Outcome of Treated Advanced Non-small Cell Lung Cancer With and Without Central Airway Obstruction

Feasibility, Tolerability, and Effectiveness of Transbronchial Interventions in Elderly Patients With Malignant Central Airway Obstruction: A Retrospective Single-institution Study

BACKGROUND

In elderly patients with malignant central airway obstruction (MCAO), the treating physicians often hesitate to undertake transbronchial interventions (TBIs) as a palliative procedure in view of the advanced age of the patients.

METHODS

We conducted this retrospective study to evaluate the differences in the feasibility, tolerability, and effectiveness of TBIs between elderly (aged 75 years old or above; elderly group; n=27) and nonelderly (aged below 75 years old; nonelderly group; n=50) patients with MCAO. The primary endpoint was the incidence of complications during (within 24 hours) and after (>24 hours) TBIs.

RESULTS

The mean age of the patients was 81 years in the elderly group and 61 years in the nonelderly group. The complications encountered during/after TBI included endobronchial bleeding or hypoxemia requiring intubation occurring during the TBIs, and bacterial pneumonia, airway reocclusion, and stent migration occurring after the TBIs, although there was no difference in the frequency of complications during/after the TBIs between the elderly group and nonelderly group (26% vs. 30%, P =0.706). There was no difference in the percentage of patients in whom successful airway recanalization was achieved by TBI (93% vs. 80%, P =0.197), the percentage of patients who showed symptomatic improvement after the TBIs (67% vs. 76%, P =0.380) and the OS after the TBIs (6.1 vs. 7.3 months, P =0.704) between the 2 groups.

CONCLUSION

TBIs can be undertaken without hesitation as a palliative procedure in elderly patients with MCAO.

[Non-infectious respiratory emergencies in patients with cancer]

Patients with a solid tumor or hematologic malignancy are often addressed to emergency units for an acute respiratory complication associated with the underlying cancer or secondary to treatments. The current article is part of a thematic series: "Intensive care and emergencies in solid tumours and blood cancer patients" and will develop the following points: (1) malignant proximal airway obstruction and, more specifically, the role of therapeutic bronchoscopy; (2) superior vena cava syndrome by tumor compression and/or secondary to thrombosis (diagnosis, local and systemic treatments); (3) cancer-related pulmonary embolism (incidence, indications for low-molecular weight heparins and direct oral anticoagulants). Other respiratory emergencies will be dealt in the other articles of this series.

First-In-Human Computer-Optimized Endobronchial Ultrasound-Guided Interstitial Photodynamic Therapy for Patients With Extrabronchial or Endobronchial Obstructing Malignancies

Objective

Patients with inoperable extrabronchial or endobronchial tumors who are not candidates for curative radiotherapy have dire prognoses with no effective long-term treatment options. To reveal that our computer-optimized interstitial photodynamic therapy (I-PDT) is safe and potentially effective in the treatment of patients with inoperable extra or endobronchial malignancies inducing central airway obstructions.

Methods

High-spatial resolution computer simulations were used to personalize the light dose rate and dose for each tumor. Endobronchial ultrasound with a transbronchial needle was used to place the optical fibers within the tumor according to an individualized plan. The primary and secondary end points were safety and overall survival, respectively. An exploratory end point evaluated changes in immune markers.

Results

Eight patients received I-PDT with planning, and five of these received additional external beam PDT. Two additional patients received external beam PDT. The treatment was declared safe. Three of 10 patients are alive at 26.3, 12, and 8.3 months, respectively, after I-PDT. The treatments were able to deliver a prescribed light dose rate and dose to 87% to 100% and 18% to 92% of the tumor volumes, respectively. A marked increase in the proportion of monocytic myeloid-derived suppressor cells expressing programmed death-ligand 1 was measured in four of seven patients.

Conclusions

Image-guided light dosimetry for I-PDT with linear endobronchial ultrasound transbronchial needle is safe and potentially beneficial in increasing overall survival of patients. I-PDT has a positive effect on the immune response including an increase in the proportion of programmed death-ligand 1-expressing monocytic myeloid-derived suppressor cells.

