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Ann Thorac Surg 2006;81:1839-1843
© 2006 The Society of Thoracic Surgeons

Original article: General thoracic

Therapeutic Bronchoscopy Interventions Before Surgical Resection of Lung Cancer

Prashant N. Chhajed, MD a , * , Ralf Eberhardt, MD b , Hendrik Dienemann, MD c , Andrea Azzola, MD a , Martin H. Brutsche, MD a , Michael Tamm, MD a , Felix J.F. Herth, MD b

a Pulmonary Medicine, University Hospital Basel, Switzerland
b Department of Pulmonology, Thoraxklinik, University Heidelberg, Germany
c Department of Thoracic Surgery, Thoraxklinik, University Heidelberg, Germany

Accepted for publication November 28, 2005.

* Address correspondence to Dr Chhajed, Pulmonary Medicine, University Hospital Basel, Petersgraben 4, Basel CH-4031, Switzerland (Email: pchhajed{at}uhbs.ch).


   Abstract
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BACKGROUND: Therapeutic bronchoscopy is used for endobronchial staging of lung cancer and symptomatic relief of central airway obstruction or postobstructive pneumonia. The aim of this study was to assess the utility of therapeutic bronchoscopy as a complementary tool in the combined bronchoscopic and surgical management of malignant airway lesions before curative lung surgery.

METHODS: Seventy-four consecutive patients with nonsmall cell lung carcinoma undergoing a therapeutic bronchoscopy procedure followed by surgery with a curative intent were included.

RESULTS: A single interventional bronchoscopic method was used in 27 patients (36%) and a combination of methods in 47 patients (64%). Median forced expiratory volume in 1 second (FEV1) before and after bronchoscopy were 1.7 L and 2.2 L, respectively, and forced vital capacity (FVC) was 2.5 L and 3.3 L, respectively. Sleeve upper lobectomy was performed in 22 patients (30%), sleeve upper bilobectomy in 16 patients (22%), lower bilobectomy in 2 patients (3%), pneumonectomy with sleeve resection in 2 patients (3%), and pneumonectomy in 28 patients (38%). The following surgeries were performed in 1 patient each: sleeve middle lobectomy, sleeve lower lobectomy, carina resection and complex reconstruction, and exploratory thoracotomy. Overall, parenchyma-sparing surgery (lobectomy or bilobectomy) could be performed in 57% patients after therapeutic bronchoscopy. There were no in-hospital deaths or deaths in the first 30 days after surgery.

CONCLUSIONS: Therapeutic bronchoscopy can be used as a complementary tool in the combined bronchoscopic and surgical management of malignant airway obstruction before curative lung surgery. Therapeutic bronchoscopy might permit parenchyma-sparing surgery in patients with lung cancer.


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The role of interventional bronchoscopy with laser, bronchial dilatation, or stent insertion is well established for the palliative treatment of malignant endobronchial lesions as well as for the management of benign central airway lesions [1, 2]. Indications for therapeutic endoscopic treatment are mainly palliation of advanced cancerous lesions, but increasingly also as a cure for early lung cancer [3]. Laser resection, balloon dilatation, and endoluminal stenting have been reported to optimize the timing of operation in patients with subglottic or benign tracheal stenosis [4, 5]. Therapeutic bronchoscopy has also been reported in patients with malignant disease followed by surgery with curative intention [6, 7]. In patients with malignant disease, bronchoscopic laser resection may allow improved evaluation of tumor extensions and staging, functional measurements, and planning of the appropriate lung resection procedure [7].

A recent meta-analysis of results of sleeve lobectomy and pneumonectomy has concluded that sleeve lobectomy offers better long-term survival and quality of life than does pneumonectomy and is more cost effective [8]. Recanalization of central airway obstruction using therapeutic bronchoscopic modalities allows the assessment of the extent of malignant airway involvement and the status of the airway distal to the obstruction, and thus better endobronchial staging of lung cancer. Bronchoscopic intervention before pulmonary resection also leads to improvement in lung function [6, 7]. There are limited data about using a combined bronchoscopic and surgical approach to increase the possibility of offering the patient parenchyma-sparing surgery [6, 7, 9, 10]. The aim of this study was to assess the utility of therapeutic bronchoscopy modalities as complementary tools in the combined bronchoscopic and surgical management of malignant airway lesions before curative lung surgery.


