Temporary Use of Silicone Stents for Severe Airway Stenosis in Untreated Malignant Lymphoma

World Association for Bronchology and Interventional Pulmonology (WABIP) guidelines on airway stenting for malignant central airway obstruction

Malignant Central Airway Obstruction (MCAO) encompasses significant and symptomatic narrowing of the central airways that can occur due to primary lung cancer or metastatic disease. Therapeutic bronchoscopy is associated with high technical success and symptomatic relief and includes a wide range of airway interventions including airway stents. Published literature suggests that stenting practices vary significantly across the world primarily due to lack of guidance. This document aims to address this knowledge gap by addressing relevant questions related to airway stenting in MCAO. An international group of 17 experts from 17 institutions across 11 countries with experience in using airway stenting for MCAO was convened as part of this guideline statement through the World Association for Bronchology and Interventional Pulmonology (WABIP). We performed a literature and internet search for reports addressing six clinically relevant questions. This guideline statement, consisting of recommendations addressing these six PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with expert experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique.

Contributions of Airway Stent for Long-term Outcome in Patients With Malignant Central Airway Stenosis or Obstruction

BACKGROUND

Although an airway stent is used for malignant central airway stenosis or obstruction, long-term outcomes are unknown. In this study, we retrospectively analyzed the clinical features of patients who required stenting for malignant central airway stenosis or obstruction.

PATIENTS AND METHODS

We retrospectively analyzed clinical data from 116 patients with stenting for central airway stenosis or obstruction who underwent treatment at Toho University Hospital from 1998 to 2018. We evaluated the clinical features, prognoses, and complications for stenting in these patients.

RESULTS

The distribution of the 116 patients was as follows: lung cancer, 53; esophageal cancer, 40; thyroid cancer, 8; and others, 15. Patients with thyroid cancer had a significantly higher rate of complications after stenting than patients with lung cancer (P=0.0062), esophageal cancer (P=0.0029), and others (P=0.0062). Patients with esophageal cancer had a significantly worse prognosis than patients with lung and thyroid cancer. In patients with lung cancer the prognosis was significantly different between patients who underwent additional treatment for lung cancer after stenting and patients with no treatment (P=0.0398), and patients who received chemoradiotherapy for lung cancer after stenting had a significantly better prognosis than patients with no treatment (P=0.0306).

CONCLUSION

Stenting for airway stenosis/obstruction may improve prognosis in patients with lung or thyroid cancer, especially if patients with lung cancer undergo additional treatments after stenting, although airway stenting for patients with esophageal cancer was palliative. New treatment strategies may be necessary for patients with esophageal cancer after stenting to improve prognosis.

Long-term survival of airway silicone stents in patients with central airway stenosis or obstruction due to thoracic malignancy

OBJECTIVES

Silicone airway stents are used to manage central airway stenosis or obstruction, although their impact on long-term survival remains unknown in patients with central airway stenosis or obstruction due to thoracic malignancy. In this study, we retrospectively analyzed the impact of silicone stents on survival.

METHODS

We retrospectively analyzed clinical data of 106 patients with central airway stenosis or obstruction due to thoracic malignancy treated by stenting at Toho University Omori Medical Center between 1998 and 2018.

RESULTS

Patients treated with silicone stents had significantly higher survival rates than patients treated with metallic stents (p = 0.0173). Silicone stents patients also had significantly more additional treatments for thoracic malignancy after stenting than metallic stents patients (p = 0.0007). Notably, significantly more silicone stents patients underwent chemoradiotherapy or radiotherapy (p = 0.0268, p = 0.0300). During multivariate analyses, the additional treatment, including chemoradiotherapy or radiotherapy, was an independent optimal prognostic factor.

CONCLUSIONS

Silicone stents patients had significantly higher survival rates than metallic stents patients. Although stenting for airway stenosis or obstruction due to thoracic malignancy may be mainly palliative, additional treatments after stenting should be considered to improve the prognoses of patients with airway stenosis or obstruction due to thoracic malignancy.

Clinical outcomes and survival following placement of self-expandable metallic stents for central airway stenosis and fistula

Background

Self‐expandable metallic stent (SEMS) placement is an urgent procedure for patients with malignant central airway stenoses (CASs) and central airway fistulas (CAFs). The aim of this study was to determine the outcome and survival after SEMS placement in patients with malignant CASs and CAFs.

