Primary tracheobronchial tumor

Introduction to primary tracheobronchial tumors Primary trachea, bronchial tumor originated from squamous cell carcinoma of the mucosal epithelium, adenocarcinoma, papilloma; adenoid cystic carcinoma originating from mucosal glands or submucosal glands, mucoepidermoid carcinoma; origin Kulchitsky cells in the mucosal epithelial argyrophilic cells have poorly differentiated carcinomas and carcinoids; stromal tissues originate from leiomyomas, hemangiomas, chondromas, neurofibromas, hamartomas, carcinosarcomas, and the like. basic knowledge The proportion of illness: 0.34% (the above is the probability of men over 40 years old) Susceptible people: no special people Mode of infection: non-infectious Complications: atelectasis

Cause of primary tracheobronchial tumor

Highly malignant (50%):

Malignant squamous cell carcinoma, adenocarcinoma and poorly differentiated carcinoma, of which squamous cell carcinoma is the most common, accounting for about 50% of primary tracheal tumors.

Low grade malignancy (30%):

Low-grade malignant tumors include adenoid cystic carcinoma, mucoepidermoid carcinoma and carcinoid, of which adenoid cystic carcinoma is the most common, accounting for about 30% of primary tracheal tumors.

Other malignant tumors (20%):

Benign tumors of the trachea include leiomyomas, hamartomas, papilloma, neurofibromas, mixed tumors of the parotid gland, hemangioma, etc. There are also some rare tumors such as carcinosarcoma, chondrosarcoma, and chondroma.

Primary trachea, bronchial tumor originated from squamous epithelial cell carcinoma of the mucosal epithelium, adenocarcinoma, papilloma; adenoid cystic carcinoma originating from mucosal glands or submucosal glands, mucoepidermoid carcinoma; origin Kulchitsky cells in the mucosal epithelial argyrophilic cells have poorly differentiated carcinoma and carcinoid; stromal tissue has leiomyomas, hemangioma, chondroma, neurofibromatosis, hamartoma, carcinosarcoma, etc., tracheobronchial Primary tumors, benign or malignant, have multiple posterior horns at the junction of the membranous part of the posterior wall of the tracheobronchial and the cartilage ring.

Pathogenesis

Although the primary tracheal and bronchial tumors belong to the upper respiratory tract tumors, the clinical symptoms of the two may be completely different due to the location of the lesions; while the benign tumors of the trachea or bronchus have the same clinical symptoms as the malignant tumors. In the early stage of the disease, a small amount of blood can be taken in the sputum, which is not easy to attract the attention of the patient. It is not easy to find such intracavitary lesions in general clinical examination, and the diagnosis is often delayed.

Primary tracheobronchial tumor prevention

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Primary tracheobronchial tumor complications Complications of atelectasis

The lungs are atelect.

Primary tracheobronchial tumor symptoms Common symptoms Squamous cell metaplasia Repeated infection of bronchial tree by pressure, dry cough, tracheal obstruction, asphyxia, hemoptysis, hoarseness

Tracheal tumors, benign, malignant, the main cause of symptoms are obstruction of the lumen, ventilatory disorders, severe ventilatory disorders occur when the tracheal lumen is blocked 1/2 to 2/3. The common symptom of patients with tracheal tumors is dry cough. , shortness of breath, asthma, wheezing, difficulty breathing, cyanosis, physical activity, body position changes, tracheal secretions can make the symptoms worse, malignant lesions can have hoarseness, difficulty in swallowing, etc., recurrent unilateral or bilateral Pneumonia, if the lesion is at the side of the tracheobronchial junction, even if the tracheal stenosis is very obvious, only one side of the pneumonia can be seen. If the tumor is located in the trachea, bilateral pneumonia can be seen, except for the symptoms of tracheal obstruction, persistent stubbornness Cough is also a clinical manifestation of primary tracheal tumors. Bronchial tumors, benign or malignant, often manifest as purulent infection of the lungs, bronchiectasis, lung abscess, etc. when not completely obstructing the lumen; when the lumen is completely obstructed , it is manifested as atelectasis.

1. Characteristics of various benign tumors of trachea

(1) papilloma: papilloma is common in the larynx. Papilloma originating from bronchial tree is rare. This disease is more common in children. It is rare in adults. It is often multiple in children. It is isolated and malignant in adults. The cause may be related to the inflammatory reaction caused by viral infection. The papilloma originates from the trachea and bronchial mucosa, and has an irregular nipple-like bulge. The vascular connective tissue is the core, and several layers of differentiated mature epithelial cells are covered. Arranged, the surface layer is squamous epithelial cells, and the keratinized.

