Treatment Of Malignant Airway Obstruction Research Articles

Treatment of malignant airway obstruction with Y-shape sigma stent loaded with I125 seeds installed via rigid bronchoscopy

PurposeTo summarize and analyze the safety and efficacy of a Y-shape Sigma stent loaded with I125 in patients with inoperable malignant main airway obstruction.MethodsThis study was approved by the Institutional Ethics Committee, and a written informed consent was obtained from each participant. A Y-shape Sigma stent loaded with I125 was placed under vision from rigid bronchoscopy. The primary endpoint was alleviation of symptoms and improvement of Karnofsky Performance Status (KPS) score, and the secondary endpoint was complications and technical success.ResultsFrom November 2018 through June 2023, total 33 patients with malignant airway obstruction were palliatively treated by installing Y-shape Sigma stents loaded with I125. The airway lumen was immediately restored and the average airway opening significantly increased to 70 ± 9.4% after the procedure from baseline 30.2 ± 10.5% (p < 0.05). Average KPS score was improved from baseline 30.0 ± 10.0 to 70.0 ± 10.0 (p < 0.05) as well as PaO2 from baseline 50.1 ± 15.4 mmHg to 89.3 ± 8.6 mmHg (p < 0.05). The technical success rate of placing the stent in this study was 73%, and adverse events or complications including bleeding, I125 loss, and airway infection occurred during or after the procedure.ConclusionPlacement of Y-shape Sigma stents under vision from rigid bronchoscopy in the patients with malignant airway obstruction is feasible and it immediately alleviates dyspnea and significantly improves quality of life.

Recent progress in radioactive seed implantation brachytherapy of non-small cell lung cancer: a narrative review.

Brachytherapy, a new form of radiation therapy, has been used to treat lung cancer and consists of two main forms of treatment: endobronchial brachytherapy and radioactive seed implantation brachytherapy (RSI-BT), the latter of which is used to treat non-small cell lung cancer (NSCLC). The use of RSI-BT in the treatment of NSCLC at our centre has yielded some positive results. To more fully consider the context of this application, we conducted a search of PubMed from 2018 to March 5, 2023. The search included a combination of the MeSH terms: "brachytherapy" and "lung neoplasm". The majority of NSCLC patients who received RSI-BT achieved positive benefits. Most patients had a progression-free survival (PFS) of between 12 and 18 months. Additionally, radioactive particle stent implantation as a specific RSI-BT has shown therapeutic potential in the treatment of malignant airway obstruction. With the application of new technologies, RSI-BT will become more precise, efficient and inexpensive. This review demonstrates that RSI-BT can be therapeutic in the treatment of both early and advanced NSCLC with manageable complications. There have also been reports on the combination of RSI-BT with other therapies, but more research is needed on the combination of RSI-BT with them.

External beam radiation therapy combined with airway stenting leads to better survival in patients with malignant airway obstruction.

Malignant airway obstruction (MAO), a common complication of patients with advanced lung cancer, causes debilitating dyspnoea and poor quality of life. Two common interventions used in the treatment of MAO include bronchoscopy with airway stenting and external beam radiotherapy (EBRT). Data are limited regarding their clinical effectiveness and overall effect on survival. A retrospective chart review of patients treated with airway stenting and/or EBRT at the Johns Hopkins Hospital for MAO between July 2010 and January 2017 was reviewed. Demographics, performance status, cancer histology, therapeutic intervention and date of death were recorded. Survival was calculated using cox regression analysis. Of the 606 patients who were treated for MAO, 237 were identified as having MAO and included in the study. Sixty-eight patients underwent rigid bronchoscopy and stenting, 102 EBRT and 67 a combined approach. Patients who underwent stenting hand an increased hazard ratio (HR) of death in comparison to those who received combination therapy (HR: 2.12, 95% CI: 1.02, 4.39), while there was a trend towards significance in the EBRT alone group in comparison to the combination therapy group (HR: 1.62, 95% CI: 0.93, 2.83). In this retrospective analysis, combination therapy with stenting and EBRT led to better survival in comparison to stenting or EBRT alone. Prospective cohort trials are needed to confirm these results.

