CASE REPORT
Bronchoscopic Drainage of a Malignant Lung Abscess Stamatis Katsenos, MD, PhD,*w Konstantinos Psathakis, MD, PhD,*w Fotini Chatzivasiloglou, MD,* Elvira-Markela Antonogiannaki, MD,* Anthoula Psara, MD,* and Konstantinos Tsintiris, MD*
Summary: Bronchoscopic drainage of a pyogenic lung
abscess is an established therapeutic approach in selected patients in whom conventional antibiotic therapy fails. This intervention has also been undertaken in patients with abscess owing to underlying lung cancer and prior combined radiochemotherapy. However, this procedure has rarely been performed in cavitary lesions of advanced tumor origin before initiating any chemotherapy/radiotherapy scheme. Herein, we describe a case of a 68-year-old woman with lung adenocarcinoma stage IIIB, who underwent bronchoscopic drainage of necrotizing tumor lesion, thus improving her initial poor clinical condition and rendering other treatment modalities, such as radiotherapy, more effective and beneficial. Bronchoscopic drainage of a symptomatic cancerous lung abscess should be considered as an alternative and palliative treatment approach in patients with advanced inoperable non–small cell lung cancer. Key Words: abscess, bronchoscopic drainage, lung cancer (J Bronchol Intervent Pulmonol 2015;22:148–151)
L
ung abscess may be associated with either bacterial, mycobacterial, fungal, and/or parasitic infection. It could also be associated with pulmonary infarction, vasculitides, necrotic conglomerate lesions of silicosis, and primary and metastatic malignancies.1 Treatment with antibiotics remains the most common therapeutic approach for the infectious lung abscesses. Postural drainage is also a useful adjunct therapy, and bronchoscopy is reserved for patients who fail to show improvement “on schedule” and in whom there is a strong suspicion of endobronchial malignancy or a foreign body.
Received for publication November 13, 2013; accepted November 11, 2014. From the *Department of Pneumonology; and wInterventional Bronchoscopy Unit, General Army Hospital of Athens, Athens, Greece. Disclosure: There is no conflict of interest or other disclosures. Reprints: Stamatis Katsenos, MD, PhD, Department of Pneumonology, Army General Hospital of Athens, 158 Mesogion& Katehaki Avenue, Athens 115 25, Greece (e-mail: skatsenos@ yahoo.gr). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
148 | www.bronchology.com
Bronchoscopic drainage is an established therapeutic approach in selected patients in whom conventional antibiotic therapy fails.2 Percutaneous catheter drainage or surgical resection may also be considered, however, with varying results.3 Bronchoscopic drainage has also been performed on patients with infectious abscesses because of the immunosuppressive effect of combined radiochemotherapy regimen for underlying lung cancer.4 However, this procedure has rarely been performed in locally advanced cavitary lung cancer before initiating any chemotherapy/radiotherapy scheme. Herein, we present a case of a 68year-old woman with lung adenocarcinoma who underwent bronchoscopic drainage of necrotizing tumor lesion, thus improving her initial poor clinical condition and making other treatment modalities more effective. CASE REPORT A 68-year-old woman, a heavy smoker with a smoking history of over 50 pack-years, was admitted for an evaluation of a right-lung mass. Bronchoscopy revealed occlusion of the posterior segment of the right upper lobe by an exophytic tumor mass, which was diagnosed as poorly differentiated adenocarcinoma. Further work-up using abdominal and brain computed tomography (CT) as well as bone scan did not detect any distant metastases. In addition, an integrated fluorodeoxyglucose-positron emission tomography and axial CT of the thorax demonstrated a right upper lobe mass measuring 7.2 cm in diameter with high standardized uptake value (SUV = 12), with associated enlarged ipsilateral hilar lymph node and prevascular mediastinal lymph nodal involvement (SUV = 8.4). Thus, the disease was clinically classified as stage IIIA (T3N2M0). Surgical resection was attempted as the tumor was considered resectable because of its clinical stage (single N2 disease). Nevertheless, the tumor was technically inoperable as it invaded the great vessels. Consequently, the disease was reclassified as stage IIIB (T4N2M0) and chemoradiotherapy was advocated. After 5 days of the thoracotomy and before the inception of chemoradiotherapy, the patient developed
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
FIGURE 1. Chest radiograph showing cavitation of tumor lesion.
