Background Benign tracheal stenoses not attributable to iatrogenic or infectious causes represent a rare condition and a constant therapeutic challenge. Clinical onset is generally insidious, characterized by non-specific symptoms such as dyspnea and wheezing. These stenoses can sometimes be associated with systemic symptoms in the context of inflammatory diseases, although in most cases the cause remains unknown. To date, no standard approach for these conditions has been clearly defined, and there is a proportion of patients who, despite therapy, may be at risk of relapse. Aim and Methods The aim of this study is therefore to identify potential predictors of therapeutic success, defined as the time to or absence of tracheal stenosis relapse, based on the rigid bronchoscopy techniques used and endoscopic appearance. For this purpose, we retrospectively collected the clinical, laboratory, and endoscopic data (including review of recorded clips during the bronchoscopic exam), as well as bronchoscopic and medical treatment data of 40 patients with benign tracheal stenosis, either idiopathic or secondary to autoimmune disease, who were treated at the Interventional Pulmonology Service of the Spedali Civili in Brescia between February 2007 and November 2024. Malignant tracheal stenoses and those secondary to iatrogenic or infectious damage were excluded from this study. Results In the study population, there is a clear female predominance (90%), a median age at diagnosis of 48 years (range 30–85), and a notable prevalence of non-smokers (93%). The patients were divided into two groups: 16 patients underwent fewer than 3 procedures during the observation period, and 24 patients underwent 3 or more procedures. No significant differences were found between the two groups in terms of sex, smoking habits, BMI, stenosis etiology, ANCA positivity, or endoscopic features. However, the two groups differ significantly in terms of age at diagnosis: this was lower in the second group (56.5 vs. 45, p=0.006). Multivariate analysis showed that both “age at diagnosis” and “maximum dilation caliber of 13.2 mm” were independent risk factors for relapse (≥3 dilation treatments). Furthermore, univariate analysis showed that pre- and post-treatment medical therapy are associated with relapse within two years after the procedure. Other variables investigated did not show an association with this risk. Discussion In our sample of patients with idiopathic or inflammatory tracheal stenosis, there was a marked prevalence of middle-aged, non-smoking women. Neither etiology, comorbidities, nor endoscopic features correlated with the need for a greater number of dilation interventions. We observed that an earlier age of onset correlates with a higher risk of recurrence, as does maximal dilation (Dumon 13.2 mm). Patients with frequent recurrences proved to be those more frequently treated with systemic medical therapy. Conclusions Endoscopic management of idiopathic and autoimmune-related benign tracheal stenoses is a valid alternative to more invasive approaches such as thoracic surgery or tracheostomy creation. However, there is a high relapse rate and a frequent need for re-treatment. Younger age of onset appears to be associated with a higher risk of relapse. Comorbidities, stenosis etiology, and the various endoscopic treatments available do not seem to influence recurrence time. Further studies are needed to better define the role of medical therapy in association with endoscopic treatment.
Background Le stenosi tracheali benigne non riconducibili a cause iatrogene o infettive rappresentano una condizione rara e una sfida terapeutica costante. L’esordio clinico è generalmente insidioso, caratterizzato da sintomi aspecifici quali dispnea e respiro sibilante. Tali stenosi possono talvolta associarsi a sintomi sistemici nel contesto di malattie infiammatorie, sebbene nella maggior parte dei casi la causa rimanga sconosciuta. Ad oggi, non è stato ancora chiaramente definito un approccio standard di queste condizioni, e vi è una percentuale di pazienti che, nonostante la terapia, potrebbe essere a rischio di recidiva. Scopo e metodi Lo scopo di questo studio è quello, pertanto, di individuare possibili predittori di successo terapeutico, inteso come tempo o assenza di recidiva di stenosi tracheale sulla base delle tecniche di broncoscopia rigida utilizzate e dell’aspetto endoscopico. A tale scopo sono stati raccolti retrospettivamente i dati clinici, laboratoristici, endoscopici (con revisione delle clip registrate durante l’esame broncoscopico), di trattamento broncoscopico e medico di 40 pazienti affetti da stenosi tracheale benigna idiopatica o secondaria a patologia autoimmune, trattati presso il servizio di Pneumologia Interventistica degli Spedali Civili di Brescia tra febbraio 2007 e novembre 2024. Sono state escluse dallo studio le stenosi tracheali maligne, secondarie a danno iatrogeno ed infettivo. Risultati Nella popolazione in studio vi è una netta prevalenza del sesso femminile (90%), una età mediana alla diagnosi di 48 anni (range 30-85), e una netta prevalenza di non fumatori (93%). I pazienti sono stati suddivisi in due gruppi: 16 pazienti sono stati sottoposti a meno di 3 procedure nel periodo di osservazione, 24 pazienti sono stati sottoposti a 3 o più procedure nel periodo di osservazione. Non si osservano differenze significative tra i due gruppi per sesso, tabagismo, BMI, eziologia della stenosi, positività degli ANCA, caratteristiche endoscopiche. I due gruppi differiscono con