Bronchoscopic ablation techniques in the management of lung cancer

Abstract

Central airway involvement is a common manifestation of lung cancer during the disease course. Some patients will require bronchoscopic therapeutic interventions to palliate symptoms, or less commonly to provide more definitive therapy of airway involvement. We describe an overview specifically of bronchoscopic ablative techniques that are available for use in malignant airway obstruction. Techniques that are more commonly used include bronchoscopic application of laser, electrocautery, argon plasma coagulation (APC), cryotherapy and mechanical debulking techniques. Less commonly employed are brachytherapy and photodynamic therapy. These techniques may be applied via flexible or rigid bronchoscopy depending upon the clinical scenario. The choice of technique depends on available tools and expertise, the urgency of the clinical scenario, and whether the lesion is predominately endobronchial, extrinsic compression, or a combination of both. Malignant airway obstruction is a common finding in lung cancer and there are a number of effective bronchoscopic ablative techniques that may be employed safely to palliate patients with a significant symptom burden.

Keywords: Lung cancer; airway obstruction; argon plasma coagulation (APC); brachytherapy; bronchoscopy; cryotherapy; debulking; electrocautery; laser; microdebrider; photodynamic therapy.

Figure 1

Multimodality bronchoscopic ablation of medial right mainstem bronchus tumor. (A) Tumor visualization prior to treatment; (B) mechanical debulking with microdebrider; (C) post-treatment after debridement followed by application argon plasma coagulation.

Figure 2

Multimodality bronchoscopic ablation of mid-tracheal obstructing tumor. (A) Tumor visualization prior to treatment; (B) Nd:YAP laser application for devascularization prior to debulking; (C) mechanical debulking (core-out technique) with beveled edge of rigid bronchoscope.

Figure 3

Multimodality bronchoscopic ablation of obstructing right mainstem tumor. (A) Application of Nd:YAP laser for devascularization of tumor prior to mechanical debulking; (B) mechanical debulking (core-out technique) with beveled edge of rigid bronchoscope; (C) removal of tumor through the rigid bronchoscope with rigid cupped forceps.

Figure 4

Bronchoscopic tumor ablation modalities. (A) Application of argon plasma coagulation (APC) to tumor base; (B) application of spray cryotherapy (SCT) in circumferential manner to tumor and surrounding involved mucosa.