Therapeutic bronchoscopy in lung cancer. Laser therapy, electrocautery, brachytherapy, stents, and photodynamic therapy

Therapeutic bronchoscopic techniques such as LPR, EC, brachytherapy, stents, and PDT are effective tools in the palliation and local control of lung cancer. Palliation of malignant tracheobronchial obstruction by LPR, stents, brachytherapy, PDT, or a combination thereof results in relief of dyspnea, hemoptysis, and postobstructive pneumonia. Importantly, it avoids intubation in patients with respiratory distress and facilitates the weaning of patients from MV. In the exciting field of lung cancer screening and treatment of early lung cancer, PDT, brachytherapy, EC, and LPR may represent treatment alternatives to surgical resection, especially in a select group of patients with high surgical risk or favorable endobronchial lesions. Clinicians await the results of future studies, which will (1) better define the impact of each treatment modality on patient care in terms of cost, survival, and improvement in quality of life, and (2) determine the optimal combination therapy relative to bronchoscopic and conventional treatment for effective palliation and cure of lung cancer.     

Endobronchial electrocautery

Endobronchial electrocautery was successfully used to treat three patients with major airway obstruction resulting from bronchogenic carcinoma and to establish a diagnosis in a fourth. Electrocautery was applied through fiberoptic bronchoscopes. In two cases, a wire snare was used to remove polypoid lesions and in two others, probes were used to ablate tumor tissue. As a result of high inspired oxygen concentration in one patient, a tracheal fire occurred without injury to the patient. Electrocautery is an available economical tool which has potential value in the diagnosis and therapy of endobronchial obstructing airway lesions.     

Tissue effects of bronchoscopic electrocautery: bronchoscopic appearance and histologic changes of bronchial wall after electrocautery

STUDY OBJECTIVES: To study tissue effects of bronchoscopic electrocautery (BE). DESIGN: In six patients with non-small cell lung cancer, a BE procedure was performed immediately before surgery. After patients were placed on ventilation, normal mucosa on different carinae was treated with a cautery probe (2-mm(2) surface area) at a power setting of 30 W with a variable time of application of 1 to 5 s. Bronchoscopic appearance of the treated area was documented photographically, and histologic changes of the bronchial wall were examined. SETTING: Bronchoscopy unit of a university hospital. MEASUREMENTS AND RESULTS: BE resulted bronchoscopically in whitening of the bronchial mucosa with crater-shaped lesions. After longer duration of BE application, deeper craters with more profound charring were seen. Histologic changes of the lesions showed craters containing a variable amount of necrotic tissue. In one case, thin subsegmental carinae were coagulated and measurements could not be performed. In the remaining five cases, microscopic findings revealed 0.2 +/- 0.1-mm necrosis after 1 s; 0.4 +/- 0.2-mm necrosis after 2 s; 0.9 +/- 0.5-mm necrosis after 3 s; and 1.9 +/- 0.8-mm necrosis after 5 s. A variable degree of tissue damage surrounding the necrotic tissue area was found. In one case, cartilage damage appeared after 3 s of coagulation, and extensive damage of the underlying cartilage was seen in four cases after 5 s of application. CONCLUSIONS: Superficial damage was obtained by short duration of BE (< or = 2 s), and longer duration of coagulation (3 s or 5 s) caused damage to the underlying cartilage. Bronchoscopic appearance after endobronchial electrocautery corresponded with the histologic changes.     

