Endobronchial Resection Research Articles

Endobronchial resection as a bridge to curative resection in patient with poor preoperative lung function secondary to an airway blocking endobronchial carcinoid tumour

We present a 70-year-old gentleman with chronic cough with haemoptysis found to have left lower zone collapse on imaging. The bronchoscopy showed an endobronchial mass histologically of a non-secreting atypical carcinoid. Poor baseline lung function excluded surgical resection, and instead, he successfully underwent a bronchoscopic debulking procedure which improved his FEV1 to 84% and DLCO 83% predicted. Unfortunately, the tumour regrew, but the calculated percentage predicted postoperative for FEV1 (64%), and DLCO (65%) enabled definitive surgical resection to take place. Surgical resection remains the definite curative option for localised endobronchial atypical carcinoid tumours. Achieving this in proximal endobronchial carcinoid tumour is a challenge. We described an endoscopic tumour debulking procedure as a bridge for curative surgical resection in a patient with an inoperable proximal atypical carcinoid tumour due to poor predicted postoperative lung function. We highlighted the need to assess predicted postoperative lung function with functional and quantitative perfusion methods to aid surgical planning. Debulking the tumour by endoscopy can be used as a conduit to curative surgical resection in bronchial carcinoid tumour. The choice of calculating the percentage predicted values by either or both methods must be individualised based on tumour location and the probability of converting a lobectomy to a pneumonectomy. This precautionary approach could evaluate the postoperative lung function and morbidity and mortality risk if considering a pneumonectomy. Endoscopic debulking can be a successful bridge to a curative surgical resection aided by comprehensive preoperative lung function tests to predict postoperative lung values

A case of multiple squamous papillomas in the trachea treated by rigid bronchoscopy.

Key messageTracheal papilloma is a rare benign lung tumour. It often recurs and sometimes transforms into a malignant tumour. While historically radical resection has been the primary treatment, endobronchial resection, a less invasive procedure to manage the airway using a flexible and rigid bronchoscope, was effectively used in our patient.

Benign Endobronchial Tumors: A Clinicopathologic Review.

Purpose: Benign endobronchial tumors are rare entities that can be difficult to diagnose because they often present with non-specific symptoms and vague radiographic findings. The current study reviews the clinical, radiologic and pathologic features, diagnosis, and treatment of patients with benign endobronchial tumors.Methods: We examined the charts of all patients who presented with biopsy-proven benign endobronchial tumors at a tertiary-care academic medical center between 1993 and 2018. Pertinent clinicopathologic and radiologic data were analyzed, with particular attention paid to treatment modalities and mean overall patient survival.Results: A total of 28 cases were identified. The most common benign neoplasm was hamartoma (37%), followed by lipoma (19%), squamous papilloma (11%), pleomorphic adenoma (7%), mucin gland adenoma (7%), papillary adenoma (3%), hemangioma (3%), neurofibroma (3%), leiomyoma (3%), and papillomatosis (3%). Cough (58%), shortness of breath (44%), and hemoptysis (15%) were the most frequent presentations. Most cases demonstrated well-defined submucosal or pedunculated endobronchial lesions with segmental pneumonia or atelectasis on imaging. Histologic diagnosis was obtained by endobronchial resection in 43% of patients, thoracoscopic lobectomy in 36%, endobronchial biopsy in 18%, and thoracoscopic wedge resections in 3%. All procedures were performed with no intraoperative or in-hospital deaths (mean overall survival: 20.2 years).Conclusion: Benign endobronchial tumors typically present as well-defined submucosal and/or pedunculated lesions, and may lead to post-obstructive complications. Endobronchial resection is the preferred strategy for diagnosis and treatment of these tumors.

Typical carcinoid involving the main carina managed with arterial embolisation, endobronchial resection and ablation, ultimately followed by carinal resection

Bronchial carcinoids are uncommon pulmonary tumours, and the gold standard management is surgical resection. Their management is often complicated by their proximal location and propensity to bleed when manipulated. A...

