Pilot Study of External Beam Radiotherapy for Recurrent Unremitting Tracheal Stenosis.

OBJECTIVE: Tracheal stenosis can have a variety of presentations, severities, causes, and be a difficult condition to treat. Some patients demonstrate recurrent stenosis after multiple endoscopic treatments and are either poor candidates for open procedures or do not desire open surgery. We sought to evaluate low-dose postoperative external beam radiotherapy (EBRT) as a novel therapy for patients with recurrent tracheal stenosis refractory to endoscopic therapies. METHOD: We performed a retrospective review of patients with recurrent tracheal stenosis who underwent EBRT in addition to endoscopic dilation. We compared the number of endoscopic procedures required in the 6 months before EBRT to the number required in the 6 months after EBRT. RESULTS: Six patients met criteria for inclusion in our study. The cause of stenosis was variable among the study population. In the 6 months leading up to EBRT, patients underwent an average 6.2 endoscopic procedures. This dropped to an average 1.9 procedures in the 6 months following EBRT (P < .001). CONCLUSION: Herein, we show that low-dose postoperative external beam radiotherapy (EBRT), a novel therapy for patients with recurrent tracheal stenosis refractory to endoscopic therapies, is effective in decreasing the frequency of endoscopic dilations. LEVEL OF EVIDENCE: 4.

[The clinicopathological features and curative effect of the bronchoscopic interventional therapy combined with radiotherapy for the treatment of locally recurrent lung adenoid cystic carcinoma].

Objective: To explore the clinical value of endoscopic interventional therapy for locally recurrent primary lung adenoid cystic carcinoma (ACC). Methods: The clinical data of 42 patients with locally recurrent ACC were retrospectively analyzed, and the differences of tracheal and bronchial diameter, airway scoring grade and airway obstruction degree before and after treatment were compared among three treatment methods: bronchoscopic interventional therapy + palliative radiotherapy, interventional therapy alone, and non-interventional therapy. Log rank test and Cox proportional risk model multi-factor analysis were used to determine the prognostic factors of ACC patients with local recurrence, and the long-term effect of bronchoscopic interventional therapy on ACC with local recurrence was determined. Results: The median overall survival of 42 patients was 59 months and 5-year survival rate was 54.2%.Univariate analysis showed that vascularized cancer, pleural invasion, pulmonary atelectasis, incisal margin, microscopic classification, tumor diameter, initial TNM stage, ki-67 index, and treatment after local recurrence were associated with long-term survival of ACC patients with local recurrence (all P<0.05). Cox multivariate regression analysis showed that margin status (RR=0.272, P=0.011), tumor diameter (RR=2.586, P=0.005), initial TNM staging (RR=0.369, P=0.035), ki-67 index (RR=3.569, P<0.001), and treatment methods after local recurrence (RR=0.126, P<0.001) were independent factors influencing the prognosis of ACC patients with local recurrence. After three months of treatment, the tracheal bronchus diameters, rating of shortness of breath, and degree of airway obstruction were all improved significantly (all P<0.05), both in the interventional therapy + palliative radiotherapy group [(14.5±2.8 mm, 0.86±0.45, (14.50±10.67)%, respectively], and the interventional therapy alone group [(13.7±2.3) mm, 0.97±0.25, (15.38±12.02)%, respectively]. Meanwhile, the difference before and after non-interventional therapy was not statistically significant (all P>0.05). 5-year overall survival rates were 55.8%, 46.6% and 42.6% for patients undergoing interventional therapy+ palliative radiotherapy, interventional therapy alone, and non-interventional therapy after recurrence, with statistically significant differences (P=0.015). Patients underwent bronchial endoscopic interventional therapy and palliative radiotherapy had the best efficacy of treatment. Conclusion: Endoscopic interventional therapy plus palliative radiotherapy is an effective local palliative treatment for locally recurrent ACC patients, which can rapidly relieve airway stenosis, improve the quality of life of patients and prolong the survival time of patients.

A Novel Self-Expandable, Radioactive Airway Stent Loaded with 125I Seeds: A Feasibility and Safety Study in Healthy Beagle Dog.

