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Management of Tracheobronchial Ulceration Induced By High-Dose Brachytherapy
HOW TO DO IT
Management of Tracheobronchial Ulceration Induced By High-Dose Brachytherapy Isao Matsumoto, MD, Makoto Oda, MD, Takehisa Imagawa, MD, Tsuyoshi Yachi, MD, Hideki Fujimori, MD, and Go Watanabe, MD Department of General and Cardiothoracic Surgery, Kanazawa University, Kanazawa, Japan
The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer
alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis.
H
by computed tomographic (CT) scans and bronchoscopy findings, hemoptysis suddenly occurred 3 weeks after admission. Bronchial arterial angiography revealed the blood supply from the right bronchial artery to the ulcer site. Therefore, bronchial artery embolization (BAE) was performed. The hemoptysis stopped once. Six hours later, the CT scan clearly revealed a blood flow to the bronchial artery nearby the tracheal ulcer. As soon as the CT examination was finished, massive hemoptysis suddenly occurred and the patient died.
Technique Patient 1 A 66-year-old man was admitted for the examination of tracheobronchial squamous cell carcinoma (SCC). The patient previously underwent right S6 segmentectomy for SCC of the lung at 60 years of age, with left sleeve lower lobectomy for SCC of the lung at 62 years, and external irradiation of 40 Gy and HD-EBBT with 3 fractions of 6 Gy for in situ SCC of the trachea at 64 years. After admission, ulceration was identified by bronchoscopy at the trachea where HD-EBBT was previously performed. The tissues at the ulcer site were biopsied and no cancer recurrence was found. The ulcer gradually worsened. Although once the ulcer appeared to be stable Accepted for publication August 19, 2008. Address correspondence to Dr Matsumoto, Department of General and Cardiothoracic Surgery, Kanazawa University, Takara-machi 13-1, Kanazawa, 920-8641, Japan; e-mail: [email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
Patient 2 A 67-year-old man was diagnosed as having SCC. There was an extended superficial SCC at the bifurcation from the right main bronchus to the left main bronchus with the center and more spreading at the left main bronchus side. Submucosal invasion at the left main bronchus in a small area was suspected due to mucosal thickening found by bronchoscopy. There was no extension outside the tracheobronchial wall, even in the CT findings. He had poor pulmonary function and refused surgical treatment. Due to the large extent of the cancer and the suspicion of submucosal invasion, photodynamic therapy was performed to decrease the area of SCC, and was followed by external irradiation of 40 Gy and HD-EBBT with three fractions of 6 Gy to the left main bronchus. Fourteen months after radiotherapy, the patient had a cough develop with a small amount of hemoptysis, and he was admitted to our hospital. Ulceration was identified in the left main bronchus by bronchoscopy, although recurrent cancer was not identified by biopsy. Because the ulcer site gradually progressed to be partially necrotic (Fig 1A), surgery was performed a week after admission to prevent an occurrence of massive hemoptysis, as experienced in case 1. First through a median small laparotomy, the omentum was divided from the stomach preserving the right gastroepiploic artery. This pedicled omentum was inserted to the thoracic cavity through the 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2008.08.045
FEATURE ARTICLES
igh-dose endobronchial brachytherapy (HD-EBBT) is widely used as a palliative treatment for symptomatic airway obstruction by malignant tumors. Recently, HD-EBBT has been used successfully as a curative treatment for lymph node-negative central lung cancer and even for peripheral lung cancer [1, 2]. However, the most severe complication of HD-EBBT is fatal hemoptysis (0 to 50%; average, 9% to 10%) [3]. Intractable tracheobronchial ulceration due to HD-EBBT often develops into tracheobronchial necrosis and fatal hemoptysis. Once necrosis and hemoptysis occur, no effective treatment is clinically established at present. Herein we discuss the management of tracheobronchial ulceration after HD-EBBT for early central lung cancer from our experience. We believe that this is the first report that suggests an effective management for preventing fatal hemoptysis.
