Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents

Bronchoscopic treatment of early-stage peripheral lung cancer

PURPOSE OF REVIEW

This review article focuses on bronchoscopic treatment of early-stage peripheral lung cancer.

RECENT FINDINGS

Bronchoscopic treatment modalities have garnered considerable attention for early-stage lung cancer. Studies using photodynamic therapy, thermal vapor ablation, laser ablation, cryoablation, and intra-tumoral injection have recently been published. However, the evidence supporting these approaches largely derives from single-arm studies with small sample sizes. Based on the IDEAL-D framework, no technology has progressed passed the idea phase (1). The main weakness of these technologies to date is lack of evidence suggesting they can achieve local control. Presently, no bronchoscopic intervention for lung cancer has sufficient data to warrant its use as part of the standard of care.

SUMMARY

Despite notable progress, current technologies remain suboptimal, and there is insufficient evidence to support their use outside of a research setting.

Endobronchial Obstruction: A Case of Well-Differentiated Liposarcoma

Atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDL) is a rare subtype of endobronchial tumor that has been rarely reported in medical literature. Due to its low incidence, distinguishing it from endobronchial lipoma poses a significant diagnostic challenge, necessitating histopathologic and cytogenetic analysis. As of today, the treatment and surveillance protocols for these neoplasms remain poorly defined, often resulting in their misclassification and treatment as endobronchial lipomas. We present a case involving a 72-year-old male who presented with worsening dyspnea and cough. Diagnostic imaging revealed an endobronchial lesion obstructing the left main bronchus. The patient underwent a flexible bronchoscopy that identified a polypoid mass causing significant obstruction, which was subsequently resected via cryoablation. Histopathology confirmed ALT/WDL, supported by genetic analysis revealing chromosomal alterations. Following the intervention, symptoms resolved, with no recurrence on follow-up imaging. Differentiating ALT/WDL from endobronchial lipomas is necessary not only because it influences treatment decisions but also because it can significantly affect the prognosis of patients diagnosed with ALT/WDL. In this case, we emphasize the importance of considering ALT/WDL in the differential diagnosis of endobronchial tumors and highlight the use of flexible bronchoscopy as a viable substitute for rigid bronchoscopy, serving not only as a diagnostic tool but also as a therapeutic method.

The "Hitch-Stitch" for Preventing High Tracheal Stent Migration: Expanding Indications and Extended Experience

BACKGROUND

Airway stenting is a standard treatment option for tracheo-bronchial obstruction and other conditions like tracheo-esophageal fistula (TEF).

METHODS

To prevent stent migration, a percutaneous fixation strategy called the "hitch-stitch" was described in 2016 as an efficient technique. We describe an extended experience of the "hitch-stitch" for silicone stents in high tracheal stenting situations and expanding indications to metal stents.

RESULTS

Seventy-four percutaneous stitches were placed in 54 patients (36 males and 18 females). The mean age of the patients was 42 (±19) years. The indication for stenting was tracheal stenosis in 63/74 (85%) cases and TEF in 11/74 (15%) cases. Silicone stents were used in 56/74 (75.5%) cases while self-expanding metal stents (SEMS) were used in 18/74 (24.5%) cases. The majority of the stents (62/74, 85%) were high tracheal stents. The "hitch-stitch" as an anti-migration strategy had a high success rate, with distal stent migration in only 2 cases (2.7%) as the stitch had given way-these were repositioned and hitched with double stitches. Minor complications included delayed skin healing (2.8%) and suture site infection (1.4%), which was successfully managed with oral antibiotics. Stitch removal was easy with no complications.

CONCLUSION

In this large series of percutaneous "hitch-stitch" as a stent migration prevention strategy, long-term data shows it is safe and effective in an expanded cohort of silicone stents. Its extended utility is the successful application to metal stents, especially in TEF, where the consequences can be deleterious. It is simple to do, with minimal extra requirements and not associated with any significant complications.

[Interventionnal bronchoscopy for the treatment of tracheobronchomalacia]

Tracheobronchomalacia is usually characterized by more than 50% expiratory narrowing in diameter of the trachea and the bronchi. The expiratory collapse includes two entities: (1) the TBM related to the weakness of the cartilaginous rings, and (2) the Excessive Dynamic Airway Collapse (EDAC) due to the excessive bulging of the posterior membrane. Patients have nonspecific respiratory symptoms like dyspnea and cough. Diagnosis is confirmed by dynamic tests: flexible bronchoscopy and/or computed tomographic scan of the chest. There are different forms of tracheobronchomalacia in adults: primary (genetic, idiopathic) or secondary to trauma, tracheotomy, intubation, surgery, transplantation, emphysema, infection, inflammation, chronic bronchitis, extrinsic compression; or undiagnosed in childhood vascular rings. Some management algorithms have been proposed, but no specific recommendation was established. Only symptomatic patients should be treated. Medical treatments and noninvasive positive pressure ventilation should be the first line therapy, after evaluation of various quality measures (functional status, performance status, dyspnea and quality of life scores). If symptoms persist, therapeutic bronchoscopy permits: (1) patient's selection by stent trial to determine whether patient benefit for surgical airway stabilization; (2) malacic airways stenting in patients who are not surgical candidates, improving QOL despite a high complication rate; (3) the management of stent-related complication (obstruction, plugging, migration granuloma); (4) alternative therapeutics like thermo-ablative solution. Lasty, the development of new types of stents would reduce the complication rates. These different options remained discussed.

Tumor-Related Factors Affecting the Success of Interventional Bronchoscopy in Malignant Airway Obstructions

BACKGROUND

It is difficult to select patients who will benefit from endobronchial treatment (ET) in malignant central airway obstruction (MCAO). We aimed to determine the tumor-related factors that affect the success of MCAO treatment.

METHODS

ETs for MCAO between March 2019 and June 2021 were analyzed retrospectively. The relationships between the success of the procedure and the percentage of endoluminal obstruction, tumor size, and type of lesion were evaluated.

RESULTS

Totally, 220 ETs were administered to 205 patients. Treatment was significantly more successful for the patients with pure endobronchial lesions than those with mixed lesions. The success rate was significantly lower when the tumor size was greater than 54.5 mm and the degree of endoluminal stenosis exceeded 92%; the area under the curve was 0.734 (0.625-0.842; P=0.001) and 0.733 (0.597- 0.870; P=0.001), respectively. There was no difference in the procedural success between lung cancer and extrathoracic malignancies and tumor treatment before the procedure.

