Techniques of endoscopic airway tumor treatment

Abstract

Interventional bronchoscopy has a predominant role in the management of both early and advanced-stage airway tumors. Given the very poor prognosis of lung cancer, there is a need for new tools to improve early detection and bronchoscopic treatment of endo-bronchial precancerous lesions. In more advanced stages, interventional bronchoscopy plays an important role, as nearly a third of lung cancers lead to proximal airway obstruction. This will cause great discomfort or even life-threatening symptoms related to local extension, such as dyspnea, post-obstructive pneumonia, and hemoptysis. Surgery for very locally advanced disease is only effective for a limited number of patients and the effects of conventional antitumor therapies, like radiation therapy or chemotherapy, are inconstant and are too delayed in a palliative context. In this review, we aim to provide pulmonologists with an exhaustive technical overview of (I) the bronchoscopic management of benign endobronchial lesions; (II) the bronchoscopic management of malignant tumors, including the curative treatment of localized lesions and palliative management of malignant proximal airway stenosis; and (III) descriptions of the emerging endoscopic techniques used to treat peripheral lung tumors.

Keywords: Interventional bronchoscopy; airway stent; brachytherapy; central airway obstruction; laser; lung cancer.

Figure 1

Example of brachytherapy for an endobronchial infiltration of the upper left lobe. Bronchoscopic view of the two catheters (1= apical of the culminal bronchus; 2= anterior segment of the culminal bronchus); showing local dramatic improvement: before (A) and after (B) the three first fractions (6 Gy); (C) planning of dose distribution from radiographic images.

Figure 2

Example of a scanographic result after laser treatment, mechanical debulking, and airway stenting (a Dumon Y stent^®) of a life-threatening malignant central-airway obstruction involving the carina (A); (B) frontal view after airway stenting; (C,D) scanographic sagittal views after airway stenting.

Figure 3

Example of a bronchoscopic result after stenting of the primary main carina for a malignant stenosis of the right main bronchi. (A) Extrinsic compression of the right main bronchus; (B) result after airway stenting (a Dumon Oki stent^®); (C) CT-scan after stenting.

Figure 4

Examples of stents available: from left to right: (A) Polyflex^®; (B) Covered Ultraflex^®; (C) Silmet stent^®; (D) Nova-Stent^®; (E) Dumon stent^®; (F) Dynamic Freitag^® stent; (G) Hood stent^®.

Figure 5

Bronchoscopic management of an airway metastasis (type I) from a fibrolamellar hepatocellular carcinoma. (A and C) Complete intraluminal obstruction of the left main bronchus (bronchoscopic and scanographic views); (B and D) results after laser and mechanical debulking.