high-grade fever (391C) with purulent expectoration and fatigue. A new chest radiograph revealed cavitation of the tumor lesion (Fig. 1). Empirical broadspectrum antibiotic treatment was given for 3 weeks with no tangible results, as the abscess cavity did not decrease in size, the white blood cell count remained high with prolonged therapy, and the general status of the patient progressively deteriorated. Bronchoscopic drainage was considered in view of her recent major surgery. Endoscopic Procedure Description The patient underwent flexible bronchoscopy through a nasal route in a standard manner. Under fluoroscopic guidance, a guidewire was introduced into the cavity through the working channel of the bronchoscope. A nasogastric radiopaque catheter of
Bronchoscopic Drainage of a Malignant Lung Abscess
110 cm in length (Flocare Nutricia Ltd, Trowbridge; UK) of 10 Fr diameter was inserted over the wire into the cavity (Fig. 2). The position of the catheter was confirmed with the administration of a small amount of contrast medium (Ultravist 300; Schering AG, Berlin, Germany), followed by the removal of the guidewire (Fig. 3). The catheter was secured at the nose. When the catheter was placed in its right position, 500 mL of frank pus drained immediately (Fig. 4). Moreover, the abscess cavity was flushed twice daily with 80 mg gentamycin in 20 mL of normal saline aliquots and the catheter was open to gravity. The patient continued to receive intravenous antibiotics including tazobactam/clavulanic acid plus ciprofloxacin. An improvement of patient’s clinical condition was noted as she became afebrile with white blood cell count normalization. In addition, the abscess size decreased as a total of 950 mL of cavity contents were aspirated (Fig. 5). Nevertheless, 3 days after the procedure, the catheter was removed because of the patient’s intolerance. Antibiotic treatment was discontinued 15 days after the bronchoscopic drainage as the serial chest radiographs documented reduction in the size of the lesion and the patient exhibited complete remission of her symptoms. A thoracic palliative radiotherapy was administered (39 Gy/13fractions) following removal of the catheter. The disease remained quiescent for 3 more months, but repeat CT imaging revealed a new metastatic brain lesion. Once again, brain radiotherapy provided slight symptomatic improvement; however, her disease continued to progress. Her level of appetite and overall performance status continued to decline. She eventually succumbed to the disease in approximately 9 months after her diagnosis. DISCUSSION
Lung abscesses are generally treated with prolonged systemic antibiotic therapy, thereby
FIGURE 2. A nasogastric radiopaque catheter was slipped over the wire and introduced into the cavity through bronchoscopy. RB2 indicates posterior segment of the right upper lobe bronchus. Copyright
r
FIGURE 3. Fluoroscopy showing the correct position of the catheter after administration of contrast medium.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.bronchology.com |
149
Katsenos et al
J Bronchol Intervent Pulmonol
FIGURE 4. Aspiration of purulent fluid shortly after the catheter placement.
achieving cure without relapse. However, it has been estimated that surgery or drainage is required in 11% to 21% of patients in whom medical therapy fails. Mortality rates of 11% to 28% have been reported, thus making physicians more skeptical about surgery as the first
FIGURE 5. Chest radiograph showing improvement of the abscess size after the catheter introduction and drainage.
150 | www.bronchology.com
Volume 22, Number 2, April 2015
therapeutic option after the antibiotic failure.2 Percutaneous drainage (PTD) may also be considered in treating lung abscesses but with contradictory results regarding its efficacy. Bronchoscopic drainage is a minimally invasive procedure in the armamentarium of the chest physicians dealing with patients with lung abscess. The procedure was first described by Metras and Chapin in 1954.5 Since then, 4 more case series have been reported.4,6–8 The largest and most recently published study by Herth and colleagues addressed the role of bronchoscopic drainage in patients in whom antibiotic therapy for lung abscess was unsuccessful (enlarging cavity or lack of improvement of clinical status). The study showed a high success rate (90%), as 38 of 42 participants experienced improvement in their clinical status, with insignificant rate of complication.4 Bronchoscopic drainage can also been successfully achieved with the use of laser if an endobronchial lesion is obstructing the abscess site.9 Furthermore, similar favorable results are demonstrated in a recently published study using argon plasma coagulation to penetrate the abscess wall, thus facilitating the catheter introduction.10 In the present case, the abscess cavity was unresponsive to antibiotic therapy. The obstructing cancerous lesion was an additional reason for the failure of the conventional treatment and the indication for endoscopic drainage. PTD was contraindicated as the patient had an endobronchial occluding lesion. Poor performance status that emerged after the first thoracotomy and the presence of the cavitary lesion also rendered surgical approach more problematic. Bronchoscopic drainage resulted in improvement of the patient’s clinical outcome. Furthermore, the procedure enabled external beam radiotherapy to be more effective as the cavity was nearly collapsed, thus relieving the patient’s symptoms and improving quality of life. In conclusion, endoscopic drainage is a safe and effective method for treating infectious lung abscesses and may be an alternative to PTD in patients who are coagulopathic, have airway obstruction, or have a relatively central abscess, if an airway leading to the abscess can be demonstrated. More specifically, it should be considered as an alternative and palliative treatment approach in patients with advanced inoperable non–small cell lung cancer presenting symptomatic lung abscess before any cancer therapy inception.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
REFERENCES 1. Desai H, Agrawal A. Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema. Med Clin North Am. 2012;96: 1127–1148. 2. Wali SO. An update on the drainage of pyogenic lung abscesses. Ann Thorac Med. 2012;7:3–7. 3. Yu H. Management of pleural effusion, empyema, and lung abscess. Semin Intervent Radiol. 2011;28: 75–86. 4. Herth F, Ernst A, Becker HD. Endoscopic drainage of abscesses: technique and outcome. Chest. 2005;127: 1378–1381. 5. Metras H, Chapin J. Lung abscess and bronchial catheterization. J Thorac Surg. 1954;27:157–159.
