Radiofrequency resection of bronchial tumours in combination with cryotherapy: evaluation of a new technique

Radiofrequency ablation for stage <IIB non-small cell lung cancer: Opportunities, challenges, and the road ahead

Pulmonary carcinoma represents the second common cancer for human race while its mortality rate ranked the first all over the world. Surgery remains the primary option for early-stage non-small cell lung cancer (NSCLC) in some surgical traditions. Nevertheless, only less than half of patients are operable subjected to the limited lung function and multiple primary/metastatic lesions. Recent improvements in minimally invasive surgical techniques have made the procedure accessible to more patients, but this percentage still does not exceed half. In recent years, radiofrequency ablation (RFA), one of the thermal ablation procedures, has gradually advanced in the treatment of lung cancer in addition to being utilized to treat breast and liver cancer. Several guidelines, including the American College of Chest Physicians (ACCP), include RFA as an option for some patients with NSCLC although the level of evidence is mostly limited to retrospective studies. In this review, we emphasize the use of the RFA technique in patients with early-stage NSCLC and provide an overview of the RFA indication population, prognosis status, and complications. Meanwhile, the advantages and disadvantages of RFA proposed in existing studies are compared with surgical treatment and radiotherapy. Due to the high rate of gene mutation and immunocompetence in NSCLC, there are considerable challenges to clinical translation of combining targeted drugs or immunotherapy with RFA that the field has only recently begun to fully appreciate.

MINIMALLY INVASIVE METHODS IN TREATMENT OF COMPLICATED FORMS OF CENTRAL LUNG CANCER

Despite certain achievements in lung cancer treatment, the essential number of patients is subjected to palliative and symptomatic treatment. Hemoptysis addition is the one of most heavy symptoms of unresectable lung cancer. No less heavy complication is an atelectasis and hypoventilation of a lobe or a whole lung, which clinical image is attended by respiratory failure phenomena or association of purulent-septic pneumonia. The combination of endoscopic hemostasis with roentgen endovascular embolization of bronchial arteries (REEBA) allows to increase patients’ live quality and to prolong it for some time. In the clinic REEBA has been done in 121 patients with unresectable forms of lung cancer. The causes of surgical treatment refusal were a widespread tumor process, age, and severity of associated pathology. Hemostasis was achieved in 112 patients. A relapse of pulmonary bleeding was observed in 11 patients, who underwent the repeated REEBA. Lethal outcome was observed in 5 cases. Hemostasis was ineffective in 9 patients. Thus, the experience of using REEBA and endoscopic hemostasis at complicated forms of unresectable lung cancer allows to increase the life quality and in further to realize chemoradial therapy that gives a possibility to prolong a patient’s life.

Cryosurgery for Tumors — A Clinical Overview

Cryosurgery, a method of treating disease by the production of freezing temperatures in the tissue, is a useful technique for the treatment of tumors. When the modern era of cryosurgery began in the mid 1960's, the technique was used only for tumors easily accessible by direct observation or via endoscopy, such as those of the skin, oral cavity, and prostate gland. In general, the technique had limited usefulness in the next two decades. However, with the advent of intraoperative ultrasound as a method of monitoring the process of freezing and with the development of more effective cryosurgical apparatus, the cryosurgical treatment of tumors of the viscera and other deep tissues became practical in the 1990's. This review assesses the present day status of cryosurgery in the management of diverse tumors.

THE USE OF RADIO-FREQUENCY ABLATION IN THE TREATMENT OF MALIGNANT TUMORS OF LUNGS AND PLEURA

Aim of the work. Analysis of the possibilities of the different methods of RFA of lung and pleura tumors. Material and methods. There were considered the different methods of radio-frequency ablations using FOTEK-150 apparatus in 186 patients with the malignant tumors of lungs and pleura. Results. In the result of use of the different methods of radio-frequency ablation the direct positive effect was attained in 91 % of observations. The complications were observed in 9 % of patients. This method must be used for patients with the malignant tumors of lungs and pleura when the radical surgical treatment is impossible. Conclusions. The radio-frequency ablation can be used as a palliative method of treatment of the malignant tumors of lungs and pleura.