Survival and Predictors of Mortality in Patients Submitted to Endoscopic Treatment of Malignant Airway Obstruction

Survival and Predictors of Mortality in Patients Submitted to Endoscopic Treatment of Malignant Airway Obstruction

A Novel Approach for Treatment of Malignant Airway Obstruction: Design of Radioactive Stents and Experimental Studies on Normal Canine Tracheas

A Novel Approach for Treatment of Malignant Airway Obstruction: Design of Radioactive Stents and Experimental Studies on Normal Canine Tracheas

Bronchoscopic management of malignant airway obstruction.

Approximately one-third of patients with lung cancer will develop airway obstruction and many cancers lead to airway obstruction through meta stases. The treatment of malignant airway obstruction is often a multimodality approach and is usually performed for palliation of symptoms in advanced lung cancer. Removal of airway obstruction is associated with improvement in symptoms, quality of life, and lung function. Patient selection should exclude patients with short life expectancy, limited symptoms, and an inability to visualize beyond the obstruction. This review outlines both the immediate and delayed bronchoscopic effect options for the removal of airway obstruction and preservation of airway patency with endobronchial stenting.

Biodegradable Cisplatin-Eluting Tracheal Stent for Malignant Airway Obstruction

Self-expandable metallic stents (SEMSs) are effective in the palliation of malignant airway obstruction. Tumor ingrowth, however, frequently occurs because of a shortage of effective local therapy. Additionally, SEMSs are frequently associated with problems of fracture, migration, and difficult removals. Our goal was to develop a novel bioabsorbable stent with cisplatin elution to circumvent such problems.Biodegradable stents made of polycaprolactone were fabricated by a laboratory-made, microinjection molding machine. In vitro mechanical strength of the stents was compared with the strength of Ultraflex SEMSs. Polylactide-polyglycolide copolymer and cisplatin were coated onto the surfaces of the stents. Elution method and high-performance liquid chromatography (HPLC) analysis were used to examine the in vitro cisplatin release characteristics. In vivo, the stents were surgically implanted into the cervical trachea of 15 New Zealand white rabbits. Bronchoscopic examination was performed weekly (1 to approximately 5 weeks) before killing. Cisplatin concentrations in trachea, lung, and blood were analyzed by HPLC. Histologic examination was also performed.The biodegradable stent exhibited mechanical strength comparable to the strength of Ultraflex SEMSs and provided a steady release of cisplatin for >4 weeks in vitro. The in vivo study showed sustained cisplatin levels in rabbit trachea for >5 weeks with a minimum drug level in blood. Histologic examination showed an intact ciliated epithelium and marked leukocyte infiltration in the submucosa of the stented area.Our study demonstrated that the biodegradable stents provided physical properties comparable to the properties of SEMSs and a sustained release of cisplatin for >5 weeks, which showed great potential in the treatment of malignant airway obstruction.

Cryosurgery for the Immediate Treatment of Acute Central Airway Obstruction

Central airway obstruction commonly occurs in thoracic malignancies. Treatment is usually palliative but may be significantly challenging. Several endoscopic interventions are available to establish airway patency; however, their use is sometimes limited by certain factors like availability and high oxygen requirement. Cryosurgery has been established as a safe and effective technique for treatment of malignant airway obstruction, but its use has been limited to being adjunctive to other modalities and to low-grade stenosis. This is mainly due to the delayed effect and inability to achieve immediate airway patency. We report the successful use of this technique as stand-alone modality in a tracheal tumor with severe obstruction leading to acute respiratory failure. Immediate recanalization was achieved resulting in rapid resolution of symptoms.