Tracheal lamellar phase, CT is helpful for diagnosis. Fibrobronchoscopy is a reliable method for definite diagnosis. Under bronchoscopy, papilloma is cauliflower-like, light red, brittle and easy to bleed, and the base is wide or fine. Prepare for biopsy to avoid suffocation caused by bleeding or tumor shedding.

The papilloma of the trachea grows in clusters and adheres to the tracheobronchial membrane through a thin pedicle. The papillary tumor is brittle and easy to fall off. The papilloma has multiple symptoms and recurrence after surgery. According to the large group of tracheal tumor surgery The clinical experience, no matter what kind of treatment can not prevent its recurrence tendency, which brings certain difficulties to clinical treatment.

Small-sized benign papilloma can be removed by fiberoptic bronchoscopy, or treated with fiberoptic bronchoscope laser, or tracheotomy can be removed, large volume, wide base and suspected malignant transformation, tracheal sleeve resection or tracheal side Wall localized resection.

(2) fibroids: intratracheal fibroids are rare, the tumor surface is covered with normal tracheal mucosa, the tumor under bronchoscopy is round, grayish white, smooth surface, wide base, inactive, not easy to bleed, often multiple biopsy Negative situation.

(3) hemangioma: can be divided into cavernous hemangioma, vascular endothelial cell tumor, vascular epithelioma, etc., can be primary in the trachea, or from the mediastinal hemangioma extending into the trachea, hemangioma can diffuse infiltration of tracheal mucosa and The tracheal lumen is narrowed, and it can also protrude into the tracheal cavity to cause obstruction. Under the fiberoptic bronchoscope, the hemangioma that protrudes into the cavity is soft, reddish, polypoid, and biopsy is generally prohibited, so as to avoid bleeding, causing asphyxia, and treating feasible endoscopy. Excision, laser treatment or surgery.

(4) neurofibromatosis: intratracheal neurofibroma is a benign tumor of the nerve sheath, often isolated, with a capsule, hard, tumor can be pedicled into the tracheal cavity, under the fiberoptic bronchoscopy, visible tracheal wall circle Shape, hard, smooth surface mass, histologically, spindle cells and mucus-like matrix alternate, nerve sheath cells arranged in a typical grid, intratracheal neurofibroma can be removed by endoscopy or tracheotomy .

(5) fibrous histiocytoma: intratracheal fibrous histiocytoma is rare, the tumor is often located in the upper third of the trachea, which is polypoid, soft, grayish white, protruding into the lumen, histologically difficult to identify good, malignant, It is mainly based on whether the tumor has external invasion, metastasis and more nuclear mitotic figures. Fibrosial cell tumors often recur after local excision. Therefore, the scope of surgery can be more extensive, and local excision or tracheal sleeve resection should be performed. Surgery, tracheal malignant fibrous histiocytoma should be supplemented with radiation therapy and chemotherapy.

(6) lipoma: endotracheal lipoma is extremely rare, originating from mature mature fat cells or primitive interstitial cells, light red or yellow round mass can be seen under the bronchioles, blocking the lumen, smooth surface, mostly wide Base, sometimes with short pedicles, covered with bronchial mucosa, softer, intratracheal lipoma can be removed by bronchoscopy, and the base is burned with a laser. When the tumor is large and passes through the cartilage ring to the trachea, the tracheal wall should be partially removed. Or tracheal sleeve resection.

(7) chondroma: tracheal chondroma is rare, only a few cases reported in the literature, the tumor is round, hard, white, part of the tracheal wall, part of the stenosis into the tracheal cavity, small volume of chondroma can generally be through the fiber After bronchectomy, tracheal chondroma can be recurred and malignant after surgery.

(8) leiomyomas: tracheal leiomyomas often occur in the lower third of the trachea, originating from the lower part of the tracheal mucosa, round or oval, smooth surface, protruding into the cavity, pale mucosa, histology, tumor by Well-differentiated, arranged in a staggered fusiform cell bundle, tracheal leiomyoma grows slowly, can be removed by fiberoptic bronchoscopy when the tumor is small, and tracheal sleeve resection should be performed when the tumor is large.

(9) hamartoma: the tumor is round or oval, and the capsule is intact. Generally, the small pedicle is connected with the tracheobronchial wall. The surface of the tumor is smooth and hard. The fiberoptic bronchoscope biopsy forceps are not easy to obtain tumor tissue. Laser ablation by bronchoscopy, vaporization of the tumor or removal with a biopsy forceps.

