Ann Thorac Surg 2002;74:995-998
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Nd:YAG laser resection of lung cancer invading the airway as a bridge to surgery and palliative treatment
Federico Venuta, MD*a,
Erino A. Rendina, MDa,
Tiziano De Giacomo, MDa,
Edoardo Mercadante, MDa,
Federico Francioni, MDa,
Francesco Pugliese, MDa,
Marco Moretti, MDa,
Giorgio F. Coloni, MDa
a Department of Thoracic Surgery, University of Rome "La Sapienza," Rome, Italy
* Address reprint requests to Dr Venuta, Cattedra di Chirurgia Toracica, Policlinico Umberto I, University of Rome "La Sapienza," V.le del Policlinico, Rome 00100, Italy
e-mail: sofed{at}libero.it
Presented at the Poster Session of the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Abstract
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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.
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Introduction
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Lung cancer may directly involve the airway at different levels with a number of therapeutic and prognostic implications. The onset of respiratory failure usually requires immediate bronchoscopic management to restore adequate ventilation and provide a correct diagnosis. This approach is often the only one feasible for unresectable tumors with anatomic limitations, metastatic disease, and poor clinical status of the patient, even if long-term results are dismal [1]. Primary surgery may sometimes be considered for tumors originating from the lobar bronchi and involving the adjacent main stem bronchus [2], as well as in selected cases with carinal involvement [3]. Endoscopic palliation could be the first step of a multimodality approach, including surgery [4–6] associated or not to induction chemotherapy [7]. In this setting, preliminary endoscopic resection may contribute to improve evaluation of tumor extensions and staging, functional measurements, and quality of life; the most appropriate lung resection can be planned and also the postoperative course is improved by relieving airway obstruction in the remaining lobe (when lobectomy is to be performed). Preliminary laser vaporization could also help to prevent infectious complications when chemotherapy is to be administered.
We reviewed our experience with Nd:YAG laser resection of lung cancer invading the airway as a palliative treatment alone or as a bridge to surgery with and without induction chemotherapy.
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Patients and methods
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Since 1993, 351 Nd:YAG laser resections were performed in 273 patients (181 males and 92 females; mean age 57 ± 14 years old) with lung cancer. In 257 patients the primary tumor directly involved the airway, whereas in 16 patients airway obstruction was related to endoluminal metastatic disease. The site of invasion and the number of treatments are reported in Table 1.
Histology was epidermoid carcinoma in 111 patients (41%), adenocarcinoma in 120 patients (44%), large cell carcinoma in 12 patients (4%), and small cell carcinoma in 30 patients (11%). Twelve procedures were performed in emergency. All the procedures were performed with the rigid bronchoscope (Efer-Dumon rigid bronchoscope; Efer Medical, La Ciotat, Cedex, France) under deep sedation with short-acting narcotics and local anesthesia (2% xylocaine). In 237 patients only a palliative resection was performed because there were anatomic, oncologic, and functional limitations precluding surgery; 108 silicon stents (Endoxane-Novatech; Aubagne, France) were placed in 104 patients of this group. After the endoscopic resection 36 patients were operated on (23 after induction chemotherapy); in this group of patients, the reason for endoscopic resection was related to the presence of an endobronchial lesion obstructing more than 80% of the central airway and preventing adequate ventilation, clearance of secretions, and correct evaluation of the site of origin and real extension of the tumor. Ten patients had complete atelectasis and 9 patients had lobar atelectasis; preliminary endoscopic palliation was performed to improve ventilation and define correctly the borders of airway invasion: normal airway beyond the tumor was usually histologically confirmed. In the group of patients subsequently undergoing induction chemotherapy mediastinoscopy was always performed to stage the mediastinal lymph nodes. Also 7 of 13 patients undergoing surgery without induction chemotherapy underwent mediastinoscopy. Before induction chemotherapy 4 patients (17%) had T2N2 lung cancer, 2 patients (9%) T4N0, 9 patients (39%) T3N2, 3 patients (13%) T4N1, and 5 patients (22%) T4N2. In patients undergoing induction chemotherapy a cisplatinum based regimen was administered. When multimodality treatment was planned, spirometry, arterial blood gas analysis and Karnofsky performance status were recorded before and after laser treatment and after induction chemotherapy, when performed. Also quality of life was measured at the three different steps using the EORTC QLQ-C30 Questionnaire [8]; this is a 30-item questionnaire composed of multi-item scales and single items that reflect the multidimensionality of the quality of life construct [9, 10]. When surgery was to be performed after preliminary endoscopic resection, it was not considered before at least 1 week, when adequate clearance of secretions and ventilation distal to the previous obstruction was obtained. Complications during chemotherapy, surgical morbidity, and mortality were recorded as well as survival for patients undergoing endoscopic palliation only and palliation followed by surgery with and without induction chemotherapy.
