TUMOR BOARDS

SECTION OF PULMONARY
MEDICINE

Wychelle May A. Enriquez, MD

Ruel D. Paez, MD
Pulmonary Fellows-in-Training

Ronald A. Fajardo, MD
Moderator
1
OBJECTIVES

• To present a case of a 68 year old male presenting with chest

pain

• To present the different bronchoscopic approaches to malignant

airway obstruction

• To discuss treatment or palliative options for malignant airway

obstruction

2
General Data

68 year old male

Filipino

Manila

cc: Chest pain

3
HISTORY OF PRESENT ILLNESS
68/M, chest pain

One year PTA

• Blood-tinged sputum
• Occasional throat clearing
• No fever, night sweats, weight loss, dyspnea
• No consult

4
 HISTORY OF PRESENT ILLNESS
68/M, chest pain

Two months PTA

• Intermittent sharp chest pain, rated as 5/10
• precipitated by movement and cough
• relieved by rest and repositioning
• Consult: Ibuprofen & topical NSAID
• No dyspnea, no diaphoresis, no dizziness

5
 HISTORY OF PRESENT ILLNESS
68/M, chest pain

One month PTA,

• Progression of chest pain, 6/10
• Cough with whitish sputum
• (+) Generalized weakness, (+) intentional weight loss
• No fever, hemoptysis, dyspnea, night sweats
• Consult: chest x ray
• Chest CT scan – not done

6
HISTORY OF PRESENT ILLNESS
68/M, chest pain

One week
• Philippines – consult
• CXR and Chest CT Scan
• Further evaluation

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 REVIEW OF SYSTEMS 68/M, chest pain

Skin (-) Pruritus , rashes, lumps, jaundice

HEENT (-) Blurring of vision, headache, tinnitus, epistaxis, hoarseness
Cardiac (-) palpitations

Gastrointestinal (-) diarrhea, constipation, vomiting, nausea, epigastric pain, melena

Endocrine (-) Heat or cold intolerance
Genitourinary (+) intermittency, (-) Dysuria, chills, incontinence, hematuria, nocturia
Hematologic (-) Easy bruisability, spontaneous bleeding
Neurologic/ Psychiatric (-) Syncope, seizures, dizziness, numbness, headache, behavioral
changes
Musculoskeletal (-) Arthralgia, muscle pains

11
 68/M, chest pain

PAST MEDICAL HISTORY FAMILY HISTORY

• Hypertension St I • Diabetes Mellitus - mother

• Diabetes Mellitus type II • Asthma – siblings

• No history of cancer, thyroid diseases,
CAD

12
 PERSONAL AND SOCIAL HISTORY
68/M, chest pain

• Resides in Marikina • Fair functional capacity

• Recent travel to Canada • COVID-19 vaccine – Pfizer,
• Retired at Printing Press Moderna
• Previous smoker – 18 pack years • Booster- Pfizer (Jan 2022)
• No history of biomass fuel exposure • flu vaccine (2021)
• Occ alcoholic beverage drinker
• Denies illicit drug use

13
 PHYSICAL EXAMINATION 68/M, chest pain

GENERAL Conscious, coherent, not in distress

VITAL SIGNS BP 140/70, PR 94 bpm, RR 20, T 36.0 ºC 02 99%
Ht 65in Wt 62 kg BMI 22.7 kg/m2
HEENT Anicteric sclerae, pink palpebral conjunctivae, pupils 2-3
mm ERTL, moist lips and buccal mucosa, non distended
neck veins, no lymphadenopathy, no crepitus, trachea
midline
CVS Adynamic precordium, normal rate, regular rhythm, no
murmur, S1>S2 , no heaves/lifts/thrills

14
 PHYSICAL EXAMINATION 68/M, chest pain

LUNGS No chest deformities, no retractions, no use of accessory

muscles, no crackles no wheezes on the right lung,
decreased breath sounds on the left lung field
ABDOMEN Flat abdomen, normoactive bowel sounds, soft, nontender
on all quadrants, no palpable masses
EXTREMITIES No edema, pulses full and equal

