The application of photodynamic therapy in the treatment of metastatic endobronchial disease

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.

The Application of Liquid Nitrogen Spray Cryotherapy in Treatment of Bronchial Stenosis

OBJECTIVE

Spray cryotherapy (SCT), the application of liquid nitrogen in a noncontact form, has been demonstrated to have efficacy in treating various types of pathologic lesions of the airway when used as an adjunct with bronchoscopy. The purpose of the study was to evaluate the results of the use of bronchoscopic SCT on the airway in a single institution.

METHODS

We performed a retrospective review of data collected on all patients who underwent SCT to re-establish or improve airway patency in an 11-month period. Patients were classified based on the nature of their disease into benign or malignant. Demographic data, change in luminal patency, and clinical outcomes were recorded. The percent of stenosis was divided into grades according to the following classification: 1, ≤25%; 2, 26% to 50%; 3, 51% to 75%; and 4, ≥76%. We defined successful completion of treatment as obtaining a final patency of grade 1.

RESULTS

Twenty-two patients met inclusion criteria, with 45.5% (10 patients) having benign stenosis and 54.5% (12 patients) malignant. At initial bronchoscopic evaluation, the median grade of stenosis was 4 for malignant disease and 3.5 for benign disease. The median final posttreatment grade of stenosis was 2 for malignant disease and 1 for benign. The median improvement in grade of stenosis after treatment was 2 for both malignant and benign causes (Wilcoxon test, P = 0.92). Final patency of grade 1 was achieved in 42% of malignant stenosis and 80% of benign. Overall, 86.4% of patients had an improvement in grade of stenosis after treatment. The rate of morbidity was 4.5% (1/22) of all patients.

CONCLUSIONS

The median change in grade after treatment was 2 grades of improvement for both the benign and malignant groups. These results provide evidence that the use of SCT is equally efficacious for both types of stenosis with an expectation of overall improvement in luminal patency, offering a safe and effective method of achieving airway patency in a minimally invasive fashion. This study contributes to the small but growing body of literature supporting the use of SCT in benign and malignant disease.

Endobronchial brachytherapy for metastasis from extrapulmonary malignancies as an effective treatment for palliation of symptoms

PURPOSE

Endobronchial metastasis (EBM) originating from primary cancers outside the lung is rare. External beam radiotherapy is often attempted for control of symptoms with variable effectiveness and retreatment is challenging if symptoms recur. There is limited documentation of high-dose-rate brachytherapy for EBM in the literature.

METHODS AND MATERIALS

A prospective database was created from 2006 to 2015. Patients with EBM who received high-dose-rate brachytherapy were included. Cough, dyspnea, chest pain, and hemoptysis were assessed and graded (0-4) at the time of initial consult and in followup. Symptom-free survival and re-expansion were assessed.

RESULTS

Thirty-five patients with EBM were identified. Most patients received three fractions of 700 cGy, and 17 patients had prior external beam radiotherapy. Median symptom-free and overall survival were 67 and 117 days. After brachytherapy, improvement in cough was documented in 75.0%, hemoptysis in 76.4%, dyspnea in 60.0% for a median of 3-6 months. Of the 22 patients who had subsequent chest imaging, re-expansion was documented in 32%. There were no significant toxicities reported.

CONCLUSIONS

Brachytherapy appears effective in achieving durable symptom control of cough hemoptysis, and dyspnea in patients with EBM and should be considered routinely for palliation where available. Further studies are required to better characterize expected symptom improvement, lung re-expansion rates, and efficacy in comparison with other local treatments.

Photodynamic therapy in the management of endobronchial metastatic lesions from renal cell carcinoma

STUDY OBJECTIVES

Bronchoscopic procedures to ablate endobronchial lesions (EBL) from renal cell carcinoma (RCC) are frequently complicated by hemorrhage because of the vascular nature of the metastases. After ablation, recurrence of symptoms from the EBLs is common. Photodynamic therapy (PDT), because of its mode of action, may be a safer and a more effective alternative in the nonemergent management of EBL from RCC.

METHODS

Medical records of patients undergoing PDT at the authors' institutions between December 2005 and December 2008 were reviewed and patients undergoing treatment for EBLs from RCC were identified. Procedure-related complications, 30-day mortality, and efficacy of PDT measured by recurrence in symptoms and the need for additional interventions on the treated EBLs were reviewed.

RESULTS

Eleven patients underwent a total of 13 treatments with PDT. Hemoptysis, with or without symptomatic airway obstruction, was the most common presenting symptom. The most common location for the EBLs was the lobar or segmental bronchi. Six patients had undergone other interventions (rigid bronchoscopy, mechanical debridement, or argon plasma coagulation) before treatment with PDT, with recurrence in symptoms. No immediate complications were seen with PDT and none of the patients had recurrence of symptoms or required airway interventions during the 30-day follow-up. Four patients died at a median of 4 months (range: 3 to 6 mo) after PDT and all deaths were due to progression of cancer and none of the deaths were due to airway complications.

CONCLUSIONS

PDT is a safe and effective option for the management of hemoptysis or airway obstruction caused by EBLs from RCC.