Methods

SEMSs were inserted into 20 patients with malignant CASs and four with malignant CAFs. Hospital records, the modified Medical Research Council dyspnea scale (mMRC) grade, performance status (PS), symptoms, procedure‐related complications and survival after placement were retrospectively reviewed.

Results

Spiral Z stents were inserted in nine patients, covered Ultraflex stents in 14, and a bare Ultraflex in one patient. After SEMS placement, 20 patients (83.3%) showed improvement in mMRC grade, 19 (79.2%) showed improvement in PS, and 21 (87.5%) showed improvement in symptoms. There were three patients whose stents migrated out of place, but there were no patients with obstructive granulation, infection, or mucous plugs. Median survival days after stent insertion was 98 days for CAS and 103 days for CAF, and mean survival days was 383 ± 707 days for CAS and 93 ± 33 days for CAF. Two patients with CAS by malignant lymphoma and thymic cancer survived more than six years because they were also treated with efficient therapies. The five‐year survival rate after stent insertion was 7.7%.

Conclusions

SEMS placement for CAS and CAF is associated with improvement in mMRC grade, PS and symptoms in 87.5% of patients. Patients with a malignant CAS are usually terminal, but the possibility of increasing survival rate will become a reality with new efficient therapies.

Key points

Significant findings of the study

Reasonable clinical outcomes and improved survival of patients following SEMS placement for thoracic malignancy with central airway stenosis and fistula.

What this study adds

The possibility of increasing survival rate will become a reality with new efficient therapies.

Tracheal Perforation following Chemotherapy of Diffuse Large B-Cell Lymphoma

Tracheal perforation is a rare and life-threatening complication following the treatment of lymphoma. There are only a few published cases of tracheal disruption from invasive lymphoma, and most of the patients did not survive. Tumor erosion and nodal necrosis from rapid tumor growth or chemotherapeutic response can cause tracheal disruption. We report here a case of tracheal perforation after chemotherapy of lymphoma. A 69-year-old Thai man presented with upper airway obstruction from a large neck mass encasing and invading the trachea. The patient was intubated to bypass the tracheal obstruction. Biopsy of the mass showed diffuse large B-cell lymphoma. Chemotherapy was urgently administered. Two days after treatment, the patient developed acute respiratory distress with high airway resistance. Emergency bronchoscopy and chest computerized tomography revealed disrupted anterior wall of trachea and endotracheal tube displacement, which created a false track into the mass. Tumor necrosis was thought to be the cause of this perforation and tube malposition. The tube was repositioned by bronchoscopic guidance. Unfortunately, the disrupted trachea could not be reconstructed. Palliative care was consequently provided, and the patient finally passed away a week after the catastrophic event. This report demonstrates clinical presentation, chest imaging, and bronchoscopic findings of tracheal perforation, which is a rare complication following the treatment of lymphoma.

Airway stenting in patients requiring intubation due to malignant airway stenosis: a 10-year experience

Background

Critically ill patients with severe acute respiratory failure due to malignant airway stenosis often require emergency intubation and mechanical ventilation. Urgent intervention is necessary for the survival of such patients. The aim of this study was to determine the efficacy and outcomes of airway stenting in patients with malignant airway stenosis requiring emergency intubation.

Methods

Patients with malignant airway stenosis who underwent emergency intubation prior to airway stent placement from September 2005 to September 2015 in a single center were retrospectively reviewed. All stenting procedures were performed using both rigid and flexible bronchoscopes under general anesthesia.

Results

Thirty patients with malignant airway stenosis (17 with lung cancer, 6 with esophageal cancer, and 7 with other types of malignancy) who required emergency intubation prior to stenting procedures (silicone stenting in 23 and metallic stenting in 7) were analyzed. Extubation within 48 hours after stenting could be performed in 28 of 30 patients (93%). Of the 21 chemoradiotherapy-naïve patients, 18 (86%) received chemotherapy and/or radiation therapy after stenting. No significant complications occurred during the stenting procedures. The median survival after stenting was 198 days (range, 13-3,009 days).

Conclusions

Airway stenting facilitates extubation in critically ill patients with malignant central airway stenosis. It plays an important role as a bridge to additional tumor-specific therapies, especially in chemoradiotherapy-naïve patients.