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Anesthesia for the application of endotracheal and endobronchial radiation therapy
J
THoRAc CARDIOVASC SURG
87:693-697, 1984
Anesthesia for the application of endotracheal and endobronchial radiation therapy Higb-activity remote afterloading was recently adapted at Memorial Sloan-KetteringCancer Center for the treatment of carcinoma of the IlDlg recurrent to the major airways. An anesthesia approach is presented which aids in the performance of this beneficial preeedere, The remote afterloader is a device containing a bigh-intensity radioactive source which is appned intraiuminaDy to control both endobronchial andendotracheal tumors. The patient is intubated with an endobronchial or endotracheal tube which facilitates passage and measurement of the Gamma Med catheter. The potential usage for airway maintenance is a secondary benefit After bronchoscopic placement is verified radiographically, computerized treatment is initiated. The several advantages of this technique are presented.
Sharon-Marie Rooney, M.D.,· Paul L. Goldiner, M.D.,·· Manjit S. Bains, M.D.,**· Basil Hilaris, M.D., **•• and Subhash Jain, M.D., ****. New York. N. Y.
h e treatment of carcinoma of the lung recurrent to the major airways has always been a challenge usually offering only supportive care to a suffocating patient. Little can be offered to patients who present with recurrence in the trachea or major bronchus following extensiveoperation and radiation therapy. Most of these patients have hemoptysis and airway obstruction, often severe enough to cause near asphyxia. Transbronchial excision or cauterization of the tumor is often necessary to open the airway or to control hemorrhage. Cryosurgery.!" interstitial brachytherapy,7'10 and more recently laser photoirradiation" have been used. Two of the authors (M. B. and B. H.) initiated intraluminal applications by remotely controlled high-intensity radionuclides (remote afterioader) in an attempt to control the tumor as well as to relieve symptoms.
****Chief, Brachytherapy Service, Department of Radiation Therapy.
High-activity remote afterioading was introduced in 1964 by Henschke, Hilaris, and Mahan I2. 13 at Memorial Sloan-Kettering Cancer Center. The original afterioader contained cobalt 60 as the source. In 1979 this was replaced with a Gamma Med II· remote afterioader which uses a high-intensity iridium 192 source. This source measures about 1 mm' and is attached to a cable, coiled within a metal container. The activity of the source is about 10 Ci. The source is driven by motor to the appropriate position. The source then can be retracted in 0.5 to 1.0 em steps. An isodose pattern is thus created around the linear source, tailored to the patient's tumor. Patients considered for treatment are those with carcinoma of the lung who have been maximally irradiated externally and who have recurrent carcinoma with disease localized around the major airways. One of several other criteria must also exist: (1) A long segment of a major airway must be involved which would be too expensive to allow the endobronchial permanent implantation. (2) The tumor must be inaccessible for endobronchial implantation. (3) The lesion must be surgically unresectable for any of several reasons: the extensiveness of the local disease, the discovery of metastatic disease beyond the lung, or the poor medical condition of the patient. (4) A major airway must remain compromised by tumor after it has been reopened with a laser photoirradiation.
*****Clinical Assistant Anesthesiologist, Department of Anesthesiology.
*Isotopen Technik, Essen, West Germany.
From Memorial Sloan-Kettering Cancer Center, New York, N. Y. Received for publication May II, 1983. Accepted for publication July 17. 1983. Address for reprints: Sharon-Marie Rooney, M.D., Department of Anesthesiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, N. Y. 10021. *Clinical Chief, Department of Anesthesiology. **Chairman, Department of Anesthesiology. ***Associate Attending Surgeon, Thoracic Service.
693
694
The Journal of Thoracic and Cardiovascular Surgery
Rooney et af.
c
a
b
Fig. 1. a, Placement of endotracheal tube with Gamma Moo catheter in patientwith prior pneumonectomy with nonobstructing endotracheal tumor. b, Artist's sketch of a. A, Endotracheal tube. B, Gamma Moo catheter. C, Tumor mass.
