The patients in this study first had laser and stent treatment followed by percutaneous or endobronchial radiotherapy. This permitted immediate normalization of ventilation distal to the obstruction and clearance of retained secretions and pus. In a previous group of patients with endobronchial tumor, who were first treated with full-dose percutaneous radiotherapy and then referred for endoscopic laser resection or stent-ing, the anatomy of the airways was often distorted rendering laser resection difficult. Similar results were reported by Jain et al. We therefore prefer to delay both percutaneous or endobronchial radiotherapy until after endoscopic palliation in all patients for whom stent insertion was considered necessary at the initial bronchoscopic evaluation.
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Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Discussion (5)
Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Discussion (4)
As survival in group В was significantly longer than in group A, one might conclude that adjuvant radiotherapy was the causative factor. However, 50 percent of group A patients vs only 17 percent of group В had stage IV disease, and all four patients with stage IV disease in group A died of their metastases. At the time of endoscopic palliation, their disease was too far advanced to qualify for adjuvant therapy. This clearly made tumor stage a confounding factor. When we limited our analysis to the ten patients with stage IIIB squamous cell carcinoma, survival was not longer in group В any more. This underlines the importance of tumor stage for survival.
Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Discussion (3)
Further migrations did not occur after we excluded the abovementioned type of stenosis as an indication for the Dumon stent. Lethal hemoptysis in terminally ill patients may be more frequent if the central airways are kept patent by endobronchial palliation but in our series only one death (1/30) was directly related to endobronchial treatment; the other three fatal hemoptyses were caused by terminal hemorrhages not originating in the vicinity of the stents.
The efficacy of the stents in relieving respiratory symptoms was excellent in most patients. Our three patients who did not benefit from reopening of the airways, although results of their lung function tests had improved significantly, all had additional causes preventing them from leaving their beds.
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Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Discussion (2)
A correctly positioned stent represents much less of an irritation than the obstruction it relieved and improves the expectoration of mucus dramatically, although the stented area is devoid of the normal mucociliary clearance mechanism. However, in contrast to the report of Dumon, migration remains a problem in certain types of stenoses. Our five migrations all occurred in short (<2.5 cm axial length) and conical stenoses with mostly intact mucosa, although adequate-size stents had been chosen. This is not surprising as the cylindrical Dumon stent does not fit a conical airway, and short stents have very few studs on the outside. This becomes especially important when the stenotic airway is lined with smooth mucosa and there is no intraluminal tumor growth permitting firm anchorage of the studs. We therefore think that this type of stenosis presents a clear limitation for an otherwise excellent stent. In this situation, we prefer to insert Gianturco stents for vital indications although we have observed tumor growth through the wire mesh.
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Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Discussion (1)
Obstruction of the stented airway due to local tumor recurrence was observed in 4/5 (80 percent) in group A and in 0/5 in group В (p = 0.02); median survival in group A was 4 months (4 days to 7 months) and in group В it was 6 months (3 to 8 months); this difference did not reach significance. All recurrent obstructions were due to tumor growth either proximal or distal to the indwelling stents, while the stents themselves were never compressed.
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Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Results (4)
Adjuvant Radiotherapy, Stent Patency, and Patient Survival Over Time
Of the 31 patients, 30 had died at the time of writing with a median survival of 2.5 months. The 20 patients suffering from advanced stages of bronchogenic carcinoma (stage IIIB and IV) (Table 3) also had a median survival of 2.5 months (19 dead and 1 alive at the time of writing) compared with 2.25 months in the remaining 10 malignancies. Of the 20 patients with bronchogenic carcinoma, 8 did not undergo adjuvant radiotherapy (group A) and 12 did (group B). Local tumor recurrence above or below the stent led to recurrent airway obstruction in 6 of 8 patients (75 percent) of group A and in 0/12 of group В (p = 0.001). Median survival was 1 month (range, 1 day to 7 months) in group A and 4 months (2 weeks to 13 months) in group В (p<0.05), but patients in group A had more advanced local disease and 4/8 (50 percent) had metastases, whereas in group В only 2/12 (17 percent) had metastases.
Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Results (3)
Immediate Efficacy of Stents
Twenty-eight of the 31 patients had immediate improvement of their respiratory symptoms; the three patients whose conditions did not improve despite technically successful relief of a local obstruction and proved perfusion of the lung distal to the stent (contrast enhancement of the pulmonary artery on computed tomographic scan) had additional causes for dyspnea, two with left heart failure, and one with obstruction of the vena cava. Comparison of the pretreatment and posttreatment scores of the variables (dyspnea, Kar-nofsky performance scale, and World Health Organization activity index) showed highly significant improvement (p<0.01) (Fig 5).
Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Results (2)
Tolerance of Stents
The tolerance of the stents was excellent in 27 patients (87 percent). The postoperative complications are listed in Table 2. The only intraoperative complication was a short fire to an indwelling prosthesis on a subsequent laser therapy session, which could be extinguished with saline solution; the prosthesis was left in place. One very high tracheal stent (proximal end < 1 cm below the vocal cords) had to be removed due to otalgia and dysphagia necessitating a tracheostomy. One lethal complication occurred in a patient 4 months after stent placement in the right main bronchus. He was readmitted to the hospital because of slight hemoptysis, and fiberoptic bronchoscopy revealed a totally obstructed intermediate bronchus due to tumor recurrence distal to the stent. The stent was removed and repeated laser therapy was performed.
Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Results (1)
Statistical Analysis
The change in the patients performance status pretreatment vs posttreatment for the variables dyspnea, Karnofsky scale, and activity index was analyzed by the paired Students t test. The comparison between the patients with and without adjuvant radiotherapy was made by the Mann-Whitney test for survival and by the Fisher s exact test for the rate of local tumor recurrence leading to reobstruction of the stented airw ay. Significance for all tests w as chosen at the 95 percent confidence level.
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Silicone Stents in the Management of Inoperable Tracheobronchial Stenoses – Methods (3)
Assessment of Stent Patency and Patient Survival Over Time
Patients were discharged from the hospital 24 to 48 h after the procedure and were seen by their general practioners at least twice a month. In addition, they were seen at our clinic monthly or more frequently ifa deterioration in the clinical course indicated recurrent obstruction. All general practioners were informed about the stent position and were asked to regularly record the state of ventilation of the lung distal to the stent. When a patient died, the cause of death and stent patency were assessed by autopsy and/or through an interview with the general practioner and the physician certifying the patients death.