Malignant Airway Disease Research Articles

1:38 PM Abstract No. 207 - Tracheobronchial stenting for malignant airway disease

Purpose To investigate both the immediate and long term outcomes following self-expandable metallic stents (SEMSs) deployment for the management of tracheobronchial malignant disease. Materials and Methods We retrospectively searched our department’s database for patients treated with covered or uncovered SEMSs for the management of tracheobronchial pathology owing to local or metastatic disease. Between January 2009 and December 2010, in total 49 patients (27 male, mean age 60.9±15 years) underwent 77 SEMS insertions (57 uncovered, 20 covered). All procedures were performed in the operation room under both bronchoscopic and fluoroscopic guidance. The study’s primary endpoints included technical success, and symptomatology recurrence rates, while secondary endpoints included patients’ survival and complications rates. Baseline demographics and procedural details were recorded. Results Technical success rate was 97.9% (48/49 cases). Overall 14 kissing, 23 main bronchus, 1 distal bronchus, 9 tracheal and 2 tracheal plus main bronchus stenting deployments, were performed. The mean time follow-up was 5.5±5.9 months (range 0.03-24 months), while the symptomatology recurrence rate was 14.5% (7/48 patients) and was attributed to stent occlusion due to tumor in-growth (4/48, 8.3%), stent migration (2/48, 4.1%) and bronchospasm (1/48, 2%). According to the Kaplan-Meyer analysis the estimated patients’ survival rate was 21.5%, up to 2-years follow-up, while the overall complications rate was 3.8% (3/77 stents). Conclusion Tracheobronchial SEMS stenting is a safe and effective minimally invasive management option for patients suffering from symptomatic malignant airway disease.

Broncho-vascular fistulas from self-expanding metallic stents: A retrospective case review

To highlight a potentially fatal complication of broncho-vascular fistula arising from the self expanding metallic stent (SEMS) placement. We retrospectively analyzed five patients with benign and malignant airway diseases, who developed tracheo/broncho-vascular fistulas following SEMS placement in our tertiary care setting. All patients received either Wallstent or Ultraflex® stent (Boston Scientific, Natick, MA) between 1999 and 2007. All patients had received adjunct therapy such as balloon bronchoplasty, laser therapy or electrocautery. Most patients presented with massive hemoptysis. A total of 483 SEMS were placed during this period. SEMS placement can be complicated by Broncho-vascular fistula formation. True incidence and precise time interval between the insertion of stent and onset of this complication is unknown. Additional therapeutic modalities to maintain stent patency may enhance the risk of fistula formation. SEMS should only be used in a select sub-group of patients, after exhaustive evaluation of other treatment options. These cases provide evidence that broncho-vascular fistulas can develop at any time following SEMS placement, suggesting the need for a more cautious approach, especially while using them for a long term management. In benign airway disease, the stent should be removed as soon as healing has taken place.

Interventional pulmonology: Focus on pulmonary diagnostics

Interventional pulmonology (IP) allows comprehensive assessment of patients with benign and malignant airway, lung parenchymal and pleural disease. This relatively new branch of pulmonary medicine utilizes advanced diagnostic and therapeutic techniques to treat patients with pulmonary diseases. Endobronchial ultrasound revolutionized assessment of pulmonary nodules, mediastinal lymphadenopathy and lung cancer staging allowing minimally invasive, highly accurate assessment of lung parenchymal and mediastinal disease, with both macro- and microscopic tissue characterization including molecular signature analysis. High-spatial resolution, new endobronchial imaging techniques including autofluorescence bronchoscopy, narrow-band imaging, optical coherence tomography and confocal microscopy enable detailed evaluation of airways with increasing role in detection and treatment of malignancies arising in central airways. Precision in peripheral lesion localization has been increased through innovative navigational techniques including navigational bronchoscopy and electromagnetic navigation. Pleural diseases can be assessed with the use of non-invasive pleural ultrasonography, with high sensitivity and specificity for malignant disease detection. Medical pleuroscopy is a minimally invasive technique improving diagnostic safety and precision of pleural disease and pleural effusion assessment. In this review, we discuss the newest advances in diagnostic modalities utilized in IP, indications for their use, their diagnostic accuracy, efficacy, safety and challenges in application of these technologies in assessment of thoracic diseases.

