A narrative review of oncologic emergencies in patients with head and neck cancers: initial management and the role of radiation therapy.

BACKGROUND AND OBJECTIVE: Head and neck cancers (HNCs) encompass a complex group of malignancies with high morbidity, often leading to critical emergencies such as pain crises, airway obstruction and hemorrhage. This review aims to outline an evidence-based approach to the multidisciplinary management of HNC oncologic emergencies with a focus on the role of emergent radiotherapy (RT). METHODS: A literature search was performed using Medline, Embase and the Cochrane Central Register of Controlled Trials databases with a focus on three common oncological emergencies using the following keywords: "head and neck cancer", "radiation OR radiotherapy", "pain", "bleeding OR haemorrhage", and "airway obstruction". All English language articles published up to April 2022 were screened to identify studies pertaining to the management of oncologic emergencies in HNC. KEY CONTENT AND FINDINGS: The management of oncologic emergencies in HNC present a unique set of challenges that require early recognition and aggressive treatment. In this narrative review, we summarize the evidence supporting the role of RT in the management of HNC patients presenting with pain crisis, malignant airway obstruction and acute haemorrhage. We demonstrate that while RT can be used as a primary or adjunct therapy, optimal management depends on the involvement of a multi-disciplinary team that includes head and neck surgeons, interventional radiology and palliative care. CONCLUSIONS: RT plays a critical role in the multidisciplinary management of HNC oncological emergencies. Further prospective and comparative studies are needed to assess optimal management strategies.

Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy.

PURPOSE: Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions. METHODS AND MATERIALS: Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible. RESULTS: Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively. CONCLUSIONS: Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.

Role of radiotherapy in the management of malignant airway obstruction.

BACKGROUND: A significant proportion of lung cancer patients suffer from malignant airway obstruction (MAO). Palliative external beam radiotherapy (EBRT) is often used to control the symptoms caused by MAO. In this study, we report the effect of palliative EBRT on lung cancer with MAO and analyze the factors that influence it. METHODS: This study included 75 patients with MAO in lung cancer who underwent palliative EBRT, between 2009 and 2018 and were analyzed retrospectively. Change of dyspnea, tumor response, and overall survival (OS) were recorded. Univariate and multivariate analyses were performed to determine the prognostic factors for treatment outcomes. RESULTS: The median follow-up duration was 2.5 months, and median OS was 2.3 months. Out of 75 patients, dyspnea was improved in 46 patients (61.3%), and tumor was partially decreased in 39 patients (52%). Symptoms improved in all tumor responding patients. The symptom improvement was significantly affected by radiation dose and time to EBRT. The tumor response was significantly affected by pathology, radiation dose, and time to EBRT. CONCLUSIONS: Palliative EBRT is an effective and safe treatment option for patients with MAO in lung cancer. In particular, high-dose irradiation and prompt treatment can improve treatment results. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: In MAO patients, tumor response is an important factor for resolving dyspnea and improving survival rate. In order to increase the tumor response, high-dose irradiation and prompt treatment after symptoms occur are necessary. WHAT THIS STUDY ADDS: Our study reported the effects of EBRT and prognostic factors in MAO patients. We emphasize that palliative EBRT is a relatively safe and effective treatment in MAO patients, which is a complement to previous studies.

A Novel Tracheobronchial Stent Loaded with 125I Seeds in Patients with Malignant Airway Obstruction Compared to a Conventional Stent: A Prospective Randomized Controlled Study.

BACKGROUND: To evaluate the safety and efficacy of a novel radioactive bare metal stent (RBMS) compared with a conventional bare metal stent (CBMS) in patients with inoperable malignant airway obstruction. METHODS: This prospective study was approved by the Institutional Ethics Committee, and informed consent was obtained from each participant. Patients with malignant airway obstruction who had dyspnea were randomly assigned to receive RBMS or CBMS placement. The primary endpoint was stenosis grade, while the secondary endpoints were technical success, overall survival, and complications. A p value of <0·05 was considered statistically significant. RESULTS: Between September 2013 and July 2015, 66 patients with inoperable malignant airway obstruction received stent placement fluoroscopically (33 in either group). The median follow-up time was 154 days (range, 15-335 days). The baseline stenosis was immediately relieved in both groups after stent placement, and the stenosis grades in the RBMS group were significantly lower than that in the CBMS group since the second month (p < 0·05). The technical success rates of stent placement were 100% in both groups. The median survival in the RBMS group was significantly longer than that in the CBMS group (170 days vs. 123 days, p < 0·05). There was no significant difference in the incidence of complications between the two groups (p < 0·05). CONCLUSIONS: The placement of RBMS in patients with inoperable malignant airway obstruction is feasible and safe, and it significantly reduces restenosis and improves overall survival compared with the placement of CBMS.

