Case Report
Palliative Care for Stenosing Central Lung Tumors: Case Report
Meshkov MV1*, Kazakov NV2, Kovalev MG2 and Rusanov AA2
1Department of Surgery, Centrosoyuz Hospital, Moscow, Russia
2Department of Surgery, Pavlov First Saint Petersburg State Medical University, St. Petersburg, Russia
*Corresponding author: Mikhail Meshkov, Department of Surgery, Centrosoyuz Hospital, Moscow, Russia
Published: 26 Feb 2018
Cite this article as: Meshkov MV, Kazakov NV, Kovalev
MG, Rusanov AA. Palliative Care for
Stenosing Central Lung Tumors: Case
Report. Clin Surg. 2018; 3: 1927.
Abstract
General condition of a number of patients at the time of diagnosis of central lung cancer or during
the therapy period may be quite severe and not allow the continuation of medication or other
special treatment, as well as prolonged endoscopic treatment. Of times, the cause of the severity
of the condition is total or partial tracheal obturation or primary bronchial obturation with the
development of the following complications.
Keywords: Paracancroic pneumonia; Lung destruction; Intoxication; Acute respiratory failure;
Strident breathing; Asphyxia
Introduction
Expansion of such complications requires urgent medical measures including endobronchial
procedures for palliative purposes, which improve the quality of life and lifetime expectancy [1,2]. In
national and foreign scientific literature there are practically no works devoted to the combination
of endoprosthesis placement and local and regional combined treatment with the use of various
physical influencing factors, including PDT and argon plasma coagulation of stenosing central lung
cancer. There is no a single multicentre trial, but occasionally there are certain case reports [3,4].
There is no cross-light on applicability of regional treatment of unresectable central stenosing lung
tumors after stenting.
For recent years there are known dynamically developing endoscopic techniques that offer
the possibility of intraluminal treatment and have an advantage over other techniques due to
low invasiveness and high effectiveness [5,6]. Sometimes, such variants of endoscopic treatment
as photodynamic therapy and argon plasma coagulation for the purpose of destruction are the
only possible methods of treatment or an alternative to surgical treatment. However, a patient’s
population who may be submitted to intraluminal therapy is limited due to diminution of the
central bronchus or trachea and severe respiratory failure associated with this narrowing, which
makes it impossible to conduct completed intraluminal treatment.
There are known results of combined treatment of regional malignant tumors of the trachea and/
or bronchus(Arseniev A.I. et al. [7] patent of the Russian Federation No. 2372119, publ., 10.11.2009),
as a preparation for brachytherapy and radiotherapy, including an argon plasma recanalization
of the lumen of the trachea and/or bronchus at rate of 60W-80W and subsequent photodynamic
therapy with the use of medications of chlorin e6 derivatives and radiation of a semiconductor laser
with a wavelength of 662 nm. In comparison with, for example, laser recanalization this method
allows to double duration of the recurrence-free period. However, argon plasma effect of high rate
for the purpose of recanalization, for example, with complete tumor obstruction and inability to
accurately establish the anatomical structure of the lumen, can lead to the wall perforation, bleeding
and development of other life-threatening complications. In addition, argon plasma recanalization
takes quite a long time, which limits the possibility of its use in a large number of severe patients with
obstruction of primary bronchus and trachea and infectious-associated purulent complications.
We have proposed a method for the safe and effective treatment of central stenosing lung cancer,
which includes both endoprosthetic placement and subsequent regional therapy aimed at tumor
cytoreduction, increasing and maintaining ventilation of intact lung parenchyma.
Indications for the implementation of the developed methodology are:
• Histologically proven lung cancer (bronchus).
• Presence of tumor tissue visualized by bronchoscopy,
lumen stenosing of the main bronchus or trachea, or extraluminal
tracheal/bronchial compression (exophytic, mixed or compression
version of tumor stenosis).
• Violation of ventilation of the pulmonary parenchyma
distal to the bronchospasm stenosis, lung atelectasis.
• Possibility of restoring the patency of the trachea/bronchus,
ventilation of the lung lobe or the entire lung after restoration of
bronchial/tracheal lumen.
• Duration of atelectasis of the intact part of the lung less
than 6 weeks.
• Life time expectancy is not less than 6 months.
• Assessment of general status due to ECOG scale < 2.
Absolute contraindications to endoprosthetic replacement and
combination therapy:
• Total tumor lesion of the lung parenchyma.
• Acute myocardial infarction, cerebral circulation disorder.
• III degree cardiovascular insufficiency.
• Decompensated renal and hepatic insufficiency.
• Presence of any contraindications to chemotherapy and/or
surgery, not mentioned above.
• Photosensitizer allergy.
Relative contraindications:
• Chronic co-morbidities not mentioned among absolute
contraindications.
• Exhaustion (body weight less than 70% of that due).
