Endobronchial treatment modalities in thoracic oncology

Preparation of the Patient for Palliative Procedures

The primary intent of surgical procedures traditionally has been the achievement of cure. Palliative surgery is emerging as an equally legitimate strategy of care; its goals are symptom relief and enhanced quality of life based on the patient's preferences. The key to successful palliative surgery is understanding patient and family dynamics, interdisciplinary team approaches, and producing a consistent and rational treatment plan. Far from condemning a patient, palliative surgery has a potential place in many treatment plans for enhanced quality of life and longevity.

The role of parallel stent insertion in patients with esophagorespiratory fistulas

BACKGROUND

Patients with malignant esophagorespiratory fistulas have a poor prognosis. Treatment is palliative and involves restoration of the ability to ingest food and prevention of aspiration by insertion of esophageal or tracheobronchial stents. Because insertion of a single stent may be insufficient for palliation, a series of patients who underwent parallel stent insertion were studied.

METHODS

Thirteen patients with esophagorespiratory fistulas who required parallel stents were studied retrospectively. Palliation was evaluated by assessing dyspnea, dysphagia, and coughing associated with eating and/or drinking before and after insertion of stents.

OBSERVATIONS

Insertion of the first stent (n = 13) resulted in complete relief of symptoms attributed to an esophagorespiratory fistula in 46% and in a reduction in symptoms in 54% of patients. The interval between insertion of the first and second stents ranged from 1 to 182 days (mean 46 days). Insertion of the second stent (n = 12) resulted in complete relief of symptoms in 42% and a reduction in symptoms in 58% of the patients.

CONCLUSION

Parallel stent insertion may be indicated in patients with symptoms caused by malignant esophagorespiratory fistula.

Cryotherapy in early superficial bronchogenic carcinoma

BACKGROUND

Treatment of early superficial bronchogenic carcinoma (ESBC) is under debate, and no consensus has been achieved. Different therapeutic methods have been proposed, including surgical resection and endoscopic methods.

STUDY OBJECTIVE

To assess the efficacy of cryotherapy in patients with ESBC.

PATIENTS AND METHODS

Patients included in the study had histologically proven ESBC after fiberoptic bronchoscopy. Cryotherapy was performed through a rigid bronchoscope. Efficacy was assessed by endoscopy with multiple biopsies 1 month after treatment and during the follow-up period. Parameters studied were response to treatment, adverse effects, and survival.

RESULTS

We included 35 patients (34 men and 1 woman). The mean age was 61 +/- 9 years. Multiple locations of ESBC were observed in seven patients (20%). Complete response rate at both 1 month and 1 year was 91% (32 patients). No severe adverse effects were noted. Local recurrence was observed within 4 years in 10 patients (28%). A follow-up period of at least 4 years was available in 22 patients; of them, 11 patients (50%) were long-term survivors.

CONCLUSION

Our results suggest that cryotherapy is an effective method of treatment in patients with ESBC. Due to its relative tolerance compared to surgery, cryotherapy could be proposed as a first-line therapy in this population with high carcinogenic risk.

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.

Curative irradiation of limited endobronchial carcinomas with high-dose rate brachytherapy. Results of a pilot study

OBJECTIVES OF THE STUDY

Pilot study to assess high-dose rate (HDR) brachytherapy as sole treatment for limited endobronchial non-small cell lung carcinomas.

INCLUSION CRITERIA

Proximal non-small cell lung cancer in a not previously irradiated area, with a maximal diameter of 1 cm, no visible tumor on CT scan, lack of other treatment options in patients with severe, chronic respiratory failure, surgery, or external radiotherapy for a previous lung cancer.

TREATMENT PROTOCOL

Treatment was based on an escalating dose protocol. Patients received three to five fractions of 7 Gy prescribed at 10 mm from the center of the applicator, once a week.

RESULTS

Nineteen patients were included in this trial. The first two patients received three fractions of 7 Gy, the four next patients received four fractions, and the 13 remaining patients were treated with five fractions of 7 Gy. Two months after the end of the procedure, tumors in 15 of 18 evaluable patients (83%) were locally controlled with negative results of biopsies. At 1 year, local control was still obtained in 12 of 16 evaluable patients (75%). With a mean follow-up of 28-months, 1-year and 2-year actuarial survival rates were 78% and 58%, respectively, with a 28-month median survival. One patient with local control died from hemoptysis 12 months after treatment. Two patients suffered from severe necrosis of the bronchial wall; one of them died from hemoptysis.

CONCLUSIONS

HDR brachytherapy is an effective treatment for small endobronchial tumors. Late toxicity on the bronchial wall is still too high and was attributed mainly to contact between the catheter and the bronchial mucosa. Exclusive HDR brachytherapy should be restricted to carefully selected patients for whom there is no alternative curative treatment. New bronchial applicators and a lower dose per fraction may reduce the incidence and attenuate the severity of late complications.