Tracheal and carinal resection for primary adenoid cystic carcinoma

purpose: Adenoid cystic carcinoma (ACC) is the second most common malignant tumor of the airway. Complete surgical resection of tracheal or carinal ACC remains the treatment of choice and is associated with long survival. This video illustrates the imaging studies and the surgical techniques adopted in 5 different tumor location. methods: The first two patients presented with an upper and lower tracheal ACC, respectively. They underwent an en bloc tracheal resection followed by an end-to-end tracheal anastomosis through a cervico-sternal and a posterolateral thoracotomy, respectively. In the third case, ACC was located in the left tracheo-bronchial angle: a reverse Barclay carinal resection through a trans-sternal, trans-pericardial approach was accomplished. In the fourth patient the ACC involved the right tracheo-bronchial angle and the carina. A large portion of the lateral wall of the trachea and the carina were removed through a lateral thoracotomy (LT). The main right bronchus was shaped as a "flute-beak" and anastomosed to the trachea and the main left bronchus. Finally, an ACC involving the lower left tracheal wall and the main right bronchus with the carina was removed by a right tracheal sleeve pneumonectomy by LT. Results: On 40 carinal resections performed for airway neoplasms, 5 (12.5%) were for ACC. Neither operative nor major postoperative complications occurred and all patients obtained an excellent surgical result, survival, and disease free survival ranging from 1 to 72 months. Only one patient had regional nodal involvement by tumor. Postoperative radiotherapy (PR) was administered in 3 patients who presented microscopic tumor infiltration of resected margins. Conclusions: ACC of the trachea and carina has a good long-term prognosis if treated by surgical resection. Surgical technique must be individualized according to tumor location. Patients with tumor infiltration of the surgical margins should receive PR