AIRWAY SIMULATION TO GUIDE STENT PLACEMENT FOR TRACHEOBRONCHIAL OBSTRUCTION IN LUNG-CANCER

Background. To effectively palliate large airway obstruction in advanc ed unresectable lung cancer (stage IIIB or IV), we developed an airway imaging technique to guide selective endobronchial metallic stent pla cement. Methods. Fourteen consecutive patients with severe dyspnea (Am erican Thoracic Society grade 4) had a combination of fiberoptic bronc hoscopy, chest roentgenography, computed tomographic scanning, helical computed tomography with three-dimensional reconstruction, and intral uminal bronchography with selective bronchial guidewire placement unde r fluoroscopy to visually reconstruct and simulate the abnormal airway before and during stent placement. Wallstent or Gianturco intralumina l stents were used alone or in combination (up to five stents) to esta blish patency of the distal trachea and the major bronchi. Results. Al l 14 patients had successful deployment with initial relief of airway stenosis (>75% predicted diameter). No procedural complications were n oted. However, technical problems included stent foreshortening and im precision of placement, misinterpretation of bronchography (mucous ver sus tumor), and airway maintenance during manipulation. Length of stay attributable to the procedure averaged 4 days. Stent placement initia lly improved the dyspnea score in 7 of 14 patients. Five of 14 died in less than 1 month, with the remainder alive at up to 8 months' follow -up. Of those surviving more than 1 month, the Karnofsky score improve d in 4 and was unchanged in 5, with 2 dependent (Karnofsky score <50), 3 functional (Karnofsky score, 50 to 70), and 4 active (Karnofsky sco re >70). Conclusions. A protocol combining helical computed tomography with three-dimensional reconstruction, bronchography, and bronchoscop y allows accurate assessment of malignant airway obstruction to facili tate intralumenal stent placement for relief of stenosis. Patient sele ction to favor effective palliation and cost effectiveness has yet to be defined. (C) 1997 by The Society of Thoracic Surgeons.