A balanced perspective for management of tracheal salivary gland-type carcinomas

Abstract

I read with great interest the article by Wurtz and colleagues describing their experience with aortic allografts for tracheal reconstruction after resection of salivary gland–type tumors. A series of 6 patients underwent tracheal resection for adenoid cystic carcinoma (ACC) (n 1⁄4 5) or a mucoepidermoid tumor (n 1⁄4 1). Three patients required tracheal resections measuring 5.5, 9, and 10.5 cm. Resections in the remaining 3 patients extended from the first, second, or sixth tracheal ring to at least the level of the carina. Negative resection margins were achieved by frozen section analysis in each case. An average of 5.3 frozen sections was required, and it is unclear how much additional tracheal length was resected to achieve negative margins compared with the initial resection. In each case, the trachea was reconstructed with an aortic allograft supported with a silicone stent. With a mean follow-up of 32 months, several significant complications were honestly described by the authors. These complications included tracheoesophageal fistulas (n 1⁄4 3), an anastomotic dehiscence, anterior spinal cord ischemia, sternal dehiscence, acquired respiratory distress syndrome, and a single patient who required 11 tracheal stent replacements. Two patients required a tracheostomy, and the mean length of hospital stay was 46 days. At the time of article submission, 4 of 6 patients were free of disease. One patient had died of distant metastatic disease, and another patient died of massive hemoptysis. The authors should be congratulated for their attempts to advance our ability to surgically treat central airway tumors. The described case series represents a logical step following their own previously published report of 2 cases and prior large animal studies. However, this operation, with the numerous major complications, should be interpreted in the context of more traditional treatment strategies. Microscopically positive margins in patients with ACC have been previously accepted and treated with adjuvant