ED04.01 Surgery in Bronchopulmonary Typical and Atypical Carcinoids

ED04.01 Surgery in Bronchopulmonary Typical and Atypical Carcinoids

Dyspnea, Fatigue, and Generalized Weakness in a 67-Year-Old Man: Approach to the Patient Between Guidelines and Clinical Judgment

Mucormycosis are an emerging group of life-threatening fungal infections caused by filamentous fungi of the Mucorales family. Mucormycosis are most common in stem-cell transplant recipients and patients with underlying hematologic malignancies, poorly controlled diabetes mellitus, trauma, neutropenia, corticosteroid and deferoxamine therapy due to deficiency of phagocytic function, elevated serum levels of available iron and host-pathogen interaction. The fungi penetrate blood vessels causing endothelial damage and extensive angioinvasion with infarction, necrosis, and thrombosis of different tissues. Mucormycosis carries a very high mortality in cases of pulmonary disease, with even higher rates when there is difficulty establishing the diagnosis. We present a case of 67-year-old man with pulmonary form of mucormycosis presenting as opportunistic infection post induction chemotherapy for acute myeloid leukemia FAB M2. We treated the patient with intravenous amphotericin B for 4 weeks and endobronchial resection, after which he clinically and radiographically improved. Overall, early consideration of mucormycosis can lead to an earlier diagnosis, medical and surgical therapy, and an increased survival rate. Furthermore, we provide a real example of multiple thinking strategies, needed for a patient oriented clinical practice. Overall, this case is a challenging example between clinical judgment and available validated guidelines.

Endobronchial tumor laser resection: handling anesthetic challenges through a modified technique

Reported is a case of left mainstem bronchus carcinoid that was managed by means of a modified technique using a microlaryngeal tube for right lung ventilation and laser resection using an AMBU Ascope. The upper lobe of the left lung showed dramatic improvement on postoperative chest radiograph and computed tomography scan. Precautions for laser surgery and sharing of the airway by the surgeon and the anesthetist were taken care of during ventilation of the right lung. Soiling and tumor migration of the opposite lung were prevented intraoperatively and postoperatively.

Combined Bronchial Artery Embolization and Endobronchial Resection for Bronchial Carcinoid: A Safety and Feasibility Pilot Study

Background: There is growing evidence to support bronchoscopic resection of well-circumscribed typical carcinoids. However, massive bleeding and risk of recurrence can potentially complicate this approach. Objectives: The aim of this study was to assess the safety and feasibility of endobronchial resection of carcinoids preceded by bronchial artery embolization. Methods: Five patients with centrally located typical carcinoids were recruited, 4 with a curative intent and 1 for palliation of a carcinoid with mediastinal invasion. All patients underwent selective embolization of the feeding bronchial artery 24-48 h prior to endobronchial resection, which was performed with a rigid bronchoscope and neodymium:yttrium-aluminium-perovskite laser. Results: Minimal bleeding was noted during tumour resection. After a median (range) follow-up of 20 (14-48) months, only the case with segmental extension of the tumour had local recurrence, which was treated successfully using cryotherapy (with negative endobronchial biopsies since), and no cases of metastatic spread occurred. One patient, in whom the histopathological diagnosis was changed from typical to atypical carcinoid following resection, went on to have a surgical bilobectomy 3 months later. Extensive fibrosis was noted at the site of original tumour resection with no evidence of residual disease. Conclusions: Bronchial artery embolization prior to endobronchial resection of centrally located carcinoids is feasible and safe. The reduction in bleeding may facilitate and simplify the procedure. The possible application of this combined therapy to the management of atypical carcinoids warrants the design of a larger prospective clinical trial.

Traitement par bronchoscopie rigide de l’obstruction maligne des voies aériennes centrales

Endobronchial resection is now the standard treatment for tracheobronchial narrowing due to malignancy. The clinical and functional respiratory improvement has been evaluated previously but only in heterogeneous population. Between February 2009 and February 2011, we conducted a prospective single centre study at the University Hospital of Lille. Twenty-five patients with malignant tracheobronchial stenosis received a clinical and functional respiratory evaluation before and after a rigid bronchoscopy procedure to reduce the obstruction followed where appropriate by placement of an endobronchial stent. Thirteen patients (52%) had primary lung cancer and in 12 the tumor had another origin. Nineteen patients (76%) received a stent after bronchial unblocking. Clinically, all patients felt an improvement in their dyspnea estimated by the Borg score with a median improvement of -2 points [-1; -4] following the procedure (P<0.001). In 96% the dyspnea visual analogic scale improved by 40 mm [27; 67] (P<0.0001). The FEV1 increased significantly after unblocking by 9% [-3.5; 28.5] (P<0.05). The Rint decreased significantly by -0.19 kPa/L per second [-0.06; -0.023] (P=0.001). Correlations between scales of dyspnea and spirometric values were not significant (P>0.05). The survival rate at 1 year was 29%. Interventional bronchoscopy decreases dyspnea. It modestly improves respiratory function and decreases the Rint. However, lung function and dyspnea scales are not correlated. No spirometry factor can predict clinical dyspnea response but an elevated Borg dyspnea scale might be a good indicator.

