颈段气管肿瘤的诊治经验

目的 总结原发性颈段气管肿瘤的诊治经验，提高治疗效果。方法 回顾性分析1981年1月—2002年12月在中国医学科学院肿瘤医院头颈外科治疗的38例原发性颈段气管肿瘤患者的临床资料。手术治疗26例，单纯放疗12例。气管袖状切除11例；气管壁部分切除13例，其中Ⅰ期气管修复6例；全喉、部分气管和甲状腺腺叶切除2例。结果 恶性肿瘤34例，其中腺样囊性癌19例，鳞状细胞癌10例，非霍奇金淋巴瘤2例，低分化癌1例，中分化腺癌1例，小细胞未分化癌1例。颈段气管腺样囊性癌患者3年和5年生存率分别为79．80％和48．36％，鳞状细胞癌分别为80．00％和20．00％。良性肿瘤患者均无瘤生存。治疗后并发症的发生率为18．4％（7／38），其中气管狭窄的发生率11．5％（3／26）。结论 原发性气管肿瘤多数为恶性，其中以腺样囊性癌和鳞状细胞癌居多。手术治疗为气管肿瘤首选治疗措施，气管袖状切除为手术方式之一。     

侵犯气管的分化型甲状腺癌气管袖状切除术

目的 寻找侵入气管及喉的分化型甲状腺癌手术治疗的方法,探讨包括气管及喉部分切除在内的根治性手术可行性和有效性。 方法 3例均为女性,2例为甲状腺乳头状癌,1例滤泡状癌,均侵入气管。一例采取右侧甲状腺腺叶切除术、气管袖状切除术及声门下喉部分切除术,术后因喉切缘肿瘤残留补充放疗总量55 Gy;另一例采取左侧甲状腺腺叶切除术、气管袖状切除术及左改良根治性颈淋巴结清扫术;第三例采取全甲状腺切除、气管袖状和喉部分切除术、双侧改良根治性颈淋巴结清扫术和上纵隔淋巴结清扫术。 结果术后均无声音嘶哑,呼吸平稳,无需气管切开,均无吻合口漏。随访近2年均未见吻合口狭窄和肿瘤复发。 结论对侵入气管及喉的分化型甲状腺癌患者进行包括气管袖状切除术在内的根治性手术治疗是可行和有效的。     

儿童颈段原发性气管恶性肿瘤的临床表现和治疗

目的：探讨儿童颈段原发性气管恶性肿瘤的临床表现和治疗方法。方法：对1998年以来经纤维喉镜、CT扫描、组织病理学诊断的5例原发性气管恶性肿瘤患儿的诊治进行回顾性分析。4例患儿于肿瘤下方行紧急气管切开,1例气管插管后气管切开,用气管镜和鼻内镜联合摘除气管内肿瘤;术后4例接受放疗,1例激光加放疗。结果：5例患儿随访3～8年无复发。结论：儿童气管恶性肿瘤,影像检查是有效的诊断手段,就诊时病情危重,宜行低位气管切开,逆行鼻内镜及硬管气管镜联合下彻底摘除肿瘤,术后辅以放疗可获得良好效果。儿童患者一般不宜行有创的气管壁切除术。     

Fibrous histiocytoma of the trachea: management of a rare cause of upper airway obstruction

We describe a case of fibrous histiocytoma of the trachea diagnosed in a 17-year-old female who presented with symptoms of 'asthma'. Management included rigid bronchoscopy with biopsy and debulking of this obstructing tumor, later excised with partial tracheal resection. Although tracheal tumors are quite rare in children, the majority (6/9) of reported cases of fibrous histiocytoma of the trachea have been described in the pediatric age group. The possibility of a tracheal neoplasm as a cause of wheezing, stridor or hemoptysis in children should be recognized. Control of the airway without tracheotomy may facilitate surgical cure via tracheal resection in such cases.     

