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Ann Thorac Surg 1999;67:1448-1450
© 1999 The Society of Thoracic Surgeons

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Original Articles

Temporary tracheobronchial stenting in malignant lymphoma

^a Division of Pneumology, Department of Internal Medicine I, Medical School Charité, Humboldt University, Berlin, Germany
^b Division of Oncology/Hematology, Department of Internal Medicine II, Medical School Charité, Humboldt University, Berlin, Germany

Accepted for publication November 16, 1998.

Address reprint requests to Dr Witt, Division of Pneumology, Department of Internal Medicine I, Medical School Charité, Humboldt University, Schumannstr 20/21, D-10117 Berlin, Germany

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Temporary stenting is a new strategy in the treatment of malignant airway stenoses. Patients receive stents as primary palliation followed by tumor-specific therapy in order to reduce the stenosis and subsequently remove the stent.

Methods. We investigated this strategy of temporary airway stenting in 5 consecutive patients with malignant lymphoma (Non-Hodgkin’s lymphoma, n = 3; Hodgkin’s lymphoma, n = 2) who presented with severe dyspnoea. Nine stents (six Strecker, three Dumon stents) were implanted into the trachea or main bronchi. After stenting, patients underwent tumor-specific therapy (chemotherapy, n = 4; percutaneous radiotherapy, n = 1).

Results. Clinical improvement of dyspnoea and stridor was observed in each patient after stent implantation. In 4 patients (80%), stents could easily be removed after successful tumor-specific therapy, which led to reduction of stenosis after a mean interval of 26 days (14 to 52 days). One patient died during chemotherapy 6 days after stenting.

Conclusions. The results show that temporary stenting is a valuable strategy in chemo- and radiosensitive malignancies, as it ameliorates the patients’ respiratory condition until tumor-specific therapy is effective, and prevents poststenotic complications. It integrates stent implantation in a multi-therapy concept.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Bulky mediastinal manifestation of malignant lymphoma can be complicated by airway stenoses. The imminent respiratory failure due to compression or infiltration of central airways represents a respiratory emergency and indicates bronchoscopic stent implantation [1].

Temporary stenting combines stent implantation as primary palliation followed by tumor-specific therapy in order to reduce the stenosis and subsequently remove the stent. The intention is to bridge the respiratory emergency situation and to improve patients’ condition. This new strategy has been successfully used in bronchial carcinoma [1].

The aim of this clinical study was to evaluate the efficacy of this therapeutic strategy in the treatment of tracheobronchial stenoses due to malignant lymphoma.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Five consecutive patients with malignant lymphoma between 16 and 64 years of age (mean age 37 years) were included in this study (Table 1). All patients presented with severe dyspnoea and danger of asphyxia due to external compression of central airways by a mediastinal tumor in the upper or middle anterior mediastinum (Figs 1A, 1B). Histologic diagnosis was established before stenting. 3 patients had a high-grade Non-Hodgkin’s lymphoma and two had Hodgkin’s disease diagnosed.

View larger version (63K): [in this window] [in a new window]   Fig 1. (A) Bronchoscopy before therapy (patient no. 4). Subtotal stenosis of the carina and main bronchi. (B) Computed tomographic scan before therapy (patient no. 4).

Recanalization results were verified bronchoscopically immediately after stenting. Follow-up controls were routinely performed every week or when indicated. Removal of stents was done with simple bronchoscopic forceps once the stent had loosened.

Lymphoma-specific therapy was initiated immediately after stenting. Three patients received external beam irradiation with 3 x 3 Gy, together with steroids, and thereafter were started on a polychemotherapeutic regimen comprising CHOEP (cyclophosphamide, vincristine, doxorubicin, etoposide, prednisolone), COPP-ABVD (cyclophosphamide, vincristine, procarbazine, prednisone-doxorubicin, bleomycin, vinblastine, decarbazine), or the German B-ALL protocol. The 2 other patients were treated with chemotherapy from the onset, 1 with BEACOPP (bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procarbazine, prednisone) according to the German Hodgkin’s Study Group, and the other with CHOP (cyclophosphamide, hydroxydaunomycin, vincristine, prednisone).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Clinical improvement of the dyspnoea was noticed in every case immediately after stent implantation, and the respiratory situation (dyspnoea score, blood gases, lung function) normalized within a few days. This was verified as a rapid shrinking of the mediastinal tumor on roentgenogram or computed tomographic scan of the chest within several days. One patient died due to a major pulmonary embolus while he was mechanicallly ventilated 7 days after stenting (patient no. 5). Bronchoscopic controls at weekly intervals or when indicated clinically revealed correct position of all stents (Figs 2A, 2B). The bridging of the period of respiratory emergency was successful in all patients. Toleration of lymphoma-specific therapy was improved, and the danger of asphyxia reduced.