Treating cancerous large airway stenosis with staging radioactive particle implantation guided by computed tomography and fiber bronchoscopy: a clinical study.

BACKGROUND: The purpose of this study is to investigate the clinical effectiveness of staging radioactive particle implantation guided by computed tomography (CT) and fiber-optic bronchoscopy in treating cancerous large airway stenosis. METHODS: A total of 102 patients were included; 57 had undergone staging radioactive particle implantation guided by CT and fiber bronchoscopy and 45 did not. Patients were evaluated by CT and fiber-optic bronchoscopy to determine the feasibility of the implantation of radioactive seeds for the treatment of cancerous large airway stenosis. The treatment planning system (TPS) was used to plan the doses. Radioactive seeds were implanted using fiber-optic bronchoscopy. One week later, CT-guided implantation of radioactive seeds was performed. RESULTS: The clinical evaluation showed complete, partial, slight, and non-response in 38, 14, 5, and 0 patients, respectively. None of the patients were found with serious complications. The diameter of the affected airway, Karnofsky score, dyspnea index, survival, and quality of life of the patients in both groups was significantly higher and significantly different after the treatment (P < 0.05). The dyspnea index was significantly lower in the treatment group as compared with the control group (P < 0.001). CONCLUSION: CT- and fiber bronchoscopy-guided staging radioactive particle implantation has definite treatment effectiveness in treating cancerous large airway stenosis. It should be widely used in clinical practices.

A prospective analysis of high-dose-rate endobronchial brachytherapy in the palliation of obstructive symptoms in lung cancer patients: A single-institution experience.

PURPOSE: Obstructive symptoms that affect quality of life (QOL) are commonly caused by endobronchial disease in many patients with locally advanced, inoperable lung cancer. High-dose-rate endobronchial brachytherapy (HDREBBT) has been used to palliate these symptoms, yet its role is not well defined in the literature. METHODS AND MATERIALS: Ninety-eight patients with locally advanced, inoperable lung cancer received HDREBBT. They were prospectively followed for survival, QOL, and toxicity endpoints. QOL measures were captured using the Quality of Life Questionnaire-Lung Cancer 30 and -Lung Cancer 13. RESULTS: At 1-year follow-up, no significant toxicities were seen. Overall survival was 13.4% at 12 months (mean 192 days). Performance status, additional treatment after HDREBBT and treatment intent affected overall survival on univariate analysis (p < 0.05). Mean hemoptysis-free survival for all patients was 232.3 days, cough-free survival was 140.3 days, and dyspnea-free survival was 173.5 days. There was no impact of any treatment- or patient-related factors of these outcomes on multivariate analysis, including additional treatment modalities and HDREBBT dose. CONCLUSIONS: HDREBBT is a safe and effective way to palliate endobronchial symptoms. Additional external-beam radiation therapy, chemotherapy, or chemoradiation after HDREBBT improves survival, but does not affect QOL measures.

Ablative therapies for central airway obstruction.

Central airway obstruction (CAO) is seen in malignant and nonmalignant airway disorders and can lead to significant morbidity and mortality. Endobronchial ablative therapies are used in conjunction with mechanical debridement to achieve hemostasis and restore airway patency. These therapies can be classified into modalities with immediate or delayed effect. Therapies with immediate effect include heat therapies (such as electrocautery, argon plasma coagulation, and laser) and cryorecanalization using a cryoprobe for tissue extraction. These modalities can be used in severe CAO for immediate relief of obstruction. Therapies with delayed effect include cryotherapy, brachytherapy, and photodynamic therapy. These modalities should not be used for acutely symptomatic CAO, and typically require follow-up bronchoscopy for removal of debris from the airway. Multimodality approach typically leads to better outcomes.