Radiological and pathological correlation of lung malignant tumors treated with percutaneous radiofrequency ablation

Radiological and histological correlation was evaluated in patients with malignant tumors of the lung that underwent radiofrequency ablation (RFA). One of the patients had a primary lung tumor and another patient had three metastatic lung tumors. RFA was performed under computed tomography (CT) fluoroscopic guidance. CT showed ground glass shadows around the tumoral lesions immediately after RFA, but one week later homogenous opacification without tumoral enhancement was noted. Two months after RFA, most lesions showed cystic changes without activity on FDG-PET. Histological evaluation showed massive coagulation necrosis throughout the tumor and some viable cells at the peripheral areas in all lesions. Although RFA is a promising therapeutic approach for malignant lung tumors, some viable cells may persist in peripheral areas of the tumor.

The use of selective bronchography in predicting reversal of neoplastic obstructive atelectasis

OBJECTIVES

To assess the ability of selective bronchography to predict which patients with neoplastic postobstructive atelectasis will respond to interventional therapies directed at the reexpansion of the affected lung. Furthermore, to compare the utility of selective bronchography with the current predictive standard that reversal of postobstructive atelectasis is unlikely when it is > or = 4 weeks in duration (ie, the 4-week rule).

DESIGN

A prospective observational study.

SETTING

A tertiary care referral center/medical school.

PATIENTS

Twenty-seven consecutive patients with advanced lung cancer or other malignancy, with documented neoplastic postobstructive atelectasis involving a total of 44 lobes.

INTERVENTIONS

Lobar collapse was documented radiographically. The duration of atelectasis was investigated and quantified as accurately as possible. Prior to the use of interventional therapies, selective bronchography was performed on each collapsed lobe, and the results were documented. Bronchography results did not influence the decision to proceed with interventional therapies. Patients had each of their collapsed lobes manipulated by interventional techniques that were directed at reexpansion of the lung. One week after the patient underwent the intervention, the degree of reexpansion was assessed radiographically.

RESULTS

Interventional therapies leading to significant reversal of airway narrowing were completed in all 44 lobes. These were successful in reexpanding 28 of 44 collapsed lobes (64%). Selective bronchography demonstrated the following two distinct patterns: an intact bronchial tree (ie, tree pattern); or the absence of a distinguishable, distal bronchial tree (ie, blush pattern). The sensitivity of selective bronchography to predict reexpansion is 1.00 (95% confidence interval [CI], 0.90 to 1.00), and its specificity is 0.56 (95% CI, 0.30 to 0.80). There were no complications attributable to selective bronchography. The sensitivity of the 4-week rule to predict reexpansion is 0.61 (95% CI, 0.41 to 0.78), and its specificity is 0.75 (95% CI, 0.48 to 0.93). The results of selective bronchography and use of the 4-week rule were significantly different in predicting which lobes would reexpand and which would not (p = 0.0026). Using selective bronchography to predict the reversal of lobar atelectasis, the positive predictive value of the tree pattern was 0.80 and the negative predictive value of the blush pattern was 1.00. The values for the 4-week rule are 0.81 and 0.52, respectively.

CONCLUSIONS

Selective bronchography is a useful tool for predicting whether patients with neoplastic postobstructive atelectasis would benefit from interventional techniques that are directed at lobar reexpansion. Selective bronchography appears to be superior to the 4-week rule in this regard.

Photodynamic therapy: a case series demonstrating its role in patients receiving mechanical ventilation

Photodynamic therapy (PDT) has long been used to treat cancers within the tracheobronchial tree. There have been many reports about the use of PDT for the treatment of carcinoma in situ and for obstructive endobronchial lesions. PDT has not been previously reported in patients receiving mechanical ventilation. PDT offers the advantages of a relatively short duration of treatment, a low side effect profile, and relatively low risk when compared to Nd-YAG laser in patients receiving mechanical ventilation. We report the first successful use of PDT to wean patients from mechanical ventilation.

Future of flexible bronchoscopy

Despite some potential "threats" (Table 3), the future of bronchoscopy is likely full with ever expanding applications in clinical medicine and research (Tables 1 and 2). The role of bronchoscopy in lung cancer continues to expand and the usefulness of newer techniques needs to be established. The role of FB is also ever expanding in the immuno compromised host and critically ill patients. Future studies, however, should concentrate on patient outcome, especially survival and performance status. Therapeutic bronchoscopy has been extended to many areas and the emphasis of future research will likely continue to be at the molecular level rather than on studies of better instruments for retrieval purposes. The most exciting developments are likely to be in the field of gene therapy, which has made remarkable progress in the past decade. Gene therapy can be a powerful technology, but several hurdles must be overcome to make gene therapy a reality for treating human disease in the future. As the cost of technology continues to challenge health care delivery systems, a major challenge for the future of bronchoscopy is to evaluate new technologies and applications based on their impact on patient outcome, survival, and management of cost.