Primary tumors of the trachea are rare, accounting for less than 0.2% of respiratory malignancies. The most common primary malignant tracheal tumors are squamous cell carcinoma and adenoid cystic carcinoma. Evaluation of tracheal tumors involves CT, bronchoscopy and biopsy to determine resectability while assessing for metastatic disease. Surgical resection is the primary treatment when possible but unresectable disease may be treated with stents or chemoradiation to relieve obstruction and slow progression. Postoperative radiation is recommended for intermediate or high-grade malignancies due to risk of positive margins.

1. A R D I A N S Y A H
Cardiothoracic and Vascular Surgery Trainee
University of Indonesia

2. Kozower BD, Patterson GA. Pearson’s thoracic and esophageal surgery. Patterson GA, Cooper JD, Deslauriers J. Et al. Philadelphia: Elsevier; 2008
Primary tumors of the trachea are rare
Malignant tracheal obstruction is caused far more often by
metastatic than primary tumors
Malignant tumors of trachea are more common than benign
tumors
Tracheal tumors account for less than 0.2% of all respiratory
tract malignancies in the United States
• 55% male,
• 77-86% with history of smoking,
• Predominant histology: squamous cell carcinoma 45%,
adenoid cystic carcinoma 16.3%
SEER database (1973-2004):

3. Shields TW (ed.). General Thoracic Surgery 7th edition. Philadelphia: Lippincott Williams & Wilkins, 2009.

4. Nonspecific symptoms  diagnostic delay
Imperceptibly progressive respiratory symptoms
Hemoptysis, cough
Dyspnea, near-asphyxiation
Wheezing (misdiagnosed as asthma)
Hoarseness (involvement of recurrent laryngeal nerve)
Dysphagia – locally advanced or unresectable lesion

5. Primary Malignant
Squamous cell carcinoma
Adenoid cystic carcinoma
Other types of
bronchogenic carcinoma
Mucoepidermoid carcinoma
Carcinoid tumor
Sarcoma
Lymphoma
Secondary/Metastatic
Direct invasion: thyroid,
larynx, lung, esophagus
Mediastinal tumors:
lymphoma
Hematogenous metastases:
melanoma, breast, colon,
kidney
Benign
Chondroma
Papilloma
Fibroma
Hamartoma
Mesenchymal tumors

6. •Most common primary malignancy of
trachea (histology like SCC of lung)
•M > F, 60–70 years
•90% smokers
•Usually exophytic or ulcerative
•Biologically aggressive, grow rapidly,
metastasize early; 30% have synchronous
or metachronous malignancies
Usual diagnosis within 4–6 months of
symptom onset
Occurs most commonly in the distal third of
the trachea and originates frequently along
the posterior wall
•Arise from bronchial glands (histology like
salivary glands)
•M = F, 40–50 years
•No smoking association
•Usually exerts mass effect rather than
regional invasion; submucosal spread
•Slow growth, late recurrences
•Usual diagnosis more than 1 year after
symptom onset
More commonly arises in the upper third of
the trachea
Squamous
cell
carcinoma
(SCC)
Adenoid
cystic
carcinoma
(ACC)

7. Rarely present in a manner amenable to surgical resection
Laryngeal carcinoma: surgical excision during laryngectomy with end
tracheostomy formation
Lung carcinoma:
• Mediastinal lymph node involvement: not candidates for resection 
palliative for intraluminal obstructive growth
• Without mediastinal lymph node involvement: possible resection (tracheal
sleeve pneumonectomy)
Thyroid carcinoma involving trachea or adjacent larynx:
• To attempt to achieve cure by accomplishing complete resection of the tumor
• To provide prolonged palliation by relief or prevention of airway obstruction in
patients with slowly progressive neoplasms
• To prevent death by asphyxiation or hemorrhage
Esophageal cancer: esophagorespiratory fistula; esophageal stent,
gastrostomy

8. CXR
• Mediastinal widening, tracheal stenosis
CT
• Tracheal mass, invasion to adjacent structures, lymph node
metastases
Broncho
-scopy
• Rigid  better visualization and more accurate determination
of size and length of lesion
• Stent
Metas-
tatic
• rradiographic evaluation of lung, brain, bone, adrenal glands
and liver

9. • Tracheal lumen size
• Measurement of tumor
• Mediastinal extension
• Esophageal compression
• Compression of vascular
structures
• Lymph node and
metastases
• Benign: round, smooth,
approximately 2cm in
diameter, calcification
• Malignant: irregular,
possibly ulcerated,
invasion, extraluminal
growth
Shields TW (ed.). General Thoracic Surgery 7th
edition. Philadelphia: Lippincott Williams & Wilkins,
2009.

