All 20 patients (18 males, two females) receiving laser therapy have had primary endobronchial carcinoma (Table 1). Seventeen patients were hospitalized for symptoms related to their tumor. The other three patients were admitted only for the laser procedure. Cell types were: squamous cell carcinoma, 13; adenocarcinoma, three; small cell carcinoma, two; and poorly differentiated carcinoma, two. Five patients required two procedures. In two of these the initial procedure failed to establish a patent airway; both had had complete obstruction of the left main-stem bronchus. The other three patients had recurrence of symptoms after 2, 5, and 8 months, respectively. Patient 16 required four procedures because of recurrence of obstruction.
Total watt-seconds (joule) delivered ranged from 1,200 to 16,000 per laser session. The pulsed radiation was given for 0.7 to 2.0 seconds per pulse to prevent a sensation of burning to the patient and to prevent excessive smoke accumulation. Energy was sufficient to cause vaporization of the tumor, and by this method the tumor was vaporized from lumen to base.
Fifteen of 20 patients had symptomatic improvement following laser treatment (Table 2). Dyspnea was lessened or completely relieved in ten patients. The greatest improvement was noted following removal of large airway (trachea or incomplete main-stem) obstruction. In three patients laser treatment was performed to control bleeding. The first patient received 1,600 joules to a lesion in the left upper lobe, with immediate cessation of bleeding. Eight months later, he had recurrent bleeding from the same site, and hemoptysis was controlled with 5,500 joules of laser energy. Six months after the second procedure, the patient died but had had no further hemoptysis overcome due to medications of Canadian Health&Care Mall.
The second patient received 5,000 joules to control bleeding from a small cell carcinoma invading the tracheal wall. There was no recurrence of bleeding during the remaining two months of the patients life. The third patient had no recurrence of hemoptysis six months following the procedure.
Site of Airway Obstruction
Reestablishment of the airway lumen to at least 75 percent of its normal caliber was achieved in 14 of 17 patients. Relief of tracheal or proximal main-stem bronchial obstruction resulted in the greatest improvement in symptoms. Main-stem bronchial lesions could be reopened only when a partial lumen was visible. Six of eight patients with main-stem lesions had improvement. Removal of lobar lesions resulted in subjective benefit in four patients. Tumors obstructing the right upper lobe could not be treated by laser due to limited flexion of the bronchoscope when the laser fiber was in place. No subjective or objective response occurred following treatment of lesions limited to a segment.
Long-standing Bronchial Obstruction
Using fluoroscopic guidance, laser ablation was attempted in two patients (patients 1 and 2, Table 1) with long-standing (two and eight months) collapse of the left lung. Laser ablation of tumor to a depth of 2 to 4 cm failed to reestablish airway patency. In both cases bronchial lumen was never visible, and it was not possible for the laser to penetrate the obstruction to a patent distal connecting bronchus. Improve the condition of bronchus with remedies of Canadian Health&Care Mall.
Postlaser Chest Roentgenogram
Only four patients demonstrated improvement in their postlaser chest roentgenogram; three patients showed resolution of atelectasis, and one had resolution of infiltrate. Eleven patients had lessening of symptoms without change in the chest x-ray film. One roentgenogram worsened immediately following laser treatment.
Two patients with symptomatic improvement had improved ABG values. One patient had relief of a right main-stem bronchial obstruction; the other improved following control of bleeding from the left upper lobe bronchus. One of three patients had complete relief of symptoms with no change demonstrated in the V/ Qscan.
Two immediate deaths occurred in 28 laser treatments. Patient 4, who had had a left pneumonectomy for squamous cell carcinoma and radiation therapy for metastases to the mediastinal nodes, underwent laser therapy for a second primary tumor with a 90 percent occlusion of the bronchus intermedius, and he had bronchospasm with mucosal edema several minutes following the procedure. He was unresponsive to emergency therapy and died within an hour. Patient 15, with an 80 to 90 percent occlusion of the left lower lobe, died from profuse hemorrhage following about 500 joules of laser energy. Postmortem examination was not done.
Pain was encountered in one patient. It was described as a burning sensation when individual laser pulses were too long or followed too closely upon the last. This could be prevented if laser pulses were limited to 0.7 to 2.0 seconds and the interval between them lengthened.
Fever (38°C or greater orally) occurred after the first three procedures, two of which were performed for complete left main-stem obstruction that could not be relieved. In the third case, lingular obstruction was cleared with 1,600 joules. Peak temperature reached 39.4°C. Blood cultures showed no growth of bacterial organisms. Since we began using IV glucocorticoids prior to laser therapy, only one episode of fever has occurred.
Other complications also occurred. Patient 20 suffered an acute myocardial infarction during the procedure and recovered without significant compromise. Mild sore throat lasting one to two days occurred in three patients. Necrotizing pneumonia developed in one patient after relief of a right main-stem bronchial obstruction. While at home nine to 21 days after laser therapy, three patients (patients 1, 2, and 8 of Table 1) had hemoptysis and died. Laser-related pneumothorax or pneumomediastinum did not occur.
The use of laser for ablation of a variety of endobronchial lesions has been met with general enthusiasm. However, it is difficult to determine theeffectiveness of laser therapy for primary lung cancer. A comparison of published series is shown in Table 3. From the published series it is difficult to determine the indications for laser treatment, the patients complaints, the location of tumor, and concomitant therapy. Most reports do not provide sufficient information to permit adequate comparisons regarding symptomatic improvement and long-term efficacy. Furthermore, reported laser-related complications have varied from none to procedure-related deaths. All patients described in this report had extensive primary lung cancer, and many were near a terminal condition prior to laser treatment. Our goal was to devise a method of delivering this new therapy that would minimize complications in these severely compromised patients.