(Ann Thorac Surg 2009;87:1301–3) © 2009 by The Society of Thoracic Surgeons
1302
HOW TO DO IT MATSUMOTO ET AL BRACHYTHERAPY INDUCED TRACHEOBRONCHIAL ULCERATION
Ann Thorac Surg 2009;87:1301–3
Fig 1. (A) The ulcer at the left main bronchus. (B) The left main bronchus was wrapped using the pedicled omentum.
front of the diaphragma. Second, a left thoracotomy was done. The left main bronchus, the pulmonary artery, and the pulmonary vein were carefully separated, because all of them had become thicker and had adhered to each other. After the bronchial artery was ligated and divided, the left main bronchus was wrapped using the pedicled omentum (Fig 1B). Postoperatively, hemoptysis disappeared. Although the degree of the necrotic portion of the bronchus worsened once (Fig 2A), it gradually improved and was covered with normal epithelia, although the patient had mild bronchial stenosis (Fig 2B). FEATURE ARTICLES
Comment With the increasing use of local radiation therapies such as HD-EBBT, thoracic surgeons will see this complication of fatal hemoptysis after HD-EBBT more frequently. Regarding the cause of fatal hemoptysis, fractional dosing of HD-EBBT, the total dose of HD-EBBT and external irradiation, the treated site and the administration of laser photocoagulation have been reported to be involved [1]. Recent studies demonstrated that the proximity of HD-EBBT to the great vessels was the main factor contributing to fatal hemoptysis, even when using an applicator that fixes the source axis to maintain a certain distance from the tracheobronchus [1, 3]. The HD-EBBT Fig 2. (A) The partial necrosis of the bronchus worsened once. It appeared as though there was a third hole at the left second carina. (B) The bronchus was covered with normal epithelia.
induced tracheobronchial ulceration never heals spontaneously once it becomes progressive and no effective treatment is established. In regard to resection of the necrotic or ischemic tracheobrochus in which high doses of radiation have been administered, tracheobronchial anastomotic dehiscence often occurs. In fact, necrosis of bronchus extended over a large area once in patient 2 after being operated on. The BAE treatment is widely used for management of massive and recurrent hemoptysis. However, BAE is a palliative treatment and recurrent hemoptysis after BAE has been reported to occur in 9% to 29% [4]. It may be due to partial embolization, recruitment of other systemic collaterals, or recanalization of an embolized artery. Using BAE treatment can stop bleeding temporally; however, it can not heal the tracheobronchial necrosis. Patient 1 demonstrated that BAE alone is insufficient to prevent fatal hemoptysis. Bleeding from HD-EBBT-induced tracheobronchial ulcer can also happen any time, and once massive bleeding occurs, it leads to sudden death without allowing enough time to perform BAE. We believe it is necessary to perform a prophylactic treatment before fatal hemoptysis occurs when ulcers that are either progressive or bleeding (even in a small amount) are detected by bronchoscopy or computed tomographic scan after HD-EBBT. It is
HOW TO DO IT MATSUMOTO ET AL BRACHYTHERAPY INDUCED TRACHEOBRONCHIAL ULCERATION
important not only to block the blood supply to the tracheobronchial ulcer, but to also separate the tracheobronchus and surrounding major blood vessels. Also, to avoid perforation of the tracheobronchus, it is preferable to use the patient’s own biological tissues. The pleura, the diaphragma, pedicled pericardial fat pads, intercostal muscles, and the omentum can be used to protect and revascularize the bronchial suture line for bronchoplasty [5]. We use the omentum to wrap the partially necrotic bronchus, even though the treatment becomes more invasive. The omentum will reach any part of the airway with ease. The activated omentum releases a potent mixture of growth factors (vascular endothelial growth factor, basic fibroblast growth factor, stromal cell-derived factor-1 alpha and others) that facilitate the growth of new blood and lymphatic vessels assuring a fresh blood supply that salvages the tissue from ischemic damage and infection [6]. In patient 2, we successfully managed the hemoptysis and the healing of the partially necrotic bronchus using the pedicled omentum. In conclusion, when bleeding from tracheobronchial ulcer occurs after HD-EBBT for early central lung cancer,
1303
blocking the blood supply to the bronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis.
References 1. Hara R, Itami J, Aruga T, et al. Risk factors for massive hemoptysis after endobronchial brachytherapy in patients with tracheobronchial malignancies. Cancer 2001;92:2623–7. 2. Imamura F, Ueno K, Kusunoki Y, et al. High-dose-rate brachytherapy for small-sized peripherally located lung cancer. Strahlenther Onkol 2006;182:703–7. 3. Carvalho Hde A, Gonçalves SL, Pedreira W Jr, Gregório MG, de Castro I, Aisen S. Irradiated volume and the risk of fatal hemoptysis in patients submitted to high dose-rate endobronchial brachytherapy. Lung Cancer 2007;55:319 –27. 4. Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest 2002;121:789 –95. 5. Nakanishi R. Revascularization of trachea in lung and tracheal transplantation. Clin Transplant 2007;21:668 –74. 6. Vernik J, Singh AK. Omentum: power to heal and regenerate. Int J Artif Organs 2007;30:95–9.
