Management of Airway Problems in Lung Cancer Patients Using the Neodymium-Yttrium- Aluminum-Garnet (Nd-YAG) Laser and

Endobronchial Radiotherapy Nicholas Lang, MD, Ann Maners, MD, John Broadwater, hiD, Kris Shewmake, MD, David Chu, ~!o,

Kent Westbrook, MD, Little Rock, Arkansas

This study summarizes our experience in the evolu- tion of a management technique for unresectable or recurrent lung cancer using the neodymium-ynri- um-aluminum-garnet (Nd-YAG) laser with high- dose endobronchial brachytherapy. The laser gave good palliation for hemoptysis and obstruction with a low complication rate, and the addition of endo- bronchial radiotherapy was a useful adjunct for maintaining airway patency. Iligh-dose brachyther- apy delivered by the Gammamed lli | remote after- loader proved to be the best method of delivering this treatment.

M " anagement of airway problems in lung cancer pa- tients is a frustrating task because no definitive

treatment exists. Lung cancer can affect the airway by obstruction or hemoptysis and result in the patient seek- ing medical assistance. This study summarizes our expe- rience in the evolution of a management technique com- bining endobronchial laser therapy with high-dose endobronchial brachytherapy. This has proved to be a safe, easy method for the treatment of airway obstruction or hemoptysis.

MATERIAL AND METHODS From November 1985 through February 1988, 55

patients were treated for airway problems related primar- ily to lung cancer. The patients were referred for laser bronchoscopy because more conventional therapy (sur- gery or external radiotherapy) had failed or could not be tolerated by the patient. Before treatment, each patient was reviewed by a surgical oncologist, a medical oncolo- gist, and a radiation oncologist to plan overall therapy. In

From the Department of Surgery, University of Arkansas for Medical Sciences; the John L. McClellan Veterans Administration Medical Center; and the Central Arkansas Radiation Therapy Institute, Little Rock, Arkansas.

Requests for reprints should be addressed to Nicholas Lang, MD, 4301 West Markham, Slot 520, Little Rock, Arkansas 72205.

Presented at the 40th Annual Meeting of the Southwestern Surgi- cal Congress, Phoenix, Arizona, April 10-13, 1988.

addition, most patients were seen by a pulmonary medi- cine specialist before treatment.

The age of the patients ranged from 26 to 79 years, with an average age of 54 years. Forty-eight were men and seven were women. Patients were referred for airway obstruction (71 percent) hemoptysis (12 percent) or both (17 percent). Primary tumor occurred in the lung in 95 percent of patients studied; of these, squamous cell carci- noma was the most common tumor treated (73 percent). The most common tumor site was the right or left main- stem bronchus (49 percent) with distal sites (lobar bron- chi) occuring slightly less frequently (35 percent). Tra- cheal problems were least frequent (16 percent). The upper lobe bronchus required treatment in 40 percent of the patients.

All patients were treated by one surgeon using the neodymium-yttrium-aluminum-garnet (Nd-YAG) laser (Molectron 8000 ND| Cooper LaserSonics, Santa Clara, CA) delivered by a flexible quartz fiber (model 8255) through a Pentax FB19D or FB19H flexible bron- choscope (Pentax, Orangeburg, NY). During the laser treatments, the patients were maintained on less than 50 percent forced inspiratory oxygen. In addition to stan- dard blood pressure and electrocardiographic monitor- ing, each patient was monitored continuously for oxygen saturation, forced inspiratory oxygen, and exhaled car- bon dioxide during the procedure. The quartz fiber tip was cooled using a high flow of air (50 ml/s) through the Teflon | sheath.

The patients were divided into three groups according to therapy used. Group I (18 patients) were treated with the endobronchial laser only. The treatment was repeated at 3- to 10-day intervals until an open airway was achieved, then repeated only when the patients became symptomatic. Group II (16 patients) received endobron- chial laser therapy plus conventional dose (50 to 120 cGy/hour) brachytherapy. Each course required hospi- talization in a shielded room for 2 to 4 days while the catheter was in place. This group was treated at 7- to 28- day intervals for 1 to 3 coarses. Therapy was repeated when the patients became symptomatic. Group III (21 patients) received endobronchial laser therapy, if neces- sary, to allow passage of a guide catheter or to control hemorrhage followed by high-dose endobronchial bra- chytherapy (675 cGy/min at 1 cm) delivered by a Gam- mamed IIi (Isotopentechnik, Haan, W. Germany) re- mote afterload!ng unit. The brachytherapy lasted for 4 to 15 minutes, after which the catheter was removed. The

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LANG ETAL

patients were then discharged or observed overnight de- pending on their condition.

