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Stratakos G, Gerovasili V, Dimitropoulos C, Giozos I, Filippidis FT, Gennimata S, Zarogoulidis P, Zissimopoulos A, Pataka A, Koufos N, Zakynthinos S, Syrigos K, Koulouris N. Survival and Quality of Life Benefit after Endoscopic Management of Malignant Central Airway Obstruction. J Cancer 2016; 7:794-802. [PMID: 27162537 PMCID: PMC4860795 DOI: 10.7150/jca.15097] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/21/2016] [Indexed: 02/07/2023] Open
Abstract
Background: Although interventional management of malignant central airway obstruction (mCAO) is well established, its impact on survival and quality of life (QoL) has not been extensively studied. Aim: We prospectively assessed survival, QoL and dyspnea (using validated EORTC questionnaire) in patients with mCAO 1 day before interventional bronchoscopy, 1 week after and every following month, in comparison to patients who declined this approach. Material/Patients/Methods: 36 patients underwent extensive interventional bronchoscopic management as indicated, whereas 12 declined. All patients received full chemotherapy and radiotherapy as indicated. Patients of the 2 groups were matched for age, comorbidities, type of malignancy and level of obstruction. Follow up time was 8.0±8.7 (range 1-38) months. Results: Mean survival for intervention and control group was 10±9 and 4±3 months respectively (p=0.04). QoL improved significantly in intervention group patients up to the 6th month (p<0.05) not deteriorating for those surviving up to 12 months. Dyspnea decreased in patients of the intervention group 1 month post procedure remaining reduced for survivors over the 12th month. Patients of the control group had worse QoL and dyspnea in all time points. Conclusions: Interventional management of patients with mCAO, may achieve prolonged survival with sustained significant improvement of QoL and dyspnea.
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Affiliation(s)
- Grigoris Stratakos
- 1. 1st Pulmonary Medicine Department of National and Kapodistrian University of Athens, "Sotiria" General Hospital Athens, Greece
| | - Vasiliki Gerovasili
- 2. 1st Respiratory and Critical Care Medicine department of National and Kapodistrian University of Athens, "Evangelismos" Hospital Athens, Greece
| | - Charalampos Dimitropoulos
- 1. 1st Pulmonary Medicine Department of National and Kapodistrian University of Athens, "Sotiria" General Hospital Athens, Greece
| | - Ioannis Giozos
- 3. Oncology Unit, 3rd Department of Internal Medicine of National and Kapodistrian University of Athens, "Sotiria" General Hospital, Athens, Greece
| | - Filippos T Filippidis
- 2. 1st Respiratory and Critical Care Medicine department of National and Kapodistrian University of Athens, "Evangelismos" Hospital Athens, Greece
| | - Sofia Gennimata
- 1. 1st Pulmonary Medicine Department of National and Kapodistrian University of Athens, "Sotiria" General Hospital Athens, Greece
| | - Paul Zarogoulidis
- 4. Pulmonary Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Zissimopoulos
- 5. Nuclear Medicine Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Athanasia Pataka
- 4. Pulmonary Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikos Koufos
- 1. 1st Pulmonary Medicine Department of National and Kapodistrian University of Athens, "Sotiria" General Hospital Athens, Greece
| | - Spyros Zakynthinos
- 2. 1st Respiratory and Critical Care Medicine department of National and Kapodistrian University of Athens, "Evangelismos" Hospital Athens, Greece
| | - Konstantinos Syrigos
- 3. Oncology Unit, 3rd Department of Internal Medicine of National and Kapodistrian University of Athens, "Sotiria" General Hospital, Athens, Greece
| | - Nikos Koulouris
- 1. 1st Pulmonary Medicine Department of National and Kapodistrian University of Athens, "Sotiria" General Hospital Athens, Greece
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Hardavella G, George J. Interventional bronchoscopy in the management of thoracic malignancy. Breathe (Sheff) 2015; 11:202-12. [PMID: 26632425 PMCID: PMC4666450 DOI: 10.1183/20734735.008415] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Educational Aims Interventional bronchoscopy is a rapidly expanding field in respiratory medicine offering minimally invasive therapeutic and palliative procedures for all types of lung neoplasms. This field has progressed over the last couple of decades with the application of new technology. The HERMES European curriculum recommendations include interventional bronchoscopy skills in the modules of thoracic tumours and bronchoscopy [1]. However, interventional bronchoscopy is not available in all training centres and consequently, not all trainees will obtain experience unless they rotate to centres specifically offering such training. In this review, we give an overview of interventional bronchoscopic procedures used for the treatment and palliation of thoracic malignancy. These can be applied either with flexible or rigid bronchoscopy or a combination of both depending on the anatomical location of the tumour, the complexity of the case, bleeding risk, the operator’s expertise and preference as well as local availability. Specialised anaesthetic support and appropriately trained endoscopy staff are essential, allowing a multimodality approach to meet the high complexity of these cases. Interventional bronchoscopy is integral to the treatment and palliation of lung cancerhttp://ow.ly/R25w0