Efficacy and safety of transbronchial microwave ablation therapy under moderate sedation in malignant central airway obstruction patients with respiratory failure: a single-institution retrospective study

BACKGROUND

The safety and efficacy of transbronchial microwave ablation (TMA) therapy in patients with malignant central airway obstruction (CAO) with respiratory failure remains unclear.

METHODS

A total of 38 patients with advanced non-small cell lung cancer (NSCLC) or lung metastases with malignant endoluminal obstruction received TMA therapy under moderate sedation and high fractions of inspired oxygen (FiO₂). The success rate of airway patency restoration, complication rate, and overall survival time (OS) from the initiation of TMA therapy were compared in the following two groups of patients with malignant CAO patients: the group with respiratory failure (PaO₂/FiO₂ ≤ 300) (RF group, n = 10) and the group without respiratory failure (PaO₂/FiO₂ > 300) (non-RF group, n = 28) at the time of the TMA therapy.

RESULTS

Both the RF group and non-RF group received a median of two sessions of TMA. There was no significant difference in the percentage of patients who showed restored airway patency after the first session of TMA (90% vs. 96%), in the complication rate of TMA therapy (10% vs. 11%), or in the OS (7.1 months vs. 9.1 months) between the RF group and the non-RF group. Multivariate analysis identified no significant association between TMA therapy and the risk of death in malignant CAO patients with respiratory failure (p = 0.196).

CONCLUSION

TMA therapy under moderate sedation was well tolerated and effective in patients with malignant CAO, including those with respiratory failure.

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Integrated intErventional bronchoscopy in the treatment of locally adVanced non-small lung cancER with central Malignant airway Obstructions: a multicentric REtrospective study (EVERMORE)

OBJECTIVES

Despite new therapeutic perspectives, the presence of central airways occlusion (CAO) in patients with locally advanced non-small cell lung cancer (NSCLC) is associated with poor survival. There is no clear evidence on the clinical impact of interventional bronchoscopy as a part of an integrated treatment to cure these patients.

MATERIALS AND METHODS

This retrospective cohort study was conducted in two teaching hospitals over a 10 years period (January 2010-January 2020) comparing patients with NSCLC at stage IIIB and CAO at disease onset treated with chemotherapy/radiotherapy (standard therapy-ST) with those receiving interventional bronchoscopy plus ST (integrated treatment-IT). Primary outcome was 1-year survival. The onset of respiratory events, symptoms-free interval, hospitalization, need for palliation, and overall mortality served as secondary outcomes.

RESULTS

A total of 100 patients were included, 60 in the IT and 40 in the ST group. Unadjusted Kaplan-Meier estimates showed greater effect of IT compared to ST on 1-year survival (HR = 2.1 95%CI[1.1-4.8], p = 0.003). IT showed a significantly higher survival gain over ST in those patients showing KRAS mutation (7.6 VS 0.8 months,<0.0001), a lumen occlusion >65% (6.6 VS 2.9 months,<0.001), and lacking the involvement of left bronchus (7 VS 2.3 months,<0.0001). Compared to ST, IT also showed a favorable difference in terms of new hospitalizations (p = 0.03), symptom-free interval (p = 0.02), and onset of atelectasis (p = 0.01).

CONCLUSIONS

In patients with NSCLC stage IIIB and CAO, additional interventional bronchoscopy might impact on 1-year survival. Genetic and anatomic phenotyping might allow identifying those patients who may gain life expectancy from the endoscopic intervention.

Silicone Stent Versus Fully Covered Metallic Stent in Malignant Central Airway Stenosis

BACKGROUND

Airway stenting to restore airway patency in cases of malignant central airway obstruction is an effective palliation treatment. Our goal was to compare the efficacy after deployment and complications of a fully covered self-expandable metal stent (SEMS) (Aerstent) and a silicone stent (Dumon).