RESULTS Group I patients received an average of 1.7 laser treat-

ments of 5,517 joules per treatment. The procedure re- quired an average of 55 minutes operating room time. Three patients were treated for hemoptysis; the rest were treated for obstruction of the trachea (one patient), main stem bronchi (eight patients) or lobar bronchi (six pa- tients). Sixteen patients in this group died, with a mean survival of 12 weeks after the first treatment. Two pa- tients were alive at 2 and 20 weeks after the first treat- ment.

Group II patients received an average of 2.2 laser treatments of 6,762joules per treatment. The laser thera- py and catheter placement required an average of 53 minutes operating room time. In addition, the patients received an average of 1.6 endobronchial low-dose bra- chytherapy treatments using iridium 192. One patient in this group was treated for hemoptysis and the others, for obstruction of the trachea (three patients), main stem bronchi (six patients) or lobar bronchi (six patients). Six- teen patients in this group died an average of 18 weeks after the first treatment. Two patients were alive at 89 and 91 weeks after therapy. The endobronchial radiation delivered was an average of 2,500 cGy at 5 to 10 mm per treatment, requiring 24 to 48 hours of endobronchial catheter placement. During this time, the patients were housed behind a radiation shield in a private room.

Group III patients received an average 1.3 laser treat- ments of 2,480 joules per treatment. In addition, each patient averaged 1.4 high dose endobronchial braehy- therapy treatments with iridium 192. The laser therapy and catheter placement required an average of 48 min- utes operating room time. The patients in this group were treated for hemoptysis (two patients) or obstruction of the trachea (three patients), mainstem bronchi (nine pa- tients), or lobar bronchi (seven patients). Eight patients in this group died an average of 12 weeks after the first treatment, and 13 patients were alive at 2 to 49 weeks after the first treatment. The endobronchial radiation delivered was an average of 800 cGy at 5 to 10 mm per treatment, requiring 4 to 15 minutes of endobronchial catheter treatment. After the treatment catheter was re- moved, the patient was discharged or observed overnight, depending on the patient's condition.

During 87 endobronchial laser treatments, the only life-threatening complication was one tension pneumo- thorax that was recognized and treated without sequela. There were no bronchial or tracheal perforations. Several brass tips were lost off the quartz fiber; all were recovered without problem.

Three patients had problems because an obstruction was relieved that opened into an abscess cavity. One of these patients died 3 days after laser therapy. The other two survived several months but the draining abscess cavity never resolved. Both patients eventually died from respiratory failure without receiving radiotherapy. No patient had respiratory failure due to inhaled smoke from

the laser therapy. Many patients had reocclusion of the obstructed airway from a mucus plug. This was managed with bronchoscopy and plug removal.

Only two patients had a complication related to com- bined laser and radiotherapy. After five courses of laser therapy and three courses of radiotherapy (one low-dose, two high-dose brachytherapy) for a tracheal lesion, one patient developed necrosis down to the tracheal rings with three exposed cartilages. No symptoms were referrable to these exposed areas. The second patient developed ex- posed cartilage rings after one high-energy laser treat- ment and one high-dose brachytherapy treatment. No symptoms were referrable to the exposed tracheal rings.

The low-dose method was uncomfortable for the pa- tients because the catheter had to stay in place for a prolonged period. Two patients coughed up the catheter before the planned end of the treatment session. No pa- tient developed airway obstruction symptoms due to ei- ther type of catheter.

COMMENTS Airway problems are most often due to squamous cell

carcinoma of the lung, with obstruction being the usual presentation. Those patients inoperable because of poor pulmonary function or unresectable because of tumor location present the physician with few good treatment choices. External beam radiotherapy can provide some relief but is limited both in treatment area and total dose that can be given. Chemotherapy is likewise limited by a poor response rate and the low tolerance of normal tis- sues. Since Toty et al [1] and Dumon et al [2] outlined methods for Nd-YAG laser photoresection of endobron- chial lesions in patients, interest in this method has in- creased. Several characteristics make this laser ideal for use in the bronchus: (I) The wavelength of the Nd-YAG laser light (1,050 nm) allows transmission through a flex- ible quartz fiber; (2) this wavelength is poorly absorbed by hemoglobin or water, thus giving deeper penetration; and (3) the unit is capable of tissue vaporization because of its high-power output.

The Nd-YAG laser proved very efficient at handling hemoptysis. Treatment failed in only one patient, and this failure was due to a technical problem--the site of hem- orrhage was in the parenchyma and could not be reached. This patient was treated with a right upper lobe lobecto- my. A second patient died from hemorrhage 9 months after the last laser treatment. He refused retreatment when the bleeding started 1 week before death. Obstruct- ing lesions can likewise be managed with the Nd-YAG laser. This usually requires more power and there is a greater risk of perforation. In addition, the obstructing lesions tend to recur. For these reasons, endobronchial radiotherapy seemed a reasonable addition to laser thera- PY.

