DOI:10.2214/AJR.08.2037
AJR 2009; 193:W38-W42
© American Roentgen Ray Society
Palliative Treatment of Inoperable Malignant Tracheobronchial Obstruction: Temporary Stenting Combined With Radiation Therapy and/or Chemotherapy
Jin Hyoung Kim1,
Ji Hoon Shin1,
Ho-Young Song1,
Joon-Young Ohm1,
Jae Moung Lee1,
Dae Ho Lee2 and
Sang-We Kim2
1 Department of Radiology and Research Institute of Radiology, Asan Medical
Center, University of Ulsan College of Medicine, Poongnap-2dong, Songpa-gu,
Seoul 138-736, Korea.
2 Department of Internal Medicine, Asan Medical Center, University of Ulsan
College of Medicine, Seoul, Korea.
Received November 1, 2008;
accepted after revision December 19, 2008.
Address correspondence to J. H. Shin
(jhshin{at}amc.seoul.kr).
WEB This is a Web exclusive article.
Abstract
OBJECTIVE. The purpose of our study was to evaluate the clinical
results of temporary stenting followed by radiation and/or chemotherapy in
patients with inoperable malignant tracheobronchial strictures.
CONCLUSION. Temporary stenting combined with radiation therapy
and/or chemotherapy may be clinically effective in the palliative treatment of
patients with malignant tracheobronchial strictures. Stent placement may serve
as an effective bridge to radiation and/or chemotherapy, allowing the latter
to consolidate durable relief of obstructing symptoms by reducing tumor
burden. Furthermore, our treatment strategy may increase patients' quality of
life by reducing stent-related complications.
Keywords: chemotherapy • malignant tracheobronchial stricture • radiation therapy • stent placement
Introduction
Malignant tracheobronchial obstruction can result in dyspnea,
respiratory distress, obstructive pneumonia, and even early death by
suffocation
[1-3].
Although external-beam radiation has been the method of choice for the
palliative treatment of inoperable malignant tracheobronchial obstructions,
radiation effects were often delayed and unpredictable
[4]. Placement of metallic
stents has been increasingly used for the palliative treatment of patients
with inoperable malignant tracheobronchial obstructions
[5,
6]. Factors favoring the use of
metallic stents include dramatic relief of dyspnea, effectiveness for both
intrinsic and extrinsic obstructions, improved performance, and better quality
of life [2].
Metallic stent placement for malignant tracheobronchial strictures has
several potential disadvantages, however, including stent migration, tumor
ingrowth or overgrowth, formation of granulation tissue, mucus retention,
infection, and hemorrhage [7].
The incidence of these complications may be associated with the duration of
stent placement. Moreover, these complications may impair the quality of life
in patients who undergo permanent metallic stent placement.
In recent years, the design of tracheobronchial stents has improved
substantially. In particular, retrievable metallic stents have been used
safely and effectively in the treatment of benign or malignant
tracheobronchial strictures. Retrievable stents can be removed easily when
they are no longer needed, for example, after underlying strictures have
healed or when stent-related complications occur
[2,
8,
9]. Temporary stenting followed
by reduction of tumor burden using radiation and/or chemotherapy has been
shown to be effective in the palliative treatment of patients with malignant
esophageal strictures [10,
11]. We therefore hypothesized
that rapid relief of airway obstruction by temporary stenting with subsequent
reduction of tumor burden by radiation and/or chemotherapy might be a safe and
effective therapeutic strategy in the palliative treatment of patients with
malignant tracheobronchial strictures. The aim of this preliminary prospective
study is to report the clinical results of this treatment strategy in six
patients with inoperable malignant tracheobronchial strictures.
Subjects and Methods
Patients
Between February 2004 and April 2008, fluoroscopically guided placement of
fully covered retrievable metallic stents was performed prospectively in six
patients with inoperable malignant tracheobronchial strictures. The inclusion
criteria were documented and inoperable malignancy, as established by
histologic diagnosis of endoscopic or percutaneous biopsy samples and the TNM
staging system; intra- or extraluminal malignant lesions causing dyspnea or
respiratory failure; and ability to undergo follow-up CT including 3D imaging
to evaluate improvements in the stricture and tumor burden. Patients were
excluded if they were mildly symptomatic, so that an adult endoscope could be
passed through the stricture; had already undergone maximal radiation therapy;
were in a terminal state such that their life expectancy was less than 1
month; or were unable to participate in the follow-up regimen. Written
informed consent was obtained from each patient, and our institutional review
board approved the design of this prospective clinical trial.
