Central airway obstruction (CAO) : laser, APC, stents and other techniques.

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2 Central airway obstruction (CAO) : laser, APC, stents and other techniques. Christophe Dooms, MD, PhD. Dept. of Respiratory Diseases University Hospitals Leuven Belgium

3 x Conflict of interest disclosure I have no real or perceived conflicts of interest that relate to this presentation. I have the following real or perceived conflicts of interest that relate to this presentation: Affiliation / Financial interest Grants/research support: Commercial Company Honoraria or consultation fees: Participation in a company sponsored bureau: Stock shareholder: Spouse / partner: Other support / potential conflict of interest: This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker s interests, or relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value ofthe speaker s presentation. Drug or device advertisement is forbidden.

4 Introduction AIMS Aim 1 : How to evaluate central airway obstruction. Aim 2 : Which classification is useful in daily clinical practice. Aim 3 : Central airway desobstruction techniques. Aim 4 : Outcome of bronchoscopic desobstruction : Symptom palliation. Quality of life. Survival.

5 CAO : EVALUATION. Medical history : disease stage - symptoms. Physical examination : tachypnea - fever - vena cava syndrome - performance status -. Thoracic CT scan with intravenous contrast. Pulmonary function test. Videobronchoscopy : localisation - length - degree or diameter (50%) - type of stenosis (structural/dynamic) - distal airway patency - biopsy for diagnosis - Oncological treatment plan/options ; life expectancy.

6 CAO : EVALUATION.

7 CAO : EVALUATION.

8 CAO : ETIOLOGY. Malignant : primary metastatic. Benign : papilloma, lipoma, hamartoma, leiomyoma, anastomotic connective tissue disease GPA trauma -. Stuctural : aim = re-estabilishing airway patency. Dynamic : aim = stabilising collapsing airway.

9 CAO : DESOBSTRUCTION ALGORITM. 1. Query whether symptomatic - palliation. 2. Identify type of airway stenosis. 3. Treat the intraluminal component. 4. Assess residual degree of airway stenosis. 5. Treat residual or mural component.

10 BENEFITS OF TREATING CAO. ACCP 2013 In lung cancer patients with inoperable disease and symptomatic airway obstruction, therapeutic bronchoscopy employing mechanical debridement, tumor ablation or airway stent placement is recommended for improvement in dyspnea, cough, hemoptysis and overall quality of life (Grade 1C) Techniques and technical success rates? Improvement symptoms, spirometry, QoL? Timing of airway stenting? Survival benefit related to airway stenting? Simoff M, et al. Chest 2013;143:e455S.

11 MALIGNANT CAO. Technical success rate? = re-opening airway lumen to >50% of normal = within AQuIRE registry (n=947) = 93% (range 90-98%) < patient selection & expert centers Clinical significant improvements (n=188)? < Symptoms (dyspnea) : 48% < Quality Of Life : 42% Ost et al. Chest 2015;147:

12 THERAPEUTIC BRONCHOSCOPY. Clinical improvements : prospective study with RB Spirometry Dyspnea HRQOL Improvements regardless of underlying cause of CAO RB secure airway, maximal debulking, silicone stents Mahmood et al. Respiration 2015;89:

13 TIMING OF AIRWAY STENTING. Timing of airway stenting? Saji H, et al. ICVTS 2010;11:425.

14 THERAPEUTIC BRONCHOSCOPY. Survival benefit related to therapeutic bronchoscopy? Chhajed P, et al. Chest 2006;130:1803.

15 THERAPEUTIC BRONCHOSCOPY. Survival benefit related to therapeutic bronchoscopy? Chhajed P, et al. Chest 2006;130:1803.

16 THERAPEUTIC BRONCHOSCOPY. Survival benefit related to etiology and technical succes? 40% Mahmood et al. Respiration 2015;89:

17 BENEFITS OF AIRWAY STENTING. Survival benefit in relation to MRC or PS? Razi S, et al. Ann Thorac Surg 2010;90:1088.

18 THERAPEUTIC BRONCHOSCOPY. Symptomatic airway stenosis >50%. Main goals are improvement in survival and/or QOL.? Need for stent if residual stenosis <50%.? Impact on survival and/or QOL if stent for residual stenosis <50%. RCT SPOC = Role of a Silicone Prosthesis to Prevent Airway Obstruction Recurrence in Lung Cancers Vergnon et al. ERS Congress 2013 Oral presentation.

