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A method for selective endobronchial and endotracheal irradiation
J
THORAC CARDIOVASC SURG
84:59-61, 1982
A method for selective endobronchial and endotracheal irradiation A method for selective endobronchial and endotracheal irradiation is described. This method was used to treat a young woman with an unresectable adenoid cystic carcinoma of the trachea involving the main bronchi. The treatment provided good palliation, as indicated by increase of maximal breathing capacity (MBC) and forced expiratory volume in the first second (FEVl.o),
Anders Boedker, M.D., Anders Hald, M.D., and Dan Kristensen, M.D.,
Copenhagen, Denmark
Primary cancers of the trachea are rare, and of these the adenoid cystic carcinoma represents about thirty percent. 1 Most tracheal carcinomas have an insidious onset and cause symptoms only in the later stages. The symptoms are nonspecific, dominated by cough, hemoptysis, and dyspnea." There will be no local symptoms before seventy-five percent or more of the tracheal lumen is obstructed." Because of the nonspecific symptomatology and absence of changes on chest roentgenograms, a delay in diagnosis is not unusual and the mean interval from onset of symptoms to diagnosis is fifteen months. 1 In case of adenoid cystic carcinoma, surgical excision is the preferred treatment if the extent of the tumor allows a radical operation. The purpose of this report is to draw attention to a prolonged palliative response obtained by selective endotracheal and endobronchial irradiation in a patient with an unextirpable adenoid cystic carcinoma.
Case report In June of 1974 a 31-year-old woman was admitted to the Department of Radiotherapy and Oncology, Arhus Municipal Hospital, with a Ilh year history of increasing dyspnea. A roentgenogram of the trachea showed stenosis, and bronchoscopy with biopsy revealed adenoid cystic carcinoma.
Fig. 1. Roentgenogram of the trachea and main bronchi showing the irradiative source within a plastic catheter placed in the right main bronchus.
From Gentofte County Hospital, Copenhagen, Department of Thoracic Surgery, and Herlev Hospital, University of Copenhagen, Department of Anaesthesia, Department of Oncology and Radiotherapy, Copenhagen, Denmark. Received for publication July 27, 1981. Accepted for publication Oct. 23, 1981. Address for reprints: Anders Boedker, M.D., Olfert Fischersgade 46-11-3, DK-1311 Copenhagen, Denmark.
In September of 1974 a thoracotomy showed involvement of the lower third of the trachea, the carina, and the main bronchi. The tumor was unresectable. Because of this, external irradiation (total dose 6,000 rads, 1,760 rems) was given and provided some relief of symptoms. In January of 1975 the patient was referred to the Radium Center, The Finsen Institute, Copenhagen, Denmark. Bronchoscopy in April of 1975 showed persistent tumor. Since further external radiotherapy was prohibitive, cytostatic treatment with hydroxy-casbamide (Hydrea) was begun. The medication was stopped in June of 1978 because the patient
0022-5223/82/070059+03$00.30/0 © 1982 The C. V. Mosby Co.
59
The Journal of
60 Boedker, Hald, Kristensen
Thoracic and Cardiovascular Surgery
Fig. 2. The distal part of the cuffed endotracheal tube containing the irradiative source within a small tube, which is fixed with silk sutures. In order to visualize the principal windows have been made in both tubes.
Table I. Increase of maximal breathing capacity (MBC) and forced expiratory volume in the first second (FEVl.o) Date
MBC (Llmin}
FEVI.O (L)
September, 1978
25.0 59 .5
0 .70 1.70
January , 1979
had increasing dyspnea , cough, and several episodes of pneumonia during the preceding year. The patient's follow-up care was shifted to the Department of Oncology and Radiotherapy , Herlev Hospital , University of Copenhagen . Her condition was deteriorating and, since further cytostatic treatment was considered futile, intraluminal radiotherapy was planned in cooperation with the Department of Thoracic Surgery, Gentofte County Hospital, and the Department of Anaesthesia, Herlev Hospital. Bronchoscopy in September, 1978, showed tumor involving the lower half of the trachea , the carina , and the main bronchi. The diameter of the trachea was normal, but the left main bronchus had a slit-formed opening, 5 by 2 mm, and the right main bronchus had a circular opening with a diameter of 3 mm. Pulmonary functions tests showed a maximum breathing capacity (MBC) of 25 L/min (normal range I IOto 170 L/min) and a forced expiratory volume in the first second (FEVl.o) of 0 .7 L (normal range 2.2 to 2.9 L). Despite these critical values, endobronchial and endotracheal radiotherapy was agreed upon as the only possible means of palliation. Cesium 137 was chosen as the radiation source. Fig. I shows the principle of the endobronchial irradiation. During general anesthesia a narrow plastic catheter was inserted in one of the main bronchi through a bronchoscope. This procedure was followed by conventional endotracheal intubation , and the plastic catheter was then loaded with the radioactive sources . The proper position of the sources was confirmed by roentgenography and the sources were left in position for about 3 hours. Endobronchial radiotherapy was given four times at about 3 week intervals. Each main bronchus was treated twice and the dose in 3 mm depth was calculated to 7 plus II Gy in the right bronchus and 7 plus 7 Gy in the left. After these treatments MBC and FEVl.o increased (Table I). The treatments were without complication except for the first one, after which the patient had to be ventilated for 3 days, presumably because of postradiation edema .
