Bronchial obstruction

An obstructed bronchus results in symptoms out of proportion to the size of the tumour. It results in an atelectatic infected lobe or lung through which unoxygenated blood is shunted. Effective doses of radiation and chemotherapy are not possible because of the associated sepsis. One of the aims of external beam radiation is to reduce such obstruction. However, post radiation fibrosis and protracted pre-treatment atelectasis makes such a desirable effect less common.

Intraluminal brachytherapy with sources delivered by bronchoscopy can relieve obstructed bronchi and can lead to complete resolution of superficial tumours. The effect is enhanced by external beam radiotherapy. Neodymium YAG laser delivered by flexible fibre-optic bronchoscopy can also be used to re-open obstructed major bronchi. CO2 laser is effective in a straight line for laryngeal and tracheal tumours. Recently, self-expanding wire stents, deliverable over a guidewire under radiological control, have been successfully used to re-canalise bronchi. Relief of obstructive pneumonitis by intraluminal brachytherapy, Neodymium YAG laser or self expanding wire stent can relieve otherwise untreatable sepsis and allow the use of radiation and chemotherapy.

Massive haemoptysis

Haemoptysis is one of the primary alert signs for bronchogenic carcinoma. It is ironic that in many cases of lung cancer the haemoptysis arises from another lesion such as an area of bronchitis. Similarly massive haemoptysis is more common with benign diseases such as TB, cystic fibrosis or terminal congenital heart disease than with malignancy.

The situation of massive haemoptysis when it does occur is particularly distressing for the patient family and medical attendants but the amount of blood loss is rarely enough to compromise the circulation. Bleeding is usually from a bronchial artery and most cases settle spontaneously. The initial management is to prescribe appropriate sedation and anti-hypertensive medication. The bleeding site may be identified by percutaneous transaortic arteriography during active bleeding. Embolisation of the offending bronchial artery can control the acute situation to allow further investigation and therapy. Urgent radiotherapy has a place in controlling haemorrhage when a tumour has been identified.

Flexible bronchoscopy is usually impractical in the face of massive blood loss as a good view canot be obtained. Rigid bronchoscopy may allow better control of the airway and allow larger suction catheters to be used but at the expense of allowing contamination of the contralateral lung as the cough reflex is temporarily anbolished. Often the only useful bronchoscopic manoeuvre is to pass a balloon catheter as a bronchial blocker. This tamponades the affected lung till other treatment can be commenced.

SVC obstruction

Facial and upper limb oedema with distension of veins on the upper torso are the immediate signs of superior vena caval obstruction. The commonest cause in western societies is malignant mediastinal lymphadenopathy. In young patients lymphoma is frequently the culprit but in the aging smoker bronchogenic carcinoma must be suspected. The presence of the syndrome of SVC obstruction is an indicator of advanced local disease usually indicating that the azygous system has also been blocked. It is an indication for urgent treatment as cardiac decompensation due to impaired venous return can develop rapidly. Thus general anaesthetic for mediastinoscopy or anterior thoracotomy may not be possible and treatment may need to commence before definitive histology is available. Percutaneous intraluminal stenting is now possible and serves as excellent palliation to allow full oncological workup before a treatment plan is initiated.

Dysphagia

Mediastinal metastases from lung cancer, particularly those in subcarinal nodes may compress the oesophagus causing dysphagia. This may be treatable with chemotherapy or radiotherapy but such treatment may be compromised by aspiration pneumonitis. Self-expanding metal endo-oesophageal stents can be passed endoscopically under fluoroscopic control to immediately relieve the dysphagia and the danger of aspiration.

Hypercalcaemia

Hypercalcaemia in lung cancer may be the result of multiple bone metastases. However, it may also be a paraneoplastic effect of a peptide resembling parathyroid hormone. It is commoner in small cell carcinoma and when it does occur in NSCLC it is frequently an indication of a poorly differentiated tumour with poor prognosis. Initial treatment involves rehydration with normal saline accompanied by a frusemide induced diuresis. Bisphosphonate drugs such as palmidronate or etidronate may also be effective in the acute phase. Further treatment is that which is appropriate to the underlying malignancy.

Spinal cord compression

Vertebral metastasis compromising the spinal cord is not uncommon in lung cancer. If it leads to paralysis it is a disastrous complication as a patient living with his cancer, able to carry on the activities of daily living, is transformed into a bedbound cripple requiring total care for the remainder of their short life. Once neurological signs are present there is rarely any return of function. Therefore anticipation and early recognition are essential. Any suggestion of back pain, loss of bowel or bladder function or limb signs should be treated as an oncological emergency and urgent CT, myelogram or MRI obtained. Some patients are suitable for neurosurgical spinal decompression but most will be treated with radiotherapy.

Malignant pleural effusion

The pleura is a common site for metastatic disease. A malignant pleural effusion can produce breathlessness out of proportion to the amount of disease present. As patients can live for extended periods even in the presence of metastatic pleural disease, effective palliation should be undertaken.

A malignant effusion will virtually always recur after an initial diagnostic pleural aspirate. Attempts at repeated aspiration will result in a trapped, collapsed lung due to a loculated effusion which can no longer be drained. Early pleurodesis is a more effective strategy. This can be achieved by insertion of sclerosant substances into the pleural cavity though there are circumstances when surgical pleurectomy or mechanical pleural abrasion are indicated. The most effective sclerosant is sterile talc which can be introduced by insufflation at thoracosopy when pleural and lung biopsies may also be obtained and pleural loculations broken down. When the diagnosis has already been established it is often easier to drain the pleura to dryness with a chest drain and insert the talc through the drain as a slurry.

Malignant pericardial effusion

Malignant pericardial effusion presents with the more acute clinical picture of pericardial tamponade. Acute decompression can be achieved by pericardiocentesis under echocardiographic control. To prevent recurrent tamponade a pericardial window can be fashioned either at thoracoscopy or via a sub-xiphoid laparotomy. The latter can be performed even in debilitated patients under local anaesthetic without the need for special anaesthetic techniques such as double lumen endo-tracheal intubation.