eMedicine Specialties > Pulmonology > Lung Tumors

Adenoma, Bronchial: Treatment & Medication

Author: Charles W Van Way III, MD, The Ralph Ringo Coffey Professor and Chairman, Department of Surgery, University of Missouri-Kansas City; Chief, Department of Surgery, Truman Medical Center
Coauthor(s): Gerald L Early, MA, MD, BA, FACS, FCCP, Associate Professor, Department of Surgery, University of Missouri-Kansas City
Contributor Information and Disclosures

Updated: Nov 13, 2008

Treatment

Medical Care

In the absence of distant metastases, the treatment  of choice is complete removal of the primary carcinoid with maximal parenchymal preservation. This is based on the knowledge that most bronchial adenomas are only locally invasive. See Surgical Care below.

Chemotherapy
Combination therapy, as is used for small cell lung carcinoma, has some effect in treating metastatic carcinoids. However, the response rate is only approximately 50%. Adjuvant chemotherapy along with postoperative radiation has been advocated for atypical lesions associated with mediastinal nodal extension.
 
Radiation therapy

Carcinoid tumors are generally radioresistant. Anecdotal reports describe tumor responses in inoperable cases. Radiation therapy is recommended for postoperative management of incompletely resected atypical lesions and in the presence of mediastinal nodal involvement. Data supporting the efficacy of this treatment are lacking.

Adenoid cystic tumors are radiosensitive and postoperative radiotherapy is of value.

Surgical Care

Endoscopic resection

Bronchoscopic resection

This procedure is plagued by incomplete tumor removal, with frequent recurrence due to extraluminal tumor bulk, often with limited tumor visibility and accessibility via the bronchoscope. It also carries a high risk of hemorrhage.

Bronchoscopic resection is warranted to alleviate bronchial obstruction in patients in whom thoracotomy is prohibitive. Additionally, occasional preoperative use of this technique may allow assessment of the reversibility of distal parenchymal damage. Finally, the technique of argon-beam electrocoagulation may be very useful for bronchoscopic control of bleeding prior to definitive resection.

Neodymium:Yttrium-aluminum-garnet laser
The Nd:YAG laser reduces the risk of hemorrhage-related complications by means of photocoagulation. It is not recommended as a primary mode of tumor removal. Rarely, the Nd:YAG laser is applicable to a polypoid, easily accessible lesion on a narrow, uninvolved stalk.

Surgical resection

In the past, as many as 62% of patients with bronchial adenomas underwent lobectomy or pneumonectomy. They frequently had significant delays in their diagnosis and had complete obstruction of a bronchus with distal parenchymal destruction. Complete tumor removal, removal of all destroyed lung parenchyma, nodal dissection, and preservation of functional parenchyma are the goals of resectional therapy.

Surgical procedures

Preoperative endobronchial resection may be used as part of the preparation of the patient for surgical resection.

Bronchotomy/simple bronchial wedge resection
Polypoid tumors are accessible by bronchotomy and excision, including the involved bronchial wall. Bronchotomy ensures complete resection as compared to endoscopic removal. Wedge resection is appropriate only for small lesions lacking atypia. These procedures may be accompanied by nodal sampling.

Lobectomy with or without sleeve resection

This is the most commonly used technique because most tumors occur in or near the origin of lobar bronchi. Concomitant sleeve resection of the main stem is required if the orifice of the lobar bronchus or the adjacent main stem bronchus is involved. Bronchoplastic adjuncts may permit preservation of normal distal parenchyma and are preferred over pneumonectomy when possible.

Pneumonectomy

Pneumonectomy may be required if all lobes on the involved side are destroyed because of a proximal obstructing lesion.

Preoperative risk assessment

Tests and evaluations other than those listed below may be appropriate as suggested by history, physical examination, and laboratory testing findings.

History (focusing on factors known to affect operative risk)
  • Chronic obstructive pulmonary disease
  • Chronic renal failure 
  • Cor pulmonale 
  • Diabetes mellitus 
  • Myocardial infarction within 6 months or unstable ischemic disease 
  • Severe cardiac valvular disease 
  • Congestive heart failure 
  • Bleeding disorders 
  • Peripheral vascular disease
Pulmonary function evaluation
  • Exercise tolerance - May include informal evaluation using the patient’s history, a stair testing test, or a formal walk test
  • Arterial blood gas testing 
  • Pulmonary function tests - Spirometry, diffusion capacity, and split-function testing
  •  Pulmonary reserve criteria
    • Forced expiratory volume in 1 second (FEV 1 ): Mortality risk is inversely proportional to FEV1. With low FEV1, expect prolonged postoperative mechanical ventilation.
    • Forced vital capacity: This value should be greater than 2 liters or at least 3 times the tidal volume. Mortality risk is inversely proportional to forced vital capacity.
    • Ratio of residual volume to total lung capacity: A value of greater than 50% suggests severe chronic obstructive pulmonary disease with airway closing volumes approaching total lung capacity. A contraindication includes a ratio of residual volume to total lung capacity of greater than 50%. 
    • Maximum breathing capacity: This should be more than 50% of predicted.
    • PaCO2: A contraindication is a PaCO2 of greater than 40.

