Tumors of the Trachea constitute 2% of the upper respiratory tumors. Dyspnea cough and wheezing are common symptom as the airway becomes narrow. Tracheal tumors can be easily missed on CXR and are usually discovered on Bronchoscopy or CT scan.
A 65-year-old man with 100 pack year smoking history presented with shortness of breath and cough. He had been seen with similar complaints on multiple occasions in the ER and discharged on Proventil and Advair with diagnosis of COPD. He was using accessory muscles of respiration, breathing 28 per minute. CXR showed no abnormality. CT scan showed a Tracheal mass obstructing the lower trachea. Bronchoscopy confirmed an endotracheal mass just above the carina, obliterating the airway almost completely(picture 1,2,3). PET scan revealed no metastases. After consultation with surgery and oncology, resection of the tumor was done with the Rigid Bronchoscope, knife/snare Cauterization and ND YAG LASER with no complication. The pathology showed Squamous cell carcinoma in the background of Squamous papilloma with clear margin. A follow-up Bronchoscopy showed residual thickening in the posterior wall of the trachea (Picture 4). Photodynamic therapy was indicated for treatment of possible microscopic residual malignancy. The patient received Photofrin II, 2mg/kg and 2 days later the area was treated with PDT LASER and the debris in the Trachea was cleared 2 days later. (picture 5). The patient has been followed with CT scan and bronchoscopy for more than 8 months so far and there is no evidence of recurrent tumor and the patient remains symptom free. (Picture 6).
Interventional Pulmonology is a new field within Pulmonary Medicine. Advanced Bronchoscopic techniques such as Rigid Bronchoscopy, Laser therapy, Dilatation, Cauterization, Cryotherapy, Brachytherapy, Stenting and Photodynamic therapy are commonly used in Interventional Pulmonary Medicine. The number of centers and pulmonologists with experience in all of these procedures are limited. Laser produces a beam of monochromatic, coherent light. This light energy is transformed into heat as the laser interact with living tissue causing vaporization, coagulation, hemostasis & necrosis. Photocoagulation with ND Yag laser can be performed through a rigid or flexible Bronchoscope. Complications of laser therapy includes fistula formation, perforation of the airway, pneumothorax, hemorrhage, hypoxemia, or Endobronchial fire Photodynamic Therapy is used for the palliative treatment of endoluminal non-small cell cancer and for curative treatment of carcinoma In-situ. This procedure involves a photosensitizing agent (Photofrin II) which, when exposed to light of a proper wavelength, forms toxic oxygen radicals that result in cell death. PDT can destroys malignant cells while sparing adjacent normal tissues. The selective effect of photodynamic therapy is due to the greater uptake and retention of photosensitizing agents in neoplastic cells than in normal cells. The effect appears to be more pronounced 24 to 48 hours after infusion of the photosensitizing agent. The Bronchoscopic light therapy is performed 1-2 days after the injection of the agent. Electro Cauterization converts electrical energy to heat that is used to destroy tumors.
Laser therapy is minimally invasive procedure with low morbidity and mortality. Combining different modalities of Laser, Cautery and Photodynamic therapy in Interventional Pulmonology have shown the best outcome in the treatment of airway involvement with primary and metastatic lung cancer. The interventional modalities are also considered safer and cost-effective as major surgery can be avoided.
A.R. Shad, None.