D Deepa Swamina han. (2025). T acheal Resec ion and Anas omosis o Malignan Tumou s: A Te ia y
Cen e Expe ience. MAR Oncology and Hema ology. (2025) 5:08
T acheal Resec ion and Anas omosis o Malignan Tumou s: A Te ia y
Cen e Expe ience
Deepa Swamina han 1*, S Bha ga i 2, K Ka hikesh 3
1. Head and Neck Su gical Oncologis , KG Hospi al, Coimba o e, Tamil Nadu, India.
2 Su gical Oncologis , S i Ramak ishna Hospi al, Coimba o e, Tamil Nadu, India
*Co espondence o: Deepa Swamina han, Head and Neck Su gical Oncologis , KG Hospi al,
Coimba o e, Tamil Nadu, India.
Copy igh .
© 2025 D Deepa Swamina han This is an open access a icle dis ibu ed unde he C ea i e Commons
A ibu ion License, which pe mi s un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided
he o iginal wo k is p ope ly ci ed.
Recei ed: 02 Sep 2025
Published: 11 Sep 2025
MAR Oncology and Hema ology (2025) 5:08
Case Repo
D Deepa Swamina han, MAR Oncology and Hema ology (2025) 5:08.
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In oduc ion
P ima y neoplasms o achea a e a e and uncommon malignancies ha accoun o less han 0.01% o all
umou s and abou 0.2% o espi a o y malignan lesions, ep esen ing a low a e o all ai way neoplasm dea hs
[1-3]. The mos common his ologic ypes a e squamous cell ca cinoma (SCC), ep esen ing abou 50–66%,
and adenoid cys ic ca cinoma (ACC), accoun ing o 10–15% o hem [4]. Se e al malignan his ologies, o
di e en g ade, ha e also been desc ibed, as mucoepide moid ca cinoma, non-squamous b onchogenic
ca cinoma, sa coma, ca cinoid umou s, melanomas [5,6]. Ano he possibili y, hough less equen , is acheal
in ol emen by well di e en ia ed hy oid ca cinoma (WDTC). This scena io is exempli ied by a a e o 3.4–
13% [7].
In he ea ly s ages o he disease, symp oms o en lack speci ici y, and some indi iduals may exhibi
mani es a ions like cough, spu um p oduc ion, ches igh ness, and sho ness o b ea h, o en leading o
misdiagnosis as o he espi a o y condi ions. De ini i e diagnosis is es ablished h ough imaging and
his ological examina ions [8].
In mos cases, whe e e esec able, su gical esec ion is he ea men o choice. Radio he apy (RT) is ese ed
o adju an se ings o in cases wi h ex ensi e disease o hose who a e medically un i o su ge y. The basic
challenges in su gical esec ion o acheal umo s a e he ollowing: ype and access o anes hesia, dissec ion
Abs ac
P ima y neoplasms o achea a e a e and uncommon malignancies ha accoun o abou 0.2%
o espi a o y malignan lesions, ep esen ing a low a e o all ai way neoplasm dea hs. In he
ea ly s ages o he disease, symp oms o en lack speci ici y o en leading o misdiagnosis as o he
espi a o y condi ions. In mos cases, whe e e esec able, su gical esec ion is he ea men o
choice. Radio he apy (RT) is ese ed o adju an se ings o in cases wi h ex ensi e disease o
hose who a e medically un i o su ge y. He e we epo h ee cases o malignan acheal umo s
wi h desc ip ion o he su gical echniques employed along wi h a e iew o li e a u e on his
condi ion. This a icle unde sco es he impo ance o clinical suspicion, endoscopic and CT
e alua ion in imely diagnosis. App op ia e su gical esec ion and econs uc ion is s ill he bes
modali y o achie e long e m su i al wi h a decen quali y o li e.
Key Wo ds- acheal umou s, acheal esec ion, adenoid cys ic ca cinoma, papilla y ca cinoma
hy oid.
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a ound he achea, ype o acheal esec ion, and es o a ion o con inui y o he achea [9].
He e we epo h ee cases o malignan acheal umo s wi h desc ip ion o he su gical echniques employed
along wi h a e iew o li e a u e on his condi ion.