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Results
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Major complications during laser resection were bleeding (7 patients) and hypoxia (5 patients). Bleeding was recorded as a complications when exceeded 200 mL; it was managed with adequate suctioning (usually two suction catheters are placed when this complication occurs), extensive coagulation with low power laser (we either retract the fiber or reduce the power to less than 30 W), instillation of epinephrine and compression by the tip of the rigid bronchoscope or small swabs. Hypoxia was recorded as a complication when a prolonged desaturation below 85% was observed; all patients showing this complication had huge tumors originating at the level of the carina with a 100% obstruction on one side and an almost complete obstruction on the contralateral side. In these cases laser vaporization was interrupted and mechanical resection was quickly performed on one side with the tip of the rigid bronchoscope to gain a viable airway and ventilate the patient. Three patients (0.8%) died within 24 hours after the endoscopic procedure. No complications occurred in the group of patients subsequently undergoing induction chemotherapy or surgery. Complications related to stent placement were dislocation (2% to 1.8%), plugging with secretions (2% to 1.8%) and obstruction by cancer requiring replacement (2% to 1.8%). In the group of patients undergoing only endoscopic palliation PaO2 improved from 59 ± 8 mm Hg (21 patients with supplemental O2) to 78 ± 6 mm Hg (6 patients with supplemental O2) (p < 0.001). One patient developed pneumonia during induction chemotherapy. In the group of patients undergoing surgery with or without induction chemotherapy FEV1 significantly improved after laser treatment (from 1.4 ± 0.5 L/s to 2.2 ± 0.6 L/s; p < 0.001); PaO2 improved from 68 ± 7 mm Hg pre laser to 83 ± 4 mm Hg post laser. Two patients requiring supplemental oxygen before laser resection were completely weaned after the endoscopic procedure. In 5 of 10 patients with complete atelectasis the lung was completely ventilated after endoscopic resection, whereas in 5 patients lobar atelectasis persisted. Also the Karnofsky performance status (from 77 ± 5 pre laser to 91 ± 4 post laser; p < 0.001) and the global QLQ-C30 score (from 44 ± 4 pre laser to 32 ± 3 post laser; p < 0.001) significantly improved after laser treatment and remained stable after induction chemotherapy. Preliminary endoscopic resection contributed to palliate hemoptysis, dyspnea, cough and infection in all patients presenting with these symptoms.
In the group of 36 patients undergoing surgery after laser treatment we performed 8 pneumonectomies (6 after induction chemotherapy with 1 tracheal sleeve) and 28 lobectomies (15 bronchial sleeves of which 6 after induction chemotherapy). At surgery, in the group of 23 patients operated on after induction chemotherapy, 1 (4%) was staged T0N0 (T4N1 preinduction chemotherapy), 10 (44%) were T2N1, 5 (22%) T3N1, 2 (9%) T1N2, 4 (17%) T3N2, and 1 (4%) T4N0. In the group of 13 patients undergoing immediate surgery after laser resection, 2 were T2N0 (15.5%), 5 (38%) were T2N1, 2 (15,5%) T3N0, 2 (15.5%) T3N1, and 2 (15.5%) T2N2.
One patient died after right tracheal sleeve pneumonectomy performed after induction chemotherapy: the postoperative course was complicated by a complete dehiscence of the tracheal anastomosis, sepsis, and multiple organ failure. Five patients experienced minor postoperative complications after induction chemotherapy and surgery (arrhythmia in 2; wound infection in 1; prolonged air leaks in 2). No postoperative complications were observed in patients undergoing immediate surgery after laser stabilization of the airway.
The 3-year survival after induction chemotherapy and surgery and surgery alone was 52% and 59%, respectively. The quality of improvement of the airway caliber in patients undergoing only palliative endoscopic treatment is reported in Figure 1;
in this group of patients median survival was 12.1 months.
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Fig 1. Quality of airway caliber improvement after endoscopic palliation only. (BI = bronchus intermedius; MB = main bronchi; PB = peripheral bronci; TR = trachea.)