FEATURE ARTICLES
Ann Thorac Surg 2009;87:1301–3
Management of Tracheobronchial Ulceration Induced By High-Dose Brachytherapy Isao Matsumoto, MD, Makoto Oda, MD, Takehisa Imagawa, MD, Tsuyoshi Yachi, MD, Hideki Fujimori, MD, and Go Watanabe, MD Department of General and Cardiothoracic Surgery, Kanazawa University, Kanazawa, Japan
The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer
alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis.
H
by computed tomographic (CT) scans and bronchoscopy findings, hemoptysis suddenly occurred 3 weeks after admission. Bronchial arterial angiography revealed the blood supply from the right bronchial artery to the ulcer site. Therefore, bronchial artery embolization (BAE) was performed. The hemoptysis stopped once. Six hours later, the CT scan clearly revealed a blood flow to the bronchial artery nearby the tracheal ulcer. As soon as the CT examination was finished, massive hemoptysis suddenly occurred and the patient died.
Technique Patient 1 A 66-year-old man was admitted for the examination of tracheobronchial squamous cell carcinoma (SCC). The patient previously underwent right S6 segmentectomy for SCC of the lung at 60 years of age, with left sleeve lower lobectomy for SCC of the lung at 62 years, and external irradiation of 40 Gy and HD-EBBT with 3 fractions of 6 Gy for in situ SCC of the trachea at 64 years. After admission, ulceration was identified by bronchoscopy at the trachea where HD-EBBT was previously performed. The tissues at the ulcer site were biopsied and no cancer recurrence was found. The ulcer gradually worsened. Although once the ulcer appeared to be stable Accepted for publication August 19, 2008. Address correspondence to Dr Matsumoto, Department of General and Cardiothoracic Surgery, Kanazawa University, Takara-machi 13-1, Kanazawa, 920-8641, Japan; e-mail: [email protected].
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
Patient 2 A 67-year-old man was diagnosed as having SCC. There was an extended superficial SCC at the bifurcation from the right main bronchus to the left main bronchus with the center and more spreading at the left main bronchus side. Submucosal invasion at the left main bronchus in a small area was suspected due to mucosal thickening found by bronchoscopy. There was no extension outside the tracheobronchial wall, even in the CT findings. He had poor pulmonary function and refused surgical treatment. Due to the large extent of the cancer and the suspicion of submucosal invasion, photodynamic therapy was performed to decrease the area of SCC, and was followed by external irradiation of 40 Gy and HD-EBBT with three fractions of 6 Gy to the left main bronchus. Fourteen months after radiotherapy, the patient had a cough develop with a small amount of hemoptysis, and he was admitted to our hospital. Ulceration was identified in the left main bronchus by bronchoscopy, although recurrent cancer was not identified by biopsy. Because the ulcer site gradually progressed to be partially necrotic (Fig 1A), surgery was performed a week after admission to prevent an occurrence of massive hemoptysis, as experienced in case 1. First through a median small laparotomy, the omentum was divided from the stomach preserving the right gastroepiploic artery. This pedicled omentum was inserted to the thoracic cavity through the 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2008.08.045
FEATURE ARTICLES
igh-dose endobronchial brachytherapy (HD-EBBT) is widely used as a palliative treatment for symptomatic airway obstruction by malignant tumors. Recently, HD-EBBT has been used successfully as a curative treatment for lymph node-negative central lung cancer and even for peripheral lung cancer [1, 2]. However, the most severe complication of HD-EBBT is fatal hemoptysis (0 to 50%; average, 9% to 10%) [3]. Intractable tracheobronchial ulceration due to HD-EBBT often develops into tracheobronchial necrosis and fatal hemoptysis. Once necrosis and hemoptysis occur, no effective treatment is clinically established at present. Herein we discuss the management of tracheobronchial ulceration after HD-EBBT for early central lung cancer from our experience. We believe that this is the first report that suggests an effective management for preventing fatal hemoptysis.
