1. Tumor of Trachea and Esophagus

2. Tracheal neoplasm

3. Overview Tracheal anatomy Primary tracheal tumors
Benign primary tracheal tumors
Malignant primary tracheal neoplasms
Secondary tracheal tumors

4. Anatomy: Trachea
Trachea เป็นอวัยวะที่อยู่แนวกลางตัว ยกเว้นส่วนปลายที่จะเอียงไปทางด้านขวา
จะมีรอยเว้า 2 แห่ง เนื่องจากมีรอยกดของ aortic arch ทางด้านซ้าย และ arch of azygos veinทางด้านขวา
Trachea wall ประกอบด้วย horseshoe-shaped cartilages อัน เชื่อมติดกันด้านหลังด้วย thick fibromuscular membrane
เส้นผ่าศูนย์กลาง 19.5 ม.ม ในผู้ชาย และ 17.5 ม.ม ในผู้หญิง

5. Anatomy: Trachea Fibromuscular tube Support by cartilagenous rings
Lower border of cricoid cartilage – top of the carina spur
Average length 11 cm (10-13 cm)
Adult trachea cm in diameter
Extrathoracic trachea ~ 6-9 cm
Trachea, Anatomy 1
 ประกอบด้วย fibromuscular และ cartilaginous tube มีความยาว เซนติเมตร
เริ่มต้นจาก cricoid cartilage ในคอจนถึง bifurcation ที่เรียก tracheal carina
Trachea เป็นอวัยวะที่อยู่แนวกลางตัว ยกเว้นส่วนปลายที่จะเอียงไปทางด้านขวา
จะมีรอยเว้า 2 แห่ง เนื่องจากมีรอยกดของ aortic arch ทางด้านซ้าย และ arch of azygos veinทางด้านขวา
Trachea เมื่อเข้ามาในส่วนของทรวงอกได้ประมาณ 6-9 ซ.ม จะแบ่งออกเป็น Bronchi 2 อัน
Right main bronchus จะยาวประมาณ 2.2 ซ.ม และ Left main bronchus จะยาวประมาณ 5 ซ.ม
Right main bronchus จะมีเส้น ผ่าศูนย์กลาง 15.3 ม.ม และ
Left main bronchus จะยาวมีเส้นผ่าศูนย์กลาง 13 ม.ม

6. C shaped with posterior membranous wall connecting the arms of the “C”
Mucosa : a ciliated pseudostratified columnar epithelium

7. Anatomy: Blood supply to trachea
Branches of inferior thyroid artery supply the upper trachea
Branches of bronchial artery supply the lower trachea
Branches arrive the trachea via lateral pedicles

8. Tumor of trachea Tracheal tumor 2 type - primary tracheal tumor
- secondary tracheal tumor

9. Tracheal resection with end to end anastomosis
Tracheal mobilization maneuvers
Extreme flexion of the neck (1-6 cm)
Incising the annular ligament (1-2 cm)
Suprahyoid or infrahyoid release of the upper laryngotracheal unit (2.5-5 cm)
Blunt dissection and mobilization of the lower tracheal segment (0.5-1 cm)
All combinations yields 4-6 cm (~ patient age and range of neck motion)

10. Primary Tracheal Tumors

11. Primary Tracheal Tumors
Uncommon
Incidence 2 case/million/year
Men = Women
Peak age : yr
Risk factor : Smoking
In adults : Malignant >80%
In children : Benign > 90 %
Most frequent : proximal and distal 1/3 of trachea
Originate from any layer in tracheal wall
Classified : - Epithelial tumors
- Mesenchymal tumors
Primary tumor can originate from any layer in the tracheal wall
Cummings, 5 th ed.

