The Oncologist 1997;2:245-253 Management of Tracheal Neoplasms

Primary tracheal tumors are rare neoplasms which often present with indolent and nonspecific symptoms. Despite a tendency for late presentation, more than half of patients with benign and malignant neoplasms will be candidates for curative resection upon diagnosis. This review describes the diagnostic and staging evaluation of tracheal neoplasms. Curative surgical procedures including laryngotracheal resection, tracheal resection, and carinal resection are discussed. Palliative therapies such as external beam radiation, endolumenal brachytherapy, bronchoscopic laser resection, and endoprosthetic stenting are reviewed. The Oncologist 1997;2:245-253 Correspondence: Douglas J. Mathisen, M.D., Thoracic Surgical Unit, Massachusetts General Hospital, 55 Fruit Street, Blake 1570, Boston, Massachusetts 02114, USA. Telephone: 617-726-6826; Fax: 617-726-7667. Accepted for publication May 14, 1997. ©AlphaMed Press 1083-7159/97/$5.00/0 INTRODUCTION Primary tracheal neoplasms comprise a rare group of benign and malignant tumors of the trachea (Tables 1 and 2). The rarity of this condition has been estimated to be 0.1% to 0.4% of all malignancies, with an annual incidence of 2.6 new cases per million per year [1-3]. The infrequency of cases creates a low level of suspicion among physicians, thus leading to delays in diagnosis and treatment. The resectability rate of benign and malignant tracheal tumors has been reported as high as 90% for benign lesions and 70% for malignant ones. Our experience with the management of primary tracheal neoplasms at the Massachusetts General Hospital (MGH) was last reviewed in 1990 and now exceeds 300 cases since our first tracheal resection for tumor in 1962 [4]. The present review will provide discussion and guidelines for the diagnosis, staging, and treatment of patients with primary tracheal tumors. ESTABLISHING THE DIAGNOSIS The first challenge in treating these patients is to make the diagnosis of a rare condition which presents with common and nonspecific symptoms. The symptoms reported by 240 patients with tracheal neoplasms at MGH are recorded in Table 3. The tumor must generally advance to a size which obstructs more than half of the cross-sectional area of the airway before dyspnea is experienced. Unfortunately, the chest radiograph has proven normal in 30%-75% of patients, causing many who present with dyspnea and a normal radiograph to be treated inappropriately for asthma or chronic obstructive pulmonary disease [3, 5]. It has been common in our experience to see patients with indolent tracheal neoplasms treated for months or even years with bronchodilators and steroids until hemoptysis or obstructive pneumonia leads to a diagnostic bronchoscopy. Table 1. Primary benign tracheal tumors Carcinoid tumor (typical)