Postmus, P.E.

Sutedja, G.

Vries, P.M.J.M. de

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Diagnostic and Therapeutic Endoscopy, Vol. 4, pp. 9-11
Reprints available directly from the publisher
Photocopying permitted by license only
(C) 1997 OPA (Overseas Publishers Association)
Amsterdam B.V. Published in The Netherlands
by Harwood Academic Publishers
Printed in Singapore
Long Term Complete Remission of lntraluminal Squamous
Cell Carcinoma by Bronchoscopic Electrosurgery
PETER M.J.M. DE VRIES *, PIETER E. POSTMUS and TOM G. SUTEDJA
Department ofPulmonary Medicine, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands
(Received 7 August 1996; In finalform 23 January 1997)
A patient is described with a synchronous intraluminal squamous cell carcinoma of the
left upper lobe carina. He refused photodynamic therapy after sleeve lobectomy of the
right upper lobe. The intraluminai tumor was treated with fiberoptic bronchoscopic
electrosurgery. Complete remission was achieved, at the moment already for 36 months.
Keywords: Bronchoscopic electrosurgery, Curation, Squamous cell carcinoma
INTRODUCTION
Tumor in the central airways can cause serious
morbidity. Dyspnea, hemoptysis and pneumonia
due to obstruction by the tumor can be palliated
by bronchoscopic techniques [1] including electro-
surgery as was recently shown in a pilot study
[2]. The following case report is to show the
curative potential of electrosurgery in a patient
with intraluminal tumor.
CASE REPORT
A 63-year-old man with a history of mild chronic
obstructive pulmonary disease presented with
worsening exercise-induced dyspnea. His medica-
tion included inhalation of salbutamol and bude-
sonide. Breath sounds were increased at the apex
of the anterior side of the fight lung; expiration
was normal. Inspiratory vital capacity was slightly
decreased (4.2 liter, 72% of predicted) with mod-
erate bronchoconstriction (FEV1/VC 0.55, 72%
of predicted). A chest roentgenogram demon-
strated atelectasis of the fight upper lobe. Bron-
choscopy and computed tomography revealed
that this was due to a squamous cell carcinoma
of the right upper lobe bronchus. At broncho-
scopy a small elevation was seen at the carina of
the left upper lobe (See Fig. 1) with a diameter
of 5 mm. This synchronous squamous cell carci-
noma was not visible at the CT scan, but was
histologically proven. Sleeve resection of the right
Corresponding author. Tel.: 31 20 4444 782. Fax: 31 20 4444 328.
10 P.M.J.M. DE VRIES et al.
FIGURE Small squamous cell carcinoma at the carina of
the left upper lobe (diameter 5 mm).
upper lobe was performed, the margins being free
of tumor (TNoM0).
Photodynamic therapy was proposed for the
carcinoma in the left lung. However, the patient
refused this due to the necessity to avoid expo-
sure to any strong light, indoors or outdoors.
Fiberoptic bronchoscopic electrosurgery was cho-
sen as a treatment alternative. The procedure
was performed under sedation with midazolam
intravenously, according to the standards pub-
lished recently [2]. Oxygen saturation was moni-
tored by pulse oximetry and supplementary
oxygen was given by nasal sprongs. The fiber-
optic bronchoscope (OlympusR, diameter 6mm,
diameter suction channel 2.6mm) had an insu-
lated and electrically grounded inner sheath. A
flexible electrosurgery probe (diameter 1.2mm)
was used for coagulation with standard electro-
cautery equipment. Energy at 35Watt was ap-
plied. The probe was gently pressed against the
tumor and slowly advanced and retracted through
the tumor during the coagulation procedure until
coagulation appeared to be sufficient. The tip of
the bronchoscope was then used to shear off
necrotic tissue and repeated washing and suction
was applied to clean up all tumor debris. A
clean-up bronchoscopy appeared not to be neces-
sary.
Repeated bronchoscopies 3, 6, 12, 18 and 36
months after the electro-surgical session did not
show any sign of recurrence of tumor. (See Fig. 2)
FIGURE 2 Carina of the left upper lobe 6 months after
bronchoscopic electrosurgery.
DISCUSSION
In patients with radiologically occult lung cancer,
the standard treatment is surgery. In one study,
even for these small bronchial cancers, a lobect-
omy was needed in 70 percent of the patients
and a bilobectomy or a pneumonectomy in 30
percent [3]. The chance of getting a second lung
cancer following the first resection was about 20
percent. Clearly, a curative treatment that does
not result in loss of normal lung tissue would be
desirable, particularly in patients with limited
pulmonary reserve or with synchronous or meta-
chronous tumors as presently described.
Technically speaking any bronchoscopic inter-
vention is capable of eradicating small intralum-
inal tumors. A study of tissue necrosis after
PDT, Nd-YAG laser, diathermy and cryosurgery
indicated various necrotic depth up to several
millimeters [1]. Bronchoscopic electrosurgery has
not widely been used despite its advantages over
PDT and Nd-YAG laser therapy. It is cost effec-
tive, easy and quick to perform, even under local
anesthesia using standard electrosurgery equip-
ment which is widely available in every hospital.
The technique provides rapid pallation in patients
with intraluminal tumor and a poor prognosis
[2]. The only disadvantage is the unpredictable
amount of necrosis. Nevertheless, this form of
CURATIVE BRONCHOSCOPIC ELECTROSURGERY 11
treatment might provide a cheap and safe alter-
native for curative endobronchial treatment of
small intraluminal tumors as intraluminal early
stage cancers are only several millimeters thick.
References
[1] Sutedja, G. and Postmus, P.E. Bronchoscopic treatment in
lung cancer. A review. Lung Cancer 1994; 11: 1-17.
[2] Sutedja, G., Van Kralingen, K., Schramel, F. and
Postmus, P.E. Fiberoptic bronchoscopic electrosurgery
under local anesthesia for rapid palliation in patients with
central airway malignancies. A preliminary report. Thorax
1994; 49: 1243-6.
[3] Cortese, D.A., Pairolero, P.C., Bergstrahl, E.J., Woolner,
L.B., Uhlenhopp, M.A. and Piehler, J.M. Roentgenogra-
phically occult lung cancer: a ten-year experience.
J. Thorac. Cardiovasc. Surg. 1983; 86: 373-80.


Long term complete remission of intraluminal squamous cell carcinoma by bronchoscopic electrosurgery

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Long term complete remission of intraluminal squamous cell carcinoma by bronchoscopic electrosurgery

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