Several local modalities of therapy can be used for palliation of lung cancers involving the bronchial wall.
Guideline: Endobronchial therapy with brachytherapy, lasers or photodynamic therapy may provide symptomatic benefit for patients with bronchial obstruction.
Level of Evidence: II
Grade of Recommendation: B
Brachytherapy
Brachytherapy refers to endobronchial radiotherapy using a high dose rate microSelectron. The objective of the treatment is to palliate symptoms of shortness of breath, hemoptysis or cough in patients with obstructive bronchial cancers. The treatment is performed by placing a small plastic catheter into the obstructed bronchial lumen via the biopsy channel of a fibre-optic bronchoscope. The advantage of this treatment over YAG laser therapy lies in its simplicity. The treatment is done under local anesthesia similar to a standard fibre-optic bronchoscopy. In addition, brachytherapy is efficacious in treating the mucosal component of the tumour, it can also treat the submucosal and part of the peribronchial component of the tumour. The treatment is well tolerated by patients who do not present with respiratory distress or failure. The later group of patients are best managed by YAG laser therapy.
YAG Laser
The Neodymium Yttrium-Aluminum-Garnet (YAG) laser is a useful tool for coagulation and vaporization of malignant tissue. It provides an effective means for reopening obstructed tracheal or bronchial lumen in patients with inoperable obstructive endobronchial tumours. The procedure is generally done under general anesthesia using rigid bronchoscopy. Its major indication is in patients presenting with respiratory distress or respiratory failure due to obstruction of the trachea or main carina by tumour. The objective of the treatment is to palliate symptoms of dyspnea, cough or hemoptysis.
Photodynamic Therapy
Photodynamic therapy refers to the use of a photosensitizing drug which selectively accumulates in the tumour such as porfimer (PHOTOFRIN®) in combination with light to treat malignant tumours. The treatment is done under local anesthesia similar to a standard fibre-optic bronchoscopy twenty-four to forty-eight hours after intravenous injection of porfimer. A red laser light is conducted to the tip of the bronchoscope by a fine quartz fibre to activate the porfimer in the tumour tissue to produce a photochemical reaction to destroy the tumour. It is a potentially curative treatment for small early bronchial cancers that are confined to within the bronchial wall. The major indication of photodynamic therapy is in patients with small early lung cancers who are inoperable due to limited pulmonary capacity and in patients with multiple bronchial cancers.
Stents
Stents are silicone tubes with or without a metal spring. They are sometimes helpful in maintaining a patent airway in patients with extrinsic compression of the airway by tumour in patients who have failed radiotherapy.
Key References:
Mostovych M, Mathisen, D. Management of malignant airway obstruction. Lung Cancer: Principles and Practice. Pass HI, Mitchell JB, Johnson DH, Turrisi AT. Lippincott-Raven, Philadelphia, 1996,663.
Lam S, Muller NL, Miller RR, et al. Predicting the response of obstructive endobronchial tumors to photodynamic therapy. Cancer 1986;58:2298