METHODS

This was a retrospective cohort of 2 similar groups of patients with malignant central airway obstruction treated with stents between August 2012 and July 2017. Complications were assessed bronchoscopically. A competing risk for death analysis was performed to adjust the probability of developing a complication.

RESULTS

Seventy patients (29 with silicone stents and 41 with SEMS) were included. Stent insertion was successful in all cases. Mucus retention was the most frequent complication (75.9% with silicone stents and 84.8% with SEMS; P = .51), followed by granulation tissue (51.7% with silicone stents and 41.3% with SEMS; P = .52) and migration (6.9% with silicone stents and 13.0% with SEMS; P = .47). In the first month, the cumulative incidence of a complication was 36.7% for silicone stents and 41.3% for SEMS and increased to 90.0% and 97.8% after 6 months, respectively (hazard ratio = 1.66; P = .04). A competing risk for death analysis showed an adjusted hazard ratio of 1.41 (P = .49) indicating no differences in overall complications between stents.

CONCLUSIONS

Both stents were equally successful and safe. The incidence of complications increased over time to 90% at 6 months for both stents. The risk of overall complications was higher for SEMS; nevertheless, when mortality was measured in a competitive risk analysis, no differences were found between SEMS and silicone stents.

Prognostic factors for survival after bronchoscopic intervention in patients with airway obstruction due to primary pulmonary malignancy

BACKGROUND

Malignant central airway obstruction (MCAO) occurs in 20-30% of patients with primary pulmonary malignancy. Although bronchoscopic intervention is widely performed to treat MCAO, little data exist on the prognosis of interventional bronchoscopy. Therefore, we evaluated the clinical outcomes and prognostic factors of bronchoscopic interventions in patients with MCAO due to primary pulmonary malignancy.

METHODS

This retrospective study was conducted at a university hospital and included 224 patients who received interventional bronchoscopy from 2004 to 2017, excluding patients with salivary gland-type tumor. A multivariable Cox proportional hazard regression analysis was used to identify independent prognostic factors associated with survival after the first bronchoscopic intervention.

RESULTS

Among 224 patients, 191 (85.3%) were males, and the median age was 63 years. The most common histological type of malignancy was squamous cell carcinoma (71.0%). Technical success was achieved in 93.7% of patients. Acute complications and procedure-related death occurred in 15.6 and 1.3% of patients, respectively. The median survival time was 7.0 months, and survival rates at one year and two years were 39.7 and 28.3%, respectively. Poor survival was associated with underlying chronic pulmonary disease, poor performance status, extended lesion, extrinsic or mixed lesion, and MCAO due to disease progression and not receiving adjuvant treatment after bronchoscopic intervention.

CONCLUSIONS

Interventional bronchoscopy could be a safe and effective procedure for patients who have MCAO due to primary pulmonary malignancy. In addition, we found several prognostic factors for poor survival after intervention, which will help clinicians determine the best candidates for bronchoscopic intervention.

Therapeutic Bronchoscopic Techniques Available to the Pulmonologist: Emerging Therapies in the Treatment of Peripheral Lung Lesions and Endobronchial Tumors

Therapeutic bronchoscopy for both endobronchial tumors and peripheral lung cancer is rapidly evolving. The expected increase in early stage lung cancer detection and significant improvement in near real-time imaging for diagnostic bronchoscopy has led to the development of bronchoscopy-delivered ablative technologies. Therapies targeting obstructing central airway tumors for palliation and as a method of local disease control, patient selection and patient-centered outcomes have been areas of ongoing research. This review focuses on patient selection when considering therapeutic bronchoscopy and new and developing technologies for endobronchial tumors and reviews the status of bronchoscopy-delivered ablative tools for peripheral lung cancers.

