Repeated partial endoscopic resections as treatment for two patients with inoperable tracheal tumours

Use of endotracheal silicone stents for relief of tracheobronchial obstruction

In this article we describe our initial experience with bifurcated and longitudinal silicone stents that can be inserted entirely endoscopically. A total of 10 patients were stented; half had upper airways obstruction resulting from malignant disease and half had anastomotic obstruction after single-lung (3 patients), double-lung (1 patient), or heart-lung transplantation (1 patient). All patients derived immediate relief of life-threatening stridor. Stents were in place for between 5 days and 2 1/2 years (mean, 232.9 days). In the patients with malignant disease, the stents have provided effective relief from stridor for the remainder of their lives. In the transplant recipients, the medium-term results are encouraging, with the stents providing effective relief from stridor, although the longitudinal stents have been associated with distal migration, requiring that the stents be replaced on up to five occasions. The stents have not been associated with infection in the nonimmunosuppressed patients, and during the relatively short follow-up period there has been no tissue reaction to the material.

Endoscopic relief of malignant airway obstruction

The ability to manage acute airway obstruction can be life-saving. Airway relief should be expeditious and immediate, with low morbidity and mortality. It should not interfere with future definitive therapy. In patients with terminal malignancy, it should be economical in cost and should minimize hospitalization. We used biopsy forceps and the rigid bronchoscope to "core out" 56 patients with obstructing airway neoplasms. The location of the obstruction was trachea in 16 patients, carina in 24, main bronchi in 8, and distal airway in 8. Improvement in the airway was accomplished in 90% of patients. A single bronchoscopy was sufficient in 96%. Nineteen complications occurred in 11 patients: pneumonia in 5, bleeding in 3, pneumothorax in 2, hypoxia/hypercarbia in 2, arrhythmias in 6, and laryngeal edema in 1. There were four deaths within 2 weeks of core-out related to respiratory failure. Further therapy consisted of resection in 28.6% (tracheal in 9, carinal in 3, pulmonary in 4), irradiation alone or in combination with chemotherapy in 60.7%, and no therapy in 10.7%. Palliation of symptoms and establishment of an airway in acute obstruction is the goal. Survival depends on the effectiveness of the proposed treatment. We find this time-honored method superior to use of the laser.

Recurrent adenoid cystic carcinoma of the trachea: intraluminal radiotherapy

Malignant neoplasms of the trachea are rare lesions, of which adenoid cystic carcinoma constitutes 30%. A case of extensive tumor recurrent after primary radiotherapy is presented. Surgical resection and radioisotope implantation were impossible. A method was devised for placement of intraluminal iridium 192 by casting six small hollow plastic tubes to the outer circumference of a Silastic endotracheal tube. This was an easy, safe, and effective method of delivering radiation to the trachea while sparing other vital structures and organs. Excellent tumor response and palliation were achieved. The literature is reviewed and the problems in diagnosis of this tumor are discussed. A comprehensive plan for early diagnosis is presented. All current methods of treatment are discussed, and the need for aggressive surgical management is stressed.