Intratumoral ethanol injection for malignant tracheobronchial lesions: a new bronchofiberscopic procedure

Bronchial ethanol injection therapy for airway obstruction in lung cancer patients

Obstructive endobronchial tumours often cause decreased quality of life. Bronchial ethanol injection (BEI) therapy is considered an effective modality for airway dilatation or haemoptysis without specialist equipment. Here, we report experiences of two cases in which BEI therapy was effective for obstructive endobronchial tumours. In Case 1 with adenoid cystic carcinoma of the lung, BEI therapy and balloon dilatation were performed as treatment for the left main bronchus restenosis after metallic stent insertion. In Case 2 with squamous cell carcinoma of the lung, BEI therapy was performed after radiation therapy to the lesion that recurred in the entrance of the superior segment of the right lower lobe. Tumour progression was controlled with multiple BEI therapy. We consider BEI therapy useful because this procedure is easy to conduct, has low cost and can be done under particular conditions including post-tracheobronchial stent placement and post-radiation.

Bronchoscopic intratumoural therapies for non-small cell lung cancer

The past decade has brought remarkable improvements in the treatment of non-small cell lung cancer (NSCLC) with novel therapies, such as immune checkpoint inhibitors, although response rates remain suboptimal. Direct intratumoural injection of therapeutic agents via bronchoscopic approaches poses the unique ability to directly target the tumour microenvironment and offers several theoretical advantages over systemic delivery including decreased toxicity. Increases in understanding of the tumour microenvironment and cancer immunology have identified many potential options for intratumoural therapy, especially combination immunotherapies. Herein, we review advances in the development of novel bronchoscopic treatments for NSCLC over the past decade with a focus on the potential of intratumoural immunotherapy alone or in combination with systemic treatments.

Endobronchial ultrasound-guided transbronchial needle aspiration of pulmonary artery tumors: A systematic review (with video)

Convex probe endobronchial ultrasound (CP-EBUS) was originally introduced as a diagnostic and staging tool for lung cancer and subsequently utilized for diagnosis of other malignant and benign mediastinal diseases such as melanoma, lymphoma, and sarcoidosis. More recently, CP-EBUS has been successfully used for the visualization and diagnosis of pulmonary emboli and other vascular lesions including primary and metastatic pulmonary artery (PA) tumors. In this review, we will underline the role of EBUS-guided transbronchial needle aspiration (EBUS-TBNA) for the diagnosis of pulmonary arterial tumors such as sarcomas and tumor emboli. We will concisely discuss the clinical applications of EBUS-TBNA and the types of pulmonary arterial tumors and their different diagnostic modalities. We searched the Cochrane Library and PubMed from 2004 to 2014 to provide the most comprehensive review. Only 10 cases of EBUS-TBNA for intravascular lesions were identified in the literature. Although many cases of EBUS and EUS-guided transvascular tumor biopsies were described in the literature, there were no reported cases of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for intravascular tumor biopsies. Except for one paper, all cases were published as case reports.

Antitumor effect of para-toluenesulfonamide against lung cancer xenograft in a mouse model

BACKGROUND

Conventional chemotherapy and radiation therapy against non-small cell lung cancer (NSCLC) are relatively insensitive and unsatisfactory. Para-toluenesulfonamide (PTS), a unique antitumor drug for local intratumoral injection, shows an efficacy of severely suppressing solid tumor growth with mild side effects in clinical trials. The aim of this study was to investigate the effect of PTS on lung cancer H460 cells in vivo in nude mice and its underlying mechanisms in vitro.

METHODS

A lung cancer model for in vivo experiment was established in BALB/c nude mice using H460 cells to examine the effect of local injection of PTS on tumor suppression. We also assessed the injury to the normal tissue by subcutaneous injection of PTS. In vitro, PTS was diluted into different doses for study on its antitumor mechanisms. We evaluated the necrotic effect of PTS on H460 cells by PI and Hoechst 33342 staining. Cell viability and membrane permeability were also determined by using CCK-8 and LDH assays respectively. All these tests were conducted in comparison with traditional local injection of anhydrous ethanol.

RESULTS

PTS was shown to significantly inhibit the growth of H460 tumor xenografts in nude mice by inducing necrosis of the tumor histologically. Its effect on tumor growth was significantly stronger than that of anhydrous ethanol. By contrast, the injured normal tissue by PTS injection was less than that by ethanol. In vitro, PTS still demonstrated excellent necrotizing effect on H460 cells when diluted to a lower concentration. Detailed analysis of PTS on H460 cells indicated that PTS had a better effect on attenuating the cell viability and increasing the cell membrane permeability than ethanol at the same level.