Radiotherapy for intubated patients with malignant airway obstruction: futile or facilitating extubation?

INTRODUCTION: The optimal approach to patients with malignant airway obstruction who require intubation and mechanical ventilation but are ineligible for bronchoscopic interventions is uncertain. Radiotherapy (RT) may be delivered but requires substantial resources in this patient population. In the absence of evidence, it is unknown whether RT facilitates extubation or delays an appropriate transition to end-of-life care. METHODS: We performed a 10-year retrospective review of intensive care unit (ICU) patients treated with RT while on mechanical ventilation for malignant airway obstruction. Primary study endpoints were overall survival (OS) and extubation success (ES), defined as 48 hours or more without reintubation or death. Secondary endpoints included rates of discharge from the ICU and to home. Logistic regression and Cox regression analyses were performed to identify factors associated with OS and ES. RESULTS: Twenty-six patients were eligible for analysis. Seven patients (27%) were extubated; extubations occurred between days 4 and 22 after RT initiation. All patients were discharged from the ICU and most (n = 6) were also discharged home. An association between higher radiation doses and ES was observed (odds ratio per 5 Gy increase: 0.63; p = 0.080). Median OS was only 0.36 months (range, 0-113 months), and 6-month OS was 11%. On Cox regression analysis, increased radiation dose was predictive of improved OS (hazard ratio per 5 Gy increase: 0.74; p = 0.016). CONCLUSIONS: A significant minority of patients receiving RT were successfully extubated. Higher radiation doses were predictive of improved OS and showed a trend for increased ES. Survival beyond 6 months was uncommon, however, the majority of patients with ES were able to be discharged home.

High-dose-rate brachytherapy in symptom palliation due to malignant endobronchial obstruction: a quantitative assessment.

PURPOSE: This study was performed to objectively evaluate the effect of high-dose-rate endobronchial brachytherapy (HDREB) in symptom palliation of patients with malignant airway obstruction and treatment-related toxicity. METHODS AND MATERIALS: Seventy-eight patients were treated with palliative intent according to a prospective observational protocol. HDREB was delivered in three fractions of 7.5 Gy at weekly or fortnightly intervals, associated or not with external beam irradiation. Most patients presented with lung cancer primaries and were treated because of lesions located in the trachea and/or main bronchi. Performance status, degree of obstruction, and symptom palliation were graded according to an objective score index, defined before and after HDREB at the last followup visit. Survival was considered from the end of HDREB for at least 3 years or until death. RESULTS: Overall, there was a 70% improvement, with migration of patients from lower to higher performance status. Bronchial obstruction was improved in 73.4% of the patients. The symptom that presented the better response was hemoptysis (100% complete relief) followed by postobstructive pneumonia (80%), dyspnea (57.4%), and cough (33.9%). Median survival was 6 months and improved in patients with complete response at bronchoscopy (9 months). There were two (2.6%) cases of bronchial fistulae and eight cases (10.2%) of fatal hemoptysis. CONCLUSIONS: HDREB is an excellent modality for palliating malignant airway obstruction resulting in quality of life improvement, with a good tolerance, patient compliance, and low rate of complications.

HDR brachytherapy: an option for preventing nonmalignant obstruction in patients after lung transplantation.

PURPOSE: Interventional bronchoscopy is the main treatment modality in managing benign airway obstructions following lung transplantation. We analyzed the effect of intraluminal brachytherapy on preventing recurrence of hyperplastic tissue. PATIENTS AND METHODS: From September 2002 to September 2004, a total of 24 intraluminal brachytherapy applications were carried out on 12 lung transplant patients in 15 different locations. A single dose of 3 Gy was calculated at a 5-mm distance from the catheter surface; the target volume included a stenosis plus safety interval of 0.5-1.0 cm. RESULTS: All patients had a mean 10.6 local interventions (Argon plasma coagulation, balloon dilatations, stenting) over 4.4 months before the first application of endobronchial brachytherapy, with a mean amount of 2.4 applications per month. The mean forced expiratory volume in 1 s (FEV1) was 2,219 ml in the 3 months before application of brachytherapy. After endobronchial brachytherapy, all patients experienced improvement in clinical status and respiratory function. The mean level of FEV1 in the 3 months after application was 2,435 ml (p = 0.02), and the number of invasive interventions dropped to a mean rate of 5.2 interventions in the 5.1 months after the first intervention, with an amount of 1 application per month. No treatment-related complications were seen. Four patients were treated twice, 1 patient three times, and 1 patient four times at the same localization. CONCLUSIONS: Recurrent symptomatic benign airway obstruction from hyperplastic tissue in the bronchus after lung transplantation can be successfully treated with intraluminal high-dose-rate brachytherapy with a dose of 3 Gy at a 5-mm distance from the catheter surface and a longitudinal safety margin of 1 cm.