气管切开内镜下治疗气管肿瘤的临床观察

目的探讨经过气管切开内镜下治疗气管肿瘤的方法与效果。方法对11例气管肿瘤病例经过气管切开,在内镜下进行肿瘤切除,其中良性肿瘤8例,恶性肿瘤3例,2例腺样囊性癌术后给予放射治疗,甲状腺乳头状腺癌仅做了气管内肿瘤的切除,口服甲状腺素治疗。结果经过临床随访,良性肿瘤未见复发,3例恶性肿瘤已经随访17～38个月,未见复发,取得了很好的临床效果。结论经气管切开内镜下进行气管肿瘤的切除,方法简单,处理有效,可以避免开胸,体外循环等较大的损伤,可以选择部分病例进行。     

Pleomorphic adenoma of the trachea

Primary pleomorphic adenoma of the trachea is rare, as only 33 cases have been previously reported worldwide since 1922. We describe a new case of primary tracheal pleomorphic adenoma that was discovered incidentally in a 78-year-old man. The tumor was excised, and the patient recovered without complication. Salivary gland tumors of the trachea should be considered in the differential diagnosis of tracheal lesions; the diagnosis is confirmed by pathologic evaluation. Patients are adequately treated with sleeve resection and primary anastomosis whenever possible.     

胸锁乳突肌肌骨膜瓣修复颈段气管缺损

目的:探讨利用胸锁乳突肌肌骨膜瓣修复颈段气管缺损的方法。方法:对13例恶性肿瘤侵犯颈段气管及原发性气管肿瘤患者,切除肿瘤及受累气管壁后利用胸锁乳突肌肌骨膜瓣修复气管壁缺损。结果:13例患者中,气管切开患者为10例,9例分别于术后1~5个月拔除气管套管,1例因声门区狭窄,戴管呼吸,3例未行气管切开患者术后呼吸通畅。结论:带蒂胸锁乳突肌肌骨膜瓣是较好的气管修复材料。     

Current aspects of endolaryngeal and endotracheal microsurgery in children

Achievements of today's laryngeal and tracheal surgery came for the most part from novel optic techniques and anesthesia. All the operations were performed with application of the microscope or endoscopic devices. Gas exchange was provided differently: using volume, injection and high frequency artificial ventilation of the lungs. An individual approach to gas exchange technique in respiratory obstruction allowed to avoid emergency tracheotomy. A laryngeal mask was used in children for air delivery in fibrotracheobronchoscopy. Removal of tumors, dissection of laryngeal scars, trachea and bronchi were made by means of ultrasound and laser equipment. Interventions are considered for each condition.     

Surgical treatment of non-malignant laryngotracheal stenosis

The objectives of this study were the following: (1) to analyze the results of surgical treatment of non-malignant subglottic laryngeal and tracheal stenosis, (2) to evaluate the feasibility and technical aspects of the video mediastinoscopy for the mobilization of the mediastinal trachea, (3) to evaluate the influence of the early internal condition of the anastomosis on the development of restenosis. From 1996 up to 2013, 75 patients aged 11–78 years underwent surgery for post-intubation/tracheostomy (71 patients), post-traumatic (3 patients), and idiopathic (1 patient) subglottic laryngeal and tracheal stenosis. Twenty-three (30.7 %) patients with subglottic laryngeal and upper tracheal stenosis underwent cricotracheal resection and thyrotracheal anastomosis (group A), while 52 (69.3 %) patients with tracheal stenosis underwent tracheal resection and cricotracheal or tracheotracheal anastomosis (group B). The length of the resected segment in patients of groups A and B was 28–55 (42 ± 11) mm and 18–65 (36 ± 14) mm, respectively, (p = 0.22). Perioperative complications within 30 days occurred in eight (34.8 %) patients of group A, and in six (11.5 %) patients of group B (p = 0.04). There was one intraoperative and one postoperative death on the third day due to heart failure. The excellent results were achieved in 63 (86.3 %), satisfactory in 8 (11.0 %), and unsatisfactory in 2 (2.7 %) patients. The incidence rate of perioperative complications is related to the location of the stenosis and the type of the resection and anastomosis. Video mediastinoscopy simplifies the mobilization of the mediastinal trachea, which allows for carrying out the anastomosis with minimal tension. Early internal abnormalities of the anastomosis predict its restenosis.     

