Introduction Treatment of malignant tracheoor broncho-oesophageal fistulas (TOF) using therapeutic bronchoscopy (TB) is not standardised and its outcomes are poorly described. This study aimed to analyse the characteristics of patients treated with TB for a TOF and to identify prognostic factors. Methods We analysed data from 96 patients undergoing TB for TOF entered in the EpiGETIF registry between January 2019 and December 2022. Results The mean age was 61.4 years. Median survival after TB was 2.40 months (95% CI 1.81-3.32). Histology was mainly represented by oesophageal (72%) and lung (23%) cancers and did not influence prognosis (p=0.15), whereas smoking did (2.17 versus 3.32 months for nonsmokers, p=0.04). Patients with poor performance status (Eastern Cooperative Oncology Group >2) had shorter survival (1.99 versus 3.02 months, p=0.04). 69% of patients had already received oncologic treatment, with no difference in survival (3.02 versus 2.21 months for treatment-naive patients, p=0.14). Neither the localisation (trachea 61.5%, left main bronchus 34.4%, other 4.1%) nor the size of the fistulas (23% <5 mm, 20% 5-10 mm, 54% >10 mm) impacted survival (p=0.91 and p=0.83, respectively). An airway stent (AS) was placed in 92.7% of patients, mainly self-expanding metallic stents (45%). Patients treated with both an oesophageal stent and AS had a better prognosis than patients treated with an AS alone (2.88 versus 1.77 months, respectively, p=0.02). Conclusion Survival of patients treated with TB for a TOF is very poor, and is impacted by smoking, performance status and the presence of an oesophageal stent.

INTRODUCTION:Therapeutic bronchoscopy (TB) is considered a safe and effective treatment for patients with malignant central airway obstruction (MCAO). While many factors have been associated with technical success, it does not always translate in clinical success. Few factors to predict clinical response have been described. The objective of this study was to determine predictive factors of clinical success for patients with MCAO undergoing TB. METHODS:We used the multicenter prospective registry EpiGETIF to collect data from patients with MCAO undergoing TB from January 2019 to June 2021. The criterion for clinical success was dyspnea measured on the Borg scale. Patients were classified as super responders if they had an improvement of 4 points after the procedure. Uni- and multivariate analyses were performed to highlight an association between preprocedural features and clinical success. RESULTS:A total of 496 patients from 24 centers met inclusion criteria. The mean preprocedural Borg score was 6.5 ± 2.0 versus 2.2 ± 1.7 postprocedural (mean difference 4.3 ± 2.3). Overall, 302 patients (60.9%) were considered super responders. The only factor associated with super responders in multivariate analysis was a higher baseline Borg score. The only factor associated with non-super responders was a poor performance status and mechanical ventilation. CONCLUSION:Patients show good clinical results following TB for MCAO, influenced positively by a worse pre-procedure dyspnea and negatively by a worse performance status. No other data could help predict the effectiveness of TB, confirming the complexity of the process and heterogeneity of the target population.

Background and Objective: Little is known about malignant central airway obstruction (MCAO) complicating the metastatic spread of non-bronchogenic solid cancers (NBC) and their bronchoscopic management. This study aimed to describe the epidemiology of this population and determine prognostic factors before therapeutic bronchoscopy (TB). Methods: In this multicenter study using the EpiGETIF registry, we analysed patients treated with TB for MCAO caused by NBC between January 2019 and December 2022. Results: From a database of 2389 patients, 436 patients (18%) with MCAO and NBC were identified. After excluding patients with direct local invasion, 214 patients (8.9%) were analysed. The main primaries involved were kidney (17.8%), colon (16.4%), sarcoma (15.4%), thyroid (8.9%) and head and neck (7.9%) cancers. Most patients (63.8%) had already received one or more lines of systemic treatment. Obstructions were purely intrinsic in 58.2%, extrinsic in 11.1% and mixed in 30.8%. Mechanical debulking was used in 73.4% of cases, combined with thermal techniques in 25.6% of cases. Airway stenting was required in 38.4% of patients. Median survival after TB was 11.2 months, influenced by histology (p = 0.002), performance status (p = 0.019), initial hypoxia (HR 1.45 [1.01-2.18]), prior oncologic treatment received (HR 1.82 [1.28-2.56], p < 0.001) and assessment of success at the end of the procedure (HR 0.66 [0.44-0.99], p < 0.001). Complications rate was 8.8%, mostly mild, with no procedure-related mortality. Conclusion: TB for MCAO caused by a NBC metastasis provides rapid improvement of symptoms and prolonged survival. Patients should be promptly referred by medical oncologists for bronchoscopic management based on the prognostic factors identified.