Temporary Stent Placement
Polytetrafluoroethylene- or silicone-covered retrievable expandable nitinol
stents were used in all patients
[2,
12]. Tracheal stents were 18
or 20 mm in diameter and 50-60 mm in length when fully expanded, and bronchial
stents were 12 mm in diameter and 40 mm in length.
Before stent placement, the severity and length of the strictures were
evaluated by chest radiography; CT, including 3D reconstructions (Figs.
1A,
1B, and
2A); and bronchoscopy. The
pharynx and larynx were routinely anesthetized topically with an aerosol spray
followed by administration of drugs for conscious sedation and monitoring of
oxygen saturation.
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Fig. 1A —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Axial CT scan (A) and
anteroposterior view (B) of 3D surface-rendered reconstruction CT
obtained 3 days before stent placement show severe left main bronchial
stricture (arrows).
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Fig. 1B —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Axial CT scan (A) and
anteroposterior view (B) of 3D surface-rendered reconstruction CT
obtained 3 days before stent placement show severe left main bronchial
stricture (arrows).
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Fig. 2A —68-year-old man (patient 2) with tracheal stricture caused by
sarcomatoid carcinoma. Anteroposterior view of 3D surface-rendered
reconstruction CT obtained 4 days before stent placement shows severe tracheal
stricture (arrow).
|
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Under bronchoscopic guidance, a 0.035-inch exchange guidewire was inserted
across the stricture and into the distal portion of the trachea or bronchus.
To measure the length of the stricture, a straight 5-French graduated catheter
was passed over the guidewire to the distal part of the stricture
(Fig. 1C). The 0.035-inch
exchange guidewire was then changed to a super-stiff J-tip guidewire. Stents
were inserted over the stiff wire under fluoroscopic guidance
(Fig. 1D).
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Fig. 1C —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Radiograph shows sizing
catheter (arrowhead) passed over guidewire to measure length of
stricture (3.3 cm).
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Fig. 1D —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Radiograph shows retrievable
covered stent 12 mm in diameter and 4 cm in length placed at stricture.
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Stent placement was followed by scheduled radiation therapy and/or
chemotherapy. After completion of therapy, the stent was removed under
fluoroscopic guidance using a retrieval hook
[13]. When the hook captured
and pulled the drawstring of the proximal end of the stent into a sheath, the
proximal end collapsed and the stent could be removed (Figs.
1E,
1F, and
1G).
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Fig. 1E —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Radiograph shows stent removal
after completion of radiation therapy and chemotherapy. Sheath
(arrow) with dilator was placed face-down over guidewire into
proximal stent lumen, and dilator was replaced with hookwire
(arrowhead).
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Fig. 1F —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Radiograph shows collapse of
proximal end of stent while hookwire was withdrawn into sheath.
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Radiation Therapy and/or Chemotherapy
The target volume for radiation therapy was defined as the tumor volume,
and all patients received a total dose of 5,580-6,600 cGy (over schedules of
5-7 weeks). In four of the six patients, chemotherapy, including cisplatin and
paclitaxel, was administered during the period of radiation therapy.
Follow-Up
Bronchoscopy was performed immediately after stent placement in all
patients to evaluate the position and expansion status of the stent. All
patients underwent chest radiography and clinical examination 1-3 days after
stent placement to evaluate the status of the stent and respiratory function.
Radiation therapy and/or chemotherapy commenced after stent placement.
The Hugh-Jones classification was used in all patients to evaluate
improvement in respiratory function before and 1-7 days after stent removal.
This classification is a 5-grade system used to assess breathlessness during
daily activities, with grade 5 indicating the most severe form of dyspnea
[8]. Follow-up CT including 3D
imaging was performed 1-2 months after stent removal to evaluate improvements
in the stricture. Examinations were also performed 1 month and then every 3
months after stent removal. When it was not possible to perform a clinical
examination, the patient or a family member was contacted by telephone every 3
months for as long as the patient remained alive to obtain information
concerning respiratory status.
Results
Patient characteristics and clinical outcomes are summarized in
Table 1. Before stent
placement, four patients showed dyspnea, cough, and noisy respiration, and two
patients (patients 3 and 6) underwent intubation because of acute respiratory
failure.
Stent placement was technically successful in all six patients, without
immediate complications. After stent placement, four patients showed rapid
relief of dyspnea. Two patients were extubated after respiratory function was
restored. One patient (patient 5) showed a recurrence of dyspnea and increased
sputum 2 days after tracheal stent placement because of a partial downward
migration of the stent. This stent (6 cm in length) was successfully removed
using the retrieval hook under fluoroscopic guidance and a second, longer (9
cm) stent was inserted.