PURPOSE: Airway stent placement is an effective treatment for the immediate palliation of malignant airway obstruction. However, restenosis caused by tumor ingrowth and/or overgrowth after stenting is common. The purpose of this study was to investigate the feasibility and safety of a novel self-expandable stent loaded with 125I seeds in healthy beagle dog. MATERIALS AND METHODS: Under fluoroscopic guidance, forty-eight self-expandable airway stents loaded with 125I seeds were perorally placed in the main trachea of 48 healthy beagle dogs, who were randomly divided into four groups (Group A: 0.3 mCi; Group B: 0.6 mCi; Group C: 0.9 mCi; Control group: 0 mCi). The estimated radiation dose was calculated using the isotropic point source approximation. Radiological follow-up examinations and histopathological examinations of stented tracheal segments and their adjacent organs and tissues were performed at 2, 4, 8, and 16 weeks following the stenting. RESULTS: All stents were successfully deployed in the targeted tracheal segment in the beagle dogs without procedure-related complications. Tracheal stenosis became severe gradually in all the four groups, which was not associated with the radioactivity of 125I seeds (p > 0.05). The tracheal injury scores increased along with the higher dose of radioactive seeds which reached peak at 8 weeks and then turned back slightly at 16 weeks. The adjacent tissue did not show pathohistological changes under microscope, while mild and reversible ultrastructure changes were showed under electronic microscope. CONCLUSIONS: This study demonstrates that it is feasible and safe to insert this novel self-expandable airway stent loaded with 125I seeds in healthy beagle dog.

Treatments for complications of tracheal sleeve resection for papillary thyroid carcinoma with tracheal invasion.

OBJECTIVE: To evaluate the treatment, prognosis, and complications of differentiated thyroid carcinoma with tracheal invasion. We report our outcomes from a single center using a tracheal sleeve resection. PATIENTS AND METHODS: Retrospective analysis of clinicopathological data on tracheal sleeve resection in patients with thyroid cancer and accompanying tracheal invasion from January 2009 to July 2012. The postoperative complications were analyzed and the literature was reviewed. RESULTS: Nineteen patients with thyroid carcinoma and accompanying tracheal invasion underwent tracheal sleeve resection followed by end-to-end anastomosis. The median survival time was 22 months. Five patients (5/19) developed postoperative complications. The major complications included bilateral recurrent laryngeal nerve paralysis (2 cases), tracheal anastomotic stenosis (1 case), esophageal fistula (2 cases), and anastomotic dehiscence (2 cases). The treatment for these complications included partial posterior cordectomy by CO2 laser for bilateral recurrent laryngeal nerve paralysis; CO2 laser treatment followed by postoperative external beam radiotherapy (EBRT) (20 Gy/10 times) for tracheal anastomotic stenosis, femoral anterior dissociative flap to repair esophageal fistula, and a T-tube positioned in the wound in cases of anastomotic dehiscence. CONCLUSIONS: Tracheal sleeve resection remain a safe option with less morbidity and perioperative complications for the management of patients with differentiated thyroid carcinoma accompanied by intratracheal invasion.

[Improved results of the trachea scar stenosis treatment by inclusion in the complex therapy of combined application diprospan and low-intensity infrared laser radiation].

The experience of treating 61 patients over the rumen of stenosis of the trachea was summarizes. To improve the results suggested inclusion complex diprospan treatment in combination with low intensity infrared laser radiation. The advantages of the proposed method of treatment of tracheal stenosis scarring are reduced severity of chronic inflammation, reducing the proliferation of granulation tissue.

Palliative radiotherapy for patients with tracheobronchial and esophageal compression due to intrathoracic malignant tumors.