10. Evaluation of vocal cord function, entire larynx and cricoid cartilage
The gross characteristics: an impression  benign or
malignant
The size of the tracheal lumen  planning anesthetic
management of the airway during the initial phase of
tracheal resection
A biopsy sample can be obtained  potential hazardous,
bleeding may cause obstruction
Small, flexible fiberoptic bronchoscope can be inserted past the
neoplasm and the distal airway carefully examined

12. Complete resection of tracheal tumors
• Absence of distant metastasis and advanced regional
disease
• Safe limits of tracheal resection: age, mobility of neck,
body weight
Resectable disease
Cervical collar incision: subglottic region, upper and middle
trachea are exposed
Sternotomy or right thoracotomy: Lower tracheal tumors
involving carina
Microscopically positive margin vs. attempt on complete
resection
Adjuvant radiation therapy

13. Unresectable disease
Reasons to not resect tumor length, distant metastatic
disease
Goal of treatment: restore patent airway, slow
progression of disease
Bronchoscopic (local) destruction: coring out tumor,
cryotherapy, laser, brachytherapy
Regional radiation
Role of chemotherapy: bronchogenic carcinoma
Malignant strictures: stent  adequate airway

14. The decision regarding
postoperative radiation therapy is
based on the completeness of
the surgical resection and the
histologic type of tumor
An atypical carcinoid tumor with
negative margins at resection is
not a candidate for adjuvant
radiation
Postoperative radiation therapy
is recommended for all patients
undergoing tracheal resection
forvsquamous cell carcinoma
Adenoid cystic carcinomas are
radiosensitive and slow-growing

15. Honings J, van Dijck JAAM, Verhagen, AFTM. et al. Incidence and Treatment of Tracheal Cancer: A Nationwide Study in
The Netherlands. Ann Surg Oncol. 2007;14:968–976. doi:10.1245/s10434-006-9229-z

16. Madariaga MLL, Gaissert HA. Overview of malignant
tracheal tumors. Ann Cardiothorac Surg.
2018;7(2):244-254. doi:10.21037/acs.2018.03.04

17. • absence of lung masses except those consistent with pulmonary
metastases of tracheal carcinoma,
• absence of extensive mediastinal or hilar lymph node enlargement,
• and absence of distant metastasis.
Is the Observed
Tracheal Mass a
Primary Tumor?
• less than 10% of tumors were benign
Is the Tumor
Benign or
Malignant?
• an assessment of local disease, the confirmation of histology, and clinical
staging of regional and distant disease
• CT, bronchoscopy, +/- biopsy, CT/PET/MRI for distant disease
How Are These
Tumors
Evaluated?
• the selection of definitive therapy proceeds from a determination of
resectability
• tumor length, neck mobility, comorbid factors, and age
What Therapy
Should Be
Selected?

18. What Is the Role of
Neoadjuvant Therapy?
• no clinical to support
preoperative radiation or
chemotherapy
• may impairs tracheal blood
supply and delays healing of
the tracheal anastomosis
What Are the
Indications for
Insertion of a Tracheal
Stent?
• Once resection is eliminated
as treatment
When Is Resection Not
Indicated?
• when tumor resection is not
feasible
• locally invasive disease into
organs (other than esophagus),
and metastatic disease are
considered unresectable
• candidates for primary radiation or
radiochemotherapy to palliate
breathing
What Length of Resection Is Safe?
• no generally valid answer
• variables to be considered: patient age, mobility of
neck, body weight, and endoscopically measured
length of lesion
• planned resections of <4 cm of trachea will almost
always be tolerated
Which Patients Require
Postoperative Adjuvant Therapy?
• based on the compromised completeness of
almost all resections for intermediate or high-
grade malignant tumors
• concerns about the anastomosis, usually
started for 2 months after operation

19. Patterson GA (ed.). Pearson's Thoracic and Esophageal Surgery 3rd edition. Philadelphia: Churchill
Livingstone, 2008.
Shields TW (ed.). General Thoracic Surgery 7th edition. Philadelphia: Lippincott Williams & Wilkins,
2009.
Furlow PW, Mathisen DJ. Surgical anatomy of the trachea. Ann Cardiothorac Surg. 2018;7(2):255-260.
doi:10.21037/acs.2018.03.01
Madariaga MLL, Gaissert HA. Overview of malignant tracheal tumors. Ann Cardiothorac Surg.
2018;7(2):244-254. doi:10.21037/acs.2018.03.04
Honings J, van Dijck JAAM, Verhagen, AFTM. et al. Incidence and Treatment of Tracheal Cancer: A
Nationwide Study in The Netherlands. Ann Surg Oncol. 2007;14:968–976. doi:10.1245/s10434-006-
9229-z
Gaissert HA, Honings J, Gokhale M. Treatment of tracheal tumors. Semin Thorac Cardiovasc Surg.
2009;21(3):290-295. doi:10.1053/j.semtcvs.2009.06.001