Tratamento do câncer de pulmão localmente avançado

Dentre as neoplasias malignas, o câncer do pulmao e a segunda causa mais frequente de morte. Em metade dos pacientes, o diagnostico e feito tardiamente (nos estagios III e IV), e, nessa fase, a terapeutica esta voltada principalmente para o tratamento sintomatico e a melhoria da qualidade de vida. A maior parte desses pacientes morre de complicacoes locais, sobretudo decorrentes de obstrucao da via aerea. O presente artigo aborda o tratamento dessas obstrucoes — a causa principal de morbidade e mortalidade nesses pacientes. Fazemos uma revisao anatomica da via aerea para, em seguida, descrever as principais formas de obstrucao das vias aereas por doenca maligna. Discutimos as diferentes tecnicas utilizadas para esse fim: o desbridamento e a dilatacao endobronquica, a resseccao das lesoes com laser, eletrocauterio, pincas de biopsia ou a ponta do broncoscopio (core out), assim como a utilizacao de orteses de vias aereas. Enfatizamos a importância da melhora da qualidade de vida desses pacientes com a utilizacao desses metodos, aliviando a dispneia e diminuindo a ocorrencia de pneumonias associadas a obstrucao bronquica. Ressaltamos que o manuseio dos pacientes com obstrucao por invasao intraluminal ou por compressao extrinseca requer uma equipe multidisciplinar com experiencia em broncoscopia flexivel e rigida e que disponha de equipamentos apropriados e de suporte de terapia intensiva. Ressaltamos ainda a importância do envio precoce dos pacientes para tratamento especializado. Lung cancer is the second leading cause of cancer death. Approximately half of all lung cancer patients are diagnosed at anadvanced stage (stage III or IV), and the treatment of such patients is aimed primarily at improving quality of life and alleviating symptoms. Most patients with advanced stage lung cancer will die from local complications, primarily from those related to airway obstruction. The objective of this review was to explore practical approaches to airway obstruction, which is the main cause of morbidity and mortality in such patients. We review airway anatomy and describe the various processes of airway obstruction in malignancy. We also discuss methods for alleviating airway obstruction: debridement; endobronchial dilation; laser resection; electrocauterization; core biopsy with forceps and a rigid bronchoscope; and airway stent placement. By alleviating dyspnea and reducing the incidence of pneumonia related to bronchial obstruction, the methods describedhere can improve quality of life in patients with advanced stage lung cancer. We stress the importance of a multidisciplinary approach in cases of intraluminal tumor invasion or extrinsic airway compression. The multidisciplinary team must includeprofessionals with experience in performing fiberoptic and rigid bronchoscopy, as well as having access to the equipment required in order to provide intensive care. In addition, patients should be referred to specialized facilities as early as possible.