CONCLUSION

Mixed lesions, tumor size over 54.5 mm, and a degree of stenosis over 92% are risk factors for unsuccessful endoluminal obstruction procedures. These parameters should be considered when selecting patients for ET interventions.

Two cases of large tracheobronchial schwannomas completely resected by rigid bronchoscopy with multiple instruments

Primary tracheobronchial schwannomas are extremely rare. Surgical treatment has been the first choice for these benign tumours due to the substantial residual rates and recurrences after bronchoscopic resection. In addition, there has been limited information on bronchoscopic removal of endobronchial schwannomas. We describe two cases of large tracheal and bronchial schwannomas that were completely and successfully resected by snare electrocautery, insulation-tipped knife, and argon plasma coagulation under rigid bronchoscopy. These cases highlight that rigid bronchoscopic treatment with these multiple instruments can be a good treatment option for endotracheal or endobronchial schwannomas.

A prediction model for risk of low oxygen saturation in patients with post-tuberculosis tracheobronchial stenosis during bronchoscopy

BACKGROUND

Low oxygen saturation (LOS) is a frequent occurrence for patients with post-tuberculosis tracheobronchial stenosis (PTTS) during bronchoscopic procedures. However, there are currently no systematic assessment tools to predict LOS risk in PTTS patients during bronchoscopy.

OBJECTIVES

This study aimed to develop an effective preoperative predictive model to guide clinical practice.

DESIGN

Retrospective cohort study.

METHODS

Data was retrospectively collected from PTTS patients who underwent bronchoscopic interventions between January 2017 and December 2022. Among all patients included in this study, patients between January 2017 and December 2021 were used as training cohort for the logistic regression model, and patients between January 2022 and December 2022 were utilized as validation cohort for internal validation. We used consistency index (C-index), goodness-of-fit test and calibration plot to evaluate the model performance.

RESULTS

A total of 465 patients who met the inclusion criteria were enrolled in the study. The overall incidence of LOS was 26.0% (121/465). Comorbidity, degree of stenosis, bronchoscopist level, thermal ablation therapy, balloon dilation, and airway stenting, as independent risk factors for the presence of LOS, were used to construct the nomogram prediction model. The C-index of training cohort was 0.827 (95% CI, 0.786-0.869), whereas that of validation cohort was 0.836 (95% CI, 0.757-0.916), combining with the results of the calibration plot and goodness-of-fit test, demonstrating that this model had good predictive ability.

CONCLUSION

The predictive model and derived nomogram with good predictive ability has been developed to preoperatively predict the risk of LOS in PTTS patients during bronchoscopy, allowing for individualized interventions for high-risk patients.

Bronchoscopy Laser and Silicone Y-Stents as Emergency Airway Management in Central Airway Stenosis Due to Secondary Thyroid Carcinoma: A Case Report

Total airway obstruction in thyroid cancer is rare and has high morbidity and mortality. Airway management in such cases is challenging, especially in cases in which thyroid masses cannot be totally resected. It is important to choose the appropriate airway treatment modality. Currently, therapeutic rigid bronchoscopy procedures and endoluminal lasers, as well as airway stent insertion, are a management modality of near-total malignant airway obstruction. We report a rigid bronchoscopy procedure combined with laser and Y-stent silicone insertion in thyroid cancer with extension infiltration, as well as compression in the trachea covering the subglottic tracheal area up to the main carina and tracheo-bronchomalacia, manifesting as acute respiratory failure.

Novel use of metallic stent to control post-debulking bleeding in a patient with central airway obstruction

Bronchoscopy-related bleeding is often encountered and is usually self-limiting or controllable by conservative measures. However, major bleeds can be life threatening for the patient as well as challenging for the physician to manage. There are several methods to achieve adequate haemostasis should a significant airway bleed occur. In this context, we describe a patient who had a post-bronchoscopic debulking bleed which persisted despite use of all available measures, and we deployed a self-expanding metallic stent in an attempt to control it. To the best of our knowledge, this is the first instance of a metallic airway stent being used to control bronchoscopy associated bleeding, though reports of its usage in management of intractable haemoptysis exist in the literature.

Obstructive Pneumonia Associated with Endobronchial Aspergilloma: Successful Treatment with Interventional Bronchoscopy and Antifungals

Endobronchial aspergilloma is a rare disease. A 64-year-old man with severe diabetes mellitus developed a cough and fever and was referred to our hospital. He was diagnosed with obstructive pneumonia associated with endobronchial aspergilloma, underwent interventional bronchoscopy, and was treated with antifungals. While the optimal treatment has not been established, interventional bronchoscopy along with systemic antifungals may improve the outcome in such cases.

Therapeutic bronchoscopy followed by sequential radiochemotherapy in the management of life-threatening tracheal adenoid cystic carcinoma: a case report

Background

Adenoid cystic carcinoma of the lung is a distinctive salivary-gland-type malignant epithelial neoplasm that rarely presents as a primary tumor of the respiratory tract. Complete surgical resection remains the treatment of choice for adenoid cystic carcinoma. We present a case of large ACC tumors that caused severe central airway obstruction and were effectively treated with therapeutic bronchoscopy followed by radiotherapy and chemotherapy.

Case presentation

A 31-year-old Malay Indonesian female patient who was a nonsmoker and had no family history of cancer was admitted to the emergency ward because of worsening breathlessness accompanied by stridor since 1 week prior. Chest computed tomography revealed segmental atelectasis of the left lung; a mass on the left main bronchus, with infiltrates in segments 1, 2, and 3 of the left lung; and consolidation in the left inferior lobe, with narrowing of the main left bronchus. Lobulated masses obstructing almost the entire distal trachea up to the carina and the entire left main bronchus were found on bronchoscopy. Owing to the large tumors causing severe central airway obstruction, the medical team decided to perform central airway mass removal through rigid bronchoscopy. A neodymium-doped yttrium-aluminum-garnet laser was used first to facilitate mass shrinkage. After the laser treatment, mechanical mass removal using a rigid scope was performed. The tracheal and carinal lumens were opened to > 50% of their diameter, with the left main bronchus lumen opened only slightly. After the treatment, the patient was stable, and no stridor was found. Adjuvant intensity-modulated radiotherapy and chemotherapy were performed after the therapeutic bronchoscopy. At the end of the entire treatment, reevaluation by thoracic computed tomography scan and bronchoscopy revealed no remaining mass.

