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

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.

Clinical Practice of Photodynamic Therapy for Non-Small Cell Lung Cancer in Different Scenarios: Who Is the Better Candidate?

BACKGROUND

Photodynamic therapy (PDT) is a relatively safe and highly selectivity antitumor treatment, which might be increasingly used as a supplement to conventional therapies. A clinical overview and detailed comparison of how to select patients and lesions for PDT in different scenarios are urgently needed to provide a basis for clinical treatment.

SUMMARY

This review demonstrates the highlights and obstacles of applying PDT for lung cancer and underlines points worth considering when planning to initiate PDT. The aim was to make out the appropriate selection and help PDT develop efficacy and precision through a better understanding of its clinical use.

KEY MESSAGES

Increasing evidence supports the feasibility and safety of PDT in the treatment of non-small cell lung cancer. It is important to recognize the factors that influence the efficacy of PDT to develop individualized management strategies and implement well-designed procedures. These important issues should be worth considering in the present and further research.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Central airway obstruction treatment with self-expanding covered Y-carina nitinol stents: A single center retrospective analysis

Background

Central airway obstruction (CAO) is one of the most challenging, potentially lethal complications in malignant and benign respiratory diseases. Worsening dyspnea is also a relevant cause for reduced quality of life in such patients. Here, we present our data on the application of covered, self‐expanding Y‐carina nitinol stents due to benign and malignant diseases.

Methods

We retrospectively identified 27 patients who had undergone 31 rigid bronchoscopies with implantation of covered Y‐carina nitinol stents over a period of 10 years in order to evaluate indication, clinical course, and outcome.

Results

Short‐term survival of successfully stented patients with palliative and curative treatment goal did not differ, allowing for diagnosis independent indication. With respect to overall survival, patients with endoluminal obstruction benefited most compared to patients with fistula and/or external compression. Granulation tissue formation (61.3%) and mucus plugging (80.6%) were the most frequent complications. Material defect (6.5%) and migration (3.2%) were rare complications that could be handled by revisional rigid bronchoscopy and stent exchange in some cases.

Conclusions

Implantation of self‐expanding covered Y‐carina nitinol stents via rigid bronchoscopy is a feasible and safe treatment option for benign and malignant central airway obstruction. Especially in palliative, malignant airway stenosis, stenting might facilitate additional treatment options and optimize dyspnea and eventually quality of life.

Photodynamic therapy for primary tracheobronchial malignancy in Northwestern China

BACKGROUND

Photodynamic therapy (PDT) has been increasingly performed to treat tracheobronchial malignancy. However, the experience in tracheobronchial adenoid cystic carcinoma (ACC) and peripheral lung cancer is still insufficient. This study aimed to share the experience of PDT for patients with primary tracheobronchial malignancy, especially the adenoid cystic carcinoma and peripheral lung cancer, and evaluated the efficacy and safety of PDT in Northwestern Chinese patients.

METHODS

This study retrospectively analyzed the clinical data of 23 patients with primary tracheobronchial malignancy receiving PDT in our center. The short-term effect was evaluated by the objective tumor response and the clinical response. The long-term effect was estimated by recurrence-free survival (RFS).

RESULTS

Of 23 patients, SR was achieved in 18 patients and MR in 3 patients. The clinical symptoms and the quality of life were significantly improved after PDT (P<0.05). And the mean RFS was 8.9 ± 1.9 months. SR for 6 cases of ACC were achieved with significant improvement of clinical symptoms and quality of life. No procedure-related complications appeared. And PDT was successfully performed for the peripheral lung cancer with the guidance of electromagnetic navigation bronchoscopy (ENB).

CONCLUSIONS

This study demonstrated that PDT achieved satisfactory efficacy and safety for Northwestern Chinese patients with primary tracheobronchial malignancy. Patients with ACC can benefit from PDT. And ENB-guided PDT is a novel and available option for the peripheral lung cancer. In short, this study accumulated valuable experience for the application of PDT in Chinese patients with primary tracheobronchial malignancy.

Secondary pulmonary malignancies requiring interventional bronchoscopic procedures

Background

In this study, we aimed to share our singlecenter experience and to investigate the effect of interventional bronchoscopic procedures on secondary pulmonary malignancies in terms of complications, success, and survival rates.