Cryotherapy for liver metastases

Cryotherapy is undergoing a renaissance in the treatment of nonresectable liver tumors. In a prospective case control study we assessed the morbidity, mortality, and efficacy of hepatic cryotherapy for liver metastases. Between January 1996 and September 1999 a total of 54 cryosurgical procedures were performed on 49 patients (median age 66 years, 21 women) with liver metastases. Patient, tumor, and operative details were recorded prospectively. Liver metastases originated from colorectal cancer (n=37), gastric cancer (n=3), renal cell carcinoma (n=2), and other primaries (n=7). Median follow-up was 13 months (1–32). The median number of liver metastases was 3 (range 1–10) with a median diameter of 3.9 cm (range 1.5–11). Twenty-one patients (43%) had cryoablation only, and 28 (57%) had liver resection in combination with cryoablation. One patient (2%) died within 30 postoperative days. Another 13 patients (27%) developed reversible complications. In 19 of 25 patients (76%) with preoperatively elevated serum CEA and colorectal metastases it returned to the normal range postoperatively. Twenty-eight patients (57%) developed tumor recurrence, eight of which with involvement of the cryosite. Overall median survival patients was 23 months, and survival in patients with colorectal metastases was 29 months. Hepatic cryotherapy is associated with tolerable morbidity and mortality. Efficacy is demonstrated by tumor marker results. Survival data are promising; however, long-term results must be provided to allow comparison with other treatment modalities. Accepted: 14 April 2000     

Cryotherapy for inoperable rectal cancer

Summary Cryotherapy was used for palliation of symptoms in seven patients with inoperable rectal cancer and in one with perineal recurrence of cancer after abdominoperineal resection. Bleeding was controlled, obstruction was relieved and colostomy was not required. These benefits were related to reduction of tumor bulk. It appears that cryotherapy can compete successfully with irradiation and electrocoagulation in the management of selected cases of inoperable rectal cancer. Ease of administration, relief of symptoms, lessened risk, and avoidance of colostomy are advantages which indicate the general suitability of cryotherapy for the patient with inoperable cancer who cannot tolerate major operations. Read at the meeting of the American Proctologic Society, New Orleans, Louisiana, April 17 to 19, 1967.     

Pancreatic division by electrocautery in pancreatoduodenectomy

To assess whether electrocautery is appropriate for cutting the pancreas in pancreatoduodenectomy, we compared leakage of the pancreatojejunostomy (PJ-stomy) in patients who underwent pancreatic division by electrocautery and with a conventional scalpel, in a retrospective study. Eighty-four patients with invaginating end-to-end PJ-stomies (performed in the period 1986—1996) were enrolled in this study; 34 patients underwent pancreatic division with a conventional scalpel (group A) and 50 by electrocautery (group B). Of the 84 patients, 12 (14%) had leakage from the PJ-stomies. In relation to consistency of the pancreatic parenchyma, the incidence of leakage in patients with hard pancreas (1/28; 3.6%) was significantly lower than that in patients with soft or moderate pancreas consistency (11/56; 20%) (P < 0.05). Nine patients (27%) in group A and 3 (6%) in group B presented with leakage. The incidence of leakage was significantly lower in group B than in group A (P < 0.05). Even when patients with hard pancreas were excluded, the incidence of leakage was significantly lower in group B (3/34; 9%) than in group A (8/22; 36%) (P < 0.05). These results suggest that pancreatic division by electrocautery can reduce the incidence of leakage from the pancreatojejunostomy and make pancreatoduodenectomy a safer procedure.     

Endobronchial electrosurgery: argon plasma coagulation and electrocautery

Endobronchial electrosurgery is used to remove endobronchial lesions in the trachea and bronchi, using either a rigid or a flexible bronchoscope. The thermal property of electric current is used to destroy tissue or coagulate bleeding sites. Electrosurgery, electrocautery, electrotherapy, and surgical diathermy are terms often used when referring to the use of heat for tissue destruction. In this article, we specifically use the term electrocautery ( EC) to describe an electrosurgical technique that requires probe-to-tissue contact whereby the conduction of electric current ionizes air resulting in tissue destruction or hemostasis or both. In contrast, argon plasma coagulation (APC) is a relatively new electrosurgical method whereby argon gas is ionized by an electric current to create a noncontact, homogeneous "bridge" to target tissue for coagulation or ablation. Both EC and APC are effective in ablating and coagulating tissue. In this article, we further elucidate the basic principles of electrosurgery; indications, complications, and techniques associated with both EC and APC; and how they compare with other standard endobronchial interventions, including mechanical debridement, laser photoresection, cryotherapy, photodynamic therapy (PDT), and brachytherapy.     