Fig. 2 shows the principle of endotracheal irradiation . An ordinary cuffed endotracheal tube, size 7.0 mm (Portex), was used. In its distal end a small tube containing the cesium sources was placed centrally and fixed with silk sutures . The endotracheal tube was placed under general anesthesia and the trachea was irradiated for 3 hours to a dose of 7.3 Gy . This treatment caused no complications and was repeated 2 months later. The palliative response lasted for almost 1 year. In November , 1979, the patient was readmitted with extreme dyspnea and stridor. Bronchoscopy again showed severe obstruction of the main bronchi. As further irradiation was judged impossible , dilatations were performed once a month for half a year. In April of 1980 the patient died of suffocation the day after a treatment. Autopsy showed adenoid cystic carcinoma involving the entire trachea, the larynx , and main bronchi with spread to peritracheal connective tissue and metastasis to the left pleura.
Discussion Primary cancers of the trachea occur in less than O. 1% of patients dying of cancer. 4 One tracheal cancer is expected to be found in approximately 180 lung cancers ;' The most common type of malignant tracheal tumors is the squamous cell carcinoma, which is found in about 50% of the cases .!: 5 Adenoid cystic carcinoma comprises approximately 30% .5 Other important malignant lesions are mucoepidermoid carcinoma and mucus-secreting adenocarcinoma . Adenoid cystic carcinoma (cylindroma) of the trachea is regarded as histologically identical to that of the salivary gland." The natural history of the tumor has a distinct course: It grows slowly, submucosal spread is common, and it has a low potential for metastasis . The course of the disease is often protracted and insidious . Survival with local recurrency of the disease for 10 to 13 years has been seen. 6 The treatment of choice for localized lesions of adenoid cystic carcinoma seems to be resection, usually followed by adjunctive external irradiation . The results obtained show prolonged good palliation or even cure ." Many tumors are not amenable to resection because of the length of the trachea involved and extension into
Volume 84 Number 1 July, 1982
adjacent structures. Radiotherapy alone has long been regarded as having a poor effect radically or palliatively.!: 6 However, cobalt 60 therapy has resulted in complete disappearance of an extensive adenoid cystic carcinoma of the trachea within 2 weeks." Endoscopic resection is also regarded as an important means of achieving palliation because of the slow growth. I. 9 Recently a case has been reported of palliation by transbronchoscopic carbon dioxide laser resection before final operation. The result was encouraging, and use of a laser may be of value for the palliation of unresectable tumors.'? Lately a new method in relieving upper airway obstruction has been presented. By this method, endoscopic intubation of malignant tumors of the trachea or main bronchus with a Souttar tube was introduced. This procedure combined with external irradiation provided urgent relief of the respiratory obstruction. 11 Intraluminal irradiation is a new technique in the management of unextirpable tracheal tumors. One case has been reported previously. This technique was used to treat a patient with adenoid cystic carcinoma of the trachea involving the midtrachea and the left main bronchus." Through a tracheostomy the trachea was intubated with a specially designed tube. The tube in place was loaded with iridium 192 and thus the patient received a total dose of 2,300 rads calculated at 0.5 ern peripheral to the tracheal mucosa. Following the treatment the patient experienced an immediate, dramatic palliative response which lasted for 20 months.": 13 In our case the palliative response was significant, indicated by the increase of MBC and FEVl.O' and it lasted for 12 months. The technique is easily accomplished and nontraumatic and it allows irradiation of the trachea and the main bronchi selectively.
