Endobronchial management of malignant central airway obstruction: the first 6-year single center experience

Abstract

Objectives: Central airway obstruction (CAO) develops in 20-30% of lung malignancies during the disease. The symptoms related to obstruction often result in poor quality of life and poor prognosis. Interventional bronchoscopic treatments are now recommended in guidelines to improve quality of life and symptom palliation in this patient group. In our study, we aimed to determine the efficacy and safety of our methods in the malignant CAO caused by endobronchial exophytic tumors.

Methods: Between May 2012 and August 2018, 432 endobronchial debulking procedures were performed in 388 patients with symptomatic malignant CAO due to endobronchial exophytic or mixed lesions.

Results: Primary lung tumors were the most common cause of airway stenosis (84.0%). The most common debulking technique was argon plasma coagulation assisted mechanical debridement (APC+MD) (79.9%). Airway patency was achieved with additional stents (10.2%) in the operations. The success rate of airway patency was 85.5% in APC+MD method, 75.6% in cryorecanalisation method, 91.7% in electrocautery assisted MD method, 100% in MD method and overall success rate was 85.4%. Stent use rate was significantly higher in the stenosis around main carina (42.9%) than in other localizations (p < 0.001). The overall serious complication rate was 2.1%. Procedure-related dead rate was 0.2%.

Conclusions: Endobronchial treatment of malignant CAO with interventional bronchoscopic procedures is effective and safe. The first 6 years of experience in our interventional pulmonary clinic show that it has similar characteristics with the world experience in the endobronchial treatment of malignant CAO. 

Keywords

• Interventional bronchoscopy,debulking,malignant central airway obstruction

References

1. [1] Ginsberg RJ, Vokes EE, Ruben A. Non-small cell lung cancer. In: DeVita VT, Hellman S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 5th Edn. Philadelphia: Lippincott-Raven, 1997:858-911.
2. [2] Laumanen R, Watson W. Autopsy findings. In: Watson W, ed. Lung Cancer: a Study of Five Thousand Memorial Hospital Cases. St Louis: Mosby, 1968;504-10.
3. [3] Hollingsworth HM. Wheezing and stridor. Clin Chest Med 1987;8:231-40.
4. [4] Macha HN, Becker KO, Kemmer HP. Pattern of failure and survival in endobronchial laser resection. A matched pair study. Chest 1994;105:1668-72.
5. [5] Walser EM, Robinson B, Raza SA, Ozkan OS, Ustuner E, Zwischenberger J. Clinical outcomes with airway stents for proximal versus distal malignant tracheobronchial obstructions. J Vasc Interv Radiol 2004;15:471-7.
6. [6] Nihei K, Ishikura S, Kawashima M, Ogino T, Ito Y, Ikeda H. Short-course palliative radiotherapy for airway stenosis in non-small cell lung cancer. Int J Clin Oncol 2002;7:284-8.
7. [7] Simoff MJ, Lally B, Slade MG, Goldberg WG, Lee P, Michaud GC, et al. Symptom management in patients with lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143(5 Suppl):e455S-e497S.
8. [8] Herth FJ, Eberhardt R, Becker HD, Ernst A. Relief of malignant airway obstruction: a prospective and randomised comparison of five different endoscopic techniques. Chest 2005;128:209S.