Copyright
r
Bronchoscopic Drainage of a Malignant Lung Abscess
6. Connors JP, Roper CL, Ferguson TB. Transbronchial catheterization of pulmonary abscesses. Ann Thorac Surg. 1975;19:254–260. 7. Rowe LD, Keane WM, Jafek BW, et al. Transbronchial drainage of pulmonary abscesses with the flexible fiberoptic bronchoscope. Laryngoscope. 1979;89:122–128. 8. Schmitt GS, Ohar JM, Kanter KR, et al. Indwelling transbronchial catheter drainage of pulmonary abscess. Ann Thorac Surg. 1988;45:43–47. 9. Shlomi D, Kramer MR, Fuks L, et al. Endobronchial drainage of lung abscess: the use of laser. Scand J Infect Dis. 2010;42:65–68. 10. Goudie E, Kazakov J, Poirier C, et al. Endoscopic lung abscess drainage with argon plasma coagulation. J Thorac Cardiovasc Surg. 2013;146:e35–e37.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.bronchology.com |
151
Bronchoscopic Drainage of a Malignant Lung Abscess Stamatis Katsenos, MD, PhD,*w Konstantinos Psathakis, MD, PhD,*w Fotini Chatzivasiloglou, MD,* Elvira-Markela Antonogiannaki, MD,* Anthoula Psara, MD,* and Konstantinos Tsintiris, MD*
Summary: Bronchoscopic drainage of a pyogenic lung
abscess is an established therapeutic approach in selected patients in whom conventional antibiotic therapy fails. This intervention has also been undertaken in patients with abscess owing to underlying lung cancer and prior combined radiochemotherapy. However, this procedure has rarely been performed in cavitary lesions of advanced tumor origin before initiating any chemotherapy/radiotherapy scheme. Herein, we describe a case of a 68-year-old woman with lung adenocarcinoma stage IIIB, who underwent bronchoscopic drainage of necrotizing tumor lesion, thus improving her initial poor clinical condition and rendering other treatment modalities, such as radiotherapy, more effective and beneficial. Bronchoscopic drainage of a symptomatic cancerous lung abscess should be considered as an alternative and palliative treatment approach in patients with advanced inoperable non–small cell lung cancer. Key Words: abscess, bronchoscopic drainage, lung cancer (J Bronchol Intervent Pulmonol 2015;22:148–151)
L
ung abscess may be associated with either bacterial, mycobacterial, fungal, and/or parasitic infection. It could also be associated with pulmonary infarction, vasculitides, necrotic conglomerate lesions of silicosis, and primary and metastatic malignancies.1 Treatment with antibiotics remains the most common therapeutic approach for the infectious lung abscesses. Postural drainage is also a useful adjunct therapy, and bronchoscopy is reserved for patients who fail to show improvement “on schedule” and in whom there is a strong suspicion of endobronchial malignancy or a foreign body.
Received for publication November 13, 2013; accepted November 11, 2014. From the *Department of Pneumonology; and wInterventional Bronchoscopy Unit, General Army Hospital of Athens, Athens, Greece. Disclosure: There is no conflict of interest or other disclosures. Reprints: Stamatis Katsenos, MD, PhD, Department of Pneumonology, Army General Hospital of Athens, 158 Mesogion& Katehaki Avenue, Athens 115 25, Greece (e-mail: skatsenos@ yahoo.gr). Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved.