Endobronchial and endotracheal intubation
2 3 4
5
6
7 8
9
10
II 12
13
61
REFERENCES Houston HE, Payne WS, Harrison EG, Olsen AM: Primary cancers of the trachea. Arch Surg 99: 132-139, 1969 Salm R: Primary carcinoma of the trachea. A review. Br J Dis Chest 58:61-72, 1964 Belsey R: Resection and reconstruction of intrathoracic trachea. Br J Surg 38:200-205, 1950 Weber AL, Grillo HC: Tracheal tumors. A radiological, clinical and pathological evaluation of 84 cases. Radiol Clin North Am 16:227-246, 1978 Zunker HO, Moore RL, Baker DC, Lattes R: Adenoid cystic carcinoma (cylindroma) of the trachea. Cancer 23:699-707, 1969 Hajdu I, Huvos AG, Goodeur IT, Foote FW, Beattie EJ: Carcinoma of the trachea. Clinocopathologic study of 41 cases. Cancer 23: 1448-1456, 1970 Grillo HC: Tracheal tumors. Surgical management. Ann Thorac Surg 26:112-125, 1978 Richardson JD, Grover FL, Trinkle JK: Adenoid cystic carcinoma of the trachea. Response to cobalt-60. J THoRAc CARDIOVASC SURG 66:311-314, 1973 Nakratzaz G, Wagenaar JPM, Reiuties M, Scheffer E, Swiereuga J: Repeated partial endoscopic resections as treatments for two patients with inoperable tracheal tumors. Thorax 29: 125-131, 1974 Laforet EG, Berger RL, Vaughan CW: Carcinoma obstructing the trachea. Treatment by laser resection. N Engl J Med 294:941-943, 1976 Clarke DB: Palliative intubation of the trachea and main bronchi. J THORAC CARDIOVASC SURG 80:736-741, 1980 Percapio B, Price JC, Murphy P: Endotracheal irradiation of adenoid cystic carcinoma of the trachea. Radiology 128:209-210, 1978 Price JC, Percapio B, Murphy PW, Henderson RL: Recurrent adenoid cystic carcinoma of the trachea: Intraluminal radiotherapy. Otolaryngeal Head Neck Surg 87:614-623, 1979
THORAC CARDIOVASC SURG
84:59-61, 1982
A method for selective endobronchial and endotracheal irradiation A method for selective endobronchial and endotracheal irradiation is described. This method was used to treat a young woman with an unresectable adenoid cystic carcinoma of the trachea involving the main bronchi. The treatment provided good palliation, as indicated by increase of maximal breathing capacity (MBC) and forced expiratory volume in the first second (FEVl.o),
Anders Boedker, M.D., Anders Hald, M.D., and Dan Kristensen, M.D.,
Copenhagen, Denmark
Primary cancers of the trachea are rare, and of these the adenoid cystic carcinoma represents about thirty percent. 1 Most tracheal carcinomas have an insidious onset and cause symptoms only in the later stages. The symptoms are nonspecific, dominated by cough, hemoptysis, and dyspnea." There will be no local symptoms before seventy-five percent or more of the tracheal lumen is obstructed." Because of the nonspecific symptomatology and absence of changes on chest roentgenograms, a delay in diagnosis is not unusual and the mean interval from onset of symptoms to diagnosis is fifteen months. 1 In case of adenoid cystic carcinoma, surgical excision is the preferred treatment if the extent of the tumor allows a radical operation. The purpose of this report is to draw attention to a prolonged palliative response obtained by selective endotracheal and endobronchial irradiation in a patient with an unextirpable adenoid cystic carcinoma.
Case report In June of 1974 a 31-year-old woman was admitted to the Department of Radiotherapy and Oncology, Arhus Municipal Hospital, with a Ilh year history of increasing dyspnea. A roentgenogram of the trachea showed stenosis, and bronchoscopy with biopsy revealed adenoid cystic carcinoma.
Fig. 1. Roentgenogram of the trachea and main bronchi showing the irradiative source within a plastic catheter placed in the right main bronchus.
From Gentofte County Hospital, Copenhagen, Department of Thoracic Surgery, and Herlev Hospital, University of Copenhagen, Department of Anaesthesia, Department of Oncology and Radiotherapy, Copenhagen, Denmark. Received for publication July 27, 1981. Accepted for publication Oct. 23, 1981. Address for reprints: Anders Boedker, M.D., Olfert Fischersgade 46-11-3, DK-1311 Copenhagen, Denmark.