CONCLUSIONS

PTS exhibits excellent inhibition effect on the growth of lung cancer by necrotizing tumor in vivo and in vitro, reducing tumor cell viability and augmenting the membrane permeability in vitro, with only mild injury to normal tissue. The antitumor effect of PTS on lung cancer in vivo and in vitro is stronger than that of ethanol.

Interventional management for benign airway tumors in relation to location, size, character and morphology

OBJECTIVE

To select minimally stressful methods for patients with benign bronchial tumors, and evaluate interventional strategies in relation to location, size, character and morphology.

METHODS

We reviewed the indications and efficacy of various interventional bronchology techniques at our institution, including individual or combined laser resection, electrocautery, argon plasma coagulation and high radiofrequency snaring for the treatment of various types of benign bronchial tumors.

RESULTS

It is essential to treat endoscopically that the tumor is visible and has a stalk and not invade beyond bronchial wall. By using combined techniques, no complications or recurrences were encountered.

CONCLUSIONS

Interventional bronchology techniques for benign bronchial tumors can be simple and safe, and therapeutic strategies should be designed in relation to location, size, character and morphology of tumors.

Bronchoscopic ethanolamine injection therapy in patients with persistent air leak from chest tube drainage

Background

Chest tube drainage (CTD) is an indication for the treatment of pneumothorax, hemothroax and is used after a thoracic surgery. But, in the case of incomplete lung expansion, and/or persistent air leak from CTD, medical or surgical thoracoscopy or, if that is unavailable, limited thoracotomy, should be considered. We evaluate the efficacy of bronchoscopic injection of ethanolamine to control the persistent air leak in patients with CTD.

Methods

Patients who had persistent or prolonged air leak from CTD were included, consecutively. We directly injected 1.0 mL solution of 5% ethanolamine oleate into a subsegmental or its distal bronchus, where it is a probable air leakage site, 1 to 21 times using an injection needle through a fiberoptic bronchoscope.

Results

A total of 15 patients were enrolled; 14 cases of spontaneous pneumothorax [idiopathic 9, chronic obstructive pulmonary disease (COPD) 3, post-tuberculosis 2] and one case of empyema associated with broncho-pleural fistula. Of these, five were patients with persistent air leak from CTD, just after a surgical therapy, wedge resection with plication for blebs or bullae. With an ethanolamine injection therapy, 12 were successful but three (idiopathic, COPD and post-tuberculosis) failed, and were followed by a surgery (2 cases) or pleurodesis (1 case). Some adverse reactions, such as fever, chest pain and increased radiographic opacities occurred transiently, but resolved without any further events. With success, the time from the procedure to discharge was about 3 days (median).

Conclusion

Bronchoscopic ethanolamine injection therapy may be partially useful in controlling air leakage, and reducing the hospital stay in patients with persistent air leak from CTD.

Transbronchial Needle Injection: A Systematic Review of a New Diagnostic and Therapeutic Paradigm

BACKGROUND AND OBJECTIVE

Transbronchial needle catheters are commonly used during flexible and rigid bronchoscopy for needle aspiration. The use of these catheters can be expanded by employing the technique of transbronchial needle injection.

METHODS AND RESULTS

By injecting lesions in the airways, peribronchial structures, mediastinum, or lung parenchyma, transbronchial needle injection has been applied to the treatment of lung cancer, inflammatory disorders of the airways, recurrent respiratory papillomatosis, as well as bronchopleural fistulas. Diagnostic applications have included the localization of peripheral lung nodules as well as sentinel lymph nodes.

CONCLUSIONS

Our review defines this bronchoscopic technique and summarizes its various reported applications.

Advances in the management of endobronchial lung malignancies

The effective palliation of endobronchial malignancies often involves the use of multiple modalities including surgery, external beam radiation, chemotherapy, or a variety of interventional bronchoscopic techniques. The authors discuss in detail recent advances in interventional bronchoscopy that enhance local tumor control. An integrated and individualized approach to the use of these complementary modalities can provide rapid palliation and may improve survival in a subset of patients.

Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol

Five consecutive bronchopleural fistulas (BPFs) were successfully treated by injecting absolute ethanol directly into the submucosal layer of the fistula under flexible bronchoscopic observation. No complications occurred as a result of this treatment. Our nonsurgical treatment may be very useful to reduce the costs of and duration of hospitalization and to improve the patient's quality of life. This is the first report of the bronchoscopic closure of BPFs by injecting absolute ethanol, and we would recommend this treatment as a first-line therapy for patients with a postoperative central BPF with an orifice that is < 3 mm in diameter.

