Management of airway problems in lung cancer patients using the neodymium-yttrium-aluminum-garnet (Nd-YAG) laser and endobronchial radiotherapy

Surgical palliation of thoracic malignancies

Primary and metastatic thoracic malignancies are often incurable. Surgeons caring for these patients must be familiar with the options,indications, techniques, and limitations of interventions for palliative treatments in these patients. This article is an overview of the current practices for palliation of a broad spectrum of complaints relating to patients with carcinomas of the lung, esophagus,and mesothelium. The information can be used for treatment of patients with complaints secondary to less common malignancies and metastatic disease of the thorax.

Use of endoscopic fibrinogen-thrombin in the treatment of severe hemoptysis

Bronchial artery embolization (BAE) is the treatment of choice in the majority of patients with severe hemoptysis. However, this procedure may be unavailable and even fail or be counterindicated in 4-13% of cases. In these cases, the efficacy of fibrinogen-thrombin (FT) instilled endoscopically as treatment for massive hemoptysis was assessed. Between August 1993 and February 1996 a prospective clinical study was performed. FT instillation was indicated in all patients with severe hemoptysis (> 150 ml/12 h) in whom BAE had failed, was counterindicated or not available. FT was instilled endoscopically. Patients were followed up until June 2001. Eleven of 101 patients (11%) with hemoptysis > 150 ml/12 h in whom BAE was not possible or proved ineffective were included. The severe hemoptysis was controlled immediately in all cases. During the follow-up period (mean: 39.4 months), early relapse of the severe hemoptysis occurred in two patients (18%) and a long-time relapse in one. Mean procedure duration was 3 min and no attributable complications were observed in any case. In conclusion, these results suggest that topical treatment with FT could be considered in the initial endoscopic evaluation of patients with severe hemoptysis while awaiting BAE or surgery, or as alternative treatment to arterial embolization when the latter is not available, has proved ineffective or is counterindicated.

Intraluminal Brachytherapy for Malignant Endobronchial Tumors: An Update on Low-Dose Rate Versus High-Dose Rate Radiation Therapy

Although the evolution from low-dose rate (LDR) to high-dose rate (HDR) brachytherapy for malignant endobronchial tumors was presumably based on economy, patient convenience, and radiation protection, our experience with both modalities permits assessment of the pros and cons of each technique. In November 1991, our HDR remote afterloading brachytherapy unit became operational. By that time, we had treated 110 patients (group 1) with malignant endobronchial obstruction with LDR brachytherapy. Since then, all patients have been treated with HDR brachytherapy. The outcome of our first 110 patients (group 2) treated with HDR brachytherapy is presented in this communication, using group 1 as the historic control group. In group 1, patients were treated with 1 or 2 sessions of 30-60 Gy, each calculated at a 1-cm radius. In group 2, patients received 3 or 4 weekly treatments of 7 Gy, each calculated at a 1-cm radius. The majority of patients in each group had previously received a full course of external beam irradiation, and a history of laser bronchoscopy was also similar for the 2 groups. Differences in bronchoscopic response rate (82% vs. 96%, respectively) and complications (3.6% vs. 2.7%, respectively) were statistically insignificant between the LDR group and the HDR group. We believe HDR brachytherapy is the state-of-the-art modality in intraluminal therapy for endobronchial malignancies.

Role of bronchoscopy in modern medical intensive care unit

This article gives a broad overview of the increasingly important applications of bronchoscopy, flexible (FOB) and rigid (RB), in a modern medical intensive care unit. Special emphasis is made to bronchoscopy use in mechanically ventilated patients. Therapies such as endobronchial stenting and Nd:YAG laser are being used to improve respiratory failure and facilitate weaning from mechanical ventilation. Practical applications of recent advancements in technology (endobronchial stenting, laser therapy, and so forth), the increasing use of rigid bronchoscopy, and the new generation of flexible bronchoscopes like battery bronchoscopes, and ultra-thin bronchoscopes, are also discussed. The risks, potential benefits, complications, and suggested technique of performing bronchoscopy in mechanically ventilated patients are reviewed.

Endoscopic treatment of malignant airway obstructions in 2,008 patients

We report our 13-year experience with endoscopic treatment of malignant obstructions of the airway by Nd:YAG laser, stents, and intraluminal brachytherapy in 2,008 patients. We performed 2,610 laser resections in 1,838 patients, 66 high dose rate brachytherapies, and we placed 393 tracheobronchial silicone stents in 306 patients. We used the rigid bronchoscope in 96% of the laser procedures and in all cases requiring stent placement; general anesthesia was given to 90% of these patients. Endobronchial radiotherapy was performed under local, anesthesia. In 93% of patients undergoing laser resection, we obtained an immediate patency of the airway with consequent improvement of quality of life. The median time between the first and second laser treatment was 102 days, being longer in the case of stent placement (when required) or in association with brachytherapy. Even if endoscopic treatment should be considered only for palliation, laser vaporization could be curative in case of in situ carcinoma. Since 1983, we have treated 23 such lesions in 17 patients and up to now, none has recurred. Finally, endoscopic resection may allow a better assessment of the true extent of the tumor, shifting to surgery patients originally considered to have inoperable disease or allowing lung-sparing operations (21 and 18 patients of our series, respectively). The total mortality rate was 0.4% (12 patients over 2,798 treatments; 2,710 Nd:YAG laser + 151 stents without laser + 37 brachytherapies without laser) in the first week after the procedures, and was mainly related to cardiovascular problems and respiratory failure. In conclusion, endoscopic resection of lung malignancies is rapid, effective, repeatable, and complementary to other treatments; although it should be considered only palliative, laser resection could be curative in patients with in situ carcinomas and early cancers. Laser, stents, and endoluminal brachytherapy should be available in all centers with major experience; a well-trained team is mandatory to plan the most appropriate treatment and manage any possible complication.