Methods

A total of 83 patients (42 males, 41 females; mean age: 57.8±15.2 years; range, 18 to 94 years) with secondary pulmonary malignancies who underwent interventional bronchoscopic procedures between January 2009 and December 2019 were retrospectively reviewed. Data including demographic and clinical characteristics of the patients, complications, and success and survival rates were recorded.

Results

The most common secondary pulmonary malignancies were kidney and thyroid tumors with the complaints of cough, shortness of breath, and hemoptysis. The mean duration before the diagnosis was 34.7±52.8 (range, 0.1 to 219.3) months, and the mean survival after the diagnosis were 10±13.1 (range, 0.2 to 44.4) months. A total of 92% of the patients had an airway obstruction of >50% and the interventional bronchoscopic procedures such as argon plasma coagulation, laser, cryo, and mechanical resection were successful in achieving airway patency. Laser application was found to significantly improve survival (p=0.015). Acute complication rate was 8.4% and mortality rate was 0%.

Conclusion

In patients with tracheobronchial lesions due to secondary pulmonary malignancies, interventional bronchoscopic procedures, regardless of the stage of the disease, provide rapid palliation in life-threatening symptoms such as dyspnea and hemoptysis due to airway obstruction, prolonging patient"s survival and gain time for additional treatments to take effect for primary disease.

Survival and prognostic factors for patients with malignant central airway obstruction following airway metallic stent placement

Background

There have been many studies on the effectiveness and complications of airway stent, but few had focused on factors that affect survival after stent placement. This study intended to assess the factors associated with the survival in patients with malignant central airway obstruction (MCAO) after airway metallic stent placement.

Methods

The clinical data of adult MCAO patients who underwent stent placement form February 2003 to June 2017 in the First Affiliated Hospital of Soochow University in China were retrospectively analyzed. The survival rates were compared using Log-rank tests. Potential prognostic factors were identified using multivariate Cox hazard regression models.

Results

Total 102 MCAO patients were included in this study. The median survival time of these patients after airway metallic stent placement was 4.1 months. Multivariate analysis showed that MCAO patients receiving radiotherapy [hazard ratio (HR) 0.554; 95% confidence interval (CI): 0.308–0.999] or chemoradiotherapy (HR 0.251; 95% CI: 0.126–0.499) after stenting had better prognosis. However, ECOG PS ≥3 score prior to the stenting (HR 2.193; 95% CI: 1.364–3.526) and stents placed in both trachea and main bronchus (HR 2.458; 95% CI: 1.384–4.366) were associated with worse survival.

Conclusions

In our results, survival of MCAO patients after airway metallic stenting was related to ECOG PS score prior to the stenting, the site of stent placement and we have hereby proposed for the first time that having opportunity to receive radiotherapy or chemoradiotherapy after stenting contribute to better prognosis.

Therapeutic bronchoscopy for central airway diseases

Over the past century rigid bronchoscopy has been established as the main therapeutic means for central airway diseases of both benign and malignant aetiology. Its use requires general anaesthesia and mechanical ventilation usually in the form of manual or high-frequency jet ventilation. Techniques applied to regain patency of the central airways include mechanical debulking, thermal ablation (laser, electrocautery and argon plasma coagulation) and cryo-surgery. Each of these techniques have their advantages and limitations and best results can be attained by combining different modalities according to the type, location and extent of the airway blockage. If needed, deployment of airway endoprostheses (stents), as either fixed-diameter silicone or self-expandable metal stents, may preserve the airways patency often at the cost of several complications. Newer generation of customised stents either three-dimensional printed or drug-eluting stents constitute a promise for improved safety and efficacy results in the near future. Treating central disease of benign or malignant aetiology, foreign body aspiration or massive bleeding in the airways requires a structured approach with combined techniques, a dedicated team of professionals and experience to treat eventual complications. Specific training and fellowships in interventional pulmonology should therefore be offered to those who wish to specialise in this field.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.