   Patients and Methods
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We retrospectively reviewed all 74 consecutive patients (male: female, 37:37) with lung cancer undergoing an interventional bronchoscopic procedure followed by surgery with a curative intent at two centers (Germany and Switzerland). Therapeutic bronchoscopy was performed to relieve significant malignant obstruction of the central airways for symptomatic relief of central airway obstruction due to dyspnea or post–obstructive pneumonia and endobronchial staging of lung cancer. All patients with non-small cell lung cancer were stage III or less and were discussed at a multidisciplinary meeting in both institutions. Approval was obtained from the Ethikkommision Beider Basel for this retrospective analysis.

Rigid bronchoscopy under general anesthesia was performed in all patients [3]. If necessary, the flexible bronchoscope was inserted through the rigid bronchoscope. Laser, argon plasma coagulation or contact electrocautery probes were used based on operator preference. These probes were passed either through the rigid bronchoscope or the working channel of the flexible bronchoscope. Mechanical coring of the tumor was performed with the rotating movement of the tip of the rigid bronchoscope [3]. Stent insertion was undertaken in selected patients with lung cancer in whom it was not possible to achieve more than 50% opening of the airway diameter and were removed at surgical resection. Surgical resection was performed 1 to 23 weeks after the therapeutic bronchoscopy procedure. Before and after therapeutic bronchoscopy spirometry data were available in 73 patients (99%). Postprocedure spirometry was performed within 1 week after the therapeutic bronchoscopy.

Statistical Methods
Data are presented as median and range. The Mann-Whitney test was used to compare the differences between two means.


   Results
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The underlying diagnoses in the 74 patients included in this study were squamous cell carcinoma in 34 patients (45%), adenocarcinoma in 14 patients (19%), non-small cell carcinoma (mixed tumor) in 21 patients (28%), large cell tumor in 4 patients (5%), and carcinoid in 1 patient. Forty-seven lesions (64%) were present in the right and 27 lesions (36%) in the left bronchial tree.

A single interventional bronchoscopic method was used in 27 patients (38%), and in the remaining 47 patients (62%), a combination of methods was used to relieve endobronchial obstruction. A single modality was used as follows: laser resection in 13 patients (17%), mechanical debridement with the rigid bronchoscope in 5 patients (7%), argon plasma coagulation in 4 (5%), contact electrocautery in 4 (5%), and cryotherapy in 1 patient (1%). Combined methods used were as follows: combined argon plasma and mechanical debridement in 42 patients (56%), combined laser and mechanical debridement in 3 patients (4%), argon plasma coagulation plus silicone stent insertion in 1 patient (1%), and laser plus nitinol stent in 1 patient (1%). Overall, 4 patients had moderate bleeding that was controlled endoscopically, and 1 patient had pneumothorax, which was treated with insertion of an intercostal drainage tube.

The median forced expiratory volume in 1 second (FEV1) before the therapeutic procedure was 1.7 L (1.0 to 3.0 L), and after the procedure it was 2.2 L (1.3 to 4.7 L; p < 0.0001). The median forced vital capacity (FVC) before the therapeutic bronchoscopy was 2.5 L (1.3 to 4.1 L), and after the procedure it was 3.3 L (1.9–6.1 L) (p < 0.0001). The median FEV1/FVC ratio before therapeutic bronchoscopy was 67%, and after the procedure it was 68% (p = 0.7; Fig 1). The changes in lung function before after endobronchial interventions in patients who subsequently underwent lobectomy, bilobectomy, or pneumonectomy are presented in Table 1.


Figure 1
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  		Fig 1. Box plot representation of (A) Forced expiratory volume in 1 second (FEV1) before and after therapeutic bronchoscopy in all patients. The 25th, 50th, and 75th percentiles and extreme values are shown. (B) Forced vital capacity (FVC) before and after therapeutic bronchoscopy in all patients. (C) Ratio of FEV1/FVC before and after therapeutic bronchoscopy in all patients.