significatività statistica per quanto riguarda l’età alla diagnosi: inferiore nel secondo gruppo (56.5 vs 45, p=0.006). Dall’analisi multivariata è emerso che sia la variabile “età alla diagnosi” che la variabile “calibro massimo di dilatazione di 13.2 mm”, sono risultati fattori indipendenti di maggior rischio di recidiva ( 3 trattamenti di dilatazione). Inoltre, all’analisi univariata è emerso che la terapia pre e post trattamento si associano a recidiva nell’arco dei due anni successivi alla procedura. Le altre variabili esplorate invece, non si associano a tale rischio. Discussione Nel nostro campione costituito da pazienti affetti da stenosi trachale idiopatica o infiammatoria è emersa una netta prevalenza in donne di mezza età, non fumatrici. Né l’eziologia, né le comorbidità, né le caratteristiche endoscopiche correlano con la necessità di un maggior numero di interventi di dilatazione. È stato osservato che l’età di esordio più precoce correla con un maggior rischio di recidiva, così come la dilatazione massimale (Dumon 13.2 mm). I pazienti con frequenti recidive sono risultati essere i pazienti maggiormente sottoposti a terapia medica sistemica. Conclusioni Il management endoscopico delle stenosi tracheali benigne idiopatiche e secondarie a patologia autoimmune è una valida alternativa ad approcci più invasivi quali la chirurgia toracica o il confezionamento di tracheotomia; tuttavia, vi è un’alta frequenza di recidiva e di necessità di re-trattamento. L’età di esodio più giovanile sembrerebbe essere correlata ad un maggior rischio di recidiva. Le comorbidità, l’eziologia della stenosi e i differenti trattamenti endoscopici disponibili, non sembrano influenzare il tempo di recidiva. Ulteriori studi sono necessari per meglio definire il ruolo della terapia medica associata al trattamento endoscopico.
STENOSI TRACHEALI BENIGNE AD EZIOLOGIA INFIAMMATORIA ED IDIOPATICA: MANAGEMENT ENDOSCOPICO IN BRONCOSCOPIA RIGIDA
DALLA ROSA, INDIA SOFIA
2022/2023
Abstract
Background Benign tracheal stenoses not attributable to iatrogenic or infectious causes represent a rare condition and a constant therapeutic challenge. Clinical onset is generally insidious, characterized by non-specific symptoms such as dyspnea and wheezing. These stenoses can sometimes be associated with systemic symptoms in the context of inflammatory diseases, although in most cases the cause remains unknown. To date, no standard approach for these conditions has been clearly defined, and there is a proportion of patients who, despite therapy, may be at risk of relapse. Aim and Methods The aim of this study is therefore to identify potential predictors of therapeutic success, defined as the time to or absence of tracheal stenosis relapse, based on the rigid bronchoscopy techniques used and endoscopic appearance. For this purpose, we retrospectively collected the clinical, laboratory, and endoscopic data (including review of recorded clips during the bronchoscopic exam), as well as bronchoscopic and medical treatment data of 40 patients with benign tracheal stenosis, either idiopathic or secondary to autoimmune disease, who were treated at the Interventional Pulmonology Service of the Spedali Civili in Brescia between February 2007 and November 2024. Malignant tracheal stenoses and those secondary to iatrogenic or infectious damage were excluded from this study. Results In the study population, there is a clear female predominance (90%), a median age at diagnosis of 48 years (range 30–85), and a notable prevalence of non-smokers (93%). The patients were divided into two groups: 16 patients underwent fewer than 3 procedures during the observation period, and 24 patients underwent 3 or more procedures. No significant differences were found between the two groups in terms of sex, smoking habits, BMI, stenosis etiology, ANCA positivity, or endoscopic features. However, the two groups differ significantly in terms of age at diagnosis: this was lower in the second group (56.5 vs. 45, p=0.006). Multivariate analysis showed that both “age at diagnosis” and “maximum dilation caliber of 13.2 mm” were independent risk factors for relapse (≥3 dilation treatments). Furthermore, univariate analysis showed that pre- and post-treatment medical therapy are associated with relapse within two years after the procedure. Other variables investigated did not show an association with this risk. Discussion In our sample of patients with idiopathic or inflammatory tracheal stenosis, there was a marked prevalence of middle-aged, non-smoking women. Neither etiology, comorbidities, nor endoscopic features correlated with the need for a greater number of dilation interventions. We observed that an earlier age of onset correlates with a higher risk of recurrence, as does maximal dilation (Dumon 13.2 mm). Patients with frequent recurrences proved to be those more frequently treated with systemic medical therapy. Conclusions Endoscopic management of idiopathic and autoimmune-related benign tracheal stenoses is a valid alternative to more invasive approaches such as thoracic surgery or tracheostomy creation. However, there is a high relapse rate and a frequent need for re-treatment. Younger age of onset appears to be associated with a higher risk of relapse. Comorbidities, stenosis etiology, and the various endoscopic treatments available do not seem to influence recurrence time. Further studies are needed to better define the role of medical therapy in association with endoscopic treatment.File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/81352