Outcomes of patients with advanced non-small cell lung cancer and airway obstruction treated with photodynamic therapy and non-photodynamic therapy ablation modalities

Background

Non-small cell lung cancer (NSCLC) patients with central airway obstruction (CAO) may have better survival on systemic therapy if the airway patency is successfully restored by bronchoscopic interventions. It remains unclear which therapeutic bronchoscopic modality [laser, stenting, external beam radiation, brachytherapy and photodynamic therapy (PDT)] used for restoring airway patency positively affects outcomes in these patients. We analyzed the effectiveness of PDT in terms of mortality, and time to subsequent treatments in patients with stage III and IV NSCLC.

Methods

Study used Surveillance, Epidemiology, and End Results (SEER) Medicare linked data. We categorized NSCLC patients diagnosed between 2000 and 2011 and with stage III and IV, into three treatment groups: PDT + radiation ± chemotherapy, non-PDT ablation therapy + radiation ± chemotherapy, and radiation + chemotherapy. We analyzed all-cause and cause-specific mortality using Cox proportional hazard models with an inverse probability weighted propensity score adjustment. Time to subsequent treatment was analyzed using GLM model.

Results

For the PDT group, hazard for all-cause and cause-specific mortality was comparable to the radiation + chemotherapy group (HR =1.03, 95% CI: 0.73-1.45; and HR =1.04, 95% CI: 0.71-1.51, respectively). The non-PDT ablation group had higher hazard for all-cause (HR =1.22, 95% CI: 1.13-1.33) and cause-specific mortality (HR =1.10, 95% CI: 1.01-1.20), compared to the radiation + chemotherapy group. The PDT group had longer time to follow-up treatment, compared to non-PDT ablation group.

Conclusions

In our exploratory study of stage III and IV NSCLC patients with CAO, addition of PDT demonstrated hazard of mortality comparable to radiation + chemotherapy group. However, addition of non-PDT ablation showed higher mortality compared to the radiation + chemotherapy group. Future studies should investigate the efficacy and effectiveness of multimodal therapy including radiation, chemo, immunotherapy and bronchoscopic interventions.

The prognostic predictors of patients with airway involvement due to advanced esophageal cancer after metallic airway stenting using flexible bronchoscopy

Background

Patients with advanced esophageal cancer and airway involvement have a poor prognosis. Self-expandable metallic stent (SEMS) implantation via bronchoscopy can immediately relieve airway stenosis and improve survival. The purpose of this study was to determine the factors that predict survival in patients with airway involvement due to advanced esophageal cancer after SEMS implantation.

Methods

We conducted this retrospective study from February 2007 to October 2013 at a university hospital. Forty-two patients with advanced esophageal cancer and airway involvement were included. The patients underwent flexible bronchoscopy with electrosurgery and SEMS implantation under bronchoscopic visualization and local anesthesia with no fluoroscopic guidance throughout the procedure.

Results

Acute respiratory failure (ARF) occurred in 14 patients (33.3%). After SEMS implantation, 28 patients (66.7%) received additional anti-cancer therapy. The median survival after the procedure was 83 days. A longer survival was seen in the patients who received further anti-cancer therapy [hazard ratio (HR), 0.146; 95% confidence interval (CI), 0.06-0.34; P<0.001]. Persistent pneumonia and poor performance status (PS) were potential factors for not receiving further therapy. The patients who received anti-cancer therapy before the procedure (HR, 3.429; 95% CI, 1.54-7.60; P=0.002) and those with ARF (HR, 5.224; 95% CI, 2.23-12.26; P<0.001) had worse survival.

Conclusions

SEMS insertion with flexible bronchoscopy without fluoroscopic guidance in the patients with airway involvement due to advanced esophageal cancer was safe and feasible. The patients who received anti-cancer therapy before the procedure and those with ARF had a poor prognosis. Post-airway stenting therapy had the positive impact on survival in these patients.

A Pilot Study of a Novel through-the-Scope Self-Expandable Metallic Airway Stents Delivery System in Malignant Central Airway Obstruction

Objective

Self-expandable metallic (SEM) airway stents are an important approach to malignant central airway obstruction (CAO). SEM airway stent insertions are usually performed under fluoroscopic guidance over a guide wire placed through a flexible bronchoscope often resulting in a longer procedure time and exposure to radiation. In this pilot study, we designed a novel delivery system of the through-the-scope (TTS) SEM airway stent insertion and observed its feasibility.

