Theraeutic Bronchoscoy Interventions Before Surgical Resection of Lung Cancer Prashant N. Chhajed, MD, Ralf Eberhardt, MD, Hendrik Dienemann, MD, Andrea Azzola, MD, Martin H. Brutsche, MD, Michael Tamm, MD, and Felix J. F. Herth, MD Pulmonary Medicine, University Hosital Basel, Switzerland, and Deartments of Pulmonology and Thoracic Surgery, Thoraxklinik, University Heidelberg, Germany Background. Theraeutic bronchoscoy is used for endobronchial staging of lung cancer and symtomatic relief of central airway obstruction or ostobstructive neumonia. The aim of this study was to assess the utility of theraeutic bronchoscoy as a comlementary tool in the combined bronchoscoic and surgical management of malignant airway lesions before curative lung surgery. Methods. Seventy-four consecutive atients with nonsmall cell lung carcinoma undergoing a theraeutic bronchoscoy rocedure followed by surgery with a curative intent were included. Results. A single interventional bronchoscoic method was used in 27 atients (36%) and a combination of methods in 47 atients (64%). Median forced exiratory volume in 1 second (FEV 1 ) before and after bronchoscoy were 1.7 L and 2.2 L, resectively, and forced vital caacity (FVC) was 2.5 L and 3.3 L, resectively. Sleeve uer lobectomy was erformed in 22 atients (30%), sleeve uer bilobectomy in 16 atients (22%), lower bilobectomy in 2 atients (3%), neumonectomy with sleeve resection in 2 atients (3%), and neumonectomy in 28 atients (38%). The following surgeries were erformed in 1 atient each: sleeve middle lobectomy, sleeve lower lobectomy, carina resection and comlex reconstruction, and exloratory thoracotomy. Overall, arenchyma-saring surgery (lobectomy or bilobectomy) could be erformed in 57% atients after theraeutic bronchoscoy. There were no in-hosital deaths or deaths in the first 30 days after surgery. Conclusions. Theraeutic bronchoscoy can be used as a comlementary tool in the combined bronchoscoic and surgical management of malignant airway obstruction before curative lung surgery. Theraeutic bronchoscoy might ermit arenchyma-saring surgery in atients with lung cancer. (Ann Thorac Surg 2006;81:1839 43) 2006 by The Society of Thoracic Surgeons Acceted for ublication Nov 28, 2005. Address corresondence to Dr Chhajed, Pulmonary Medicine, University Hosital Basel, Petersgraben 4, Basel CH-4031, Switzerland; e-mail: chhajed@uhbs.ch. The role of interventional bronchoscoy with laser, bronchial dilatation, or stent insertion is well established for the alliative treatment of malignant endobronchial lesions as well as for the management of benign central airway lesions [1, 2]. Indications for theraeutic endoscoic treatment are mainly alliation of advanced cancerous lesions, but increasingly also as a cure for early lung cancer [3]. Laser resection, balloon dilatation, and endoluminal stenting have been reorted to otimize the timing of oeration in atients with subglottic or benign tracheal stenosis [4, 5]. Theraeutic bronchoscoy has also been reorted in atients with malignant disease followed by surgery with curative intention [6, 7]. In atients with malignant disease, bronchoscoic laser resection may allow imroved evaluation of tumor extensions and staging, functional measurements, and lanning of the aroriate lung resection rocedure [7]. A recent meta-analysis of results of sleeve lobectomy and neumonectomy has concluded that sleeve lobectomy offers better long-term survival and quality of life than does neumonectomy and is more cost effective [8]. Recanalization of central airway obstruction using theraeutic bronchoscoic 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. Bronchoscoic intervention before ulmonary resection also leads to imrovement in lung function [6, 7]. There are limited data about using a combined bronchoscoic and surgical aroach to increase the ossibility of offering the atient arenchyma-saring surgery [6, 7, 9, 10]. The aim of this study was to assess the utility of theraeutic bronchoscoy modalities as comlementary tools in the combined bronchoscoic and surgical management of malignant airway lesions before curative lung surgery. Patients and Methods We retrosectively reviewed all 74 consecutive atients (male: female, 37:37) with lung cancer undergoing an interventional bronchoscoic rocedure followed by surgery with a curative intent at two centers (Germany and Switzerland). Theraeutic bronchoscoy was erformed 2006 by The Society of Thoracic Surgeons 0003-4975/06/$32.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2005.11.054