Palliative radiotherapy for patients with tracheobronchial and esophageal compression due to intrathoracic malignant tumors.

AIMS: To evaluate palliative outcomes of patients with extrinsic malignant tracheobronchial or esophageal stenosis treated with radiation. Mediastinal or hilar lymphadenopathy surrounding the tracheobronchi or esophagus may cause compression, presenting as dyspnea and dysphagia respectively. Treatment is important for symptom relief and maintaining patients' quality of life. METHODS: Dyspnea and dysphagia were assessed using the Hugh-Jones score and a modified dysphagia scale, respectively. A total of 13 patients (median age, 60 years) with dyspnea received palliative radiotherapy. The primary organs were lung (n = 6), colorectum (n = 5), hypopharynx (n = 1) and uterine cervix (n = 1). Three patients received concurrent chemotherapy. The median time-adjusted biological effective dose (BED) was 33.0 Gy(10) . Ten patients (median age, 61) with dysphagia received palliative radiotherapy. The primary organs were lung (n = 7), esophagus (n = 2) and hypopharynx (n = 1). Three patients received concurrent chemotherapy. The median time-adjusted BED was 32.1 Gy(10) . RESULTS: Palliation of dyspnea and dysphagia occurred in seven (54%) and five (50%) patients, respectively. Patients treated with doses over 35 Gy(10) had greater score improvements than those treated with less than 35 Gy(10) in both groups. Patients who received concurrent chemoradiotherapy had greater score improvements than those treated with radiotherapy alone. Dyspnea patients with pretreatment scores of 2 (n = 5) had greater score improvements than those with scores of 3 or more (n = 8). CONCLUSION: External beam radiotherapy should be considered for patients with tracheobronchial or esophageal stenosis before their symptoms worsen. The prescription dose should be over 35 Gy(10) .

Safety and efficacy of thoracic external beam radiotherapy after airway stenting in malignant airway obstruction.

PURPOSE: We retrospectively evaluated the outcome and toxicity of external beam radiotherapy (EBRT) after airway stents were placed in patients treated for malignant airway obstruction. METHODS AND MATERIALS: Between 2004 and 2009, we performed airway stenting followed by EBRT in 43 patients for symptomatic primary lung cancer (n = 31) or other thoracic malignancies (n = 12). The median time interval between stent placement and first irradiation was 14 days. A median total dose of 50 Gy was delivered. Sixty-seven percent of the patients had reduced performance status (Karnofsky performance score, ≤70). RESULTS: EBRT had to be stopped prematurely in 16 patients (37%), at a median total dose of 17 Gy, for various reasons. In this group of patients, the survival was poor, with a median overall survival (OS) of only 21 days. Twenty-seven patients (63%) completed radiotherapy as planned, with a median OS of 8.4 months. Fourteen of 43 patients (33%) developed at least one Common Terminology Criteria for Adverse Event of grade 3 to 5. The most common event was a malignant restenosis of the stent leading to asphyxia (n = 7), followed by fistula formation (n = 4), necrosis (n = 3), mediastinitis with abscess (n = 1), secondary nonmalignant airway stenosis (n = 1), and hemoptysis (n = 1). With the exception of one event, all events were associated with a local progression of the tumor. CONCLUSIONS: Although the long-term prognosis for patients with malignant airway obstruction is poor, airway stenting combined with EBRT offers a possible therapeutic option, achieving fast relief of acute respiratory distress with an associated antitumor effect, resulting in a potential survival benefit. However, due to local advanced tumor growth, increased rates of adverse events are to be expected, necessitating careful monitoring.