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Affiliation(s)
- Georgia Hardavella
- Dept of Thoracic Medicine, University College London Hospitals, London, UK ; Dept of Respiratory Medicine, King's College Hospital, London, UK
| | - Jeremy George
- Dept of Thoracic Medicine, University College London Hospitals, London, UK
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Lee P, Kupeli E, Mehta AC. Therapeutic bronchoscopy in lung cancer. Laser therapy, electrocautery, brachytherapy, stents, and photodynamic therapy. Clin Chest Med 2002; 23:241-56. [PMID: 11901914 DOI: 10.1016/s0272-5231(03)00075-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Therapeutic bronchoscopic techniques such as LPR, EC, brachytherapy, stents, and PDT are effective tools in the palliation and local control of lung cancer. Palliation of malignant tracheobronchial obstruction by LPR, stents, brachytherapy, PDT, or a combination thereof results in relief of dyspnea, hemoptysis, and postobstructive pneumonia. Importantly, it avoids intubation in patients with respiratory distress and facilitates the weaning of patients from MV. In the exciting field of lung cancer screening and treatment of early lung cancer, PDT, brachytherapy, EC, and LPR may represent treatment alternatives to surgical resection, especially in a select group of patients with high surgical risk or favorable endobronchial lesions. Clinicians await the results of future studies, which will (1) better define the impact of each treatment modality on patient care in terms of cost, survival, and improvement in quality of life, and (2) determine the optimal combination therapy relative to bronchoscopic and conventional treatment for effective palliation and cure of lung cancer.
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Affiliation(s)
- Pyng Lee
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Moghissi K, Bond MG, Sambrook RJ, Stephens RJ, Hopwood P, Girling DJ. Treatment of endotracheal or endobronchial obstruction by non-small cell lung cancer: lack of patients in an MRC randomized trial leaves key questions unanswered. Medical Research Council Lung Cancer Working Party. Clin Oncol (R Coll Radiol) 2000; 11:179-83. [PMID: 10465472 DOI: 10.1053/clon.1999.9037] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Symptoms of endotracheal or endobronchial obstruction caused by non-small cell lung cancer (NSCLC) may be relieved with external beam radiotherapy (XRT) or endobronchial treatment. The comparative roles of these two methods need to be established. Patients with predominantly intraluminal obstruction of the trachea, a main bronchus or a lobar bronchus by unresectable NSCLC were randomized to XRT versus the clinician's choice of endobronchial treatment with brachytherapy, laser resection or cryotherapy, according to local availability and practice. Clinicians' assessments included symptoms of obstruction, WHO performance status, lung function tests and adverse effects of treatment. Patients completed a Rotterdam Symptom Checklist at all assessments and a daily diary card to record the severity of major symptoms during the first 4 weeks. To show a difference of 15% in the relief of breathlessness rates at 4 months (from 65% to 80%), 400 patients were required. In spite of our many previously successful lung cancer trials, and initial interest from clinicians in 24 UK centres, who estimated they could randomize 200 patients per year into the present trial, only 75 patients were randomized from seven centres over 3.5 years. Intake to the trial was therefore abandoned in November 1996 although an independent Data Monitoring and Ethics Committee had concluded in April 1996 that the scientific case for the trial was still strong; there were no competing trials; there were no design problems; and much had been done to promote the trial. The main reasons given by centres for the slow intake were: lack of referrals of untreated patients; patients being referred specifically for endobronchial treatment; patients having already received XRT; emergency endobronchial relief of obstruction being necessary; and XRT and endobronchial treatment being considered complementary and not as alternatives. The relative advantages and disadvantages of XRT versus endobronchial treatment remain to be determined. The lack of recruitment to this trial raises the issue of innovative techniques not being given the chance of proving their worth compared with traditional treatments.
