Laser therapy for an obstructing primary tracheal lymphoma in a patient with AIDS: DISCUSSION (2)
Chemotherapy and/or radiotherapy are the primary treatment modalities of NHL. However, in the present case, neither therapy was appropriate at the time of diagnosis. Chemotherapy was initially rejected because the patient’s high viral load and low CD4+ count created greater potential for an opportunistic infection and a higher risk for death. Moreover, a CD4+ count over 100,000 lymphocytes/pL in HIV/AIDS patients with NHL undergoing chemotherapy is the single most important predictor of survival. Radiation therapy in intubated patients is feasible, but unavailable at our centre.
Tracheal stenting is a potential method of local control to relieve a malignant obstruction. Schmidt et al reported five patients who required temporary airway stenting for mediastinal lymphoma. No patient had endoluminal disease. Stenting of the trachea or main stem bronchi led to clinical improvement in dyspnea and stridor. After tumour-specific
therapy, four patients underwent successful stent removal 14 to 52 days after placement. They concluded that temporary stent-ing was a valuable therapy. In the present case, rigid Dumon stents may have caused significant bleeding with a friable, endotracheal tumour during placement. Expandable stents could potentially have been used, but concerns about the proximity to the carina prevented their use. buy flovent inhaler
Surgical resection of tracheal lymphoma followed by adjuvant therapy is another strategy for airway control. In the present patient, the role of primary surgical therapy was limited because of the extent of the tumour and its proximity to the carina. Additionally, the effect of HIV on wound healing and the patient’s poor performance status all precluded this option. In general, surgical resection is not recommended because of disseminated disease.