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Li Y, Jiang J, Jiang Q, Lu W, Cui H, Song Y, Li W, Zhang T, Li L. Advanced navigation technology enables endobronchial brachytherapy for peripheral lung cancer: An old technique plays a new role. Brachytherapy 2024; 23:199-206. [PMID: 38161082 DOI: 10.1016/j.brachy.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/19/2023] [Accepted: 12/06/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To investigate the feasibility of super-selectively endobronchial brachytherapy in the treatment of peripheral lung cancer guided by advanced navigation technology. METHODS AND MATERIALS Six patients with peripheral lung tumors successfully underwent treatment with super-selectively endobronchial brachytherapy guided by advanced navigation technology following pathway planning and were subsequently followed up to assess survival and treatment-related toxicities. RESULTS The endobronchial applicators were successfully placed inside the tumors of all patients using advanced navigation techniques according to the pretreatment plan, and brachytherapy was delivered at curative doses after evaluation using radiotherapy planning software. None of the patients showed local progression of the treated lesions during the follow-up for a duration ranging from 11 months to 35 months, with a median follow-up time of 23 months. The patient with the longest follow-up, nearly 3 years, exhibited a stable condition. After undergoing endobronchial brachytherapy, patients predominantly experienced localized fibrosis as indicated. No significant alterations in cardiopulmonary function were detected during the follow-up, and no other adverse effects were found. CONCLUSIONS The use of endobronchial brachytherapy for the curative treatment of peripheral lung cancers is feasible. Furthermore, the development of novel bronchial navigation techniques has the potential to broaden the application of endobronchial brachytherapy.
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Affiliation(s)
- Yishi Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juan Jiang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingfeng Jiang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenli Lu
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haixia Cui
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yanbo Song
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wencong Li
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Zhang
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Longhao Li
- Department of Oncology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Miyake K, Shiroyama T, Satoh S, Adachi Y, Ohira K, Abe Y, Takata S, Masuhiro K, Naito Y, Hirata H, Nagatomo I, Takeda Y, Kumanogoh A. Balloon Dilatation for Bronchoscope Delivery in a Swine Model: A Novel Technique for Ultra-Peripheral Lung Field Access and Accurate Biopsy. Respiration 2024; 103:205-213. [PMID: 38316121 DOI: 10.1159/000536666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION In transbronchial biopsy of peripheral pulmonary lesions, the bronchoscope can reach only a limited depth due to the progressive narrowing of bronchi, which may reduce the diagnostic rate. This study examined the balloon dilatation for bronchoscope delivery (BDBD) technique, employing a novel balloon device to enhance bronchoscopy into the peripheral lung areas. METHODS Anaesthetised swine served as our primary model. Using computed tomography (CT) scans, we positioned virtual targets characterised by a positive bronchus sign and a diameter of 20 mm beneath the pleura. The bronchoscope was navigated along the pathways determined from the CT images. We performed balloon dilatation when bronchial narrowing obstructed progress to assess whether balloon dilatation would enable the bronchoscope to enter further into the periphery. RESULTS We established 21 virtual targets on the CT scans. An average of 12.1 branches were identified along the pathways on the CT scans; however, bronchoscopy without BDBD only allowed access to an average of 6.7 branches. Based on 72 balloon dilatations with 3.0-mm or 4.0-mm ultra-thin bronchoscopes, there was an average increased access of 3.43 and 5.14 branches per route, respectively, with no significant BDBD complications. The bronchoscope was able to reach the planned location along all pathways, and the mean final bronchoscopic endpoints were at an average distance of 14.7 mm from the pleura. Post-procedure CT confirmed biopsy accuracy. CONCLUSION The BDBD technique can enhance access of a flexible bronchoscope into the peripheral lung fields, which could potentially allow more accurate transbronchial interventions for peripheral targets.