Tracheobronchial Stenting for Malignant Airway Disease

The aim of this retrospective study is to investigate the immediate and long-term outcomes following the insertion of covered and uncovered self-expandable metallic stent (SEMS) for the management of malignant tracheobronchial disease. A total of 49 patients (27 male, mean age 60.9 ± 15 years) underwent 77 SEMS insertions (57 uncovered). The procedure was performed in theater using combined bronchoscopic and fluoroscopic guidance. The study's primary end points included technical success (97.9%), clinical success (91.8%), and symptom recurrence (14.2%). The mean follow-up time was 5.5 ± 5.9 months. We concluded that tracheobronchial SEMSs provide safe and effective minimally invasive long-term management of patients with symptomatic malignant airway disease.

Protective Effect of Immunosuppression on Granulation Tissue Formation in Metallic Airway Stents

The use of self-expanding metallic airway stents has been extended in recent years in inoperable patients with malignant and benign airway diseases. The risk of granulation tissue formation in the stent is a major concern. The objective of the present study was to determine whether immunosuppression modulates granulation tissue formation in airway stents, as seen in coronary stents. The study included 19 patients with benign airway obstructions and 11 recipients of lung transplants with anastomotic obstructions who were receiving immunosuppression therapy. The degree of in-stent granulation tissue formation was evaluated (score range, 0-3) every 3 months for 2 years. Granulation tissue formation was significantly lower in the transplant recipients than in the nontransplant patients at 3 months (score 0.7 vs. 1.6, P = .031), 15 months (score 0 vs. 1.1, P = .026), and 18 months (score 0 vs. 1.8, P = .020). During the 2 years of follow-up, the transplant recipients underwent significantly fewer laser resections and brachytherapy treatments for in-stent granulation. The immunosuppression given to lung transplant recipients may have an inhibitory effect on granulation tissue formation in metallic airway stents. Further studies are needed to evaluate the effect of systemic therapy or coated stents with drugs such as sirolimus.

Outcomes of Tracheobronchial Stents in Patients With Malignant Airway Disease

Outcomes of Tracheobronchial Stents in Patients With Malignant Airway Disease

Outcomes of Tracheobronchial Stents in Patients With Malignant Airway Disease

Malignant central airway obstruction is difficult to manage and is associated with poor outcome. We sought to identify the short (< 30 days) and intermediate (> 30 days) benefits and risks of tracheobronchial stents in patients with malignant airway disease. Two hundred and twenty-five tracheobronchial stents were placed in 172 patients for benign (n = 32) and malignant (n = 140) disease from January 1, 1997, to May 31, 2003. The records of the patients with malignant disease were retrospectively analyzed to determine complication rate, reintervention rate, and survival. The malignant diagnoses included nonsmall cell cancer, small cell cancer, esophageal cancer, and metastatic disease. There were 172 stents placed in 140 patients with malignant disease, with no intraoperative mortality. The mean follow-up period was 142 +/- 12 days. There were 23 complications, including tumor ingrowth (n = 9), excessive granulation tissue (n = 7), stent migration (n = 5), and restenosis (n = 2). Five of the complications occurred during the short-term period (< 30 days) with the remaining complications (n = 18) occurring after 30 days. The complications required interventions including laser debridement (n = 14), dilation (n = 4), and stent removal (n = 5). Tracheobronchial stents offer minimally invasive palliative therapy for patients with unresectable malignant central airway obstruction. The benefit of airway stents is particularly seen in the short-term period where they provide symptomatic improvement and have low complication risk. The major impediment is excessive granulation tissue and tumor ingrowth, which occur primarily after 30 days.

O-194 10 year review of use of the Gianturco stent in malignant airway disease

O-194 10 year review of use of the Gianturco stent in malignant airway disease

The Use of Expandable Metal Stents to Facilitate Extubation in Patients With Large Airway Obstruction

To determine the clinical utility of placing airway stents to facilitate weaning in ventilator-dependent patients with large airway obstruction. A chart review of mechanically ventilated patients who received expandable metal airway stents to attempt a facilitation of weaning. Eight patients, 3 women and 5 men, ranging in age from 37 to 82 years, had respiratory failure associated with large airway obstruction and underwent flexible bronchofluoroscopic placement of 12 expandable metal stents (7 Wallstents [Schneider; Minneapolis, MN], 2 Palmaz [Johnson & Johnson; Warren, NJ], and 3 Ultraflex [Microinvasive; Natick, MA]). Six had respiratory failure that was secondary to malignant airway disease, and two had benign airway disease. Seven patients with tracheal or mainstem bronchial obstruction were weaned from the ventilator within 0 to 11 days of stent placement after having previously required mechanical ventilation from 2 to 52 days. There were no associated complications. Following prolonged attempts at weaning, one patient with lobar bronchus obstruction died after mechanical ventilation was withdrawn. Expandable metal airway stents may be safely deployed in mechanically ventilated patients and can facilitate weaning from the mechanical ventilator. Mechanically ventilated patients with tracheal and mainstem bronchus obstruction are the best candidates for deployment of expandable airway stents to facilitate weaning.

