Asian Cardiovasc Thorac Ann 2005;13:280-282
© 2005 Asia Publishing EXchange Ltd
A New Surgical Techique for Adenoid Cystic Carcinoma Involving Tracheal Carina
Adnan Sayar, MD,
Muzaffer Metin, MD,
Okan Solak, MD,
Akif Turna, MD,
Süha Alzafer, MD1,
Turan Ece, MD2
Department of Thoracic Surgery, Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Istanbul, Turkey
1 Acibadem Hospital, Istanbul, Turkey
2 Istanbul Faculty of Medicine Department of Pulmonary Diseases, Istanbul, Turkey
For reprint information contact: Akif Turna, MD Tel: 90 212 664 1700 Fax: 90 216 411 6651 Email: aturna{at}turk.net, Cami Sok. Muminderesi Yolu. Emintas Camlik Sit. No: 32/22, Sahrayicedid, Kadikoy, Istanbul 81080, Turkey.
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ABSTRACT
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Reported is the successful treatment of a 24-year-old male with adenocystic carcinoma involving the tracheal carina, in which the tumor extended along the right main bronchus across the orifice of the right upper lobe. The patient underwent a carinal resection plus right upper lobectomy and reconstruction of the carina, resulting in neither anastomotic complication nor recurrence of disease during 28 months of follow-up.
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INTRODUCTION
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Pulmonary or tracheal tumor in close proximity to, or involving the carina, remains a challenging problem. Techniques to allow complete surgical resection are available, but due to the demanding nature of carinal resection and reconstruction, postoperative complications occur frequently.1–2 Due to concerns over perioperative morbidity and mortality rates, Miyamoto and associates described a new method of carinal reconstruction and subsequently Yamamoto and colleagues justified its safety and effectiveness.3–4 The present case study describes the successful treatment of a 24-year-old male with adenocystic carcinoma at the carina. The patient was treated surgically using Miyamoto’s technique, with bronchial end-to-side anastomosis added to the tracheobronchial end-to-end anastomotic site.3 No postoperative complications occurred.
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CASE REPORT
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A 24-year-old male presented with cough, dyspnea and hemoptysis, although routine laboratory studies including pulmonary function tests appeared normal. A chest radiography was initially interpreted as normal, but in retrospect it showed a mass at the carina. Computed tomography (CT) revealed a 3 x 3 x 4 cm circular mass at the carina, which extended along the right main bronchus (Figure 1A and 1B
). There was no mediastinal lymphadenopathy or obvious findings of bronchial invasion. A flexible bronchoscopy demonstrated a broad-based polypoid lesion located at the carina, protruding into the lumen of the right main bronchus. A bronchoscopic biopsy was performed, and the tumor was found to be an adenocystic carcinoma of low grade.
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Figure 1. Spiral computed tomography unveiled tumor involving the distal trachea (A) and extending just across the orifice of the right upper lobe (B).
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An epidural catheter was inserted preoperatively to provide postoperative analgesia, and a single-lumen endotracheal tube was used until the trachea and bronchus were resected. The patient underwent a carinal resection plus right upper lobectomy, followed by a reconstruction of the carina. This technique was first described by Miyamoto and colleagues, and was subsequently first reported in the English language by Yamamoto and associates in 2000.3–4 Briefly, following a right thoracotomy, the azygos vein was transected and a paratracheal and subcarinal lymph node sampling was performed. Traction sutures were placed at the trachea and remaining part of the left main bronchus, the vessels of the right upper lobe were sutured, and the bronchus intermedius transected below the take-off of the upper lobe bronchus. The left main bronchus was transected 1 cm below the carina, and then intubated across the operative field with a sterile endotracheal tube to maintain ventilation. The trachea was then transected four rings above the carina. For anastomosis between the trachea and left main bronchus, insertion of simple interrupted sutures (3-0 Vicryl, Ethicon Inc., Summerville, NJ, USA) were instigated at the deepest site, and two thirds of the circumference received end-to-end anastomosis (Figure 2). Each suture was placed through all layers of the mucosa, during which tension was applied to the traction sutures to reduce the force on the anastomotic sutures whilst they were being tied. One ring of cartilage was additionally trimmed from the remaining one third of the circumference of the trachea and left main bronchus. The anastomotic site was shaped to an oval of a size a little larger than the end of the bronchus, even if some of the tied sutures were cut, in order to prevent postoperative stenosis at the anastomosis. The membranous portion of the trachea was not involved in order to maintain rigidity of the anastomotic site. The right bronchus was then anastomosed end-to-side with running 3/0 polypropylene (Prolene, Ethicon Inc, Somerville, NJ, USA) sutures to this trimmed site. After confirming that there was no air leak from the anastomosis, a pedicled parietal pleura flap was used to cover the anastomotic site and Fibrin glue (Beriplast P Combi Set, Aventis, Marburg, Germany) was applied over the parietal pleura in order to tauten the anastomosis.
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Figure 2. The diagram shows the localization of the tumor (A). First, the trachea, the left main bronchus, and the bronchus intermedius were transected (B). Following the anastomosis between the trachea and left main bronchus using interrupted sutures (C),  of the primary end-to-end anastomosis remained to be performed. The remaining lumen was trimmed to create an appropriate aperture for the secondary end-to-side anastomosis (D). Finally, the bronchus intermedius was re-implanted into the aperture using running sutures (E).