Cardiac evaluation

  • Electrocardiogram
  • Stress testing 
  • Echocardiography

Perioperative  management

Monitoring and positioning
Routine monitoring is needed, and an arterial catheter should be placed for blood pressure monitoring and blood sampling.

With regard to positioning, pay special attention to maximize operative exposure and reduce the risk of peripheral nerve injury.

Single-lung ventilation
Double-lumen endotracheal tubes and bronchial blockers allow single-lung ventilation, which increases operative safety. Management of one-lung ventilation includes (1) using tidal volumes low enough to maintain peak airway pressure at less than 30-35 mm Hg and plateau airway pressures less than 25-30 mm Hg, (2) limiting the fraction of inspired oxygen to that required to maintain acceptable oxygen saturations, (3) avoiding auto–positive end expiratory pressure, and (4) maintaining a heightened awareness of the risk for hypoxic pulmonary vasoconstriction.

Intraoperative details
The margin of resection for endobronchial lesions usually requires frozen section examination, especially if bronchoplastic procedures are used. The presence of microscopic tumor at the resection margin mandates wider resection. For atypical carcinoids, nodal staging by frozen section analysis and/or extensive mediastinal nodal dissection is required.
 
Postoperative details
Pulmonary care frequently includes bronchodilators and chest physiotherapy. Deep venous thrombosis prophylaxis is necessary. Monitoring should include cardiac rhythm studies and pulse oximetry in addition to routine care and surveillance of vital signs.

Pain management
Pain promotes atelectasis, impairs secretion clearance and ventilation, and leads to a restrictive defect. Adjunctive measures such as epidural techniques, patient-controlled analgesia, and nonsteroidal agents all may be of value in addition to standard narcotic-based regimens. Intercostal nerve blocks, both intraoperatively and postoperatively, can be helpful.

Postoperative complications
Postoperative complications can include delayed hemorrhage, bronchial leak, respiratory failure, and/or cardiac dysfunction.

More on Adenoma, Bronchial

Overview: Adenoma, Bronchial
Differential Diagnoses & Workup: Adenoma, Bronchial
Treatment & Medication: Adenoma, Bronchial
Follow-up: Adenoma, Bronchial
References
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References

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  4. Dagostino RS, Ponn RB. Adenoid Cystic Carcinoma and Other Primary Salivery Gland-Type Tumors of the Lung. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:1768-77.

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  6. Faber LP. Sleeve Lobectomy. In: Shields TW, LoCicero J 3rd, Ponn RB, Rusch VW, eds. General Thoracic Surgery. 6th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2005:458-69.

  7. Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, et al. Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature. Chest. Jun 2001;119(6):1647-51. [Medline].

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Further Reading

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Keywords

bronchial adenoma, endobronchial neuroendocrine tumor, Kulchitsky tumor, bronchial carcinoid, bronchial gland tumor, mucous gland carcinoma, mucous gland adenomas, mucoepidermoid carcinoma, adenoid cystic carcinoma, cylindromas, small cell undifferentiated carcinoma, malignant lung neoplasms, lung tumor, lung cancer, lung malignancy

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Contributor Information and Disclosures

Author

Charles W Van Way III, MD, The Ralph Ringo Coffey Professor and Chairman, Department of Surgery, University of Missouri-Kansas City; Chief, Department of Surgery, Truman Medical Center
Charles W Van Way III, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physician Executives, American College of Surgeons, American Medical Association, American Medical Informatics Association, American Society for Clinical Nutrition, American Society for Nutritional Sciences, American Society for Parenteral and Enteral Nutrition, American Surgical Association, Association of Military Surgeons of the US, Central Surgical Association, Missouri State Medical Association, Shock Society, and Southwestern Surgical Congress
Disclosure: Sanofi-Aventis Grant/research funds Local PI

Coauthor(s)

Gerald L Early, MA, MD, BA, FACS, FCCP, Associate Professor, Department of Surgery, University of Missouri-Kansas City
Gerald L Early, MA, MD, BA, FACS, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American College of Surgeons, American Medical Association, Society of Critical Care Medicine, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Michael Peterson, MD, Chief of Medicine, Vice-Chair of Medicine, University of California at San Francisco; Endowed Professor of Medicine, University of California at San Francisco-Fresno
Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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