 

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  		Table 1. Lung Function Tests Before and After Endobronchial Intervention in Patients Subsequently Undergoing Lobectomy, Bilobectomy, or Pneumonectomy
 
Pneumonectomy was performed in 28 patients (37%), sleeve upper lobectomy in 22 patients (29%) patients, upper bilobectomy in 16 patients (21%), pneumonectomy with sleeve resection in 2 patients (3%), and lower bilobectomy in 2 patients (3%). The following procedures were performed in 1 patient each: sleeve middle lobectomy, sleeve lower lobectomy, carina resection with reimplantation of right upper lobe in trachea and bronchus intermedius in left main bronchus, and exploratory thoracotomy. In 1 patient, the tumor was found to invade the atrium and aorta, hence definitive surgery was not performed (exploratory thoracotomy). Lobectomy or bilobectomy was performed in 42 patients (57%). Overall, parenchyma-sparing surgery could be performed in 45 patients (61%). Resection margins were clean in all patients. Furthermore, parenchyma-sparing surgery was performed in 30 patients (41%) with lesions in the main bronchi. The endobronchial site of lesion and the subsequent surgery are presented in Table 1. There was no in hospital mortality or mortality in the first 30 days after surgery. Four patients underwent repeated bronchoscopy postoperatively for retention of mucous secretions, 1 patient needed prolonged postoperative ventilation (4 days), 1 patient underwent reexploration (thoracotomy) due to postoperative intrathoracic bleeding, 1 patient had a prolonged chest tube drainage (6 days), and 1 patient had pulmonary embolism.


   Comment
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Surgical resection remains the most important element in potentially curative lung cancer [8]. Parenchymal-sparing operations such as sleeve lobectomy were introduced as a means of conserving lung parenchyma in patients with compromised lung function [8]. Recent studies have suggested that sleeve resection can be performed routinely in patients with anatomically centrally located tumors, even in the presence of sufficient pulmonary reserve to permit pneumonectomy [11, 12]. In patients with lung cancer without or minimal endobronchial involvement, it might be possible to make an assessment of the tumor extent at conventional bronchoscopy. However, in patients with significant malignant central airway obstruction, such as the main bronchi, it is not possible to evaluate the complete endobronchial extension of the tumor beyond the obstruction. In such cases, debulking of the central airway obstruction using interventional bronchoscopy is useful and allows to optimize endobronchial staging of lung cancer [7]. Recanalization of central airway obstruction may also be beneficial in the treatment of post–obstructive pneumonia or collapse.

In our study, lobectomy or bilobectomy was performed in 57% of patients (Table 2). Seventy-six percent of lesions were present in the main bronchi (Table 2). That would be an indication for pneumonectomy in many centers. In our study, a considerable number of patients could undergo sleeve resection. Parenchyma-sparing surgery in the form of lobectomy or bilobectomies were performed in 30 patients (41%) with lesions in the main bronchi (Table 2). The real impact of therapeutic interventions before lung resection surgery can be best confirmed by having a control group. There was no postoperative mortality or significant postoperative morbidity attributed to the interventional bronchoscopy procedure performed before the thoracotomy. The findings of our study lead us to believe that therapeutic bronchoscopy might permit lobectomies or bilobectomies and thereby has the potential to permit parenchyma-sparing surgery in patients with lung cancer.


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  		Table 2. Site of Malignant Endobronchial Obstruction and Subsequent Surgery in 74 Patients With Lung Cancer
 
Tumor debulking using the rigid bronchoscope to core through the obstruction was the first method to treat endobronchial tumors, followed by laser therapy [13]. Since then, there have been several other tumor ablative tools that have been introduced for endobronchial use, such as contact electrocautery, argon plasma coagulation, and cryotherapy [3]. Cost, availability, training, and individual preferences are the major factors that influence the choice of a particular endobronchial ablative tool. In our study, the choice was based on individual preference and successful relief of endobronchial obstruction was obtained by a variety of methods, which included laser, contact electrocautery, argon plasma coagulation and cryotherapy either singly or in combination with mechanical debridement. Therefore, any of the methods discussed above can be used successfully to restore airway patency followed by surgical resection. This use of interventional bronchoscopy modalities in the combined endoscopic and surgical management of patients with lung cancer is in contrast to the common perception of its application for palliative treatment of patients with only advanced and inoperable lung cancer.

It has been suggested that stent placement should be avoided in patients with potentially resectable malignant disease owing to the possible risks of mucous retention, infection, and damage to the healthy mucosa by stimulating granulation tissue formation [7]. In our study, stent insertion was undertaken in 2 patients, who later underwent a surgical procedure. In 1 patient, laser therapy was used, followed by Ultraflex stent insertion; and in another, argon plasma was used, followed by insertion of a Dumon stent. Combination therapy was chosen in these patients to ensure airway patency as both had severe post-stenotic pneumonia. These 2 patients subsequently underwent a pneumonectomy and a middle and lower bilobectomy, respectively.

