Management of tracheal chondrosarcoma almost completely obstructing the airway: a case report
Andolfi et al. Journal of Cardiothoracic Surgery
Management of tracheal chondrosarcoma almost completely obstructing the airway: a case report
Marco Andolfi 0
Maurizio Vaccarili 1
Roberto Crisci 1
Francesco Puma 0
0 Department of Thoracic Surgery, S. Maria della Misericordia Hospital, University of Perugia Medical School , Perugia , Italy
1 Department of Thoracic Surgery, G. Mazzini Hospital, University of L'Aquila , Teramo , Italy
Background: Primary malignant tracheal tumors account for only 0.2 % of all malignancies of the respiratory tract. Tracheal chondrosarcoma is a rare condition and only 17 cases have been described in the literature from 1965 to date. Herein we report the very unusual case of a patient with a tracheal chondrosarcoma, electively treated by curative surgery despite the virtually complete obstruction of the airway. Case presentation: We present the case of a 79-year old Caucasian man with long-lasting wheezing misdiagnosed as asthma and affected by a tracheal chondrosarcoma almost completely obstructing the airway. Videobronchoscopy and imaging investigations revealed a well-circumscribed mass arising from the cartilaginous rings of the cervical trachea with a posterior residual respiratory space of about 1 mm. Because of the mobility and flaccidity of the uninvolved pars membranacea, the tiny respiratory space slightly expanded during inspiration and expiration allowing the patient to be treated without an essential emergency procedure. Standard tracheal intubation was impossible. Rigid bronchoscopy enabled placement of a small tracheal tube distally to the tumor. Successful cervical tracheal resection and reconstruction was then performed, achieving complete tumor excision. Histologically, the mass was characterized as a low-grade tracheal chondrosarcoma. Videobronchoscopy performed 9 months after surgery showed a wide, well healed tracheal anastomosis. Ten months after surgery, the patient is alive and disease free. Conclusion: Complete surgical resection is the treatment of choice for tracheal chondrosarcoma. Rigid bronchoscopy is an essential tool for diagnostic and therapeutic purposes. It allows the palliative maneuvers for obstruction relief but also, in resectable patients, the intraoperative safe and straightforward management of the obstructed airway.
Tracheal chondrosarcoma; Tracheal resection; Rigid bronchoscopy; Tracheal stenosis; Trachea
Background
Primary malignant tracheal tumors account for only
0.2 % of all malignancies of the respiratory tract.
Tracheal chondrosarcoma (TCS) is an extremely rare
condition, with just 17 cases described in the English
literature [
1–4
].
In all previously reported cases, TCS appeared as a
bulky tracheal tumor, with variable airway obstruction:
16 patients presented with a long clinical history [
1–3
]
and one with past history of radioiodine therapy for
thyroid cancer [
4
]. Most TCS are low grade malignancy
with a 5-year survival rate of 90 %, when correctly
removed [
1–3
]. Indeed, despite these tumors growing
slowly and having a low tendency to metastasize, they
recur after incomplete resection with potential risk of
dedifferentiation [
5
].
We report the unique case of a patient with a TCS
treated with a curative resection without need of
emergency procedures despite a virtually complete airway
obstruction.
Case presentation
A 79-year old Caucasian male, non smoker, was referred
to our Department for a tracheal tumor. He reported a
3-year history of dyspnea, tirage and cornage, initially
misdiagnosed as asthma. A chest X-ray was normal.
During a flu episode, dyspnea became extremely severe
making the patient bedridden. A computed tomography
(CT) scan was performed revealing a 34×29×31 mm
tumor in the upper third of the trachea with almost
complete airway obstruction. The lesion had an
inhomogeneous density characterized by the presence of
osteocartilaginous clods and solid tissue without significant
contrast enhancement, and involved the anterior extra
tracheal soft tissues (Fig. 1). Videobronchoscopy showed
a gray-white, firm, well-circumscribed mass, originating
from the first cartilaginous rings of the trachea. The
respiratory lumen appeared virtually obliterated with
a supposed respiratory lumen of about 1 mm at the
level of the uninvolved pars membranacea (Fig. 2).
An additional movie file shows this in more detail
(see Additional file 1). Standard tracheal intubation
was deemed impossible and extremely risky, even if
the tumor didn’t bleed.
Although severely symptomatic, amazingly the patient
did not require an emergency procedure; indeed, the tiny
respiratory space slightly expanded during inspiration
and expiration because of the flaccidity of the
uninvolved pars membranacea.
Electively, we smoothly inserted a pediatric 4 mm rigid
bronchoscope on the posterior side of the trachea
beyond the tumor allowing the positioning of a thin airway
exchange catheter through the instrument. The
bronchoscope was (...truncated)