148 | www.bronchology.com
Bronchoscopic drainage is an established therapeutic approach in selected patients in whom conventional antibiotic therapy fails.2 Percutaneous catheter drainage or surgical resection may also be considered, however, with varying results.3 Bronchoscopic drainage has also been performed on patients with infectious abscesses because of the immunosuppressive effect of combined radiochemotherapy regimen for underlying lung cancer.4 However, this procedure has rarely been performed in locally advanced cavitary lung cancer before initiating any chemotherapy/radiotherapy scheme. Herein, we present a case of a 68year-old woman with lung adenocarcinoma who underwent bronchoscopic drainage of necrotizing tumor lesion, thus improving her initial poor clinical condition and making other treatment modalities more effective. CASE REPORT A 68-year-old woman, a heavy smoker with a smoking history of over 50 pack-years, was admitted for an evaluation of a right-lung mass. Bronchoscopy revealed occlusion of the posterior segment of the right upper lobe by an exophytic tumor mass, which was diagnosed as poorly differentiated adenocarcinoma. Further work-up using abdominal and brain computed tomography (CT) as well as bone scan did not detect any distant metastases. In addition, an integrated fluorodeoxyglucose-positron emission tomography and axial CT of the thorax demonstrated a right upper lobe mass measuring 7.2 cm in diameter with high standardized uptake value (SUV = 12), with associated enlarged ipsilateral hilar lymph node and prevascular mediastinal lymph nodal involvement (SUV = 8.4). Thus, the disease was clinically classified as stage IIIA (T3N2M0). Surgical resection was attempted as the tumor was considered resectable because of its clinical stage (single N2 disease). Nevertheless, the tumor was technically inoperable as it invaded the great vessels. Consequently, the disease was reclassified as stage IIIB (T4N2M0) and chemoradiotherapy was advocated. After 5 days of the thoracotomy and before the inception of chemoradiotherapy, the patient developed
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
FIGURE 1. Chest radiograph showing cavitation of tumor lesion.
high-grade fever (391C) with purulent expectoration and fatigue. A new chest radiograph revealed cavitation of the tumor lesion (Fig. 1). Empirical broadspectrum antibiotic treatment was given for 3 weeks with no tangible results, as the abscess cavity did not decrease in size, the white blood cell count remained high with prolonged therapy, and the general status of the patient progressively deteriorated. Bronchoscopic drainage was considered in view of her recent major surgery. Endoscopic Procedure Description The patient underwent flexible bronchoscopy through a nasal route in a standard manner. Under fluoroscopic guidance, a guidewire was introduced into the cavity through the working channel of the bronchoscope. A nasogastric radiopaque catheter of
Bronchoscopic Drainage of a Malignant Lung Abscess
110 cm in length (Flocare Nutricia Ltd, Trowbridge; UK) of 10 Fr diameter was inserted over the wire into the cavity (Fig. 2). The position of the catheter was confirmed with the administration of a small amount of contrast medium (Ultravist 300; Schering AG, Berlin, Germany), followed by the removal of the guidewire (Fig. 3). The catheter was secured at the nose. When the catheter was placed in its right position, 500 mL of frank pus drained immediately (Fig. 4). Moreover, the abscess cavity was flushed twice daily with 80 mg gentamycin in 20 mL of normal saline aliquots and the catheter was open to gravity. The patient continued to receive intravenous antibiotics including tazobactam/clavulanic acid plus ciprofloxacin. An improvement of patient’s clinical condition was noted as she became afebrile with white blood cell count normalization. In addition, the abscess size decreased as a total of 950 mL of cavity contents were aspirated (Fig. 5). Nevertheless, 3 days after the procedure, the catheter was removed because of the patient’s intolerance. Antibiotic treatment was discontinued 15 days after the bronchoscopic drainage as the serial chest radiographs documented reduction in the size of the lesion and the patient exhibited complete remission of her symptoms. A thoracic palliative radiotherapy was administered (39 Gy/13fractions) following removal of the catheter. The disease remained quiescent for 3 more months, but repeat CT imaging revealed a new metastatic brain lesion. Once again, brain radiotherapy provided slight symptomatic improvement; however, her disease continued to progress. Her level of appetite and overall performance status continued to decline. She eventually succumbed to the disease in approximately 9 months after her diagnosis. DISCUSSION
Lung abscesses are generally treated with prolonged systemic antibiotic therapy, thereby
FIGURE 2. A nasogastric radiopaque catheter was slipped over the wire and introduced into the cavity through bronchoscopy. RB2 indicates posterior segment of the right upper lobe bronchus. Copyright
r
FIGURE 3. Fluoroscopy showing the correct position of the catheter after administration of contrast medium.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.bronchology.com |
149
Katsenos et al
J Bronchol Intervent Pulmonol
FIGURE 4. Aspiration of purulent fluid shortly after the catheter placement.
achieving cure without relapse. However, it has been estimated that surgery or drainage is required in 11% to 21% of patients in whom medical therapy fails. Mortality rates of 11% to 28% have been reported, thus making physicians more skeptical about surgery as the first
FIGURE 5. Chest radiograph showing improvement of the abscess size after the catheter introduction and drainage.
