Talking Tall Rounds®: Tracheal Neoplasm

Podcast Transcript

Announcer:

Welcome to the Talking Tall Rounds Series, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic

Sudish Murthy, MD, PhD:

I'm going to be presenting another interesting disease scenario from our annals of chest medicine and chest surgery here at Cleveland Clinic main campus. We're going to start today's presentation with Dr. Mike Javorski, one of our residents, who will introduce the case to the audience. Mike?

Michael Javorski, MD:

So I will start with the case. This is a 28-year-old male who presented with worsening shortness of breath, wheezing and hemoptysis over several weeks. He had no significant medical history, and he was a non-smoker. On exam, he had bilateral expiratory wheezing, and he was saturating at 98% on room air. In the emergency room, the CT scan showed a 1.5-by-1.5 centimeter mass in the distal trachea. The differential diagnosis was a clot versus neoplasm. The patient was intubated with a rigid bronchoscope, and an exophytic mass emanating from the right distal trachea was seen obstructing 80% of the lumen. The lesion was cored out and bleeding was controlled with pressure, ice cold saline, and then cautery. After this, his respiratory symptoms were palliated, and he was discharged home with follow-up for surgical planning. The final pathology was mucoepidermoid carcinoma. A repeat bronchoscopy before surgery was done, and it showed that the lesion was isolated in the distal trachea with a focal stalk. The patient was taken to the operating room and a mediastinoscopy was first performed. And this was done by anterior dissection of the trachea and the left main stem.

Michael Javorski, MD:

After this was done, the patient was put on veno-venous ECMO with percutaneous access in the right IJ and right common femoral vein. The patient was repositioned into the left lateral decubitus, and ventilation was discontinued. Four ports were then placed into the patient and the da Vinci robot was docked onto the patient. After this, after gaining access to the thoracic cavity, the distal trachea and the main stem bronchi were mobilized, and then a right hilar release was performed as well. Once the trachea was fully mobilized, the distal trachea was resected. And after margins were negative, an end-to-end anastomosis was performed with a vascularized pedicle flap buttress the anastomosis. Once this was done and air leak was confirmed to be negative, the ECMO was decannulated and he was extubated in the OR. The patient was transferred to the step down unit postop day one, and he was discharged on postop day three. Six months postop the patient's doing well. He's exercising again. And bronchoscopy showed a well-healed anastomosis with no lesions. Thank you.

Sudish Murthy, MD, PhD:

The problem was, of course, that we had this tumor in the distal trachea, and we have to resect and reconstruct that. And it's a fairly uncommon operation even here. This is done for benign and malignant conditions. You've heard about some of the cancers that impact the distal airway. We see benign tracheostenosis. And Mike and I have managed those as well with this type of approach using a combined interventional bronchoscopy and surgical approach. And the airway control during the operation, as you can imagine, when you're cutting on the airway can be quite complex. So this is the airway, and just to highlight everyone. We're down here close to the carotid. Veno-venous ECMO seems to be a nice adjunct to these types of operations to really free up the airway of the tracheal appliance. The advantages is we're oxygenating on the venous side of the heart. You got to understand that, so the blood that is being oxygenated is going into the right side of the heart and is going back through the lungs themselves and actually loses a fair bit of his oxygenation during that travel. It then returns to the arterial side and is somewhat desaturated, but more than sufficiently saturated to provide reasonable oxygenation for the systemic circulation. More importantly, the carbon dioxide is scrubbed by the machine, and so you're really sending peripheral arterial blood that has relatively normal carbon dioxide profiles. The advantage of the ECMO circuit in our case, and we're trying to do things with less collateral damage here, there's percutaneous access. And you saw Pat show some of the catheters that we used. But there are disadvantages to this technology as there are with most things. You need a perfusion team like Pat has behind him and that I have behind me. These kinds of technologies and techniques are not necessarily universally translatable to other institutes across the country. And you can imagine having these big catheters in some of these central veins for extended periods of time does leave the patient open for deep venous thrombosis, which is not particularly uncommon in some of these cases.

Sudish Murthy, MD, PhD:

Why would you use veno-venous ECMO on a case like this? Well, it should dramatically simplify intraoperative airway control and I think it allows for an unobstructed reconstruction. And when you're trying to pull two pieces of tissue together, the last thing you really need is a foreign body, and an endotracheal tube that is in the way.

Sudish Murthy, MD, PhD:

I'm going to show you two different ways how we do this operation, both of them using ECMO. So we'll start with the old way. This is a different patient and a different tumor. This is actually a squamous cell tumor. And I think, Mike, actually saw this one too, because he's got his fingerprints over here. That's the PET scan. This one, as Jason was telling you about, using PET scan for airway tumor. This lesion was fairly PET positive, actually. There's the snare, I think that Mike had through a rigid bronchoscope. He's snaring down on the lesion and getting it out of the way. And that's what was left. It's almost identical presentation, very close to the case that we're talking about right now was. But it's slightly different, slightly more central in the airway on the membranous part of the airway.

