Preoperative laser therapy in a patient with resectable bronchogenic carcinoma and severe coronary artery disease

Endobronchial intratumoral chemotherapy (EITC) followed by surgery in early non-small cell lung cancer with polypoid growth causing erroneous impression of advanced disease

BACKGROUND

Seventeen patients with (M0) non-small cell lung cancer (NSCLC) without distant metastasis were treated by preoperative endobronchial intratumoral chemotherapy (EITC) followed by surgery. Preoperative intratumoral chemotherapy was performed for the purpose of either reducing the extent of resection or increasing operability. Clinically, in the preliminary diagnostic bronchoscopic examination, the tumor was located in the main stem bronchus closer than 2 cm to the carina [T3] in 12 patients, or at the level of carina or bulging towards the trachea [T4] in 5 patients. In this series of patients, the tumors were originally inoperable due to the inability to achieve a negative margin by standard pneumonectomy techniques. However, EITC rendered resection possible.

THERAPEUTIC METHODS

EITC consisted of direct injection of a maximum dose of 40 mg cisplatin in aqueous solution (4 mg/ml) into the tumor through a flexible bronchoscope; administered four times: once a week during a 3-week period (on days 1, 8, 15 and 22). Necrotic tumor debris was removed by piecemeal resection with forceps and suction at each session.

RESULTS

In all patients, the bulk of tumor in the main bronchus was eliminated by the end of 3 weeks of EITC treatment. Post-EITC treatment bronchoscopy revealed that primary tumors originated in a lobe or segment without invasion of the mucous membrane of the major bronchus. EITC treatment reduced the extent of tumor such that inoperable tumors became operable. Patients could then undergo conventional surgery successfully without postoperative complications.

CONCLUSIONS

In this selected group of 17 patients, EITC was shown to be a safe, effective and easy to perform method for debulking of obstructed airways before surgery; without any important side effects or systemic drug toxicity. Because this type of obstructive lung cancer may lead to inappropriate initial diagnosis, we suggest that obstructive lung cancer patients such as described here, with a potentially a very favorable prognosis, should be considered a distinct clinical entity perhaps best described as "Early NSC Lung Cancer with polypoid growth in a major airway causing the erroneous impression of advanced disease".

Nd:YAG laser resection of lung cancer invading the airway as a bridge to surgery and palliative treatment

BACKGROUND

Thirty percent of patients with lung cancer have airway obstruction requiring palliation. In addition, endoscopic resection may be considered before surgery or induction therapy to improve quality of life and functional status, and to allow better staging. It may also help to prevent infectious complications during induction chemotherapy.

METHODS

Since 1993, 351 Nd:YAG laser resections were performed in 273 patients with lung cancer. The tumor involved the trachea in 36 patients, the carina in 28, the main bronchi in 154, the bronchus intermedius in 29, and the distal airway in 26. One hundred eight stents were placed. After the endoscopic treatment 36 patients were operated on (23 after induction chemotherapy) with 8 pneumonectomies (1 tracheal sleeve) and 28 lobectomies (15 bronchial sleeves). Spirometry, arterial blood gas analysis, and quality of life and performance status were recorded before and after laser treatment and after induction chemotherapy. Complications during chemotherapy, surgical morbidity and mortality, and survival were also recorded.

RESULTS

Major complications during laser resection were bleeding (7 patients) and hypoxia (5 patients). Three patients died within 24 hours after the procedure. No complications were observed in the group of patients who subsequently underwent induction chemotherapy or surgery. One patient developed pneumonia during induction chemotherapy. The airway caliber improved in 89% of patients undergoing palliation only. In the group of patients undergoing induction chemotherapy and/or surgery, the performance status, quality of life, and functional measurements significantly improved after endoscopic treatment (FEV1 from 1.4 +/- 0.5 L/s to 2.2 +/- 0.6 L/s). Three-year survival after induction chemotherapy and surgery, was 52%. Median survival after palliation alone was 12.1 months.

CONCLUSIONS

Nd:YAG laser resection is a safe and effective means of relieving airway obstruction. Before induction chemotherapy or surgery preliminary endoscopic palliation helps to improve evaluation and staging and contributes to reducing morbidity during chemotherapy without increasing surgical complications.