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The postoperative course was uneventful with the patient being discharged home on the 12th postoperative day. Pathology revealed adenoid cystic carcinoma and the surgical margin was found to be microscopically involved with tumor. A control fiberoptic bronchoscopy and computerized CT of the chest revealed no anastomotic complications, nor recurrence at 28 months after the operation.
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DISCUSSION
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Adenoid cystic carcinoma is encountered most commonly in the trachea and major bronchi, arising from mucus-secreting cells, whereas its occurrence in the peripheral parts of the lung is exceptional. The symptoms are related to upper airway obstruction, with wheezing, stridor, and hoarseness reported most frequently, followed by cough, hemoptysis, and recurrent pulmonary infection.
Assessment of the cardiovascular and pulmonary status is indicated, particularly in elderly patients and in those in whom major pulmonary or tracheal resection is contemplated. The completeness of the excision must be verified by frozen section examination of the surgical margins, with special attention paid to the submucosa and perineurial lymphatic channels, in which invasion is notorious.4 Radiotherapy should be used in patients in whom a complete resection is not possible, and for recurrences.
Carinal reconstruction was first performed by Barclay and colleagues in 1957. Since then, other procedures have been reported such as the double-barrel carinal reconstruction method.5–6 The double-barrel type of reconstruction is used only after resection of a small segment of the airway, since end-to-end anastomosis of the trachea with the side-to-side anastomosis of the right and left bronchi causes severe tension at the anastomotic site. Also, the difference in size between trachea and bronchi cannot be altered, so it is difficult to adjust the anastomosis. Indeed, Mitchell and associates reported a high rate of anastomotic complications in patients who underwent carinal plus lobar resection.2 Barclay also described an end-to-end anastomosis of the trachea and left main bronchus plus end-to-site anastomosis of left intermediary bronchus to the lateral tracheal wall.5 This type of reconstruction makes it possible to reduce tension at the anastomosis, and is especially applicable for resection of a long segment of the trachea. However, this method can cause the impairment of blood flow to the stump and stricture at the end-to-side anastomosis.
In 1994, Miyamoto and co-workers proposed the new method reported in this case study, and reported on its effectiveness in a small number of cases.3 Yamamoto and colleagues subsequently introduced the method to the English language literature and confirmed the effectiveness and safety of the method.4 They also indicated a number of advantages of the method including low tension at the anastomotic site due to lack of long traction of the right bronchus, lower chance of stricture at the site of trimming, dissipation of anastomotic tension in three directions and easier applicability compared to the end-to-site anastomosis. Chen and associates also reported a patient with mucoepidermoid carcinoma of the carina who was successfully treated using the modified technique.7 However, in our patient, the anastomosis between the trachea and bronchus intermedius was performed using running prolene sutures. We believe that a running suture provides a well balanced anastomotic force along the edges of the trachea and bronchi.
Regarding the microscopic tumor positivity after resection, it was thought to be clinically unimportant since patients with adenoid cystic carcinoma and microscopic tumor at resection sites are reported to have low recurrence rate and favorable prognosis following radiotherapy.8 However, the maximum resectable segments of the trachea, right and left bronchi remains unknown since the method was used in a small number of patients. Nevertheless, in adenoid cystic carcinoma patients excessive tracheal and bronchial resection should be avoided in order not to endanger the anastomosis and to prevent postoperative dehiscence, since resection margin positivity is of limited clinical and prognostic importance.
Despite the small number of patients who have undergone this technique, and in our case, only one patient who has been successfully treated, the technique seems to be very easy and allows carinal reconstruction without complications. Although the method needs confirmation with a larger series, it could be considered for carinal reconstruction in selected patients.
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REFERENCES
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- Grillo HC. Carinal reconstruction. Ann Thorac Surg 1982;34:356–73.[Abstract]
- Mitchell JD, Mathisen DJ, Wright CD, Wain JC, Donahue DM, Moncure AC, et al. Clinical experience with carinal resection. J Thorac Cardiovasc Surg 1999;117:39–53.[Abstract/Free Full Text]
- Miyamoto Y. Carinal reconstruction of lung cancer (in Japanese). In: Hitomi S, Wada H, eds. The practice in chest surgery: learning from 130 cases (Kokyukiga-no-Jissai). Kyoto: Kingpodo 1994:24–6.
- Yamamoto K, Kosaba S, Ikeda T. Tumors involving the tracheal carina: new technique of carinal reconstruction. Ann Thorac Surg 2000;70:1419–22.[Abstract/Free Full Text]
- Barclay RS, McSwan N, Welsh TM. Tracheal reconstruction without the use of grafts. Thorax 1957;12:177–80.
- Mathey J, Binet JP, Galey JJ, Evrard C, Lemoine G, Denis B. Tracheal and tracheobronchial resections: technique and results in 20 cases. J Thorac Cardiovasc Surg 1966;51:1–13.[Medline]
- Chen F, Tatsumi A, Miyamoto Y. Successful treatment of mucoepidermoid carcinoma of the carina. Ann Thorac Surg 2001;71:366–8.[Abstract/Free Full Text]
- Maziak DE, Todd TR, Keshavjee SH, Winton TL, Van Nostrand P, Pearson FG. Adenoid cystic carcinoma of the airway: thirty-two-year experience. J Thorac Cardiovasc Surg 1996;112:1522–32.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