Although Yankauer [3] first reported endobronchial radiotherapy in 1921, it was not in common use until the development of flexible bronchoscopes in the late 1960s. Schray et al [4] of the Mayo Clinic reported the use of endobronchial laser therapy with conventional-dose bra- chytherapy. A small catheter, placed through the biopsy

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AIRWAY PROBLEMS IN LUNG CANCER PATIENTS

channel of the flexible bronchoscope, acts as a guide for an iridium 192 after-loaded wire. The dose of radiation given is 50 to 120 cGy/hour. Although this system had a good response, there were problems. The first difficulty involved protecting hospital personnel while the patient underwent the 24 to 48 hours of radiotherapy. This re- quired a private room and lead shielding for the patient. The second problem was catheter displacement. Keeping the catheter in place for up to 48 hours proved very difficult for some patients. Complete catheter displace- ment occurred in two patients. Finally, the exact length of the iridium 192 source was not always available. This resulted in suboptimal treatment or excessive treatment depending on the length of the source. These problems have been addressed by the use of the Gammamed IIi computer-controlled remote afterloader [5]. This device allows the bronchoscopists to map very specific areas for treatment. The radiotherapist can then plan optimal and exact treatment for the patient's disease.

Our experience with 21 patients using 28 laser thera- py treatments and 30 radiotherapy treatments demon- strates the safety and utility of this method. Those pa- tients in good general condition are treated as outpatients receiving both laser and endobronchial radiotherapy on the same day. Two patients in this group had exposed tracheal cartilage rings, but no other complications relat- ed to treatment have occurred.

Based on our experience, we conclude that (1) tra- cheobronchial obstruction or hemoptysis in the inopera- ble cancer patient can be managed safely with the Nd- YAG laser; (2) endobronchial radiotherapy is a useful adjunct in malignant obstructing lesions of the tracheo- bronchial tree; (3) the Gammamed IIi high-dose system is a significant improvement over conventional dose bra- chytherapy in ease of use and radiation safety; and (4) repeated application of laser and endobronchial radio- therapy can be performed with low complication rates.

REFERENCES 1. Toty L, Personne C, Colchen A, Vourch G. Bronchoscopie management of tracheal lesions using the neodymium yttrium alu- minum garnet laser. Thorax 1981; 36: 175-8. 2. Dumon JF, Reboud E, Garbe L, Aueomte F, Merit B. Treat- ment of tracheobronchial lesions by laser photoresection. Chest 1982; 81: 278-84. 3. Yankauer S. Two cases of lung tumor treated bronchoscopically. NY MOd J 1922; 115: 741-2. 4. Schray MF, McDougall JC, Martinez A, Cortese DA, Brutinel WM. Management of malignant airway compromise with laser and low dose rate brachytherapy. Chest 1988; 93: 264-9. 5. Alberti W, Bauer PC, Busch M. The management of recurrent

or obstructive lung cancer with the Essen afterloading technique and the neodymium-YAG laser. Technical and clinical consider- ations. Tumordiagn 1986; 7(suppl 1): 22-5.

DISCUSSION Ronald C. Elkins (Oklahoma City, OK): Laser ther-

apy has developed over the past several years with the management of endobronchial disease. There are two different laser systems available: the YAG laser and the carbon dioxide laser. The choice really varies by surgeon.

One of the interesting things that has been suggested is that laser therapy is more effective and easier to use if external beam irradiation in a dose greater than 2,000 rads is given before use of the laser. A concern of laser therapy relates to its risk for both immediate and late mortality and morbidity. Certainly, in this series, there was an incredibly low morbidity rate.

Some have suggested that before use of laser therapy, one should carefully evaluate the ventilation-perfusion scans of the patient so that the laser is not used to open up a segment of the lung that has no perfusion because it has been blocked by the tumor process. Of the patients who had laser therapy, the worst prognosis occurred in three found to have significant pulmonary abscess. Dr. Lang, what is your thought about the management of a patient who has presumed distal abscess from an obstructing carcinoma of the lung? Finally, do you think there is a role for laser therapy and phototherapy in patients who have extensive carcinoma of the lung?

Nicholas P. Lang (closing): Dr. Elkins, we go down the endobronchial tree to subsegmental bronchi in most patients. Our current management of abscesses is to use external-beam radiation first so that we get a very slow opening of the obstruction that the patient can tolerate. I have not used the ventilation-perfusion scan. Some people are enthusiastic about this method, whereas others have very little confidence in it. I certainly agree that extrinsic compression of the airway is one problem that cannot be managed very well with the laser and endobronchial ra- diotherapy.

Many patients in this series received external beam treatment, some before we treated them, some concomi- tantly, and some after laser and endobronchial radiother- apy. We have not been able to tell whether it is better to give external radiotherapy before or after laser therapy. Most of our patients were treated to prevent or relieve pneumonia. None of these patients had ventilation prob- lems sufficient to require respirator support at the time of treatment.

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