Technique The anesthesia technique requires the continuous monitoring of a mildly sedated awake patient and the passage of an endotracheal tube. Various approaches may be used to accomplish these goals. The blood pressure, pulse, and electrocardiogram are continuously monitored. Placement of the endotracheal tube is facilitated by having the patient breathe nebulized lidocaine through an Acorn inhaler," so that the airway is anesthetized. Medication is given for sedation during this time. Oxygen mayor may not be delivered as required. The endotracheal tube is used for the passage of the Gamma Med catheter. It must be positioned under direct bronchoscopic vision for accurate placement. The position of the catheter varies depending upon the location of the tumor and it is guided through this area over a bronchoscope. A spiral-wire endotracheal tube facilitates easy passage through the tracheobronchial tree and visualizes well on x-ray films to confirm proper placement. An 8 or 9 mm tube may be used for
tracheal lesions. The cuff is not inflated and the patient breathes through and around the tube. For bronchial lesions a smaller tube is required, for the tube is advanced into the bronchus again to be positioned relative to the lesion. The cuff is not inflated. The "intubated" lung breathes through and around this endobronchial tube while the unaffected lung breathes independently around the tube. A bronchoscope is passed through the endotrachealj endobronchial tube and measures the proximal and distallirnits of the tumor. This distance is transferred to the plastic Gamma Med catheter. The catheter is inserted into the endotracheal/endobronchial tube and positioned against the tumor at the designated distance. After roentgenographic verification of the proper positioning of the endotrachealjendobronchial tube and the Gamma Med catheter, this information is entered into the computer. In the adjacent control room the technologist enters the prescription (500 rads at 1 em from the source) into the computer and the treatment begins.
Volume 87
Endotracheal and endobronchial radiation therapy 6 9 5
Number 5 May, 1984
~ ~----
/~~~~--
---~~----~
b Fig. 2. a, Radiation treatment field for an endotracheal tumor. b. Artist's sketch of
a
G.
A, Endotracheal tube.
b
Fig. 3. G, Placement of endobronchial tube with Gamma Moo catheter in relation to an obstructing endobronchial tumor. b, Artist's sketch of a. A, Endobronchial tube. B, Gamma Moo catheter. C. Tumor mass.
The Journal of Thoraci c and Cardiovascular Surgery
6 9 6 Rooney et al.
Fig. 4. a. Radiation treatment field of the endobronchial tumor . b, Artist's sketch of a. A, Endobronchial tumor. B. Gamma Med catheter. C. Tumor mass.
Endotracheal tube and Gamma Med catheter placement is presented radiographically in Fig. 1, a in a patient with prior pneumonectomy with a recurrent nonobstructing endotracheal tumor. Fig. 2, a is the radiation treatment field for an endotracheal tumor. Figs. 1, band 2, b are an artist's sketch of the corresponding figure. Fig. 3, a shows the placement of the endobronchial tube with the Gamma Med catheter in relation to an obstruct ing endobronchial tumor, and the radiation treatment field of the endobronchial tumor is shown in Fig. 4, a. Figs. 3, band 4, b are again sketches of the corresponding figures. The remote afterloader is a device consisting of a lead safe containing a high-intensity radioactive source. The source is attached to the end of a long cable that can be advanced to its treatment position outside the lead safe by means of a mechanism on the control panel. The radioactive source remains in each position for a few seconds as determined by the computer and then moves to the next position until the treatment is completed. During the radiation treatment the patient's condition is closely monitored from the control room by television screen and intercom.
Discussion
Gynecologic malignant tumors have been the major clinical application of the remote afterloader, although it has been used for other sites. This is the first known application to lung carcinomas." Understanding the placement and rationale of the endotracheal/endobronchial tube is particularly important if complications arise. These vary considerably depending on the location of the tumor in the major airway and its degree of occlusion to that airway. The possibility of airway obstruction because of tumor occlusion and/or hemorrhage must be realized and properly anticipated . It must be remembered that endotracheal or endobronchial tube placement is primarily to facilitate the measurement and passage of the Gamma Med catheter. The potential usage for airway maintenance is a secondary benefit. This anesthesia approach is advantageous, for it maintains spontaneous respiration in a potentially compromised airway while permitting ease of anesthetic care in a specialized facility. There are several advantages to this technique. First, there is complete elimination of radiation exposure to personnel, since remote control of the radiation is used.