19 MULTICENTER RCT IN MALIGNANT CAO. Eligible : inoperable NSCLC with symptomatic CAO >50% silicone stent (n= 39) FU bronchoscopy at 1 year if not performed earlier Bronchoscopic resection due to symptoms ; recurrence defined with residual stenosis <50% as restenosis >50% R no stent (n=36) FU bronchoscopy at 1 year. Stratification factors : stage (III vs IV) ; line of therapy (first vs relapse) Primary endpoint : recurrence free survival : HR 0.71 (95%CI ); P=0.17. Secondary endpoints: - median overall survival 5 months in both arms. - recurrence rate at 1 year significant higher without stent (P=0.04) - stenting maintains benefit in dyspnea (Borg, P=0.079) and QoL. Vergnon et al. ERS Congress 2013 Oral presentation.

20 TECHNIQUES FOR IMMEDIATE DESOBSTRUCTION HOT techniques : - Laser - Electrocautery - Argon Plasma Coagulation (APC) COLD techniques : - Rigid mechanical debulking - Cryotherapy - Airway stenting Which technique? - Type and nature of lesion - Location of lesion - Available equipment - Training skills operator - Specifications of techniques

21 HOT TECHNIQUES: LASER - APC - ELECTRO. Laser : Nd-YAG laser ; CO2 laser ; diode laser ; YAP laser type wavelength vaporisation coagulation Nd-YAG CO Diode YAP-Nd Non-contact method. Precautions : Fi02 <40% ; eye protection, anatomy. Thermic effect according to distance, power, duration coagulation (10-20W) carbonization (40W) - vaporization

22 HOT TECHNIQUES: LASER - APC - ELECTRO. Laser : Nd-YAG laser ; CO2 laser ; diode laser ; YAP laser Succes rate 92% in malignancy. Cavaliere S. et al. Chest 1988;94:15-21.

23 HOT TECHNIQUES: LASER - APC - ELECTRO. Argon Plasma Coagulation : - Ionized argon gas carries a high-frequency current. - Flame goes to nearest point ; non-contact mode. - Precautions : grounding pad ; FiO2 <40%. - Mode : Pulsed : Hemostasis (10-25W) - Coagulation (20-30W) Forced : Deep coagulation - Recanalization (20-50W). - Low risk of airway wall perforation ; <3-5mm.

24 HOT TECHNIQUES: LASER - APC - ELECTRO. Argon Plasma Coagulation :

25 HOT TECHNIQUES: LASER - APC - ELECTRO. Electrocautery : monopolar probe, snare, knife, forceps - Contact mode thermal ablation for conduction of electric current (neutral plate electrode). - Precautions : grounding pad ; FiO2 <40% ; pacemaker. - Coagulation at low, vaporization at high temperature - Effect < power, duration, area of contact, tissue - Success rate 90% in malignancy. Van Boxem et al. Chest 1999;116:1108. Wahidi et al. J Thorac Oncol 2011;6:1516.

26 HOT TECHNIQUES: LASER - APC - ELECTRO. Electrocautery : monopolar probe, snare, knife, forceps

27 COLD TECHNIQUES : AIRWAY STENT. synthetic polymer silicone stent polyflex stent self-expanding metal stents Ultraflex stent Aero stent, Silmet, Taewoong stent, Microtech stent, Leufen stent biodegradable-bioabsorbable stents

28 STENT TYPES : BIOMECHANICAL ASPECTS. Noppen Polyflex Dumon Microtech Alveolus Ultraflex

29 STENT TYPES : STRAIGHT SILICONE STENT. 1. De facto gold standard stent for >75% of indications. 2. Complication rate at short/long term : - 20% migration rate ; - 10% granulation tissue ; - 30% in-stent mucus plugging Freitag. Eur Respir Mon Warning for resectable benigne tracheastenosis : long term stenting can make a patient technically inoperable. 4. Removal (when complication) : feasible and safe.