Exercise Capacity, Lung Function, and Quality of Life After Interventional Bronchoscopy

Malignant airway obstruction accounts for significant morbidity and mortality in patients with lung and metastatic cancer. We prospectively assessed the effects of bronchoscopic interventions for the treatment of malignant airway obstruction, with specific attention to exercise capacity and quality of life (QoL). This is a prospective cohort study. Patients with high-grade, symptomatic central malignant airway obstruction were assessed at baseline and then at days 30, 90, and 180 after bronchoscopic intervention with spirometry, 6-minute walk test (6MWT), and QoL and dyspnea questionnaires (European Organization for Research and Treatment of Cancer Quality of Life [C30] and Lung Cancer [LC-13] modules). Thirty-seven patients were included in the final statistical analysis. Increases in 6MWT distance by 99.7 m (95% CI 33.2-166.2 m, p = 0.002), FEV1 by 448 ml (95% CI 203-692 ml, p < 0.001), and FVC by 416 ml (95% CI 130-702 ml, p = 0.003) were seen at day 30 compared with baseline. Clinically and statistically significant improvements were noted in composite dyspnea scores at day 30 by both QoL C30 (decrease of 39.9, 95% CI 21.4-58.4, p < 0.001) and LC-13 (decrease of 28.2, 95% CI 12.9-43.5, p < 0.001) questionnaires. Bronchoscopic intervention for malignant airway obstruction is associated with improvement in 6MWT, spirometry, and dyspnea at 30 days.

Endoscopic argon plasma coagulation for the management of solid, centrally located lung cancer

Argon plasma coagulation (APC) is one of the interventional pulmonology techniques primarily aimed at the treatment of hemoptysis. It represents a form of non contact electrosurgey that uses ionized argon gas in order to produce electrical current that affects soft tissues. APC is reported to be effective in the treatment of early stage lung cancer, in the treatment of benign granulation tissue surrounding tracheal stents and in palliative treatment of malignant airway obstruction. Major indication for APC is hemostasis in severe hemoptysis, it can also be used as an alternative technique for laser resection or electrocautery, in urgent removal of tumors situated in large airways. The present article reports successful use of APC in the treatment of centrally located squamous cell lung cancer that caused complete right lung atelectasis. The use of APC led to complete reexpansion of the right lung and improvement in dyspnoea and chest discomfort of the patient. Significant improvement was observed in lung function parameters and blood gas analysis. With the use of APC solid tumor was completely removed from the right main bronchus and airway integrity was restored. From this case we can conclude that APC can be safely and successfully used for urgent debulking of malignant central airway obstruction.