In September of 1974 a thoracotomy showed involvement of the lower third of the trachea, the carina, and the main bronchi. The tumor was unresectable. Because of this, external irradiation (total dose 6,000 rads, 1,760 rems) was given and provided some relief of symptoms. In January of 1975 the patient was referred to the Radium Center, The Finsen Institute, Copenhagen, Denmark. Bronchoscopy in April of 1975 showed persistent tumor. Since further external radiotherapy was prohibitive, cytostatic treatment with hydroxy-casbamide (Hydrea) was begun. The medication was stopped in June of 1978 because the patient
0022-5223/82/070059+03$00.30/0 © 1982 The C. V. Mosby Co.
59
The Journal of
60 Boedker, Hald, Kristensen
Thoracic and Cardiovascular Surgery
Fig. 2. The distal part of the cuffed endotracheal tube containing the irradiative source within a small tube, which is fixed with silk sutures. In order to visualize the principal windows have been made in both tubes.
Table I. Increase of maximal breathing capacity (MBC) and forced expiratory volume in the first second (FEVl.o) Date
MBC (Llmin}
FEVI.O (L)
September, 1978
25.0 59 .5
0 .70 1.70
January , 1979
had increasing dyspnea , cough, and several episodes of pneumonia during the preceding year. The patient's follow-up care was shifted to the Department of Oncology and Radiotherapy , Herlev Hospital , University of Copenhagen . Her condition was deteriorating and, since further cytostatic treatment was considered futile, intraluminal radiotherapy was planned in cooperation with the Department of Thoracic Surgery, Gentofte County Hospital, and the Department of Anaesthesia, Herlev Hospital. Bronchoscopy in September, 1978, showed tumor involving the lower half of the trachea , the carina , and the main bronchi. The diameter of the trachea was normal, but the left main bronchus had a slit-formed opening, 5 by 2 mm, and the right main bronchus had a circular opening with a diameter of 3 mm. Pulmonary functions tests showed a maximum breathing capacity (MBC) of 25 L/min (normal range I IOto 170 L/min) and a forced expiratory volume in the first second (FEVl.o) of 0 .7 L (normal range 2.2 to 2.9 L). Despite these critical values, endobronchial and endotracheal radiotherapy was agreed upon as the only possible means of palliation. Cesium 137 was chosen as the radiation source. Fig. I shows the principle of the endobronchial irradiation. During general anesthesia a narrow plastic catheter was inserted in one of the main bronchi through a bronchoscope. This procedure was followed by conventional endotracheal intubation , and the plastic catheter was then loaded with the radioactive sources . The proper position of the sources was confirmed by roentgenography and the sources were left in position for about 3 hours. Endobronchial radiotherapy was given four times at about 3 week intervals. Each main bronchus was treated twice and the dose in 3 mm depth was calculated to 7 plus II Gy in the right bronchus and 7 plus 7 Gy in the left. After these treatments MBC and FEVl.o increased (Table I). The treatments were without complication except for the first one, after which the patient had to be ventilated for 3 days, presumably because of postradiation edema .
Fig. 2 shows the principle of endotracheal irradiation . An ordinary cuffed endotracheal tube, size 7.0 mm (Portex), was used. In its distal end a small tube containing the cesium sources was placed centrally and fixed with silk sutures . The endotracheal tube was placed under general anesthesia and the trachea was irradiated for 3 hours to a dose of 7.3 Gy . This treatment caused no complications and was repeated 2 months later. The palliative response lasted for almost 1 year. In November , 1979, the patient was readmitted with extreme dyspnea and stridor. Bronchoscopy again showed severe obstruction of the main bronchi. As further irradiation was judged impossible , dilatations were performed once a month for half a year. In April of 1980 the patient died of suffocation the day after a treatment. Autopsy showed adenoid cystic carcinoma involving the entire trachea, the larynx , and main bronchi with spread to peritracheal connective tissue and metastasis to the left pleura.
