Bronchial Adenoma Treatment & Management

Updated: Sep 19, 2019
  • Author: Charles W Van Way, III, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Treatment

Approach Considerations

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.

Although adenoid cystic carcinoma (ACC) is a low-grade malignant tumor and complete resection is the preferred treatment, often because of late diagnosis and tumor location surgical intervention is not possible. Radiation therapy is the best option for unresectable tumors. Chemotherapy is not effective for ACC. [3]  

The treatment of mucoepidermoid carcinomas (MECs) is usually surgical by traditional or sleeve lobectomy, performed with an open or video-assisted technique, especially for low-grade early-stage lesions. [4]

See Surgical Care, below.

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Medical Care

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.

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Surgical Care

Surgical resection is the mainstay of treatment for patients with bronchopulmonary carcinoid. Radical surgery based on lung cancer treatment is performed for MEC, and this operation has increasingly performed using video-assisted thoracic surgery (VATS). MECs of the lung are often treated by lobectomy, sleeve resection, local resection, segmental resection, or endoscopic removal. [2]

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. Patient selection is important, as only about 5-10% of carcinoid tumors are polypoid lesions without extension through the cartilaginous wall.

Bronchoscopic resection is warranted to alleviate bronchial obstruction in patients in whom thoracotomy poses prohibitive risk. 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.

Endoscopic 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 overview

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

Bronchotomy/bronchial wedge resection

Parenchyma-sparing techniques may be appropriate in cases of typical carcinoid, provided that an R0 resection can be achieved. Polypoid tumors are accessible by bronchotomy and excision, including the involved bronchial wall. Bronchotomy ensures complete resection (as compared with endoscopic removal, which may not), and wedge resection may be appropriate 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. Case reports have demonstrated eventual reinflation of even severely atelectatic lung parenchyma, along with improvement in pulmonary function, when parenchyma-sparing techniques, such as sleeve lobectomy, are used.

Pneumonectomy

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

Preoperative risk assessment

Preopertive testing is done to assist in risk assessment and to identify areas of concern that can be mitigated prior to surgical intervention. Tests and evaluations other than those listed below may be appropriate as suggested by history, physical examination, and laboratory testing findings, but all of the listed tests are not routinely required.

History (focusing on factors known to affect operative risk) may include the following:

  • 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 includes the following:

  • Exercise tolerance - May include informal evaluation using the patient’s history, a stair climbing test, or a formal walk test
  • Areterial blood gases
  • Pulmonary function tests - Spirometry, diffusion capacity, and split-function testing

Pulmonary reserve criteria include the following:

  • Forced expiratory volume in 1 second (FEV1): 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 concern is a PaCO2 greater than 40.

Cardiac evaluation includes the following:

  • Electrocardiogram
  • Stress testing
  • Echocardiography

Perioperative management

Routine monitoring, which includes an arterial catheter for blood pressure monitoring and blood sampling, is required.

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

Double-lumen endotracheal tubes and bronchial blockers allow single-lung ventilation, which increases operative safety. Management of one-lung ventilation includes the following:

  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
  4. Maintaining a heightened awareness of the risk for hypoxic pulmonary vasoconstriction

Intraoperative details

The margin of resection for endobronchial lesions frequently 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 and pulse oximetry as well as 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 the following:

  • Delayed hemorrhage
  • Bronchial leak
  • Respiratory failure
  • Cardiac dysfunction
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Complications

Perioperative complications include the following:

  • Delayed hemorrhage
  • Bronchial anastomotic leak
  • Bleeding and coagulopathy
  • Myocardial ischemia
  • Atelectasis or pneumonia
  • Respiratory failure, need for persistent mechanical ventilation

Mucoepidermoid carcinoma is known to result in intracranial metastases, even in cases of minimal bronchial wall involvement.  In carcinoid, solid organ metastases (eg, to the liver) are possible.

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