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Affiliation(s)
- Kotaro Miyake
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Takayuki Shiroyama
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Shingo Satoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yuichi Adachi
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Kika Ohira
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yuko Abe
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - So Takata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Kentaro Masuhiro
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yujiro Naito
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Haruhiko Hirata
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Izumi Nagatomo
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Yoshito Takeda
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University, Osaka, Japan
- Department of Immunopathology, World Premier Institute Immunology Frontier Research Centre (WPI-IFReC), Osaka University, Osaka, Japan
- Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives, Osaka University, Osaka, Japan
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HE J, XIA G, WANG S, CHEN K. [Application of Rapid HE Staining in Cytological Rapid On-site Evaluation of
Peripheral Lung Cancer Needle Biopsy]. Zhongguo Fei Ai Za Zhi 2023; 26:572-578. [PMID: 37752537 PMCID: PMC10558760 DOI: 10.3779/j.issn.1009-3419.2023.101.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Rapid on-site evaluation (ROSE) is a technique used for simultaneous evaluation of biopsy specimens through rapid cytology staining. Diff-Quik (DQ) staining is the most commonly employed method for cytological rapid on-site evaluation (C-ROSE). However, the utilization of DQ staining for on-site cytological interpretation remains uncommon among pathologists in China, posing challenges to the implementation of C-ROSE. This study aims to assess the application of rapid hematoxylin-eosin (HE) staining and DQ staining for C-ROSE during percutaneous needle biopsy of peripheral lung cancer and evaluate the value of rapid HE staining in C-ROSE. METHODS Computed tomography (CT)-guided lung biopsies were conducted on 300 patients diagnosed with peripheral lung cancer. The patients were randomly assigned to two groups for C-ROSE using either rapid HE staining or DQ staining, and subsequently the two methods were compared and evaluated. RESULTS The concordance rate between C-ROSE and histopathological diagnosis was 96.7%. The median staining time for rapid HE staining was 160 s, while that for DQ staining was 120 s, representing a significant difference between the two groups (P<0.001). However, there were no significant differences observed in terms of total biopsy time, concordance rate with histopathology, cytology specimen peeling rate, and incidence of serious adverse reactions between the two groups (P>0.05). CONCLUSIONS Both staining methods comply with C-ROSE criteria in the biopsy setting of peripheral lung cancer. Rapid HE staining is more aligned with domestic clinical requirements and holds potential for further promotion and adoption in C-ROSE.
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Chang H, Chiu YC, Lee SW, Yen CC, Pai JT, Lee CY, Wu YL, Lee CM, Hsieh YS. Novel light delivery method for performing transbronchial photodynamic therapy ablation to treat peripheral lung cancer: A pilot study. Photodiagnosis Photodyn Ther 2022; 40:103063. [PMID: 35963527 DOI: 10.1016/j.pdpdt.2022.103063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Photodynamic therapy involves using a photosensitizer with l illumination and is recommended for treating early, centrally located lung cancers, but it is not a standard treatment for peripheral lung tumor.. We previously proposed a novel light delivery method, in which lipiodol is perfused into the bronchial tree to increase the scope of illumination via the fiber effect. Herein, we attempted this novel technique under electromagnetic bronchoscope guidance in a hybrid operation room where lipiodol facilitated light diffusion, and evaluated the effectiveness and feasibility of this technique for peripheral lung cancers. METHODS This phase 0 pilot study included three patients with peripheral lung cancers (primary tumors ≤20-mm diameter). The photodynamic therapy was administered using Porfimer sodium as the photosensitizer, and an electromagnetic navigation bronchoscope in a hybrid operating room to guide the catheter to the tumor. This facilitated lipiodol infusion to encase the tumor and permit the transbronchial photodynamic therapy ablation. RESULTS Administering 630 nm 200 J/cm (400mW/500sec) energy through a 3-cm cylindrical diffusing laser fiber was safe; no significant acute complications were observed. Although the treatment outcome was unsatisfactory due to the low light dose, tumor pathology in one case revealed tumor necrosis, with no significant damage to the surrounding lung tissue. CONCLUSIONS Novel light delivery transbronchial photodynamic therapy ablation for peripheral lung tumors is feasible and safe. Additional clinical trials may help determine the best illumination plan and light dose through multiple deliveries from multiple angles.