Parenchymal sparing operations for bronchogenic carcinoma

By the end of the 1950s, the principles of tracheobronchial and pulmonary artery (PA) reconstruction had been established, and their successful clinical application had taken place. It was not until very recently, however, that these techniques aroused widespread interest among thoracic surgeons as a means to achieve complete cancer resection while preserving functioning lung parenchyma. At the present time, sleeve resection of the bronchus and/or PA has a definite role in the surgical management of lung cancer. Growing interest in this field is evidenced by an increasing number of technical variations intended to adapt the basic technique to the different anatomical settings. Also pitfalls, complications, and their prevention and treatment are being extensively described. Last but not least, functional and oncological long-term results, comparing favorably with those of more extended resections, are being reported by many groups. This demonstrates that sleeve lobectomy is no longer reserved only for particularly skillful surgeons. Sleeve lobectomy has achieved its rightful position among the techniques commonly used in thoracic surgery after 40 years of improving understanding and alternating enthusiasm and legitimate doubts.

Endoscopic treatment of lung cancer invading the airway before induction chemotherapy and surgical resection

OBJECTIVE

Many patients with advanced lung cancer invading the airway require only palliation; however, induction chemotherapy and surgery may sometimes be considered. Preliminary endoscopic palliation may improve quality of life and functional status, allows better evaluation of tumor extension and contributes to prevent infectious complications. We reviewed our experience with preliminary laser treatment, induction chemotherapy and surgical resection in patients with lung cancer invading the airway.

METHODS

Twenty-one patients with stage IIIA and IIIB lung cancer presenting with an 80% unilateral airway obstruction were treated with laser resection, induction chemotherapy and surgery. Spirometry, arterial blood gas analysis, quality of life (QLQ-C30 score) and performance status were recorded before and after laser treatment and after chemotherapy. Complications during chemotherapy, surgical morbidity and mortality, and survival were also recorded.

RESULTS

No complications were observed after endoscopic treatment. FEV(1) significantly improved from 1.4+/-0.4 l/s to 2.2+/-0.7 l/s, as well as FVC (from 2+/-0.5 to 3.1+/-0.8 l), and remained stable after chemotherapy. The QLQ-C30 score significantly improved after laser treatment (from 45+/-4.8 to 31+/-2.5) as well as the Karnofsky status (from 76+/-5 to 90). One patient developed pneumonia during induction chemotherapy. Three patients were not operated on. We performed five pneumonectomies (one right tracheal sleeve pneumonectomy) and 13 lobectomies (five associated to a bronchial sleeve resection). One patient (5.5%) died after the operation. Four patients experienced minor postoperative complications. Three-year survival after the operation was 52%.

CONCLUSIONS

Preliminary endoscopic palliation of lung cancer invading the airway is feasible, improves evaluation and staging, helps to reduce the incidence of complications during induction chemotherapy without increasing surgical morbidity and mortality.

Resection with curative intent after endoscopic treatment of airway obstruction

BACKGROUND

Endoscopic treatment of malignant central airway obstructions usually is done for palliation. The exact role of such a procedure as preparatory to operation remains controversial.

METHODS

From 1987 through 1996, 24 patients at our institution underwent tracheobronchial pulmonary resection after preliminary endoscopic treatment. During the same period, 304 patients underwent 449 operative rigid bronchoscopies for airway obstructions, most involving the use of a neodymium:yttrium-aluminum-garnet laser. The indications for operation were squamous cell carcinoma in 14 patients, bronchial gland tumors in 8 patients, and papillary thyroid cancer infiltrating the trachea in 2 patients. The total resection rate was 9.5% (5% for squamous cell carcinoma, 75% for low-grade malignant bronchial tumors, and 75% for papillary thyroid cancer). The median period between operative rigid bronchoscopy and operation was 18 days.

RESULTS

No complications were observed after endoscopic treatment. There were two perioperative deaths (adult respiratory distress syndrome after carinal resection and pulmonary embolism after pneumonectomy) and one major complication (poor postoperative pulmonary function after pneumonectomy). No anastomotic complications were observed in the tracheobronchoplastic procedures. Follow-up was possible in every patient but 1: 6 patients died at a median of 30.5 months after operation (range, 3 to 46 months), 2 patients are alive with disease, and the rest are alive without evidence of disease at a median of 21 months (range, 2 to 61 months).

CONCLUSIONS

Most patients who require endoscopic therapy for malignant airway obstructions are not candidates for operative resection. Preliminary endoscopic relief of obstruction can increase operability and improve surgical results in a highly selected group of patients.