Bronchial Fibroepithelial Polyp: A Case Report and Review of the Literature

Fibroepithelial polyps of the bronchus are uncommon. We herein report a rare case of a recurrent bronchial fibroepithelial polyp. A 61-year-old man was admitted to the hospital due to recurrent pneumonia. Chest computed tomography showed consolidation and atelectasis in the right lower lobe. Bronchoscopy revealed a mobile polypoid tumor protruding from the right lower lobe bronchus. We performed endobronchial resection, and a pathological examination revealed a fibroepithelial polyp. However, surveillance bronchoscopy performed six months after tumor resection detected a relapse. We herein report a case of a recurrent bronchial fibroepithelial polyp and also review the relevant literature.

Endobronchial brachytherapy provides excellent long-term control of recurrent granulation tissue after tracheal stenosis

PurposeTo review the experience of using endobronchial brachytherapy (EBB) as a treatment for recurrent tracheal granulation tissue. Methods and MaterialsPatients referred for EBB at the Rabin Medical Center for benign stenosis were reviewed with institutional review board approval. Patients underwent bronchoscopic resection of granulation tissue followed by insertion of self-expanding metallic stents. After stenting, repeat laser resection was done at least 1 week before brachytherapy. After CT simulation, patients had three-dimensional brachytherapy treatment planning. A single 10-Gy dose was prescribed to 1.0cm from the source and treatment was delivered using high-dose-rate afterloader with 192Ir source. Patients were followedup with bronchoscopy every 3 months after the completion of therapy. ResultsFrom November 2001 to January 2009, 29 patients were treated with EBB to prevent granulation tissue reformation. Median age was 70 years and 55% of patients were male. Ninety percent of patients were treated to the trachea and the remaining patients had stenoses in the main stem bronchi. The primary cause of stenosis was prolonged mechanical ventilation (76%). The median time from stent placement to brachytherapy was 69 days. Median active length of treatment was 7cm. With a median followup of 36 months, 66% (19 of 29) of patients remained free of granulation tissue. Forty-eight percent of patients have died, with all except 1 patient dying of their underlying condition. A single patient experienced death from tracheoesophageal fistula. ConclusionEBB is an effective and safe treatment to prevent recurrent granulation tissue formation after endobronchial resection and should be considered in patients who are unable to undergo surgical resection.

Endobronchial Fibroepithelial Polyp Treated by Endobronchial Resection

Endobronchial Fibroepithelial Polyp Treated by Endobronchial Resection

Gammagrafía con análogos de la somatostatina en el diagnóstico y el seguimiento del carcinoide bronquial pediátrico

Carcinoid tumor is a rare neuroendocrine neoplasm with different locations, the most frequent ones during the pediatric age being the appendix and lung. Scintigraphy with (111)In-DTPA-d-Phe(1)-octreotide has led to an importance advance in the diagnosis of extension in carcinoid tumor patients. We present three pediatric patients with bronchial carcinoid studied with somatostatin analogue scintigraphy (SSRS). The first patient (9 years) was studied using the SSRS after surgery due to carcinoid tumor in the right lower lobe in which tumor remains was observed (this being clearer in the tomography study). The second patient (10 years) presented due to endobronchial tumor in the left lower lobe together with atelectasis of the LUL and emphysema of the LLL. Radiology imaging techniques suggested the differential diagnosis between the endobronchial carcinoid tumor or plasma cells or foreign body gramuloma. The SSRS showed an abnormal deposit of activity in the left hemithorax consisted with carcinoid tumor. No other areas suggesting metastasis were observed. After the surgery (endobronchial resection), new controls with SSRS showed absence of disease. The third patient (12 years) came after a lobectomy (RUL) due to bronchial carcinoid. The SSRS did not show any abnormal areas of activity. In the subsequent control (3 months), a deposit of activity was observed in the middle third of the right hemithorax, after which a lobectomy was performed (RLL and ML) that showed small remains of neuroendocrine carcinoid. Subsequent controls were negative. The SSRS has demonstrated great utility in the diagnosis, follow-up and staging of pediatric patients, carriers of neuroendocrine carcinoid tumors.