Conclusions

In cases of nonresectable large adenoid cystic carcinoma tumors with life-threatening central airway obstruction, therapeutic bronchoscopy followed by sequential radiochemotherapy might achieve a complete response outcome.

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.

Endoscopic Applications of Near-Infrared Photoimmunotherapy (NIR-PIT) in Cancers of the Digestive and Respiratory Tracts

Near-infrared photoimmunotherapy (NIR-PIT) is a newly developed and promising therapy that specifically destroys target cells by irradiating antibody-photo-absorber conjugates (APCs) with NIR light. APCs bind to target molecules on the cell surface, and when exposed to NIR light, cause disruption of the cell membrane due to the ligand release reaction and dye aggregation. This leads to rapid cell swelling, blebbing, and rupture, which leads to immunogenic cell death (ICD). ICD activates host antitumor immunity, which assists in killing still viable cancer cells in the treated lesion but is also capable of producing responses in untreated lesions. In September 2020, an APC and laser system were conditionally approved for clinical use in unresectable advanced head and neck cancer in Japan, and are now routine in appropriate patients. However, most tumors have been relatively accessible in the oral cavity or neck. Endoscopes offer the opportunity to deliver light deeper within hollow organs of the body. In recent years, the application of endoscopic therapy as an alternative to surgery for the treatment of cancer has expanded, providing significant benefits to inoperable patients. In this review, we will discuss the potential applications of endoscopic NIR-PIT, especially in thoracic and gastrointestinal cancers.

Dilation versus laser resection in subglottic stenosis: protocol for a prospective international multicentre randomised controlled trial (AERATE trial)

INTRODUCTION

Subglottic stenosis (SGS) is a rare condition that results from progressive narrowing of the upper airways. Outcomes and treatment options depend on the benign or complex nature of the stenosis. Treatment options for SGS include surgery and endoscopic techniques. The main endoscopic techniques used are dilation and laser resection. Observational and retrospective studies suggest that endoscopic laser resection may be more effective than dilation. We, therefore, aimed to compare the effectiveness of dilation and laser resection in preventing recurrence of SGS.

METHODS AND ANALYSIS

AERATE (dilAtion vs laser Endoscopic Resection in subglottic trAcheal sTEnosis) is a multicentre, investigator-initiated, randomised controlled trial, comparing endoscopic dilation to endoscopic laser resection for simple benign SGS (less than 1 cm long without underlying cartilaginous damage) referred for endoscopic treatment (first treatment or recurrence). The study will be conducted in three centres in France and one in Canada with other centres from France and Canada expected to join. The primary outcome is the recurrence rate of stenosis at 2 years. Recurrence is defined as having a new onset of symptoms along with a stenosis of more than 40% (confirmed by bronchoscopy) requiring a new procedure. A sample size of 100 patients is calculated for the primary endpoint assuming a 10% recurrence rate in the laser resection group and 33% in the dilation group with a statistical significance level of 5%, a power of 80%.

ETHICS AND DISSEMINATION

This study is approved by local and national ethics committees as required. Results will be published, and trial data will be made available.

TRIAL REGISTRATION NUMBER

NCT04719845.

Self-Expandable Metallic Stent Implantation Combined With Bronchial Artery Infusion Chemoembolization in the Treatment of Lung Cancer With Complete Atelectasis

Background

Atelectasis is a common complication of lung cancer, and there are few reports about the treatment methods. This study retrospectively analyzed the safety and effectiveness of endotracheal metal stent implantation combined with arterial infusion chemoembolization in the treatment of non-small cell lung cancer with complete atelectasis.

Methods

The clinical data of patients with non-small cell lung cancer and complete atelectasis treated by self-expandable metallic stent implantation combined with arterial infusion chemotherapy were retrospectively analyzed. The clinical efficacy was evaluated and postoperative adverse reactions were observed. Progression-free survival and overall survival were analyzed by Kaplan-Meier method.

Results

In all, 42 endotracheal metallic stents were implanted in 42 patients under fluoroscopy. 5–7 days after stent implantation, CT showed that 24 patients (57.1%) had complete lung recruitment, and that 13 (31.0%) had partial lung recruitment. The technical success rate was 100%, and the clinical success rate was 88.1% (37/42). 5–7 days after stent implantation, bronchial artery infusion chemoembolization was performed in all patients. The median progression-free survival and overall survival were 6 months (95% CI: 2.04-9.66) and 10 months (95% CI: 7.22-12.79), respectively.

Conclusion

Self-expandable metallic stent implantation combined with arterial infusion chemoembolization may be an effective and safe strategy in the treatment of lung cancer with atelectasis clinically.

Endobronchial mucoepidermoid carcinoma in a child with postinfectious bronchiolitis obliterans

Endobronchial mucoepidermoid tumors are rare neoplasms. Due to nonspecific symptoms, diagnosis can be challenging, but early diagnosis and treatment are crucial for prognosis. We present the case of a boy, with chronic respiratory insufficiency due to bronchiolitis obliterans, that presented worsening exertional dyspnea at 12 years. Spirometry showed unexpected deterioration of respiratory function and a computed tomography scan revealed an obstructive polypoid mass in the intermediate bronchus. Given the severe basal ventilatory compromise and risk associated with surgical treatment, rigid bronchoscopy, and laser photocoagulation were performed, with clinical and functional improvement. The histological examination revealed a low-grade mucoepidermoid carcinoma. The option for a minimally invasive procedure requires careful follow-up due to the risk of tumor recurrence.

