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Johannes M.A. Daniels

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    IBS20 - Endoscopic Solution to Iatrogenic Complications (Interactive Q and A) (Ticketed Session) (ID 60)

    • Event: WCLC 2019
    • Type: Interactive Breakfast Session
    • Track: Interventional Diagnostics/Pulmonology
    • Presentations: 1
    • Now Available
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      IBS20.01 - Airway Fistulas (Now Available) (ID 3405)

      07:00 - 08:00  |  Presenting Author(s): Johannes M.A. Daniels

      • Abstract
      • Presentation
      • Slides



      Airway fistula as an iatrogenic complication of lung cancer treatments present a particular challenge to the multidisciplinary lung cancer team. It is a rare but very severe complication which requires prompt treatment because of the involved disruption of the natural tissue barriers against infection. Different types of fistulas exist, the most common airway fistulas that are encountered after lung cancer treatment are bronchopleural fistula (BPF) and tracheo or broncho-oesophageal fistula (T/BEF). These are two very different entities that require their own specific management.

      Bronchopleural fistula

      BPF is a feared complication after anatomical resection of lung cancer, occurring in 1-4% of the patients [1-3]. Rare causes of BPF in lung cancer patients can include destruction of the airway wall by direct tumor invasion and airway wall necrosis after high-dose radiotherapy. Presenting symptoms can be cough, empyema, persistent air leak and hemoptysis. Significant dyspnea can occur because of increased dead space ventilation if there is a massive air leak. The diagnosis can be made by bronchoscopy and if the bronchoscopist cannot see a fistula, deposition of methylene blue at the site of the stump can help. In case of persistent air leak and no identifiable airway fistula, an alveolar-pleural fistula (more common) should be considered. Imaging techniques such as chest X-ray and CT scan can help to diagnose ensuing pneumothorax and empyema and in large fistulas can sometimes be visualized.

      The management of BPF can be challenging, especially in complicated empyema, frail patients who have already deteriorated during the postoperative phase and patients that underwent salvage surgery after high-dose radiotherapy [4]. Small BPF (up to 8 mm) without surrounding necrosis can be managed by endoscopically with the help of polyvinyl alcohol sponge and cyanoacrylate glue [5,6]. Larger BPF, presence of airway wall necrosis or failure to close the BPF endoscopically is a reason for surgery. Reconstruction of the stump or anastomosis can be followed by adding a muscle flap to improve perfusion. In case of necrosis, debridement should precede these procedures. Extensive airway necrosis sometimes renders surgical repair impossible. In case of complex empyema, open window thoracostomy can be necessary, especially if more conservative measures have been unsuccessful.

      Tracheo-esophageal and broncho-esophageal fistula

      T/BEF is a relatively common complication in patients with esophageal cancer (5-15%), but rare in lung cancer patients (1%)[7-10]. Symptoms include cough, especially during intake of food or liquids, infection (bronchitis, pneumonia), recurrent aspiration and weight loss. In patients with lung cancer, the most important causes are malignant invasion of the membranous part of the trachea or bronchi and high-dose radiotherapy with involvement of airways in close proximity to the esophagus (trachea and proximal left main bronchus). The diagnosis can be made with contrast-enhanced esophagography, demonstrating displacement of the contrast into the lung. Bronchoscopy can be used to localize the fistula, to determine its extent, to assess the vitality of the surrounding airway wall and to evacuate aspirated liquids and mucus from the central airways.

      Immediate treatment is crucial to avoid deterioration of the patient. To minimize further aspiration, oral intake should be eliminated and adequate measures should be taken to minimize reflux and ensure adequate feeding (e.g. gastro-/jejunostomy or total parenteral nutrition). Small fistulas (up to 5 mm) can be treated endoscopically with cyanoacrylate glue or clips. Larger fistulas can be treated with an esophageal stent, airway stent or a combination: double stenting. In case of insufficient effect of a esophageal stent or concomitant airway obstruction, double stenting is preferable and seems to provide better survival than a single stent [11,12]. It is important to realize that pressure on the fragile tissues between both stents can further enlarge the T/BEF. Often multiple endoscopic interventions are required to achieve and maintain adequate palliation.

      During this presentation the management of airway fistulas will be discussed, with emphasis on the bronchoscopic techniques such as (double) stenting and the application of cyanoacrylate glue. Selection of patients, alternative solutions and specific endoscopic techniques will be important topics.


      Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456–63.

      Boudaya MS, Smadhi H, Zribi H, et al. Conservative management of postoperative bronchopleural fistulas. J Thorac Cardiovasc Surg 2013;146:575–9.