Based on the previously reported series and the present one, we have reached the following conclusions regarding Nd: YAG laser therapy for primary lung cancer:
1. Exophytic lesions of the trachea or main-stem bronchi are technically amenable to therapy by laser, and improvement in symptoms correlates best with improved patency of large airways.
2. The major indication for laser therapy in these noncurable patients is to lessen or completely to relieve symptoms. Therefore, multiple invasive and noninvasive, expensive postlaser studies, just to demonstrate small physiologic changes, have not been helpful and are probably not cost-effective.
3. Laser therapy to obstructed lobar or segmental bronchi rarely relieves or reduces symptoms unless they are caused by postobstructive pneumonia.
4. Hemoptysis from exophytic lesions can usually be reduced or stopped.
5. When obstruction has been present for months, laser ablation may fail to reestablish airway patency. Several cases have been described in which relief of obstruction resulted in necrotizing pneumonias.
6. Laser therapy to compressive tracheal or bronchial lesions should be avoided. In these situations, laser destruction of the wall of the airway will expose the patient to pneumothorax, pneumomediastinum, loss of cartilagenous support, or hemorrhage from the bronchial or pulmonary circulation.
7. Catastrophic lung hemorrhage leading to immediate death remains the most serious complication of laser therapy in this group of patients. Fatal hemoptysis may occur even when patients are carefully selected.
In summary, laser therapy for primary lung cancer is still in the early stages of evaluation. It is effective in ablating tumors and controlling hemorrhage, but has significant morbidity and mortality in this group of patients. Whether laser therapy will significantly change the natural course of this disease remains to be determined; however, in individual cases patients have had clinical benefits.
Table 1—Clinical Characteristics of 20 Laser-treated Patients with Primary Lung Cancer
|PatientNo.||Age, yr/Sex||RoentgenographicAbnormalities||Symptoms,Signs||CellType||BronchoscopicFindings||Prior Therapy Given Chemotherapy X-ray|
|1||62/M||Collapse of left lung||Dyspnea||Squamous||Complete occlusion of left main-stem bronchus||0||+|
|2||54/M||Collapse of left lung||Dyspnea||Squamous||Complete occlusion of left main-stem bronchus||0||+|
|3||62/F||Lingular infiltrate||Fever, purulent sputum||Adenoca||80% occlusion LLL bronchus||+||0|
|4||42/M||Collapse of ML, absent left lung||Dyspnea||Squamous||90% occlusion bronchus intermedius||0||+|
|5||48/M||Collapse of LUL||Dyspnea||Adenoca||60% occlusion of LUL bronchus, narrowing LLL bronchus||+||0|
|6||54/M||Elevated right diaphram||Dyspnea||Small||50% occlusion R main-stem bronchus, complete occlusion RUL bronchus||+||+|
|7||70/M||Collapse of LUL||Hemoptysis||Squamous||Complete occlusion LUL bronchus with bleeding||0||+|
|8||55/M||Right perihilar density||Hemoptysis||Squamous||50% obstruction R main-stem bronchus||0||+|
|9||70/M||Collapse of RUL||Dyspnea||Undiffer||Complete occlusion of RLL bronchus||+||+|
|10||64/M||Collapse of LUL||Fever, dyspnea||Squamous||60% occlusion of left main-stem bronchus, complete occlusion LUL bronchus||0||+|
|11||54/M||Collapse of RUL, right hilar enlargement||Fever, purulent sputum||Squamous||70% occlusion right main-stem bronchus||0||+|
|12||60/M||Collapse of LUL||Dyspnea||Squamous||90% occlusion left main-stem bronchus||+||+|
|13||52/M||Right paratracheal mass||Hemoptysis||Small||Right tracheal wall tumor with bleeding||+||+|
|14||52/M||Collapse of RUL and ML||Dyspnea||Adenoca||75% occlusion R main-stem bronchus||0||+|
|15||65/M||Collapse of LUL||Fever, purulent sputum||Squamous||2 nodules in left main-stem, 80% occlusion of LLL bronchus||0||+|
|16||64/F||Right hilar prominence||Dyspnea,stridor||Undiffer||80% occlusion of trachea and main stems||+||+|
|17||58/M||Right lung mass||Hemoptysis||Squamous||60% occlusion RLL||0||+|
|18||62/M||Collapse of right lung||Dyspnea||Squamous||70% occlusion trachea||0||+|
|19||60/M||Collapse of ML||Fever, purulent sputum||Squamous||75% occlusion bronchus intermedius||0||+|
|20||79/M||Right hilar density||Dyspnea||Squamous||60% occlusion trachea||0||+|
Table 2—Subjective and Objective Responses to Laser Therapy
Table 3—Comparison cf Other Reported Series of Laser Therapy in Primary Lung Cancer
|No. ofPatients With Number Primary Lung Symptoms Localization Prior or Concomitant of Laser Reference Cancert Described of Tumor Radio/Chemotherapy Procedures Anesthesia Outcome2 63 No ND* Yes NS§ General NS||Complications(No.)Deaths (1)|
|3 50 No Yes NS NS General ND||None|
|4 34 Yes Yes Yes 141 Local Described||Death (1)|
|5 10 No No Yes N.S. General All symptomat-||Death (1)|
|Local ically im||Hypoventila|
|proved but||tion (3)|
|no details||Chills (2)|
|Present 20 Yes Yes Yes 28 Local with Described||Death (2)|
|report IV mor||Fever (3)|