Treatment of Malignant Airway Obstruction with YAG Laser Photo Resection

Treatment of Malignant Airway Obstruction with YAG Laser Photo Resection

Treatment of Malignant Airway Obstruction with YAG Laser Photo Resection

Thirty percent of inoperable lung malignancies involve the trachea or proximal main bronchi and may cause significant respiratory distress, hemoptysis, and postobstructive pneumonia. We report a case of successful debulking of a non-small-cell lung cancer (NSCLC) involving the carina and both main bronchi using YAG-laser photo resection (LPR). CASE REPORT A 77-year-old woman was transferred to our hospital for further management of respiratory failure due to malignant large airway obstruction. Prior to admission, she had experienced 3 weeks of dry cough and progressive dyspnea, but no hemoptysis, fever, chills, night sweats, or weight loss. On the day of admission she had a respiratory arrest and was intubated. She was a nonsmoker with no significant medical or surgical history. An urgent flexible bronchoscopy (FFB) at the referring hospital revealed a large vascular appearing tumor overlying the main carina. She was then transferred to our facility for further management. A computed tomographic scan of her chest revealed a large subcarinal mass extending into the trachea and both main bronchi. FFB at our facility confirmed the presence of a saddle-shaped vascular tumor arising from the carina and causing subtotal occlusion of the right main bronchus and more than 80% occlusion of the left main bronchus (Fig. 1). Biopsy of the lesion showed NSCLC. She was extremely difficult to ventilate, with an arterial blood gas showing pH 7.24, Paco2 89 torr, Pao2 114 torr while paralyzed and on synchronized intermittent mandatory ventilation of 16, tidal volume 250 mL, and positive end-expiratory pressure of 5 cm H2O and pressure support of 10 cm H2O on 50% Fio2. She was taken to the operating room for YAG–LPR rigid bronchoscopy and successful opening of the luminal obstruction was achieved using 15,997 joules of energy (Fig. 2). Arterial blood gas after laser therapy revealed pH 7.46, Paco2 49 torr, and Pao2 105 torr, on 30% Fio2. She was successfully extubated over the next few days, and was discharged to home. She underwent radiation therapy as an outpatient and, at last follow-up 2 months after discharge, her functional status had resumed to baseline.FIG. 1.: Flexible bronchoscopy shows saddle-shaped tumor arising from carina with subtotal occlusion of the right main bronchus and 80% occlusion of the left main bronchus.FIG. 2.: Bronchoscopic view of the carina immediately after YAG laser therapy shows successful opening of the luminal obstruction.DISCUSSION Eighty percent of all newly diagnosed lung cancers are not resectable for cure. Of these, 30% involve the carina and proximal main bronchi, accounting for significant morbidity and a dismal prognosis. This case demonstrates the utility of YAG-LPR in patients with severe respiratory compromise due to such lesions. In the largest reported case series of laser resection, over 90% of patients experienced immediate airway patency and improvement in quality of life. 1 The site and the degree of invagination, rather than histologic features of the tumor, dictate the quality of result. Lesions involving the trachea have the highest immediate response and those with extrinsic compression the least. Improvement of pulmonary status, shorter duration of ventilatory support, radiologic clearance, and better survival have all been reported in patients undergoing YAG-LPR compared with patients receiving only conventional therapy. 2–5 What favors YAG-LPR over conventional methods such as mechanical debridement, external beam radiation, or cryotherapy is its rapid effect and better immediate palliation. A more timely weaning from mechanical ventilation also expedites discharge to a home environment. CONCLUSION YAG-LPR can achieve immediate resolution of symptoms and improvement in quality of life in advanced stage lung carcinoma involving the proximal airways. In less advanced tumors, YAG laser can either be curative (carcinoma in situ) or serve as a bridge to other treatment options (external beam radiation, brachytherapy, cryotherapy). YAG-LPR should therefore be considered in all patients with inoperable malignant central airway tumors who would otherwise have little chance of survival or acceptable quality of life.

IR-192, low dose rate endobronchial brachytherapy in the treatment of malignant airway obstruction : Raju PI, Roy T, McDonald RD, Harrison BR, Crim C, Hyers TM et al. Blair Oncology Associates, Building E, 501 Howard Ave., Altoona, PA 16601. Int J Radiat Oncol Biol Phys 1993;27:677–80

IR-192, low dose rate endobronchial brachytherapy in the treatment of malignant airway obstruction : Raju PI, Roy T, McDonald RD, Harrison BR, Crim C, Hyers TM et al. Blair Oncology Associates, Building E, 501 Howard Ave., Altoona, PA 16601. Int J Radiat Oncol Biol Phys 1993;27:677–80

105 Our experience with low dose rate endobronchial irradiation in the treatment of malignant airway obstruction

105 Our experience with low dose rate endobronchial irradiation in the treatment of malignant airway obstruction

High dose rate afterloading intraluminal brachytherapy in malignant airway obstruction of lung cancer