Case P esen a ion
Pa ien 1
A 46 yea old emale p esen ed wi h complain s o b ea hing di icul y o he pas i e mon hs. She had
consul ed a pulmonologis o he abo e symp oms and was s a ed on medical managemen . As he e was no
elie in he symp oms, she was hen e alua ed wi h CT scan o neck and ho ax which e ealed a suspicious
subglo ic g ow h. No ob ious neck o medias inal nodes we e no ed. Flexible b onchoscopy e ealed a
polypoidal lesion a ising om he igh la e al wall wi h signi ican lumen na owing ex ending om he
second acheal ing ill abou h ee cen ime e s dis ally. Res o he clinical and labo a o y examina ions we e
no mal. To elie e he o he b ea hing di icul y and o ob ain a diagnosis, she was aken up o lase debulking
o he said lesion unde gene al anaes hesia. His opa hologic examina ion showed ea u es o adenoid cys ic
ca cinoma. She was hen e e ed o ou cen e. He e u he e alua ion and a mul imodali y umou boa d
mee ing was conduc ed and i was decided o p oceed wi h p ima y su ge y ollowed by adju an RT. An e io
ce ical app oach was used wi h a low colla incision. Resec ion was pe o med om he i s acheal ing
ill he i h ing. Adequa e g oss ma gins we e con i med. The la ynx and he lowe s ump o he achea we e
hen mobilised digi ally and anas omosis done in end o end ashion. A acheos omy was done wo ings dis al
o he anas omosis. The su u e si e was u he bu essed wi h he s ap muscles and he wound was closed.
S ay su u es we e placed om skin o e he lowe jaw o he cla icle (Gua dian su u es) o main ain neck
lexion and he same was e ained o a pe iod o wo weeks a e which she was discha ged.
Pos ope a i e his opa hology epo showed adenoid cys ic ca cinoma wi h a close in e io ma gin (<5 mm).
She ecei ed adju an RT (60 Gy) and was decannula ed a e comple ion o he same. She was hen egula ly
ollowed up and has been disease ee o wo yea s.
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Fig 1: T ans ce ical iew o he achea pos esec ion
Fig 2: Neck lexed in pos ope a i e pe iod wi h Gua dian su u e
Pa ien 2
A 51 yea old emale pa ien p esen ed wi h a his o y o neck swelling ha had been g adually inc easing in
size o e he pas six mon hs and b ea hing di icul y o he las wo mon hs. A CT o he neck showed a mass
lesion in he igh lobe o hy oid in il a ing he igh la e al wall o achea wi h signi ican igh le el III
lymph node. FNAC o he hy oid swelling showed e idence o papilla y ca cinoma o hy oid. Flexible
b onchoscopy e ealed g ow h in he igh wall o achea a ound 1 cm below he subglo is.
Fig 3: Con as enhanced CT (axial iew) image showing umou in ol ing he igh lobe o hy oid wi h
ex a hy oidal ex ension in o achea igh la e al wall
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Fig 4: B onchoscopic image o acheal in il a ion
She unde wen o al hy oidec omy wi h en bloc esec ion o he an e io wall and pa o he igh pos e io
wall o achea ex ending om he i s o i h ings. Addi ionally, igh comp ehensi e neck dissec ion was
done. To ensu e ha he closu e does no signi ican ly comp omise he acheal lumen, he pos e io wall was
di ided in a diagonal ashion and he p oximal and dis al s umps we e o a ed and anas omosis was done in a
skewed manne . The anas omosis was bu essed wi h he s ap muscles, acheos omy was pe o med and
gua dian su u es we e placed. Gua dian su u es and acheos omy ube we e emo ed in he second pos
ope a i e week. He his opa hology e ealed a con en ional ype o papilla y ca cinoma wi h in asion o
achea. Ma gins o esec ion we e ee. She also had egional me as asis o he igh middle jugula g oup o
nodes. She ecei ed adju an high dose adio Iodine abla ion and hen was s a ed on a supp essi e dose o
hy oxine.
Pa ien 3
A 64 yea old emale pa ien had a his o y o igh sided neck swelling o wo yea s. She was e alua ed a an
ou side cen e and was ound o ha e a hy oid nodule. An FNAC o he same did no show any e idence o
malignancy. She unde wen a igh hemi hy oidec omy. As pos ope a i e his opa hology e ealed mul i ocal
papilla y ca cinoma o hy oid she was ad ised o unde go comple ion hy oidec omy, howe e she de aul ed
u he ea men . A e a pe iod o i e mon hs she p esen ed o us wi h swelling on bo h sides o he neck
and had de eloped hoa seness o e he las h ee mon hs. Con as enhanced CT o he neck and ho ax
e ealed a he e ogenous so issue lesion in he egion o he le lobe o hy oid and bila e al signi ican
ce ical lymphadenopa hy. FNAC o he node showed papilla y ca cinoma hy oid. Flexible endoscopy
e alua ion e ealed le ocal co d palsy alone. She unde wen comple ion hy oidec omy wi h bila e al
comp ehensi e neck dissec ion. The le ecu en la yngeal ne e was seen o be en e ing he umo and could
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no be sal aged. The hy oid was seen o be adhe en o he i s acheal ca ilage on he le side and he
an e io wall o he same was excised. Cu ends o he achea we e su u ed p ima ily and ein o ced wi h s ap
muscles. T acheos omy was done. Gua dian su u es we e de e ed as he e was no ension a he anas omosis.
