Journal of Bronchology & Interventional Pulmonology:
Therapeutic Bronchoscopy Followed by Lobectomy for Pulmonary Sarcoma
Hata, Yoshinobu MD, PhD*; Takagi, Keigo MD, PhD*; Sato, Fumitomo MD*; Isobe, Kazutoshi MD, PhD†; Mitsuda, Aki MD, PhD‡; Shibuya, Kazutoshi MD, PhD‡; Goto, Hidenori MD*; Sasamoto, Shuichi MD, PhD*; Otsuka, Hajime MD*
Departments of *Chest Surgery
‡Surgical Pathology, Toho University Omori Medical Center, Tokyo, Japan
Disclosure: There is no conflict of interest or other disclosures.
Reprints: Yoshinobu Hata, MD, PhD, Department of Chest Surgery, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Ota-ku, Tokyo 143-8541, Japan (e-mail: firstname.lastname@example.org).
Received December 05, 2012
Accepted December 10, 2012
Malignant central airway obstruction is a life-threatening presentation requiring emergency palliative procedure. In selected patients, bronchoscopic intervention could be used as a bridge to curative resection. Here we report a 54-year-old male with pulmonary sarcoma of the right upper lobe, presenting with acute respiratory failure because of endobronchial extension. Emergency coring with the rigid bronchoscope and Dumon stent insertion stabilized the patient, and subsequent lobectomy resulted in occurrence-free survival over a 71-month follow-up.
A central airway obstruction is frequently a life-threatening presentation requiring emergency relief procedures. Although most patients who require bronchoscopic intervention are not candidates for curative surgery, preliminary bronchoscopic relief can increase operability and improve surgical results in a selected group of patients.1 Here we report a patient with pulmonary sarcoma presenting with acute respiratory failure because of its endobronchial extension. Emergency coring out of the lesion and Dumon stent insertion followed by lobectomy resulted in recurrence-free survival for a 71-month follow-up period.
A 54-year-old male was referred with dyspnea and complete collapse of the right lung due to the tumor effect (Fig. 1A). His SpO2 was 94% on supplemental oxygen at 3 L/min. Patient was being considered for right pneumonectomy. On day 3, his dyspnea suddenly progressed and SpO2 declined to 90% on supplemental oxygen at 10 L/min. Chest computed tomography revealed right pneumothorax and endobronchial extension of the lesion protruding into the main trachea (Figs. 1B, C). The lumen of the truncus intermedius was patent and the aeration of the middle and lower lobes was maintained. Incidental pneumothorax seemed to collapse the right lung and push the polypoid extension proximal to the carina. A chest tube was inserted and emergency rigid bronchoscopy was performed. The endobronchial lesion was cored out using the beveled end of the rigid bronchoscope. The stump of the lesion was completely occluding the right upper lobe orifice. To retain patency, a straight Dumon stent of an appropriate size was placed in the right main bronchus, sealing the right upper bronchial orifice. The patient became ambulatory without requiring oxygen supplementation on the next day. Histologic examination of the cored out specimen revealed spindle-shaped undifferentiated malignant tumor, suspicious for sarcoma. After thorough evaluation, he underwent removal of the Dumon stent and a right upper and middle bilobectomy, 13 days after the therapeutic bronchoscopy (Fig. 2A). Examination of frozen samples revealed that the resection margin of the right upper bronchus free of tumor. Dumon stent was reinserted at the site of anastomosis. The resected specimen revealed the presence of an undifferentiated sarcoma, 90 mm in size (Figs. 2B, C). The patient has since remained well without any evidence of tumor recurrence during 71 months of follow up. The Dumon stent was removed at 14th month as the patient had remained symptom free during the period.
Bronchoscopic intervention for malignant central airway obstructions is usually palliative. However, as Mathisen and Grillo2 pointed out that we must be aware of the surgical options available to these patients. There are now several reports describing therapeutic rigid bronchoscopy with mechanical coring out or laser ablation before successful curative surgery (Table 1).1–5 In our institute, 5 patients with acute respiratory failure have undergone emergency bronchoscopic intervention and subsequent surgery. Three of these patients went on to become long-term survivors of >5 years (Table 2).6,7
For patients with life-threatening central airway obstruction, emergency bronchoscopic relief results in stabilization and provides sufficient time for evaluation and planning the appropriate therapy.4,5 Although emergency surgical resection is an option, surgical risk and potentially unnecessarily excessive resection can be minimized by prior bronchoscopic relief.5 Procedures for bronchoscopic intervention may vary according to the indications. Rigid-bronchoscopic debulking, with adjunct laser therapy or electrocautery, is recommended for emergency recanalization9,10; an obstructing lesion can be “cored out” quickly, and argon plasma coagulation is suitable for superficial coagulation. Chhajed et al5 reported that combined argon plasma coagulation and mechanical debridement was the most frequently used method, at 56% of cases, followed by laser resection in 17%.
The proportion of patients going on to resection after the emergency intervention is reported to be 9.5% to 29% in different centers.1,2 In our institute, from January 2001 through December 2010, only 6.5% (5 of 77) of such patients then underwent later surgical resection. This represented 0.7% of all resected primary lung tumors (n=696). In the literature reporting on patients resected after emergency intervention, the most common histologic diagnosis was squamous cell carcinoma (45% to 58%).1,5 In contrast, our 5 cases consisted of sarcoma in 2, poorly differentiated adenocarcinoma in 2, and small cell carcinoma in the remaining patient. Poorly differentiated tumors may tend to show more rapid growth, resulting in endobronchial polypoid extensions and acute respiratory failure, especially for those tumors originating in the right upper lobe.
Regarding the interval after the initial intervention before eventual surgery, Venuta et al4 reported that induction chemotherapy was started 2 to 3 weeks after laser resection, to completely clear the airway of secretions. Chhajed et al5 reported that surgical resection of their patients had taken place between 1 and 23 weeks after bronchoscopy. Among the 5 cases in our institute, a 22-year-old patient who underwent sleeve pneumonectomy 40 days after the intervention suffered local recurrence. For best results, it may be that subsequent surgery should be planned without delay for patients with rapidly growing tumors.
Stent placement is usually not recommended in patients with potentially resectable malignant disease owing to the possible risks of mucous retention, infection, and damage to the healthy mucosa by stimulating formation of granulation tissue.1,5 Chhajed et al5 reported 2 patients with severe poststenotic pneumonia who had undergone stent insertion to achieve patency of the airway until surgical resection. In the present patient, a Dumon stent was inserted for sealing the right upper bronchial orifice to protect against endobronchial egression. Because the surgical margin was free of tumor, bronchial suturing was performed at the right upper bronchus where the mucosa was not in contact with the Dumon stent. In another patient in our series, during right sleeve pneumonectomy with extended resection of 5 cartilaginous rings of the trachea and 2 rings of left main bronchus, anastomotic stricture occurred and a Dumon stent was inserted and fixed at the anastomotic site.7 The postoperative course of the presented patient was uneventful, and the stent was removed 14 months after surgery. Dumon stent insertion is not generally to be recommended, but could be considered if necessary for protection against regrowth or anastomotic strictures.
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coring out; Dumon stent; pulmonary sarcoma; acute respiratory failure
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