Physical Examination, Complementary Tests, and Functional Status Assessment

This patient required considerable assistance at home. His functional impairment was consistent with a Karnofsky Performance Scale score (KPS) of 50. At the time of hospitalization, however, KPS was only 20 (severely disabled, where hospitalization was necessary but death was not imminent).¹ His Eastern Cooperative Oncology Group (ECOG) performance scale, which may be a better predictor of prognosis than KPS,^2,3 was 3 (i.e., the patient was capable of only limited self-care and was confined to bed or chair for more than 50% of waking hours). Assessment of this patient’s performance status is essential for guiding therapeutic interventions because this degree of impairment, due to lung cancer or comorbid conditions (e.g., chronic obstructive pulmonary disease [COPD]), may preclude resection or, alternatively, chemoradiotherapy.⁴ In fact, this patient was not operable based on his pulmonary function tests and functional status. Relevant to his case, however, is that the combination of interventional bronchoscopy and external beam radiation therapy (EBRT) might improve survival, symptoms, and quality of life, as has been previously shown in patients with lung cancer, central airway obstruction, and KPS less than 50.

The patient’s weak voice and hoarseness are explained by unilateral (left) vocal cord immobility as noted on bronchoscopy (see video on ExpertConsult.com) (Video V.24.1). This was likely due to unilateral recurrent laryngeal nerve (RLN) injury, which caused the affected vocal fold to rest in the paramedian position. The contralateral vocal fold may or may not provide adequate glottic closure during phonation. If closure is not achieved, the residual glottal gap results in air escape with a weak voice secondary to a “leaky valve” phenomenon.⁵ In unilateral RLN injury, the glottic aperture is usually adequate, and related dyspnea and stridor are rare. Glottal incompetence, however, increases the risk for aspiration, particularly with thin liquids. Cough, which requires transient tight glottic closure, may also be affected; this is important in cases of airway stent insertion with risk for mucus plugging and difficulty raising secretions. Associated sensory loss from RLN involvement may also cause dysphagia, a symptom not seen in our patient. With regard to staging, RLN involvement is consistent with T4 disease. In conjunction with N2 disease on computed tomography (CT) scan (involvement of stations 7 and 4 L), this patient’s clinical stage is at least IIIB, and estimated median survival time is 10 months and 5 years for 7% despite multimodality treatment.⁶

Comorbidities

This patient had moderate, Global Obstructive Lung Disease (GOLD) stage II COPD. Although no other comorbidities were reported, careful examination and review of systems are warranted because COPD is associated with hypertension, coronary heart disease, stroke, obstructive sleep apnea, depression, anxiety, and cognitive dysfunction, which could preclude or complicate interventions under general anesthesia.⁴

Support System

The patient had good social support from his daughter and his wife. Early discussions about quality of life and symptom concerns are warranted because patients suffering from cancer will commonly develop pain, dyspnea, cough, and fatigue during the course of their illness.⁷ These conversations took place with the patient and his family because a diagnosis of cancer has a significant psychological and emotional impact on family members and caregivers as well.⁸

Patient Preferences and Expectations

This gentleman had expressed his desire for diagnosis and was ready to consider all available treatment options. He was very clear, however, that he did not want to live “being dependent on machines,” and he wanted to make all decisions regarding his care. In the United States, most patients diagnosed with cancer want a shared or active role in the decision-making process, usually with greater participation than what actually occurs. Role preferences (active vs. passive), however, vary greatly during decision making, and repeated assessments are required to meet patients’ expectations and improve their satisfaction with treatment decisions.⁹

Indications

This patient required tissue diagnosis. We elected to proceed with rigid bronchoscopy under general anesthesia to restore airway patency with laser and silicone stent insertion and to diagnose the airway lesion using endobronchial biopsy, bronchial washing, and/or endobronchial needle aspiration. Chemoradiotherapy currently constitutes the standard of care for patients with inoperable locally advanced non–small cell lung cancer (NSCLC).¹⁰ This treatment, however, is usually restricted to patients who maintain a good performance status.¹¹

Central airway obstruction (CAO) in the setting of NSCLC is associated with a very poor prognosis. In one study, median and 1 year survival of patients with malignant CAO were reportedly as low as 3.4 months and 15%, respectively.¹² However, patients with advanced NSCLC with locally treated CAO combined with systemic chemotherapy might have survival rates similar to those patients without CAO treated with chemotherapy alone.¹³ Interventional bronchoscopic procedures in this patient with inoperable disease are expected to restore airway patency and improve lung function, dyspnea, and functional status, thus allowing initiation of systemic therapy, which could improve his survival.¹⁴

Contraindications

No absolute contraindications to rigid bronchoscopy were noted. Although COPD treatment should be optimized before elective interventions to reduce perioperative complications, our patient had stable disease at the time of evaluation and was being treated with short-acting β₂-agonists and long-acting anticholinergic agents in accordance with international guidelines.¹⁵

Expected Results

For diagnosis, endobronchial needle aspiration (EBNA) with rapid on-site evaluation (ROSE) was performed. In patients with visible endobronchial lesions such as this, the diagnostic yield increases from 76% with conventional procedures alone to 96% with EBNA in addition to conventional procedures (washings, brushings, and biopsy).¹⁶

For restoring airway patency in our patient with near complete obstruction in the distal left main bronchus (LMB), left secondary carina (LC2) involvement, and a mixed pattern of obstruction (extrinsic and endoluminal exophytic), a straight metal or silicone stent would not have restored patency to the obstructed lobar bronchi. Therefore we decided to insert a silicone Y stent. This type of stent can be used for patients with fixed or dynamic CAO from benign or malignant disease, but the most common uses are to restore airway patency, to improve dyspnea and quality of life for patients with malignant CAO involving the mainstem bronchi and the lower trachea (Figure 24-2), and to reduce recurrent infection in patients with tracheoesophageal or bronchoesophageal fistulas.^17–20 Y stents are also effective in restoring airway patency, and they improve symptoms in patients with severe diffuse tracheobronchomalacia, but with a high rate of nonfatal complications.^21,22 In our patient, a Y silicone stent insertion was planned to restore and maintain LMB and left upper lobe (LUL) and left lower lobe (LLL) airway patency, which would allow the following:

Figure 24-2 Main carinal tumor in different patient (A) before and (B) after Y stent insertion. Y stents are shaped with (C) a long tracheal and left main bronchial limbs and a shorter right main bronchial limb. Models with and without external studs are available.

Team Experience

Studies reporting an association between results of interventional bronchoscopy, procedure-related complications, and the required level of technical expertise have not yet been performed. It is known, however, that survival and complications after such procedures are worse for malignant than for benign CAO, and it was suggested that these patients should be considered distinct populations to be analyzed and reported separately.²³ One can only hypothesize that referral to an experienced bronchoscopist and oncologic team will result in reduced complications, more rapid diagnosis, greater restoration of airway patency, and earlier discharge from the hospital.

Risk-Benefit Analysis

For diagnosis, we chose to perform EBNA before proceeding with laser photocoagulation. In our experience, EBNA has a lower risk of bleeding and provides immediate diagnosis when ROSE is available. In contrast with endobronchial biopsy, however, tissue architecture is not seen.¹⁶ With regard to restoring airway patency, the risks of further physiologic compromise and massive bleeding were considered to be outweighed by the benefit of restoring airway patency, the ability to diagnose the lesion, and improved functional status and the offer of systemic therapy. Alternatives to our approach should be considered on a case-by-case basis.

Therapeutic Alternatives for Restoring Airway Patency

These include endobronchial and systemic therapies.