Sudish Murthy, MD, PhD:

When we were looking at this case, we had a plan of an autofluorescence bronchoscopy to really look for a field cancerization phenomenon because this one actually was a squamous cell cancer. We started the case with a mediastinoscopy, which was used to both stage the cancer as well as to free up the airway. We have to remember that we're going to be removing a segment of airway. And so, the two cut ends have to be able to be reapproximated in as free a manner as possible, so tension has to be relaxed. And the mediastinoscopy does in fact do that. The veno-venous ECMO setup was, as Pat just went over in this case, which was the drainage catheter to the ECMO machine was a 24 French put in through the right femoral vein and the return or the inflow to the patient was through the right IJ and it was an 18 French catheter. We used a thoracotomy here. I guess, we were a little nervous about doing things really minimally invasively. And this is a few years ago.

Sudish Murthy, MD, PhD:

This is the standard schema for the ECMO. And ECMO was put in first, and then the mediastinoscopy was done second, and then the patient was positioned for a right-side approach. Here's the autofluorescence bronchoscopy and you can see that blush, that's what we're looking at, that’s kind of the vasculature of the mucosa and there was nothing else. Here's the mediastinoscopy. Down below is the airway. This is the trachea down here. These are the investing tissues and that scope is used to dissect that area. Here's the thoracotomy. That's the azygos vein that's being divided. It's an important landmark that overlies the airway very close to the carina perhaps a centimeter away. It's just divided. We've gotten around the airway there. That's the airway where you see that taper around it. And we're pulling out lymph nodes. And you heard from Christine Booth about some of the staging. And again, these are cancer operations. We do take out lymph nodes. We're cutting the airway now. And that catheter you see in there, it's just an oxygen exchange. It's a tube exchange catheter. It's not an endotracheal tube. That's just a blow by oxygen to the contralateral lung to additionally oxygenate the patient. But you see that we're totally free. We're starting to cut the airway now, and we often use bronchoscopy to help us define where we incise the airway. The last thing you need to do is take out too much airway that you suddenly then cannot reconstruct. We're cutting on both sides of where we think the lesion is, and we're just doing this sharply here. And we take additional margins and cut further back, but that's kind of where the lesion was.

Sudish Murthy, MD, PhD:

And then, we're going to just sew everything together. There's really no appliance. We have that little jet catheter there just to apply oxygen. That's the membranous part that we're closing. And here's the final close here. We'll cut the sutures. Most of the time, we like to separate the airway reconstruction from tissues around it, which would include, say, the aorta and the esophagus below and the pulmonary artery above. We get a vascularized flap of the thymus that we mobilize, and then we bring up the lung. Hopefully, there's no significant air leak. You can't leave a case like this with an air leak. This has to be completely hemostatic. That was a five-day hospital stay. That person had negative margins. And I don't want to get Christine too excited here, but this was the pathology that we had. And we'll move on.

Sudish Murthy, MD, PhD:

What's the new way? And I'm not sure this is the new way everywhere. This is still, what I would consider, an experimental procedure to do this procedure with robotics where the biggest incision is maybe about a half inch. And we have probably four of those poke holes to do the exact same operation we just did with an eight-inch incision. But robotics, there's no doubt that it's a technology that's here to stay and the optics are just terrific. And I think we leverage the optics and the magnification, which are generally between five and 10 times the human eye to really do the operations and to understand anatomy. And we actually in our group have demonstrated oncologic legitimacy of using the robot for lung cancer resection. We're pretty comfortable that it provides at least the same oncologic impact. And we think it is, when done hopefully in experienced hands, far more user-friendly from a patient side.

Sudish Murthy, MD, PhD:

We thought why not try it here? This is the lesion that you've all know will see in your dreams tonight. This is actually Mike's initial bronchoscopy image. And this is when he finished and you saw that as well. There's his rigid bronchoscope and there's that char that he left behind. Just to review, you heard from Christine about the pathology and Jason about some of the other studies and Mike about what he did. And so, we had a mucoepidermoid, which was considered low grade and this was a completely fit, never-smoking man who is only 28 years old. Our operative plan we’re to perform a flexible bronchoscopy and we used some autofluorescence. I'm not going to show you that in this video. We did the mediastinoscopy to fully free up the central mediastinum and to biopsy additional lymph nodes there. We also stuff a gauze pack in that central mediastinum that we retrieved when we go into the right chest.

