Treatment of Malignant Airway Obstruction with YAG Laser Photo Resection

Abstract

Thirty percent of inoperable lung malignancies involve the trachea or proximal main bronchi and may cause significant respiratory distress, hemoptysis, and postobstructive pneumonia. We report a case of successful debulking of a non-small-cell lung cancer (NSCLC) involving the carina and both main bronchi using YAG-laser photo resection (LPR). CASE REPORT A 77-year-old woman was transferred to our hospital for further management of respiratory failure due to malignant large airway obstruction. Prior to admission, she had experienced 3 weeks of dry cough and progressive dyspnea, but no hemoptysis, fever, chills, night sweats, or weight loss. On the day of admission she had a respiratory arrest and was intubated. She was a nonsmoker with no significant medical or surgical history. An urgent flexible bronchoscopy (FFB) at the referring hospital revealed a large vascular appearing tumor overlying the main carina. She was then transferred to our facility for further management. A computed tomographic scan of her chest revealed a large subcarinal mass extending into the trachea and both main bronchi. FFB at our facility confirmed the presence of a saddle-shaped vascular tumor arising from the carina and causing subtotal occlusion of the right main bronchus and more than 80% occlusion of the left main bronchus (Fig. 1). Biopsy of the lesion showed NSCLC. She was extremely difficult to ventilate, with an arterial blood gas showing pH 7.24, Paco2 89 torr, Pao2 114 torr while paralyzed and on synchronized intermittent mandatory ventilation of 16, tidal volume 250 mL, and positive end-expiratory pressure of 5 cm H2O and pressure support of 10 cm H2O on 50% Fio2. She was taken to the operating room for YAG–LPR rigid bronchoscopy and successful opening of the luminal obstruction was achieved using 15,997 joules of energy (Fig. 2). Arterial blood gas after laser therapy revealed pH 7.46, Paco2 49 torr, and Pao2 105 torr, on 30% Fio2. She was successfully extubated over the next few days, and was discharged to home. She underwent radiation therapy as an outpatient and, at last follow-up 2 months after discharge, her functional status had resumed to baseline.FIG. 1.: Flexible bronchoscopy shows saddle-shaped tumor arising from carina with subtotal occlusion of the right main bronchus and 80% occlusion of the left main bronchus.FIG. 2.: Bronchoscopic view of the carina immediately after YAG laser therapy shows successful opening of the luminal obstruction.DISCUSSION Eighty percent of all newly diagnosed lung cancers are not resectable for cure. Of these, 30% involve the carina and proximal main bronchi, accounting for significant morbidity and a dismal prognosis. This case demonstrates the utility of YAG-LPR in patients with severe respiratory compromise due to such lesions. In the largest reported case series of laser resection, over 90% of patients experienced immediate airway patency and improvement in quality of life. 1 The site and the degree of invagination, rather than histologic features of the tumor, dictate the quality of result. Lesions involving the trachea have the highest immediate response and those with extrinsic compression the least. Improvement of pulmonary status, shorter duration of ventilatory support, radiologic clearance, and better survival have all been reported in patients undergoing YAG-LPR compared with patients receiving only conventional therapy. 2–5 What favors YAG-LPR over conventional methods such as mechanical debridement, external beam radiation, or cryotherapy is its rapid effect and better immediate palliation. A more timely weaning from mechanical ventilation also expedites discharge to a home environment. CONCLUSION YAG-LPR can achieve immediate resolution of symptoms and improvement in quality of life in advanced stage lung carcinoma involving the proximal airways. In less advanced tumors, YAG laser can either be curative (carcinoma in situ) or serve as a bridge to other treatment options (external beam radiation, brachytherapy, cryotherapy). YAG-LPR should therefore be considered in all patients with inoperable malignant central airway tumors who would otherwise have little chance of survival or acceptable quality of life.