Background and Objective EpiGETIF is a web-based, multicentre clinical database created in 2019 aiming for prospective collection of data regarding therapeutic rigid bronchoscopy (TB) for malignant central airway obstruction (MCAO). Methods Patients were enrolled into the registry from January 2019 to November 2022. Data were prospectively entered through a web-interface, using standardized definitions for each item. The objective of this first extraction of data was to describe the population and the techniques used among the included centres to target, facilitate and encourage further studies in TB. Results Overall, 2118 patients from 36 centres were included. Patients were on average 63.7 years old, mostly male and smokers. Most patients had a WHO score <= 2 (70.2%) and 39.6% required preoperative oxygen support, including mechanical ventilation in 6.7%. 62.4% had an already known histologic diagnosis but only 46.3% had received any oncologic treatment. Most tumours were bronchogenic (60.6%), causing mainly intrinsic or mixed obstruction (43.3% and 41.5%, respectively). Mechanical debulking was the most frequent technique (67.3%), while laser (9.8%) and cryo-recanalization (2.7%) use depended on local expertise. Stenting was required in 54.7%, silicone being the main type of stent used (55.3%). 96.3% of procedure results were considered at least partially successful, resulting in a mean 4.1 points decrease on the Borg scale of dyspnoea. Complications were noted in 10.9%. Conclusion This study exposes a high volume of TB that could represent a good source of future studies given the dismal amount of data about the effects of TB in certain populations and situations.

"Outcomes of Therapeutic Bronchoscopy in Malignant Airway Obstruction Causing Acute Respiratory Failure." Annals of the American Thoracic Society, 21(5), pp. 833–837

Introduction: Bronchoscopic treatment of malignant tracheo-or broncho-oesophageal fistula (TOF) is not well standardized and its outcomes poorly known. This study aimed to describe the population of patients undergoing therapeutic bronchoscopy (TB) for a TOF and to identify prognostic factors. Methods: We analyzed data prospectively collected in the French EpiGETIF registry from all patients undergoing TB for a TOF, with or without airway stenting (AS). Results: 96 patients were treated from January 2019 to December 2022. Mean age was 61.4 (±9.5 SD)years old. Median survival after TB was 2.4 months. Histology distribution was dominated by oesophageal (72%) and lung (23%) cancers and did not influence prognosis (p=0.15), while tobacco did (2.2 vs 3.3 months for non-smokers, p=0.04). Patients with an altered performance status (PS>2) had a lower survival compared to others (1.9 vs 3.0 months, p=0.04). 68.8% of patients were pretreated, with no significant difference in survival (3.0 vs 2.2 months for treatment-naïve patients, p=0.14). Fistulas were mostly into the trachea (61.5%) or the left main bronchus (34.4%). 23% of TOF were < 5 mm, 20% 5-10 mm and 54% > 10 mm, without impact on survival (p=0.83). AS was performed in 92.7% of patients, mostly covered self-expandable metallic stents (45%) and silicone stents (44%). Patients who underwent both oesophageal and AS had a better survival compared to patients treated only with AS (2.8 and 1.7 months, respectively, p=0.03). Conclusion: Bronchoscopic treatment of TOF is associated with a poor survival that is related with tobacco use, PS and the absence of an oesophageal stent, but not with histology, previous treatments or the size of the fistula.

BackgroundMedical thoracoscopy (MT) is the gold-standard to investigate unexplained pleural exudates. However, the major prerequisite is an easy pleural access obtained by creating an artificial pneumothorax at the beginning of the procedure which can be a challenge in case of pleural adhesions and make the procedure unsafe. The detection of pleural adhesions prior to MT is necessary. Nowadays chest ultrasonography (CUS) is considered the best procedure to detect pleural adhesions. However, this technique is not available in all countries where the assessment of the pleural cavity is only based on chest radiography. Therefore, we conducted this study to compare the performance of lateral decubitus chest radiography (LDCR) and CUS to predict pleural adhesions.MethodsLDCR and CUS were performed prior MT in consecutive patients presenting exudative pleural effusion to detect pleural adhesions. The diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for each pre thoracoscopy procedure were calculated.ResultsData analysis for the sixty-six enrolled patients showed a higher superiority to detect pleural adhesions for CUS in comparison to LDCR for all the parameters analyzed.ConclusionsThese results confirm that pre-MT CUS is the cornerstone to evaluate the access to the pleural cavity and justify educational program in this field in all centers which intends to develop interventional pulmonology.