Imaging of therapeutic airway interventions in thoracic oncology

Tracheobronchial obstruction, haemoptysis, and airway fistulas caused by airway involvement by primary or metastatic malignancies may result in dyspnoea, wheezing, stridor, hypoxaemia, and obstructive atelectasis or pneumonia, and can lead to life-threatening respiratory failure if untreated. Complex minimally invasive endobronchial interventions are being used increasingly to treat cancer patients with tracheobronchial conditions with curative or, most often, palliative intent, to improve symptoms and quality of life. The selection of the appropriate treatment strategy depends on multiple factors, including tumour characteristics, whether the lesion is predominately endobronchial, shows extrinsic compression, or a combination of both, the patient's clinical status, the urgency of the clinical scenario, physician expertise, and availability of tools. Pre-procedure multidetector computed tomography (MDCT) imaging can aid in the most appropriate selection of bronchoscopic treatment. Follow-up imaging is invaluable for the early recognition and management of any potential complication. This article reviews the most commonly used endobronchial procedures in the oncological setting and illustrates the role of MDCT in planning, assisting, and follow-up of endobronchial therapeutic procedures.

[Interventional bronchoscopy-an overview]

Die Bronchoskopie stellt neben der Lungenfunktion und der radiologischen Bildgebung das wichtigste Diagnostikum bei Patienten mit Atemwegs- und Lungenerkrankungen dar. Aufgrund des kombinierten Einsatzes flexibler und starrer Bronchoskope kommt sie heutzutage aber auch zunehmend als endoskopisches Therapieverfahren bei pulmonalen Erkrankungen in Frage. Bei thorakalen Tumoren kann die interventionelle Bronchoskopie sowohl in palliativer als auch kurativer Intention zum Einsatz kommen. Neben der bronchoskopischen Tumorbehandlung rückten in den letzten Jahren zunehmend die Techniken der endoskopischen Lungenvolumenreduktion in den Fokus. Darüber hinaus bieten sich Therapiemöglichkeiten für Asthma und chronische Bronchitis sowie bei Atemwegsstenosen und -fisteln.

Choice of bronchoscopic intervention working channel for benign central airway stenosis

The purpose of this study is to report our experiences over 12 years with bronchoscopic interventions in patients with benign central airway stenosis using three types of working channels (rigid bronchoscope, laryngeal mask, and endotracheal intubation), with a focus on their related advantages, disadvantages, and postoperative complications. We analyzed the clinical data from 273 patients with benign central airway stenosis who underwent a bronchoscopic intervention. The Wilcoxon rank-sum test was used to analyze the immediate results after the first bronchoscopic intervention, and the Chi-square test was used to analyze the correlation between glottic edema and operation time. The 273 patients underwent a total of 479 bronchoscopic interventions, with satisfactory results. The immediate effective rates of the first bronchoscopic intervention by rigid bronchoscope, laryngeal mask, and endotracheal intubation were 91.4%, 91.3%, and 85.2%, respectively. Postoperative complications related to the working channels included hoarseness, glottic edema, pharyngalgia, paresthesia pharynges, cough, and tooth loss. Glottic edema was the most serious complication, and it occurred in 37.7% (23/61) of the rigid bronchoscope group and 9.8% (32/326) in the laryngeal mask group. And the incidence rate was significantly correlated with the operation time (P < 0.01). Therefore, for patients with benign central airway stenosis, the best choice of working channel during an operation should be made by the operation procedure, lesion location, and pathology of the patients. Shortening the operation time was an important factor in preventing glottic edema.

Risk-score model to predict prognosis of malignant airway obstruction after interventional bronchoscopy

Background

Interventional bronchoscopy exhibits substantial effects for patients with malignant airway obstruction (MAO), while little information is available regarding the potential prognostic factors for these patients.

Methods

Between October 31, 2016, and July 31, 2019, a total of 150 patients undergoing interventional bronchoscopy and histologically-confirmed MAO were collected, in which 112 eligible participants formed the cohort for survival study. External validation cohort from another independent institution comprised 33 MAO patients with therapeutic bronchoscopy. The least absolute shrinkage and selection operator regression (LASSO) was applied to the model development dataset for selecting features correlated with MAO survival for inclusion in the Cox regression from which we elaborated the risk score system. A nomogram algorithm was also utilized.

Results

In our study, we observed a significant decline of stenosis rate after interventional bronchoscopy from 71.7%±2.1% to 36.6%±2.7% (P<0.001) and interventional bronchoscopy dilated airway effectively. Patients in our study undergoing interventional bronchoscopy had a median survival time of 614.000 days (95% CI: 269.876–958.124). Patients receiving distinct therapeutic methods of interventional bronchoscopy had different prognosis (P=0.022), and patients receiving treatment of electrocoagulation in combination with stenting and electrosurgical snare had worse survival than those receiving other options. Multivariate Cox analysis revealed that nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, as independent predictive factors for better overall survival (OS) of MAO patients. Then, the nomogram based on Cox regression and risk score system based on results from LASSO regression were elaborated respectively. Importantly, this risk score system was proved to have better performance than the nomogram and other single biomarkers such as traditional staging system (area under the curve 0.855 vs. 0.392–0.739). Survival curves showed that patients with the higher risk-score had poorer prognosis than those with lower risk-score (third quantile of OS: 126.000 days, 95% CI: 73.588–178.412 vs. 532.000 days, 95% CI: 0.000–1,110.372; P<0.001).

Conclusions

Nonsmoking status, adenoid cystic carcinoma, and low preoperative stenosis length, were independent predictive factors for better OS of MAO patients. We proposed a nomogram and risk score system for survival prediction of MAO patients undergoing interventional bronchoscopy with good performance.

Intraoperative argon-plasma coagulation treatment for patients with malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is often associated with asbestos exposure and carries an extremely poor prognosis. The present study assessed the effectiveness of argon plasma coagulation (APC) treatment in patients with MPM who underwent radical pleural decortication (PD). The clinical data from 11 patients who underwent radical PD treated with APC at Toho University Omori Medical Center from July 2015 to March 2020 were retrospectively analyzed. Clinical features, local recurrence, and clinical prognoses were evaluated. The median overall survival was 18.5 months, and the 1- and 2-year overall survival rates were 71.6 and 43.0%, respectively. One patient survived 5 years but had recurrent tumors. The median disease-free survival was 11.1 months. The 1- and 2-year disease-free survival rates were 49.9 and 12.5%, respectively. Three patients had no recurrences, two of whom were followed continuously (39.6 and 10.2 months). The present study revealed that APC treatment for MPM might be associated with good survival and prognosis. APC as an additional intraoperative treatment for patients with MPM may be further investigated with larger multi-center clinical trials to support its efficacy.