150 | www.bronchology.com
Volume 22, Number 2, April 2015
therapeutic option after the antibiotic failure.2 Percutaneous drainage (PTD) may also be considered in treating lung abscesses but with contradictory results regarding its efficacy. Bronchoscopic drainage is a minimally invasive procedure in the armamentarium of the chest physicians dealing with patients with lung abscess. The procedure was first described by Metras and Chapin in 1954.5 Since then, 4 more case series have been reported.4,6–8 The largest and most recently published study by Herth and colleagues addressed the role of bronchoscopic drainage in patients in whom antibiotic therapy for lung abscess was unsuccessful (enlarging cavity or lack of improvement of clinical status). The study showed a high success rate (90%), as 38 of 42 participants experienced improvement in their clinical status, with insignificant rate of complication.4 Bronchoscopic drainage can also been successfully achieved with the use of laser if an endobronchial lesion is obstructing the abscess site.9 Furthermore, similar favorable results are demonstrated in a recently published study using argon plasma coagulation to penetrate the abscess wall, thus facilitating the catheter introduction.10 In the present case, the abscess cavity was unresponsive to antibiotic therapy. The obstructing cancerous lesion was an additional reason for the failure of the conventional treatment and the indication for endoscopic drainage. PTD was contraindicated as the patient had an endobronchial occluding lesion. Poor performance status that emerged after the first thoracotomy and the presence of the cavitary lesion also rendered surgical approach more problematic. Bronchoscopic drainage resulted in improvement of the patient’s clinical outcome. Furthermore, the procedure enabled external beam radiotherapy to be more effective as the cavity was nearly collapsed, thus relieving the patient’s symptoms and improving quality of life. In conclusion, endoscopic drainage is a safe and effective method for treating infectious lung abscesses and may be an alternative to PTD in patients who are coagulopathic, have airway obstruction, or have a relatively central abscess, if an airway leading to the abscess can be demonstrated. More specifically, it should be considered as an alternative and palliative treatment approach in patients with advanced inoperable non–small cell lung cancer presenting symptomatic lung abscess before any cancer therapy inception.
Copyright
r
2015 Wolters Kluwer Health, Inc. All rights reserved.
J Bronchol Intervent Pulmonol
Volume 22, Number 2, April 2015
REFERENCES 1. Desai H, Agrawal A. Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema. Med Clin North Am. 2012;96: 1127–1148. 2. Wali SO. An update on the drainage of pyogenic lung abscesses. Ann Thorac Med. 2012;7:3–7. 3. Yu H. Management of pleural effusion, empyema, and lung abscess. Semin Intervent Radiol. 2011;28: 75–86. 4. Herth F, Ernst A, Becker HD. Endoscopic drainage of abscesses: technique and outcome. Chest. 2005;127: 1378–1381. 5. Metras H, Chapin J. Lung abscess and bronchial catheterization. J Thorac Surg. 1954;27:157–159.
Copyright
r
Bronchoscopic Drainage of a Malignant Lung Abscess
6. Connors JP, Roper CL, Ferguson TB. Transbronchial catheterization of pulmonary abscesses. Ann Thorac Surg. 1975;19:254–260. 7. Rowe LD, Keane WM, Jafek BW, et al. Transbronchial drainage of pulmonary abscesses with the flexible fiberoptic bronchoscope. Laryngoscope. 1979;89:122–128. 8. Schmitt GS, Ohar JM, Kanter KR, et al. Indwelling transbronchial catheter drainage of pulmonary abscess. Ann Thorac Surg. 1988;45:43–47. 9. Shlomi D, Kramer MR, Fuks L, et al. Endobronchial drainage of lung abscess: the use of laser. Scand J Infect Dis. 2010;42:65–68. 10. Goudie E, Kazakov J, Poirier C, et al. Endoscopic lung abscess drainage with argon plasma coagulation. J Thorac Cardiovasc Surg. 2013;146:e35–e37.
2015 Wolters Kluwer Health, Inc. All rights reserved.
www.bronchology.com |
151
