approach by a cervical or cervicomediastinal route utilizes cervical flexion to devolve the larynx and tracheal mobilization with preservation of the lateral blood supply. The transthoracic route is employed for lower tracheal lesions.

Over 100 tracheal resections have been done using these methods of direct reconstruction. Eighty-four patients suffered from benign strictures, 79 resulting from intubation injuries. Eleven primary tracheal tumours and five secondary tumours are included. The majority of lesions following intubation occurred at the level of the cuff. It was possible to repair 78 of the 84 stenotic lesions through a cervical or cervicomediastinal approach. Seventy-three of the 84 patients with inflammatory lesions obtained an excellent or good functional and anatomic result. Nine of 11 patients with primary neoplasms who underwent reconstruction are alive and without known disease. There were five early postoperative deaths in these 100 consecutive patients who underwent tracheal reconstruction.

The use of the covered Wallstent for the palliative treatment of inoperable tracheobronchial cancers. A prospective, multicenter study

STUDY OBJECTIVE

To investigate the safety, efficacy, and tolerance of the covered Wallstent for the palliative treatment of inoperable tracheobronchial cancer.

DESIGN

An 8-month prospective study employing either a rigid bronchoscope or a flexible delivery system for prosthesis insertion.

SETTING

Multicentric setting involving four teaching hospitals in Switzerland and Germany.

PATIENTS

Forty patients (29 men, 11 women), average age of 62 years, presenting with an inoperable tracheobronchial cancer.

INTERVENTIONS

After partial airway recanalization with an Nd-YAG laser, the covered Wallstent was inserted 23 times using a rigid bronchoscope (Rigidstep device), and 27 times using a flexible delivery system (Telestep device) under fluoroscopic and endoscopic visualization.

RESULTS

Clinical and endoscopic examination at 1, 30, and 90 days showed improvement in the bronchial lumen and in the dyspnea index. No serious complication (death, perforation, hemorrhage, inability to remove an improperly placed prosthesis) was observed during surgery. Late complications included migration (12%), inflammatory granulations or tumor regrowth at the tip of the prosthesis (36%), and symptomatic retention of secretion (38%).

CONCLUSIONS

Compared with other tracheobronchial prostheses, notably the Dumon stent, the covered Wallstent presents the following advantages: insertion with visual guidance, treatment of extrinsic compressions and esophagobronchial fistulas, and little chance of migration when the prosthesis diameter is chosen correctly. The following disadvantages can be noted: high price; both repositioning and extraction of the released stent are more difficult, though certainly possible; and risk of granulations at the tips of the prosthesis and retention of secretions. Suggestions are made for potential improvements to the stent and insertion system that may result in a significant decrease in early and late complications.

Office-Based Laryngeal Laser Surgery: A Review of 443 Cases Using Three Wavelengths

BACKGROUND: Unsedated office-based laser surgery (UOLS) of the larynx and trachea has significantly improved the treatment options for patients with laryngotracheal pathology including recurrent respiratory papillomas, granulomas, leukoplakia, and polypoid degeneration. UOLS delivered by flexible endoscopes has dramatically impacted office-based surgery by reducing the time, costs, and morbidity of surgery.

OBJECTIVES: To review our experience with 443 laryngotracheal cases treated by UOLS.

METHODS: The laser logbooks at the Center for Voice and Swallowing Disorders were reviewed for UOLS, and the medical and laryngological histories were detailed, as were the treatment modalities, frequencies, and complications.

RESULTS: Of the 443 cases, 406 were performed with the pulsed-dye laser, 10 with the carbon-dioxide laser, and 27 with the thulium: yttrium-aluminum-garnet laser. There were no significant complications in this series. A review of indications and wavelength selection criteria is presented.

CONCLUSION: Unsedated, office-based, upper aerodigestive tract laser surgery appears to be a safe and effective treatment option for many patients with laryngotracheal pathology.

