Fibrobronchoscopic cryosurgery for secondary malignant tumors of the trachea and main bronchi

Abstract

Background: Patients with secondary malignant tracheal and main bronchial tumors may suffer severe symptoms as a result of major airway obstruction. Curative surgical resection is usually not suitable because of the presence of metastatic disease and poor performance status. In this study, the use of bronchoscopic cryosurgery to reopen the airway is analyzed.

Methods: The clinical records of 37 patients who experienced secondary maglinancies from December 2001 to January 2013 were retrospectively reviewed. Low temperature cryotherapy (-50°C to -70°C) was delivered to the central part of the tumor by cryoprobe for four to six minutes causing destruction of the tumor mass (Cryo-melt method). Subsequently, the edge of the tumor was frozen for 30 seconds to two minutes, followed by piecemeal removal of the frozen tumor tissue (Cryo-resection method).

Results: The endpoints of the study were degree of symptomatic improvement and survival. The rates of dramatic and partial symptomatic alleviation were 57.1% and 28.6%, respectively, there were no intraoperative deaths, and median survival was 16.0 months. Prolonged survival was significantly correlated to age (under 60 years of age 22.2% vs. over 60 100%, P = 0.011), tumor location (main bronchi 0% vs. trachea 77.8%, P = 0.003), and cryorecanalization times (once 33.3% vs. twice or more 80.0%, P = 0.037).

Conclusion: Bronchoscopic cryorecanalization is a safe, effective, non-invasive choice for improving the symptoms of malignant airway obstruction. In addition to achieving local-regional control, the technique may also contribute to improved survival.

Keywords: Airway obstruction; bronchoscopy; cryosurgery; secondary tracheobronchial tumors.

Figure 1

Cryorecanalization of the uterus leiomyosarcoma (type I). (a) Fibronchoscopy revealed a polypoid lesion totally obstructing the left main bronchus. (b) The tumor was frozen with the cryo‐probe. (c) Cryo‐melt and cryo‐resection were combined to remove the tumor completely. (d,e) The left main bronchus was recanalized after extraction of the tumor. (f) Polypoid tumor tissue was smooth and soft with a pedicel on the internal bronchial wall. The size of the tumor was 6 cm × 1.5 cm.

Figure 2

(a) A 64‐year‐old man with lung squamous cell carcinoma of the right upper lobe. Fibrobronchoscopy revealed a mass covered by necrotic tissue totally obstructing the right upper lobe. (b) There were no lesions on the anastomotic stoma 17 months after complete right upper lobe sleeve resection. (c,d) Multiple discrete lesions were found on the tracheal wall with exophytic propagation. (e) Illustration of type I disease. (f) Tracheal tumors were totally removed by cryoresection.

Figure 3

Cryorecanalization of the thyroid papillary carcinoma (type II). (a) Chest computed tomography revealed the right tracheal wall was invaded by recurrent thyroid papillary carcinoma. (b) Fibrotic bronchoscopy showed a submucosal mass protruding into the tracheal lumen. (c) Illustration of type II disease. (d) Eighty percent of the tumor was removed after cryotherapy, leaving a a wide tumor basement remaining.

Figure 4

(a) Superfine curved cryosurgical probe. (b) The metal tip of the probe (5 mm). (c) Formation of an ice ball after 70 seconds of freezing.

Figure 5

(a) Chest computed tomography revealed the left main bronchus was totally obstructed by left upper lobe atelectasis. (b) The left lung recovered spontaneously after cryorecanalization, and multiple pulmonary nodules were found in both lungs (the same patient as in Fig 1).