Argon Plasma Coagulation (APC) for the Treatment of Excessive Dynamic Airway Collapse (EDAC): An Animal Pilot Study

BACKGROUND

Surgical stabilization of the airway through tracheobronchoplasty (TBP) is the current treatment modality for patients with severe symptomatic excessive dynamic airway collapse. However, TBP is associated with increased morbidity and mortality. Bronchoscopic treatment of the posterior membrane using argon plasma coagulation (APC) may be a safer alternative to TBP in highly selected patients. This study aimed to evaluate the effect of APC in the tracheobronchial tree of a sheep animal model.

PATIENTS AND METHODS

Two adult sheep were used for this study. Under flexible bronchoscopy, the posterior tracheal membrane was treated with precise APC using different power settings. Chest computed tomography was done at 2 days and bronchoscopy was performed at 30 days following initial procedure, before euthanasia. The airways were assessed for the presence of treatment-related histopathologic changes along with expression of genes associated with fibrosis.

RESULTS

There was no perioperative or postoperative morbidity or mortality. Chest computed tomography showed no signs of pneumomediastinum or pneumothorax. Flexible bronchoscopy showed adequate tracheobronchial tissue healing process, independent of the power settings used. Histologic changes demonstrated an increased extent of fibroblastic collagen deposition in the treated posterior membrane when higher power settings were used. In a similar manner, APC treatment managed to activate fibrosis-associated gene transcription factors, with higher settings achieving a higher level of expression.

CONCLUSION

APC at high-power settings achieved higher levels of fibroblast collagen deposition at the posterior membrane and higher expression of fibrosis-associated gene transcription factors, when compared with lower settings.

Argon plasma coagulation with atezolizumab and chemoradiation in lung pleomorphic cancer showed a remarkable response: Case report

RATIONALE

Lung pleomorphic carcinoma (LPC) is generally resistant to chemotherapy or radiotherapy. However, a combination of immune checkpoint inhibitors and radiotherapy has a remarkable efficacy against LPC.

PATIENT CONCERNS AND DIAGNOSES

Here, we report the case of a 50-year old man diagnosed with progressive LPC. The tumor invaded the carina and predominantly obstructed the right main bronchus; therefore, a combination of palliative chemoradiotherapy and atezolizumab was initiated. However the trachea was gradually obstructed.

INTERVENTION AND OUTCOME

Argon plasma coagulation (APC) was performed to prevent tumor invasion. After three APC sessions, the tumor showed a necrotic change and was easily excised using biopsy forceps.

LESSONS

A combination of chemoradiotherapy, atezolizumab, and APC showed a good efficacy, and the patient had a good response to atezolizumab maintenance therapy. Multidisciplinary treatments, such as a combination of immune checkpoint inhibitors and APC, could have synergistic efficacy in lung cancer.

Clinical effects of cisplatin plus recombinant human endostatin (rh-endostatin) intratumoral injection on malignant central airway obstruction: a retrospective analysis of 319 cases

Background

Primary lung cancer with severe central airway obstruction (CAO) is often life-threatening. In this study, we investigated the clinical efficacy and safety of cisplatin plus recombinant human endostatin (rh-endostatin) intratumoral injection in treatment of malignant central airway obstruction (MCAO) caused by primary squamous cell lung cancer.

Methods

We retrospectively analyzed patients with MCAO caused by primary squamous cell lung cancer treated with and without bronchoscopic intratumoral injection of cisplatin plus rh-endostatin between January 2007 and June 2016.

Results

A total of 206 patients received cisplatin plus rh-endostatin intratumoral injection, and 113 without injection. Dyspnea grade, degree of stenosis, quality of life and lung function of all patients were significantly improved at 1 week after treatment compared with baseline. Both groups achieved good airway patency (97.1% vs. 93.8%, P=0.156). Followed up at 2 months, all parameters were improved in the injection group compared with baseline, while no statistical differences were observed in the non-injection group (P>0.05). The injection group achieved airway patency in 155 (75.2%) of 206 patients, which was significantly superior to the non-injection group [20 (17.7%) of 113, P<0.001]. In addition, the restenosis rate of the injection group was lower compared with the non-injection group (22.5% vs. 81.1%, P<0.001, respectively). No serious complications were observed in two groups.

Conclusions

Cisplatin plus rh-endostatin intratumoral injection is effective and safe for the therapy of MCAO caused by primary squamous cell lung cancer.

A modified rabbit model of tracheal stenosis and a household endoscope. More simplicity and accessibility

Purpose:

To develop a simpler animal model for benign tracheal stenosis and introduce a low-cost household endoscope for postmodeling endotracheal evaluation.

Methods:

Twenty rabbits were randomly divided into a model group (15 rabbits, subjected to transoral nylon brush scraping of the trachea) and a mock group (5 rabbits, merely exempted from scraping), a household endoscope was then introduced for weekly endoscopic examination. Meanwhile, other 15 rabbits (modeling like the model group) underwent batch tracheal resection at different postintervention times for pathological analysis.

Results:

The model group presented a low mortality and few complications. The endoscope could obtain adequate images for stenosis assessment, which showed that the models presented homogeneous injury after scraping and developed a mature scar stricture at 28 days postoperatively with a mean stenosis degree of 65.9%, and 71.4% (10/14) above Myer–Cotton’s grade II. The pathological findings were consistent with the clinicopathological process of human. No stenosis was found in mock group.

Conclusion:

The modified model is simpler, minimally invasive and reliable, while the household endoscope is competent for model’s follow-up, providing easily accessible and useful tools for facilitating more extensive studies of benign tracheal stenosis.

A Prospective Outcome Assessment After Bronchoscopic Interventions for Malignant Central Airway Obstruction

BACKGROUND

A systematic assessment of comprehensive clinical outcomes after various therapeutic procedures for malignant central airway obstruction (CAO) is lacking.

METHODS

Patients with symptomatic malignant CAO undergoing various therapeutic bronchoscopy procedures were assessed for symptomatic and functional improvement using the Speiser Score, spirometry, 6-minute walk distance (6MWD), and St. George Respiratory Questionnaire (SGRQ) up to 3 months after the procedures.