15
 NEUROLOGIC EXAMINATION69/M, chest pain

• Conscious, coherent, oriented to 3 spheres, appropriate affect

• CN I – not assessed
• CN II- Pupils Equally reactive to light, 2 mm
• CN III, IV, VI – not assessed
• CN V – not assessed
• CN VII- no facial asymmetry
• CN VIII- Gross hearing intact
• CN IX, X- can swallow
• CN XI – not assessed
• CN XII- midline tongue
• Motor – with spontaneous movement
• Sensory – not assessed
• Cerebellar – not assessed 16
 SALIENT FEATURES 69/M, chest pain

SUBJECTIVE DATA OBJECTIVE DATA

• 68/M • Conscious, coherent, not in respiratory distress
• Blood tinged sputum, occasional throat • BP 140/70, PR 94 bpm, RR 20, T 36 ºC 02 99% at RA
clearing • No chest deformities, no retractions, no use of
• Chest pain accessory muscles, no wheezes, no crackles,
• cough with whitish sputum decreased breath sounds left lung field
• generalized weakness • CXR: pulmonary mass in the left causing mass effect
• No hemoptysis, fever, night sweat • Chest CT Scan : left lung mass
• No Asthma, COPD, allergies
• No exposure to TB confirmed patient, no
exposure to biomass fuel
• No orthopnea, no PND, no palpitations, no
dizziness
• Previous smoker- 18 pack years

17
ADMITTING DIAGNOSIS 69/M, chest pain

• Lung mass, left probably:

1. Malignancy
2. PTB
• COPD Probable
• HTN St II
• Diabetes Mellitus type 2

18
• 68/M INITIAL EVALUATION PROCEDURAL STRATEGIES
• Hemoptysis
• Clinical examination • Indications, contraindications
• Chest pain
• Comorbidities and results
• Cough • Team experience
• Functional status
• Previous smoker • • Risk-Benefit analysis and
Patient preferences
• Hypertensive and expectation therapeutic alternatives
• Diabetic • Consent
• Good functional
capacity LONG-TERM MANAGEMENT
TECHNIQUES AND RESULTS
• Anesthesia and perioperative care • Outcome assessment
• Techniques and instrumentation • Follow-up tests, visit and
• Anatomic dangers and other risks procedures
• Results and procedure- related • Referrals
complications • Quality Improvement and team
evaluation
 MALIGNANT CENTRAL AIRWAY OBSTRUCTION

refers to any malignant, mechanical, obstructive process

that impedes the airflow within the central airways

20
Rafanan AL, Mehta AC. Role of bronchoscopy in lung cancer. Semin Respir Crit Care Med 2000;21:405-20.
 • estimated 80,000 cases are treated annually in the US
• Approximately 20% to 30% of patients with lung cancer may develop
complications
• About 40% of lung cancer-related deaths result from complications

Dutau H, Toutblanc B, Lamb C, et al. Use of the Dumon Y-stent in the management of malignant disease involving the carina: a retrospective review of 86 patients. Chest 2004;126:951-8.
Miyazawa T, Miyazu Y, Iwamoto Y, et al. Stenting at the flow-limiting segment in tracheobronchial stenosis due to lung cancer. Am J Respir Crit Care Med 2004;169:1096-102.6. Chhajed PN, Baty F, Pless M, et al. Outcome of
treated advanced non-small cell lung cancer with and without central airway obstruction. Chest 2006;130:1803-7
21
 ✔️