The pa ien was nu sed wi h he neck lexed du ing he pos ope a i e s ay. She was discha ged one week
pos ope a i ely and decannula ed a week la e . He his opa hology epo showed e idence o con en ional
papilla y ca cinoma hy oid wi h ex a capsula in asion and in il a ion o acheal ca ilage wi h no
in amu al ex ension. Bila e al Jugula g oup o lymph nodes showed e idence o me as asis. She oo ecei ed
high dose adio Iodine abla ion and is now on egula ollow up.
Discussion
O iginally mean o esolu ion o benign acheal s enosis, acheal esec ion wi h an end- o-end anas omosis
is now widely used o ea acheal umo s. The pionee s o his echnique we e D . He mes G illo and D .
Joel Coope in he 1960s. Since hen, many signi ican ad ancemen s in ai way managemen and in maneu e s
o ob ain a ension- ee anas omosis ha e been achie ed [10]. Howe e , i is impe a i e o he ea ing su geon
o be well e sed wi h he ana omy o he in ol ed ield be o e en u ing in o he same.
The achea has a D-shaped c oss-sec ion s uc u e consis ing o 16 o 20 incomple e, ho seshoe-shaped
ca ilaginous ings an e io ly and la e ally wi h a memb anous wall pos e io ly. The achealis muscle lines
be ween he memb anous wall and he esophagus. In e ca ilaginous memb anes connec each ca ilaginous
ing [11].
The blood supply is segmen al and app oaches la e ally and di ides longi udinally in o supe io and in e io
b anches. The b anches anas omose wi h he segmen al a e ies abo e and below. A he same ime, he a e ies
b anch an e io ly and pos e io ly wi hin he in e ca ilaginous memb ane and anas omose o he con ala e al
side [11].
The mos common indica ion o acheal esec ion su ge y s ill is subglo ic/ acheal s enosis un esponsi e o
balloon dila a ion o CO2 lase sca excision. Resec ion o malignan umo is ano he indica ion and is he
p e e ed modali y whe e e easible. Radio he apy and chemo he apy a e ese ed o subjec s wi h ex ensi e
disease o when he pa ien is un i o such a su ge y. O he less common indica ions include ai way auma,
inhala ion bu ns, adia ion inju y, acheoesophageal/ acheoinnomina e is ulas and congeni al lesions [11].
Role o Endoscopy and Imaging in e alua ion o ex en o in ol emen
While planning o su ge y, i is o u mos impo ance o know he p ecise ex en o he disease and assess he
easibili y o a p ima y anas omosis. A ho ough e alua ion wi h endoscopy and imaging is manda o y.
Ishiha a e al [12] ecommend endoscopic examina ion o he achea and s ess he di icul y o accu a ely
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assessing he ex en o in asion by his echnique. Nakao e al [13] ecommend endoscopy and compu ed
omog aphy as pa o he p eope a i e e alua ion o a pa ien . They also s ess he need o examine he ma gins
o he esec ed achea wi h ozen sec ions, as p oposed by Ma hey e al,[14].
T anscu aneous ul asonog aphy is ano he echnique ha can de ec he dep h o ai way in asion, eliably
dis inguishing supe icial (Shin I-II) s. deepe (Shin III-IV) in il a ion wi h a diagnos ic accu acy po en ially
eaching 93% [15].
Secu ing he Ai way
The peculia p oblem while ope a ing on achea is secu ing he ai way as i is sha ed bo h by anes he is and
su geon. The con en ional me hod is bypassing he endo acheal ube beyond he g ow h o passing he ube
a e incising he achea dis al o he g ow h [16]. O he echniques include high- equency je en ila ion,
igid b onchoscopy, and la yngeal mask ai way and ca diopulmona y bypass [9].