1840 CHHAJED ET AL Ann Thorac Surg BRONCHOSCOPY BEFORE LUNG CANCER SURGERY 2006;81:1839 43 to relieve significant malignant obstruction of the central airways for symtomatic relief of central airway obstruction due to dysnea or ost obstructive neumonia and endobronchial staging of lung cancer. All atients with non-small cell lung cancer were stage III or less and were discussed at a multidiscilinary meeting in both institutions. Aroval was obtained from the Ethikkommision Beider Basel for this retrosective analysis. Rigid bronchoscoy under general anesthesia was erformed in all atients [3]. If necessary, the flexible bronchoscoe was inserted through the rigid bronchoscoe. Laser, argon lasma coagulation or contact electrocautery robes were used based on oerator reference. These robes were assed either through the rigid bronchoscoe or the working channel of the flexible bronchoscoe. Mechanical coring of the tumor was erformed with the rotating movement of the ti of the rigid bronchoscoe [3]. Stent insertion was undertaken in selected atients with lung cancer in whom it was not ossible to achieve more than 50% oening of the airway diameter and were removed at surgical resection. Surgical resection was erformed 1 to 23 weeks after the theraeutic bronchoscoy rocedure. Before and after theraeutic bronchoscoy sirometry data were available in 73 atients (99%). Postrocedure sirometry was erformed within 1 week after the theraeutic bronchoscoy. Statistical Methods Data are resented as median and range. The Mann- Whitney test was used to comare the differences between two means. Results The underlying diagnoses in the 74 atients included in this study were squamous cell carcinoma in 34 atients (45%), adenocarcinoma in 14 atients (19%), non-small cell carcinoma (mixed tumor) in 21 atients (28%), large cell tumor in 4 atients (5%), and carcinoid in 1 atient. Forty-seven lesions (64%) were resent in the right and 27 lesions (36%) in the left bronchial tree. A single interventional bronchoscoic method was used in 27 atients (38%), and in the remaining 47 atients (62%), a combination of methods was used to relieve endobronchial obstruction. A single modality was used as follows: laser resection in 13 atients (17%), mechanical debridement with the rigid bronchoscoe in 5 atients (7%), argon lasma coagulation in 4 (5%), contact electrocautery in 4 (5%), and cryotheray in 1 atient (1%). Combined methods used were as follows: combined argon lasma and mechanical debridement in 42 atients (56%), combined laser and mechanical debridement in 3 atients (4%), argon lasma coagulation lus silicone stent insertion in 1 atient (1%), and laser lus nitinol stent in 1 atient (1%). Overall, 4 atients had moderate bleeding that was controlled endoscoically, and 1 atient had neumothorax, which was treated with insertion of an intercostal drainage tube. The median forced exiratory volume in 1 second (FEV 1 ) before the theraeutic rocedure was 1.7 L (1.0 to Fig 1. Box lot reresentation of (A) Forced exiratory volume in 1 second (FEV 1 ) before and after theraeutic bronchoscoy in all atients. The 25th, 50th, and 75th ercentiles and extreme values are shown. (B) Forced vital caacity (FVC) before and after theraeutic bronchoscoy in all atients. (C) Ratio of FEV 1 /FVC before and after theraeutic bronchoscoy in all atients. 3.0 L), and after the rocedure it was 2.2 L (1.3 to 4.7 L; 0.0001). The median forced vital caacity (FVC) before the theraeutic bronchoscoy was 2.5 L (1.3 to 4.1 L), and after the rocedure it was 3.3 L (1.9 6.1 L) ( 0.0001). The median FEV 1 /FVC ratio before theraeutic bronchoscoy was 67%, and after the rocedure it was 68% ( 0.7; Fig 1). The changes in lung function before after