9. [9] Reichle G, Freitag L, Kullmann HJ, Prenzel R, Macha HN, Farin G. Argon plasma coagulation in bronchology: a new method--alternative or complementary? J Bronchology Interv Pulmonol 2000;7:109-17.
10. [10] Schumann C, Hetzel M, Babiak AJ, Hetzel J, Merk T, Wibmer T, et al. Endobronchial tumour debulking with a flexible cryoprobe for immediate treatment of malignant stenosis. J Thorac Cardiovasc Surg 2010;139:997-1000.
11. [11] Yilmaz A, Aktaş Z, Alici IO, Cağlar A, Sazak H, Ulus F. Cryorecanalization: keys to success. Surg Endosc 2012;26:2969-74.
12. [12] Kızılgöz D, Aktaş Z, Yılmaz A, Öztürk A, Seğmen F. Comparison of two new techniques for the management of malignant central airway obstruction: argon plasma coagulation with mechanical tumor resection versus cryorecanalization. Surg Endosc 2018;32:1879-84.
13. [13] Sutedja G, van Kralingen K, Schramel FM, Postmus PE. Fibreoptic bronchoscopic electrosurgery under local anaesthesia for rapid palliation in patients with central airway malignancies: a preliminary report. Thorax 1994;49:1243-6.
14. [14] van Boxem T, Muller M, Venmans B, Postmus P, Sutedja G. Nd-YAG laser vs bronchoscopic electrocautery for palliation of symptomatic airway obstruction: a cost effectiveness study. Chest 1999;116:1108-12.
15. [15] Petrou M, Kaplan D, Goldstraw P. Bronchoscopic diathermy resection and stent insertion: a cost effective treatment for tracheobronchial obstruction. Thorax 1993;48:1156-9.
16. [16] Vishwanath G, Madan K, Bal A, Aggarwal AN, Gupta D, Agarwal R. Rigid bronchoscopy and mechanical debulking in the management of central airway tumors: an Indian experience. J Bronchology Interv Pulmonol 2013;20:127-33.
17. [17] Mathisen DJ, Grillo HC. Endoscopic relief of malignant airway obstruction. Ann Thorac Surg 1989;48:469-73.
18. [18] Guibert N, Mazieres J, Lepage B, Plat G, Didier A, Hermant C. Prognostic factors associated with interventional bronchoscopy in lung cancer. Ann Thorac Surg 2014;97:253-9.
19. [19] Verma A, Goh SK, Tai DYH, Kor AC, Soo CI, Seow DGF, et.al. Outcome of advanced lung cancer with central airway obstruction versus without central airway obstruction. ERJ Open Res 2018;4(2). pii: 00173-2017.
20. [20] Hespanhol V, Magalhães A, Marques A. Neoplastic severe central airways obstruction, interventional bronchoscopy: a decision-making analysis. J Thorac Cardiovasc Surg 2013;145:926-32.
21. [21] Ost DE, Ernst A, Grosu HB, Lei X, Diaz-Mendoza J, Slade M, et al. Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life. Chest 2015;147:1282-98.
22. [22] Dutau H, Toutblanc B, Lamb C, Seijo L. Use of the Dumon Y-stent in the management of malignant disease involving the carina: a retrospective review of 86 patients. Chest 2004;126:951-8.
23. [23] Ost DE, Ernst A, Grosu HB, Lei X, Diaz-Mendoza J, Slade M, et. al. Complications following therapeutic bronchoscopy for malignant central airway obstruction: results of the AQuIRE registry. Chest 2015;148:450-71.
24. [24] Ernst A, Simoff M, Ost D, Goldman Y, Herth FJF. Prospective risk-adjusted morbidity and mortality outcome analysis after therapeutic bronchoscopic procedures: results of a multi-institutional outcomes database. Chest 2008;134:514-9.
25. [25] Ernst A, Feller-Kopman D, Becker HD, Mehta AC. Central airway obstruction. Am J Respir Crit Care Med 2004;169:1278-97.
26. [26] Du Rand IA, Barber PV, Goldring J, Lewis RA, Mandal S, Munavvar M, et al. British Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults. Thorax 2011;66 Suppl 3:iii1-21.
27. [27] Chen CH, Wu BR, Cheng WC, Chen CY, Chen WC, Hsia TC, et al. Interventional pulmonology for patients with central airway obstruction: An 8-year institutional experience. Medicine (Baltimore) 2017;96:e5612.
28. [28] Stephens KE Jr, Wood DE. Bronchoscopic management of central airway obstruction. J Thorac Cardiovasc Surg 2000;119:289-96.