Commentary on “Endoscopic Laser Ablation as Palliative Treatment of Endobronchial, Nonresectable, or Recurrent Lung Cancer: Assessment of its Impact on Quality of Life”

Abstract

This article by Mantovani and his colleagues emphasizes the most important aspects of palliative interventions for patients with advanced cancer – the impact upon patient performance status and functional quality of life (QOL). Numerous papers have documented the feasibility and efficacy of endoscopic modalities for the relief of airway obstruction. 1 Most authors, including this paper by Mantovani and colleagues, have emphasized a single modality as the optimum treatment for malignant endobronchial obstruction. Other authors have reported a variety of endobronchial therapeutic techniques to achieve palliation, based on algorithms for progressive interventions dependent on patient anatomy. 1-3 As the authors emphasize, malignant obstruction of the trachea or mainstem bronchi may present with non-specific symptoms of asthma or obstructive pneumonia. Patients may also present with a tenuous airway due to critical obstruction, with dyspnea and stridor preceding patient suffocation in the absence of aggressive intervention. Although these patients have locally advanced or metastatic disease, their quality of life and length of life may be severely impacted by correctable airway obstruction. Most of us caring for these patients have witnessed dramatic improvement in symptoms after therapeutic bronchoscopy, but there has been a paucity of objective data documenting either the improved quality of life or length of life after endoscopic palliation. The authors have contributed to this body of literature by systematically evaluating performance status and quality of life before and after interventions for airway palliation. Like many other authors, Mantovani and his colleagues have emphasized laser ablation as the critical component in the management of malignant airway obstruction. The benefits of the Nd:YAG laser are its ability to be utilized during flexible or rigid bronchoscopy, vaporization of tumor, hemostasis, and accessibility to airways not directly approachable by rigid bronchoscopy. However, experienced airway programs have often found little added benefit of laser bronchoscopy over simple mechanical debridement or of endobronchial tumor. 1, 2 Significant bleeding is rarely encountered after core-out of tumor and there is no data to suggest that the addition of the laser decreases, rather than increases, the potential for significant bleeding. In fact, in this series, the authors used laser vaporization to coagulate the tumor and to vaporize residual tumor, but it appears that the predominant technique of reestablishing airway patency was mechanical debridement. The obvious question is what the additional contribution is of adding the laser in this setting. The majority of patients in this series had combined extrinsic compression along with endobronchial tumor requiring stenting in 90% of patients. This combination of treatment modalities is consistent with our own experience and further questions the added utility of the laser given its cost, technical requirements, and risks. Although we enthusiastically agree with the authors that endobronchial palliation of malignant airway obstruction provides prompt and durable palliation for these patients, we would disagree that laser vaporization is a mainstay of this therapy. Physicians and surgeons adept at rigid bronchoscopy, but without access to a laser, can achieve similar results by mechanical coreout of the endobronchial tumor, with the addition of stenting for extrinsic compression, or residual or recurrent endobronchial tumor. The authors have considered obstruction of the bronchus intermedius as a contraindication for their techniques due to the concern of laser perforation of the overlying pulmonary artery. However, the bronchus intermedius is a common site of symptomatic airway obstruction and can be palliated as readily as the trachea or mainstem bronchi by similar endoscopic strategies. Patients with malignant endobronchial disease often have profound symptoms, with our series revealing 56% of patients in respiratory distress, 21% of patients with stridor or wheezing, 16% of patients with pneumonia, and 6% of patients presenting with respiratory failure requiring intubation. 4 In a series of 466 procedures for