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.1–3 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.
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
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.
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.
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