Clinical and radiographic predictors of successful therapeutic bronchoscopy for the relief of malignant central airway obstruction

Background

Malignant central airway obstruction (CAO) occurs in approximately 20–30% of patients with lung cancer and is associated with debilitating symptoms and poor prognosis. Multimodality therapeutic bronchoscopy can relieve malignant CAO, though carries risk. Evidence to guide clinicians regarding which patients may benefit from such interventions is sparse. We aimed to assess the clinical and radiographic predictors associated with therapeutic bronchoscopy success in relieving malignant CAO.

Methods

We reviewed all cases of therapeutic bronchoscopy performed for malignant CAO at our institution from January 2010–February 2017. Therapeutic bronchoscopy success was defined as establishing airway patency of > 50%. Patient demographics and baseline characteristics, oncology history, degree of airway obstruction, procedural interventions, and complications were compared between successful and unsuccessful groups. Univariate and multivariate logistic regression identified the significant clinical and radiographic predictors for therapeutic success. The corresponding simple and conditional odds ratio were calculated. A time-to-event analysis with Kaplan–Meier plots was performed to estimate overall survival.

Results

During the study period, 301 therapeutic bronchoscopies were performed; 44 (14.6%) were considered unsuccessful. Factors associated with success included never vs current smoking status (OR 5.36, 95% CI:1.45–19.74, p = 0.010), patent distal airway on CT imaging (OR 15.11, 95% CI:2.98–45.83, p < 0.0001) and patent distal airway visualized during bronchoscopy (OR 10.77, 95% CI:3.63–31.95, p < 0.001) in univariate analysis. Along with patent distal airway on CT imaging, increased time from radiographic finding to therapeutic bronchoscopy was associated with lower odds of success in multivariate analysis (OR 0.96, 95% CI:0.92–1.00, p = 0.048). Median survival was longer in the successful group (10.2 months, 95% CI:4.8–20.2) compared to the unsuccessful group (6.1 months, 95% CI:2.1–10.8, log rank p = 0.015).

Conclusions

Predictors associated with successful therapeutic bronchoscopy for malignant CAO include distal patent airway visualized on CT scan and during bronchoscopy. Odds of success are higher in non-smokers, and with decreased time from radiographic finding of CAO to intervention.

Prospective Multicentered Safety and Feasibility Pilot for Endobronchial Intratumoral Chemotherapy

BACKGROUND

Malignant airway obstruction (MAO) occurs in 30% of patients with advanced-stage lung cancer, leading to debilitating dyspnea, cough, and hemoptysis. Other than recanalization of the airways, these patients lack long-lasting palliative therapy. The goal of this study was to determine the safety and feasibility of local injection of paclitaxel into the airway wall with a novel microinjection catheter.

METHODS

In this multicentered prospective trial, 23 patients with non-small cell lung cancer and MAO were enrolled from July 2014 through June 2016 to undergo rigid bronchoscopy with recanalization, followed by injection of 1.5 mg of paclitaxel with a novel injection catheter. Primary end points consisted of safety (adverse events, severe adverse events, and unanticipated adverse device effects) as well as feasibility (number of injections, injection success). Secondary end points consisted of airway patency improvement, quality of life metrics, and need for further interventions and/or stenting.

RESULTS

Nineteen patients underwent rigid bronchoscopy with successful recanalization and paclitaxel injection. There were no adverse events, severe adverse events, or unanticipated adverse device effects. There was an average of 3.4 injections given for a total dose of 1.5 mg of paclitaxel in all patients. There was significantly less stenosis postprocedure vs preprocedure (25%-50% vs 75%-90%; P < .001), which was unchanged at 6 weeks (25%-50%). None of the participants required further interventions or airway stenting.

CONCLUSIONS

The injection of paclitaxel after recanalization of MAO in patients with non-small cell lung cancer is safe and feasible, using a novel airway injection device.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02066103; URL: www.clinicaltrials.gov.

