Malignant Tracheal Stenosis: A Narrative Review of Current Diagnostic and Therapeutic Approaches

Background: Malignant tracheal stenosis (MTS) is a rare, life-threatening condition caused by primary tracheal tumor, mainly adenoid cystic carcinoma (ACC) and squamous cell carcinoma (SCC), and more rarely other primary neoplasms such as lymphomas, or local extension/metastasis from adjacent malignancies (thyroid, esophageal, lung, or mediastinal cancers). Accounting for <0.1% of respiratory tumors, MTS presents with progressive respiratory failure, requiring urgent multidisciplinary care involving thoracic surgery, interventional pulmonology, oncology, and intensive care. Diagnosis relies on clinical evaluation, advanced imaging and endoscopy. Bronchoscopy (BC) remains the best investigation for direct visualization and biopsy or performing therapeutic maneuvers. Prognosis depends on histology, local extent, and achieving R0 resection. Tracheal resection with primary anastomosis remains the curative standard for resectable cases. Interventional procedures (debulking, laser, cryotherapy, stenting) are essential for palliative management and acute stabilization. Methods: A structured (non-systematic) search of PubMed/MEDLINE, Embase, Scopus, and Web of Science (1965-2025) was performed using MeSH/Emtree terms and free-text keywords. Studies were included if they evaluated adult patients with malignant central airway stenosis, primary tracheal tumors, or secondary invasion undergoing surgical, bronchoscopic, or multimodal interventions, including ECMO support. Results: Malignant tracheal stenosis (MTS)-predominantly adenoid cystic and squamous cell carcinomas-imposes a critical clinical burden despite its low incidence. Complete surgical resection with negative margins remains the curative treatment for resectable disease. In unresectable cases, multimodal palliative interventions (stenting, laser/electrocautery ablation, and mechanical debulking) provide rapid airway restoration and quality-of-life improvements, whereas ECMO is an established rescue or adjunctive support strategy in selected critical airway procedures performed in experienced centers. Three-dimensional bioprinting and tissue-engineered reconstruction remain experimental or early clinical, and bioresorbable stents and artificial intelligence (AI)-based tools remain investigational; none is currently part of routine MTS management. Conclusions: R0 resection for appropriately selected resectable disease and interventional airway management for unresectable symptomatic disease are the best-supported strategies, although the evidence derives mainly from retrospective series from specialized centers. Emerging technologies require prospective validation before clinical adoption. Management should be individualized, multidisciplinary and centralized in experienced airway centers.