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Ann Thorac Surg 1998;65:203-207
© 1998 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Resection With Curative Intent After Endoscopic Treatment of Airway Obstruction

Department of Surgery and General Thoracic Surgery, University of Perugia Medical School-Perugia, Terni, Italy

Accepted for publication July 16, 1997.

Dr Daddi, Clinica Chirurgica Generale e Toracica, Ospedale Civile, 05100 Terni, Italy.

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
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.

	Introduction

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Obstructing neoplasms of the central airways may be submitted to preliminary endoscopic treatment, sometimes as an emergency [1]. After adequate patency has been restored, several therapeutic options are available depending on the patient’s condition and the type, location, and extent of the lesion.

Endoscopic relief of obstruction may result in a definitive cure for rare, truly benign endobronchial tumors (eg, hamartomas), but it must be considered a palliative measure for primary or secondary malignant growths. This opinion, however, is not shared universally, and the exact role of surgery remains controversial. Most available data come from medical centers, and greater emphasis is placed on palliation of obstruction and even endoscopic cure of low-grade malignant bronchial tumors by the neodymium: yttrium-aluminum-garnet (Nd-YAG) laser [2][3]. Few reports from thoracic surgeons deal with the importance of combined endoscopic and surgical treatment, either in particular circumstances [4] or to stress the value of certain techniques (mechanical removal versus laser treatment) [5].

We analyzed our experience in the endoscopic and surgical management of tracheobronchial pulmonary malignant growths to evaluate the indications for and results of combined treatment.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment References

 
The charts of 24 patients who underwent resection after endoscopic treatment were reviewed. From March 1987 through June 1996, we performed 449 operative rigid bronchoscopies for tracheobronchial obstructions in 304 patients. Four patients with benign endoluminal tumors (two hamartomas, one hemangioma, and one fibroepithelial polyp) were cured with endoscopic laser treatment. Malignant airway obstruction was the indication for endoscopic treatment in 251 patients, with a resection rate of 9.5%.

There were 18 men and 6 women; the median age of the men was 63 years (range, 33 to 74 years) and the median age of the women was 55 years (range, 22 to 82 years). All treated patients were symptomatic.

A routine chest roentgenogram always was performed before endoscopic treatment. Fiberoptic findings, such as intraluminal tumors or mixed polypoid and infiltrative centrally located lesions (involving the trachea, carina, or main bronchi), were indications for rigid bronchoscopy.

All endoscopic laser procedures were performed with a ventilating rigid bronchoscope (Karl Storz GmbH & Co, Tuttlingen, Germany) under general anesthesia with the patient in spontaneous ventilation. The anesthetic management was based on premedication with neuroleptanalgesia and atropine, followed by induction with propofol and tracheal instillation of 2% lidocaine. Spontaneous ventilation was maintained throughout the procedure with inhalation of an O₂/N₂O mixture, with care taken to maintain the oxygen concentration within a 40% limit to avoid ignition by the laser beam and the possibility of explosions and burns. During the procedure, oxygen saturation (pulse oximetry) and cardiovascular parameters (electrocardiogram, arterial blood pressure) were monitored continuously.

The first step in the endoscopic technique consisted of establishing the airway axis to avoid damage to the wall and the adjacent mucosa; Jackson bougies were very useful for this purpose. An Nd:YAG laser (Sharplaser; Laser Industries Ltd, Israel) then was aimed precisely at the surface of the tumor, with care taken to maintain the beam parallel to the axis of the airway. Finally, tumor debris was removed with biopsy forceps and residual intraluminal tumor was coagulated and vaporized (if necessary). An alternative method used for necrotic lesions consisted of immediately establishing a satisfactory airway by "coring out" the tumor, followed by laser coagulation. Once patency had been restored, secretions accumulated beyond the tumor were cleared thoroughly and collected for bacteriologic examination. Sometimes, a flexible bronchoscope inserted through the rigid bronchoscope was used to explore and clear the airways at the segmental and subsegmental levels. The total amount of laser energy delivered always was kept as low as possible (median energy used, 1,650 J; range, 300 to 3,800 J).

Squamous cell carcinoma was the most common type of growth encountered in our series (14 patients); in 1 patient, foci of small cell lung cancer were discovered in association with squamous cell carcinoma. Other histologic findings were typical carcinoid (3 patients, 1 at the carinal level), adenoid cystic carcinoma involving the trachea or the larynx and trachea (3 patients), high-grade mucoepidermoid carcinoma involving the carina or the thoracic trachea (2 patients), and papillary thyroid cancer infiltrating the trachea (2 patients). The correct diagnosis was obtained in 3 patients only after rigid bronchoscopy was performed.

