Tracheobronchial Polyflex stents for the management of benign refractory hypopharyngeal strictures

AIM:To describe a modified technique for placement of a tracheobronchial self-expanding plastic stent(SEPS) in patients with benign refractory hypopharyngeal strictures in order to improve dysphagia and allow stricture remodeling.METHODS:A case series of four consecutive patients with complex hypopharyngeal strictures after combinedtherapy for laryngeal cancer,previously submitted to multiple sessions of dilation without lasting improvement,is presented.All patients underwent placement of a small diameter and unflared tracheobronchial SEPS.Main outcome measurements were improvement of dysphagia and avoiding of repeated dilation.RESULTS:The modified introducer system allowed an easy and technically successful deployment of the tracheobronchial Polyflex stent through the stricture.All four patients developed complications related to stent placement.Two patients had stent migration(one proximal and one distal),two patients developed phanryngocutaneous fistulas and all patients with stents in situ for more than 8 wk had hyperplastic tissue growth at the upper end of the stent.Stricture recurrence was observed at 4 wk follow-up after stent removal in all patients CONCLUSION:Although technically feasible,placement of a tracheobronchial SEPS is associated with a high risk of complications.Small diameter stents must be kept in place for longer than 3 mo to allow adequate time for stricture remodeling.

Health Related Quality of Life and Biochemical Markers for Cachexia Evaluation in Head and Neck Cancer Patients

Cachexia is a multifactorial syndrome related to unintentional weight loss and to loss of muscle and fat mass. In head and neck cancer (HNC) its incidence is important and not only related to a deficient intake of food due to the impact of the disease in the vital functions. A complex disturbance in the normal metabolism of the patient promotes a persistent inflammatory state and a shifting in the metabolism balance toward a catabolic predominance affecting primarily the skeletal muscle. This leads to severe impairment of the functional, emotional and social status and quality of life of the patients that will compromise response to treatment and the disease prognosis. Understanding this deleterious syndrome and mainly identifying it in early stages of the disease is of a major importance in achieving better outcomes to head and neck cancer patients. This study pretends to identify clinical aspects related to cachexia in HNC in a clinical perspective for application on the routine clinical practice. In our study, 30 HNC patients were enrolled and evaluated in terms of nutritional values (actual and loss of weight in the past 6 months, body mass index (BMI), nutritional risk index (NRI), malnutrition universal screening tool), serum biochemical markers (albumin, total proteins, cholesterol, triglycerides, urea, C-reactive protein (CRP), interleukin-6 (IL-6), tumour necrosis factor-α (TNF-α) and myostatin) and health related quality of life (HRQoL) evaluation (using European Organisation for the Research and Treatment of Cancer (EORTC) quality of life questionnaires (QLQ): EORTC QLQ-C30 and EORTC QLQ-HN43). A minimum follow-up of 48 months was considered for all patients. Our results showed that NRI is a good and sensitive index to identify cachexia. This index uses two parameters, one constitutional (loss of weight) and one biochemical (level of serum albumin). According to this criterion, 16 patients were assigned to the No-cachexia group and 14 patients to the Cachexia group. Significant differences in the constitutional and nutritional values between the two groups were found: the median weight loss was 4.44 kg in the No-cachexia group and 11.29 kg in the Cachexia group, while the BMI was 21.88 and 18.33, respectively. In terms of biochemical markers, significant low values of albumin and cholesterol in the Cachexia group were encountered when compared to the No-cachexia group. Regarding the inflammatory and cachexia biomarkers studied, the results show that patients in the Cachexia group had significantly higher levels of CRP and of the proinflammatory cytokines IL-6 and TNF-α and presented significantly raised levels of the myostatin. In terms of HRQoL evaluation, the scores of the EORTC QLQ-C30 revealed that all the scales and the Summary Score showed lower scores in the Cachexia group, indicating worst quality of life evaluation. The items scores were globally higher in the Cachexia group indicating more important problems related to those items in the Cachexia group. The difference encountered between the groups was significant (p < 0.001) in all considered scales but two: Dyspnoea and Constipation. Considering the EORTC QLQ-HN43 all the scales and in all single items but one (Wound Healing) the scores were higher in the Cachexia group, indicating a worst degree of problems affecting these group of patients. The difference found between the groups was significant (p < 0.001) in all scales and items but six: Dry Mouth and Sticky Saliva, Skin problems, Problems with Teeth, Trismus, Social Contact and Wound Healing. There were no significant differences in the clinical presentation of the disease between the two groups. The median survival was of 13.5 months in the Cachexia group, significantly lower when compared to the No-cachexia group (p < 0.0001), confirming the major impact of cachexia in survival and clinical outcomes in HNC patients. These results of our study show that HRQoL evaluation and serum biochemical markers are sensitive and important tools in identifying and screening cachexia in HNC patients. The methodology followed in this study correlating HRQoL with biochemical markers supports the development of clinical protocols in HNC that include cachexia evaluation. Hopefully this new approach can help to improve prognosis of the disease.