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Journal of Clinical Oncology, Vol 24, No 9 (March 20), 2006: pp. 1478-1479 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.01.8218
CASE 4. Pulmonary Stent Migration and Ingestion in a Lung Cancer PatientUniversity of Pittsburgh, Pittsburgh, PA An 81-year-old male smoker with a past medical history of hypertension, chronic obstructive pulmonary disease, and coronary artery disease requiring bypass was admitted for shortness of breath, hemoptysis, and cough, which increased in severity over the previous 2 weeks. He had a right hilar mass with evidence of postobstructive pneumonia, and a bronchoscopic biopsy revealed small cell carcinoma. The patient experienced complete right lung collapse, and a repeat bronchoscopy was performed. A 3-cm portion of the bronchus intermedius was narrowed by extrinsic compression, but re-expansion of the distal portion of the bronchus proximal to the middle and lower lobe bronchial bifurcation was apparent. Because the obstructed portion was not amenable to laser ablation, a 30-mm x 8-mm covered metal Wallstent (Boston Scientific, Natick, MA) was placed at the site of the extrinsic compression. The distal portion of the stent was positioned just proximal to the bifurcation of the middle and lower lobe bronchi, and the stent was fully deployed (Fig 1; arrow indicates stent). The bronchoscope was easily advanced through the expanded stent, and the position of the stent was thought to be satisfactory. The patient's oxygen saturation immediately improved after the procedure, and there was dramatic radiographic improvement. The patient received two 3-Gy radiation treatments to the right hilum and one cycle of chemotherapy, consisting of carboplatin area under the time-concentration curve 5 on day 1 and etoposide 75 mg/m2 on days 1 through 3. The patient was discharged from the hospital with plans to continue radiation and chemotherapy as an outpatient, but returned to the emergency department 3 days after discharge complaining of a coughing episode immediately followed by a foreign body sensation in his throat. He drank several glasses of water, after which the sensation resolved. A chest x-ray demonstrated adequate airation of the right lung; however, there was no stent in the right mainstem bronchus. An abdominal film revealed the metal Wallstent in the right upper quadrant below the diaphragm (Fig 2). The patient was underwent careful observation, and passed the stent in his stool 2 days later without complications.
This case represents an unusual instance of pulmonary stent migration resulting in stent ingestion. Indications for stenting include1: recurrent benign strictures that are not surgically resectable2; active inflammation or edema necessitating support while the pathologic process resolves3; rapidly growing or recurrent obstructive endobronchial tumors4; tumors producing extrinsic obstruction5; early anastomotic strictures that might stabilize over a stent during postoperative remodeling6; tracheobronchial malacia7; and palliation of patients facing impending suffocation from airway compromise.1,2 A variety of stents and techniques for their deployment have evolved since the first reported use of silastic stents with rigid bronchoscopy,3,4 and each of them is associated with certain advantages and disadvantages. Metal Wallstents, which were originally designed for intravascular use, have become popular choices for placement in the tracheobronchial tree. The advantages of the metal stents include ease of placement, visibility on an ordinary radiograph, conformation ability, preservation of ventilation when placed across lobar orifices, and stent stability. However, metal mesh stents are prone to ingrowth of tumor and granulation tissue formation, which makes them less desirable in situations where malignant tissue is likely to invade the patent airway. Metal stents are also difficult, if not impossible, to remove from the airway once they are seated.5 Therefore, metal mesh stents may be more effective in cases in which the goal is short-term palliation. To circumvent these problems, but retain the advantages of the metal stents, a circumferential polyurethane sleeve was added to minimize intralumenal tissue penetration. Unfortunately, although covered metal stents offer the durability and flexibility of Wallstents, they also appear to be more prone to migration and subsequent complications. A previous study6 presented data on 27 patients with airway obstruction who were stented with polyurethane-covered metal Wallstents. The majority of these patients had a bronchogenic carcinoma, while the remaining patients had esophageal carcinoma, thyroid carcinoma, or lymphoma. Six patients experienced stent migrations that required endoscopic stent removal. Two of the migrations occurred after patients had received full-dose external-beam radiation that produced re-expansion of the airway lumen to a size greater than the maximum circumference of the stent. Other complications included secretion retention and granuloma formation at the ends of stents. Another study2 reported frequencies of stent migration (12%), secretion retention (38%), and tissue regrowth at the tip of the stent (36%) in a series of 40 patients with tracheobronchial cancer. However, other authors have reported much higher migration rates and life-threatening complications related to covered stents.7 Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES
1. Stephens KE Jr, Wood DE: Bronchoscopic management of central airway obstruction. J Thorac Cardiovasc Surg 119:289-296, 2000 2. Monnier P, Mudry A, Stanzel F, et al: The use of the covered Wallstent for the palliative treatment of inoperable tracheobronchial cancers: A prospective, multicenter study. Chest 110:1161-1168, 1996[Medline] 3. Dumon JF: A dedicated tracheobronchial stent. Chest 97:328-332, 1990[CrossRef][Medline] 4. Dasgupta A, Dolmatch BL, Abi-Saleh WJ, et al: Self-expandable metallic airway stent insertion employing flexible bronchoscopy: Preliminary results. Chest 114:106-109, 1998[Medline] 5. Wood DE: Airway stenting. Chest Surg Clin N Am 11:841-860, 2001[Medline] 6. Bolliger CT, Heitz M, Hauser R, et al: An Airway Wallstent for the treatment of tracheobronchial malignancies. Thorax 51:1127-1129, 1996 7. Ladas G, Goldstraw P: Airway Wallstent. Thorax 52:664-665, 1997[Medline]
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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