Ann Thorac Surg CHHAJED ET AL 2006;81:1839 43 BRONCHOSCOPY BEFORE LUNG CANCER SURGERY 1841 endobronchial interventions in atients who subsequently underwent lobectomy, bilobectomy, or neumonectomy are resented in Table 1. Pneumonectomy was erformed in 28 atients (37%), sleeve uer lobectomy in 22 atients (29%) atients, uer bilobectomy in 16 atients (21%), neumonectomy with sleeve resection in 2 atients (3%), and lower bilobectomy in 2 atients (3%). The following rocedures were erformed in 1 atient each: sleeve middle lobectomy, sleeve lower lobectomy, carina resection with reimlantation of right uer lobe in trachea and in left main, and exloratory thoracotomy. In 1 atient, the tumor was found to invade the atrium and aorta, hence definitive surgery was not erformed (exloratory thoracotomy). Lobectomy or bilobectomy was erformed in 42 atients (57%). Overall, arenchyma-saring surgery could be erformed in 45 atients (61%). Resection margins were clean in all atients. Furthermore, arenchyma-saring surgery was erformed in 30 atients (41%) with lesions in the main bronchi. The endobronchial site of lesion and the subsequent surgery are resented in Table 1. There was no in hosital mortality or mortality in the first 30 days after surgery. Four atients underwent reeated bronchoscoy ostoeratively for retention of mucous secretions, 1 atient needed rolonged ostoerative ventilation (4 days), 1 atient underwent reexloration (thoracotomy) due to ostoerative intrathoracic bleeding, 1 atient had a rolonged chest tube drainage (6 days), and 1 atient had ulmonary embolism. Comment Surgical resection remains the most imortant element in otentially curative lung cancer [8]. Parenchymal-saring oerations such as sleeve lobectomy were introduced as a means of conserving lung arenchyma in atients with comromised lung function [8]. Recent studies have suggested that sleeve resection can be erformed routinely in atients with anatomically centrally located tumors, even in the resence of sufficient ulmonary reserve to ermit neumonectomy [11, 12]. In atients with lung cancer without or minimal endobronchial involvement, it might be ossible to make an assessment of the tumor extent at conventional bronchoscoy. However, in atients with significant malignant central airway obstruction, such as the main bronchi, it is not ossible to evaluate the comlete endobronchial extension of the tumor beyond the obstruction. In such cases, debulking of the central airway obstruction using interventional bronchoscoy is useful and allows to otimize endobronchial staging of lung cancer [7]. Recanalization of central airway obstruction may also be beneficial in the treatment of ost obstructive neumonia or collase. In our study, lobectomy or bilobectomy was erformed in 57% of atients (Table 2). Seventy-six ercent of lesions were resent in the main bronchi (Table 2). That would be an indication for neumonectomy in many centers. In our study, a considerable number of atients could undergo sleeve resection. Parenchyma-saring Table 1. Lung Function Tests Before and After Endobronchial Intervention in Patients Subsequently Undergoing Lobectomy, Bilobectomy, or Pneumonectomy FEV 1 /FVC FVC in Liters Preintervention Postintervention Preintervention Postintervention Preintervention Postintervention FEV 1 in Liters FEV 1 Postbronchoscoy Surgical Procedure Lobectomy (n 24) 1.7 (1.2 2.8) 2.1 (1.4 4.0) 0.0007 2.6 (1.7 3.9) 3.0 (2.1 6.1) 0.0002 67% 67% 0.7571 Bilobectomy (n 18) 1.7 (1.1 2.3) 2.4 (1.6 4.7) 0.0001 2.5 (1.8 3.1) 3.4 (2.7 5.7) 0.0001 69% 71% 0.3995 Pneumonectomy (n 30) 1.7 (1.0 3.0) 2.2 (1.3 3.7) 0.0001 2.5 (1.3 4.1) 3.4 (1.9 5.4) 0.0001 68% 66% 0.7618 FEV 1 forced exiratory volume in 1 second; FVC forced vital caacity.
