Electrosurgical and Laser Therapy Tools for the Treatment of Malignant Central Airway Obstructions

Malignant Airway Stenosis Successfully Treated Using a Combination of Interventional Pulmonology, Chemotherapy, and Radiotherapy

Interventional pulmonology can be helpful in cases of malignant airway stenosis. We present a 73-year-old man diagnosed with lung cancer who presented with symptomatic airway stenosis caused by a large endobronchial tumor. Oncological treatment was started with chemotherapy, radiotherapy, and a multimodality bronchoscopic approach using balloon bronchoplasty, electrosurgery, and argon plasma coagulation. Response evaluation showed relief of symptoms, disappearance of the endobronchial tumor, and complete resolution of the airway stenosis.

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

Therapeutic bronchoscopy for malignant central airway obstruction: impact on quality of life and risk-benefit analysis

PURPOSE OF REVIEW

Malignant central airway obstruction (CAO) is a common complication in cancer and confers significant symptom burden and reduction in quality of life. Multiple bronchoscopic interventions exist for malignant CAO. In this review, we discuss the role of therapeutic bronchoscopy in the management of malignant CAO, emphasizing its impact on symptom control and quality of life while balancing the risks and benefits of intervention.

RECENT FINDINGS

Significant practice variations exist among practitioners of therapeutic bronchoscopy, and limited data exist to guide real-time clinical decision-making. Recent analyses demonstrate that therapeutic bronchoscopy is effective for symptoms associated with malignant CAO with infrequent complications. These studies also show that many of the improvements in symptoms and quality of life are sustained after intervention and are associated with improved overall survival in patients with malignant CAO. Recent data have also shown that the improvement in symptoms associated with therapeutic bronchoscopy may enable more definitive cancer treatment, further improving patient outcomes.

SUMMARY

Therapeutic bronchoscopy is safe and effective at improving patient-centered outcomes in malignant CAO. Research is ongoing to better understand its optimal role in this setting, refine decision-making regarding advanced bronchoscopic interventions, and further improve patient outcomes.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Microwave Ablation for Malignant Central Airway Obstruction: A Pilot Study

Background

Malignant central airway obstruction (CAO) is a debilitating complication of primary lung cancer and pulmonary metastases. Therapeutic bronchoscopy is used to palliate symptoms and/or bridge to further therapy. Microwave ablation (MWA) heats tissue by creating an electromagnetic field around an ablation device. We present a pilot study utilizing endobronchial MWA via flexible bronchoscopy as a novel modality for the management of malignant CAO.

Methods

Therapeutic bronchoscopy with a flexible MWA probe was performed in 8 cases. We reviewed tumor size, previous ablative techniques, number of applications, ablation time, amount of energy delivered, rate of successful recanalization, complications, and 30-day follow-up.

Results

Successful airway recanalization was achieved in all cases. No complications were noted. In 1 case, tumor in-growth within a silicone stent was ablated with no damage to the stent.

Discussion

Endobronchial MWA is a novel technique for tumor destruction while maintaining an airway axis. The oven effect and air gap around a tumor allow for safe and effective tissue devitalization and hemostasis without a thermal effect on structures surrounding the airway.

Current practices in the management of central airway obstruction

PURPOSE OF REVIEW

Airway obstruction continues to cause substantial pulmonary morbidity and mortality. We present a review of classic, current, and evolving management techniques, highlighting recently published studies on the topic. Recommendations have historically been primarily based on anecdotal experience, case reports, and retrospective studies, but more solid evidence has emerged in the last decade.

RECENT FINDINGS

Novel endobronchial stents are being developed to mitigate the issues of stent migration, mucus plugging, fracture, and granulation tissue formation. Endobronchial drug delivery has become an active area of translational and clinical research, especially with regards to antineoplastic agents used for malignant airway stenosis. Even classic or updated techniques such as spray cryotherapy, injections of mitomycin-c, and balloon dilation have recently been examined in methodologically sound studies. Finally, recently published data have confirmed that patient breathlessness and quality of life improve significantly with therapeutic airway interventions. A multimodal and multidisciplinary approach to patient care is key to achieving the best outcomes.

SUMMARY

The treatment of central airway stenosis is often multimodal and should focus on patient-centric factors, taking into account risks and benefits of the procedure, operator, and center expertise, and always occur in the context of a multidisciplinary approach. Evidence-based clinical research is increasingly driving patient management.

Lung squamous cell carcinoma with rare epidermal growth factor receptor mutation G719X: a case report and literature review

Asians who develop non-small cell lung cancer (NSCLC) have a chance of approximately 50% of harboring the epidermal growth factor receptor (EGFR) mutation. The G719X mutation in EGFR has 3 subtypes (i.e., G719A, G719C, or G719S), all of them being classified as uncommon EGFR mutations. The EGFR mutation G719X is most often associated with lung adenocarcinoma. Conversely, its occurrence in lung squamous cell carcinoma is rare. Its response to tyrosine kinase inhibitor (TKI) treatment remains unknown. A 50-year-old Asian male with no smoking history was admitted to our hospital (Affiliated Hospital of Qingdao University) with an irritating dry cough and 1 month of progressive dyspnea. The patient was diagnosed with lung squamous cell carcinoma (cT4N3M0, stage IIIC). Lung biopsy revealed the presence of EFGR G719X mutation. The patient received a tracheobronchial stent, targeted therapy, chemotherapy, seed implantation and radiotherapy, and survived for 25.4 months following diagnosis. It is crucial that gene mutation analysis is performed in non-smoking male squamous cell carcinoma patients. Compared to lung adenocarcinoma patients with rare G719X mutation, this lung squamous cell carcinoma patient with G719X-mutant tumor had a higher sensitivity to 2^nd-generation EGFR-TKI treatment, but similar progression-free survival. Importantly, the patient clearly benefited from the used comprehensive treatment plan. This article seeks to shed light on the treatment of lung squamous cell carcinoma patients with the uncommon EGFR G719X mutation.

Computed tomography-guided implantation of 125I radioactive seeds in patients with malignant airway compression induced by advanced lung cancer: effectiveness and safety in 40 patients

Purpose

To evaluate the safety and efficacy of computed tomography (CT)-guided ¹²⁵I radioactive seed implantation in patients with malignant airway compression induced by advanced lung cancer.

Material and methods

Between June 2015 and June 2018, 40 patients from three medical institutions with malignant airway compression induced by advanced lung cancer were treated with ¹²⁵I seed implantation. The outcomes were measured in technical success and safety, objective response rate, complications, Karnofsky performance status (KPS) score, and survival time.

Results

All 40 patients successfully underwent implantation procedure. No procedure-associated death occurred. The most common complications were irritable cough, temporary hemoptysis, chest pain, fever, and pneumothorax, which occurred in 26 (65.0%), 31 (77.5%), 12 (30.0%), 15 (37.5%), and 11 (27.5%) patients, respectively. The objective response rates were 100%, 100%, 100%, 87.5%, and 83.3% at the 3^rd, 6^th, 12^th, 24^th, and 36^th months post-procedure, respectively. The KPS score significantly improved at post-procedure. Median survival time was 25.1 months. Actuarial survival rates were 100%, 60%, and 15% at the 12^th, 24^th, and 36^th months after the procedure, respectively.

Conclusions

For patients with malignant airway compression induced by advanced lung cancer, implantation with ¹²⁵I seed is a safe and effective alternative treatment option.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.