INTRODUCTION: More than half of the patients with advanced lung cancer have stenoses of the central airways. Intraluminal tumors can be removed endoscopically by means of laser photoresection. However, when resection is not possible, carinal stenosis can be treated with stenting.
CASE PRESENTATION: A 62 year-old Italian female with laryngeal carcinoma diagnosed thirteen months ago, treated with chemotherapy and radiation, presented complaining of two weeks of dyspnea and “wheezing”. After a week of symptoms, the patient was treated by her medical doctor with levofloxacin, prednisone and fluticasone/salmeterol (Advair®), without any relief. A month prior a lung mass was found in her right upper lobe that was thought to be metastatic. A chemoport was placed and a new cycle of chemotherapy was initiated. On admission, she was hypoxic with oxygen saturation of 90% on room air, and physical examination revealed expiratory stridor and bilateral expiratory wheezing. The results of her laboratory tests were normal. Chest radiography showed the right upper lobe mass. Laryngoscopy failed to visualize any upper air obstruction. However, flexible bronchoscopy discovered the presence of a mass at the carina, partially occluding both the right and left main-stem bronchi. The patient was started on heliox (70% helium to 30% oxygen) with some improvement and subsequently had rigid bronchoscopy with debulking of the mass and balloon dilation of the airway. The placement of Ultraflex metallic tracheobronchial stents was done the following day. The patient was discharged home and died nine months later.
DISCUSSIONS: Signs and symptoms of central airway obstruction vary, but often include wheezing, cough, expiratory stridor, hoarseness, hemoptysis, and chest pain. Although pulmonary function test and thoracic imaging techniques such as CT & MRI may be useful in the evaluation of a patient with suspected obstruction of the central airway, bronchoscopy, either rigid or flexible, remains the diagnostic gold standard. The bronchoscopic approach to the management of endoluminal obstruction depends on the location of the lesion, the presence or absence of associated extrinsic compression, and the degree of clinical urgency. Rigid-bronchoscopic debulking, with adjunctive laser therapy or electrocautery, is recommended when airway recanalization must be performed on an emergency basis. If endobronchial obstruction is accompanied by marked extrinsic compression, the placement of a stent may be beneficial. Chakraverty et al. in their work showed that the indications for laser therapy were, dyspnea due to bronchial occlusion (60%), tracheo-carinal stridor (24%) and hemoptysis (13%). Over 75% of their patients had already received prior treatment. Laser therapy reduced stridor in 67% of patients with tracheal and carinal tumors and produced symptomatic improvement in 72% of patients with bronchial obstruction. Hemoptysis was controlled in all but one of patients treated.  Several types of stenting devices (long T-tube, T-Y tube, wire reinforced Y tracheostomal tube, Freitag Dynamic, and covered metallic stents) may be used in patients with severe tracheobronchial stenosis involving a carinal bifurcation region. However, when the stenosis exists in the carinal area, establishing an excellent airway remains challenging because of the anatomic structure. Mean survival after successful stenting in this area is reported as 4.3 months. .
CONCLUSION: Treatments and management of endobronchial carinal masses include surgical excision, local radiotherapy (especially endobronchial irradiation), chemotherapy, and transbronchial endoscopic procedures. The latter include photodynamic therapy, electrocoagulation, forceps, intratumoral ethanol injections, diathermic snares, prosthetic stents, and Nd-YAG laser-debulking therapy. Surgical resection should be confined to patients with localized disease. Treatment plans must be individualized, because in some cases long-term survival can be expected.
DISCLOSURE: Raymond Khan, None.