Diathermy resection and radioactive gold grains for palliation of obstruction due to recurrence of bronchial carcinoma after external irradiation

Integration of interventional bronchoscopy in the management of lung cancer

Tracheal or bronchial proximal stenoses occur as complications in 20-30% of lung cancers, resulting in a dramatic alteration in quality of life and poor prognosis. Bronchoscopic management of these obstructions is based on what are known as "thermal" techniques for intraluminal stenosis and/or placement of tracheal or bronchial prostheses for extrinsic compressions, leading to rapid symptom palliation in the vast majority of patients. This invasive treatment should only be used in cases of symptomatic obstructions and in the presence of viable bronchial tree and downstream parenchyma. This review aims to clarify 1) the available methods for assessing the characteristics of stenoses before treatment, 2) the various techniques available including their preferred indications, outcomes and complications, and 3) the integration of interventional bronchoscopy in the multidisciplinary management of proximal bronchial cancers and its synergistic effects with the other specific treatments (surgery, radiotherapy or chemotherapy).

Fibrobronchoscopic cryosurgery for secondary malignant tumors of the trachea and main bronchi

Background

Patients with secondary malignant tracheal and main bronchial tumors may suffer severe symptoms as a result of major airway obstruction. Curative surgical resection is usually not suitable because of the presence of metastatic disease and poor performance status. In this study, the use of bronchoscopic cryosurgery to reopen the airway is analyzed.

Methods

The clinical records of 37 patients who experienced secondary maglinancies from December 2001 to January 2013 were retrospectively reviewed. Low temperature cryotherapy (−50°C to −70°C) was delivered to the central part of the tumor by cryoprobe for four to six minutes causing destruction of the tumor mass (Cryo‐melt method). Subsequently, the edge of the tumor was frozen for 30 seconds to two minutes, followed by piecemeal removal of the frozen tumor tissue (Cryo‐resection method).

Results

The endpoints of the study were degree of symptomatic improvement and survival. The rates of dramatic and partial symptomatic alleviation were 57.1% and 28.6%, respectively, there were no intraoperative deaths, and median survival was 16.0 months. Prolonged survival was significantly correlated to age (under 60 years of age 22.2% vs. over 60 100%, P = 0.011), tumor location (main bronchi 0% vs. trachea 77.8%, P = 0.003), and cryorecanalization times (once 33.3% vs. twice or more 80.0%, P = 0.037).

Conclusion

Bronchoscopic cryorecanalization is a safe, effective, non‐invasive choice for improving the symptoms of malignant airway obstruction. In addition to achieving local‐regional control, the technique may also contribute to improved survival.

Neodymium:yttrium-aluminum-garnet laser for the treatment of tracheobronchial recurrences in esophageal carcinomas

Tracheobronchial recurrence occurred in 55 of 559 patients (9.8%) after resection of their esophageal carcinomas and in 22 of 109 patients (20.2%) after a bypass operation. The risk of airway recurrence increases if residual disease is present in the mediastinum at resection. The median survival of 55 patients diagnosed with tracheobronchial recurrence before July 1988 was 3.7 weeks. After July 1988, there were 22 patients in whom tracheobronchial recurrence developed, 19 of whom were treated by neodymium:yttrium-aluminum-garnet laser under local anesthesia. Additional external radiotherapy was offered to 8 patients who responded to laser treatment and were in satisfactory condition. Four of these patients (21%) had complete tumor regression. Partial regression occurred in 7 patients (37%): 2 were treated by combined therapy and 5 by laser alone. Most tolerated the laser treatment well, but the procedure was abandoned in 6 patients because of smoke inhalation. A tracheoesophageal fistula developed in 2 patients. The median survival for the entire group was 7.4 weeks, with 3 long survivors who lived more than 1 year. The combined application of laser and external radiotherapy is effective for the treatment of tracheobronchial recurrences in patients with esophageal carcinoma.

Bronchoscopic diathermy resection and stent insertion: a cost effective treatment for tracheobronchial obstruction

BACKGROUND

Major airways obstruction is a distressing cause of morbidity and mortality. For disease that is extensive and recurrent, there is a need for a safe and cost effective technique for palliation.

METHODS

The results of 29 patients with tracheobronchial obstruction (24 malignant and five benign) treated by diathermy resection alone or in combination with endobronchial stenting have been reviewed.

RESULTS

The major site of obstruction was the trachea in 14, main carina in seven, right main bronchus in six, and left main bronchus in two patients. Fifteen had received other forms of treatment beforehand including external radiotherapy, endoscopic dilatation, and laser resection (Nd:YAG). Five patients required two or more treatment sessions for symptom recurrence. Ten patients also received additional treatment with a stent (nine) or insertion of gold grains (one). There were no intraoperative deaths or complications and the average length of stay was five days (range 2-14). Twenty eight patients reported immediate symptomatic relief, and objective improvement in the results of lung function tests was seen in eight patients whose condition was less acute and where preoperative lung function tests could be undertaken (average improvement in FEV1 of 53.1% and in FVC of 20.6%).

CONCLUSIONS

Bronchoscopic diathermy resection is an effective and safe method for relieving the symptoms of tracheobronchial obstruction at appreciably less cost than laser resection.

Brachytherapy for recurrent nasopharyngeal and naso-ethmoidal tumours

Recurrent or persistent carcinoma of the nasopharynx or naso-ethmoid region occurs even after combined surgery and radical external irradiation. The confined bony access and proximity of vital structures may compromise resection margins. Brachytherapy using implantable radioactive gold or iodine seeds is a useful adjunct to the skull base surgeon in eliminating residual microscopic disease. We report nine cases with recurrent or persistent disease of the nasopharynx or naso-ethmoid regions treated with brachytherapy with encouraging results.

Medium dose rate endobronchial radiotherapy with caesium-137

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Endoscopic palliation of tracheobronchial malignancies

The prognosis for tracheobronchial tumours remains poor. Most patients can be offered only palliation. When the main symptom is breathlessness or refractory haemoptysis from a large airway tumour endoscopic treatment may be very effective. Over the last decade most attention has focused on the neodymium YAG laser. This often produces dramatic effects but has some important limitations. In the last few years better techniques for stenting and intrabronchial radiotherapy (brachytherapy) have also been developed. This article discusses the range of techniques now available and aims to help clinicians decide which patients may benefit from referral to centres providing these techniques.