Bronchoscopic Management of Primary Tracheal Tumor

Diagnostic Flexible bronchoscopy Examination

Bronchoscopic Management

Bronchoscopic Management

Bronchoscopic Management

CECT at presentation: Intraluminal mass lesion in the upper trachea 

CECT at presentation

CECT at presentation

CECT at presentation

Diagnosis:

Patient had primary tracheal tumor. The tumorous growth was significantly blocking the upper trachea causing breathing difficulties and demanding immediate tumor resection.

Management:

Multidisciplinary team discussion was made with the ENT, Oncology, Anaesthesiology and Radiology departments. Decision was made to subject the patient for Rigid Bronchoscopy and mechanical debulking combined with electrosurgical snare, argon plasma coagulation and cryo-debulking using the ERBE cryoprobe under general anaesthesia.

Treatment:

Patient was intubated using a rigid bronchoscope (EFER DUMON, 10.00/9.20 mm tracheal tube) after induction with fentanyl and propofol. The procedure was done under total intravenous anaesthesia. After successful intubation with the rigid bronchoscope, flexible bronchoscope was passed through the rigid scope. A 4mm MLS endotracheal tube with standard cuff was passed next to the rigid bronchoscope and was positioned beyond the tumour with cuff inflated at about 4 cm above the carina. This approach helps the endoscopist to have total control of the ventilation through out the procedure. Initial attempt was made to cut the stalk of the tumour using an electrosurgical snare, but was unsuccessful as the tumour was attached on to the trachea at multiple sites. Tumour destruction was performed using argon plasma coagulation probe. Non-contact APC was used initially to achieve deep coagulation and effective devitalization of the tumour. After effective coagulation, the cryoprobe was pressed in to the tumour and freezing was performed. The tumour was removed with cryo-extraction technique by repeatedly freezing the tumour and extracting it until the complete tumour is removed from the lumen of the trachea. The tumour base is coagulated using APC probe and contact tamponade with the rigid tracheoscope barrel. Patient is extubated immediately after the procedure.

Treatment

There were no intra-operative and post-operative procedural complications. Histopathology of the tumour was reported as squamous cell carcinoma. Repeat CT post procedure revealed complete patency of the tracheal lumen with mild wall thickening and irregularity. The patient is being treated with External Beam radiation therapy by the oncology team.

Discussion:

Central Airway Obstruction (CAO) can result from variety of disease processes and can cause significant morbidity and mortality, especially when the cause of CAO is a malignant disease process. Primary tracheal tumours obstructing the trachea are extremely rare and pose a significant challenge in diagnosis and management. For malignant CAO, though surgery remains the standard of care in possible cases, with the advent of Interventional Pulmonology techniques, we can palliate the symptoms and perform curative endoscopic resection in selected cases. Various Interventional techniques are available includes, rigid coring, argon plasma coagulation, cryoextraction and cryotherapy, laser bronchoscopy, stent placement etc. Symptoms can range from mild shortness of breath to severe respiratory failure. Combined modality of treatment using APC, CRYO, Electrosurgery has proven to be effective in most of the cases. As with our case, we used a MLS ET tube to secure the airway, as ventilation remains a challenge during such procedures. Endoscopic management of CAO requires specialized training and should be performed only in “centres of excellence”. Bronchoscopic debulking offers a synergistic effect when combined with other cancer treatment modalities. Prior local treatment with interventional procedures can benefit patients with CAO. Interventional Pulmonology should be included in the Multimodality treatment team for malignant central airway obstruction as the first resort to provide immediate relief to the patients.

Conclusion:

Primary tracheal tumors are rare and can be a challenge to manage. Patients with obstructive tracheal tumors require immediate intervention both in terms of treating cancer and improving the quality of life. In this case study, a 51-year-old female was misdiagnosed and mistreated for bronchial asthma. The multidisciplinary team at our hospitals noticed a nodular growth which was later identified as tracheal tumor by the team of Interventional Pulmonology. The team subjected the patient to rigid bronchoscopy and mechanical debulking. The tumor was successfully removed with cryo-extraction technique by repeatedly freezing the tumor until the complete tumor was removed and the lumen of the trachea cleared. The patient has recovered completely post surgery without any eventful complications and is now undergoing exernal beam radiation therapy. The resected tumor was further investigated and confirmed to be a squamous cell carcinoma. The trache is now completely patent and the patient breaths fresh air with great relief.

References:

1. Culp OS. Primary carcinoma of the trachea. J Thorac Cardiovasc Surg1938;7:471–478
2. Ampil FL. Primary malignant tracheal neoplasms: case report and literature radiotherapy review. J
Surg Oncol 1986;33:20–23.
3. Pearson FG, Todd TRJ, Cooper JD. Experience with primary neoplasms of the trachea. J Thorac
Cardiovasc Surg 1984;88:511–516.
4. Grillo HC, Mathisen DJ. Primary tracheal tumors: treatment and results. Ann Thorac
Surg 1990;49:69– 77.

Disclaimer:

“The information contained herein is for educational purpose only and we request you to please consult a Registered Medical Practioner or Doctor before deciding the appropriate diagnosis and treatment.”

About Author –

Dr. Hari Kishan Gonuguntla, Consultant Interventional Pulmonologist, Yashoda Hospitals, Hyderabad
MD, DM (Pulmonology Medicine), Fellowship in Interventional Pulmonology (NCC, Japan)