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Affiliation(s)
- K Moghissi
- Yorkshire Laser Centre, Goole and District Hospital, Leeds, UK
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Abstract
Metastasis to the lung occurs quite commonly from certain types of extrapulmonary primary carcinoma. Spread to the bronchial lumen is relatively rare. When this does occur, symptoms resembling those of primary bronchial carcinoma are often present, in association with partial or complete obstruction of the bronchial lumen. Palliation of such symptoms is possible with the use of intraluminal radiotherapy (ILT). Between 1990 and 1998, 37 patients with endobronchial metastases were treated using this modality; a single fraction of radiation was delivered by the remote afterloading high dose rate microSelectron system. Data regarding these patients' characteristics and outcome are presented, following a retrospective review of case notes. The commonest symptoms were dyspnoea, cough and haemoptysis; the commonest primary tumour sites were breast, colorectum, oesophagus and kidney. Twenty-four (64.9%) patients had some improvement in symptoms following treatment. Mean overall survival was 280 days, range 9-1145 days. No serious adverse effects occurred. ILT is a relatively simple, safe and effective treatment in the palliation of symptoms due to endobronchial metastases.
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Sutedja G, Schramel F, Postmus PE. Bronchoscopic treatment modalities in lung cancer, indications and limitations. Ann Oncol 1995; 6:951-2. [PMID: 8624302 DOI: 10.1093/oxfordjournals.annonc.a059367] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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8
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Waller DA, Gower A, Kashyap AP, Conacher ID, Morritt GN. Carbon dioxide laser bronchoscopy--a review of its use in the treatment of malignant tracheobronchial tumours in 142 patients. Respir Med 1994; 88:737-41. [PMID: 7531359 DOI: 10.1016/s0954-6111(05)80195-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report our experience over an 8-yr period, 1984-1991, of the use of the carbon dioxide (CO2) laser in the treatment of otherwise inoperable malignant tracheobronchial lesions. In that period 142 patients (84 male, 58 female; median age 63 years) underwent 278 procedures. The trachea was the site of treatment in 44 patients, the carina in nine, a main bronchus in 80 and a lobar bronchus in nine. All resections were performed under general anaesthesia via a rigid bronchoscope. Symptomatic relief was obtained in 103 of the 116 patients whose main complaint was dyspnoea. Overall there was a mean improvement in forced expiratory volume in 1 s (FEV1) of 27%, in peak expiratory flow (PEF) of 22% and in forced vital capacity (FVC) of 7%. Most improvement in FEV1 and PEF was obtained by the treatment of tracheal lesions. Three patients died within 24 h of surgery and 30 day mortality was 18%. At a mean follow-up of 18.3 months the mean post-laser survival is 5 months. While the CO2 laser has limitations in the treatment of distal tumours when compared to the neodymium/yttrium aluminium garnet (Nd:YAG) laser, there was no higher incidence of complications. We have found CO2 laser bronchoscopy to be an effective palliation of inoperable malignant tumours particularly of the trachea and main bronchi.
