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Photodynamic therapy with cryotherapy for endobronchial typical carcinoid

Open AccessPublished:April 22, 2022DOI:https://doi.org/10.1016/j.xjtc.2022.04.018
      Figure thumbnail fx1
      Endobronchial typical carcinoid tumor after PDT.
      PDT in endobronchial typical carcinoid is an effective technique in the thoracic surgeon's armamentarium that is underused in patients unable to undergo resection or require extensive operations.
      See Commentaries on pages 164 and 165.
      Photodynamic therapy (PDT) is a seldom-reported application for endobronchial typical carcinoid (TC).
      • Downie G.H.
      • Qureshi A.
      Endobronchial ablation of typical carcinoid tumor with photodynamic therapy.
      • Loewen G.
      • Cerfolio R.
      • Bryant A.
      • Pettiford B.
      • Roundy T.
      • Skabla P.
      • et al.
      Photodynamic therapy for patients with endobronchial carcinoid.
      • Moghissi K.
      • Dixon K.
      • Gibbins S.
      Photodynamic therapy for bronchial carcinoid tumours: complete response over a 10-year follow-up.
      • Kurman J.S.
      • Pastis N.J.
      • Murgu S.D.
      Photodynamic therapy and its use in lung disease.
      Although surgical resection is the mainstay of treatment, some patients may not be candidates or require extensive operations. Consequently, the authors describe their PDT experience in 2 patients (Video 1). Patient consent for publication was obtained.

      Methods

      Patient Selection

      Patient 1 was a 65-year-old female with a 2-cm mass emanating from the left upper lobe bronchus and obstructing the mainstem bronchus (Figure 1, A and B). Patient 2 was a 70-year-old female with a 1.7-cm left mainstem pedunculated mass located at the bifurcation of the secondary carina (Figure 1, C). Biopsies revealed TC. Endobronchial ultrasound yielded negative lymph nodes.
      Figure thumbnail gr1
      Figure 1A, Typical carcinoid tumor originating from the left upper lobe bronchus (patient 1). B, Computed tomography of the chest demonstrating left upper lobe tumor extending into the proximal left mainstem bronchus (patient 1). C, Typical carcinoid tumor obstructing the left mainstem bronchus (patient 2).
      Patients with purely intraluminal central TC measuring less than 2 cm, chest computed tomography (CT) without bronchial wall or lymph node invasion, and a negative mediastinum as staged by endobronchial ultrasound are ideal candidates for PDT. PDT is beneficial in patients who may require debulking to reduce the extent of planned resection (patient 1) or have an anatomically unfavorable tumor for bronchoplasty and abnormal pulmonary function making pneumonectomy high-risk (patient 2).

      Treatment Protocol

      Porfimer sodium 2 mg/kg is injected intravenously 48 to 72 hours before light exposure. Following the first PDT session, the patient is admitted to the hospital. Bronchoscopic reassessment with debridement to clear necrotic debris and illumination is done 2 and 4 days’ post first light illumination. Follow-up bronchoscopic examination is performed at 1 month. Endobronchial tumors are initially illuminated with 200 J/cm via insertion of the diffuser fiber through the working channel of the flexible fiberoptic bronchoscope.

      Adverse Reactions Profile

      Adverse reactions may include dyspnea, photosensitivity reaction, hemoptysis, pyrexia, cough, and pneumonia. Patients are advised to avoid exposure of skin and eyes to direct sunlight or bright indoor lights for at least 30 days. Due to potential for bronchial obstruction from tumor necrosis, we performed radiographs of the chest during admission.

      Technique

      Patient 1 received 200 J/cm interstitially and 100 J/cm to the tumor adjacent on both sides using a 2.5-cm diffuser fiber on Monday. The tumor was then illuminated with a power setting of 400 mw/cm for a dose of 200 J/cm with a 1.5-cm diffuser fiber for 500 seconds on Wednesday and Friday. The lesion was debrided with cryotherapy and following this, the main bronchi were visible. One week later, the patient underwent additional debridement and illumination with 100 J/cm for 250 seconds and following this, the left upper lobe segmental bronchi were patent. The 1-month bronchoscopy demonstrated complete airway patency.
      Patient 2 initially underwent cryotherapy, but at follow-up there was persistent tumor. It was decided in our multidisciplinary tumor board to treat the refractory disease with PDT. The initial light treatment was 200 J/cm with a 1.5-cm diffuser fiber for 500 seconds. The lesion had significant tumor necrosis and debridement was performed during the next 2 sessions. Two weeks later, the lesion was illuminated with 200 J/cm for 500 seconds. Tumor necrosis was debrided with cryotherapy at 1 month. Flexible bronchoscopy revealed no tumor at 3 months (Figure 2, A).
      Figure thumbnail gr2
      Figure 2A, Bronchoscopy at 3 months demonstrating tumor clearance (patient 2). B, Bronchoscopy at 12 months demonstrating no tumor (patient 1). C, Computed tomography of the chest at 12 months demonstrating no disease (patient 1). D, Bronchoscopy at 36 months demonstrating no tumor (patient 2).

