Roswell Park Comprehensive Cancer Center in Buffalo, New York, has been an innovative and consistent leader in the study and treatment of cancer for more than 120 years. The only NCI-designated Comprehensive Cancer Center in upstate New York, Roswell Park excels at treating complex cases using evidence-based approaches to care and, at the same time, embracing newtechnologies and care pathways when they become available.
A recent case treated by interventional pulmonologist Nathaniel Ivanick, MD, FCCP, Assistant Professor of Oncology and Director of Interventional Pulmonary Services at Roswell Park Comprehensive Cancer Center, illustrates this dynamic of managing complex care needs with novel approaches to achieve optimal outcomes.
A 42-year-old woman was referred to Roswell Park Comprehensive Cancer Center by an intensivist at a local hospital for a severe airway obstruction. The woman had experienced severe shortness of breath for two months and could not lie flat on her back due to the severity of her dyspnea and cough. It was originally thought that the patient was suffering from pneumonia or bronchitis, but her condition failed to improve, and she ended up in the intensive care unit, where she suffered from respiratory arrest. She was found to have a severe airway obstruction of both main airway stems.
The patient was stabilized with BiPAP therapy but could only maintain her breathing in an upright posture because of how obstructed the airways were.
“We needed to transfer the patient quickly to our facility, but during the subsequent 24 hours, her breathing with the aid of the BiPAP could not be maintained,” says Dr.Ivanick.“The referring hospital was considering intubation but was cautious because of the risk of airway collapse due to the mass causing the obstruction being located on the anterior side of the mediastinum.They were also considering ECMO as a solution together oxygenated and able to be transferred to our facility.”
Fortunately, the patient was successfully intubated with an endotracheal tube. She remained seated as her airway and hemodynamics could onlybe supported and stabilized in a 30-degree upright position (she was unable to lie flat) and was sub sequently able to be transferred to Roswell Park Comprehensive Cancer Center and to Dr. Ivanick for care.
Diagnosis and Follow-Up Care
Through laboratory testing, a biopsy, and imaging studies, Dr. Ivanick was able to make a diagnosis of lung cancer in the patient.
“Our first course of action was to stabilize the airways and keep them open so she could breathe again on her own,” says Dr. Ivanick. “Then our teams would devise the best course of action to treat the underlying cancer.
Typically, in a case like this, you would use a silicon stent to open both main airway branches to the lungs and the trachea. However, because of the condition of her airways and the severity of her obstruction, I was apprehensive about injury to the airways if I attempted to place a silicone stent. I opted for a newer, hybrid metallic Y stent that has only been available in the U.S. in the last four to five months."
While this new device is not optimal for every case of airway obstruction needing a stent, for a small percentage of patients with very severe obstructions such as this one, the new device is a less risky option that can deliver good outcomes.
“This new device offers us an option for patients who may otherwise be deemed too ill or risky for poor outcomes, "says Dr.Ivanick. “It's a great tool to have and to be able to offer for these kinds of rare yet challenging presentations."
Once the hybrid metallic Y stent was placed by Dr. Ivanick, the patient's condition and breathing improved significantly in a short period. She was extubated at the time of the stent placement and transferred to the ICU forfollow-up care and monitoring as a precautionary measure.
The patient could breathe again on her own without the need for artificialrespiration and was discharged from the hospital after only four days to continueherjourneyintreatingherunderlyinglungcancer.
"We had a very good in itial outcome in this case," explains Dr. Ivanick." We were able to stabilize a critically ill patient's airways severely compromised by previously undiagnosed lung cancer, and also make an accurate diagnosis and get started on the path to treatment and recovery. It's the type of case we see at Roswell Park Comprehensive Cancer Center all the time. It's the kind of case we excel at managing."
Dr. Ivanick has since placed four of the new hybrid metallic Y stents in patients, two of which were for central airway obstructions caused by a malignant mass, while two stents have been used in patients presenting with tracheal esophageal fistulas.