1842 CHHAJED ET AL Ann Thorac Surg BRONCHOSCOPY BEFORE LUNG CANCER SURGERY 2006;81:1839 43 Table 2. Site of Malignant Endobronchial Obstruction and Subsequent Surgery in 74 Patients With Lung Cancer Site of Lesion Right main right Right main right uer lobe Number of Patients Oeration (Number of Patients) 21 Sleeve uer biobectomy (16) Pneumonectomy (5) 11 Pneumonectomy (8) Sleeve uer lobectomy (2) Exloratory thoracotomy Right main 9 Pneumonectomy (3) Sleeve uer uer lobectomy (6) Main carina right main Right Right uer lobe Right middle lobe Left uer lobe Left main left uer lobe 2 Sleeve neumonectomy (1) Comlex reconstruction (1) a 2 Lower bilobectomy 1 Pneumonectomy 1 Sleeve middle lobectomy 10 Sleeve uer lobectomy (9) Pneumonectomy (1) 5 Sleeve uer lobectomy Left main 4 Pneumonectomy Left main 3 Pneumonectomy left lower lobe Left uer lobe left lower lobe 3 Pneumonectomy Main carina left main Left lower lobe 1 Sleeve neumonectomy 1 Lower lobectomy a Carina resection, imlantation of right uer lobe in trachea and right in left main. surgery in the form of lobectomy or bilobectomies were erformed in 30 atients (41%) with lesions in the main bronchi (Table 2). The real imact of theraeutic interventions before lung resection surgery can be best confirmed by having a control grou. There was no ostoerative mortality or significant ostoerative morbidity attributed to the interventional bronchoscoy rocedure erformed before the thoracotomy. The findings of our study lead us to believe that theraeutic bronchoscoy might ermit lobectomies or bilobectomies and thereby has the otential to ermit arenchyma-saring surgery in atients with lung cancer. Tumor debulking using the rigid bronchoscoe to core through the obstruction was the first method to treat endobronchial tumors, followed by laser theray [13]. Since then, there have been several other tumor ablative tools that have been introduced for endobronchial use, such as contact electrocautery, argon lasma coagulation, and cryotheray [3]. Cost, availability, training, and individual references are the major factors that influence the choice of a articular endobronchial ablative tool. In our study, the choice was based on individual reference and successful relief of endobronchial obstruction was obtained by a variety of methods, which included laser, contact electrocautery, argon lasma coagulation and cryotheray either singly or in combination with mechanical debridement. Therefore, any of the methods discussed above can be used successfully to restore airway atency followed by surgical resection. This use of interventional bronchoscoy modalities in the combined endoscoic and surgical management of atients with lung cancer is in contrast to the common ercetion of its alication for alliative treatment of atients with only advanced and inoerable lung cancer. It has been suggested that stent lacement should be avoided in atients with otentially resectable malignant disease owing to the ossible 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 atients, who later underwent a surgical rocedure. In 1 atient, laser theray was used, followed by Ultraflex stent insertion; and in another, argon lasma was used, followed by insertion of a Dumon stent. Combination theray was chosen in these atients to ensure airway atency as both had severe ost-stenotic neumonia. These 2 atients subsequently underwent a neumonectomy and a middle and lower bilobectomy, resectively. According to the literature, in atients undergoing bronchoscoic alliation 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 resent in 19% of atients. That might be due to a changing attern of resentation for adenocarcinoma, which is being increasingly observed in the central location [14]. The findings of our study show that atients with almost all varieties of non-small cell carcinoma of the lung can be treated with an interventional bronchoscoic rocedure as a bridge to elective lung surgery. Sirometry is one of the initial assessment arameters in the reoerative evaluation of atients undergoing lung surgery [15]. Imrovement in lung function has been reorted after bronchoscoic laser resection before surgical treatment [6, 7]. In a study of 24 atients, the median imrovement in FEV 1 and FVC after theraeutic bronchoscoy was 0.75 L and 0.6 L, resectively [7]. In our study, also, there was a significant imrovement in both the FEV 1 and FVC after theraeutic bronchoscoy. There was no change in the FEV 1 /FVC ratio before and after the theraeutic bronchoscoy, as there was an increase in both the FEV 1 and FVC after the intervention. Therefore, the findings of imrovement in sirometry values after theraeutic bron-