All patients underwent scheduled radiation therapy and/or chemotherapy
beginning 7-19 days (median, 10 days) after stent placement. After treatment,
one patient (patient 2) showed increased cough and yellowish sputum because of
radiation pneumonitis; this patient's symptoms improved with medical
treatment. After completion of scheduled radiation and/or chemotherapy, stents
were successfully removed from all patients under fluoroscopic guidance. The
duration of stent placement ranged from 43 to 97 days (median, 64 days). In
one patient (patient 2), bronchoscopy showed a small ulcer in the stented area
caused by mucosal tearing during stent removal; this ulcer, however, healed
after conservative management. All patients show ed improvement of at least
one grade on the Hugh-Jones classification scale after stent removal
(Table 1). In all patients,
follow-up CT, including 3D imaging 1-2 months after stent removal, showed
marked improvement of all strictures (Figs.
1H,
1I, and
2B).
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Fig. 1H —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Axial CT scan (H) and
anteroposterior view (I) of 3D surface-rendered reconstruction CT
obtained 1 month after stent removal show marked improvement of stricture
(arrows).
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Fig. 1I —67-year-old man (patient 1) with left main bronchial
stricture caused by non-small-cell lung cancer. Axial CT scan (H) and
anteroposterior view (I) of 3D surface-rendered reconstruction CT
obtained 1 month after stent removal show marked improvement of stricture
(arrows).
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Fig. 2B —68-year-old man (patient 2) with tracheal stricture caused by
sarcomatoid carcinoma. Anteroposterior view of 3D surface-rendered
reconstruction CT obtained 2 months after stent removal shows marked
improvement of stricture (arrow).
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During the follow-up period of 4-54 months (median, 8 months), none of the
patients experienced recurrent dyspnea. Two patients died 7 and 9 months after
stent placement because of disease progression. At the last follow-up, the
remaining four patients were still alive.
Discussion
Intrinsic or extrinsic obstructions of the trachea or bronchi by malignant
tumors are often inoperable because of delayed diagnosis or a coexistent
disease that contraindicates surgery
[6]. Metallic stent placement
has been shown to be an effective palliative therapy in patients with
inoperable malignant central airway obstructions. In previous studies
reporting clinical outcomes of metallic stenting in 16-54 patients with
malignant central airway obstructions, the placement of such stents was
technically successful in all patients (100%), and airway obstruction symptoms
were relieved in 72-92% [6,
8,
14]. Complications related to
stent placement often occur, and these events may affect a patient's quality
of life. For example, recurrent dyspnea after stent placement may occur
because of tumor ingrowth or overgrowth, granulation tissue formation, or
stent migration. Furthermore, severe complications, including infection or
hemoptysis caused by stent placement, may reduce a patient's survival period.
For example, the survival periods of patients who died of pneumonia or
hemoptysis were significantly shorter than those of patients who died of
disease progression after stent placement (4.47 vs 13.94 weeks, p
< 0.01) [8]. Therefore,
eliminating potential stent-related complications may improve a patient's
quality of life and period of survival.
Our preliminary results showed that temporary stenting combined with
radiation therapy and/or chemotherapy was clinically effective in the
palliative treatment of patients with malignant central airway obstructions.
As expected, stent placement successfully served as an effective bridge to
radiation therapy and/or chemotherapy, consolidating durable relief of
obstructing symptoms by reducing tumor burden. In addition, airway stents may
prevent edema-induced airway obstructions during radiation therapy. We
observed improvements in central airway obstruction and no recurrence of
obstructing symptoms during follow-up or after the completion of combination
therapy.
A new therapeutic strategy for the palliative treatment of patients with
unresectable esophageal carcinoma consists of temporary stenting (for 4 weeks)
with concurrent radiation therapy
[10]. A retrospective
comparison of the results of temporary (n = 24) and permanent
(n = 23) stent placement with concurrent radiation found that
temporary stent placement delayed stent-related complications and reduced
overall complication rates and resultant interventional rates compared with
permanent stent placement. Furthermore, symptom-free and overall survival
periods were significantly longer in the temporary stent group because of
reductions in rates of stent-related complications and related dysphagia.
Temporary stenting with concurrent radiation therapy and/or chemotherapy may
have greater potential for improving a patient's quality of life and survival
period than that offered by permanent stent placement in the palliative
treatment of inoperable malignant tracheobronchial strictures. A prospective
randomized comparative trial in a large patient sample is required to draw
definitive conclusions.
In conclusion, temporary stenting combined with radiation therapy and/or
chemotherapy seems to be effective in the palliative treatment of patients
with malignant tracheobronchial strictures.
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Abstract
Introduction
