Primary carcinoma of the trachea/carina

[evilbooyaa]

Anyone have a reputable way of staging this? Never seen it before. Not in the AJCC staging manual.

1LN in subcarinal region (kind of right next to the mass which seemed subcarinal with invasion into proximal bronchi and trachea)

---

Members don't see this ad.

 

[Phantom1]

Anyone have a reputable way of staging this? Never seen it before. Not in the AJCC staging manual.

1LN in subcarinal region (kind of right next to the mass which seemed subcarinal with invasion into proximal bronchi and trachea)

I've seen it, you just have to go with general principles. Discuss with surgeon to see if resectable with reconstruction. If not (which it almost certainly is not), then it is chemoradiation to 60-66 Gy, with nodal coverage (consider one station above and below involved nodes) to normal tissue constraints. If patient fails (which is likely) then chemo, followed by immunotherapy off label.

 

[evilbooyaa]

I've seen it, you just have to go with general principles. Discuss with surgeon to see if resectable with reconstruction. If not (which it almost certainly is not), then it is chemoradiation to 60-66 Gy, with nodal coverage (consider one station above and below involved nodes) to normal tissue constraints. If patient fails (which is likely) then chemo, followed by immunotherapy off label.

Patient already had surgery with multiple anastmoses, had one positive lymph node with direct invasion on path. I'm just looking for a methodology of how to stage these things for documentation.

 

[Chartreuse Wombat]

Patient already had surgery with multiple anastmoses, had one positive lymph node with direct invasion on path. I'm just looking for a methodology of how to stage these things for documentation.

Recurrent tracheal carcinoma NOS-no staging system

 

[Palex80]

You can't, it's not covered by UICC/AJCC staging. Don't ask why...

 

[seper]

AJCC does state that cancer limited to the major airway wall is staged T1

 

[scarbrtj]

Try this if you must stage.

About 16 years ago I wrote:
"No universally accepted system for staging tracheal neoplasms has been adopted. A staging system proposed by Licht et. al seemed not to have any predictable prognostic value (patients with positive nodes fared better than those without).6 Studies examining the lymph node question have found no statistically significant adverse prognostic association.5,9 Size and location of tumor seem to be important prognostically: this feature probably represents the extent of surgical resection necessary to remove the tumor and that carinal resection patients have heightened postoperative mortality.10 Acute respiratory compromise or distant metastases at presentation—regardless of histology—are predictors of poor outcome.5 As mentioned earlier, adenoid cystic carcinoma (and probably lymphoma) has a better prognosis than any other histologic variants.

5. Yang K, Chen Y, Huang M, Perng R. Review of primary malignant neoplasms of the trachea: clinical chacracteristics and survival analysis. Japanese Journal of Clinical Oncology 1997;27(5):305-9.
6. Licht PB, Friis S, Pettersson G. Tracheal cancer in Denmark: a nationwide study. Eur J Cardiothorac Surg 2001;19(3):339-45.
7. Maziak DE, Todd TR, Keshavjee SH, Winton TL, Van Nostrand P, Pearson FG. Adenoid cystic carcinoma of the airway: thirty-two-year experience. J Thorac Cardiovasc Surg 1996;112(6):1522-31.
8. Pearson FG, Todd TR, Cooper JD. Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg 1984;88(4):511-8.
9. Regnand JF, Fourquier P, Levasseur P. Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective study. The French Society of Cardiovascular Surgery. J Cardiovasc Surg 1996;111:808-813.
10. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac Surg 1990;49:69-77."

 

[evilbooyaa]

AJCC does state that cancer limited to the major airway wall is staged T1

I guess the question becomes that there was carinal/subcarinal involvement, so on that principle it'd probably be at least T2, more likely T3. But thanks for the responses; if there is no official staging system, then I'll just call it what it is.

 

[scarbrtj]

I guess the question becomes that there was carinal/subcarinal involvement, so on that principle it'd probably be at least T2, more likely T3. But thanks for the responses; if there is no official staging system, then I'll just call it what it is.

Did you mention the histology? Squamous? ACC? Sounds like ACC with multiple recurrences, previous surgery. Never had RT before? Should have. All tracheal CA patients need adjuvant XRT regardless the "stage," histology, margins, etc. ChemoRT iffy for ACC.

 

[evilbooyaa]

Did you mention the histology? Squamous? ACC? Sounds like ACC with multiple recurrences, previous surgery. Never had RT before? Should have. All tracheal CA patients need adjuvant XRT regardless the "stage," histology, margins, etc. ChemoRT iffy for ACC.

I hadn't previously b/c her stage isn't going to change her plan, but might as well present the whole darn thing now.