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Allison RR, Ferguson JS. Photodynamic therapy to a primary cancer of the peripheral lung: Case report. Photodiagnosis Photodyn Ther 2022; 39:103001. [PMID: 35803556 DOI: 10.1016/j.pdpdt.2022.103001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 11/16/2022]
Abstract
Photodynamic therapy (PDT) is an FDA approved treatment for lung cancer. In the United States the photosensitizer porfimer sodium (Photofrin®, Pinnacle Biologics) is intravenously introduced at 2mg/kg. After approximately 48 h, illumination to activate the photosensitizer is initiated, with 630nm red light at 200J/cm, delivered by fiber-optic catheter, brought to the tumor endo- bronchially, and delivered for 500 s. This will create, in the presence of oxygen, a Type II Photodynamic Reaction (PDR) which generates singlet oxygen species that are tumor ablative. Classically, PDT for lung cancer has been employed for symptomatic central and obstructing tumors with great success. This case report describes an innovative approach to treat a peripheral, early stage lung cancer employing magnetic navigation and endobronchial treatment. We report on a 79 year old male with numerous comorbidities including pulmonary fibrosis, who was found to have a biopsy proven peripheral and solitary non-small cell cancer. Due to prior SBRT (stereotactic body radiation therapy) with dose levels causing radiation fibrosis, he was not a candidate for repeat SBRT, and he was not a surgical candidate due to comorbidities. Tumor control with PDT was achieved without treatment related morbidity. This report details our findings.
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Affiliation(s)
- Ron R Allison
- Federal Medical Center, Butner, North Carolina, 27509, USA.
| | - J Scott Ferguson
- Interventional Pulmonology, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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Luo C, Song Y, Liu Y, Wang R, Gao J, Yue S, Ding C. Analysis of the value of enhanced CT combined with texture analysis in the differential diagnosis of pulmonary sclerosing pneumocytoma and atypical peripheral lung cancer: a feasibility study. BMC Med Imaging 2022; 22:16. [PMID: 35105314 PMCID: PMC8808962 DOI: 10.1186/s12880-022-00745-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As a rare benign lung tumour, pulmonary sclerosing pneumocytoma (PSP) is often misdiagnosed as atypical peripheral lung cancer (APLC) on routine imaging examinations. This study explored the value of enhanced CT combined with texture analysis to differentiate between PSP and APLC. METHODS Forty-eight patients with PSP and fifty patients with APLC were retrospectively enrolled. The CT image features of the two groups of lesions were analysed, and MaZda software was used to evaluate the texture of CT venous phase thin-layer images. Independent sample t-test, Mann-Whitney U tests or χ2 tests were used to compare between groups. The intra-class correlation coefficient (ICC) was used to analyse the consistency of the selected texture parameters. Spearman correlation analysis was used to evaluate the differences in texture parameters between the two groups. Based on the statistically significant CT image features and CT texture parameters, the independent influencing factors between PSP and APLC were analysed by multivariate logistic regression. Extremely randomized trees (ERT) was used as the classifier to build models, and the models were evaluated by the five-fold cross-validation method. RESULTS Logistic regression analysis based on CT image features showed that calcification and arterial phase CT values were independent factors for distinguishing PSP from APLC. The results of logistic regression analysis based on CT texture parameters showed that WavEnHL_s-1 and Perc.01% were independent influencing factors to distinguish the two. Compared with the single-factor model (models A and B), the classification accuracy of the model based on image features combined with texture parameters was 0.84 ± 0.04, the AUC was 0.84 ± 0.03, and the sensitivity and specificity were 0.82 ± 0.13 and 0.87 ± 0.12, respectively. CONCLUSION Enhanced CT combined with texture analysis showed good diagnostic value for distinguishing PSP and APLC, which may contribute to clinical decision-making and prognosis evaluation.
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Affiliation(s)
- Chenglong Luo
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Yiman Song
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Yiyang Liu
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Rui Wang
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Jianbo Gao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Songwei Yue
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Changmao Ding
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China.
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Liu Y, Wang F, Zhang QC, Tong ZH. Value of virtual bronchoscopic navigation and transbronchial ultrasound-guided sheath-guided exploration in diagnosis of peripheral lung cancer. World J Clin Cases 2020; 8:3450-3457. [PMID: 32913851 PMCID: PMC7457098 DOI: 10.12998/wjcc.v8.i16.3450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/20/2020] [Accepted: 07/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Peripheral lung cancer poses a substantial harm to human health, and it is easy to become exacerbated, potentially threatening the life and safety of patients
AIM To assess the value of virtual bronchoscopic navigation (VBN) combined with transbronchial ultrasound-guided sheath-guided (EBUS-GS) exploration in the diagnosis of peripheral lung cancer.
METHODS A total of 236 patients with peripheral lung cancer (nodule diameter range, 8-30 mm; diagnosed using high-resolution computed tomography) were selected from three centers between October 2018 and December 2019. Patients who underwent EBUS-GS exploration alone were included in a control group, and those who received VBN in combination with EBUS-GS exploration were included in an observation group. The diagnostic rate and total operating time of different subgroups of the two groups were compared, and the time needed to determine the lesion was recorded.