Low dose rate versus high dose rate intraluminal brachytherapy for malignant endobronchial tumors

Although the evolution from low dose rate to high dose rate brachytherapy for malignant endobronchial malignancies was primarily based on economy, patient convenience, and radiation protection, the difference in therapeutic index, if any, between these two modalities must be kept in mind. Our experience with both methods permits assessment of the feasibility of replacing low dose rate brachytherapy with high dose rate brachytherapy. Results with our first 110 patients (group 1) treated with low dose rate brachytherapy (133 procedures) were compared with results with our initial 59 consecutive patients (group 2) treated with high dose rate brachytherapy (161 procedures). In group 1, patients were treated with one or two sessions of 30-60 Gy each calculated at a 1 cm radius. In patients in group 2, we aimed at three weekly sessions of 7 Gy each calculated at a 1 cm radius. External beam irradiation therapy had previously been given to 88% of patients in group 1 and to 85% of patients in group 2. Laser bronchoscopy was performed in 36% of patients in group 1 and in 24% of patients in group 2 before brachytherapy. Clinical or bronchoscopic improvement was noted in 72% of patients in group 1 and in 85% of patients in group 2 (p > 0.05). Complication rates were low and comparable. Survival was similar in both groups (median < 6 months). Although both low dose rate and high dose rate brachytherapy appear equally effective in palliation for malignant endobronchial obstruction, we are now practicing the latter exclusively.

Management of anastomotic complications after sleeve lobectomy for lung cancer

One hundred twelve patients (102 male and 10 female) underwent sleeve lobectomy for lung cancer from January 1969 to December 1991. Bronchopleural fistula occurred in 6 (5.6%), bronchovascular fistula in 2 (1.8%), pulmonary arterial occlusion in 2 (1.9%), anastomotic stricture or stenosis in 7 (6.3%), and local recurrence in 7 patients (6.3%). Early repair of bronchopleural fistula combined with an omentopexy achieved permanent closure of the fistula. Two patients who underwent a completion pneumonectomy for a pulmonary arterial occlusion died of respiratory failure. Two patients experienced uncontrollable bleeding into the bronchial tree through a bronchovascular fistula and sudden death. Completion pneumonectomy is indicated for a stricture due to scar formation. If pneumonectomy is precluded by poor pulmonary reserve, endoscopic excision using biopsy forceps is an alternative. Endoscopic resection is the treatment of choice for suture granulomas. Complications associated with bronchial or vascular anastomoses are serious and frequently fatal.

Endobronchial radiation therapy with or without neodymium yttrium aluminum garnet laser resection for managing malignant airway obstruction

BACKGROUND

Previous reports have shown low-dose-rate (LDR) afterloading Ir-192 endobronchial radiation therapy (EnBRT) to effectively palliate symptoms in patients with malignant airway obstruction. The authors retrospectively assessed the consequences of LDR EnBRT with or without neodymium yttrium aluminum garnet (Nd:YAG) laser resection in 37 patients.

METHODS

Between February 1986 and June 1991, 37 patients with malignant airway obstruction were treated with LDR EnBRT at The Cleveland Clinic Foundation. Inclusion criteria for LDR EnBRT with or without Nd:YAG laser resection were patients with recurrent, symptomatic endobronchial lesions treated previously with external beam irradiation. Of the 37 patients, 21 patients with endobronchial lesions underwent Nd:YAG laser resection; 16 patients with mainly extrinsic lesions received EnBRT only. Before EnBRT, selected patients (7 of 16 in the nonlaser-treatment group and 14 of 21 in the laser-treatment group) received additional external beam treatments of 2000 cGy/10 fractions. The LDR afterloading Ir-192 technique was used to deliver approximately 30 Gy to a 1.0-cm radius target.

RESULTS

All patients had one or more of the following symptoms: 1) dyspnea, 2) fever, 3) cough, and 4) hemoptysis. Good-to-excellent symptom relief was apparent in 16 of 21 (76.2%) laser-treated patients and in 12 of 16 (75%) nonlaser-treated patients. Follow-up bronchoscopy in 28 patients revealed tumor regression in 22 (79%). Median survival time was 16.3 weeks in the laser group and 11.7 weeks in the nonlaser group (P = 0.36). Longer median survival times were noted in laser-treated (22.8 weeks) and nonlaser-treated (16.4 weeks) patients receiving additional external beam treatments. Exsanguination occurred in 7 of 21 (33.3%) laser-treated patients and in 4 of 16 (25%) nonlaser-treated patients. The only factor affecting the exsanguination rate was implant location: 6 of 11 (54.5%) patients had lesions in the right or left upper lobe.