      Bazzocchi R, Bini A, Grazia M, Petrella F. Bronchopleural fistula prevention after major pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2002;22:160.

      Dickhoff C, Otten RHJ, Heymans MW, Dahele M. Salvage surgery for recurrent or persistent tumour after radical (chemo)radiotherapy for locally advanced non-small cell lung cancer: a systematic review. Ther Adv Med Oncol. 2018 Oct 5;10:1758835918804150.

      Cardillo G, Carbone L, Carleo F, Galluccio G, Di Martino M, Giunti R, Lucantoni G, Battistoni P, Batzella S, Dello Iacono R, Petrella L, Dusmet M. The Rationale for Treatment of Postresectional Bronchopleural Fistula: Analysis of 52 Patients. Ann Thorac Surg. 2015 Jul;100(1):251-7.

      Battistoni P, Caterino U, Batzella S, Dello Iacono R, Lucantoni G, Galluccio G. The Use of Polyvinyl Alcohol Sponge and Cyanoacrylate Glue in the Treatment of Large and Chronic Bronchopleural Fistulae following Lung Cancer Resection. Respiration. 2017;94(1):58-61.

      Reed MF, Mathisen DJ. Tracheoesophageal fistula. Chest Surg Clin N Am 2003; 13:271.

      Chen YH, Li SH, Chiu YC, et al. Comparative study of esophageal stent and feeding gastrostomy/jejunostomy for tracheoesophageal fistula caused by esophageal squamous cell carcinoma. PLoS One 2012; 7:e42766.

      Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008; 34:1103.

      Rodriguez AN, Diaz-Jimenez JP. Malignant respiratory-digestive fistulas. Curr Opin Pulm Med 2010; 16:329.

      Freitag L, Tekolf E, Steveling H, Donovan TJ, Stamatis G. Management of malignant esophagotracheal fistulas with airway stenting and double stenting. Chest. 1996;110(5):1155.

      Herth FJ, Peter S, Baty F, Eberhardt R, Leuppi JD, Chhajed PN. Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: a prospective study. Eur Respir J. 2010;36(6):1370. Epub 2010 Jun 4.

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    P2.11 - Screening and Early Detection (ID 178)

    • Event: WCLC 2019
    • Type: Poster Viewing in the Exhibit Hall
    • Track: Screening and Early Detection
    • Presentations: 1
    • Now Available
    • Moderators:
    • Coordinates: 9/09/2019, 10:15 - 18:15, Exhibit Hall
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      P2.11-36 - The Role of FDG-PET Scans in Pre-Invasive Endobronchial Lesions (Now Available) (ID 2010)

      10:15 - 18:15  |  Author(s): Johannes M.A. Daniels

      • Abstract
      • Slides


      Pre-invasive endobronchial squamous lesions, especially high-grade lesions, may serve as risk markers for developing lung cancer. However, it remains difficult to determine whether individual lesions will progress to lung cancer. 18 fluorodeoxyglucose (18F-FDG)-positron emission tomography (PET) is currently used as a golden standard for staging patients with lung cancer and to monitor treatment response. The role of FDG-PET-scans in patients with pre-invasive lesions has not yet been established. In our study we report the outcome of surveillance of 40 subjects with pre-invasive endobronchial lesions and investigate the use of 18F-FDG-PET-scans as part of a surveillance program.


      We retrospectively selected patients with pre-invasive endobronchial lesions who underwent pre-treatment FDG-PET scans at the VU Medical Center Amsterdam between 1995 and 2016. Patients with signs of invasive carcinoma at baseline, as confirmed by histology, were excluded. Autofluorescence bronchoscopy (AFB) was used for tissue sampling. The minimum follow up period was three months and the group underwent close surveillance with repeated AFB. Outcomes included progression-free survival (PFS) and overall survival (OS).


      Among 40 included patients, 17 patients had a positive FDG-PET-scan at baseline of which 13 (76,5%) patients developed lung cancer during follow up. Twenty-three patients had a negative FDG-PET of which 6 (26,1%) developed lung cancer during follow-up. The FDG-PET-positive group had a median progression free survival of 5,0 months and the FDG-PET-negative group 33,0 months (p<0,0001, Figure 2). There was no significant difference in overall survival between both groups.

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      Our present work demonstrates that subjects with pre-invasive endobronchial lesions and a positive FDG-PET scan are at high risk to develop lung cancer. We reported a significantly longer progression free survival in patients with pre-invasive lesions with a negative FDG-PET scan. This suggests that FDG-PET scan can be used to select patients that require more radical cancer treatment.

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