Bronchoscopic cryosurgery for metastatic tumor causing central airway obstruction: A case report

Abstract

Rationale: Bronchoscopic cryotherapy has been considered as one of the optional interventions for unresectable malignant central airway obstruction (CAO). And it provides high safety and effectiveness in airway patency re-establishment. This report describes the interventional bronchoscopic cryotherapy for a patient with CAO caused by squamous cell carcinoma of the esophagus. We display a series of dramatic change of chest radiographs before and after the intervention.

Patient concerns: A 70-year-old man with squamous cell carcinoma of the middle third of the esophagus (initial staging, pT2N0M0; stage IIB; in January 2017) underwent Video-assisted esophagectomy and reconstruction with a gastric conduit via a substernal route. Following Chest computed tomography and positron emission tomography revealed disease progression with paratracheal metastases. Progressive dyspnea and chest pain lasted for a month, and he was admitted to the ER.

Diagnoses: Blood gas analysis revealed type I respiratory failure (pH, 7.445; PaO2, 69.4 mmHg; PaCO2, 40.6 mmHg). Other laboratory data were grossly normal. Chest radiography revealed a total left lung collapse. Chest CT identified a tumor blocking the left mainstem bronchus with the consolidation of the left lung.

Interventions: Dexamethasone and epinephrine inhalation were administered for initial symptom relief. Bronchoscopy performed 4 days after admission revealed a huge tumor completely occluding the left mainstem bronchus orifice. The occlusion was completely resolved following cryotherapy. Then, the first course of palliative chemotherapy with cisplatin plus fluorouracil, followed by the second course a month later, was administered.

Outcomes: The latest chest radiograph showed a patent airway. The patient's condition remained stable for at least the following 2 months.

Lessons: Malignant CAO is a rare but potentially life-threatening condition. Several acceptable bronchoscopy techniques exist for treatment. Cryotherapy has high safety and effectiveness in airway patency re-establishment.

Figure 1

Chest CT before cryotherapy. (A) At 2 months before admission, the left mainstem bronchus (white arrow) was compressed by a tumor mass. (B) After admission, the left mainstem bronchus (black arrow) was obstructed by a paratracheal tumor. CT = computed tomography.

Figure 2

Chest radiographs (A) before cryotherapy (left lung total collapse) and (B) 1 day after cryotherapy (much clearer left lung marking).

Figure 3

Bronchoscopic cryotherapy. (A,B) Left mainstem bronchus (black arrow) was completely obstructed. (C) Cryotherapy via rigid bronchoscope. (D) After cryoablation, an opening was made. (E) Branches of left main bronchus could finally be visualized.

Figure 4

Chest radiographs. (A) Four days after cryotherapy, there was a dramatic change in the left lung. Only left pleural effusion was noted. (B,C) At 17 days 1 month after cryotherapy, there was bilateral full-lung expansion.