Primary malignant neoplasms of the trachea are rare, accounting for 0.1% of all malignancies. Primary resection and reconstruction of the trachea with post-operative radiation offers increased survival. Interventional endoscopy provides an important alternative to surgery in selected patients. We describe a patient with a life-threatening tracheal obstruction from a primary tracheal malignancy that was successfully palliated and treated with interventional endoscopy including temporary stenting with self-expanding metallic nitinol stent (SEMS) and photodynamic therapy (PDT).
A 52-year-old male presented with a 6-month history of intermittent cough and wheezing. Despite treatment he became increasingly dyspneic with severe respiratory distress and was diagnosed with a near-complete occlusion of the distal trachea from a primary squamous cell tracheal malignancy, (cT4N0M0) with extension to right and left main stem bronchi. Endoluminal core-out was attempted using electrocautery and high dose brachytherapy with unsatisfactory response. A SEMS was deployed followed by external beam radiation therapy (EBRT). PDT and cryotherapy to salvage necrotic tissue consolidated treatment. The SEMS was used as temporary bridge to therapy and was removed post-PDT without complications. This treatment achieved complete response; biopsies showed necrotic neoplasm. Our patient’s quality of life improved markedly by both Karnofsky performance scale and dyspnea index.DISCUSSION: Tracheal malignancies present diagnostic and therapeutic challenges. Surgical resection is the preferred therapy but it carries a high mortality rate (10-15%). PDT provides a minimally invasive local treatment with the potential use as curative modality. SEMS has excellent characteristics but are permanent because of rapid neoepithelization. Tissue necrosis secondary to PDT enabled us to extract the SEMS without complications.
This case shows the important palliative and therapeutic role of interventional endoscopy. PDT achieved an excellent therapeutic response and in association with EBRT it offered an alternative modality sparing the patient from the morbidity and mortality associated with surgery.
S.A. Kseibi, None.