Electrosurgical and Laser Therapy Tools for the Treatment of Malignant Central Airway Obstructions

Central airway obstruction (CAO) is associated with significant morbidity and increased mortality. Bronchoscopic electrosurgical and laser ablative tools have proven to be safe and effective instruments for the treatment of malignant CAO. Although therapeutic modalities such as electrocautery, argon plasma coagulation, and laser have been used for decades, additional tools including radiofrequency ablation catheters continue to be developed for the treatment of CAO. These modalities are considered safe in the hands of experienced operators, although serious complications can occur. This review describes various electrosurgical and laser therapy tools used for the treatment of malignant CAO along with the specific advantages and disadvantages of each device.

A Concentric Tube Robot System for Rigid Bronchoscopy: A Feasibility Study on Central Airway Obstruction Removal

New robotic systems have recently emerged to assist with peripheral lung access, but a robotic system for rigid bronchoscopy has yet to be developed. We describe a new robotic system that can deliver thin robotic manipulators through the ports of standard rigid bronchoscopes. The manipulators bend and elongate to provide maneuverability of surgical tools at the endoscope tip, without endoscope motion. We describe an initial feasibility study on the use of this system to bronchoscopically treat a central airway obstruction (CAO). CAO is prevalent and can be life-threatening in patients with large tumors, and conventional rigid bronchoscopic treatments place patients at risk of complications including broken teeth, neck trauma and damage to oropharyngeal structures due to significant forces induced by bronchoscope tilting and manipulation. In this study, we used an ex vivo ovine airway model to demonstrate the ability of a physician using the robotic system to efficiently remove tissue and restore the airway. Pre- and post-operative CT scans showed that the robot was able to reduce the degree of airway obstruction stenosis from 75 to 14% on average for five CAO resections performed in an ex vivo animal model. Using cadaver experiments, we demonstrated the potential of the robotic system to substantially reduce the intraoperative forces applied to the patient's head and neck (from 80.6 to 4.1 N). These preliminary results illustrate that CAO removal is feasible with our new rigid bronchoscopy robot system, and that this approach has the potential to reduce forces applied to the patient due to bronchoscope angulation, and thereby reduce the risk of complications encountered during CAO surgery.

Imaging of urgencies and emergencies in the lung cancer patient

Lung cancer patients often experience potentially life-threatening medical urgencies and emergencies, which may be a direct or indirect result of the underlying malignancy. This pictorial review addresses the most common thoracic, neurological and musculoskeletal medical emergencies in lung cancer patients, including superior vena cava syndrome, pulmonary embolism, spontaneous pneumothorax, cardiac tamponade, massive haemoptysis, central airway obstruction, oesophagorespiratory fistula, malignant spinal cord compression, carcinomatous meningitis, cerebral herniation and pathological fracture. Emphasis is placed on imaging findings, the role of different imaging techniques and a brief discussion of epidemiology, pathophysiology and therapeutic options. Since early diagnosis is important for adequate patient management and prognosis, radiologists have a crucial role in recognising and communicating these urgencies and emergencies.

TEACHING POINTS

• Multiplanar multidetector computed tomography is the imaging examination of choice for thoracic urgencies and emergencies. • Magnetic resonance imaging is the imaging modality of choice for investigating central nervous system emergencies. • Urgencies and emergencies can be the initial manifestation of lung cancer. • Radiologists have a crucial role in recognising and in communicating these urgencies/emergencies.

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

BACKGROUND AND OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

A case report of local treatment of inoperable squamous cell lung carcinoma with convex-probe endobronchial ultrasound-guided intratumoral injection of cisplatin in a patient with severe COPD

RATIONALE

Endobronchial ultrasound as a powerful diagnostic technology can also be used to perform intratumoral chemotherapy for extraluminal tumor.

PATIENT CONCERNS

A 69-year-old man with chronic obstructive pulmonary disease (COPD) presented with worsening dyspnea. A pulmonary function test showed severe airway obstruction and that forced expiratory volume in 1 s was 43% of the predicted value after a bronchodilator.

DIAGNOSES

A bronchoscopy and histopathological analyses revealed a squamous cell carcinoma mostly located outside of the lumen with central airway obstruction.