Discussion Primary cancers of the trachea occur in less than O. 1% of patients dying of cancer. 4 One tracheal cancer is expected to be found in approximately 180 lung cancers ;' The most common type of malignant tracheal tumors is the squamous cell carcinoma, which is found in about 50% of the cases .!: 5 Adenoid cystic carcinoma comprises approximately 30% .5 Other important malignant lesions are mucoepidermoid carcinoma and mucus-secreting adenocarcinoma . Adenoid cystic carcinoma (cylindroma) of the trachea is regarded as histologically identical to that of the salivary gland." The natural history of the tumor has a distinct course: It grows slowly, submucosal spread is common, and it has a low potential for metastasis . The course of the disease is often protracted and insidious . Survival with local recurrency of the disease for 10 to 13 years has been seen. 6 The treatment of choice for localized lesions of adenoid cystic carcinoma seems to be resection, usually followed by adjunctive external irradiation . The results obtained show prolonged good palliation or even cure ." Many tumors are not amenable to resection because of the length of the trachea involved and extension into
Volume 84 Number 1 July, 1982
adjacent structures. Radiotherapy alone has long been regarded as having a poor effect radically or palliatively.!: 6 However, cobalt 60 therapy has resulted in complete disappearance of an extensive adenoid cystic carcinoma of the trachea within 2 weeks." Endoscopic resection is also regarded as an important means of achieving palliation because of the slow growth. I. 9 Recently a case has been reported of palliation by transbronchoscopic carbon dioxide laser resection before final operation. The result was encouraging, and use of a laser may be of value for the palliation of unresectable tumors.'? Lately a new method in relieving upper airway obstruction has been presented. By this method, endoscopic intubation of malignant tumors of the trachea or main bronchus with a Souttar tube was introduced. This procedure combined with external irradiation provided urgent relief of the respiratory obstruction. 11 Intraluminal irradiation is a new technique in the management of unextirpable tracheal tumors. One case has been reported previously. This technique was used to treat a patient with adenoid cystic carcinoma of the trachea involving the midtrachea and the left main bronchus." Through a tracheostomy the trachea was intubated with a specially designed tube. The tube in place was loaded with iridium 192 and thus the patient received a total dose of 2,300 rads calculated at 0.5 ern peripheral to the tracheal mucosa. Following the treatment the patient experienced an immediate, dramatic palliative response which lasted for 20 months.": 13 In our case the palliative response was significant, indicated by the increase of MBC and FEVl.O' and it lasted for 12 months. The technique is easily accomplished and nontraumatic and it allows irradiation of the trachea and the main bronchi selectively.
Endobronchial and endotracheal intubation
2 3 4
5
6
7 8
9
10
II 12
13
61
REFERENCES Houston HE, Payne WS, Harrison EG, Olsen AM: Primary cancers of the trachea. Arch Surg 99: 132-139, 1969 Salm R: Primary carcinoma of the trachea. A review. Br J Dis Chest 58:61-72, 1964 Belsey R: Resection and reconstruction of intrathoracic trachea. Br J Surg 38:200-205, 1950 Weber AL, Grillo HC: Tracheal tumors. A radiological, clinical and pathological evaluation of 84 cases. Radiol Clin North Am 16:227-246, 1978 Zunker HO, Moore RL, Baker DC, Lattes R: Adenoid cystic carcinoma (cylindroma) of the trachea. Cancer 23:699-707, 1969 Hajdu I, Huvos AG, Goodeur IT, Foote FW, Beattie EJ: Carcinoma of the trachea. Clinocopathologic study of 41 cases. Cancer 23: 1448-1456, 1970 Grillo HC: Tracheal tumors. Surgical management. Ann Thorac Surg 26:112-125, 1978 Richardson JD, Grover FL, Trinkle JK: Adenoid cystic carcinoma of the trachea. Response to cobalt-60. J THoRAc CARDIOVASC SURG 66:311-314, 1973 Nakratzaz G, Wagenaar JPM, Reiuties M, Scheffer E, Swiereuga J: Repeated partial endoscopic resections as treatments for two patients with inoperable tracheal tumors. Thorax 29: 125-131, 1974 Laforet EG, Berger RL, Vaughan CW: Carcinoma obstructing the trachea. Treatment by laser resection. N Engl J Med 294:941-943, 1976 Clarke DB: Palliative intubation of the trachea and main bronchi. J THORAC CARDIOVASC SURG 80:736-741, 1980 Percapio B, Price JC, Murphy P: Endotracheal irradiation of adenoid cystic carcinoma of the trachea. Radiology 128:209-210, 1978 Price JC, Percapio B, Murphy PW, Henderson RL: Recurrent adenoid cystic carcinoma of the trachea: Intraluminal radiotherapy. Otolaryngeal Head Neck Surg 87:614-623, 1979