Obstructing Tracheobronchial Tumors

The application of laser technology to the endoscopic treatment of patients with tracheobronchial disorders was first introduced by Strong and colleagues in 1973, who used the CO2 laser to ablate peristomal papillomas.39 The effectiveness and safety of laser application in bronchology were enhanced after the introduction of the Nd:YAG laser in the 1980s.40-42 The special hemostatic qualities of this laser energy make it the most suitable laser for endoscopic removal of malignant tracheobronchial lesions with a propensity for hemorrhage into the airway (Table 37-3). Today, tracheobronchial obstruction secondary to primary bronchogenic carcinoma is the most common indication for Nd:YAG laser bronchoscopy, accounting for 51 to 75% of all cases.43-46

The majority of patients presenting with lesions that obstruct the central airways all have tumors that are inoperable, because of mediastinal or lymph node involvement, or lesions that are too central for surgical resection. The most common primary lung tumor treated with the Nd:YAG laser is squamous cell carcinoma, followed by adenocarcinoma (Figure 37-4 [Color Plate 9]).43 Many of these patients have failed radiation therapy and/or chemotherapy (Table 37-4). Unlike ionizing radiation therapy, the laser may be used repeatedly for the palliation of malignant tracheobronchial obstruction.

Although the CO2 laser was the initial laser used for tracheobronchial laser therapy (Figure 37-5), its use in the treatment of patients with malignant obstruction is severely limited by poor hemostatic proper-ties.47,48 The hypervascularity of many malignant endobronchial tumors, such as carcinoids, adenoid cystic carcinomas, and metastasis from renal cell, thyroid, breast, and esophageal carcinomas, is best treated with the Nd:YAG laser because of its excellent coagulation properties (Figures 37-6, 37-7 [Color Plate 9]). Tracheo-bronchial obstruction caused by endobronchial metastasis constitutes the second most common indication for Nd:YAG laser bronchoscopy, accounting for 10 to 18% of laser bronchoscopies. The Nd:YAG laser has also been used successfully in the treatment of benign conditions causing tracheobronchial obstruction, such as amyloidomas, lipomas, fibromas, and hamartomas.49,50 Some cases of tracheal stenoses are also amenable to treatment with the Nd:YAG laser. However, attention must be paid to the type of stenosis, since laser treatment of lesions secondary to tracheal collapse without an intraluminal component is contraindicated.

We use the rigid bronchoscope in the majority of procedures because this instrument offers a number of advantages over the flexible bronchoscope. Rigid bronchoscopes offer better control of hemorrhage by use of large suction catheters, assure ventilation with the Venturi jet. They also provide excellent visualization with use of the telescope, and facilitate rapid removal of tumor with large biopsy forceps. The flexible bronchoscope is often a helpful tool, when used through the rigid bronchoscope, for treatment of more distal or upper lobe tumors and for tracheobronchial toilet. In general, however, the exposure to the upper lobes is somewhat difficult and fraught with dangers of hemorrhage from pulmonary artery and vein branches.

Flexible bronchoscopy is most useful for delivery of the YAG laser in the outpatient bronchoscopy suite for treatment of patients with small, noncritically obstructing (less than 50% lumen), distal tumors that require photocoagulation for control of hemoptysis, or for benign lesions such as granulation tissue and papillomas.51 One advantage of using flexible bronchoscopy is the avoidance of general anesthesia and the inherent risks associated with it. However, this bronchoscopy technique has its limitations, especially

Table 37-3 Indications of Laser Bronchoscopy

Reestablish airway patency (malignant tumor: palliation; benign tumor: resection)

Hemoptysis

Dilation of stenosis

Stent insertion

Table 37-4 Advantages and Disadvantages of Laser Bronchoscopy

Advantages Use of flexible or rigid bronchoscope Hemostatic ability Repeatability of treatment Rapid relief of symptoms Prepares airway for stent insertion

Disadvantages Severe complications* Special training Expensive equipment

when dealing with bulky lesions that may require more than one procedure and when treating highly vascular lesions where an inability to control hemorrhage can lead to severe complications.

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