Ann Thorac Surg CHHAJED ET AL 2006;81:1839 43 BRONCHOSCOPY BEFORE LUNG CANCER SURGERY 1843 choscoy before surgical resection are confirmed by our study in a much larger atient oulation. In summary, most theraeutic bronchoscoy modalities currently available can be alied in the combined bronchoscoic and surgical management of atients with malignant airway obstruction. In this study, atients underwent a theraeutic interventional bronchoscoy rocedure for malignant central airway obstruction followed by lung surgery, with a curative intent. Theraeutic bronchoscoy might ermit arenchyma-saring surgery in atients with lung cancer. References 1. Herth F, Becker HD, LoCicero J III, et al. Successful bronchoscoic lacement of tracheobronchial stents without fluoroscoy. Chest 2001;119:1910 2. 2. Chhajed PN, Malouf MA, Tamm M, et al. Interventional bronchoscoy for the management of airway comlications following lung translantation. Chest 2001;120:1894 9. 3. Bolliger CT, Mathur PN, Beamis JF, et al. ERS/ATS statement on interventional ulmonology. Euroean Resiratory Society/American Thoracic Society. Eur Resir J 2002;19:356 73. 4. Chhajed PN, Malouf MA, Glanville AR. Bronchoscoic dilatation in the management of benign (non-translant) tracheobronchial stenosis. Intern Med J 2001;31:512 6. 5. Ciccone AM, De Giacomo T, Venuta F, et al. Oerative and non-oerative treatment of benign subglottic laryngotracheal stenosis. Eur J Cardiothorac Surg 2004;26:818 22. 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 alliative treatment. Ann Thorac Surg 2002;74: 995 8. 7. Daddi G, Puma F, Avenia N, et al. Resection with curative intent after endoscoic treatment of airway obstruction. Ann Thorac Surg 1998;65:203 7. 8. Ferguson MK, Lehman AG. Sleeve lobectomy or neumonectomy: otimal management strategy using decision analysis techniques. Ann Thorac Surg 2003;76:1782 8. 9. Shankar S, George PJ, Hetzel MR, et al. Elective resection of tumours of the trachea and main carina after endoscoic laser theray. Thorax 1990;45:493 5. 10. George PJ, Garrett CP, Goldstraw P, et al. Resuscitative laser hotoresection of a tracheal tumour before elective surgery. Thorax 1986;41:812 3. 11. Yoshino I, Yokoyama H, Yano T, et al. Comarison of the surgical results of lobectomy with broncholasty and neumonectomy for lung cancer. J Surg Oncol 1997;64:32 5. 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 71. 13. Toty L, Personne C, Colchen A, et al. Bronchoscoic management of tracheal lesions using the neodynium yttrium aluminium garnet laser. Thorax 1981;36:175 8. 14. Chhajed PN, Athavale AU, Shah AC. Clinical and athological rofile of 73 atients with lung carcinoma: is the icture changing? J Assoc Physician India 1999;47:483 7. 15. Datta D, Lahiri B. Preoerative evaluation of atients undergoing lung resection surgery. Chest 2003;123:2096 103. Member and Individual Subscriber Access to the Online Annals The address of the electronic edition of The Annals is htt://ats.ctsnetjournals.org. If you are an STS or STSA member or a non-member ersonal subscriber to the rint issue of The Annals, you automatically have a subscrition to the online Annals, which entitles you to access the full-text of all articles. To gain full-text access, you will need your CTSNet user name and assword. Society members and non-members alike who do not know their CTSNet user name and assword should follow the link Forgot your user name or assword? that aears below the boxes where you are asked to enter this information when you try to gain full-text access. Your user name and assword will be e-mailed to the e-mail address you designate. In lieu of the above rocedure, if you have forgotten your CTSNet username and/or assword, you can always send an email to CTSNet via the feedback button from the left navigation menu on the homeage of the online Annals or go directly to htt://ats.ctsnetjournals.org/cgi/feedback. We hoe that you will view the online Annals and take advantage of the many features available to our subscribers as art of the CTSNet Journals Online. These include inter-journal linking from within the reference sections of Annals articles to over 350 journals available through the HighWire Press collection (HighWire rovides the latform for the delivery of the online Annals). There is also crossjournal advanced searching, etoc Alerts, Subject Alerts, Cite-Track, and much more. A listing of these features can be found at htt://ats.ctsnetjournals.org/hel/features.dtl. We encourage you to visit the online Annals at htt:// ats.ctsnetjournals.org and exlore. 2006 by The Society of Thoracic Surgeons Ann Thorac Surg 2006;81:1843 0003-4975/06/$32.00 Published by Elsevier Inc