Papillomatosis of the lower respiratory tracts in children

Papillomatosis of the trachea, bronchi and lungs was investigated in 40 children with papillomatosis of the lower airways in comparison with 408 children with laryngeal papullomatosis. All the patients were operated in 1988-2003 with histological verification of the diagnosis. Papillomas involved the lower airways because of tracheotomy (92.5%) or tracheal intubation (7.5%). Papillomatosis of the lower airways runs a more aggressive course than laryngeal papillomatosis, its treatment efficacy is worse. All the patients suffering from laryngeal papillomatosis with a history of tracheotomy need a regular endoscopic and x-ray control as papillomatosis of the trachea and/or lungs may develop in them several years after decanulation. Pulmonary papillomatosis has an invariably poor prognosis.     

颈段气管肿瘤的外科处理

摘要：颈段气管肿瘤按照原发部位不同分为：原发性颈段气管肿瘤、继发性颈段气管肿瘤。其治疗是以手术为主的综合治疗。手术难度主要在于肿瘤彻底切除后的气道重建。主要的手术方式有气管袖状切除+端端吻合,气管窗壁式切除+气管重建、经纤维支气管镜肿块切除、全喉切除、人工气管等。通过分析各种术式,并结合临床实践经验 ,深入探讨上述各项术式的优缺点、技术细节及适应范围。方法结果结论     

Tracheasegmentresektion zur Behandlung trachealer Stenosen

Background

Segmental tracheal resection is considered to be the standard treatment of tracheal stenoses.

Materials/Methods

During the time period 1985–2002, segmental tracheal resection with a primary end-to-end anastomosis was performed in 117 patients with a cervical or upper thoracal stenosis of the trachea. The age distribution of the patients was between 7 and 77 years. Of the patients with a benign tracheal stenosis, sufficient data for a retrospective analysis were available in 101 patients. The length of the resected tracheal segments varied between 2 and 6 cm which required mobilisation of the trachea and the larynx and, if necessary, incision of the pulmonary ligament.

Results

In 5 patients a permanent damage of the recurrent laryngeal nerve was seen, of which 4 had undergone revision surgery and 10 months after surgery 93% presented with a large and stable tracheal lumen without any relevant restenosis. Due to a restenosis of 70–80% causing dyspnea at rest, 3% of the 101 patients had to undergo revision surgery. In 4% a mild and asymptomatic restenosis of 30–40% was seen which did not require any further treatment.

Conclusion

These results demonstrate that segmental tracheal resection can safely and effectively remove stenotic tracheal segments of up to 6 cm and is therefore the treatment of choice.     

分化型甲状腺癌侵犯喉气管临床分析

目的　探讨甲状腺癌累及喉、气管时的外科处理方法。方法　2000年1月～2010年12月在我院手术治疗晚期分化型甲状腺癌24例,根据肿瘤侵犯喉、颈段气管的范围及程度分别行肿瘤削除术和气管袖状切除端端吻合术;喉部分切除胸锁乳突肌或颈阔肌皮瓣修复术。结果　24例患者均接受根治性手术切除,喉、气管缺损修复重建。术式：肿瘤削除术8例,气管袖状切除8例,喉部分切除术8例。吻合方式：气管端端吻合8例,胸锁乳突肌皮瓣修复4例,颈阔肌皮瓣修复4例。本组患者肿瘤复发率为8.3%,5年累积生存率为91.6%。结论　对侵犯喉、气管的分化型甲状腺癌患者应采取更为积极的外科治疗,以减少术后复发,提高生存率。     

Cricotracheal resection for laryngeal invasion by thyroid carcinoma: our experience