Volume 87 Number 5 May, 1984
Second, the radiation dose distribution can be tailored to the size and shape of the tumor. Third, the adjoining tissues receive minimum radiation. Finally, the treatment time is short (3 to 5 minutes) and the patient is treated as an outpatient. REFERENCES
2
3
4
5
6
Carpenter RJ III, Neel HB III, Sanderson DR: Cryosurgery of bronchopulmonary structures. Chest 72:279-284, 1977 Gorenstein A, Neel HB III, Sanderson DR: Transbronchoscopic cryosurgery. Development of a new technique. Surg Forum 26:534-537, 1975 Grana L, Kidd J, Swenson 0: Cryosurgenic techniques within the tracheobronchial tree. J Cryosurg 2:62-67, 1969 Neel HB III, Ketcham AS, Hammond WG: Requisites for successful cryosurgenic surgery of cancer. Arch Surg 102:45-48, 1971 Neel HB III, Desanto LW: Cryosurgical control of cancer. Effects of freeze rates, tumor temperatures, and ischemia. Ann Otol Rhinol Laryngol 82:716-723, 1973 Sanderson DR, Neel HB III, Payne WS, Woolner LB: Cryotherapy for bronchogenic carcinoma. Report of a case. Mayo Clin Proc 50:435-437, 1975
Endotracheal and endobronchial radiation therapy
697
7 Ormerod FC: The pathology and treatment of carcinoma of the bronchus. J Laryngol Otol 52:733-745, 1937 8 Pool JL: Bronchoscopy in the treatment of lung cancer. Ann Otol Rhinol Laryngol 70: 1172-1178, 1961 9 Hilaris BS, Martini N, Luomanen RK: Endobronchial interstitial implantation. Clin Bull 9: 17-20, 1979 10 Hilaris BS, Liskow A, Bains MS, Martini N: A new endobronchial implanter. Clin Bull 9:21-23, 1979 11 Dumon JF, Meric JM, Velardocchio JM, Garbe L, Saux P: YAG laser resection of tracheobronchial lesions, The Fourth Congress of The International Society for Laser Surgery, Tokyo, Japan, Nov. 23-27, 1981 12 Henschke UK, Hilaris BS, Mahan GD: Remote afterloading with intracavity applicators. Radiology 83:344-345, 1964 13 Henschke UK, Hilaris BS, Mahan G D: Remote afterloading for intracavitary radiation therapy, Progress in Clinical Cancer IN Ariel, ed., New York, 1965, Grune & Stratton, Inc, pp 127-136 14 Vuckovic DD, Rooney SM, Goldiner PL, O'Sullivan D: Aerosol anesthesia of the airway using a small disposable nebulizer. Anesth Analg 59:803-804, 1980 15 Hilaris BS, Nori D: Brachytherapy oncology-I 982, Advances in Lung and Other Cancer, New York, 1982, Memorial Sloan-Kettering Cancer Center, Robert C. Gold Associates.
THoRAc CARDIOVASC SURG
87:693-697, 1984
Anesthesia for the application of endotracheal and endobronchial radiation therapy Higb-activity remote afterloading was recently adapted at Memorial Sloan-KetteringCancer Center for the treatment of carcinoma of the IlDlg recurrent to the major airways. An anesthesia approach is presented which aids in the performance of this beneficial preeedere, The remote afterloader is a device containing a bigh-intensity radioactive source which is appned intraiuminaDy to control both endobronchial andendotracheal tumors. The patient is intubated with an endobronchial or endotracheal tube which facilitates passage and measurement of the Gamma Med catheter. The potential usage for airway maintenance is a secondary benefit After bronchoscopic placement is verified radiographically, computerized treatment is initiated. The several advantages of this technique are presented.
Sharon-Marie Rooney, M.D.,· Paul L. Goldiner, M.D.,·· Manjit S. Bains, M.D.,**· Basil Hilaris, M.D., **•• and Subhash Jain, M.D., ****. New York. N. Y.
h e treatment of carcinoma of the lung recurrent to the major airways has always been a challenge usually offering only supportive care to a suffocating patient. Little can be offered to patients who present with recurrence in the trachea or major bronchus following extensiveoperation and radiation therapy. Most of these patients have hemoptysis and airway obstruction, often severe enough to cause near asphyxia. Transbronchial excision or cauterization of the tumor is often necessary to open the airway or to control hemorrhage. Cryosurgery.!" interstitial brachytherapy,7'10 and more recently laser photoirradiation" have been used. Two of the authors (M. B. and B. H.) initiated intraluminal applications by remotely controlled high-intensity radionuclides (remote afterioader) in an attempt to control the tumor as well as to relieve symptoms.