Braquiterapia endobronquial de alta tasa de dosis en pacientes con obstrucción de la vía aérea central: experiencia en el Instituto Nacional del Cáncer y revisión de la literatura / High dose rate endobronchial brachytherapy in patients with central airway obstruction

Introduction: The main indication of modern high dose rate end bronchial brachyherapy (HDR EBBT) is the palliation of symptoms related to the growth of the endobronchial lung cancer. Methods: EBBT was performed to 27 patients who suffered symptomatic tumoral endobronchial or tracheal pathology, due to primary bronchial disease or secondary metastasis cancer, evaluating the rate of clinical benefit. The tumors were located at tracheal, carinal or proximal bronchial level. Fibrobronchoscopy was performed to all the patients to measure the degree of airway obstruction and to install brachytherapy endobronchial catheters. Between 1 to 4 fractions of 7 to 7.5 Gy were administered. Dyspnea, cough and hemoptysis were subjectively registered before and after treatment, according to an international validated scale. Results: After treatment, all symptoms considerably decreased, disappearing all of the severe categories. Hemoptysis and dyspnea resolved in a 100 percent and 40 percent of patients, respectively; and cough disappeared or was reduced to a minimum grade in 90 percent of cases.

Introducción: La indicación principal de la braquiterapia endobronquial moderna (BTEB) de alta tasa de dosis (HDR), es la paliación de síntomas por crecimiento endobronquial de cánceres pulmonares. Métodos: Se realizó BTEB HDR a 27 pacientes sintomáticos de patología tumoral endobronquial o traqueal, debido a patologías primarias bronquiales o secundarias metastásicas. Los tumores se ubicaban en tráquea, carina o a nivel bronquialproximal. Para observar mejorías en la sintomatología clínica, a todos se les realizó una fibrobroncoscopía (FBC) para medir el grado de obstrucción bronquial e instalar catéteres endobronquiales de braquiterapia. Se administraron entre 1 y 4 fracciones de 7 a 7,5 Gy. Se registró subjetivamente la disnea, tos y hemoptisis antes y después del tratamiento, de acuerdo a una escala internacionalmente validada. Resultados: Tras el tratamiento todos los síntomas disminuyeron considerablemente, desapareciendo toda sintomatología severa. La hemoptisis y disnea desaparecieron en el 100 por ciento y 40 por ciento de los pacientes respectivamente, y la tos desapareció o disminuyó a grado leve en el 90 por ciento de los pacientes.

High dose-rate endobronchial radiotherapy for proximal airway obstruction due to lung cancer: 8-year experience of a referral center.

The efficacy of high dose-rate endobronchial radiotherapy (HDERT) against proximal airway obstruction that results from lung cancer has not been thoroughly evaluated. This study retrospectively reviewed tumor/obstruction characteristics prior to therapy, interventions applied, symptoms before and after intervention, complications, and survival of all patients with proximal airway obstruction resulting from lung cancer who received HDERT between 1995 and 2003 in a tertiary teaching center. Thirty-four (34) patients received HDERT, while 28 had additional treatment (external radiotherapy = 23, neodymium yttrium aluminum garnet laser ablation = 9, stenting = 7, electrosurgery = 5, cryosurgery = 3, and photodynamic therapy = 1). Sixteen (16) patients developed complications, the most frequent being respiratory failure and bronchial-wall necrosis, while 19 experienced symptomatic relief. The median (95% confidence interval) survival of these 34 patients was 7.8 (5.9-9.8) months, significantly longer (p = 0.004) than a historic control of 3.9 (3.7-7.1) months from the Cleveland Clinic Foundation, in Cleveland, OH, and comparable to other previous reports. No single factor predicted complications or symptomatic relief. However, female gender, presence of only one symptom, absence of fatigue/weight loss, >1 HDERT sessions, and postprocedure symptom relief were associated with improved survival. Contemporary HDERT with or without additional treatment modalities is effective against central airway compromise resulting from lung cancer.

Recombinant human thyrotropin-stimulated radioiodine therapy of large nodular goiters facilitates tracheal decompression and improves inspiration.

