By Stephen Spotswood
HOUSTON — Patients with lung cancer or other diseases where tumors are beginning to obstruct their central airway have a long, hard road ahead. As the tumor continues to grow, taking in oxygen becomes more and more difficult.
If the obstruction is left alone, shortness of breath worsens, and the prospect of more serious complications, such as post-obstructive pneumonia, increases. What usually follows is admission to the hospital for increasing doses of oxygen, treatment with antibiotics and sometimes even morphine to relieve dyspnea.
At the Michael E. DeBakey VA Medical Center (MEDVAMC) in Houston, physicians are honing the use of advanced, minimally invasive techniques to create better outcomes for these patients and avoid those long hospital stays.
In a photo from the Houston VA website, Roberto Casal, M.D. poses with patient Clara Traylor. Photo by Quentin Melson, Public Affairs Specialist
Better Diagnostic Techniques
A relatively new field, interventional pulmonology uses advanced diagnostic and therapeutic tools to manage patients with lung cancer and other diseases that block central airways.
Left untreated, obstructions, “leave patients with no quality of life whatsoever and keeps them away from their loved ones,” explained Roberto Casal, MD, MEDVAMC’s Bronchology Lab director and the physician spearheading the hospital’s interventional pulmonology (IP) efforts.
Casal came to MEDVAMC from the MD Anderson Cancer Center, which prepared him for dealing with aggressive lung cancer cases. “Training at MD Anderson was a perfect match for my job at the MEDVAMC,” he said. “Unfortunately, most cases I see are of malignant origin. That training has given me the knowledge and experience I need to deal with these cases.”
Dealing with these cases involves employing varying techniques to better examine tumors and to unblock airways and allow patients to breathe on their own.
One procedure with the biggest impact to the department in recent years is the use of endobronchial ultrasound (EBUS). A bronchoscope with an ultrasound transducer at the tip is used to take biopsies from areas near the patient’s windpipe.
“EBUS allows us to accurately and safely sample any mediatinal structure, particularly lymph nodes,” Casal said. “EBUS has rapidly replaced mediastinoscopy for staging of lung cancer in centers with high EBUS expertise, such as ours. Not only are we avoiding a more invasive and surgical procedure, but we are reducing the absolute number of invasive procedures required for diagnosis and staging of lung cancer.”Interventional Pulmonology Seeks Better Outcomes for Lung Patients
This reduces risk, time and possibly cost to the hospital. Considering that the patients benefiting from this technique tend to be older and have other comorbidities, the less time they spend in surgery, the less chance of complications.
Another advanced diagnostic tool being used at MEDVAMC is electromagnetic navigational bronchoscopy (EMN), a system which allows physicians to better navigate through airways and obtain samples from small peripheral lung nodules they otherwise could not reach.
A third of patients with lung cancer will develop obstructions at some point, and a third of these patients will die from that. Other cancers can spread to the airways or compress the airways from the outside. For treating these patients, the IP clinic can choose from several therapeutic bronchoscopic procedures.
“In the last couple of years, we have assembled an interventional bronchoscopy suite with the highest available technology in the field,” Casal said. “And we have a dedicated general anesthesia team, which allows us to perform any procedure without using the [general] OR. With a combination of techniques, we can remove the endoluminal component of any tumor that invades the central airways. We also have the capability of placing any kind of airway stent. This allows us to better customize the treatment to each one of our patients.”
Casal has received extensive training in several techniques, some of which are argon plasma coagulation (applying heat by electronic current) cryotherapy (freezing the cancerous tissue), microdebrider (using rotating blades to cut the tumor), LASER bronchoscopy (using a laser on the tumor). Casal can use one or a combination of these techniques on a patient, depending on the circumstances.
“Before the establishment of our IP service, most patients with central airway obstructions were either treated with radiation therapy, continued to receive chemotherapy, were considered hospice care patients or were referred to an outside facility, typically MD Anderson Cancer Center,” Casal said. “The effectiveness of radiation and chemotherapy for this condition is low, since most patients have already failed to respond.”
In the last two years, Casal and his colleagues have performed 120 therapeutic bronchoscopies at MEDVAMC. Casal noted that the impact of therapeutic bronchoscopy on patient survival is unknown, but there is no doubt it is successful in improving patients’ quality of life.
The services the IP clinic provides are still relatively unknown to the rest of the field, however.
“The main problem I face is the lack of awareness about our service and about the possibility of helping these patients with central airway obstruction,” Casal said. “Unfortunately, I am getting many of these patients when it is already too late.”
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