(Ann Thorac Surg 2009;87:1301–3) © 2009 by The Society of Thoracic Surgeons
1302
HOW TO DO IT MATSUMOTO ET AL BRACHYTHERAPY INDUCED TRACHEOBRONCHIAL ULCERATION
Ann Thorac Surg 2009;87:1301–3
Fig 1. (A) The ulcer at the left main bronchus. (B) The left main bronchus was wrapped using the pedicled omentum.
front of the diaphragma. Second, a left thoracotomy was done. The left main bronchus, the pulmonary artery, and the pulmonary vein were carefully separated, because all of them had become thicker and had adhered to each other. After the bronchial artery was ligated and divided, the left main bronchus was wrapped using the pedicled omentum (Fig 1B). Postoperatively, hemoptysis disappeared. Although the degree of the necrotic portion of the bronchus worsened once (Fig 2A), it gradually improved and was covered with normal epithelia, although the patient had mild bronchial stenosis (Fig 2B). FEATURE ARTICLES
Comment With the increasing use of local radiation therapies such as HD-EBBT, thoracic surgeons will see this complication of fatal hemoptysis after HD-EBBT more frequently. Regarding the cause of fatal hemoptysis, fractional dosing of HD-EBBT, the total dose of HD-EBBT and external irradiation, the treated site and the administration of laser photocoagulation have been reported to be involved [1]. Recent studies demonstrated that the proximity of HD-EBBT to the great vessels was the main factor contributing to fatal hemoptysis, even when using an applicator that fixes the source axis to maintain a certain distance from the tracheobronchus [1, 3]. The HD-EBBT Fig 2. (A) The partial necrosis of the bronchus worsened once. It appeared as though there was a third hole at the left second carina. (B) The bronchus was covered with normal epithelia.
induced tracheobronchial ulceration never heals spontaneously once it becomes progressive and no effective treatment is established. In regard to resection of the necrotic or ischemic tracheobrochus in which high doses of radiation have been administered, tracheobronchial anastomotic dehiscence often occurs. In fact, necrosis of bronchus extended over a large area once in patient 2 after being operated on. The BAE treatment is widely used for management of massive and recurrent hemoptysis. However, BAE is a palliative treatment and recurrent hemoptysis after BAE has been reported to occur in 9% to 29% [4]. It may be due to partial embolization, recruitment of other systemic collaterals, or recanalization of an embolized artery. Using BAE treatment can stop bleeding temporally; however, it can not heal the tracheobronchial necrosis. Patient 1 demonstrated that BAE alone is insufficient to prevent fatal hemoptysis. Bleeding from HD-EBBT-induced tracheobronchial ulcer can also happen any time, and once massive bleeding occurs, it leads to sudden death without allowing enough time to perform BAE. We believe it is necessary to perform a prophylactic treatment before fatal hemoptysis occurs when ulcers that are either progressive or bleeding (even in a small amount) are detected by bronchoscopy or computed tomographic scan after HD-EBBT. It is
HOW TO DO IT MATSUMOTO ET AL BRACHYTHERAPY INDUCED TRACHEOBRONCHIAL ULCERATION
important not only to block the blood supply to the tracheobronchial ulcer, but to also separate the tracheobronchus and surrounding major blood vessels. Also, to avoid perforation of the tracheobronchus, it is preferable to use the patient’s own biological tissues. The pleura, the diaphragma, pedicled pericardial fat pads, intercostal muscles, and the omentum can be used to protect and revascularize the bronchial suture line for bronchoplasty [5]. We use the omentum to wrap the partially necrotic bronchus, even though the treatment becomes more invasive. The omentum will reach any part of the airway with ease. The activated omentum releases a potent mixture of growth factors (vascular endothelial growth factor, basic fibroblast growth factor, stromal cell-derived factor-1 alpha and others) that facilitate the growth of new blood and lymphatic vessels assuring a fresh blood supply that salvages the tissue from ischemic damage and infection [6]. In patient 2, we successfully managed the hemoptysis and the healing of the partially necrotic bronchus using the pedicled omentum. In conclusion, when bleeding from tracheobronchial ulcer occurs after HD-EBBT for early central lung cancer,
1303
blocking the blood supply to the bronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis.
References 1. Hara R, Itami J, Aruga T, et al. Risk factors for massive hemoptysis after endobronchial brachytherapy in patients with tracheobronchial malignancies. Cancer 2001;92:2623–7. 2. Imamura F, Ueno K, Kusunoki Y, et al. High-dose-rate brachytherapy for small-sized peripherally located lung cancer. Strahlenther Onkol 2006;182:703–7. 3. Carvalho Hde A, Gonçalves SL, Pedreira W Jr, Gregório MG, de Castro I, Aisen S. Irradiated volume and the risk of fatal hemoptysis in patients submitted to high dose-rate endobronchial brachytherapy. Lung Cancer 2007;55:319 –27. 4. Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest 2002;121:789 –95. 5. Nakanishi R. Revascularization of trachea in lung and tracheal transplantation. Clin Transplant 2007;21:668 –74. 6. Vernik J, Singh AK. Omentum: power to heal and regenerate. Int J Artif Organs 2007;30:95–9.
FEATURE ARTICLES
Ann Thorac Surg 2009;87:1301–3