AIMS: To evaluate palliative outcomes of patients with extrinsic malignant tracheobronchial or esophageal stenosis treated with radiation. Mediastinal or hilar lymphadenopathy surrounding the tracheobronchi or esophagus may cause compression, presenting as dyspnea and dysphagia respectively. Treatment is important for symptom relief and maintaining patients' quality of life. METHODS: Dyspnea and dysphagia were assessed using the Hugh-Jones score and a modified dysphagia scale, respectively. A total of 13 patients (median age, 60 years) with dyspnea received palliative radiotherapy. The primary organs were lung (n = 6), colorectum (n = 5), hypopharynx (n = 1) and uterine cervix (n = 1). Three patients received concurrent chemotherapy. The median time-adjusted biological effective dose (BED) was 33.0 Gy(10) . Ten patients (median age, 61) with dysphagia received palliative radiotherapy. The primary organs were lung (n = 7), esophagus (n = 2) and hypopharynx (n = 1). Three patients received concurrent chemotherapy. The median time-adjusted BED was 32.1 Gy(10) . RESULTS: Palliation of dyspnea and dysphagia occurred in seven (54%) and five (50%) patients, respectively. Patients treated with doses over 35 Gy(10) had greater score improvements than those treated with less than 35 Gy(10) in both groups. Patients who received concurrent chemoradiotherapy had greater score improvements than those treated with radiotherapy alone. Dyspnea patients with pretreatment scores of 2 (n = 5) had greater score improvements than those with scores of 3 or more (n = 8). CONCLUSION: External beam radiotherapy should be considered for patients with tracheobronchial or esophageal stenosis before their symptoms worsen. The prescription dose should be over 35 Gy(10) .

[Stenting and radiotherapy for malignant tracheal stenosis due to mediastinal lymph node recurrence from gastric cancer--a case report].

The case is a 74-year-old woman,who underwent curative resection six years earlier for stomach cancer in the cardia extending to the esophagus (Stage IIIA). She noticed hoarseness and cough in September 2004, and CT revealed lymph node metastasis of the cancer in the upper mediastinum. The tumor pressured the SVC, the esophagus,and especially the trachea that narrowed up to a diameter of 5 mm. To secure the air way, first, a self-expandable metallic stent was placed in the narrowed trachea under general anesthesia. Irradiation to the upper mediastinal tumor was further applied for a total of 46 Gy from October to November, 2004. Symptom relief was obtained over the course by a marked reduction in the size of the metastatic tumor, and the disease remained stable for 5 months. In general,a stomach cancer that is mostly adenocarcinoma has been recognized to have low receptivity for radiotherapy. Nevertheless,this case suggests that radiotherapy can play an important role in local control and symptom relief for symptomatic stomach cancer patients.

Short-course palliative radiotherapy for airway stenosis in non-small cell lung cancer.

BACKGROUND: The majority of patients with non-small cell lung cancer have inoperable disease that is already too advanced for radical treatment at the initial diagnosis. But patients who suffer from symptoms caused by intrathoracic tumor often require palliative treatment to relieve the symptoms. We investigated, retrospectively, the outcome of short-course palliative radiotherapy for airway stenosis in non-small cell lung cancer. METHODS: Between October 1997 and June 2001, 24 patients were treated by palliative radiotherapy to relieve airway stenosis caused by intrathoracic tumor. The short-course radiotherapy consisted of a total dose of 30 Gy given in ten fractions over 2 weeks. The effect of treatment was assessed by improvement of radiographic findings. The duration of palliation and this duration as a percentage of the remaining survival time were also investigated. RESULTS: Palliation of airway stenosis was achieved in 13 (54.2%) patients. The time until palliation was achieved ranged from 11 to 44 days (median, 24 days). The duration of palliation ranged from 44 to 351 days (median, 116 days). In the palliated patients, the median survival time was 192 days, while that of the non-responders was 43 days. The duration of palliation as a percentage of the remaining lifetime ranged from 41% to 96% (median, 66%). CONCLUSIONS: Short-course palliative radiotherapy of 30 Gy in ten fractions over 2 weeks achieved good palliation without severe acute toxicities in over half of the patients. It is suggested that, in the palliated patient, the airway can be, potentially, maintained over the long term.

Subglottic stenosis secondary to extramedullary hematopoiesis in a patient with postpolycythemia myeloid metaplasia.

BACKGROUND: Extramedullary hematopoiesis (EMH) is known to occur in myeloproliferative disorders and hemoglobinopathies and is usually seen in the spleen and liver. METHODS: We report the first case of EMH causing subglottic stenosis in a woman with postpolycythemia myeloid metaplasia (PPMM). A tracheotomy was performed to maintain the airway and local radiotherapy was given. RESULTS: Two months after the radiotherapy was completed laryngoscopy showed an unobstructed airway with no evidence of disease, and the patient was successfully decanulated. Magnetic resonance imaging 8 months after radiotherapy confirmed the absence of local disease. CONCLUSION: Consideration should be given to EMH as a possible cause of airway obstruction in the differential diagnosis of a patient with a history of PPMM.