INTERVENTIONS

Due to the poor pulmonary function, he cannot tolerate conventional active treatments, such as surgery, full dose systemic chemotherapy, or radiotherapy. Local treatments including argon plasma coagulation, cryotherapy, and bronchoscopic endobronchial intratumoral chemotherapy with cisplatin were performed to debulk intraluminal component of the tumor and recanalize occlusive airways in the left upper lobe. Convex-probe endobronchial ultrasound-guided transbronchial needle injection (EBUS-TBNI) delivered cisplatin into the extraluminal component of the tumor to relieve the symptom of dyspnea and opened up the opportunity for systemic chemotherapy without severe systemic complications.

OUTCOMES

The patient had a good response to the comprehensive therapy of 4 cycles of low-dose intravenous chemotherapy and bronchoscopic interventions.

LESSONS

EBUS-TBNI is proven an effective and safe method to treat inoperable extraluminal central pulmonary carcinoma complicated with severe COPD. In the future, EBUS-TBNI may offer more treatment indications outlined in the existing publications.

Emergencies in Hematology and Oncology

The development of medical emergencies related to the underlying disease or as a result of complications of therapy are common in patients with hematologic or solid tumors. These oncological emergencies can occur as an initial presentation or in a patient with an established diagnosis and are encountered in all medical care settings, ranging from primary care to the emergency department and various subspecialty environments. Therefore, it is critically important that all physicians have a working knowledge of the potential oncological emergencies that may present in their practice and how to provide the most effective care without delay. This article reviews the most common oncological emergencies and provides practical guidance for initial management of these patients.

Interventional pulmonology for patients with central airway obstruction: An 8-year institutional experience

Patients with central airway obstruction (CAO) may need endobronchial intervention to relieve their symptoms. This report is on a single-center experience of using interventional bronchoscopy in terms of complications and survival. This retrospective study was conducted in a university hospital and involved 614 patients (464 men, 150 women; mean age, 60.2 years) with benign (n = 133) and malignant (n = 481) tracheobronchial disease who received 756 endobronchial intervention procedure during the period 2008 to 2015. Survival was analyzed using the Kaplan-Meier method, while the log-rank test was used for comparisons. A total of 583 patients (95%) achieved endoscopic success after interventional bronchoscopy. Four (0.7%) died within 24 hours of the procedure, while the major morbidities were halitosis (n = 41, 6.7%) and iatrogenic pneumonia (n = 24, 3.9%). Repeat procedures due to recurrent airway obstruction were done on 45 patients with benign conditions and on 60 with malignancies. The median survival after the procedure in patients with lung cancer, other metastatic cancer, and esophageal cancer was 166, 228, and 86 days, respectively. Between patients with inoperable lung cancer and CAO after therapeutic bronchoscopy and patients without CAO, there was no statistically significant difference in survival (P = 0.101). Interventional bronchoscopy is a safe and effective procedure that may be recommended for CAO. Patients with lung metastases have similar lengths of survival as patients with primary lung cancer. Patients with advanced lung cancer and CAO have similar survival as those without CAO.

Critical airway obstruction: challenges in airway management and ventilation during therapeutic bronchoscopy

BACKGROUND

Endobronchial interventions are used to alleviate symptoms of airway stenosis. The ventilatory management may be challenging during these procedures, and may influence the choice of airway device. We report our experiences from 902 procedures.

METHODS

Patients undergoing interventional bronchoscopy procedures were consecutively registered from 1999 to 2012. Critical airway obstruction (CAO) was defined as stridor, tracheal diameter <5 mm, stenosis of both the main bronchi, or clots/tumor fragments occluding the trachea or both main bronchi. Choice of airway, ventilation strategy, and survival are reported. Results are presented as median (interquartile range), and P≤0.05 was considered significant.