RESULTS

A total of 83 intervention procedures were performed in 65 patients, comprising 43 (66.2%) male individuals [overall mean age, 52.4; SD, 15.4 y]. The majority of these (92.3%) was done using rigid bronchoscope under general anesthesia. Airway stenting was the most common intervention performed (56.6%), followed by mechanical debulking (26.5%), cryodebulking (6%), electrosurgical removal (4.8%), balloon dilatation (3.6%), and laser ablation (2.4%).A total of 15 complications (18.1%) were noted. Of these, 8 (53.3%) were early complications and 7 (46.7%) were late complications. Early complications included airway bleeding, hypoxia, vocal cord injury, laryngeal injury, and pneumothorax. Late complications included significant granulation tissue formation in metallic stents and lung collapse because of mucus plug.The survival rates at 4, 8, and 12 weeks were 83%, 70.7%, and 66.1%, respectively. Significant improvement was observed in dyspnea, cough, Speiser Score, 6MWD, forced expiratory volume in 1 s, forced vital capacity, and SGRQ scores at 48 hours, 4 weeks, and at 12 weeks after the procedures and no procedure-related mortality occurred.

CONCLUSION

Various therapeutic bronchoscopic interventions, including combined modalities, provide rapid and sustained improvements in symptoms, respiratory status, exercise capacity, and quality of life in malignant CAO and have a good safety profile.

Interventional Pulmonology: A Brave New World

Interventional pulmonology is a dynamic and evolving field in respiratory medicine. Advances have improved the ability to diagnose and manage diseases of the airways. A shift toward early detection of malignant disease has generated a focus on innovative diagnostic techniques. With patient populations living longer with malignant and benign diseases, the role for interventional bronchoscopy has grown. In cancer groups, novel immunotherapies have improved the prospects of clinical outcomes and reignited a focus on optimizing patient performance status to enable access to anticancer therapy. This review discusses current and emerging diagnostic modalities and therapeutic approaches available to manage airway diseases.

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.

Interventional Bronchoscopy

For over 150 years, bronchoscopy, especially flexible bronchoscopy, has been a mainstay for airway inspection, the diagnosis of airway lesions, therapeutic aspiration of airway secretions, and transbronchial biopsy to diagnose parenchymal lung disorders. Its utility for the diagnosis of peripheral pulmonary nodules and therapeutic treatments besides aspiration of airway secretions, however, has been limited. Challenges to the wider use of flexible bronchoscopy have included difficulty in navigating to the lung periphery, the avoidance of vasculature structures when performing diagnostic biopsies, and the ability to biopsy a lesion under direct visualization. The last 10-15 years have seen major advances in thoracic imaging, navigational platforms to direct the bronchoscopist to lung lesions, and the ability to visualize lesions during biopsy. Moreover, multiple new techniques have either become recently available or are currently being investigated to treat a broad range of airway and lung parenchymal diseases, such as asthma, emphysema, and chronic bronchitis, or to alleviate recurrent exacerbations. New bronchoscopic therapies are also being investigated to not only diagnose, but possibly treat, malignant peripheral lung nodules. As a result, flexible bronchoscopy is now able to provide a new and expanding armamentarium of diagnostic and therapeutic tools to treat patients with a variety of lung diseases. This State-of-the-Art review succinctly reviews these techniques and provides clinicians an organized approach to their role in the diagnosis and treatment of a range of lung diseases.

Clinical efficacy of treatment for primary tracheal tumors by flexible bronchoscopy: Airway stenosis recanalization and quality of life

The aim of the present study was to evaluate the effectiveness of interventional treatment of primary tracheal tumors through flexible bronchoscopy. The clinical data of 38 patients with primary tracheal tumours who underwent flexible bronchoscopy intervention therapy between January 2011 and January 2017 were retrospectively analyzed. The average time interval from onset of symptoms to the appearance of actual clinical manifestations in the 38 patients ranged from 0 to 60 months, with an average of 8.1±11.6 months and a median of 4.2 months. The rate of misdiagnosis at the first visit was 36.8% (14/38). After interventional treatment, the overall efficiency (complete + partial response) of airway stenosis recanalization in the 38 patients was 89.5%. In 3 patients with benign tumors, the anhelation score was reduced following treatment (1.00±0.77 vs. 3.13±1.21 at the pre-treatment stage; P<0.001). The overall survival rates of the 35 patients at 1, 3 and 5 years were 69.3, 48.7 and 20.3%, respectively. Therefore, flexible bronchoscopic intervention may effectively smoothen the airways of patients and relieve the symptoms of anhelation. Combining radiotherapy and chemotherapy may improve patient prognosis and safety.

Endobronchial lesions cases treated with interventional bronchoscopic techniques: Our single-center experiences

Background

In this study, we aimed to present our experience with interventional bronchoscopy in the treatment of endobronchial lesions in our clinic.

Methods

Between January 2010 and December 2018, a total of 18 patients (11 males, 7 females; mean age 55.1 years; range, 17 to 82 years) who were diagnosed with an endobronchial lesion using bronchoscopy in our clinic were retrospectively analyzed. Demographic characteristics, presenting symptoms, bronchoscopic procedure, location of the lesion, pathological diagnosis, treatment approaches, success of the bronchoscopic treatment, and follow-up outcomes of the patients were evaluated.

Results

Control bronchoscopy was performed in 14 patients and a second control bronchoscopy was performed in eight patients. The lesions were located in the right bronchial system in nine (50%), in the left bronchial system in six (33%), and in the trachea in three patients (17%). Except for one pregnant patient, all interventional procedures were performed with a rigid bronchoscope under general anesthesia. Distal areas which were unable to be reached with the rigid bronchoscope were evaluated by a flexible bronchoscope. There were no complications in any of the patients. At the end of the study, the final control biopsies of all patients were found to be normal. The success rate of interventional bronchoscopic methods was 100%.

Conclusion

Interventional bronchoscopic methods are the most effective procedures in the diagnosis and treatment of bronchial lesions with a high success rate. Based on our study findings, we suggest that bronchoscopic methods should be preferred as the first-line treatment of benign and selected some malignant endobronchial lesions.

Outcomes of Airway Stents in the Palliative Care of Patients With Cancer

INTRODUCTION

A significant proportion of patients with advanced primary or metastatic intrathoracic malignancy will eventually develop central airway obstruction. The morbidity associated with malignant airway obstruction (MAO) is considerable and the management is difficult. Our aim was to evaluate the outcomes of tracheobronchial stenting in patients with MAO and its role in palliative care.