Subglottic stenosis in an HIV positive patient: an exceptional form of clinical presentation in Kaposi's sarcoma.

The case of a 29-year-old HIV positive male patient suffering from a Kaposi's sarcoma exclusively located in the proximal third of the trachea and subglottic region is presented. The patient was found to have included an obstruction of the upper airway. A characteristic endoscopic appearance led to the final diagnosis. A combined treatment with Nd-YAG laser endoscopic resection and laringotracheal irradiation was performed. Pathological examination confirmed Kaposi's sarcoma.

Intraoperative radiation therapy, endotracheal hyperthermia and IR-192-brachytherapy in patients with advanced thyroid cancer.

Tracheal stenosis due to infiltrative nonresectable thyroid cancer causes severe reduction in life quality. Palliative therapy, apart from tracheostomy is--up to now--intraluminal and/or external radiation. Good tumor control is achieved by local hyperthermia. A combined modality treatment (CMT) consisting of surgery, brachytherapy and intraoperative radiation, eventually combined with intraluminal NdYg-Laser-desobliteration was performed. An intraoperative radiation therapy (IORT)-protocol was designed for poorly differentiated non-anaplastic thyroid carcinoma. Out of 155 cases of differentiated thyroid tumors, 12 showed marked vascular and/or capsular invasion. Five entered the study (3 primarily local invasive tumors, 2 local recurring). IORT was administered after tumor surgery (4-10 Gy) and combined with postoperative percutaneous irradiation. The tumor control rate in the thyroid bed is 5/5, 1/5 developed mediastinal nodes, 1/5 with primary mediastinal tumor extend shows tumor progression. No specific complications occurred.

Tracheal sleeve resection for iatrogenic stenoses (subglottic laryngeal and tracheal).

Since 1975 200 tracheal sleeve resections for iatrogenic tracheal and subglottic laryngeal stenoses have been performed in our institution. Preoperative Nd:YAG laser is of paramount help in opening the stenoses. Tracheography is usually performed to specify the length of the stenosis and the distance from the vocal cords. Operative procedures are described. One hundred seventy five (87.5%) patients are definitely cured, but in this group 16 patients required a Montgomery tube for 6 months to 1 year to recover a normal tracheal diameter. Two patients needed a second tracheal sleeve resection. Nine (4.5%) patients died, and 16 (8%) had recurrent stenoses. Stenoses in these patients were treated with use of a tracheostomy tube, a permanent Montgomery tube, or an endotracheal stent. Partial anterior cricoid resections performed in 21 patients have had the same results as those of the whole series. Twenty one laryngeal releases were performed and proved to be efficient and safe. In our experience complications can be avoided by good selection and preparation of the patients, accurate identification of the level and length of the stenosis, and meticulous technique.

Side effects of endobronchial laser treatment.

Side effects that have occurred in over 250 endobronchial laser treatments are reported. The laser has been used in severe tracheal and in bronchial obstructions. In two cases significant bleeding had to be treated with tamponade. In one patient an emphysema of the mediastinum developed, in 2 further patients a small pneumothorax. Perforation of the airway was not detected and no special treatment was necessary. Three patients with life-threatening tracheal stenoses and one patient with severe stenosis of both the mainstem bronchi due to metastasis in the bifurcation lymph node had a large defect in the tracheal or bronchial wall with a deep necrosis five to twelve weeks after laser treatment; all these patients had extensive radiotherapy in addition. One patient died due to severe respiratory insufficiency, probably caused by smoke intoxication. After the laser treatment, rubber-like fibrin-rich plaques may develop, which can lead to life-threatening obstructions of the airway. It is recommended that laser bronchoscopy should be performed with the rigid bronchoscope. After treatment of tracheal lesion an endoscopic check must be performed within 24 hours. The combination of laser treatment and radiotherapy seems to involve a certain risk of large defects in the bronchial wall due to necrosis of the tumour.