RESULTS

A total of 561 patients underwent 902 interventional bronchoscopy procedures (mechanical debulking, laser resection, balloon dilatation, and stent placement). The procedures were performed using flexible bronchoscope through an endotracheal tube (68.2%) or laryngeal mask airway (10.4%), or by rigid bronchoscopy (9.3%). All patients were primarily ventilated by volume-controlled ventilation. CAO was classified in 60 procedures, with more frequent use of laryngeal mask airway (21.7%), and change of airway device in 20/60 procedures. The survival for patients with malignant disease with or without CAO was 100 and 182 days, respectively, with 90 days survival probability of 0.65 and 0.51 (P=0.14).

CONCLUSIONS

Bronchoscopic treatment in patients with CAO may require a change of ventilatory and airway strategy during the procedure. Despite various challenges in the management of patients with CAO, the short-term survival in these patients is comparable to that in patients without CAO.

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.

The use of self-expandable metallic stents in the airways in the adult population

The airway stents restore patency in the face of luminal compromise from intrinsic and/or extrinsic pathologies. Luminal compromise beyond 50% often leads to debilitating symptoms such as dyspnea. Silicone stents remain the most commonly placed stents worldwide and have been the "gold standard" for the treatment of benign and malignant airway stenoses over the past 20 years. Nevertheless, silicone stents are not the ideal stents in all situations. Metallic stents can serve better in some selected conditions. Unlike silicone stents, there are large and increasing varieties of metallic stents available on the market. The lack of prospective or comparative studies between various types of metallic stents makes the choice difficult and expert-opinion based. International guidelines are sorely lacking in this area.

Role of palliative tracheobronchial stenting in hospice patients: boon or bane?

Lung cancer is the leading cause of cancer mortality and morbidity. Patients with advanced lung cancer have distressful symptoms like dyspnea. It has severe negative impact on the quality of life. Airway stenting has become widespread for palliation of airway stenosis in patients with metastatic airways disease. Although it provides improvement in symptoms, actual survival benefit is limited with severe potential complications. Appropriate patient selection in terms of site of tumor, type of stent placement is needed to achieve maximum benefit for patients. Here we will discuss 2 patients with advanced lung cancer who received bronchial stent for intractable dyspnea. Although there was dramatic improvement in symptoms and quality of life, both died shortly. Was there any benefit of stenting remained unanswered.

Novel Silicone Stent to Treat Tracheobronchial Lesions: Results of 35 Patients

We describe a case series of 35 patients with either benign (14) or malignant (21) tracheal stenosis who were treated using a novel silicone stent, the HCPA-1, designed to prevent migration. Between March 2001 and September 2008, 13 women and 22 men received 41 HCPA-1 stents. The median duration of stenting in benign cases was 457 days (range, 4–2, 961 days). Successful stent removal with curative results was accomplished in 2 patients with tracheomalacia and 1 with post-intubation stenosis. In malignant cases, the median duration of stenting was 162 days (range, 1–1, 279 days). Five patients had tumor progression with obstruction requiring repeated laser resection, dilatation, or additional stents. Two patients died due to airway obstruction despite bronchoscopic intervention. Twelve patients with malignant lesions died with the stent in place. At the end of the study, 3 patients with malignant disease remained alive; 2 were lost to follow-up. The HCPA-1 stent proved to be safe, with no severe complications during the study period, and effective in improving quality of life with relief of dyspnea.

The role of airway stent placement in the management of tracheobronchial stenosis caused by inoperable advanced lung cancer

PURPOSE

To our knowledge there is no in-depth report on the benefits of airway stenting, which focuses specifically on patients with inoperable advanced lung cancer causing severe central airway obstruction. We evaluated the role of airway stenting as one aspect of the multidisciplinary management of advanced lung cancer.

METHODS

We performed airway stenting in 40 lung cancer patients, placing a total of 58 stents. Stenting was done as a final modality in 22 patients with terminal-stage lung cancer (group A). The other 18 patients received additional therapy after stenting (group B), 12 (66.7%) of whom were treatment-naïve on admission.

