Tracheobronchial malignant

The Dumon stent is the most widely accepted stent and has become the gold standard by which newer stents are evaluated. Therefore, two large series of Dumon stent placement for tracheobronchial malignancies shall be presented. 

The first publication on the polyurethane covered Wallstent appeared in 1996 (Bolliger et al. 1996). In total, 36 stents were placed in 27 patients with tracheobronchial malignancies. Stent deployment was successful in all patients. The mean dyspnea index improved significantly after stenting, as did the... 

Song and co-workers (1999) placed their self-developed potentially retrievable covered metallic stent in eight patients with tracheobronchial malignant obstructions (esophageal cancer, n=4 lung cancer, n=2 tracheal cancer, n=l gastric cancer, n=l). Stents were successfully placed in all patients but one. In this case a hinged stent (combined tracheal and bronchial stent) was placed too caudal so... 

Rousseau et al. (1993) were the first to describe complications associated with the uncovered version of the Wallstent used to treat tracheobronchial malignancies. Six compKcations were noted out of 39 Wallstent placements. In one patient, tumor was growing through the open mesh. The tumor was treated with laser ablation endoscopically. In two cases, obstruction occurred at the stent margins, necessitating additional stent placement. Three patients developed granuloma formation inside the stent, which was treated with balloon dilation. 

Bolliger CT, Heitz M, Hauser R, Probst R, Perruchoud AP (1996) An airway Wallstent for the treatment of tracheobronchial malignancies. Thorax 51 1127-1129 Bolliger CT, Wyser C, Wu X et al. (1999) Evaluation of a new self-expandable silicone stent in an experimental tracheal stenosis. Chest 115 496-501... 

A significantly (p<0.05) increased incidence of malignancies in the lymphatic and hematopoietic tissues of uranium mill workers (cohort of 662 males) was found by Archer et al. (1973). The radioactivity in the tracheobronchial lymph nodes of the workers was found to be primarily the result of alpha emissions from thorium-230 and not from uranium-234 or uranium-238. Consequently, the authors suggested that the increased incidence of malignancies may have been a result of thorium-230 exposure and not uranium exposure. Exposure levels of thorium were not reported therefore, the results of the study are not reported on Table 2-1 or plotted in Figure 2-1. 

Patients should be able to cooperate during the procedure. Some patients with severely symptomatic SVCOS may have difficulties in lying flat on the examination table. In these circumstances, the procedure should be undertaken under general anesthesia. A minority of patients will present with simultaneous tracheobronchial narrowing, due to malignant mediastinal compression. Stenting of the airways should precede management of the caval obstruction in such patients. 

The focus of this chapter is primarily on metallic stents. For a detailed overview of the results of placement of plastic tube stents for tracheobronchial obstructions due to malignant tumors, the interested reader is referred to one of the review articles on stenting of the tracheobronchial system written by experienced interventional bronchoscopists (thoracic endoscopist) (Colt and Dumon 1995 Mehta and Dasgupta 1999 Rafanan and Mehta 2000 Wood 2001). 

The series from Brescia, Italy reported by Cavaliere et al. comprises 306 patients and placement of 393 silicone stents (Cavaliere et al. 1996). The vast majority of patients were treated with 363 Dumon stents in 27 cases a Y-shaped Hood stent was placed, and in another four cases a Y-shaped Dynamic stent. Stents were inserted into the trachea in 38.7%, right main stem bronchus and bronchus intermedius in 19.8%, left main stem bronchus in 15.5%, trachea and right or left main stem bronchus in 13.5%, and in other positions in 12.5%. Stent insertion resulted in improvement in pulmonary function tests and quality of life in all but six patients (98% success rate). The median survival of patients was 108 days. All patients had malignant tracheobronchial tumors. 

A small series of four patients with malignant tracheobronchial obstruction was presented by Col-REAVY et al. (2000). Stenting was successful in all four patients and led to dramatic relief of stridor. Mean survival was 6 months. One patient died some hours after stent insertion due to bleeding from a site where laser recanalization was carried out, but did not bleed from the stent insertion site. One patient required laser treatment 3 months after stent placement for tumor regrowth. 

A larger patient population was reported by Beer et al. (1999). A total of 27 Palmaz stents were placed in 21 patients with malignant obstructive tracheobronchial obstructions (trachea, n=2 left main stem bronchus, n=8 intermediate bronchus, n=7 right main stem bronchus, n=l lobar bronchi, n=4). Following stent insertion, six patients had no further respiratory distress, and the remaining 15 patients reported relief of dyspnea. In seven patients, postobstructive pneumonia was successfully treated by stent placement. Mean survival time was 12 months. Restenosis occurred in four patients and was treated with redilation in three, and laser ablation in one patient. 

Placement of tracheobronchial stents for malignant obstructions or fistulas is not without complications. Plastic and metallic stents have different complication profiles. Some stents have their specific complications owing to the dedicated design. 

Miyayama S, Matsui O, Kamimura R, Kakuta K, Takashima T (1997) Partially covered Gianturco stent for tracheobronchial stricture caused by intraluminal tumor. Cardiovasc Intervent Radiol 20 60-62 Miyazawa T, Yamakido M, Ikeda S, Furukawa K, Takiguchi Y, Tada H, Shirakusa T (2000) Implantation of Ultraflex nitinol stents in malignant tracheobronchial stenoses. Chest 118 959-965... 

Sawadi S, Tanigawa N, Kobayashi M, Furui S, Ohta Y (1993) Malignant tracheobronchial obstructive lesions treatment with Gianturco expandable metallic stents. Radiology 188 205-208... 

Schmidt B, Massenkeil G, John M et al. (1999) Temporary tracheobronchial stenting in malignant lymphoma. Ann Thorac Surg 67 1448-1450... 

Strecker EP, Liermann D, Barth KH et al. (1990) Expandable tubular stents for treatment of arterial occlusive diseases experimental and clinical results. Radiology 175 87-102 Tan BS, Watkinson AF, Dussek JE, Adam AN (1996) Metallic endoprostheses for malignant tracheobronchial obstruction initial experience. Cardiovasc Intervent Radiol 19 91-96... 

Tanigawa N, Sawada S, Okuda Y, Kobayashi M, Mishima K (2000) Symptomatic improvement in dyspnea following tracheobronchial metallic stenting for malignant airway obstruction. Acta Radiol 41 425-428 Tojo T, lioka S, Kitamura S, Maeda M, Otsuji H, Uchida H, Mori T, Furuse K (1996) Management of malignant tracheobronchial stenosis with metal stents and Dumon stents. Ann Thorac Surg 61 1074-1078... 

Witt C, Dinges S, Schmidt B et al. (1997) Temporary tracheobronchial stenting in malignant stenoses. Eur J Cancer 33 204-208... 

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