Purpose : This is a retrospective study to review the palliation rate, survival rate and complications of high dose rate (HDR) intraluminal brachytherapy in the treatment of malignant airway obstruction of lung cancer. Methods and Materials : A total of 225 high dose rate (HDR) brachytherapy treatments were delivered to 76 patients with symptomatic malignant airway obstruction by remote afterloading technique. An average of 7 Gy at a radius of 1 cm from the center of the source was delivered by Iridium-192 (Ir-192) sources. The majority of the patients received 3 fractions at 2 week intervals. Fifty-four patients received HDR brachytherapy as part of their initial treatment; 20 patients presented as symptomatic endobronchial recurrence. Two patients received YAG laser photoresection to open up the obstruction to allow insertion of the brachytherapy catheter. Fifty-nine patients received concurrent external beam irradiation. Forty-two patients were given 60–70 Gy in 6–7 weeks with curative intent. Seventeen patients were given 20–59 Gy in 2–5 weeks as a palliative measure. Nine patients received a radiosensitizer. One patient received concurrent chemotherapy. Results : The symptomatic response rates are as follows: dyspnea had an 87% response rate (59% partial response, 28% complete response), cough had a 79% response rate (47% partial response, 32% complete response), hemoptysis had a 95% response rate (38% partial response, 57% complete response), and postobstructive pneumonia had an 88% response rate (53% partial response, 35% complete response). Sixty-six patients had follow up endoscopic examination (1–3 months after brachytherapy). Their total response rate was 87% (52% partial response and 35% complete response). There were four acute complications: three cases of massive hemoptysis and one of mild hemoptysis. There are five late complications: three cases of radiation pneumonitis and two of esophagitis. At the time of this study, 55 patients have died with the maximum survival duration 113 months (9.4 years) from diagnosis date and 18 months from first HDR treatment. Twenty-one patients are still alive with a mean follow-up duration of 20 months from diagnosis date and 7.8 months from the first HDR treatment. Conclusion : HDR brachytherapy is an excellent modality for palliating symptomatic malignant airway obstruction with an acceptable complication rate; however, no definitive increase of survival rate was observed. Prospective clinical trials are needed to better define its merit regarding survival. This paper also includes a literature review and discussion of HDR brachytherapy on bronchogenic cancer.

IR-192, low dose rate endobronchial brachytherapy in the treatment of malignant airway obstruction

Purpose : To assess the value of low-dose-rate endobronchial brachytherapy in the treatment of malignant airway obstruction. Methods and Materials : Between September 1986 and April 1989, 39 patients with malignant airway obstruction had 49 catheter placements for an afterloading, low-dose-rate Ir-192 endobronchial brachytherapy. A flexible fiberoptic bronchoscope with fluoroscopic guidance was used for positioning. Thirty-eight of 39 (97%) patients completed the prescribed treatments. Ninety-seven percent had received previous external radiation in doses ranging from 36–60 Gy. One patient had metastatic renal cell carcinoma; the remainder had recurrent lung cancer. Endobronchial laser treatments were given to three patients 2–3 weeks prior to endobronchial brachytherapy. All patients were followed until death. The median dose delivered in 48 of the 49 placements was 20 Gy at 1 cm. Results : Follow-up bronchoscopy was performed in 28 (72%) of 39 patients. Of these, 13 (46%) had a complete response, 12 (43%) had a partial response, and 3 (17%) had a minor response. Dyspnea improved in 30 of 37 patients (82%); hemoptysis in 17 of 19 patients (89%); cough in 31 of 39 patients (79%); and postobstructive pneumonia in 21 of 23 patients (92%). The median survival for the entire group was 5 months (range 1–31 months). Conclusion : This technique is simple, well-tolerated and offered significant palliation.

Palliative treatment of malignant airway obstruction by Nd-YAG laser

Photoresection using the neodymium-yttrium aluminum garnet (Nd-YAG) laser is an accepted modality for the treatment of unresectable symptomatic endobronchial lesions. The safety and efficacy of this technique when performed through a rigid bronchoscope have already been established. Forty-two such photoresection procedures were performed through a flexible fiberoptic bronchoscope at the Cleveland Clinic Foundation. The preoperative workup included sector computed tomography (CT) scanning of the mediastinum and/or magnetic resonance (MR) imaging of the chest. The results indicate that Nd-YAG laser photoresection can be safely performed using the flexible bronchoscope. Anatomic information provided by MR and sector CT may add to the safety of this procedure by allowing avoidance of major vessel perforation.