Primary ACC of Carina/Subcarina invading trachea and b/l bronchi, s/p carinal resection, direct invasion of 1 subcarinal LN, but remainder of level 7 negative multiple positive margins, will be getting post-op RT (plan for 66) to local area including level 7, no ENI

 

[Palex80]

Did they resect other nodes too besides level 7?

 

[evilbooyaa]

Reviewing path, sounds like it was a subcarinal MLND - 8 LNs negative in level 7, but report of other dissected LNs from path or the op report

 

[scarbrtj]

I hadn't previously b/c her stage isn't going to change her plan, but might as well present the whole darn thing now.

Primary ACC of Carina/Subcarina invading trachea and b/l bronchi, s/p carinal resection, direct invasion of 1 subcarinal LN, but remainder of level 7 negative multiple positive margins, will be getting post-op RT (plan for 66) to local area including level 7, no ENI

Sounds like the right plan. Surgeons who can and are willing to do this type of surgery are rare. The patient is very lucky. In the Licht paper he said: "Unduly low resection rates can not be explained by selection biases alone: tracheal surgery defeatism might be thwarting more appropriate treatment for some patients."

 

[evilbooyaa]

Sounds like the right plan. Surgeons who can and are willing to do this type of surgery are rare. The patient is very lucky. In the Licht paper he said: "Unduly low resection rates can not be explained by selection biases alone: tracheal surgery defeatism might be thwarting more appropriate treatment for some patients."

Yeah no kidding, patient looked for local thoracic surgeon x 3 - 4 and was told no.

Anatomoses are a variant on your top one, but L mainstem was to R bronchus intermedius (who knows how much farther down)

 

[seper]

Last time I've heard the word "defeatism" it was some Cuban commie documentary.
These lesions are well treated non-surgically with aid of endobronchial HDR boost

 

[Palex80]

If other node levels were not dissected, I would do limited ENI. Stations 4 and 8/9 seem reasonable.

 

[scarbrtj]

There's almost zero data on being "well treated" with HDR boost. There is much stronger data that operated-upon patients do better than non-operated-upon, regardless margins, nodes, etc. ENI is not clearly reasonable because, ACC being the "weird" tumor that is, shows no prognostically worse outcome for LN+ versus LN- patients.

 

[evilbooyaa]

If other node levels were not dissected, I would do limited ENI. Stations 4 and 8/9 seem reasonable.

For us the discussion was that ENI in lung cancers now has fallen out of favor (given that we don't even do it in a very lymph node active cancer like SCLC), doing it for something as (generally) slow growing as ACC is likely unnecessary.

Last time I've heard the word "defeatism" it was some Cuban commie documentary.
These lesions are well treated non-surgically with aid of endobronchial HDR boost

Agree with scarbtj in regards to this. Brief review of literature shows operated patients with ACC (potentially different in SCC of trachea given primary chemoRT as a treatment option in other areas) do really well, like 80% 5-year OS.

I get doing RT if a surgery is not feasible, but that wouldn't ever be my first decision for any ACC (similar to ACC of the H&N)

 

[Palex80]

For us the discussion was that ENI in lung cancers now has fallen out of favor (given that we don't even do it in a very lymph node active cancer like SCLC), doing it for something as (generally) slow growing as ACC is likely unnecessary.

That is indeed true in the context of a curative-intended radiochemotherapy. I was under the impression that this patient was scheduled to undergo only RT.
But certainly, I understand your point. I would have not done it, if the other stations had been sampled during surgery and had been negative. Since they awere not and the patient will not get any other treatment what will address microscopic disease, I think the additional toxicity of including the adjacent stations is rather low and worth it. But hey, that's all just opinions, we don't have data, that's for sure.

 

[evilbooyaa]

You are correct, no plans for chemo given it's adenoid cystic. Fair enough point about avoiding ENI when you have the back-up of chemo. I'll bring it up to the boss as an option.

 

[medgator]

Acc has perineural spread at least in the h&n. Agree with others, would not do eni, heck many stopped doing it in small cell, let alone nsclc

 

[scarbrtj]

For us the discussion was that ENI in lung cancers now has fallen out of favor (given that we don't even do it in a very lymph node active cancer like SCLC), doing it for something as (generally) slow growing as ACC is likely unnecessary.



Agree with scarbtj in regards to this. Brief review of literature shows operated patients with ACC (potentially different in SCC of trachea given primary chemoRT as a treatment option in other areas) do really well, like 80% 5-year OS.

I get doing RT if a surgery is not feasible, but that wouldn't ever be my first decision for any ACC (similar to ACC of the H&N)

yeah, i put all the data up there in a PDF. Haven't updated it in a long time, sorry