Invasion of the laryngeal framework by thyroid carcinoma requires specific surgical techniques and carries a higher rate of complications that deserve to be highlighted. We reviewed our data from 1995 to 2012 and found six patients with laryngotracheal invasion by thyroid carcinoma. All underwent total thyroidectomy and single-stage cricotracheal resection, plus anterolateral neck dissection. Three had airway obstruction that necessitated prior endoscopic debulking. None of the patients needed a tracheotomy. There were four cases of papillary carcinoma, and two cases of undifferentiated carcinoma. One patient died of complications of the procedure (anastomotic dehiscence and tracheo-innominate artery fistula). Another died 2 months after the procedure from local recurrence and aspiration pneumonia. One case presented recurrence at 15 months, which was managed by re-excision and adjuvant radiotherapy; after 26 months of follow-up, he has no evidence of locoregional recurrence. The three other patients are alive without evidence of disease at 6, 18 and 41 months, respectively. Cricotracheal resection for subglottic invasion by thyroid carcinoma is an effective procedure, but carries significant risks of complications. This could be attributed to the devascularisation of the tracheal wall due to the simultaneous neck dissection, sacrifice of the strap muscles or of a patch of oesophageal muscle layer. We advocate a sternocleidomastoid flap to cover the anastomosis. Cricotracheal resection for subglottic invasion can be curative with good functional outcomes, even for the advanced stages of thyroid cancer. Endoscopic debulking of the airway prior to the procedure avoids tracheotomy.     

Thyroid carcinoma presenting as a tracheal tumor. Case report and literature review with reflections on pathogenesis.

Ectopic thyroid tissue within the submucosa of the trachea is a rare cause of upper airway obstruction. Most case reports in the literature record examples of intratracheal goiter with only occasional reports of neoplasms arising from such thyroid rests. This report describes a young female patient with a malignant tumor, thought to be primary in the trachea, treated first by radiotherapy and eventually successfully surgically excised. The surgical resection required total thyroidectomy with partial laryngectomy and major tracheal resection, and provided an excellent functional result. The clinical history, laboratory findings and histologic sections strongly suggest that this tumor arose within the tracheal submucosa from ectopic thyroid tissue. In a series of 250 serially sectioned larynges, such ectopic thyroid tissue has been identified in only two patients.     

Laryngeal repair after resection of advanced cancer: an optimal reconstructive protocol

Tracheal autotransplantation allows for reconstruction of extended hemilaryngectomy defects after resection of laryngeal cancer. With this technique, optimal functional results were obtained after a learning curve of more than 50 patients. The objective of this paper is to present the final reconstructive concept with the typical indications. Unilateral glottic cancer and lateralized chondrosarcomas of the cricoid cartilage are resected with a hemilaryngectomy including one-half of the cricoid cartilage. After tumor resection, a radial forearm flap with a skin paddle and a fascial paddle are taken. The skin paddle restores the laryngeal defect temporarily, and the fascial paddle wraps the upper 4 cm of cervical trachea. A tracheostomy is preserved in the area between the reconstructed larynx and the fascia-wrapped trachea. The radial forearm vessels are sutured to the neck vessels. After 4 months, the skin island of the radial forearm flap is removed from the defect and the revascularized, fascial enwrapped trachea is transplanted to the laryngeal defect. The tracheal continuity is re-established with preservation of a tracheostoma. The tracheotomy can be closed after 6 weeks. Two case reports are presented: a unilateral T3 glottic cancer and a chondrosarcoma of the cricoid cartilage. The two patients showed normal oral feeding 1 week after the operation. Hand-free speaking was possible after closure of the tracheostomy. Tracheal autotransplantation after vascular induction of the trachea with the radial forearm flap leads to optimal repair of extended hemilaryngectomy defects.     