Clinical and laboratory evaluation of a new thin-walled self-expanding tracheobronchial silicone stent: Progress and pitfalls

Background: Although widely established in the management of malignant airway lesions, currently available tracheobronchial prostheses made of silicone have their drawbacks resulting from rigidity and wall thickness. Therefore we present clinical follow-up data obtained with a novel thin-walled expandable prototype silicone airway stent (Polyflex stent, Willy Rüsch AG, Kernen, Germany) in 19 patients. Methods: Seventeen of 19 patients had tracheobronchial complications of infiltrating cancer: five had respiratory-digestive fistulas, 14 had mixed-type obstructions (mucosal infiltration plus extrinsic compression), and two had diffuse tracheal hemorrhages from the tumor surface (three patients had more than one complication). Two of 19 patients had benign postintubation stricture and malacia. Overall, 33 stents were implanted either simultaneously or in a consecutive manner. Scanning electron microscopy was performed both on prototype stents and on other available silicone stents for comparison. Results: The treatment improved the patients' clinical condition substantially. The mechanical properties of the new prosthesis were excellent. Important stent-associated side effects were early mucus retention ( n = 7), infolding of the inner silicone layer ( n = 2), and stent dislodgment ( n = 2). As of February 1997, 10 patients have died of causes unrelated to stent placement. Seven patients with malignant airway disease are still alive from 2 weeks up to 7 months after initial treatment. Scanning electron microscopy of explanted and unused prototypes suggested that an extremely ragged luminal microstructure may contribute to the firm adhesion of secretory material and that technical smoothing of the surface avoids such complications. Conclusions: The novel self-expandable silicone airway stent may be a promising addition to commonly used stent types. Short-term and medium-term management of fistulas, tumor surface bleeding, and strictures (malignant and benign) is satisfactory. Scanning electron microscopy of stents provides information on peculiar features of microstructure and material that may be of use in clinical research and technical innovation. (J Thorac Cardiovasc Surg 1997;114:527-34)

Bronchoscopic Management of Malignant Airway Disease

A wide variety of bronchoscopic modalities are currently available for management of patients with malignant airway disease. Knowledge of the strengths and limitations of these procedures will allow the selection of the most appropriate procedure for each specific patient and each specific airway lesion. Neodymi-um-yttrium-aluminum-garnet laser therapy is the most widely studied and used procedure. It produces immediate results in patients with exophytic endobronchial lesions, but it is not useful for extrinsic compression. Brachytherapy gives delayed results but has the advantage of treating submucosal and peribronchial disease. Endobronchial stents are especially useful in extrinsic compression, but the devices lack standardization and outcome studies. Cryotherapy is an inexpensive alternative to laser therapy but cannot be used in patients who require immediate palliation. Photodynamic therapy and endobronchial electrosurgery are still in the experimental stages. The final procedure choice should be based on the clinical presentation of the patient, the type and location of the lesion, and the experience and skill of the bron-choscopist

AIRWAY STENTS: Present and Future

Tracheobronchial stent insertion is a relatively new technique used to palliate or cure central airways obstruction. When performed by experienced thoracic endoscopists, this procedure is both safe and effective, even if complications of indwelling stents may require repeat endoscopic intervention. Although proven clinically beneficial to many patients, airway prostheses have not yet been the subject of large comparative case studies or randomized controlled investigations. Reports are often experiential and anecdotal. Further research is needed to determine the effects of stenting on survival in patients with malignant airway disease and its degree of success in patients with benign airway strictures. Only then will airway stents truly deserve their place alongside other therapies for tracheobronchial obstruction.

Survival of Patients Undergoing Nd-YAG Laser Therapy Compared With Nd-YAG Laser Therapy and Brachytherapy for Malignant Airway Disease

I read with interest the article by Shea et al 1 Shea JM Allen RP Thurratt RS Chan AL Siefkin AD. Survival of patients undergoing Nd YAG laser therapy compared with Nd YAG laser therapy and brachytherapy for malignant airway disease. Chest. 1993; 103: 1028-1031 Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar in the April 1993 issue of Chest. The authors describe their experience with endobronchial therapy for exophytic inoperable squamous cell carcinoma of the lung with Nd-YAG plus or minus low dose brachytherapy. Their conclusions about longer survival of patients receiving combination therapy may be related to the deficiencies that exist in their study rather than a true benefit. I cite various factors that would affect survival of inoperable lung cancer and that are not addressed in their study.