Sudish Murthy, MD, PhD:

We instituted veno-venous ECMO and the inflow was the 18 French and the outflow to the machine was the 24. I, generally, use fluoro in these cases. We don't really need a TEE echo. This is VV ECMO, not VAV ECMO. And then, our plan was a right-sided approach in a distal tracheal resection and reconstruction using the da Vinci Xi platform. This was the schema of the veno-venous ECMO circuit as you've seen before. This is a little different optics. That's the azygos vein. The one you saw shrouded in blood when we did the thoracotomy. These are some lymph nodes that come out often whole. Here's some lymph nodes in the subcarina where the whole packet is coming out.

Sudish Murthy, MD, PhD:

And these were some of the lymph nodes that were passed back to Christine and her team for that. This is, believe it or not, the left side of the airway. The esophagus is to the left of the picture. That's the cut end of the azygos. And we're getting around the airway. This is the front of the airway. There's the other cut end of the esophagus. That's the SVC pulsing away because the ECMO cannula is in there. We're going to dissect on top of the airway. And there's that gauze right in there that we placed from the mediastinoscopy, so that freed up so that gauze gets pulled out. And we're going to get around the airway here using our techniques. Just if we go a little lateral, we're going to get the recurrent nerve on the left side. Just like in the open procedure, we get around the airway. Now, we do, I didn't show on the last film, but we talked about it. This is going to be a hilar release where we're just releasing that pericardium from the right side of the left atrium. This is underneath the atrium. That's the left atrium there. We're going to hook that around. These are some of the veins. The inferior pulmonary vein right there. That's the phrenic nerve just to the right of the dissector. Again, here's our airway and you can see the carina. This is right airway, this is left and we're going to cut this segment of airway out. Now, we have ECMO, so we don't have to worry about breathing the patient right now. And we're going to take a sleeve of airway. We always generally, again, take out a few margins and this is a few other rings just to make sure. And we've checked margins and then we put it together. And here is my diagram telling the resident what to do. And as you can imagine, that was just the diagram. There's a fair bit of language that comes with that when you're trying to tell them what to do. And we sew this back up together. And then, again the all-important leak test. And we're going to take the thymus and we can use the robot to do the thymus and put that right over the top.

Sudish Murthy, MD, PhD:

The critical element of this intervention is that it has to be really identical and really recapitulate. There's the immediate postop. And there's the one, three months later. That actually I think Mike saw this patient in follow up. The one thing about these procedures, they really have to recapitulate the open operation or be better. Otherwise, there's very limited value just to do them from a patient perspective.

Sudish Murthy, MD, PhD:

The postoperative course was unremarkable. The guy got out very quick, as actually Mike Javorski had said, it was just a short stay. And as Christine reviewed the final pathology with negative margins. And the patient returned to work in four weeks. I just wanted to highlight overall that this is not a one-man or woman show. This is a team sport and you've seen some of the team members. Some of whom were involved in this case and were critical elements of the case.

Sudish Murthy, MD, PhD:

You got to be rowing together. This is my daughter's regatta. And you can see where the coxswain is at the very front of the boat. It turns out that they were actually rowing in the wrong direction. The start of the race is over here to the right. And you can see the boys' boat was actually going. Not only are you in the same boat together and rowing, but you better be going in the right direction. Those are the two important lessons. And with that, I think we'll stop. And field any questions from outside, but maybe I have a few things for some of the people up here as well. And thank you for your attention.

Sudish Murthy, MD, PhD:

Let's see. I think I wanted to ask Jason about any novel agents for PET scans. We've heard about Oxygen-O15. Is there anything on the horizon for imaging that would replace our standard FDG-PET for cancer imaging? Are you aware of anything?

Jason Lempel, MD:

That's a great question. I'm not aware of anything that's in the works right now. I mean, there are certain cancers that have certain agents that are preferential for those cancers, but I'm not aware of anything that would be pretty standard across the spectrum.

Sudish Murthy, MD, PhD:

It seems like we've been stuck on FDG-PET, the FDG for a better part of 15 years or even longer than that.

Jason Lempel, MD:

Correct. Yeah and it's not terribly specific as I mentioned because infections light up at least as bright as cancers. It doesn't necessarily help narrow down the differential too much. But as we all know, it helps to stage, do a survey over the entire body since it is full body imaging, and it could help narrow down differential a bit. But I'm not aware of anything else in the works.

Sudish Murthy, MD, PhD:

I’ve got one for Christine and this is the bane of the surgeon's existence and that is crush artifact. We give you guys a biopsy and then we hear, "We can't tell because it's crush artifact." What is that and when should we worry about that?

Christine Booth, MD:

I think it's when the tissue is actually pinched and/or cauterized, those are two times. When the tissue becomes pinched or cauterized, the cells become crushed. And certain tumors like small cell will look very crushed anyway because of their high nuclear to cytoplasmic ratio. But when you see a sea of what looks like crushing, you can still immunostain those tumors sometimes and get results with crush. But it can be difficult when you can't actually see the cells when they're crushed.