2. Characteristics of tracheal malignant tumors

(1) Tracheal squamous cell carcinoma: occurs in the lower third of the trachea, accounting for 40% to 50% of primary malignant tumors. It can be characterized as a prominent lesion with a prominent shape, or an ulcer type. Invasive growth, easy to invade the recurrent laryngeal nerve and esophagus, multiple squamous epithelial cancer scattered in the trachea can be seen, surface ulcerated squamous cell carcinoma can also affect the full length of the trachea, about 1/3 of the primary Patients with tracheal squamous cell carcinoma have deep mediastinal lymph nodes and lung metastases at the time of initial diagnosis. The dissemination of tracheal squamous cell carcinoma often precedes the adjacent paratracheal lymph nodes or directly invades the mediastinal structure.

(2) Adenoidal epithelial cancer: about 10% of tracheal malignant tumors, small in size, hard in quality, less necrosis, patients often have deep tumor invasion at the time of treatment, poor prognosis, other rare tracheal cancer Oat cell carcinoma, malignant tumors originating from the tracheal interstitium, including leiomyosarcoma, chondrosarcoma, liposarcoma, etc., can be cured by surgical resection of carcinosarcoma and chondrosarcoma.

3. Characteristics of low-grade malignant tumors

(1) Carcinoid: Kulchitsky cells originating from the tracheobronchial mucosa. The cells contain neurosecretory granules, which are classified into typical carcinoid and atypical carcinoid tumors. Carcinoid tumors occur in the main bronchus and its distal bronchus. Clinical symptoms Related to the site of tumorigenesis, carcinoid tumors in the main bronchus can cause repeated lung infections, hemoptysis or hemoptysis, a few carcinoids with carcinoid syndrome and Cushing syndrome, and fiberoptic bronchoscopy can determine tumor Location and direct observation of tumor shape, biopsy to obtain pathological diagnosis, but the positive rate of biopsy is only about 50%, because Kulchitsky cells are distributed in the basal layer of bronchial epithelium, the surface of the tumor growing into the cavity is often covered with intact mucosal epithelium Therefore, it is not easy to obtain tumor tissue during biopsy. The principle of surgical treatment for tracheobronchial carcinoid is to remove the tumor as much as possible while retaining the normal tissue as much as possible. The tumor located in the main bronchus, the middle segment and the leaf bronchus, such as the distal end. Patients with obvious irreversible changes should seek bronchoplasty, and lymph node metastasis should be performed simultaneously. Door lymph node dissection, such as the distal lung tissue due to repeated infections has been significant irreversible changes shall lobectomy or pneumonectomy, carcinoid tumors have a certain sensitivity to radiotherapy, radiotherapy after surgery can be.

The prognosis of tracheobronchial carcinoma after surgery is good, the 5-year survival rate can reach 90%, and the prognosis of atypical carcinoid is relatively poor.

(2) adenoid cystic carcinoma: adenoid cystic carcinoma occurs mostly in women, about 2/3 of adenoid cystic carcinoma occurs in the lower tracheal, near the initial level of the carina and left and right main bronchus, the tumor originates from the glandular duct or The mucus secreting cells of the gland can grow polypoid, but the interstitial tissues of the tracheal cartilage are infiltrating around the trachea, blocking the lumen, and directly invading the surrounding lymph nodes. The tumor protruding into the lumen generally has no intact mucosa. Covered, but rarely formed ulcers, adenoid cystic carcinoma of the bulge can grow into the main bronchus on both sides.

Adenoid cystic carcinoma is histologically divided into pseudo acinar type and medullary type. The mucus which is positive for PAS staining inside and outside the cell is its main feature. Adenoid cystic carcinoma has clinically slow growth characteristics, and the patient's disease course can be Very long, even if distant metastasis occurs, its clinical behavior is relatively benign. Larger tracheal adenoid cystic carcinoma often causes mediastinal shift, and adenoid cystic carcinoma of the trachea can infiltrate along the tracheal submucosa, involving Long trachea, but not discernible in the general tissue, some lesions have higher malignancy, there is already pleural and lung metastasis before the tumor originating in the trachea is discovered, and tracheal adenoid cystic carcinoma seen in the clinic The patient has almost repeated repeated intratracheal tumor resection or tracheal segmental resection, and these patients often have distant metastases.

Treatment includes surgical resection, endoscopic resection or laser treatment, chemotherapy can be used as adjuvant therapy, adenoid cystic carcinoma is very insensitive to radiation therapy, but can be used for lesions that cannot be completely removed, mediastinal lymph node metastasis or surgical contraindications .