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Comment
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Direct infiltration or extrinsic compression of the central airway due to stage III A/B and stage IV lung cancer requires accurate clinical, technical and oncologic judgment. A significant reduction of airway caliber generally causes respiratory symptoms like dyspnoea, hemoptysis and recurrent infections; for this reason the first step should be restoration of a viable airway to treat symptoms and improve functional measurements; the appropriate treatment can be subsequently planned after thorough evaluation. A number of variables contribute to dictate the correct approach: site and extension of airway involvement, stage of the tumor, functional measurements and clinical status of the patient. The presence of M1 disease certainly contraindicates surgery. Other settings, and in particular the choice of the most appropriate surgical procedure should be carefully considered by thoracic surgeons with extended experience in airway surgery to offer the most appropriate treatment with the lowest morbidity. Experience with interventional bronchoscopy is an important part of any thoracic surgical program performing airway surgery and lung transplantation, providing the ability to manage difficult and acute situations and balanced judgment of airway resection versus therapeutic bronchoscopy [11]. Extensive tracheal invasion would preclude surgery; however, limited tracheal involvement at the level of the carina may still allow curative surgical resection by extended surgical techniques; carinal and bronchial sleeve resections should always be considered along with standard lobectomy and pneumonectomy when assessing resectability. Also induction chemotherapy can contribute to improve resectability and results for stage III A/B lung cancer [12–14] and can be performed safely after endoscopic resection [7].
Nd:YAG laser vaporization enables immediate restoration of a viable airway with satisfactory medium-term palliation [1], probably due to the cytocide effect deep within the tumor. Endoluminal brachitherapy may be added to prolong patency [15] and also photodynamic therapy (PTD) has been used in some centers [16, 17]. Endoscopic palliation often requires repeated interventions (1.3 treatments per patient in our series). Stenting certainly contributes to prolong airway patency, even if complications related to migration and secretion plugging has been described [18]; for this reason stents should be placed only when further surgical treatment has been excluded.
Only a few reports stress the feasibility and the effective role of a combined approach [4, 5, 6, 17, 19]; in this setting, endoscopic resection certainly allows to improve ventilation of the atelectatic lung; we prefer not to perform Nd:YAG laser resection and sleeve lobectomy simultaneously for a number of reasons: first, atelectasis of the lobe to be reimplanted is often present; 1 or 2 weeks of vigorous physiotherapy associated to the administration of steroids and antibiotics allows optimal parenchimal reexpansion and reduces inflammation of the airway; adequate treatment of postobstructive pneumonia could be guided by cultures on the bronchoalveolar lavage. This is important also for patients undergoing simple lobectomy (Fig 2).
Secondly, bronchoscopy can be repeated with a viable airway and multiple biopsies can be taken. Also, if induction therapy is indicated, it can be administered more safely after resolution of atelectasis. Tumor down staging may be obtained in different ways: reduction of atelectasis (complete atelectasis gives different T values from lobar atelectasis or no atelectasis) and definition of the true extension of airway involvement (for tumors bulging towards the carina this can be established only after laser resection); ventilation of an otherwise atelectatic lung may allow better definition of the potential mediastinal involvement. Computed tomography should be repeated after laser treatment for a reliable assessment of the extension of the primary tumor and ilo-mediastinal lymph nodes. Mediastinoscopy is mandatory to stage N2–N3 disease and also thoracoscopy may be considered to evaluate T3–T4 values.
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Fig 2. (A) Pre-laser chest roentgenogram illustrating complete atelectasis of the right lung. (B) Chest roentgenogram 1 week after laser resection of a tumor originating from the upper lobe and obstructing the main airway; it reveals ventilation of the right lower lobe and part of the upper lobe. The patient underwent a right upper lobectomy.
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A poised approach allows to palliate with the most appropriate technique tumors that are not suitable for surgery; if surgery can be considered the correct type of plmonary resection can be selected, avoiding pneumonectomy when unnecessary; in fact even complex bronchial reconstructions can be planned when the airway is correctly visualized and the borders of bronchial wall involvement are histologically confirmed.
Nd:YAG laser resection is a safe and effective means of relieving airway obstruction and palliate symptoms in patients with lung cancer invading the airway. Before induction chemotherapy or surgery preliminary endoscopic palliation helps to improve evaluation, staging, functional measurements, quality of life, and contributes to reducing morbidity during chemotherapy without increasing surgical complications.
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Abstract
Introduction