The trachea was the site of the tumor in 7 patients (the cervical trachea in 3 patients, the thoracic trachea in 2 patients, and the larynx and cervical trachea in 2 patients); the carina was involved in 3 patients (2 with obstruction of either the right or the left main bronchus). Obstruction of the main bronchus without carinal invasion was observed in 13 patients (9 on the left side and 4 on the right side). The origin of the intermediate bronchus was obstructed in 1 patient. Distal airway obstruction (ie, lobar and segmental) was not considered an indication for endoscopic treatment.

After endoscopic treatment, reevaluation was carried out with the ventilating rigid bronchoscope in 12 patients. Cervical mediastinoscopy was performed before resection in 9 patients with squamous cell lung cancer and a Chamberlain procedure was performed in 1 patient. The median period between endoscopic treatment of the obstruction and operation was 18 days (range, 2 to 110 days).

Several potential benefits of endoscopic treatment before subsequent resection were identified in our series in regard to preoperative preparation, staging, and surgical technique. Finally, the increase in overall operability was calculated for both functional and staging reasons.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
The indications for endoscopic treatment were severe dyspnea in 13 patients, dyspnea and infection in 9 patients, and life-threatening hemoptysis in 1 patient. Only three endoscopic treatments were considered emergent lifesaving procedures.

All patients experienced clinical improvement after endoscopic reopening of the airway, both subjectively and as documented by spirometry (when preoperatively feasible) or radiography (in 7 patients). The improvement in spirometric parameters after endoscopic treatment and pulmonary rehabilitation was calculated in 11 patients (Fig 1). The median rise in the forced expiratory volume in 1 second was 0.750 L (range, 0.2 to 1.6 L) and the median rise in the forced vital capacity was 0.6 L (range, 0.1 to 1.05 L). There were no complications after laser therapy and only minor amounts of bleeding were observed in all patients. No repeated endoscopic treatments were required.

View larger version (24K): [in this window] [in a new window]   Forced expiratory volume in 1 second before and after endoscopic treatment.

Two patients were operated on after neoadjuvant chemotherapy or radiation therapy (1 underwent pneumonectomy and 1 carinal resection and reconstruction). Postoperative chemotherapy was administered in 5 patients and postoperative radiation therapy in 3. One patient underwent operation for a large abdominal aortic aneurysm after endoscopic airway reopening; 2 months later, he underwent successfully middle and lower right bilobectomy for squamous cell carcinoma.

There were 2 postoperative deaths, 1 resulting from the adult respiratory distress syndrome in a 45-year-old woman who underwent carinal resection after chemotherapy and radiation therapy (the same patient had positive resection margins on microscopic evaluation) and 1 resulting from a pulmonary embolism in a 62-year-old man who underwent transthoracic tracheal resection. One patient had poor postoperative pulmonary function and died 3 months after a left pneumonectomy. The postoperative course was uneventful in the remaining patients.

Follow-up was possible in every patient but 1 and ranged from 2 to 61 months in duration. Results are summarized in Table 2. The advantages of preliminary reopening of the central airways were better preoperative preparation in 82.6% of patients, more accurate preoperative staging in 100% of patients, and improvement of surgical technique in 73.9% of patients (Table 3). Eight patients were considered to be inoperable before endoscopic treatment because of functional impairment (7 patients) or advanced disease (1 patient).

	Comment

Top Abstract Introduction Material and Methods Results Comment References

Several techniques can be used to restore airway patency depending on the type and location of the lesion, the instruments available (eg, flexible or rigid bronchoscope, Nd:YAG laser, diathermy, cryotherapy), and the training and experience of the operating physicians. The use of a rigid bronchoscope under general anesthesia allows for a quick and safe procedure with a very low complication rate. The Nd:YAG laser is an excellent in-depth coagulator and its beam can be transmitted safely through fiberoptic light guides. Key to its successful application are precision and limited energy delivery, both of which can be achieved better through a rigid bronchoscope. A high energy output, rather than proving useful, might worsen the obstruction by producing fibrin plugs [6] and jeopardize a successful resection by damaging the healthy tracheobronchial wall adjoining the tumor [4]. For this reason, we kept the total laser energy output as low as possible, delivering the laser beam precisely through the rigid bronchoscope. Using such precautions, we did not observe any anastomotic complications in our series.