• Atelectasis of the intact part of the lung for more than 6
weeks.
Technical result achieved by proposed treatment modality is to
expand the patient’s population who can be treated with endobronchial
completed treatment. The result is achieved by the implantation of
endoprosthesis into the site of the stenosing tumor, through which
subsequent photodynamic therapy and argon plasma coagulation of
the proliferating tumor tissue is carried out. Photodynamic therapy
and argon plasma coagulation are repeated as necessary every 3-6
weeks, depending on the results of the dynamic observation. In
treatment of patients with exophytic tumors, the uncoated metal
frame stent ensures the implementation of argon plasma coagulation
of prolapse tumor tissue through the stent, while it is sufficient to
limit the activity of argon (up to 35W-45W instead of 60W-80W) to a
minimum, minimizing the likelihood of complications.
Figure 1
Figure 2
Figure 3
Case Presentation and Discussion
Patient P., 59 years old. Clinical diagnosis: squamous cell
carcinoma of the right upper bronchus with transition to the right
main bronchus. Admission complaints: fever, 39°C to 40°C; Shortness
of breath on moderate physical exertion, weakness, exhaustion, cough
with purulent sputum. Due to Rg-logical and CT-studies, atelectasis
of the entire right lung was revealed, signs of obstructive pneumonia
in the atelectasized lung (Figure 1). After computer modeling an
extension of oncological stenosis of the main bronchus was defined
1 cm, 8 cm in length. Videobronchoscopy has demonstrated an
obstruction of the right main bronchus with formation of a narrow
slot in fronterior-lateral wall, through which a mucus-purulent
content is being discharged. On May 12th 2011 patient underwent
surgery prior to which he was injected a Dexter loading dose (1 mg/
kg) intravenously during 20 min with subsequent introduction of
titration 1-1,4 mg/kg/hr. 30 min prior an intervention an ampule
of Akupan (20 mg) was introduced intravenously. For sedation
improvement a Propofol was injected intravenously in the dosis of 0,
3 mg/kg, fractionally. Monitoring of ECG, SpO2, EQ was provided.
During the operation via guide a stenting with endoprosthetics
SES-0-12-20. Duration of surgery-4,5 min (Figure 2). After stent
implantation additionally Atropin solution is injected and sanation
of bronchi of the lower and middle lobes was performed for 12 min.
Postoperative period was uneventful [1-3]. Following treatment
was administered: infusion, antibacterial therapy, bronchial
spasmolytics, expectorates. After 24 hours the patient's condition improved significantly, temperature normalized, signs of intoxication
were absent. Control radiography on the third day revealed a stent
visualized with clinico-radiographic data of adequate ventilation of
the middle and lower lobes (Figure 3). Photodynamic therapy up to
achieving energy density of 100 J/cm2 is performed in a pulse mode
«though stent» on May 16th 2011 (Figure 4).
Argon plasma coagulation with argon flow 1,8 liter in a minute
with energy 35W is performed «through stent» right after PDT (Figure
5). Hereafter every 1, 5-2 month’s patient was admitted to hospital for dynamic examination and performing of local endobronchial
treatment, which included photodynamic therapy and argon plasma
coagulation [4-7]. Remission and observation period-14-months.
Application of the developed method-performing of endobronchial
PDT and APC in the presence of endoprosthesis of trachea/large
bronchus allows significantly expanding the patients population
which can receive combined treatment of central lung cancer, enables
quick and total restoration of respiratory function and reducing of
intoxication, to largely improve patients’ condition, have longer
and more frequent remissions in comparison with endoprostesis
placement without PDT.
Figure 4
Figure 5
References
- Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin. 2012;62(1):10-29.
- Alberts WM. Introduction to the Third Edition: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2013;143(5):38S-40S.
- Cai XJ, Li WM, Zhang LY, Wang XW, Luo RC, Li LB. Photodynamic therapy for intractable bronchial lung cancer. Photodiagnosis Photodyn Ther. 2013;10(4):672-6.
- Allison RR. Photodynamic therapy: oncologic horizons. Future Oncol. 2014;10(1):123-4.
- Sokolov VV. Clinical experience of Gerzen Oncological Centre in diagnostics and treatment of patients with early central lung cancer. Sokolov VV, Telegina LV, Gladyshev AA, Sokolov SA, editors. Oncology: Journal named after P.A. Gerzen. 2014;4-10.
- Sokolov VV. Endobronchial surgery and photodynamic therapy in patients with malignant tumors of trachea and bronchai. Sokolov VV, Telegina LV, Kh A. Trachtenberg and others. Russian Oncology Journal. 2010;4-9.
- Arsenyev AI. Method of combined treatment of locally advanced malignant tumors of bronchi and/or trachea: Patent RU № 2372119 from 10.11.2009. Arsenyev AI, Barchuk AS, Kanaev SV, editors.