According to the literature, in patients undergoing bronchoscopic palliation before surgery, the most common histologic diagnosis was squamous cell carcinoma (58%), and none had adenocarcinoma [7]. In our study, the most common histologic diagnosis was also squamous cell carcinoma (45%); however, adenocarcinoma was present in 19% of patients. That might be due to a changing pattern of presentation for adenocarcinoma, which is being increasingly observed in the central location [14]. The findings of our study show that patients with almost all varieties of non-small cell carcinoma of the lung can be treated with an interventional bronchoscopic procedure as a bridge to elective lung surgery.

Spirometry is one of the initial assessment parameters in the preoperative evaluation of patients undergoing lung surgery [15]. Improvement in lung function has been reported after bronchoscopic laser resection before surgical treatment [6, 7]. In a study of 24 patients, the median improvement in FEV1 and FVC after therapeutic bronchoscopy was 0.75 L and 0.6 L, respectively [7]. In our study, also, there was a significant improvement in both the FEV1 and FVC after therapeutic bronchoscopy. There was no change in the FEV1/FVC ratio before and after the therapeutic bronchoscopy, as there was an increase in both the FEV1 and FVC after the intervention. Therefore, the findings of improvement in spirometry values after therapeutic bronchoscopy before surgical resection are confirmed by our study in a much larger patient population.

In summary, most therapeutic bronchoscopy modalities currently available can be applied in the combined bronchoscopic and surgical management of patients with malignant airway obstruction. In this study, patients underwent a therapeutic interventional bronchoscopy procedure for malignant central airway obstruction followed by lung surgery, with a curative intent. Therapeutic bronchoscopy might permit parenchyma-sparing surgery in patients with lung cancer.


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   References
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  1. Herth F, Becker HD, LoCicero III J, et al. Successful bronchoscopic placement of tracheobronchial stents without fluoroscopy Chest 2001;119:1910-1912.[Abstract/Free Full Text]
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  3. Bolliger CT, Mathur PN, Beamis JF, et al. European Respiratory Society/American Thoracic Society ERS/ATS statement on interventional pulmonology Eur Respir J 2002;19:356-373.[Free Full Text]
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  5. Ciccone AM, De Giacomo T, Venuta F, et al. Operative and non-operative treatment of benign subglottic laryngotracheal stenosis Eur J Cardiothorac Surg 2004;26:818-822.[Abstract/Free Full Text]
  6. Venuta F, Rendina EA, De Giacomo T, et al. Nd:YAG laser resection of lung cancer invading the airway as a bridge to surgery and palliative treatment Ann Thorac Surg 2002;74:995-998.[Abstract/Free Full Text]
  7. Daddi G, Puma F, Avenia N, et al. Resection with curative intent after endoscopic treatment of airway obstruction Ann Thorac Surg 1998;65:203-207.[Abstract/Free Full Text]
  8. Ferguson MK, Lehman AG. Sleeve lobectomy or pneumonectomyoptimal management strategy using decision analysis techniques. Ann Thorac Surg 2003;76:1782-1788.[Abstract/Free Full Text]
  9. Shankar S, George PJ, Hetzel MR, et al. Elective resection of tumours of the trachea and main carina after endoscopic laser therapy Thorax 1990;45:493-495.[Abstract/Free Full Text]
  10. George PJ, Garrett CP, Goldstraw P, et al. Resuscitative laser photoresection of a tracheal tumour before elective surgery Thorax 1986;41:812-813.[Free Full Text]
  11. Yoshino I, Yokoyama H, Yano T, et al. Comparison of the surgical results of lobectomy with bronchoplasty and pneumonectomy for lung cancer J Surg Oncol 1997;64:32-35.[Medline]
  12. Lausberg HF, Graeter TP, Wendler O, et al. Bronchial and bronchovascular sleeve resection for treatment of central lung tumors Ann Thorac Surg 2000;70:367-371.[Abstract/Free Full Text]
  13. Toty L, Personne C, Colchen A, et al. Bronchoscopic management of tracheal lesions using the neodynium yttrium aluminium garnet laser Thorax 1981;36:175-178.[Abstract/Free Full Text]
  14. Chhajed PN, Athavale AU, Shah AC. Clinical and pathological profile of 73 patients with lung carcinomais the picture changing?. J Assoc Physician India 1999;47:483-487.
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