Pleural metastasis of thyroid carcinoma is very rarely encountered in the evaluation of pleural effusion and diagnosis may be challenging. However, an anaplastic transformation of papillary thyroid carcinoma (PTC), although a rare condition, should be considered even after a prolonged period of patient follow‐up. Here we report a case of anaplastic thyroid carcinoma mimicking malignant pleural mesothelioma diagnosed nine years after the initial diagnosis of PTC and detail the clues used to orient and confirm the diagnosis.

Saber-sheath trachea (SST) was first described by Greene and Lechner in 1975 [1] and is characterized by the reduction of the coronal diameter and elongation of the sagittal diameter of the intrathoracic trachea. SST is most frequently associated with chronic obstructive pulmonary disease (COPD) but can also be seen in bronchiolitis obliterans syndrome following lung transplantation. Despite an unclear pathophysiology, SST seems to be related to the functional severity of airway obstruction and lung hyperinflation [2]. Elevated intrathoracic pressure induces chronic remodeling and bending of the tracheal cartilage rings without causing mucosal damage. STT diagnosis is made when the tracheal index, on computed tomography, is lower than 0.67. This index is defined as the ratio between coronal and sagittal tracheal diameters in the axial plane located 1 cm above the upper edge of the aortic arch. Bronchoscopy confirms the diagnosis and establishes the degree of expiratory collapse. There is no specific treatment for this entity. We present a 71-year-old male patient with severe COPD and uncommon SST in whom the lateral collapse of the cartilages induced chronic and repetitive mucosal contact points. This phenomenon created symmetrical mucosal nodules at the level of each tracheal ring (Fig. 1; online suppl. video, www.karger.com/doi/10.1159/000488246). These nodules are described as metaplasia by the pathologists. a b

Metastatic pleural effusion (MPE) is one of the most frequent causes of pleural effusion. The aims of the therapeutic management are palliation of symptoms and improvement in patient's quality of life. The first step is a therapeutic thoracentesis. In case of a recurrent MPE, pleural maneuvers can be used to manage symptoms based on either ambulatory pleural drainage or pleurodesis to prevent fluid accumulation. The aim of this review is to describe recent advances, according to the best available evidence, in the field of pleurodesis for the management of MPE.Three different searches of the most clinically relevant articles and up-to-date results in the field of pleurodesis for the management of MPE were performed using PubMed. Different indexing terms and time restriction were chosen. From these PubMed searches, 322 articles were respectively found. After cross-checking these three lists and the selection of articles published after January 2010 specially dedicated to the management of MPE by pleurodesis, the abstracts of 106 articles were extracted to feed the corpus of this review.Treatment approaches of recurrent MPE should take into account multiple factors in particular patient's life expectancy and preference. If talc is the best sclerosing agent alone or in combination with indwelling pleural catheter which is a promising strategy, the pathophysiology of MPE has to be revisited in order to propose a personalized management targeting intrapleural key molecules involved in the genesis of malignant process.

Background: Benign stenosis involving laryngeal and upper tracheal structures represents a therapeutic challenge. Open surgery and endoscopic management have to be discussed by a multidisciplinary board in order to evaluate the risk and benefit for each patient. Objective: The objective of this retrospective study was to report the experience of two French centers with transcordal silicone stents (TSS) in the endoscopic management of benign laryngotracheal stenosis (BLTS) in adults, with focus on efficacy, safety, and tolerability. Methods: We performed a retrospective chart review of all cases of BLTS treated with TSS between January 2001 and June 2017 at two tertiary centers in France: the Centre Hospitalier Régional Universitaire de Strasbourg and the Hôpital Nord de Marseille. Results: A total of 17 patients were included. Eleven had a tracheostomy at initial management which consisted of 8 T-tubes and 9 strictly endoluminal stents placements. The main complications were minor aspirations in 5 patients (29%), granulation in 3 patients (18%), migration in 2 patients (12%), and severe dysphonia in 3 patients (18%). After a mean duration of 18.3 months, 11 patients (65%) had had their TSS definitely removed, 13 patients were tracheostomy free (76%), and a TSS remained in place in 4 patients (24%). Conclusions: Adult BLTS treatment with TSS placement is associated with low morbidity and excellent clinical outcomes, with a large proportion of patients free of airway instrumentation on long-term follow-up.