Resec ion and anas omosis
When he achea is in ol ed in he ce ical segmen , a ce ical app oach p o ides adequa e access. In e io
ex ension manda es a s e no omy o e en a ho aco omy. Adequa e ma gins o disease clea ance ha e o be
asce ained. I is ad isable o use he help o a ozen sec ion whene e easible.
Comple e esec ion a es anging om 42 o 57% ha e been epo ed in a ew se ies [17]. Howe e , a high
incidence o R1 o R2 esec ion a es ha e also been no ed because o la e de ec ion o he umo , complex
ana omy, and su geons no being exposed o his pa icula pa hology [9].
The nex mos c ucial s ep in his p ocedu e is o achie e a ension ee anas omosis. Va ious elease
maneu e s ha e been desc ibed o his pu pose. These include an e io and pos e io blun acheal dissec ion,
neck lexion, hy ohyoid, sup ahyoid, hila , and in ape ica dial elease echniques [11].
Mullikan e al. showed up o 4.5 cm o he achea can be esec ed wi h ension- ee anas omosis wi h neck
lexion alone [18].
The hy ohyoid o sup ahyoid la yngeal elease allows he la ynx o d op caudally and add 1 o 2 cm o acheal
leng h. Howe e , he sup ahyoid elease is p e e ed as i p o ides a simila leng h wi hou isking inju y o
he supe io la yngeal essels and ne e [11].
Complica ions
Auchincloss e al. [19] in hei s udy showed a median pos ope a i e hospi al s ay o 8 days, a success a e o
95%, and a complica ion a e o 18.2%.
Anas omo ic dehiscence is he mos d eaded complica ion. I s incidence anges om 4% o 14% wi h a
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mo ali y o 7.8% [20]. The leng h o he esec ed acheal segmen is di ec ly co ela ed wi h he ension o e
he su u e line. T acheal esec ions longe han 4 cm a e associa ed wi h a ema kable ise o anas omo ic
dehiscence a e [21].To p e en his con inuous neck lexion should be main ained using he gua dian s i ch,
mechanical en ila ion wi h pa aly ics, neck b ace o pos e io neck plas e splin . Pa ien s can usually be
ex uba ed 1-7 days la e . Howe e , i he su geon eels ha an ea ly ex uba ion is unlikely a acheos omy can
be pe o med ensu ing a dis ance o 2 cm om he anas omosis [11]. Ano he poin o be bo ne in mind is
p ese a ion o he acheal blood supply. The dissec ion should ake place along he an e io wall and i should
be limi ed only o he esec ed segmen . Piazza e al. sugges dissec ing no mo e han 1 cm om he esidual
s umps [22]. Some su geons co e anas omo ic line wi h musculocu aneous lap o p ese e and p o ec
acheal anas omosis [21].
Res enosis can p esen in up o 10% o pa ien s and is he mos common complica ion o acheal esec ion,
possibly due o g anula ion issue de elopmen a he su u e line [11].
Wound in ec ion can p esen wi h e y hema, d ainage, and inc eased pain. T ea men in ol es a cul u e o he
wound, an ibio ics. T acheoinnomina e o acheoesophageal is ula can esul due o anas omo ic dehiscence
and needs o be add essed immedia ely [11].
In all he h ee cases desc ibed he e, he ex en o acheal in ol emen was limi ed, hence i was possible o
adequa ely esec he umo and anas omose p ima ily. C i ical poin s o emembe while pe o ming such a
p ocedu e a e o know he exac si e and ex en o he umo . A sound ana omical knowledge o blood supply
is equally impo an . To a oid any undue ension o e he anas omosis one should asce ain adequa e neck
lexion and be awa e o he a ious elease maneu e s a ailable which will ensu e he addi ional leng h o
ension ee sa e anas omosis.
Conclusion
In mos acheal malignancies he symp om p esen a ion is o en misleading and a co ec diagnosis may be
delayed by mon hs o yea s. Clinical suspicion plays a undamen al ole and endoscopic and CT e alua ion
emain he co ne s ones in he diagnosis. App op ia e su gical esec ion and econs uc ion is s ill he bes
modali y o achie e long e m su i al wi h a decen quali y o li e. Howe e his emains a challenging
p ocedu e and an in-dep h knowledge o su gical and econs uc ion echniques is absolu ely essen ial.
Disclosu e
This ma e ial has ne e been published and is no unde e alua ion in any o he pee - e iewed publica ion.
Use o Gene a i e AI
Gene a i e AI was no used o w i e his a icle.
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Financial suppo and sponso ship
Nil.
Con lic s o in e es
The au ho s decla e no con lic s o in e es .
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