Sudish Murthy, MD, PhD:

I hate hearing that from the pathology team, especially if it's crush artifact. And for Mitch, I wanted to ask you Mike, what other endobronchial ablative strategies do we have, maybe for not a tumor this big, but other energy sources, or cryo, or PDT. What's the latest on other laser, on other strategies to treat central airway cancers?

Michael Machuzak, MD:

Sure. As Sid mentioned, there's a lot of modalities out there. Laser, cautery have been the mainstays. Argon has also been very popular. And cryotherapy is probably the newest and what most people are considering the best right now. There's a cryoprobe. But the cryospray is really what's been becoming more popular as of late. PDT, which was an old therapy, has also had a little bit of a resurgence in the world as well. Each of them have their own pluses and minuses. With the cryospray, you've got to be very diligent about making sure you vent, because it's a high pressure high flow rate. We don't want to cause any air embolism. We've seen cases of pneumothoraces in some of these. PDT, obviously, there's all the light exposure that you got to be wary of as well as the expense.

Sudish Murthy, MD, PhD:

All right. And the last thing, Pat, I just got a question for you about latest cannula. Are we getting to lower profile higher flows? The lower the profile and the higher the flows seems like would be the better the cannula as long as we're not disrupting red cells causing lysis, et cetera. And I always prefer really short cannulas, particularly in the IJ that are even 16 French. That if they're short enough, sometimes, we can generate those flows of four liters that you guys like to see. Is there some advancement or some continued development of some of these inflow and outflow cannulas that we're trying to trial and now use here?

Patrick Grady, CCP:

Yeah, so they're just starting to release some with the elastion gives them a smaller, thinner profile. They're starting to do that and they're starting to get them approved for longer than six hours In the past that we've used the same cannula as we used in open heart surgery. They're working on these types of cannulas being approved for long term. They're looking at other ones. If you do a fem-fem approach for VV ECMO with a long cannula that it goes right into the heart and then a shorter cannula for the drainage. Some of those different configurations. And those should be FDA approved within the next month or two.

Sudish Murthy, MD, PhD:

Yeah. You can imagine that this guy I think was decannulated in an operating room. And I don't think Mike Javorski was there. But I could have asked him the question, "How long did you have to hold pressure in this gentleman's groin?" Which is not insignificant. You had a 24 French cannula in an adult male's groin. There's a fair bit of pressure. And it's a good thing Mike played football at BC, because we need that training to hold pressure. But when you do that, you do get some DVTs that arise. And we often study these patients with duplex after on day of discharge just to make sure we're not sending home someone who's going to have a catastrophic pulmonary embolism. And it is not infrequent that we find some element of clot burden in the ipsilateral lower extremity that was cannulated. And we're not sure if it's the cannula or the pressure, because these are put in percutaneously. I think with that, I don't have anything else. Is there anything from the audience either here or out in cyberspace that needs to be addressed?

Audience:

What's your typical anticoagulation strategy in these kind of things?

Sudish Murthy, MD, PhD:

The question from the vast audience here was what is the anticoagulation strategy intraoperatively and perhaps even postoperatively? That's a very good question. These cannulas are actually designed at some level to be used without full heparinization and we're doing an operation. And if we're fully heparinized, you can imagine the problems with bleeding. Personally, I just bolus these patients at induction with about 5,000 of heparin and get the cannulas in. By the time we get to the operation from when the catheters go in, is about an hour or so just because you got to reposition and prep and everything else. By that time, you're already passed one half-life of the heparin. How about I'll throw that to Pat. Pat, how comfortable are you guys with a heparin bolus running at four liters flow without any additional heparin given that these are all, I assume, Carmeda bonded or something. They're all bonded and supposed to be nonthrombogenic. What's your comfort level? Because we pretty much go with you guys, when you guys get nervous, right?

Patrick Grady, CCP:

Yeah, I think we are a little bit more nervous than you are. But we do give the initial bolus of heparin when they're cannulating. But as soon as flow's going through the cannulas, it doesn't seem to be an issue. There's a paper out of here that showed VV ECMO with no heparinization was no different than VV ECMO with heparinization. I think we feel a lot more comfortable now after looking at our own numbers.

Sudish Murthy, MD, PhD:

The other issue is what do you do after? That's a different issue and I don't know we know that answer. And again, as we know, we have injured two central veins, IJ in this case and the femoral. Should we have patients on anticoagulation? At least for transplants, I used to do that, run them on some heparin after they were decannulated, but we just use Lovenox and prophylaxis for this. And then, we study them at time of discharge.

Sudish Murthy, MD, PhD:

All right, well with that we will adjourn this addition of Tall Rounds. And thank you all for your attention and have a good day.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. Like what you heard? Visit Tall Rounds online@clevelandclinic.org/tallrounds and subscribe for free access to more education on the go.