Long-Term Follow-Up of Flexible Bronchoscopic Treatment for Bronchial Carcinoids with Curative Intent

Background. Typical pulmonary carcinoids represent less than 5% of primary lung tumors. In patients with typical bronchial carcinoid, formal surgical resection still remains the gold-standard treatment. Data regarding long-term outcome in using flexible bronchoscope-based modalities under conscious sedation is very limited. Objectives. We sought to investigate, over extended follow-up period, the effectiveness of endobronchial resection for carcinoid tumors with curative intent using flexible bronchoscopy. Methods. Nd:YAG laser photoresection using flexible bronchoscope under conscious sedation. Follow-up included repeat bronchoscopy every 6 months and chest CT every year. Results. Ten patients aged 24 to 70 years with endobronchial carcinoid were treated. The tumor location was variable: 2 left Main bronchus, 1 left upper lobe bronchus, 2 right main bronchus, 2 right middle lobe bronchus and 3 right lower lobe bronchus. No major complications were observed. The patients required between 2 and 4 procedures. Patients were followed for a median period of 29 months with no evidence of tumor recurrence. Conclusions. Endobronchial laser photoresection of typical bronchial carcinoids using flexible bronchsocopy under conscious sedation is an effective treatment modality for a subgroup of patients that provides excellent long-term results that are similar to outcome obtained by more invasive procedures.

A Rare Case of a Tracheal Fibroepithelial Polyp Treated by an Endobronchial Resection

This report describes a very rare case of a tracheal fibroepithelial polyp. A 69-year-old male had been treated in this department because of chronic obstructive pulmonary disease since 2006. In July 2007, chest computed tomography revealed a bronchial tumor located at the distal end of the trachea. A bronchoscopic examination revealed a multilocular polyp. An endobronchial resection was performed to remove the lesion. A tracheobronchial fibroepithelial polyp is very rare. We herein describe and discuss the appropriate therapeutic policy and also review the pertinent literature.

Pleomorphic Adenoma with an Endobronchial Resection

A case of bronchial pleomorphic adenoma is herein presented. The patient came to the hospital for a detailed examination of a bronchial polyp that was detected by computed tomography. Chest computed tomography revealed a bronchial tumor which was located at the distal end of the left main bronchus. The patient refused surgical resection. An electrosurgical snare was performed two times and the patient received several rounds of argon plasma coagulation with a flexible bronchoscope. The diagnosis of a pleomorphic adenoma was made following examination of the resected specimens. No recurrence has been observed by biopsy at the resected site.

Intraluminal bronchial carcinoid resection by bronchoscopy

Pulmonary carcinoid tumour is an uncommon malignant neoplasm derived from the surface or glandular epithelium of the conducting or transitional airways. It is a neuroendocrine neoplasm that arises from the enterochromaffin cells of the amine precursor uptake and decarboxylation system of bronchial mucosa. They represent 1-2 % of all pulmonary neoplasms [1, 2, 3, 4]. The carcinoid tumours can be divided into two clinicopathological types, typical and atypical. They behave like low grade malignant tumours and have a high rate of resectability and better prognosis [5]. The prognosis depends on size of tumour, histological type, nodal involvement and the presence of metastasis. Majority of carcinoids are located centrally within the trachea and mainstem bronchi and are reachable with flexible bronchoscope [3, 4, 5]. Curative surgical resection with focus on lung sparing or bronchoplastic surgery is the treatment of choice [1, 2, 5]. Endobronchial laser resection via rigid or flexible bronchoscope can photocoagulate and vaporize lesions. The potassium titanyl phosphate (KTP), argon dye, yttrium aluminium pevroskite (YAP), neodymium-yttrium aluminium garnet (Nd:YAG) and diode lasers are suitable for use in fibreoptic bronchoscopes. The Nd:YAG laser is currently preferred for airway resection because of its predictable effect on living tissue (photocoagulation or vaporization), depending on the amount of energy applied [6,7]. At 980 nm diode laser shows a smaller optical penetration depth than the Nd:YAG laser at 1064 nm. Thus with identical application parameters, higher temperatures are produced with the diode in most tissues at superficial and interstitial applications. Most experts use flexible bronchoscope for laser photoresection [6]. We report a case of bronchial carcinoid in the left main bronchus causing collapse of left lung. The endobronchial resection via diode laser resulted in complete removal of obstruction with an excellent result.