View larger version (71K): [in this window] [in a new window]   Fig 2. (A) Bronchoscopy 6 weeks after initiation of lymphoma therapy (patient no. 4). Dumon-Y stent in the distal trachea and both main bronchi. (B) Computed tomographic scan showing the Y stent in place (patient no. 4).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Although mediastinal manifestation is frequently encountered in Non-Hodgkin’s lymphoma and in Hodgkin’s disease, severe airway obstruction is a rare event in both diseases, affecting approximately 5% of the patients [3]. Airway stenosis in malignant mediastinal lymphoma is mainly due to extraluminal compression, which makes stenting the treatment of choice. Stenting leads to immediate recanalization of the bronchial system and reduces the risk of pneumonia. The improvement of the respiratory condition has been verified in previous experimental and clinical investigations [4–6].

Until recently, bronchoscopic stenting has been used in advanced cancer patients when there was no other therapeutic option available. Temporary stenting combines stent implantation and subsequent tumor-specific therapies. After stent placement and restoration of the airways, tumor-specific therapy can be initiated under improved respiratory conditions. In 4 of the 5 patients reported, stents could be removed after reduction of the stenosis.

The choice of the stent depends on the site and length of the stenosis, the prognosis of the patient, and on poststenting therapy. When stents are used temporarily, their removability is decisive and has been demonstrated in previous studies for Dumon and Strecker stents [1]. We used the larger Dumon stents for tracheal stenoses. In main bronchus stenoses, we preferred the Strecker device, which allows for an easy implantation even under complicated anatomic conditions. Its major disadvantage, the penetration of tumor tissue through the meshes, does not appear to be of clinical significance in lymphoma when stenting is combined with tumor-specific therapy, and did not occur in any of our patients.

Due to shrinkage of the chemo- and radiosensitive lymphoma, reduction of the stenosis occurs and stent removal is possible. Regular bronchoscopic controls (once weekly) are needed to control the degree of stenosis and the position of the implanted stent.

The results of this study suggest that temporary stenting is especially effective in malignant lymphoma due to the available therapeutic options. We therefore consider temporary stenting as an integral part of the management of patients with symptomatic airway stenoses due to malignant lymphoma.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Witt C., Dinges S., Schmidt B., Ewert R., Budach V., Baumann G. Temporary tracheobronchial stenting in malignant stenoses. Eur J Cancer 1997;33:204-208.
2. Bolliger C.T., Probst R., Tschopp K., Solèr M., Perruchoud A.P. Silicone stents in the management of inoperable tracheobronchial stenoses: indications and limitations. Chest 1993;704:1653-1659.
3. Filly R., Blank N., Castellino R.A. Radiographic distribution of intrathoracic disease in previously untreated patients with Hodgkin’s disease and non-Hodgkin’s lymphoma. Radiology 1976;120:277-281.[Abstract]
4. Marquette C.H., Mensier M.C., Copin C., et al. Experimental models of tracheobronchial stenoses: a useful tool for evaluating airway stents. Ann Thorac Surg 1995;60:651-656.[Abstract/Free Full Text]
5. Gelb A.F., Zamel N., Colchen A., Tashkin D.P., Maurer J.R., Patterson G.A., Epstein J.D. Physiologic studies of tracheobronchial stents in airway obstruction. Am Rev Respir Dis 1992;146:1088-1090.[Medline]
6. Vergnon J.M., Costes F., Bayon M.C., Emonot A. Efficacy of tracheal and bronchial stent placement on respiratory functional tests. Chest 1995;107:741-746.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schmidt, B. Articles by Witt, C. Search for Related Content PubMed PubMed Citation Articles by Schmidt, B. Articles by Witt, C.