2-50%

Ernst A, Feller-Kopman D, Becker HD, et al. Central airway obstruction. Am J Respir Crit Care Med 2004;169:1278-97
 INITIAL EVALUATION PROCEDURAL STRATEGIES Flexible
• Clinical examination • Indications, contraindications
• Comorbidities and results bronchoscopy
• Functional status • Team experience with possible
• Patient preferences • Risk-Benefit analysis and
and expectation therapeutic alternatives resection of
• Consent endobronchial
mass
TECHNIQUES AND RESULTS LONG-TERM MANAGEMENT
• Outcome assessment
• Anesthesia and perioperative care • Follow-up tests, visit and
• Techniques and instrumentation procedures
• Anatomic dangers and other risks • Referrals
• Results and procedure- related • Quality Improvement and team
complications evaluation
Ernst A, Feller-Kopman D, Becker HD, et al. Central airway obstruction. Am J Respir Crit Care Med 2004;169:1278-97 25
• Approximately 40% are done either on an urgent or emergent basis
• Techniques for relieving the airway obstruction depends on:
1. equipment availability
2. patient’s clinical condition
3. treating physician’s expertise
4. obstruction type
26
• Approximately 40% are done either on an urgent or emergent basis
• Techniques for relieving the airway obstruction depends on:
1. equipment availability
2. patient’s clinical condition
3. treating physician’s expertise
4. obstruction type
27
• Malignant central airway obstruction requiring bronchoscopic management:
• Affecting proximal airway (trachea and main bronchi),

• With identification of healthy bronchial tree, and

• Viable parenchyma beyond stenosis

• Bronchoscopy for lobar level obstruction:

• Control of hemoptysis

• Drainage of post-obstructive pneumonia 29

31
• Approximately 40% are done either on an urgent or emergent basis
• Techniques for relieving the airway obstruction depends on:
1. equipment availability
2. patient’s clinical condition
3. treating physician’s expertise
4. obstruction type
32
Semaan R, Yarmus L. Rigid bronchoscopy and silicone stents in the management of central airway obstruction. J Thorac Dis 2015;7:S352-62. 
Lakshmi Mudambi et al, J Thorac Dis. 2017 Sep; 9(Suppl 10): S1087–S1110
Lakshmi Mudambi et al, J Thorac Dis. 2017 Sep; 9(Suppl 10): S1087–S1110
 37 vs 10 months median survival

Guibert, et al. 2014. Integration of interventional bronchoscopy in the management of lung cancer. Eur Respir Rev 2015; 24: 378–391
Mitchell, Patrick & Kennedy, Marcus. (2014). Bronchoscopic Management of Malignant Airway Obstruction. Advances in therapy. 31. 10.1007/s12325-014-0122-z
 91%

80%

Mitchell, Patrick & Kennedy, Marcus. (2014). Bronchoscopic Management of Malignant Airway Obstruction. Advances in therapy. 31. 10.1007/s12325-014-0122-z
 84%

Mitchell, Patrick & Kennedy, Marcus. (2014). Bronchoscopic Management of Malignant Airway Obstruction. Advances in therapy. 31. 10.1007/s12325-014-0122-z
Surgery - suggested for treating malignant central stenoses, usually based on
pneumonectomy and occasionally extended to the trachea and carina, with
reconstruction in cases of proximal involvement
Tumor size is often revised downwards, with nodal status at times being distorted by
the presence of post-obstructive pneumonia.
Surgical resection may enhance survival rate in patients with solitary foci of metastatic
disease.
39
Chemotherapy – standard therapy for metastatic lung cancer
-inconsistent and delayed beneficial effects
Radiotherapy –resolves atelectasis in 23-54% of cases
-Only a delayed outcome (median 24 days)

40
 INITIAL EVALUATION PROCEDURAL STRATEGIES
• Clinical examination • Indications, contraindications
• Comorbidities and results
• Functional status • Team experience
• Patient preferences • Risk-Benefit analysis and
and expectation therapeutic alternatives
• Consent

Flexible TECHNIQUES AND RESULTS LONG-TERM MANAGEMENT

bronchoscopy • Anesthesia and perioperative care • Outcome assessment
with possible • Techniques and instrumentation • Follow-up tests, visit and
• Anatomic dangers and other risks procedures
resection of • Results and procedure- related • Referrals
endobronchial complications • Quality Improvement and team
evaluation
mass
 >90%

Guibert, et al. 2014. Integration of interventional bronchoscopy in the management of lung cancer. Eur Respir Rev 2015; 24: 378–391
Mitchell, Patrick & Kennedy, Marcus. (2014). Bronchoscopic Management of Malignant Airway Obstruction. Advances in therapy. 31. 10.1007/s12325-014-0122-z
INTRAOP FINDINGS 68/M, chest pain