P1-014: Easy endobronchial resection technique with a new device

P1-014: Easy endobronchial resection technique with a new device

Long-term outcome of bronchoscopically resected endobronchial typical carcinoid tumors

Typical pulmonary carcinoid tumors represent less than 1% of lung tumors. In a subgroup of patients with this abnormality, the tumor is entirely endobronchial. We assessed the long-term outcome of such cases in which the patient was managed with endobronchial resection only. Patients who underwent bronchoscopic resection for a typical carcinoid tumor were identified through case records and histology reports. Data were collected retrospectively, but follow-up was on a prospective basis through the outpatient clinic. Between 1978 and 2004, 28 patients underwent bronchoscopic resection of endobronchial carcinoid tumors. The mean age was 49 years (standard deviation, 19 years; age range, 11-82 years), with 46% (13/28) of the patients being male. The tumor arose from the left bronchial tree in 61% (17/28), with the most common site being the left lower lobe bronchus (8/28). On average, patients required 5 bronchoscopic resections to achieve complete resection. The median follow-up was 8.8 years (interquartile range, 4.5-13.7 years). At 1 and 10 years, 100% and 94% of patients were disease free, respectively. The 1- and 10-year survivals were 89% (interquartile range, 84%-93%) and 84% (interquartile range, 77%-91%), respectively. In a selected group of patients, proximal polypoid typical bronchial carcinoid tumors can be treated endobronchially with good outcome.

Emergency resection of a carinal adenoma

A man aged 46 developed acute stridor and fibreoptic bronchoscopy showed a large pedunculated mass at the carina. The right main bronchus was completely obstructed and the left main bronchus about 50% obstructed. Biopsies were non-diagnostic. CT showed the mass to occupy the distal tracheal lumen and there was a large posterior extrabronchial component (Figure 1). The posterior tracheal wall bisected the tumour mass. Endobronchial resection, attempted via a rigid bronchoscope, caused moderate bleeding into the distal airways and the procedure was terminated. Over the next two days ventilation became increasingly difficult, high inflation pressures being required to achieve satisfactory tidal volumes and adequate oxygenation. A decision was made to attempt carinal resection through a right thoracotomy; on left lateral positioning, however, he could not be ventilated satisfactorily and inflation pressures and pCO2 rose. Therefore cardiopulmonary bypass was established by femoro-atrial cannulation. After median sternotomy the superior mediastinal structures were dissected out and the anterior pericardium was mobilized as a pedicle with a broad base of attachment to the aortic arch. The trachea was incised just above the carina to expose the endotracheal tumour (Figure 2). The posterior component arising from the posterior tracheal wall and the adjacent main bronchi was excised with a circumferential margin of normal tracheal wall. The pericardial flap was rotated to bring its serosal surface into the tracheal lumen, and was sutured to the margins of the resulting defect in the posterior wall of the trachea and principal bronchi. Completion bronchoscopy showed widely patent distal trachea and principal bronchi. Mechanical ventilation had to be continued for seven days because of non-cardiogenic pulmonary oedema. Three weeks postoperatively he underwent bronchoscopy and dilatation of a mild anastomotic stricture. After another four weeks he was discharged home. The final pathological diagnosis was pleomorphic adenoma with apparently complete resection. Over the ensuing four months he required three further tracheal dilatations, which were increasingly difficult. He then underwent permanent stenting of the left main bronchus and distal trachea with two Gianturco non-covered wire stents. 2 years later he had no stridor and was symptom-free.