Management of tracheal chondrosarcoma almost completely obstructing the airway: a case report

Journal of Cardiothoracic Surgery, Jul 2016

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.

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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)


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Marco Andolfi, Maurizio Vaccarili, Roberto Crisci, Francesco Puma. Management of tracheal chondrosarcoma almost completely obstructing the airway: a case report, Journal of Cardiothoracic Surgery, 2016, pp. 101, 11, DOI: 10.1186/s13019-016-0498-8