(3) mucoepidermoid carcinoma: the incidence rate is low, mostly occurs in the main bronchus, the middle segment of the bronchus and the leaf bronchus. The surface of the tumor is generally covered with mucosa, and its clinical manifestation is closely related to the location of the tumor. Pathological examination by bronchoscopy biopsy Can be clearly diagnosed.

Mucin epidermoid carcinoma is clinically invasive and metastasized along the lymphatic pathway. Surgical treatment includes lobectomy or pneumonectomy, hilar and mediastinal lymph node dissection, postoperative radiotherapy, and easy recurrence after mucoepidermoid carcinoma surgery The prognosis is worse than adenoid cystic carcinoma and carcinoid.

Examination of primary tracheobronchial tumors

1. X-ray examination: the posterior anterior and lateral body image of the trachea, the tracheal bifurcation layer image is important for the diagnosis of trachea and bronchial tumors. These examinations clearly show the contour, location and extent of the tumor in the tracheal cavity. And the relationship between lesions and adjacent organs, benign tumors can have calcification, the base has fine pedicles, malignant tumors have wide base, borders, and contours are incomplete. When the anterior tracheal body layer is imaged, the paralyzed patient says "E" can be very Goodly show the details of the throat in the posterior anterior direction and the length of the trachea; the swallowing action when the lateral trachea is imaged can raise the throat and clearly show the relationship between the throat and the trachea; the left and right posterior trachea The body layer is very helpful in showing the organs, especially the major branches of the bronchus.

2. CT examination: It is very helpful for the diagnosis of tracheal tumor. CT can show the soft tissue shadow of increased density in the tracheal cavity, mostly eccentricity, thickening of tracheal wall, irregular stenosis of the trachea, and about 10% of tracheal tumors. Along the trachea, 30% to 40% of tracheal tumors directly involve the mediastinum. Bronchial tumors can be expressed in the lumen or infiltrated into the cavity on CT, causing bronchial insufficiency or complete obstruction, obstructive pneumonia or atelectasis. According to the degree of infiltration of bronchial tumors, Naidich et al. divided it into six manifestations:

1 bronchial wall shows normal;

2 bronchial wall is evenly narrow;

3 bronchial irregular stenosis;

4 bronchial cavity is completely blocked;

5 bronchial lumen mass;

6 bronchial pressure shift.

3. MRI examination: The tracheal image can be reconstructed from the cross-sectional, sagittal and coronal sections, thus giving a very accurate location, extent and extent of invasiveness of the tracheal tumor. For bronchial tumors, MRI can be passed through the tracheid bifurcation. Face reconstruction shows more clearly the extent and extent of obstruction in the bronchial lumen than the X-ray image of the tracheal bifurcation.

4. Bronchoscopy: bronchial lipiodol angiography can also be performed when the obstruction of tracheobronchial tumor is not serious. At this time, the location and extent of obstruction of the lumen can be more clearly displayed.

5. Fiberoptic bronchoscopy: The morphology of the tumor can be directly observed, and biopsy can be performed to obtain pathological evidence. However, some tumors such as adenoid cystic carcinoma often have necrotic tissue on the surface, and fiberoptic bronchoscopy biopsy clamps often Tumor tissue can not be obtained; some tumors, such as carcinoid, are rich in blood supply, the tumor is brittle, and easily bleed, which brings certain difficulties to biopsy; some benign tumors such as chondroma and hamartoma have a hard texture. It is difficult to obtain tissue by biopsy. Generally speaking, for patients with tracheal tumors complicated with obvious tracheal stenosis, the time of fiberoptic bronchoscopy is often postponed until the operation, even on the operating table for advanced fiberoptic bronchoscopy, in case of emergency. deal with.

Diagnosis and diagnosis of primary tracheobronchial tumor

According to the clinical symptoms of dry cough, shortness of breath, asthma, wheezing, difficulty breathing, cyanosis and other symptoms, combined with X-ray, CT, MRI, bronchography can be a clear diagnosis, in the above methods can not be clearly diagnosed, you can take a thoracotomy Directly cut the trachea, observe the characteristics of the lesion and the extent of the invasion, and take the tissue for pathological cryosection, and confirm the diagnosis.

Early onset of tracheal tumors is easily misdiagnosed as bronchial asthma, because X-ray examination of the lungs and chest is difficult to observe the lesions in the tracheal cavity until the patient has wheezing, difficulty breathing, cyanosis and other symptoms to confirm the diagnosis, feasible CT or MRI And bronchoscopy.

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