Treatment of Malignant Tracheoesophageal Fistula

Ramucirumab is an anti-angiogenic drug that received Food and Drug Administration (FDA)-approvals for treatments of many cancers. Gastrointestinal fistulas and perforations are recognized side effects of anti-angiogenic therapies, however, there are very few reported cases of these conditions in patients managed with Ramucirumab. Here we report a case of a 46-year-old gentleman with a stage four gastroesophageal junction tumor, who developed multiple tracheoesophageal fistulas post ramucirumab containing regimen. To the best of our knowledge, this is the first case report that describes a serious uncommon complication of ramucirumab in a patient with a gastroesophageal junction tumor.

La mise en place de prothèses permet de soulager les symptômes liés aux sténoses des voies aériennes centrales dans l’immense majorité des cas. Elles peuvent être curatives dans un certain nombre de situations non tumorales et offrent un pont vers les traitements locaux ou systémiques dans le contexte des obstructions malignes. Ces 30 dernières années ont vu ce domaine évoluer de manière très importante après le développement des prothèses en silicone dédiées aux voies aériennes dans les années 1990, puis de modèles hybrides métalliques auto-expansibles couverts, avec des gammes de formes de plus en plus variées. Nous revoyons ici les grandes familles de stents, leurs avantages et limites et leurs indications préférentielles d’abord en situation néoplasique mais également pour la gestion des sténoses bénignes des voies aériennes. Les avancées récentes et perspectives, en particulier le développement de prothèses de plus en plus personnalisées ou biodégradables sont également évoquées.

In the overwhelming majority of cases, Airway stents offer relief of malignant or benign central airway obstruction. In some non-tumoral situations, they can be curative, providing a bridge to local or systemic treatments in the context of malignant obstruction. The efficacy and tolerance of these medical devices have dramatically improved over the past three decades with the development of silicone airway stents and, more recently, of third-generation, covered, self-expandable metallic stents with an increasingly widened panel of shapes. We review herein the main categories of airway stents with their specific indications, pitfalls, and advantages, not only in neoplastic situations, but also in the treatment of benign stenoses of the respiratory tract. The recent advances and perspectives in the field are also taken into consideration, particularly the development of biodegradable, drug-eluting, and patient-specific customized AS.

Airway involvement, such as airway invasion, compression, and tracheobronchoesophageal fistula (TEF), in esophageal cancer is associated with significant morbidity. However, the risk factors and outcomes of airway complications remain unclear, with limited evidence to guide management.

This retrospective analysis included 804 patients with a diagnosis of esophageal cancer from 1998 to 2018 at a tertiary care medical center (Singapore General Hospital, Singapore). Patients’ demographics, treatment details, and airway involvement, as determined by bronchoscopic evaluation or computed tomographic imaging, were recorded and analyzed to determine risk factors and outcomes of airway involvement.

The incidence of airway involvement and TEF was 36.6% and 13.1%, respectively. Airway involvement was associated with reduced survival from the time of diagnosis (hazard ratio, 1.52; 95% confidence interval [CI], 1.30 to 1.79) and increased hospitalizations per year (4.53 ± 4.80 vs 2.75 ± 3.68; P < .001). On multivariate analysis, midesophageal tumors (odds ratio [OR], 11.0; 95% CI, 6.3 to 19.0) and upper esophageal tumors (OR, 8.5; 95% CI, 4.7 to 15.6), previous treatment with esophageal stenting (OR, 17.8; 95% CI, 4.1 to 77.6), and chemotherapy or radiotherapy were associated with development of airway involvement. In patients with TEF, treatment with chemotherapy (OR, 0.34; 95% CI, 0.20 to 0.60) and combined airway and esophageal stenting (OR, 0.48; 95% CI, 0.25 to 0.91) were independently associated with improved survival.

Airway involvement and TEF are common and are associated with increased morbidity and poorer survival. Clinicians should remain vigilant for airway complications after treatment with esophageal stenting, chemotherapy, or radiotherapy, especially in patients with midesophageal and upper esophageal cancers. In patients with TEFs, survival is improved when they are treated with airway stenting, esophageal stenting, or chemotherapy.

Airway stenting has been practiced for several decades. It is one of the most common procedures performed by interventional pulmonologists. Typically, these stents are implanted to maintain the tubular patency of the tracheobronchial tree. They are only considered as a temporizing measure, or when a surgical option cannot be pursued. Through the past few decades, a number of metallic airway stents have been introduced into the market. First generation stents were comparatively simplistic and crafted from stainless steel. The latest generation of metallic airway stents are hybrid in nature and constructed with complex alloys. As airway stenting become more widely practiced, concerns arose regarding their safety. However, with improved understanding of stent-airway interactions, advancements in biomedical engineering, and a larger emphasis on post procedural care, the use of metallic endobronchial stents has been resurrected. We present the history, technological advancement, and contemporary indications of metallic airway stents.