RESULTS

The performance status (PS) and Hugh-Jones classification (H-J) scores improved in both groups after stenting: from 3.56 to 2.48 (P = 0.001) and 4.29 to 3.20 (P = 0.004) in group A, and from 3.15 to 1.25 (P < 0.001) and 4.10 to 2.10 (P < 0.001) in group B, respectively. The median survival time and 1-year survival rate after stenting were 1.6 months and 5.1%, respectively, in group A, and 5.6 months and 25.0%, respectively, in group B.

CONCLUSIONS

Airway stenting followed by adjuvant therapy may improve the survival of treatment-naïve patients with severe symptomatic airway obstruction caused by advanced lung cancer.

[Endoscopic palliation of esophageal and bronchial carcinomas]

Luminal obstruction from tumor growth can in relation to bronchial carcinoma lead to airway and/or esophageal obstruction in breathlessness or swallowing difficulties respectively. Self-expanding stents have become an established method of restoring luminal patency in both the esophagus and central airways, leading to significant symptomatic improvement. Due to anatomical constraints particularly in processes around the tracheal carina, stent implantation within the bronchial system often poses greater difficulty than within the esophagus. Technical difficulties do however arise in the esophagus, specifically in relation to stenotic high-cervical tumors, as well as distal stenosis. In this regard, advances in stent development have resulted in significantly improved outcomes with modern stents. In high-cervical esophageal tumors as well as locally invasive tumors with evidence of tracheobronchial fistulae a shared interdisciplinary care between the gastroenterology and pulmonary teams is necessary for a satisfactory outcome.

Changing patterns in interventional bronchoscopy

BACKGROUND AND OBJECTIVE

Many interventional tools for airway disorders can now be delivered via flexible bronchoscopy (FB), including neodymium-yttrium aluminium garnet laser, electrocautery, argon plasma coagulation, cryotherapy, balloon dilatation and metal or hybrid stents. Comparison of outcomes for patients undergoing rigid bronchoscopy (RB) with those treated using FB highlights the usefulness of the FB approach.

METHODS

A retrospective medical record review of all interventional bronchoscopy procedures performed at Lahey Clinic over the past 8 years was conducted. Patients were categorized into two groups according to the procedure used, that is, RB (251 patients), and FB (161 patients) groups. Patients with malignancies were included as a separate subgroup, comprising 178 RB and 117 FB patients. For every procedure, the location of the lesion, patient survival from the first interventional procedure performed, and in patients with malignancy, additional treatments received such as chemotherapy and radiation were recorded.

RESULTS

Ninety per cent of RB procedures were performed in patients with tracheal or main stem lesions, while over half the patients undergoing FB had more distal lesions. A trend towards increasing use of FB for interventional procedures in recent years was noted.

CONCLUSIONS

FB is a valuable alternative to RB for treating less advanced malignant disease or distal airway lesions.

Tracheobronchial stenting and central airway replacement

PURPOSE OF REVIEW

The present paper reviews the recent literature on the management of malignant large airway obstruction using tracheobronchial stenting and airway replacement by aortic allografts.

RECENT FINDINGS

Airway stenting is a valuable adjunct to therapeutic bronchoscopy to relieve malignant airway obstruction. Over 80% of patients with obstructing lesions who were treated by airway stenting presented immediate symptom improvement in recent series. Stenting may also function as a bridge until further curative treatment can be used. Different stent models are available; their advantages and disadvantages depend on materials and constructions; clinical experience is larger with silicon-based models than with metallic stents. An alternative strategy for the management of nonresectable primary tracheal tumors aiming to replace the central airway with an allogenic aortic allograft has been proposed. Experimental studies showed that an aortic allograft produced a respiratory conduit that shared fundamental elements of the trachea and newly formed cartilage rings were observed.

SUMMARY

Airway stenting provides efficient palliation of symptoms in patients with malignant central airway obstruction. Evidence-based studies are needed to identify patients who may have the greatest benefit from stenting. Tracheal replacement with allogenic aortic allografts is a novel technique which brings hope to the management of extensive tracheal lesions.