Methods

From Jan 2015 to Sept 2016, 25 consecutive patients with inoperable malignant CAO were enrolled requiring airway stent implantation. All patients were followed up to death or at least 6 months.

Results

36 TTS stents were inserted into 25 patients using a flexible bronchoscope under general anesthesia or local anesthesia. All stents were successfully deployed directly through the working channel (2.8 mm diameter) of the flexible bronchoscope in 91.7% (33/36) of the subjects. The mMRC score and stenosis grade improved significantly after stent implantation. The common stent-related complications were secretion retention (25%, 9/36), development of granulation tissue (13.9%, 5/36), tumor in-growth (13.9%, 5/36), and hemoptysis (8.3%, 3/36). The 6-month overall survival (OS) was 44% (11/25).

Conclusion

The novel TTS stent release system was an effective and safe approach in malignant central airway obstruction.

Application of Micro-Tech stents in malignant carinal stenosis

Malignant carinal stenosis is a disease process that is not always suitable for treatment with a Y-shaped stent. When one of the main bronchi is completely obstructed and cannot be recanalized, or its distal lung tissue has lost function, inserting a Y-shaped stent is infeasible. In this complex condition, a cone-shaped stent is selected to maintain the patency of the trachea and the other main bronchus. The efficacy of the bare cone-shaped Micro-Tech stent to treat malignant carinal stenosis was evaluated in the current study. The medical records of 47 patients with malignant carinal stenosis who underwent Micro-Tech stent placement between January 2004 and October 2017 in Beijing Tian Tan Hospital (Beijing, China) were analyzed retrospectively. A total of 47 bare Micro-Tech stents (28 Y-shaped and 19 cone-shaped) were successfully inserted in the patients. Following stent placement, immediate satisfactory results were achieved in all patients, especially an improvement of dyspnea (100%), cough (81.1%) and stridor (100%). The Karnofsky scores were significantly increased (P<0.001), and the American Thoracic Society Dyspnea Index values were significantly decreased (P<0.001). Following a median of 88 days, initial bronchoscopic interventions were performed for tumor overgrowth (84.6%), stent fracture (7.7%) and granulation tissue (7.7%). Restenting was performed in two patients due to tumor progression (n=1) and stent fracture (n=1). Removal of a Y-shaped stent was attempted in one patient, but failed, as the stent had become partly embedded in the airway mucosa. In conclusion, cone-shaped Micro-Tech stent placement maintained tracheal-unilateral main bronchus patency and benefitted patients with malignant carinal stenosis in whom Y-shaped stents were not suitable for insertion.

Interventional bronchoscopy in malignant central airway obstruction by extra-pulmonary malignancy

Background

Interventional bronchoscopy is considered an effective treatment option for malignant central airway obstruction (MCAO). However, there are few reports of interventional bronchoscopy in patients with MCAOs due to extra-pulmonary malignancy. Therefore, the objective of this study was to investigate treatment outcomes and prognostic factors for bronchoscopic intervention in patients with MCAO due to extra-pulmonary malignancy.

Methods

We retrospectively analyzed consecutive 98 patients with MCAO due to extra-pulmonary malignancy who underwent interventional bronchoscopy between 2004 and 2014 at Samsung Medical Center (Seoul, Korea).

Results

The most common primary site of malignancy was esophageal cancer (37.9%), followed by thyroid cancer (16.3%) and head & neck cancer (10.2%). Bronchoscopic interventions were usually performed using a combination of mechanical debulking (84.7%), stent insertion (70.4%), and laser cauterization (37.8%). Of 98 patients, 76 (77.6%) patients had MCAO due to progression of malignancy, and 42 (42.9%) patients had exhausted all other anti-cancer treatment at the time of bronchoscopic intervention. Technical success was achieved in 89.9% of patients, and acute complications and procedure-related deaths occurred in 20.4% and 3.1% of patients, respectively. Reduced survival was associated with MCAO due to cancer other than thyroid cancer or lymphoma, mixed lesions, and not receiving adjuvant treatment after bronchoscopic intervention.

Conclusions

Bronchoscopic intervention could be a safe and effective procedure for MCAO due to end-stage extra-pulmonary malignancies. In addition, we identified possible prognostic factors for poor survival after intervention, which could guide clinicians select candidates that will benefit from bronchoscopic intervention.