CONCLUSIONS

EnBRT alone or with Nd:YAG laser resection provided good-to-excellent symptom palliation in these patients although a high rate of exsanguination occurred in both groups.

Critical Care of Intrathoracic Complications of Lung Cancer

Lung cancer is the most common underlying malignancy in cancer patients admitted to intensive care units. Because of the proximity to vital organs in the mediastinum, lung cancer frequently causes complications requiring critical care, including cardiac tamponade, central airway obstruction, massive hemopytsis, and superior vena cava syndrome. In addition, radiation and chemotherapeutic agents used to treat lung cancer may cause life-threatening pneumonitis in a minority of patients. There are several management options available for each complication. Educated decisions must be made based on individual patient circumstances. Technological advances have allowed for successful treatment of the majority of patients with such complications. For example, photoresection with the NdYAG laser can relieve dyspnea in 18% of patients with airway obstruction; hemorrhage can be controlled 80% of the time with bronchial artery embolization; and symptoms of superior vena cava syndrome may be relieved in more than 90% of patients. Although the median survival of cancer patients admitted to the intensive care unit is relatively short, such interventions can effectively palliate symptoms and may prolong survival.

High dose rate afterloading intraluminal brachytherapy in malignant airway obstruction of lung cancer

PURPOSE

This is a retrospective study to review the palliation rate, survival rate and complications of high dose rate (HDR) intraluminal brachytherapy in the treatment of malignant airway obstruction of lung cancer.

METHODS AND MATERIALS

A total of 225 high dose rate (HDR) brachytherapy treatments were delivered to 76 patients with symptomatic malignant airway obstruction by remote afterloading technique. An average of 7 Gy at a radius of 1 cm from the center of the source was delivered by Iridium-192 (Ir-192) sources. The majority of the patients received 3 fractions at 2 week intervals. Fifty-four patients received HDR brachytherapy as part of their initial treatment; 20 patients presented as symptomatic endobronchial recurrence. Two patients received YAG laser photoresection to open up the obstruction to allow insertion of the brachytherapy catheter. Fifty-nine patients received concurrent external beam irradiation. Forty-two patients were given 60-70 Gy in 6-7 weeks with curative intent. Seventeen patients were given 20-59 Gy in 2-5 weeks as a palliative measure. Nine patients received a radiosensitizer. One patient received concurrent chemotherapy.

RESULTS

The symptomatic response rates are as follows: dyspnea had an 87% response rate (59% partial response, 28% complete response), cough had a 79% response rate (47% partial response, 32% complete response), hemoptysis had a 95% response rate (38% partial response, 57% complete response), and postobstructive pneumonia had an 88% response rate (53% partial response, 35% complete response). Sixty-six patients had follow up endoscopic examination (1-3 months after brachytherapy). Their total response rate was 87% (52% partial response and 35% complete response). There were four acute complications: three cases of massive hemoptysis and one of mild hemoptysis. There are five late complications: three cases of radiation pneumonitis and two of esophagitis. At the time of this study, 55 patients have died with the maximum survival duration 113 months (9.4 years) from diagnosis date and 18 months from first HDR treatment. Twenty-one patients are still alive with a mean follow-up duration of 20 months from diagnosis date and 7.8 months from the first HDR treatment.

CONCLUSION

HDR brachytherapy is an excellent modality for palliating symptomatic malignant airway obstruction with an acceptable complication rate; however, no definitive increase of survival rate was observed. Prospective clinical trials are needed to better define its merit regarding survival. This paper also includes a literature review and discussion of HDR brachytherapy on bronchogenic cancer.

Bronchoscopy in the intensive care unit

The development of the flexible, fiberoptic bronchoscope has made bronchoscopic examinations possible in ICU patients undergoing mechanical ventilation. Over the years, the number of such procedures has greatly increased, with both diagnostic and therapeutic objectives, such as performing difficult intubation, management of atelectasis and hemoptysis, diagnosis of nosocomial pneumonia in ventilated patients, and early detection of airway lesions in selected situations, such as high-frequency ventilation. The complication rate can be kept low if the endoscopist has a precise knowledge of the many pathophysiological and technical facets particular to bronchoscopy under these difficult conditions. This article reviews some of these aspects, in the light of our personal experience.

Intrabronchial selective coagulative treatment of hemoptysis. Report of three cases

In three patients with hemoptysis, fibrin precursors were sprayed into the bronchus selectively to the site of the bleeding. In this way, four hemoptyses, resistant to other therapy, were arrested without any adverse effect. The total loss of blood was estimated at least 9 L, and it was substituted by transfusion of more than 8 L. The new method is described and its possible modes of action are discussed. This selective intrabronchial local coagulative method may be the proper symptomatic treatment of choice if causal therapy is ineffective or not available for any reason.