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Affiliation(s)
- D A Waller
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle-upon-Tyne, U.K
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Macha HN, Becker KO, Kemmer HP. Pattern of failure and survival in endobronchial laser resection. A matched pair study. Chest 1994; 105:1668-72. [PMID: 7515777 DOI: 10.1378/chest.105.6.1668] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
To evaluate the influence of endobronchial laser resection on survival and the pattern of failure in patients with bronchial malignancies, we investigated 75 patients prospectively. These patients had radiation therapy (mean external dose, 53.1 Gy) and endobronchial laser resection to treat an inoperable or recurrent bronchial carcinoma occluding a major airway. Complete recanalization was achieved in 36 percent, partial recanalization was achieved in 51 percent, and no recanalization was achieved in 13 percent. These 75 patients were matched retrospectively with a group of 75 patients who received external radiation therapy because of the same indications, but because of endobronchial compression of a major airway by the tumor, received no laser resection. The patients were matched for age, sex, TNM-status, histologic features, external radiation dose and fractionation, lung resection, cytotoxic therapy, and brachytherapy; they were treated in the same period. The incidence of terminal hemorrhage was four times higher in patients who received endobronchial laser resection (34.5 percent) compared with those who did not (7.7 percent). Successful laser reopening of a major airway influenced the pattern of failure: with full recanalization the cause of death in 23.3 percent of cases was respiratory failure and in 26.7 percent, terminal hemorrhage; whereas with no recanalization these figures were 56.3 percent and 18.8 percent, respectively. Laser resection did not influence overall survival, but in patients with full reopening of a bronchus, the time interval from treatment to death was prolonged by more than 4 months compared with those patients in whom recanalization failed. Comparing our observations on the immediate cause of death with reports in the literature, we conclude that the higher percentage of terminal hemorrhage in patients receiving endobronchial laser resection is not directly related to the treatment, but reflects different patterns of tumor growth with respect to mucosal destruction not covered by the TNM system.
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Affiliation(s)
- H N Macha
- Department of Pneumology, Lungenklinik, Hemer, Germany
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10
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Abstract
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.
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Affiliation(s)
- M R Hetzel
- Department of Thoracic Medicine, University College Hospital, London
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George PJ, Pearson MC, Edwards D, Rudd RM, Hetzel MR. Bronchography in the assessment of patients with lung collapse for endoscopic laser therapy. Thorax 1990; 45:503-8. [PMID: 2396231 PMCID: PMC462578 DOI: 10.1136/thx.45.7.503] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In an attempt to improve selection of patients and the efficacy of endoscopic laser treatment, a bronchographic technique has been developed for patients with tumours causing complete endobronchial obstruction. This technique has shown patent distal airways in 16 out of 17 patients with a collapsed lung or lobe. These airways were abnormally dilated in each case, suggesting bronchiectasis. In one patient the appearances of bronchiectasis were sufficiently severe to decide against attempting treatment. Treatment was not attempted in another patient as a large cavity was seen within the collapsed lung and this was thought to carry a risk of postoperative infection and haemorrhage. Treatment with a neodymium YAG laser under general anaesthesia successfully recanalised the airway in 12 of the 15 remaining patients and was associated with a substantial reduction in breathlessness. The procedure was abandoned prematurely in one patient because of life threatening haemorrhage. In the remaining two patients in whom treatment was unsuccessful bronchography had suggested very extensive endobronchial obstruction. Spirometry and radionuclide lung scans were performed before and after treatment in eight patients treated successfully and showed significant improvements. Four patients were investigated within two weeks of lung re-expansion by repeat bronchography (three patients) or computed tomography (one patient); in each case the calibre of the airways had returned almost to normal. Thus the radiological demonstration of bronchial dilation in a collapsed lung does not necessarily imply a diagnosis of irreversible bronchiectasis and should not be regarded as a contraindication to treatment. It is concluded that preoperative bronchography provides reliable data on the extent of tumour, the patency of the distal airways, and presence of extensive cavitation. This information should facilitate successful laser treatment.
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Affiliation(s)
- P J George
- Department of Thoracic Medicine, London Chest Hospital
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