Hi, my name is Rishi Reddy, I am a thoracic surgeon at the University of Michigan. And today I'll be talking about palliative surgery for stage four lung cancer, specifically talking about tracheal and pleural disease. These are my disclosures. The objectives of our talk today are, again, to discuss palliative options for tracheal tumors. And also discuss surgical options for malignant pleural effusions. To begin we'll start with our pre-lecture question. Which treatment option for malignant pleural effusion will NOT result in a pleurodesis of the space? A, indwelling pleural catheter. B, Talc application by VATS. C, Talc application by chest tube slurry. Or, D, pig tail catheter placement. To begin, we'll talk about diagnostic procedures for tracheal tumors. Those can be done with radiology using either CT scans or virtual bronchoscopy. Also, you can diagnose tracheal tumors using flexible or rigid bronchoscopy. Here's an example of a thyroid tumor compressing the trachea on a neck CT. When you're thinking about the pathology of a tumor, you also want to take into account the location. Is the tumor internal, is it external, or is it both? If it's external, is it compressing the airway or is it growing into the airway? When you're thinking about the actual histology, you want to understand, is it a primary tumor, such as a adenoid cystic tumor? Or is it a metastatic tumor from elsewhere in the body? Which can occur from lung cancers, esophageal cancers, or other histologies. Here is a picture, or a few pictures, of what a tracheal tumor can look like. On the left, we have what a normal trachea should look like, and next we have an internal tumor. Which is occluding the airway but not necessarily growing outside the trachea. On the third example, we have an external tumor which is compressing the trachea. And then the fourth example is a tumor that's growing both in and outside of the trachea. Understanding the components of the external versus internal location of the tumor and compression will help dictate management. Interventions for tracheal tumors are risky, and really should be coordinated with an anesthesia team that's comfortable with these procedures along with your surgeon, or interventional pulminologist. The goals in paleative setting are truly just to improve systems and we must recognize that we can cause great harm to a patient if we lose the airway. Usually we use flexible bronchoscopy or rigid bronchoscopy to either dilate the airway or to place stents. And the options for stents should be discussed whether they're covered stents or non covered stents. And the type of stent also varies between metal versus silicone. You should not plan tracheal resection in the settings of stage four tracheal tumors. With the roads to dilation or coring out of the tumor, that can be performed by a flexible bronchoscopy using either balloon dilation or laser ablation. Rigid bronchoscopy can also be very effective by both bluntly dilating the trachea and using increasingly large sizes of rigid bronchoscopes. Or you can use a rigid bronchoscope to core out endoluminal tumors. When thinking about airway stents, you must select the appropriate stent based on the indication in the specific situation. They can be placed by either flexible or rigid bronchoscopy. Stents can have problems caused by mucus plugging. Also, when you're thinking about stent placement, you must make sure that you have a distal opening for it to be effective. Metal stents, or non-covered metal stents, can't be removed long-term because of tissue ingrowth. And really should only be used for patients who have end stage disease. They have less migration than some of the other options. Covered metal stents on the other hand can be removed later, although they may have ingrowth on the edges. Silicone stents are easily removable, but they can migrate, and they tend to have a smaller inner diameter. That also tends to cause more interference with ciliary reaction that allows someone to clear their secretions. Moving onto pleural effusions, when you have someone who has a pleural effusion. The number one thing to do is to confirm whether or not it's malignant, and also to confirm whether or not it's transudative or exudative. We would use Light's criteria and also sends fluid for cytology to evaluate for these things. For transudative effusions, we would not use a chest tube. You really want to cure the primary problem, whether it's related to heart failure, cirrhosis, kidney failure, or some other problem. Exudative effusions, on the other hand, must be then evaluated for the cause of the exudative effusion. Malignancy is the number one cause for exudative effusions, but they can also be caused by infectious etiologies. Or things such as autoimmune processes like pancreatitis, or traumatic injuries resulting in a chylothorax. When you see someone who has a pleural effusion, you have to start with a workup, including not only sending the fluid for evaluation. But also draining the fluid if possible, either by thoracentesis, or by placement of a drain, whether that's a chest tube or a pigtail. Optimally, you would repeat the chest x-ray after drainage. You'll want to understand if the lung expands or if it's trapped. And there is a persistent pneumothorax because this will change your management ultimately. The options when you have someone who has a malignant pleural effusion really is between pleurodesis versus an indwelling catheter. Pleurodesis can be accomplished either by video-assisted thoracoscopic, or VATS approach. Or it can be approached by bedside procedures using a chest tube or a pigtail placement. If you know whether or not the lung expands first, you can actually eliminate a trip to the operating room and perform some of these procedures either in a medical procedure unit, or even at bedside. When you're doing a pleurodesis, the goal is to eliminate space for fluid to reaccumulate and to prevent another procedure. Even after a pleurodesis is performed you may have small pockets of fluid that may reappear. As long as the patient doesn't need to have another intervention the original pleurodesis procedure is considered successful. Pleurodesis options could utilize talc, bleomycin, or doxycycline. When you're thinking about how to perform a pleurodesis, a VATS or a thoracoscopic surgical approach. Has a greater success rate than performing a pleurodesis through a chest tube using a talc slurry for example. When performing a pleurodesis, you want to leave a post-procedure chest tube in to drain the fluid afterwards. If you don't the fluid that accumulates may wash away the sclerosin. And really what you want is contact between the lung and the inner chest wall in the presence of the talc. Or other sclerosin, to allow for the inflammatory response that will allow the lung to stick. Our protocol is to usually leave a chest tube in for three days, usually to suction for the first 48 hours, and then to water seal for 24 hours. Will usually remove our chest tube after three days, once the volume has come down in terms of the chest tube output. If a patient has a high volume output, which can be seen in transudative infusions. That will limit the effectiveness of the pleurodesis, because usually the high volume will wash away the sclerosant. Indwelling pleural catheters are another option to help people with malignant pleural affusion's. These actually need active management and in our institution is usually performed by thoracic surgery. Indwelling pleural catheters can result, or the placement of indwelling pleural catheters can result in a pleurodesis effect over a period of 2 to 12 months. They can also be removed in clinic if needed. The original brand is called a PleurX catheter, also known as a Denver Shunt, but there are other brands now available. Here's an example of a patient who has an indwelling pleural catheter placed. The original chest x-ray, on the left, shows a patient with a left-sided pleural infusion. This person had a trapped lung their lung did not expand. And as you can see on the left, and indwelling pleural catheter was placed at the base of the left chest cavity. Patient has increased expansion of their lung, but not complete expansion of that space. Now returning to our pre lecture question, again, which treatment option for malignant pleural effusion will not result in a pleurodesis of the space? A, indwelling pleural catheter. B, Talc applications by VATS. C, Talc application by chest tube slurry. Or D, pig tail catheter placement. The answer is D, pig tail catheter placement. The other three options will all result in a pleurodesis of the space. Again indwelling pleural catheters or a pleurodesis performed by VATS. Or using a chest tube will all result in a pleurodesis of the space. Pig tail catheter placements do not have the same effectiveness at least not described in the literature. The take home points from this lecture are that airway management for patients with stage four disease requiring palliation requires a coordinated effort by anesthesia as well as the surgeon. Different stents have different benefits and this needs to be understood by the person who's placing the stents. Pleurodesis is an option when the lung fully re-expands. But otherwise, indwelling pleural catheters are usually the best long term solution. Thank you for your attention.