Survival of Patients Undergoing Nd:YAG Laser Therapy Compared With Nd:YAG Laser Therapy and Brachytherapy for Malignant Airway Disease

Brachytherapy in combination with Nd:YAG laser therapy may add to the duration of survival of the palliative period when compared with laser alone. A retrospective study of patients with inoperable squamous cell carcinoma (SCC) was undertaken to determine if there was a difference in survival between those patients treated with Nd:YAG laser alone and those treated with Nd:YAG laser and brachytherapy. Twenty-two patients were treated with brachytherapy for malignant airway disease at our institution of which 13 had SCC. All patients had previously received treatment with Nd:YAG laser for exophytic disease. Survival was compared with those patients treated with Nd:YAG laser alone for SCC involving the airway. There was no statistical difference between the two groups with regard to age. The duration of survival of patients with SCC of the airway from the first Nd:YAG laser treatment was determined. A significant difference between those patients treated with Nd:YAG laser alone and those patients treated with combined therapy was found (p < 0.001). Brachytherapy may potentiate the duration of survival in patients with SCC involving the airway compared to palliation with Nd:YAG laser alone.

Tracheobronchial stents: indications and applications

Airway narrowing due to postsurgical tracheal or bronchial stenosis, malacia, obstructing tumors, or neoplastic invasion and extrinsic compression may cause progressive dyspnea and hypoxemia. Endoscopic management of benign disorders avoids the potential morbidity of open surgery. In regards to malignancy, an estimated 20-30% of patients with diagnosed lung cancer will present with atelectasis or pneumonia due to endobronchial disease [l]. In addition, patients with malignant airway disease who have exhausted therapeutic options such as lung resection or radiation therapy are often victim to severe airway compromise, hemoptysis, obstructive pneumonitis, and slow asphyxia. In one study, 40% of lung cancer deaths were attributed to locoregional disease at autopsy [2]. Tracheobronchial stents have proven to be both safe and effective for palliating airway compromise and improving quality of life in these patients. In this chapter a description of basic proximal airway anatomy is followed by a review of the indications, techniques, and risks of tracheobronchial stents in obstructive airway disease. Results of our experience with 387 stents placed since 1987 are also discussed. Controversy surrounding airway stents may be explained by unsatisfactory material and technique previously used in their manufacture and insertion. Today, airway lumen can be partially re-established by dilatation, endoscopic laser resection or brachytherapy. New rigid bronchoscopy systems have been introduced, improved fiberoptics have resulted in smaller diameter fiberoptic bronchoscopes and easier inspection of a narrowed tracheobronchial tree, and modem CCD and video monitoring have led to improved documentation for later reference. The perfect stent, however, has not yet been designed. Ideally, it should conform well to the narrowed airway. Neither too long nor too short, it should be tailored to fit the entire stenotic zone. It must be solid enough to resist extrinsic compression. It should be difficult to displace but easy to clean or to replace if ineffective. The inert material used for its

Intermediate dose rate remote afterloading brachytherapy for intraluminal control of bronchogenic carcinoma

Forty-five patients with symptomatic proximal malignant airway disease received 128 intraluminal intermediate dose rate (IDR) brachytherapy treatments by remote afterloading technique. Multiple small catheters were bronchoscopically placed. Iridium-192 sources delivering an intermediate dose rate (200–1000 rads/hr) were guided under remote computer control. Treatment times were 1–4 hr. Fourteen of these patients also received YAG laser photoresection. External beam radiation was also given (6000 rads) to 16 patients for curative intent and (3000 rads) to 9 patients for palliative intent. Twenty recurrent disease patients were also treated, but they did not receive external irradiation. An obstruction score (OS) was developed in an attempt to quantitate the improvement in intraluminal narrowing. Patients treated with curative intent showed 66% improvement after initial therapy. Initial therapy for palliative patients showed an 84% improvement and for recurrent disease patients, 64% of luminal narrowing was seen. Patients who received laser in addition to brachytherapy showed a 70% reduction. A 67% improvement was seen in those who did not receive laser therapy. The entire group averaged a 69% improvement of narrowing. Four complications, three minor, (1 bronchospasm, and 2 episodes of transient intratreatment increased ventricular irritability) and one major (pneumothorax) were noted. The relatively short treatment times allowed most of the treatments to be performed on an outpatient basis and were well-tolerated by the patients. Forty-four of the 45 patients experienced significant symptomatic improvement. The remote afterloading technique allowed improved radiation protection for personnel.