****Chief, Brachytherapy Service, Department of Radiation Therapy.
High-activity remote afterioading was introduced in 1964 by Henschke, Hilaris, and Mahan I2. 13 at Memorial Sloan-Kettering Cancer Center. The original afterioader contained cobalt 60 as the source. In 1979 this was replaced with a Gamma Med II· remote afterioader which uses a high-intensity iridium 192 source. This source measures about 1 mm' and is attached to a cable, coiled within a metal container. The activity of the source is about 10 Ci. The source is driven by motor to the appropriate position. The source then can be retracted in 0.5 to 1.0 em steps. An isodose pattern is thus created around the linear source, tailored to the patient's tumor. Patients considered for treatment are those with carcinoma of the lung who have been maximally irradiated externally and who have recurrent carcinoma with disease localized around the major airways. One of several other criteria must also exist: (1) A long segment of a major airway must be involved which would be too expensive to allow the endobronchial permanent implantation. (2) The tumor must be inaccessible for endobronchial implantation. (3) The lesion must be surgically unresectable for any of several reasons: the extensiveness of the local disease, the discovery of metastatic disease beyond the lung, or the poor medical condition of the patient. (4) A major airway must remain compromised by tumor after it has been reopened with a laser photoirradiation.
*****Clinical Assistant Anesthesiologist, Department of Anesthesiology.
*Isotopen Technik, Essen, West Germany.
From Memorial Sloan-Kettering Cancer Center, New York, N. Y. Received for publication May II, 1983. Accepted for publication July 17. 1983. Address for reprints: Sharon-Marie Rooney, M.D., Department of Anesthesiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, N. Y. 10021. *Clinical Chief, Department of Anesthesiology. **Chairman, Department of Anesthesiology. ***Associate Attending Surgeon, Thoracic Service.
693
694
The Journal of Thoracic and Cardiovascular Surgery
Rooney et af.
c
a
b
Fig. 1. a, Placement of endotracheal tube with Gamma Moo catheter in patientwith prior pneumonectomy with nonobstructing endotracheal tumor. b, Artist's sketch of a. A, Endotracheal tube. B, Gamma Moo catheter. C, Tumor mass.
Technique The anesthesia technique requires the continuous monitoring of a mildly sedated awake patient and the passage of an endotracheal tube. Various approaches may be used to accomplish these goals. The blood pressure, pulse, and electrocardiogram are continuously monitored. Placement of the endotracheal tube is facilitated by having the patient breathe nebulized lidocaine through an Acorn inhaler," so that the airway is anesthetized. Medication is given for sedation during this time. Oxygen mayor may not be delivered as required. The endotracheal tube is used for the passage of the Gamma Med catheter. It must be positioned under direct bronchoscopic vision for accurate placement. The position of the catheter varies depending upon the location of the tumor and it is guided through this area over a bronchoscope. A spiral-wire endotracheal tube facilitates easy passage through the tracheobronchial tree and visualizes well on x-ray films to confirm proper placement. An 8 or 9 mm tube may be used for
tracheal lesions. The cuff is not inflated and the patient breathes through and around the tube. For bronchial lesions a smaller tube is required, for the tube is advanced into the bronchus again to be positioned relative to the lesion. The cuff is not inflated. The "intubated" lung breathes through and around this endobronchial tube while the unaffected lung breathes independently around the tube. A bronchoscope is passed through the endotrachealj endobronchial tube and measures the proximal and distallirnits of the tumor. This distance is transferred to the plastic Gamma Med catheter. The catheter is inserted into the endotracheal/endobronchial tube and positioned against the tumor at the designated distance. After roentgenographic verification of the proper positioning of the endotrachealjendobronchial tube and the Gamma Med catheter, this information is entered into the computer. In the adjacent control room the technologist enters the prescription (500 rads at 1 em from the source) into the computer and the treatment begins.
Volume 87
Endotracheal and endobronchial radiation therapy 6 9 5
Number 5 May, 1984
~ ~----
/~~~~--
---~~----~
b Fig. 2. a, Radiation treatment field for an endotracheal tumor. b. Artist's sketch of
a
G.
A, Endotracheal tube.
b
Fig. 3. G, Placement of endobronchial tube with Gamma Moo catheter in relation to an obstructing endobronchial tumor. b, Artist's sketch of a. A, Endobronchial tube. B, Gamma Moo catheter. C. Tumor mass.
The Journal of Thoraci c and Cardiovascular Surgery
6 9 6 Rooney et al.
Fig. 4. a. Radiation treatment field of the endobronchial tumor . b, Artist's sketch of a. A, Endobronchial tumor. B. Gamma Med catheter. C. Tumor mass.