Vascular brachytherapy and the strontium90 vascular brachytherapy system

Restenosis remains a vexing problem in patients undergoing percutaneous coronary interventions (PCI). This phenomenon is related to a combination of events, including elastic recoil, negative remodeling and fibrointimal tissue proliferation. While stenting (bare metal and drug eluting) has made a dramatic impact in preventing recoil and remodeling, restenosis still occurs. Once restenosis occurs, it presents its own set of challenges due to the excess tissue proliferation. Major predicators of restenosis include diabetes, small stent diameter and long stented lesions. Vascular brachytherapy is the only proven therapy associated with a significant reduction in angiographic restenosis and the need for target vessel revascularization for the treatment of in-stent restenosis.     

Tracheal polyp treated with endobronchial electrocautery

Fibroepithelial polyps of trachea are extremely rare. Here, we report a case of tracheal polyp in a 40-year-old woman that was managed successfully with endobronchial electrocautery with a review of the relevant literature.     

Therapeutic bronchoscopy with immediate effect: laser, electrocautery, argon plasma coagulation and stents.

Minimally invasive diagnostic and therapeutic approaches in medicine have been applied for a more selective and tailored approach to reduce patients' morbidity and mortality. The efficacy of interventional pulmonology for palliation of patients with central airways obstruction has been established and its curative potential for intralesional treatment of early cancer has raised great interest in current screening programmes. This is due to the fact that surgical resection and systemic nodal dissection as the gold standard is relatively morbid and risky, especially when dealing with individuals with limited functional reserves due to smoking-related comorbidities, such as chronic obstructive pulmonary disease. Furthermore, such comorbidities have been proven to harbour early stage lesions of several millimetres in size without involvement of nodal disease that may be amenable to local bronchoscopic treatment. Therefore, the success of minimally invasive strategies for palliation and treatment with curative intent strongly depends on the diligent identification of the various factors in lung cancer management, including full comprehension of the limits and potential of each particular technique. Maximal preservation of quality of life is a prerequisite in successfully dealing with individuals at risk of harbouring asymptomatic early lung cancer, to prevent aggressive surgical diagnostic and therapeutic strategies since overdiagnosis remains an issue that is heavily debated. In the palliative setting of alleviating central airway obstruction, laser resection, electrocautery, argon plasma coagulation and stenting are techniques that can provide immediate relief, in contrast to cryotherapy, brachytherapy and photodynamic therapy with delayed effects. With curative intent, intraluminal techniques that easily coagulate early stage cancer lesions will increase the implementation of interventional pulmonology for benign and relatively benign diseases, as well as early cancer lesions and its precursors at their earliest stage of disease.     

Cryotherapy in early superficial bronchogenic carcinoma.

BACKGROUND: Treatment of early superficial bronchogenic carcinoma (ESBC) is under debate, and no consensus has been achieved. Different therapeutic methods have been proposed, including surgical resection and endoscopic methods. STUDY OBJECTIVE: To assess the efficacy of cryotherapy in patients with ESBC. Patients and methods: Patients included in the study had histologically proven ESBC after fiberoptic bronchoscopy. Cryotherapy was performed through a rigid bronchoscope. Efficacy was assessed by endoscopy with multiple biopsies 1 month after treatment and during the follow-up period. Parameters studied were response to treatment, adverse effects, and survival. RESULTS: We included 35 patients (34 men and 1 woman). The mean age was 61 +/- 9 years. Multiple locations of ESBC were observed in seven patients (20%). Complete response rate at both 1 month and 1 year was 91% (32 patients). No severe adverse effects were noted. Local recurrence was observed within 4 years in 10 patients (28%). A follow-up period of at least 4 years was available in 22 patients; of them, 11 patients (50%) were long-term survivors. CONCLUSION: Our results suggest that cryotherapy is an effective method of treatment in patients with ESBC. Due to its relative tolerance compared to surgery, cryotherapy could be proposed as a first-line therapy in this population with high carcinogenic risk.