Customized Y Stent to Treat Local Advanced Lung Cancer

Abstract

INTRODUCTION: Stent implantation is a palliative method to treat local advanced lung cancer. Here we report a patient with severe pulmonary and cardiac comorbidities, who developed extensive cancer invading of central airway and bronchial-esophageal fistula. For better reserve his residual functional lung, a customized covered Y stent with an outlet for right upper lobe is planted. It supports the airway and seals the fistula, while preserves lung function as much as possible. CASE PRESENTATION: A 67-year-old male heavy smoker was admitted for progressive cough and severe dyspnea. Chest CT showed a bouncing mass at carina with mediastinal lymphadenopathy. A huge neoplasm was found at carina and almost completely obstructed the trachea under bronchoscope. Biopsies showed squamous cell carcinoma. Neither radical nor palliative surgery was performed for his severe comorbidities-rheumatic heart disease, abdominal aortic aneurysm and severe chronic obstructive pulmonary disease. Interventional bronchoscopy was adopted. After coring the tumor with rigid bronchoscope, the tumor was found invading bilateral main bronchi and the right bronchus intermedius. The bronchi distal to the segmental bronchi were patent. Electrocautery and cryotherapy were used to restore airway caliber. Chemotherapy, radiotherapy and repeating interventional bronchoscopy was executed. During radiotherapy(10 months after first bronchoscopy), the patient developed chocking, but no fistula was found in esophagography. An airway defect was found on CT 4 months after radiotherapy. Bronchoscopy confirmed bronchial-esophageal fistula at the right main bronchus. According to the extent of the tumor involvement, a covered Y stent was designed to cover the lower trachea, bilateral main bronchi and bronchus intermedius. As the patient had poor pulmonary and cardiac functions, it was crucial to preserve his residual lung. The distance from the carina to the right upper bronchus was measured accurately by CT and bronchoscopy. A special covered nickel-titanium shape memory hybridized Y stent with an open on the branch of right bronchus was custamized by the manufacture(microtech CO. Nanjing China). The stent was introduced into the airway under general anesthesia with rigid bronchoscope. The stent has satisfied location and the opening of the bronchus of right upper lobe was aimed at the reserved outlet. DISCUSSION: Approximately 30% of patient with lung cancer will develop central airway obstruction. Although the best choice for them is surgical resection, most patients are not surgical candidates on the basis of their poor health conditions. Interventional bronchoscopy can relieve the airway obstruction, improve the quality of life, prolong the survival time and might give the patient an opportunity to receive additional therapy[1]. Esophagorespiratory fistulas can arise spontaneously due to tumor invasion, but chemotherapy and radiation therapy is highly associated with fistula development[2]. Most of these patients could not accepted surgical repair for their advanced cancer and underlying diseases. Covered metal stents might be the only choice[3]. It can close the fistula, while avoiding the ingrowth of the tumor. CONCLUSIONS: In this patient a customized covered Y stent is implanted to open trachea, carina, bilateral main bronchi and right bronchus intermedium while leaving the right upper lobe open. It preserved patientas functional lung maximally. The implantation process is feasible, but accurate measurement should be emphasized for the anatomical variation and distortion coming from the underlying disease.