30 Case : male PITS silicone stent 10 yr in loco tracheal sleeve 4cm laryngeoplasty with rib

31 TECHNIQUE SILICONE STENT PLACEMENT Measure length and guess/measure diameter Stent lader

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33 STENT TYPES : STRAIGHT SILICONE STENT. - tubular silicone stent with on-site customization tumor ingrowth at level of customization might be an issue Breen and Dutau. Respiration Breen & Dutau. 2009;77:447. Respiration 2009;77:447.

34 STENT TYPES : STRAIGHT SILICONE STENT. - tubular hourglass stent : straight silicone stent hourglass silicone stent migration rate 18.5% migration rate 0% inoperabel benigne tracheal stenosis Vergnon et al. Chest 2000;118:422.

35 STENT TYPES : STRAIGHT SEMS. 1. Uncovered nitinol SEMS : 2. Partially covered nitinol SEMS : - tubular stent : Ultraflex (Boston Scientific) nitinol covered with synthetic polymer polyurethaan + : Dumon migration curves + : no rigid intubation + with : diameter PU >18mm + : curvature airway straight but can adapt to distal 7mm end uncovered moderate radial force (pre- distal release de voorkeur dilatation)

36 STENT TYPES : STRAIGHT SEMS. Partially covered Ultraflex stent : FDA : use only after thoroughly exploring all other treatment options (surgery or silicone stent) Lund et al. On behalf of ACCP. Chest Complication rate : 45% in benign disorders : - low migration rate < embedded in mucosa ; - 33% excessive granulation tissue ; Saad et al. Chest 2003;124: % fractures : tortuous airway median 686 days ; Chung et al. JTCS 2008;136: % colonization and potential respiratory infection Agrafiotis et al. Respiration 2009;78:69.

37 STENT TYPES : STRAIGHT SEMS. 3. Fully covered SEMS : Metallic Covered Symmetric Diameters: 6 to 26 mm every 1 mm Lengths: 20 to 110 mm every 5 mm Cover: Full to -10 mm from the total length Alveolus (Aero, USA) Taewoong/Hanaro (Korea) Silmet (Novatech, France) also conical stent Leufen and Microtech also J or Y stent

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39 STENT TYPES : BIFURCATED STENTS.

40 STENT TYPES : BIFURCATED STENTS. 1. Silicone Y -stent : Dumon ; Hood ; Dynamic size Dumon : ; ; mm. 2. Silicone Oki stent size Oki : mm

41 STENT TYPES : BIFURCATED STENTS. 1. Silicone stent - Indications Y-stent * compression tracheobronchial corner * exophytic tumour growth main carina * stenosis main bronchus + trachea

42 STENT TYPES : BIFURCATED STENTS. 1. Silicone stent - Indications Y-stent * compression tracheobronchial corner * exophytic tumour growth main carina * stenosis main bronchus + trachea courtsey of H. Dutau

43 STENT TYPES : BIFURCATED STENTS. 1. Fully covered nitinol Y-stent : Microtech stent.

44 STENT TYPES : BIFURCATED STENTS. 2. Fully covered nitinol conical Silmet or Leufen J-stent : stent oversizing to prevent air leaking Dutau et al. EJCTS 2011;39:185.

45 Dooms et al. J Thorac Oncol 2016;11:268. STENT TYPES : BIFURCATED STENTS. 2. Fully covered nitinol conical Silmet or Leufen J-stent : alternative solution for large BPF :

46 Stent types : biodegradable stents. 1.Polydioxanone (PDS) stent : synthetic polymer 2.Poly-L-lactide-co-caprolactone (Gorinchem, Nl) + drug release e.g. Mitomycine C Biomechanical expansion 6 weeks Degradation 3 months Lischke et al. EJCTS 2011;40:619. Zhu et al. Laryngoscope 2011;121.

47 Conclusions CAO. Symptomatic patients most often immediate effect required. Bronchoscopic techniques are part of a multidisciplinary approach and adjunct to further treatment strategy. Aim = impact on dyspnea, QOL and survival. Hot technique and/or cold technique Selection of intervention based on - type of lesion : benign/maligneant straight/curve - localisation of lesion : T/B/TB - physical characteristics of coagulation technique +/- stent - short/long term complications of thermotechnique +/- stent Stents = good but not yet good enough - biofilm mucus stasis - benign = temporary : removable (biodegradable??)