In our experience, stent placement after endoscopic treatment should be reserved for inoperable patients when a satisfactory airway cannot be achieved (because of compression and infiltration) or early recurrence is likely (because of a rapid tumor growth rate) [7][8]. Stent placement should be avoided in patients with potentially resectable disease because of the risk of infection and damage to the healthy mucosa. However, in patients with postintubation stenosis, resection generally is carried out several months after endoscopic relief of the obstruction, to allow time for the resolution of active inflammatory changes and weaning from steroid therapy. In such circumstances, an airway stent placed in the preoperative period might ensure safety by obviating repeated endoscopic treatments [8][9].

The number of patients who are candidates for resection after endoscopic treatment is very low in our experience compared with that of others [5] because most patients arrive at our referral center for laser endoscopy with advanced disease and a history of failed treatments (ie, chemotherapy, radiation therapy, operation). Some of these patients, however, can undergo successful resection because they erroneously were deemed inoperable as a result of either unreliable computed tomographic staging or lack of awareness of the surgical options (ie, thyroid carcinoma invading the trachea). Finally, several of our patients who were referred for operation underwent preliminary endoscopic removal of the tumor for one or more of the following reasons: to treat an acute and potentially life-threatening situation (ie, acute respiratory failure, hemorrhage, postobstructive pneumonia); to assess the origin and extent of the disease; to allow for a more accurate staging procedure; to treat an infection; or to improve functional conditions.

Endoscopic relief of malignant tracheobronchial obstructions is a time-honored procedure well known to thoracic surgeons, particularly those involved in airway operations [4][5]. It has gained a widespread and perhaps sometimes dangerous level of popularity since the introduction of the Nd:YAG laser by Toty and colleagues in the late 1970s [10]. The number of patients treated has increased dramatically, but in most published reports by medical endoscopists, the role of this procedure in managing resectable tumors scarcely is mentioned [4][5][11][12]. It is important to remember that airway restoration is only one step in the management of patients with respiratory tumors and by no means a curative procedure, except in the case of purely endobronchial benign tumors (mesenchymal or epithelial).

In our experience, the removal of endobronchial carcinoids that are obstructing the airway partially or totally is useful to improve respiratory function and assess the exact location of the tumor. Even though destruction of the tumor may appear to be complete, as in 1 of our patients, neoplastic cells originate from the submucosa and their complete extirpation by nonsurgical means is questionable. Moreover, the time to local recurrence might be very long and follow-up should be continued for several years.

Most of our patients had squamous cell carcinoma. These tumors, especially if well differentiated, may have a slow growth rate and, in a few cases, the tendency to grow predominantly inside the bronchial lumen with polypoid projections that can reach the main bronchi. Chest roentgenography and computed tomography might produce the incorrect impression of advanced disease corroborated by endoscopic findings. The site of origin often is distal (eg, lower or upper lobe bronchi). The removal of endobronchial growths relieves any acute symptoms that are present and allows time to plan and prepare for elective operation. It also enables a better assessment of tumor location and diffusion (more reliable computed tomographic scan).

Some patients who were referred to us had undergone a careful radiologic assessment of their disease (tracheal or carinal tomography, computed tomography, or, rarely, magnetic resonance imaging of the thorax). We do not consider these examinations essential to endoscopic relief of the obstructed airway. In particular, a computed tomographic scan might be more precise and meaningful after reopening of the airway and consequent aeration of the atelectatic lung; tumor and node assessment might be more reliable this way.

Downstaging of the disease can be achieved with endoscopic treatment (aeration of atelectatic lung; bronchial tumor infiltration more distal than preoperatively deemed). In such circumstances, lung-sparing procedures (sleeve lobectomies) are possible and patients who were denied operation on a functional basis can be operated on successfully.

Recovery of functioning pulmonary tissue markedly improves the performance status. In some cases, our patients could tolerate induction therapy and underwent successful resection. Pulmonary rehabilitation, accompanied by bronchodilator therapy and antibiotics when infection is present, can reduce dramatically the incidence of postoperative respiratory failure and septic complications.

Finally, in this group of patients, mediastinoscopy constitutes an essential step in the staging procedure because it allows the differentiation of metastatic from inflammatory lymph nodes; the latter are common in patients with atelectasis and postobstructive pneumonia. Moreover, accurate preoperative mapping of mediastinal lymph nodes avoids the ischemia that results from extensive mediastinal dissection and adversely affects the healing of tracheal or tracheobronchial anastomoses.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

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3. Sutedja G, Scharamel F, Postmus PE Bronchoscopic treatment of intraluminal typical carcinoid. Eur Respir J 1995;8:308s.
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