Endoscopic laser treatment for bronchogenic carcinoma

The use of laser therapy for endobronchial lesions has met with general enthusiasm. From published series it is difficult to determine specific indications for its use, based upon patients' complaints, locations of tumor, and any concomitant therapies. Most reports do not provide sufficient information to permit adequate comparisons regarding improvement in symptoms and long-term efficacy. Exophytic lesions of the trachea and mainstem bronchi are most amenable to therapy by laser, and improvement in symptoms correlates best with improved patency of large airways. In most patients the major portion of the endobronchial debulking procedure can be performed quickly and safely by physically coring out the exophytic tumor mass with the rigid end of the bronchoscope. A large biopsy forceps can help accomplish this with very little bleeding. The laser can then remove any remaining tumor and produce hemostasis by coagulation of the tumor bed. The major purpose of laser therapy is to lessen or completely relieve symptoms of airway obstruction. Laser therapy to obstructed lobar or segmental bronchi rarely reduces symptoms unless they are associated with post-obstructive pneumonia. When the obstruction is longstanding, laser ablation may fail to establish airway patency. Hemoptysis from exophytic lesions can usually be well controlled. Treatment of lesions that produce extrinsic compression of the trachea or bronchi is of little value. At present, laser therapy is one of several treatments available for neoplastic endotracheal or endobronchial obstruction. Other local therapies include external-beam irradiation, cryotherapy, electrocoagulative therapy, and intraluminal brachytherapy with insertion of afterloading catheters. Most of these modalities are available in large oncologic centers, and it will take the better part of the next decade to identify specific indications for each of these therapies individually and in combination. Currently, Nd:YAG therapy has an established role in the palliative treatment of obstructive endobronchial disease. Response rates to therapy with relief of obstruction are in the range of 80 to 85 per cent. Nd:YAG therapy is easy, quick, and, with proper caution, safe. In the majority of cases it must be repeated on one or several occasions. Photodynamic therapy is now being critically evaluated for the treatment of similar lesions.