MATERIAL AND METHODS

This retrospective study involved a consecutive case series of patients with advanced cancer with MAO who underwent tracheobronchial stenting between August 2014 and August 2019. The European Cooperative Oncology Group (ECOG) scale was used to evaluate patient functional status before and after tracheobronchial stenting. Univariate survival analysis included Kaplan-Meier curves with Log-Rank test, while Cox regression was used as a multivariate analysis.

RESULTS

We included 28 patients with median age of 55.0 years (interquartile range = 49.3-66.5) and 89.3% male. The most frequent primary tumour was the esophagus followed by lungs. The majority of the patients (75%) expressed immediate symptom relief after stenting and there was a significant improvement in the mean ECOG performance status (PS; P = .005). There was no intraprocedure mortality and complications were observed in 6 patients. The median survival after airway stenting was 39.0 days (95% CI = 32.2-45.8) with poorer PS after stent insertion associated with lower overall survival (hazard ratio = 2.3 [95% CI = 1.1-4.9], P = .030) on multivariate analysis.

CONCLUSION

Airway stent is a safe and effective procedure that offers rapid palliation of symptoms with no major complications. Therefore, stent placement should be considered as part of the treatment of patients with terminal cancer.

A small bifurcated self-expanding metallic stent for malignant bronchial fistula or severe stenosis around the upper left carina

Background

Bifurcated self-expanding metallic stents have mainly been primarily used for the treatment of airway disease around the main carina, but few studies have reported the use of small bifurcated stents to treat malignant bronchial fistula or severe stenosis around the upper left carina.

Purpose

We aimed to determine the safety, feasibility, and efficacy of small metallic bifurcated stent placement in the upper left carina.

Material and Methods

Twenty-two patients with malignant bronchial disease were treated with small bifurcated stents. All bifurcated stents were custom-designed according to the measurement of CT measurements and placed under local anesthesia with fluoroscopic guidance. Clinical outcomes and CT imaging data were retrospectively analyzed.

Results

A total of 27 stents were used in 22 patients, with two stents removed immediately after placement due to stent insufficient dilation and failure of sealing fistula. Twenty patients underwent successful treatment, with a technical success of 90.9%. Thirteen complications were found in 9 (40.9%) patients. Five patients underwent successful stent removal due to failure of sealing fistula (n = 2) or because they were effectively cured (n = 3) during the follow-up period. Ten patients died of cancer, one patient died of chronic renal failure, and one died of myocardial infarction. The one-, three-, and five-year survival rates were 48.0%, 40.0%, and 32.0%, respectively. The median survival was 12.7 months.

Conclusion

Small bifurcated self-expanding metallic stents are a safe and effective treatment option for malignant bronchial fistula or severe stenosis around the upper left carina, but complications are relatively high. Further prospective studies are needed to evaluate alternative treatment options.

Bronchoscopy-guided intervention therapy with extracorporeal membrane oxygenation support for advanced cancer metastasis to the central airway: A case report

INTRODUCTION

Dyspnea due to tracheal invasion by malignant tumors is a common oncological emergency that is difficult to manage, and a common cause of death among patients with advanced cancer. Bronchoscopy-guided intervention therapy under conventional ventilation is very risky for patients with severe central airway stenosis. Extracorporeal membrane oxygenation (ECMO) provides strong cardiopulmonary support, but is rarely used in bronchoscopy-guided interventional therapy.

PATIENT CONCERNS

The patient had advanced esophageal cancer with metastases to the trachea and left and right main bronchi. Despite several sessions of radiotherapy, chemotherapy, and bronchoscopy-guided intervention therapy, the tumor in the airway became enlarged, the lumen was severely narrow, and the patient experienced respiratory distress.

DIAGNOSIS

A thoracic computed tomography scan performed at our hospital revealed invasion of the trachea and opening of the left and right main bronchi by the esophageal cancer, blockage of the stent by the tumor, and severe luminal narrowing. An emergency bronchoscopy showed slit-like stenosis of the middle and lower part of the trachea and the left and right main bronchi, and the tumor was highly vascular.

INTERVENTIONS

To reduce the risk of major airway bleeding and asphyxia during bronchoscopy under conventional ventilation, we finally performed argon plasma coagulation with a high frequency electric knife and cryotherapy with ECMO support.

OUTCOMES

We successfully cleared the tumor tissue in the airway under ECMO support. The trachea and left and right main bronchi recovered smoothly, and the patient was soon discharged.

CONCLUSION

ECMO can meet the oxygenation needs during bronchoscopy-guided intervention therapy. For patients with severe central airway obstruction due to malignant tumors, ECMO should be considered if conventional respiratory support cannot guarantee the safety of surgery.

A quantitative evaluation of the use of medical lasers in German hospitals

The laser has become an integral part of modern medicine, procedures based on this technique have found their way into a multitude of medical disciplines. There is, however, no data available on the detailed quantitative development of laser use in the medical sector. This fact gave rise to the idea of the present study, which analyzed the raw data of the quality report of German hospitals with respect to this subject. Over the 9 years of report, a steady increase in the cumulative number of cases was evident, although not all body regions in which the medical laser is used followed this trend. The CO₂ laser was found to be the most commonly applied laser, even though a large spectrum of different laser types is used. Based on the present study, the importance of the laser for medical purposes can be confirmed.

Rigid bronchoscopic interventions for central airway obstruction - An observational study

Background

Central airway obstruction (CAO) is a significant cause of morbidity and mortality in patients with thoracic malignancies. In this prospective study, we describe the role of rigid bronchoscopy (RB) in the multimodality management of CAO.

Methods

Prospective description of different rigid bronchoscopic techniques used for CAO between July 2016 and July 2019.

