Clinical Experience

We have used this simple, direct, efficient, safe, and low-cost procedure for over 35 years. In more recent years, a large literature has grown recommending use of the laser to treat obstructed airway tumors. It is based on the argument that bleeding will be excessive without use of the laser. It has even been argued that it is impossible to clear obstruction of the airway without a laser. We therefore examined a consecutive series of 56 patients with tumor treated by the coring technique.3 All were symptomatic, with shortness of breath or dyspnea on exertion (88%), hemoptysis (45%), or obstructive pneumonia (in 18 patients). In 23%, coring was done emergently. In 15%, it was performed urgently because of obstructing pneumonia, and in 62%, it was carried out electively. Tumors were distributed widely: 16 occurred in the trachea, 24 at the carina, 8 in main bronchi, and 8 in lobar or segmental bronchi. Squamous cell carcinoma was most common at all levels, adenoid cystic was next in frequency, and the others were a variety of primary and secondary tumors including thyroid carcinomas, carcinoids, mucoepidermoid carcinomas, sarcomas, lymphomas, and metastatic lesions. Twenty-nine percent of patients ultimately went on to surgical resection. Sixty-one percent had unresectable disease that was later treated with radiotherapy, chemotherapy, and combined modalities. Six patients, following failure of prior radiotherapy and chemotherapy, had no further adjunctive therapy. Two refused additional therapy.

Complications were as follows: Five developed pneumonia in previously unaffected pulmonary parenchyma, after relief of postobstructive pneumonia. All responded to chest physiotherapy and antibiotics.

figure 19-4 Relief of carinal obstruction due to tumor. A, Computed tomography scan demonstrating complete obstruction of the left main bronchus and partial obstruction of the right by squamous cell carcinoma. B, Bronchoscopic view showing the severity of blockage. C, Right main bronchus opened by bronchoscopic core-out. D, After both main bronchi have been opened. Tumor remains at the bifurcation to avoid the danger of perforation into the mediastinum. Carinal resection and reconstruction followed.

figure 19-4 Relief of carinal obstruction due to tumor. A, Computed tomography scan demonstrating complete obstruction of the left main bronchus and partial obstruction of the right by squamous cell carcinoma. B, Bronchoscopic view showing the severity of blockage. C, Right main bronchus opened by bronchoscopic core-out. D, After both main bronchi have been opened. Tumor remains at the bifurcation to avoid the danger of perforation into the mediastinum. Carinal resection and reconstruction followed.

Three had bleeding of slightly greater amounts than usual, but none in excess of 500 mL. Bleeding was controlled conservatively in all. Pneumothorax was seen in 2 patients and 1 patient required a chest tube. Two developed hypercarbia and hypoxia and needed brief intubation (< 24 hours). Minor arrhythmia occurred during the procedure in some patients. Six required pharmacological treatment. One patient developed laryngeal edema requiring racemic epinephrine and a brief dosage of steroids. None required tracheostomy. Long-term results depended, of course, on the individual's basic disease and not on the method of unobstructing the airway.

The use of the laser to relieve airway obstruction due to neoplasm has progressed from initial tedious, repeated sessions of charring the tumor followed by scraping away of the char, to use of the rigid bronchoscope figure 19-4 (continued) E, Principal cores of tumor removed from the carina and main bronchi. F, A second patient with adenoid cystic carcinoma at the carina. The patient was on high doses of prednisone following misdiagnosis as "asthma." G, Following bronchoscopic coring, both main bronchi are open. A period of rapid weaning from the prednisone followed, prior to carinal resection and reconstruction, which was accompanied by stress doses ofcorticosteroids.

to core out the tumor, much as described above. The base from which the tumor has been cored is coagulated with the laser. Experience suggests that the results would be equally as good without the final coagulation!

A further concern must be voiced about the consequences of using laser therapy for clearing airway obstructing tumors. Treatment is frequently given by pulmonologists, otolaryngologists, and even thoracic surgeons, who are unaware of the possibilities of curative surgical therapy. Undue delay in the definitive surgical treatment of these patients has followed. In some, whatever opportunity might have existed for cure has been lost. Also evident in the literature is the misconception about the curative potential of the laser for tracheal tumors. With few exceptions, pathologic study of primary tracheal tumors, and certainly of any with malignant potential, makes it clear that endoscopic cure would require removal of the entire thickness of the tracheal wall. Infatuation with technology sometimes obscures basic science and common sense.

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