      Surveillance Protocol

      We perform bronchoscopy and radiographs of the chest, alternating with chest CTs every 3 months after complete tumor clearance for the first year, bronchoscopy with CT every 6 months for the second year and then annually.
      For patient 1, bronchoscopy at 12 (Figure 2, B) and 36 months and CT at 12 (Figure 2, C) and 36 months revealed no tumor. Bronchoscopy (Figure 2, D) along with CT at 36 months revealed patient 2 to be tumor-free. Our relatively short follow-up may be insufficient to document recurrences.

      Discussion

      Several endobronchial modalities have been reported.
      • Sachdeva A.
      • Pickering E.M.
      • Lee H.J.
      From electrocautery, balloon dilatation, neodymium-doped: yttrium-aluminum-garnet (Nd: YAG) laser to argon plasma coagulation and cryotherapy.
      We avoid electrocautery or argon plasma coagulation because of the inherent risks of airway perforation and fire for both, bronchial wall damage after electrocautery, and limited penetration depth (2-3 mm) with argon plasma coagulation. In cases in which airway obstruction requires rapid relief, our first choice of treatment is neodymium-yttrium aluminum garnet laser therapy, especially since lasers offer deep penetration (up to 10 mm). Although cryotherapy does not lead to bronchial stenosis, it has less destructive power and limited penetration depth (2-5 mm) making it a poor choice for sole therapy. We believe there is adjunctive value to cryotherapy because its rapid freezing allows for thorough necrotic tumor debridement during PDT. We prefer PDT over other modalities because it provides a predictable penetration depth (4-6 mm in a single direction, up to a 10-12 mm radius), the ability to treat large surfaces, selective tumoricidal action with immunogenic properties and curative potential.
      • Downie G.H.
      • Qureshi A.
      Endobronchial ablation of typical carcinoid tumor with photodynamic therapy.
      • Loewen G.
      • Cerfolio R.
      • Bryant A.
      • Pettiford B.
      • Roundy T.
      • Skabla P.
      • et al.
      Photodynamic therapy for patients with endobronchial carcinoid.
      • Moghissi K.
      • Dixon K.
      • Gibbins S.
      Photodynamic therapy for bronchial carcinoid tumours: complete response over a 10-year follow-up.
      • Kurman J.S.
      • Pastis N.J.
      • Murgu S.D.
      Photodynamic therapy and its use in lung disease.

      Supplementary Data

      References

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      Linked Article

      • Commentary: Sunlight, lasers, or knives? How to treat typical carcinoid tumors
        JTCVS TechniquesVol. 15
        • Preview
          The world is changing. Not too long ago, open surgical resection was the mainstay of management for endobronchial tumors.1 Treatments were limited for those who were not considered surgical candidates. Our current era affords us numerous modalities for the treatment of low-grade endobronchial lesions, ranging from minimally invasive surgical techniques to advanced endobronchial ablative therapies. In this volume of JTCVS Techniques, Shah and colleagues2 present a case series of 2 patients with endobronchial typical carcinoid who were treated with photodynamic therapy.
        • Full-Text
        • PDF
        Open Access
      • Commentary: Endobronchial treatment of central airway typical carcinoid tumors: The devil is in the details
        JTCVS TechniquesVol. 15
        • Preview
          Although bronchopulmonary carcinoid tumors account for only 1% to 2% of all lung cancers, most (80%) are centrally located.1 Consequently, understanding the role bronchoscopy plays in the diagnosis and treatment of these tumors is essential. Although anatomic resection is considered the gold standard by most,2,3 some have advocated a tissue-sparing approach with endobronchial treatment as first-line therapy for appropriately selected patients.4
        • Full-Text
        • PDF
        Open Access