Mucoepidermoid lung tumors

Mucoepidermoid lung tumors are uncommon, representing 0.2% of all lung tumors and 1% to 5% of bronchial adenomas. Eighteen patients with mucoepidermoid tumors are reported. There were 10 male and 8 female patients with a mean age of 36.8 years (range, 9 to 62 years). On the basis of mitotic activity, cellular necrosis, and nuclear pleomorphism, we subclassified these tumors as low grade (15 patients) or high grade (3 patients). The achievement of complete resection and low-grade versus high-grade staging correlated with prognosis. All 12 patients who had a low-grade tumor that was completely excised are alive with no evidence of disease at a mean follow-up of 4.7 years (range, 1 to 27 years). All high-grade tumors proved fatal within 16 months. Two of the 3 high-grade tumors were unresectable because of extensive local disease. Patients with low-grade tumors and microscopically positive margins require close follow-up and can undergo a successful repeat resection. Nine of the 16 resections were sleeve resections, high-lighting the importance of conservative lung-sparing procedures in these central airway tumors. Both patients with an unresectable high-grade tumor had radiation therapy postoperatively and died 11 months later. The role of radiation therapy with high-grade tumors or incomplete resection has yet to be determined.

Tracheal tumors: surgical management

In a 15-year period, 63 patients with primary tracheal tumors were seen. Twenty-eight patients with primary tumors and 8 with secondary tumors of the trachea were treated by resection with single-stage reconstruction. There were 24 cylindrical resections of trachea, 2 lateral resections of trachea, and 10 carinal reconstructions. Thirty-five additional patients with primary tracheal tumors were managed by staged reconstruction, irradiation, or no treatment. The most common primary lesion was squamous cell carcinoma and the second, adenoid cystic carcinoma. Benign primary tumors and low-grade malignant tumors obtained excellent palliation and usually cure. Surgical removal of squamous cell carcinoma and adenoid cystic carcinoma, usually with adjunctive irradiation, provided good palliation or the probability of cure. Resection of selected secondary tumors provided long-term palliation.

Uncommon Primary Tracheal Tumors

BACKGROUND

Primary tracheal tumors other than adenoid cystic or squamous cell carcinoma are uncommon and have a heterogeneous histologic appearance. The experience regarding their treatment and long-term outcome is limited, and alternatives to segmental tracheal resection, including endoscopic treatment or radiation, continue to be explored.

METHODS

A retrospective analysis was performed of uncommon tracheal tumors among 360 primary tracheal tumors seen over 40 years, excluding adenoid cystic and squamous cell carcinoma.

RESULTS

Of 90 patients, 34 (38%) had benign tumors and 56 malignant: 11 carcinoid tumors, 14 mucoepidermoid carcinomas, 13 sarcomas, 15 nonsquamous bronchogenic carcinomas, 2 lymphomas, and 1 melanoma. Three patients had a second tracheal malignancy. Dyspnea was the most common symptom in benign tumors and hemoptysis in malignant tumors. Twelve patients did not undergo tracheal resection (13.3%) and 1 died before resection. Surgical therapy in 77 patients (85%) consisted of laryngectomy in 3, laryngotracheal resection in 9, tracheal resection in 46, and carinal resection in 19. Hospital mortality was 2.6% (2 of 77 patients) and major complications occurred in 16% (12 of 77 patients). Mean follow-up was 9.7 years. After resection, survival at 10 years was 94% for benign and 83% for carcinoid tumors, and at 5 years survival was 60% for bronchogenic carcinoma, 100% for mucoepidermoid tumors, and 78% for sarcomas. Patients with lymphomas and melanoma are alive more than 8 years after resection. Ten patients experienced recurrence (14%).

CONCLUSIONS

Surgical resection of uncommon primary tracheal tumors alleviates airway obstruction, is curative in patients with benign or slow-growing malignant lesions, and prolongs survival in highly malignant lesions.