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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

The Troubling Symptom of Bronchorrhea in BAC
Fri, 10/10/2008 - 18:03
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

Warning: this symptom can be a little gross, so the delicate flowers out there should skip this post.

One of the more unusual but quite vexxing symptoms we sometimes see in lung cancer is called bronchorrhea, which is the copious production of watery sputum, specifically at least 100 ml per day. The setting in which it's most frequently seen is in bronchioloalveolar carcinoma (BAC), and we typically think of it as being a manifestation of the mucinous subtype. In its worst form, patients can drain vast amounts of phegm each day, typically worst in the morning. Patients have told me that they lean their head down off the bed to drain a half a liter or more at a time before starting their day. Though rare, there have been frequently cited cases that have been life-threatening because of severe electrolyte imbalances that develop from losing so much fluid and salt (case report here). Interestingly, there's a sheep virus that appears clinically remarkably similar to BAC (though there hasn't been a human form of the virus ever isolated, despite searching), and I've seen video footage of researchers demonstrating bronchorrhea by lifting the hind legs of the sheep into the air, putting a beaker under its nose, and letting the watery mucus drain out for several minutes. Sorry, I told you this post has some indelicate moments. I don't think that video's on YouTube yet.

Unfortunately, bronchorrhea is a very difficult symptom to treat effectively. Among the things that have been tried and were written up as possibly successful in individual cases have been steroids (abstract here), inhaled indomethicin (a non-steroidal anti-inflammatory drug)(abstract here and here), a drug called octreotide (reference here), radiation therapy to the most "consolidated" area of lung (reference here), and most recently EGFR tyrosine kinase inhibitors like iressa (full text here, another abstract here, and there are several other reports out there).

The ideal situation is to treat the underlying cancer effectively, rather than just the symptom. In that sense, the EGFR inhibitors are pretty unique in being the best treatment if a particular person's BAC happens to respond. Based on the fairly large phase II studies that have been done with iressa and tarceva in BAC, the response rate with this class of drugs is in the 15-25% range (see prior post for review). So for the patients who respond to an EGFR agent, it's a potentially dramatically helpful treatment for a long time. For the majority of patients who don't respond to one of these agents, the others are things that can be tried, but most of what's been reported is a single case of a treatment that worked, not a trend of multiple cases. In truth, it's probably never going to possible to run a study and enroll 20 patients to get a particular treatment, because bronchorrhea is an uncommon symptom of an uncommon disease. But these are a few things that people may try, and I'd be very interested if there are people out there who have had success with any of these approaches. Another one I'd be inclined to try, although I've never seen mention of it being done before, is inhaled lasix, the effective diuretic, which is an approach I've heard of hospice folks using to treat secretions.

In the meantime, bronchorrhea is often unpleasant, sometimes scary, and potentially life-threatening complication that nobody sees enough to become an expert at managing.

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