Endotracheal tube and Gamma Med catheter placement is presented radiographically in Fig. 1, a in a patient with prior pneumonectomy with a recurrent nonobstructing endotracheal tumor. Fig. 2, a is the radiation treatment field for an endotracheal tumor. Figs. 1, band 2, b are an artist's sketch of the corresponding figure. Fig. 3, a shows the placement of the endobronchial tube with the Gamma Med catheter in relation to an obstruct ing endobronchial tumor, and the radiation treatment field of the endobronchial tumor is shown in Fig. 4, a. Figs. 3, band 4, b are again sketches of the corresponding figures. The remote afterloader is a device consisting of a lead safe containing a high-intensity radioactive source. The source is attached to the end of a long cable that can be advanced to its treatment position outside the lead safe by means of a mechanism on the control panel. The radioactive source remains in each position for a few seconds as determined by the computer and then moves to the next position until the treatment is completed. During the radiation treatment the patient's condition is closely monitored from the control room by television screen and intercom.
Discussion
Gynecologic malignant tumors have been the major clinical application of the remote afterloader, although it has been used for other sites. This is the first known application to lung carcinomas." Understanding the placement and rationale of the endotracheal/endobronchial tube is particularly important if complications arise. These vary considerably depending on the location of the tumor in the major airway and its degree of occlusion to that airway. The possibility of airway obstruction because of tumor occlusion and/or hemorrhage must be realized and properly anticipated . It must be remembered that endotracheal or endobronchial tube placement is primarily to facilitate the measurement and passage of the Gamma Med catheter. The potential usage for airway maintenance is a secondary benefit. This anesthesia approach is advantageous, for it maintains spontaneous respiration in a potentially compromised airway while permitting ease of anesthetic care in a specialized facility. There are several advantages to this technique. First, there is complete elimination of radiation exposure to personnel, since remote control of the radiation is used.
Volume 87 Number 5 May, 1984
Second, the radiation dose distribution can be tailored to the size and shape of the tumor. Third, the adjoining tissues receive minimum radiation. Finally, the treatment time is short (3 to 5 minutes) and the patient is treated as an outpatient. REFERENCES
2
3
4
5
6
Carpenter RJ III, Neel HB III, Sanderson DR: Cryosurgery of bronchopulmonary structures. Chest 72:279-284, 1977 Gorenstein A, Neel HB III, Sanderson DR: Transbronchoscopic cryosurgery. Development of a new technique. Surg Forum 26:534-537, 1975 Grana L, Kidd J, Swenson 0: Cryosurgenic techniques within the tracheobronchial tree. J Cryosurg 2:62-67, 1969 Neel HB III, Ketcham AS, Hammond WG: Requisites for successful cryosurgenic surgery of cancer. Arch Surg 102:45-48, 1971 Neel HB III, Desanto LW: Cryosurgical control of cancer. Effects of freeze rates, tumor temperatures, and ischemia. Ann Otol Rhinol Laryngol 82:716-723, 1973 Sanderson DR, Neel HB III, Payne WS, Woolner LB: Cryotherapy for bronchogenic carcinoma. Report of a case. Mayo Clin Proc 50:435-437, 1975
Endotracheal and endobronchial radiation therapy
697
7 Ormerod FC: The pathology and treatment of carcinoma of the bronchus. J Laryngol Otol 52:733-745, 1937 8 Pool JL: Bronchoscopy in the treatment of lung cancer. Ann Otol Rhinol Laryngol 70: 1172-1178, 1961 9 Hilaris BS, Martini N, Luomanen RK: Endobronchial interstitial implantation. Clin Bull 9: 17-20, 1979 10 Hilaris BS, Liskow A, Bains MS, Martini N: A new endobronchial implanter. Clin Bull 9:21-23, 1979 11 Dumon JF, Meric JM, Velardocchio JM, Garbe L, Saux P: YAG laser resection of tracheobronchial lesions, The Fourth Congress of The International Society for Laser Surgery, Tokyo, Japan, Nov. 23-27, 1981 12 Henschke UK, Hilaris BS, Mahan GD: Remote afterloading with intracavity applicators. Radiology 83:344-345, 1964 13 Henschke UK, Hilaris BS, Mahan G D: Remote afterloading for intracavitary radiation therapy, Progress in Clinical Cancer IN Ariel, ed., New York, 1965, Grune & Stratton, Inc, pp 127-136 14 Vuckovic DD, Rooney SM, Goldiner PL, O'Sullivan D: Aerosol anesthesia of the airway using a small disposable nebulizer. Anesth Analg 59:803-804, 1980 15 Hilaris BS, Nori D: Brachytherapy oncology-I 982, Advances in Lung and Other Cancer, New York, 1982, Memorial Sloan-Kettering Cancer Center, Robert C. Gold Associates.