甲状腺乳头状腺癌侵犯气管的治疗与预后

目的探讨甲状腺乳头状腺癌（papillary thyroid carcinoma，PTC）侵犯气管的治疗方式及其预后。方法回顾性分析1980-1995年间45例PTC侵犯气管患者的临床资料。根据肿瘤侵犯气管的范围和程度不同分为气管局限性受侵组（A组）行肿瘤切除术28例，肿瘤侵及气管腔内组（B组）行根治性切除术10例和肿瘤区域广泛受侵组（C组）行姑息性切除术7例。39例行颈淋巴清扫术。术后切缘病理检查有肿瘤细胞或术中肉眼观察肿瘤切除不干净的部分患者给予术后放疗，共17例。Kaplan-Meier法计算累积生存率，组问差异采用Log．Rank法检验。结果①A组5年和10年生存率分别为85．0％和62．6％。7例术后放疗，21例术后未放疗。术后放疗与术后未放疗比较，5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。②B组5年和10年生存率分别为80．0％和58．3％。术后放疗6例，未放疗4例。术后放疗与否，5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。③C组5年和10年生存率分别为42．9％和28．6％。4例术后放疗患者，5年和10年生存率分别为50．0％和50．0％。3例术后未放疗患者，5年生存率为33．3％，无10年生存。术后放疗与否，其5年和10年生存率比较差异均无统计学意义（P值均〉0．05）。结论PTC气管受侵尚未侵及腔内黏膜层者可采用肿瘤切除术得以根治，穿透气管腔内黏膜层者行肿瘤根治性切除可延长患者的生存。术后放疗有可能提高姑息性切除患者的生存率。     

喉气管腺样囊性癌10例临床分析

目的 探讨喉气管腺样囊性癌的临床特点、治疗方法及预后。方法 回顾性分析10例行喉气管腺样囊性癌的临床资料,根据UICC　2002年TNM分期标准,喉腺样囊性癌T1N0M0 1例,T2N0M0 1例,T3N0M0 3例;根据Bhattacharwa分期,气管腺样囊性癌T1N0M0 1例,T2N0M0 3例,T3N0M0 1例。10例患者临床上以喉痛、声嘶、咳嗽及进行性呼吸困难伴喘鸣等为主要表现形式,采取手术加术后辅助放疗的治疗模式。喉腺样囊性癌以喉全切除术和喉部分切除术为主,气管腺样囊性癌以气管袖状切除加端端吻合术为主。术后辅助放疗,采用调强放疗方式,总剂量 60～70Gy。结果 10例患者术后愈合好,无并发症,随访时间为2个月～7年不等,所有病例均未见局部复发及远处转移。结论 喉气管腺样囊性癌临床上以进行性呼吸困难伴喘鸣、咳嗽及声嘶为主,纤维喉镜检查有利于早期发现。该病颈淋巴转移率低,预后较好。根治性切除加术后辅助放疗是治疗喉气管腺样囊性癌的最佳方法。     

Prognostic factors of locally invasive well-differentiated thyroid carcinoma involving the trachea

To report our experience with tracheal invasive thyroid carcinoma with emphasis on clinical characteristics and treatment modalities, and to identify the prognostic factors for tracheal invasive thyroid carcinoma. Totally 1919 patients underwent surgical extirpation of thyroid cancer from 1990 to 2010. Among them, 65 patients had well-differentiated thyroid cancer with tracheal invasion. The incidence was higher in male and older patients. Patients were treated with tracheal shave excision (n = 18), tracheal resection (n = 37) and total laryngectomy (n = 10). Locoregional recurrence occurred in 39 patients, and metastasis occurred in 25 patients. Simultaneous involvement of the trachea and the esophagus was associated with locoregional recurrence (p = 0.039) in univariate analysis, but not confirmed by multivariate analysis. There was significant difference in the disease-specific survival (DSS) according to laryngeal involvement (p = 0.002). All the patient in the shave excision group survived until the end of the study period. Although it is categorized in same classification of T4a, simultaneous involvement of the trachea and the esophagus showed higher locoregional recurrence and laryngeal involvement showed lower DSS. Despite the invasion of thyroid cancer into the adjacent aerodigestive tract, many patients showed long survival when they underwent appropriate surgery.