RESULTS There were no significant differences in diagnosis rate or total operation time between the two groups (P > 0.05), and the time needed to determine the lesion in the observation group was less than that of the control group (P < 0.05).
CONCLUSION The combined use of VBN and EBUS-GS exploration technology has little effect on the diagnosis rate and total operation time of peripheral lung cancer, but it significantly shortens the time needed to determine the lesion and is a valuable diagnostic method.
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Affiliation(s)
- Yong Liu
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Henan Provincial People’s Hospital, Zhengzhou 450003, Henan Province, China
- Department of Respiratory and Critical Care Medicine, Zhoukou Central Hospital, Zhoukou 466100, Henan Province, China
| | - Feng Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Beijing Institute of Respiratory Medicine, Beijing 100020, China
| | - Qun-Cheng Zhang
- Department of Respiratory and Critical Care Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, Henan Province, China
| | - Zhao-Hui Tong
- Department of Respiratory and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
- Beijing Institute of Respiratory Medicine, Beijing 100020, China
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Liu C, Ma C, Duan J, Qiu Q, Guo Y, Zhang Z, Yin Y. Using CT texture analysis to differentiate between peripheral lung cancer and pulmonary inflammatory pseudotumor. BMC Med Imaging 2020; 20:75. [PMID: 32631330 PMCID: PMC7339470 DOI: 10.1186/s12880-020-00475-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/26/2020] [Indexed: 12/13/2022] Open
Abstract
Background This study is to distinguish peripheral lung cancer and pulmonary inflammatory pseudotumor using CT-radiomics features extracted from PET/CT images. Methods In this study, the standard 18F-fluorodeoxyglucose positron emission tomography/ computed tomography (18 F-FDG PET/CT) images of 21 patients with pulmonary inflammatory pseudotumor (PIPT) and 21 patients with peripheral lung cancer were retrospectively collected. The dataset was used to extract CT-radiomics features from regions of interest (ROI), The intra-class correlation coefficient (ICC) was used to screen the robust feature from all the radiomic features. Using, then, statistical methods to screen CT-radiomics features, which could distinguish peripheral lung cancer and PIPT. And the ability of radiomics features distinguished peripheral lung cancer and PIPT was estimated by receiver operating characteristic (ROC) curve and compared by the Delong test. Results A total of 435 radiomics features were extracted, of which 361 features showed relatively good repeatability (ICC ≥ 0.6). 20 features showed the ability to distinguish peripheral lung cancer from PIPT. these features were seen in 14 of 330 Gray-Level Co-occurrence Matrix features, 1 of 49 Intensity Histogram features, 5 of 18 Shape features. The area under the curves (AUC) of these features were 0.731 ± 0.075, 0.717, 0.748 ± 0.038, respectively. The P values of statistical differences among ROC were 0.0499 (F9, F20), 0.0472 (F10, F11) and 0.0145 (F11, Mean4). The discrimination ability of forming new features (Parent Features) after averaging the features extracted at different angles and distances was moderate compared to the previous features (Child features). Conclusion Radiomics features extracted from non-contrast CT based on PET/CT images can help distinguish peripheral lung cancer and PIPT.
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Affiliation(s)
- Chenlu Liu
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China.,Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Changsheng Ma
- Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Jinghao Duan
- Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Qingtao Qiu
- Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Yanluan Guo
- Department of Medical Imaging, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China
| | - Zhenhua Zhang
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China
| | - Yong Yin
- Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250117, Shandong Province, China.
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Abstract
Current advances in guided bronchoscopy methods permit minimally invasive access to essentially any area of the lungs. This provides a potential means to treat patients with localized lung malignancies who might not otherwise tolerate conventional treatment, which commonly relies on surgical resection. Ablation methods have long been used for bronchoscopic treatment of central airway malignancies and percutaneous treatment of peripheral lung cancer. This article reviews ablation technologies being adapted for use with guided bronchoscopy and the current state of investigation for the treatment of peripheral lung malignancies.
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Affiliation(s)
- David W Hsia
- Division of Respiratory and Critical Care Physiology and Medicine, Harbor-UCLA Medical Center, 1000 West Carson Street, Box #402, Torrance, CA 90502, USA.
| | - Ali I Musani
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine and University Hospital, 12631 East 17th Avenue, M/S C323, Office #8102, Aurora, CO 80045, USA
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