12. Classification of Tracheal Tumors
Epithelial Neoplasms
Benign
Squamous cell papilloma
Papillomatosis
Pleomorphic adenoma
Malignant
Squamous cell carcinoma
Adenoid cystic carcinoma
Carcinoid
Mucoepidermoid carcinoma
Adenocarcinoma
Small-cell undifferentiated carcinoma
Secondary malignancy
Invasion by adjacent malignancy
Metastases
Nonneoplastic tumors
Tracheobronchopathia osteochondroplastica
Amyloidosis
Inflammatory pseudotumor
Mesenchymal Neoplasms
Benign
Fibroma
Hemangioma
Granular cell tumor
Schwannoma
Neurofibroma
Fibrous histiocytoma
Pseudosarcoma
Hemangioendothelioma
Leiomyoma
Chondroma
Chondroblastoma
Lipoma
Malignant
Leiomyosarcoma
Chondrosarcoma
Paraganglioma
Spindle-cell sarcoma
Lymphoma
Malignant fibrous histiocytoma
Rhabdomyosarcoma

13. BENIGN PRIMARY
TRACHEAL TUMORS

14. Benign primary tracheal tumors
Uncommon in adult
Usually smooth, well circumscribe, round, soft, and small < 2 cm
Chest CT
Not extend through the tracheal wall
May presence of calcium within the lesion  benign histology
Cummings, 5 th ed.

15. Benign primary tracheal tumors
Squamous papilloma
Granular cell tumor
Chondroma
Leiomyoma
Hemangioma

16. Squamous Papilloma
Superficial, sessile or papillary masses consisting of a connective tissue core covered by squamous epithelium
Adult : rare
: associate with heavy smoking
Children : most common tracheal neoplasm
Cause : HPV 6, 11
Cummings, 5 th ed.

17. Squamous Papilloma
Cause : transmitted from mother to fetus during childbirth
Frequent recurs and difficult to completely eradicate
Usually regresses spontaneously after puberty
Major lesion occur isolated to the larynx (90-95%)
- 11% occur in the trachea in addition to the larynx
- 1.2 % isolated to the trachea

18. Squamous Papilloma Treatment : similar laryngeal papilloma
- recent : CO2 laser
: Adjuvant treatment with α-interferon
Malignant transformation to SCCA or Verrucous CA
- incidence of malignant degeneration %
- associated HPV -11

19. Granular cell tumor Neurogenic in origin , from schwann cell
No sex predilection
Children : rare
50% of granular cell occur in the head and neck region
- 10 % in the larynx
- rare : in the cervical trachea

20. Granular cell tumor 20% Multicentric tumor, more aggressive
Finding : Non-encapsulated,
: tend to invade locally
Malignant degeneration 1-2%
(never report in children)

21. Granular cell tumor Management : surgery - Tumor size < 8 mm :
“ Bronchoscopic resection ”
- Tumor size > 8 mm
 high likelihood of full-thickness wall involvement
 recurrent after bronchoscopic removal
“ Segmental tracheal resection ”

22. Chondroma Most common benign mesenchymal tracheal tumor
Cartilaginous origin
Most common site
- internal aspect of the posterior cricoid lamina
Hard , smooth , broad-based and covered by intact mucosa
Radiography : 75% found calcification,
not distinguish from chondrosarcoma

23. Chondroma Management : - surgery  segmental tracheal resection
- endoscopic resection  for palliation but leads to recurrence

24. Leiomyoma
Origin : smooth muscle of tracheal wall , typically from the membranous portion of the lower third of the trachea
Finding : Smooth contoured ,
polypoid mass and usually have
a broad base

25. Leiomyoma Management : surgery - segmental tracheal resection
- incomplete resection  local recurrence

26. Hemangioma Hemangioma of the airway occur in adults and children
- cavernous hemangiomas develop in the larynx
- capillary hemangioma originate in subglottic area

27. Hemangioma
Tracheal Hemangioma  occur more often in young children and most common obstructive subglottic mass
Asymptomatic at birth, but most will cause stridor within the first 6 months of life
Cutaneous hemangioma 50% of patient