Les bonnes pratiques actuelles pour la réalisation d’une thoracoscopie recommandent le repérage de la porte d’entrée par l’imagerie thoracique afin d’identifier les adhérences et les zones symphysées pour diminuer les complications notamment les saignements. Si l’échographie thoracique (ET) est actuellement la pierre angulaire de cette évaluation, elle n’est pas encore réalisée de principe et notamment dans certains pays francophones. Nous avons mené cette étude pour comparer les performances de la radiographie thoracique en décubitus latéral (RTDL) et de l’échographie thoracique (ET) dans la prédiction des adhérences pleurales. Étude transversale, descriptive et analytique de novembre 2015 à avril 2017 portant sur des dossiers colligés de façon consécutive à partir d’une base de données institutionnelle. Il s’agissait de dossiers de patients qui présentaient un épanchement pleural, qui avaient bénéficié d’une RTDL suivie d’une ET au préalable d’une thoracoscopie médicale (TM). La sensibilité diagnostique, la spécificité, la valeur prédictive positive (VPP), la valeur prédictive négative (VPN) et la précision pour les deux examens ont été calculées. Les données étaient saisies sur un fichier Excel puis transférées sur un logiciel Epi Info TM pour être analysées. Soixante-six ont été inclus en 26 mois. L’âge moyen était de 67,6 ans. La sex-ratio était de 2,14. La sensibilité d’une opacité segmentée sur une RTDL dans la prédiction de cloisons intra-pleurales était de 63,4 % et sa spécificité de 44,0 %. Sa valeur prédictive positive était de 65 %, sa valeur prédictive négative de 42,3 % et sa précision diagnostique de 56,1 %. La sensibilité de l’ET dans la prédiction de cloisons intra-pleurales était de 92,7 % et sa spécificité de 84,0 %. Sa valeur prédictive positive était de 90,5 %, sa valeur prédictive négative de 87,5 % et sa précision diagnostique de 89,4 %. L’analyse des données a montré que l’ET est supérieure à la RTDL dans la prédiction des adhérences pleurales. L’utilité de l’ET justifie la nécessité de la mettre en place dans tous les centres de prise en charge des pathologies pleurales, accompagnée de la formation des pneumologues à sa pratique.

Les stenoses benignes, touchant les structures laryngees et tracheales hautes, representent un challenge therapeutique. La decision chirurgicale ou endoscopique interventionnelle doit etre evaluee par une equipe multidisciplinaire afin de mesurer la balance benefices-risques pour chaque patient. Objectifs : l’objectif de cette etude retrospective est de rapporter l’experience de 2 centres francais utilisant des protheses transcordales (PTC) en silicone pour la prise en charge endoscopique des stenoses laryngotracheales benignes (SLTB), en precisant l’efficacite, les complications et la tolerance de celles-ci. Methodes : nous avons procede a un recueil retrospectif de tous les cas de SLTB traitees par PTC, entre janvier 2001 et juin 2017, de 2 centres de soins tertiaires francais : le centre hospitalier regional universitaire de Strasbourg et le centre hospitalier universitaire Nord de Marseille. Resultats : dix-sept patients ont ete inclus. Onze avait une tracheotomie lors de leur prise en charge initiale qui consistait en la mise en place de 8 tubes en T et de 9 protheses droites. Les principales complications rapportees etaient des troubles mineurs de la deglutition chez 5 patients (29,4%), des granulomes chez 3 patients (17,6%), une migration de prothese chez 2 patients (11 ,7%), et une dysphonie severe chez 3 patients (17,6%). Apres une duree moyenne de 18,3 mois, la PTC de 11 patients (64,7%) a pu etre definitivement retiree, 13 patients (76,4%) n’ont plus de tracheotomie et 4 patients (23,5%) ont toujours une PTC en place. Conclusion : le traitement des SLTB de l’adulte par PTC est associe a une faible morbidite et un excellent pronostic avec une majorite de patients sevres de materiels prothetiques au long cours.