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(Chest. 1999;116:269-270.)
© 1999 American College of Chest Physicians

Successful Management of Adenoid Cystic Carcinoma of the Trachea by Laser and Irradiation

A. Aggarwal, MD; Sanjiv Tewari, MD and A. C. Mehta, MBBS, FCCP

Cleveland Clinic Foundation, Cleveland, OH

Correspondence to: A. C. Mehta, MBBS, FCCP, Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Desk A-90, 9500 Euclid Ave, Cleveland, OH 44195

To the Editor:

Segmental resection and reconstruction performed in a single stage and adjuvant pre- and post-operative irradiation have long been used to offer the best chance for cure for adenoid cystic carcinoma (ACC) of the trachea. For cases in which the ACC is nonresectable, palliative methods that yield good success rates are available.1 2 3 We report a case of ACC that was successfully managed with Nd-YAG laser photoresection and external beam irradiation and high-dose-rate (HDR) brachytherapy.

A 44-year-old white man with recurrent shortness of breath and multiple episodes of pneumonia for > 18 months was referred to us for the management of an exophytic mass involving the trachea detected on flexible bronchoscopy. A CT scan of the chest showed a tracheal mass with no hilar or mediastinal lymphadenopathy. Repeat bronchoscopy at our institution showed a large tracheal submucosal and exophytic mass starting 3 to 4 cm below the vocal cords, which extended 1 cm above the carina with a vertical length of 6 cm and caused an 80% obstruction of the mid and lower trachea (Fig 1 ). Bronchial fine needle aspiration revealed atypical cells derived from an epithelial neoplasm, which was consistent with ACC.



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  		Figure 1. Bronchoscopic image of the ACC of the trachea on initial presentation.

 
The patient's respiratory sounds were stridorous, and he was in moderate respiratory distress. Arterial blood gas analysis revealed a pH of 7.39, a PCO2 of 40 mm Hg, a PO2 of 110 mm Hg, an HCO3- of 24 mEq/L, and an arterial oxygen saturation of 98% on 4 L of O2. As a precaution, helium-oxygen mixture was kept at the patient's bedside until bronchoscopic resection was performed. The patient underwent Nd-YAG laser photoresection with a flexible bronchoscope under general anesthesia using a laryngeal airway mask at two sittings, and 90% patency of the trachea was established. There was significant relief of symptoms after the endobronchial photoresection.

The patient was started on external beam radiation, and he received a dose of 50 Gy in 25 fractions. He also received endobronchial radiation therapy in three fractions using a 192Ir device with a total dose of 21 Gy. Repeat flexible bronchoscopy a month after the radiation therapy revealed a complete patency of the trachea (Fig 2 ). The results of the cytology tests on tracheal washings were negative for malignant cells. We plan to follow the patient with flexible bronchoscopy every 4 months for any recurrence of the ACC.



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  		Figure 2. Patency of the trachea reestablished after Nd-YAG laser photoresection of the ACC.

 
ACC is a slowly growing, late metastasizing, and locally recurrent tumor with a prolonged natural history. As reported in our case above, debulking and irradiation can provide excellent palliation. This can be achieved with good precision using the laser. The role of adjuvant therapy is difficult to evaluate with certainty.4 Endobronchial brachytherapy is now widely used to increase the total dose of irradiation and to improve local tumor control. Follow-up bronchoscopies and frequent monitoring for spread of the tumor are required after initial debulking and irradiation.

Our case report supports the literature in that a combination therapy of endoscopic laser photoresection, external beam radiation, and endobronchial radiation therapy may provide better palliation and survival in patients with a nonresectable ACC. Also, in a patient presenting with critical airway obstruction, endoscopic laser photoresection allows for better ventilation of the airway. Because radiation therapy has the potential to further compromise the already obstructed airway, we prefer to perform endoscopic laser photoresection prior to radiation therapy.

References

  1. Okahara, M, Segawa, Y, Takigawa, N, et al (1996) Adenoid cystic carcinoma of the trachea effectively treated with the Nd-YAG laser followed by radiation. Intern Med 35,146-149[Medline]
  2. Huber, RM, Fischer, R, Hautmann, H, et al (1997) Does additional brachytherapy improve the effect of external irradiation? A prospective, randomised study in central lung tumors. Int J Radiat Oncol Biol Phys 38,533-540[CrossRef][ISI][Medline]
  3. Boedker, A, Hald, A, Kristensen, D (1982) A method of selective endobronchial and endotracheal irradiation. J Thorac Cardiovasc Surg 84,59-61[Abstract]
  4. Maziak, ED, Todd, TRJ, Keshavjee, SH, et al (1996) Adenoid cystic carcinoma of the airway: thirty-two year experience. J Thorac Cardiovasc Surg 112,1522-1532[Abstract/Free Full Text]



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 Eur. J. Cardiothorac. Surg.Home page
C.-M. Lin, A. F.-Y. Li, L.-H. Wu, Y.-C. Wu, F. C.-F. Lin, and L.-S. Wang
Adenoid cystic carcinoma of the trachea and bronchus - a clinicopathologic study with DNA flow cytometric analysis and oncogene expression
Eur. J. Cardiothorac. Surg., October 1, 2002; 22(4): 621 - 625.
[Abstract] [Full Text] [PDF]

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