INTRODUCTION: The impact on tracheal anatomy and respiratory function of recombinant human (rh)TSH-stimulated (131)I therapy in patients with goiter is not clarified. METHODS: In a double-blinded design, patients (age 37-87 yr) with a large multinodular goiter (range, 99-440 ml) were randomized to placebo (n = 15) or 0.3 mg rhTSH (n = 14) 24 h before (131)I therapy. The smallest cross-sectional area of the trachea (SCAT; assessed by magnetic resonance imaging) and the pulmonary function were determined before, 1 wk, and 12 months after therapy. RESULTS: Data on goiter reduction have been reported previously. In the placebo group, no significant changes in the lung function or SCAT were found throughout the study. In the rhTSH group, a slight decrease was observed in the forced vital capacity 1 wk after therapy, whereas the mean individual change in SCAT was significantly increased by 10.5% (95% confidence interval = 0.9-20.0%). A further increase in SCAT to 117 +/- 36 mm(2) (P = 0.005 compared with 92 +/- 38 mm(2) at baseline) was seen at 12 months, corresponding to a mean of 31.4% (95% confidence interval = 16.0-46.8%). The expiratory parameters did not change significantly, whereas forced inspiratory flow at 50% of the vital capacity (FIF50%) increased from initially 3.34 +/- 1.33 liters/sec to ultimately 4.23 +/- 1.88 liters/sec (P = 0.015) in the rhTSH group, corresponding to a median increase of 24.6%. By 12 months, the relative improvements in FIF50% and in SCAT were inversely correlated to the respective baseline values (FIF50%: r = -0.47, P = 0.012; SCAT: r = -0.57, P = 0.001). CONCLUSION: On average, neither compression of the trachea nor deterioration of the pulmonary function was observed in the acute phase after rhTSH-augmented (131)I therapy. In the long term, tracheal compression is diminished, and the inspiratory capacity improved, compared with (131)I therapy alone.

Utilización del láser diodo en la vía aérea pediátrica / Diode laser application for the treatment of pediatric airway pathologies

Introducción y objetivo. El tratamiento con láser de las lesiones de la vía aérea es una opción terapéutica muy atractiva por la limitada reacción inflamatoria tras la fotocoagulación. Uno de los láseres de más reciente introducción en este campo es el láser diodo. El objetivo de nuestro trabajo es presentar la experiencia preliminar en la utilización del láser diodo para el tratamiento de las lesiones de la vía aérea en niños. Material y métodos. Hemos realizado una revisión retrospectiva de los pacientes tratados con láser desde el año 1999 hasta el 2006. Diecinueve pacientes fueron tratados en nuestro centro primariamente con técnicas con láser de diodo y otros 3 enfermos fueron derivados a nuestro centro tras un tratamiento con láser. Todos los procedimientos fueron realizados a través del fibrobroncoscopio. La edad media fue de1,25 años con un rango de edad entre 1 mes y 4,8 años. Once pacientes eran hombres y once mujeres. Las indicaciones que nos han llevado a realizar una resección endoscópica con láser de la lesión fueron enormemente variadas: laringomalacia y lesiones de aritenoides (n=5), angiomas(n=3), linfangiomas (n=3), quistes saculares y otras lesiones mucosas(n=3), granulomas intraluminales (n=3), lesiones cicatriciales (n=4)y parálisis en adducción de las cuerdas vocales. Resultados. Ningún paciente ha presentado complicaciones relacionados con la aplicación del láser diodo endoscópico. La media del número de procedimientos realizados en cada paciente ha sido 1,4 (1a 3). El tiempo medio de intubación tras el tratamiento ha sido de 2,8días (de 4 horas a 13 días). La media de tiempo de estancia en UVI tras la aplicación del tratamiento ha sido de 4,6 días (1-8 días). Los mejores resultados se han conseguido en los pacientes con quistes saculares o lesiones mucosas, excelente en los 3 casos y en los 3 pacientes común granuloma endotraqueal. En los 5 pacientes con lesiones de aritenoides hemos obtenido un resultado funcional excelente tras una media de1,4 procedimientos (rango de 1 a 3). Los enfermos con lesiones vasculares han presentado un resultado variable. De los pacientes con angioma subglótico 2 han requerido una reintervención por presentar estenosissubglótica residual y otro ha precisado corticoterapia a altas dosistras el láser. De los enfermos con linfangioma, uno se ha resuelto tras3 procedimientos endoscópicos y 2 han precisado cirugía posterior. Delos 4 pacientes con lesiones cicatriciales, 3 han precisado una intervención quirúrgica tras el tratamiento con láser. Conclusiones. El láser diodo como tratamiento endoscópico es altamente eficaz en pacientes seleccionados. Las lesiones saculares, mucosas, granulomas y la patología de los aritenoides son, en nuestra experiencia, una excelente indicación. En otras situaciones el láser es un buen complemento precisando siempre hacer un enfoque individualizado (AU)