43
SURGICALPATHOLOGY REPORT 68/M, chest pain

ENDOBRONCHIAL MASS, LEFT MAIN BRONCHUS

• Squamous Carcinoma, moderately differentiated

44
 INITIAL EVALUATION PROCEDURAL STRATEGIES
• Clinical examination • Indications, contraindications
• Comorbidities and results
• Functional status • Team experience
• Patient preferences • Risk-Benefit analysis and
and expectation therapeutic alternatives
• Consent

TECHNIQUES AND RESULTS LONG-TERM MANAGEMENT

• Outcome assessment
• Anesthesia and perioperative care • Follow-up tests, visit and Referral to
• Techniques and instrumentation
• Anatomic dangers and other risks
procedures Medical
• Referrals
• Results and procedure- related • Quality Improvement and team Oncology
complications evaluation
 CONCLUSION 68/M, chest pain

• MCAO significantly impacts a patient’s quality of life and can determine candidacy for
systemic or surgical therapies.
• Invasive bronchoscopic interventions are used for rapid relief of symptoms, even in
acutely ill patients.
• Current modalities: thermal techniques, cryotherapy, mechanical debulking, airway
dilation, and airway stent placement.
• Delayed therapies such as brachytherapy and photodynamic therapy are very useful in
select cases.
• Thorough working knowledge of the risks and benefits of each modality is critical when
individualizing a patient’s treatment plan.
• A team of experts including interventional pulmonologists and thoracic surgeons should
be involved in these cases.
46
 PROGNOSIS 68/M, chest pain

• Survival of patients with untreated malignant CAO ranges from 1 to 2 months

• Risk factors for decreased survival:
1. high American Society of Anesthesiologists (ASA) score
2. non-squamous cell histology
3. previously untreated metastatic tumors
• Chhajed et al. demonstrated that patients who had received interventional
bronchoscopic therapy prior to oncological treatment, had the same expected
survival as those patients presenting in the similar stage without MCAO

47
Razi SS, Lebovics RS, Schwartz G, et al. Timely airway stenting improves survival in patients with malignant central airway obstruction. Ann Thorac Surg 2010;90:1088-93
 REFERENCES 68/M, chest pain

• Rafanan AL, Mehta AC. Role of bronchoscopy in lung cancer. Semin Respir Crit Care Med 2000;21:405-20
• Dutau H, Toutblanc B, Lamb C, et al. Use of the Dumon Y-stent in the management of malignant disease involving the carina: a
retrospective review of 86 patients. Chest 2004;126:951-8
• Miyazawa T, Miyazu Y, Iwamoto Y, et al. Stenting at the flow-limiting segment in tracheobronchial stenosis due to lung cancer. Am J
Respir Crit Care Med 2004;169:1096-102.6.
• Chhajed PN, Baty F, Pless M, et al. Outcome of treated advanced non-small cell lung cancer with and without central airway
obstruction. Chest 2006;130:1803-7
• Du Rand IA, Barber PV, Goldring J, et al British Thoracic Society guideline for advanced diagnostic and therapeutic flexible
bronchoscopy in adults Thorax 2011;66:iii1-iii21
• Semaan R, Yarmus L. Rigid bronchoscopy and silicone stents in the management of central airway obstruction. J Thorac Dis
2015;7:S352-62. 
• Lakshmi Mudambi et al, J Thorac Dis. 2017 Sep; 9(Suppl 10): S1087–S1110
• Guibert, et al. 2014. Integration of interventional bronchoscopy in the management of lung cancer. Eur Respir Rev 2015; 24: 378–391
• Mitchell, Patrick & Kennedy, Marcus. (2014). Bronchoscopic Management of Malignant Airway Obstruction. Advances in therapy. 31.
10.1007/s12325-014-0122-z
• Varela, et al. 2014. Surgical management of advanced non-small cell lung cancer. J Thorac Dis 2014;6(S2):S217-S223

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