Ann Thorac Surg 2006;82:e22-e23
© 2006 The Society of Thoracic Surgeons
Case report
Topical Mitomycin-C for Obstructing Endobronchial Granuloma
Alvin Penafiel, MD,
Pyng Lee, MD*,
Anne Hsu, MD, FCCP,
Philip Eng, MD, FCCP
Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
Accepted for publication May 10, 2006.
* Address correspondence to Dr Lee, Department of Respiratory and Critical Care Medicine Singapore General Hospital, Outram Road, Singapore 169608 (Email: lee.pyng{at}sgh.com.sg).
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Abstract
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An elderly woman with post-tuberculous stricture of the lower trachea and main bronchi underwent laser re-canalization, balloon dilation, and silicone stent insertion in the lower trachea and main bronchi. Subsequently she had recurrent dyspnea develop due to obstructing granulomas, which necessitated four endoscopic procedures in 2 years. The tracheal stent was removed and topical mitomycin-C was applied using saturated pledgets at a dose of 0.5 mg/mL for 2 minutes each over the lower trachea and both orifices of the main bronchi. Follow-up for 24 months showed no recurrence of symptoms. Bronchoscopy and spirometry performed at 2, 6, and 12 months showed resolution of the granulomas.
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Introduction
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Benign airway stenosis can be treated with laser re-canalization, balloon dilation, or stenting. However recurrent stenosis poses a challenge. We present a symptomatic elderly woman with post-tuberculous stricture who had recurrent obstructing granulomas develop that were successfully managed with topical mitomycin-C (MMC) application as an adjunct to endoscopic therapy.
An elderly woman with post-tuberculous stricture of the lower trachea and main bronchi underwent laser re-canalization and balloon dilation. Due to malacia, three silicone stents were placed in an inverted "Y" configuration over the lower trachea and main bronchi. She subsequently had recurrent dyspnea develop due to obstructing granulomas involving the lower trachea and orifices of both bronchi, which necessitated four endoscopic procedures in 2 years (Fig 1). The tracheal stent was removed and laser treatment was performed to resect granulation tissue at the carina and orifices of the right and left main bronchi. This was followed by the application of topical MMC using saturated pledgets (Fig 2) at 0.5 mg/mL for 2 minutes over each laser treated site, with the bronchial stents left in place. Bronchoscopy, which was performed at 2, 6, and 12 months, showed no recurrence of the granulomas (Fig 3). The patient's spirometry improved at 2 months, which was sustained at 12 months (Table 1). There were no adverse events observed with MMC, and she did not require any further endoscopic therapy during the 20 months of follow-up.
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Comment
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Management of recurrent tracheobronchial stenosis is challenging, and therapeutic options to relieve airway obstruction, such as balloon dilation, laser treatment, endobronchial electrosurgery, cryotherapy, stent placement, or surgical reconstruction can in itself fuel the vicious cycle of mucosal disruption, healing, and granulation tissue formation. Hence the occurrence of airway re-stenosis after surgical reconstruction or endoscopic therapy remains high, and novel techniques are required to manage this complication.
Mitomycin-C is a cytotoxic agent that is isolated from Streptomyces caespitosus, and acts by inhibiting DNA and RNA synthesis through alkylation and cross-linkages. At lower doses of less than 1 mg/mL, MMC has antifibroblast properties [1, 2]. These prolonged, localized effects are not fully understood, but they could be attributed to almost complete irreversible inhibition of fibroblast proliferation or other cellular functions such as cell migration and extracellular matrix production involved in wound healing [3].
Topical MMC has been used extensively in ophthalmology and otolaryngology [4, 5]. Recently it has been used with success as an adjunctive treatment for recurrent bronchial stenosis due to iron pill aspiration [6], endobronchial sarcoidosis [7], and granulation tissue related stenosis in post-lung transplants [8]. We report a case of post-tuberculous stricture with recurrent obstructing granuloma that was successfully treated with MMC with corresponding improvement in symptoms and spirometry. Notwithstanding that the removal of the tracheal stent could have contributed to the resolution of the granuloma, the application of MMC played a complementary role in the prevention of tracheobronchial re-stenosis from granulation tissue formation after laser therapy. We propose the use of topical MMC as an adjunct to endoscopic treatment for recalcitrant benign airway stenosis.
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References
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- Eliashar R, Eliachar I, Esclamado R, Gramlich T, Strome M. Can topical mitomycin prevent laryngotracheal stenosis? Laryngoscope 1999;109:1594-1600.[Medline]
- Jassir D, Buchman CA, Gomez-Marin O. Safety and efficacy of topical mitomycin C in myringotomy patency Otolaryngol Head Neck Surg 2001;124:368-373.[Medline]
- Khaw PT, Sherwood, MD, MacKay SL, Rossi MJ, Schultz G. Five minutes treatments with fluorouracil, floxuridine, and Mitomycin C have long term effects on human Tenon's capsule fibroblasts Arch Ophthalmol 1992;110:1150-1154.[Abstract]
- Lacayo GO, Majmudar PA. How and when to use mitomycin-C in refractive surgery Curr Opin Ophthalmol 2005;16:256-259.[Medline]
- Perepelitsyn I, Shapshay SM. Endoscopic treatment of laryngeal and tracheal stenosis—Has Mitomycin C improved the outcome? Otolaryngol Head Neck Surg 2004;131:16-20.[Medline]
- Lee P, Culver DA, Farver C, Mehta AC. Syndrome of iron pill aspiration Chest 2002;121:1355-1357.[Abstract/Free Full Text]
- Lavergne F, Clerici C, Sadoun D, et al. Bronchial obstruction in bronchial sarcoidosisoutcome of treatment. Chest 1999;116:1194-1199.[Abstract/Free Full Text]
- Erard AC, Monnier P, Spiliopoulos A, Nicod L. Mitomycin-C for control of recurrent bronchial stenosisa case report. Chest 2001;120:2103-2105.[Abstract/Free Full Text]
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Abstract
Introduction