Laser application for the treatment of pediatric airway pathologies represents a very attractive option because of the limited inflamatoy reaction after photocoagulation. One novel laser used for such pathologies is the diode laser. Aim. The purpose of this report is to present our preliminary experience in the use of diode laser in the treatment of paediatric airwaylesions. Methods. A retrospective review of 22 patients (11 males and 11females) who underwent laser procedures from 1999 to 2006 was performed. Nineteen patients were treated at our center while 3 were referred after a laser application from other institution. In all procedures flexible bronchoscopy was used. The mean age was 1.25 years(range 1 month-4.8 years). Lasers were applied for various lesions: laryngomalacia and arytenoid lesions (n=5), angiomas (n=3), lymphangiomas(n=3), sacular cyst and other mucous lesions (n=3), granulomas, scarring lesions (n=4) and paralysis of vocal cord in adduction(n=1).Results. None of the patient developed complications related tothe endoscopic laser application. The mean number of laser therapy attempts were 1.4 per patient (range 1-3). The patients remained intubated for a mean of 2.8 days (range 4 hours-13 days) after the procedure. The duration of PICU stay after laser therapy was a mean of 4.6days (range 1-8 days). The best outcomes were seen in sacular cysts(excellent in 3 patients). Also, all 3 patients with granulomas showed a good response to treatment. Multiple laser sessions (1-3; mean 1.4)were required to successfully manage the artynenoid lesions. However, the children with vascular lesions demonstrated differents outcomes. Of the 3 patients with subglottic angioma, 2 underwent a subsequent surgical procedure due to the development of subglottic stenosis; and one requiered further systemic steroid therapy. Of the children with lymphangioma, one needed 3 laser sessions and two required surgical resections. Despite laser treatment, 3 of the 4 patients with scarring lesions required surgery. Conclusions. The endoscopic application of diode laser for the management of pediatric airways lesions provides good outcomes inselected patients. Sacular lesions, granulomas and arytenoid lesions are, in our experience, excellents indications. In other anomalies laser is a good adjuvant. The application of laser should be tailored according to the pathology (AU)

High-dose-rate endobronchial brachytherapy for recurrent airway obstruction from hyperplastic granulation tissue.

PURPOSE: Benign endobronchial granulation tissue causes airway obstruction in up to 20% of patients after lung transplantation or stent placement. High-dose-rate endobronchial brachytherapy (HDR-EB) has been successful in some cases refractory to standard bronchoscopic interventions. METHODS AND MATERIALS: Between September 2004 and May 2005, 8 patients with refractory benign airway obstruction were treated with HDR-EB, using one to two fractions of Ir-192 prescribed to 7.1 Gy at a radius of 1 cm. Charts were retrospectively reviewed to evaluate subjective clinical response, forced expiratory volume in 1 second (FEV(1)), and frequency of therapeutic bronchoscopies over 6-month periods before and after HDR-EB. RESULTS: The median follow-up was 14.6 months, and median survival was 10.5 months. The mean number of bronchoscopic interventions improved from 3.1 procedures in the 6-month pretreatment period to 1.8 after HDR-EB. Mean FEV(1) improved from 36% predicted to 46% predicted. Six patients had a good-to-excellent subjective early response, but only one maintained this response beyond 6 months, and this was the only patient treated with HDR-EB within 24 h from the most recent bronchoscopic intervention. Five patients have expired from causes related to their chronic pulmonary disease, including one from hemoptysis resulting from a bronchoarterial fistula. CONCLUSION: High-dose-rate-EB may be an effective treatment for select patients with refractory hyperplastic granulation tissue causing recurrent airway stenosis. Performing HDR-EB within 24-48 h after excision of obstructive granulation tissue could further improve outcomes. Careful patient selection is important to maximize therapeutic benefit and minimize toxicity. The optimal patient population, dose, and timing of HDR-EB should be investigated prospectively.