Results

A total of 152 procedures (124 therapeutic/palliative and 28 diagnostics) in 111 adults and 10 pediatric patients were performed. The mean age in 111 adults (66 males) and 10 pediatric (5 males) patients were 45.4 ± 15.8 (range 16-80) and 5.4 ± 3.6 (range 1-10) years, respectively. Palliation of the airway obstruction (48.8%) and establishment of diagnosis (23.2%) were the main indications of RB in our study. Mechanical debulking in 53 (57%) and airway dilatation in 40 (43%) patients were the most utilized interventions during the palliative or therapeutic RB. There was a significant decrease in mean (modified Medical Research Council) dyspnea scale from 3.9 ± 1.0 to 1.42 ± 0.63 and increase in mean Visual Analogue Scale from 2.06 ± 0.74 to 8.7 ± 0.54 after the procedure (P < 0.0001). Additional therapy was undertaken in 38 (31.4%) of 121 patients, and surgical excision was the primary form of definitive treatment in 17 patients Moderate bleeding was encountered in 13.3% of the procedures mainly in the diagnostic RB. The mean procedure duration was 28.4 (range, 11-49) min and 13.2 (7-22) min in the adults and pediatric patients, respectively. A total of 31 patients succumbed to the illness due to the progressive nature of their disease.

Conclusions

An individualized approach to interventional procedures is safe and effective way to achieve and maintain palliation of CAO. RB with multimodality treatment achieves the goal in majority of the patients.

Bronchoscopic device closure of postoperative bronchopleural fistulae: Novel devices and innovative techniques

Background

Bronchoscopic device closure plays a significant role in the nonsurgical management of bronchopleural fistulae (BPF). Herein, we describe our 10-year experience in the management of postoperative BPF using various device closure modalities. This is the largest series of bronchoscopic device closure of BPF being reported from India.

Materials and Methods

This was a retrospective analysis of data of patients who underwent bronchoscopic device closure with various techniques for the management of postoperative BPF. In total, 11 patients (six males and five females) with a mean age (±standard deviation) of 42.72 ± 14.40 years with BPFs were treated with various bronchoscopic interventions for BPF closure. We used various devices such as endobronchial coils, occluder devices, and covered tracheobronchial self-expandable stents for BPF closure depending on the size of air leaks. We describe the various devices used, technique, and outcome of bronchoscopic management of BPF.

Results

All our patients had developed BPFs postoperatively. Pulmonary tuberculosis was the most common etiology seen in nine of our patients. All the devices were placed using a fiberoptic bronchoscope, and all patients were followed up for a minimum duration of 6 months. We successfully localized and closed BPFs in nine (81.81%) of our patients.

Conclusions

Bronchoscopic device closure can be a successful strategy to manage postoperative BPF with minimal complications.

A case of tracheal pleomorphic adenoma misdiagnosed as asthma

A 51-year-old woman had an incidental finding of a tracheal tumor during oesophagogastroduodenoscopy following the diagnosis of asthma for 2 months. A computed tomography scan revealed a 15-mm tumor in the subglottis. Endoscopic resection was performed safely, and pleomorphic adenoma was diagnosed histologically. The patient’s condition was satisfactory 30 months after the procedure. Tracheal pleomorphic adenoma is rare and may be misdiagnosed as asthma. If the tumor is large, surgery may be required; however, endoscopic polypectomy may be effective if the tumor is small. Therefore, early diagnosis of tracheal pleomorphic adenoma is important. At the first visit, the flow–volume curve suggested upper airway obstruction, which should have raised the suspicion of an upper airway obstruction. In patients with suspected asthma, early pulmonary function testing is needed to substantiate asthma diagnosis and prevent an alternative diagnosis being missed.

Clinical outcomes of metallic Y-shaped covered stents for bronchopleural fistula around upper carina after lobectomy

BACKGROUND

Few studies have reported the placement of metallic Y-shaped covered stents (Y stents) for bronchopleural fistula around the upper carina.

METHODS

Eighteen patients were treated with Y stents insertion under the guidance of fluoroscopy. All covered stents were custom-designed and inserted to fit the upper carina anatomy. Clinical data and medical imaging data were analyzed retrospectively.

RESULTS

The stents were implanted successfully for the first time in 17 patients, and one patient needed a second attempt due to stent migration during withdrawal of the guide wires. In total, 19 small Y single-plugged stents were inserted in the upper carina and 5 large Y stents additionally in the main carina. Nineteen complications were observed in 14 patients, including 4 major complications. Stents were successfully removed in 12 patients due to complications or cure efficacy, for a median duration in place of 89.5 days. One patient lost follow-up. Nine patients were cured, and three had clinical improvement. One patient died of ventricular fibrillation the second day after the procedure and 4 patients died of tumors 7.8 to 91.7 months after stent placement. The 1-, 3-, and 5-year survival rates were 87.5, 80.8 and 80.8%, respectively.

CONCLUSIONS

Metallic Y stent placement is technically feasible, effective and safe for bronchopleural fistula disease around the upper carina.

Role of bronchoscopy in management of central squamous cell lung carcinoma in situ

Squamous cell carcinoma in situ (SCIS) is the pre-invasive stage of squamous cell carcinoma. Early detection and management of SCIS can prevent further progression. Although surgery and external beam radiation therapy are treatment options for SCIS, smaller lesions can be easily managed by bronchoscopic modalities like photodynamic therapy (PDT), cryotherapy, mechanical debulking with biopsy forceps, electrocautery and argon plasma coagulation (APC). Endobronchial brachytherapy (EBBT) and lasers may be judiciously utilized in selected cases. Although, previous studies of treatment modalities may have inadvertently included cases of invasive carcinomas, the advent of new technologies like radial probe endobronchial ultrasound (RP-EBUS) and optical coherence tomography (OCT) can help accurately determine the of depth of invasion. Superficial extent can also be better demarcated with techniques like auto-fluorescence bronchoscopy and narrow band imaging (NBI). New drugs for PDT with deeper penetration and less phototoxicity are being developed. These advances hopefully will allow us to perform superior clinical trials in future and improve our understanding of diagnosis and management of SCIS.

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.

Endobronchial Ablative Therapies

Endobronchial ablative therapies, such as mechanical debulking, laser therapy, electrocautery, argon plasma coagulation, cryotherapy, brachytherapy, photodynamic therapy, microdebrider bronchoscopy, resector balloon deobstruction, and intratumoral chemotherapy, are performed through a rigid or flexible bronchoscope in palliating or curing symptomatic malignant and benign airway lesions to improve symptoms, quality of life, and survival. Technical factors together with patient- and lesion-specific features determine the therapy of choice, as each therapy is different in capacity, limitation, and complications. In this article, indications, contraindications, and complications of endobronchial ablative therapies as well as practical issues related to their rational and cost-effective use are reviewed.