Preliminary study of percutaneous alcohol injection into the lung

Although percutaneous ethanol injection is widely used to treat hepatic tumors, this technique has not been applied to lung tumors. We performed a preliminary experiment with percutaneous ethanol injection into the rabbit lung, and evaluated the local and systemic effects of absolute ethanol injection on pulmonary structures in order to assess the feasibility and safety of this technique as a local treatment for human lung tumors. Percutaneous injection of absolute ethanol into the rabbit lung was performed under CT guidance. The volume of ethanol injected ranged from 0.6 to 1.0 ml (approximately 0.2-0.5 ml/kg). Follow-up CT scans were performed 1, 2, 7 and 30 days after the injection. The animals were killed at intervals (range: 3 h-30 days), and the lung was examined histologically. The ethanol was well tolerated and did not induce significant systemic side-effects. All doses induced necrosis in the injected lung, but none was lethal. Although ethanol spilling into the thoracic cavity induced effusion and pleuritis, these reactions were manageable. Alcohol injection produced an area of necrosis surrounded by pulmonary edema associated with polymorphonuclear cells invasion within 24 h; moreover, granulation change, epithelial regeneration, and alveolar septal fibrosis had appeared by one week. The necrosis was sometimes multifocal, probably due to transbronchial spread of the injected ethanol. In conclusion, the feasibility and safety of absolute ethanol injection were confirmed. Neither severe systemic side effects nor lethal extensive necrosis were observed with injected ethanol; however, an unexpected side effect, multifocal necrosis, was seen. The latter reaction suggests that careful observation and care would be essential after alcohol injection into the lung.

Factors influencing survival after endoscopic Nd:YAG laser surgery for unresectable advanced malignancies of the trachea

The effects of endoscopic Nd:YAG laser surgery were studied in 36 patients with unresectable advanced primary and metastatic malignancies in the trachea with special reference to the factors influencing long-term survival. Overall effectiveness of YAG laser treatment was demonstrated in 34 of the 36 patients (94 per cent), while the overall 1, 3 and 5 year survival rates after the first laser treatment were 25 per cent, 13 per cent and 13 per cent, respectively. Neither histologic type nor the severity of clinical symptoms before laser treatment showed any significant influence on the survival curves, however, endoscopic findings of stenosis, the effect of laser treatment and irradiated longitudinal length were all significantly correlated with the survival curves. In other words, endoscopically protruding type tumors with a longitudinal length of irradiation of 3.0 cm or less, and good responses not only to laser treatment but also to other combined modalities are favorable factors for achieving long-term survival in patients with tracheobronchial malignancies undergoing endoscopic Nd:YAG laser treatment. Endoscopic Nd:YAG laser surgery is considered to be a promising part of the multi-modality treatment for unresectable advanced primary and metastatic malignancies of the trachea.

Endoscopic Nd:YAG laser surgery on malignant and benign lesions of the trachea and carina

A total of 47 patients with malignant and benign lesions in the trachea and carina were used to demonstrate the effectiveness of endoscopic Nd:YAG laser surgery. The histology consisted of 37 malignant and 10 benign lesions, and 23 of the patients had severe symptoms with laser surgery being performed as a lifesaving emergency. Endoscopic Nd:YAG laser treatment was able to dilate the tracheal calibers from 2.6 +/- 0.9 mm to 6.1 +/- 1.4 mm in the emergency cases with a remarkable effect and brought relief from wheezing and dyspnea, with an objective improvement of more than 25 per cent in peak expiratory flow rate being demonstrated. Furthermore, the tracheal diameters were able to be dilated from about 7 mm to 10 mm in the non-emergency cases. A remarkable effect was achieved in patients with intraluminal or mixed types of tumors among both the emergency and non-emergency cases. The survival rates of the emergency patients in whom a remarkable effect was achieved were definitely better than those in whom only fair or poor effects were achieved and, in the non-emergency cases, similar results were demonstrated. In conclusion, the application of endoscopic Nd:YAG laser surgery to tracheal stenotic diseases has an instantaneous and definite effect on luminal dilatation and shows significance as a lifesaving procedure. Moreover, the resultant improvement in the patients' general condition could make it possible for them to undergo other combined therapy and prolong their life span. Endoscopic Nd:YAG laser surgery is thus considered to be a very effective and established procedure for the treatment of tracheal stenotic lesions.