SYDNEY, AUSTRALIA – Use of radiological guidance for tracheobronchial stent insertion in advanced lung cancer makes no difference to outcomes such as complication rates, length of stay, or survival compared with visually-guided insertion, according to data from 79 patients.
Researchers from Harefield Hospital, London, examined outcomes from patients with advanced primary lung cancer whose airway obstructions were treated with tracheobronchial stenting; 41 were stented under radiological guidance and 38 with direct vision using bronchoscopy.
No cases of stent migration occurred in either group, and there were no significant differences between length of stay and overall survival, Henrietta Wilson, lead investigator, said at a world conference on lung cancer.
Ms. Henrietta Wilson
However, the use of radiological guidance required more staff and equipment and, by its very nature, led to more radiation exposure than did visually-guided stent insertion, said Ms. Wilson, a thoracic registrar (medical student) at Harefield Hospital.
"I had noticed that with the use of radiological guidance, it seemed to add an amount of time and organization onto the cases that we were doing, with having to get a larger number of people coming to perform the procedure, with the logistics of getting all of the equipment into theater, and that can sometimes also prolong the time of the general anesthetic while getting all of that set up," she said at the conference, which was sponsored by the International Association for the Study of Lung Cancer.
The average length of stay following the procedure was 2.73 days in the radiologically-guided group and 2.26 days in the visually-guided group (P = .93), with 69% of patients discharged on the same day, or the day after. The overall mean survival was 2.6 months, with 20% of patients alive at one year.
"I think probably those who advocate radiological guidance would feel that you get a better position of the stent and so they may have felt that it would get fewer complications from stent migration or malposition of the stent, or people requiring repeat procedures, but that certainly wasn’t something that we found," she said.
Ms. Wilson noted that tracheobronchial stenting was used generally in urgent cases of acute airway obstruction, either as a palliative procedure in itself or to provide short-term relief for patients awaiting further radiotherapy or chemotherapy.
"Acute airway obstruction can be very distressing, so if we’re able to just improve that then it may only be for weeks or a month at most but we find from a quality of life point of view, that’s a real benefit," she said in an interview.
Radiologically-guided stenting required an x-ray C-arm to enable real-time imaging of the stent placement, while in visually-guided placement, the surgeon would use a bronchoscope to assess the position of the tumor, and then use the guide wire to position the stent, Ms. Wilson noted.
Additional research is underway to examine the impact of guidance methods on the duration of the procedure and anesthetic.
Dr. Eleanor Summerhill, FCCP, comments: This small, single- center, retrospective study found no significant differences in rates of stent complications, hospital length of stay, or survival in patients with airway obstruction caused by primary lung cancers stented via direct visualization compared to under radiological guidance.
As the authors note, there are a number of disadvantages to placement under radiologic guidance. These include the need for additional equipment and staffing, as well as more radiation exposure and time under anesthesia.
This study suggests that these measures may not lead to improved outcomes, and will hopefully lead the way to a subsequent multicenter, randomized control trial.
Dr. Summerhill is the director of the Internal Medicine Residency Program at the Memorial Hospital of Rhode Island and Assistant Professor of Medicine
Alpert Medical School of Brown University.
There were no conflicts of interest declared.