Bronchoscopic treatment of patients with intraluminal microinvasive radiographically occult lung cancer not eligible for surgical resection

Abstract

Comments: This publication provides long-term followup in a group of 32 patients who underwent bronchoscopic treatment (BT) for the treatment of intraluminal microinvasive radiographically occult lung cancer (ROLC). These patients were not eligible for surgical resection because of comorbidities and other reasons. These 32 patients (28 men and 4 women) met the following inclusion criteria for the study: surgically nonresectable candidates because of poor lung function or the presence of multiple primaries; a strictly ≤ 1 cm in size, intraluminal, microinvasive ROLC (carcinoma in situ excluded) with visible distal tumor margin by conventional and autofluorescence bronchoscopy; no bronchial wall invasion or extraluminal tumor growth on highresolution computed tomography. History of prior primary lung cancer was present in 13 patients, and these were surgically resected as long as 13 years before current synchronous or metachronous primaries. The TNM stages of previous resections for the non-ROLC tumors were stage IB in seven patients, stage IIB in four patients, stage IIIA in one patient, and stage IIIB in one patient. There was no sign of recurrence or metastatic disease of the previous non-ROLC cancer before BT. In six patients, multiple ROLCs were found at different sites in both lungs (four patients with two lesions and two patients with three lesions) that met all criteria for BT as described earlier. BT was administered with intent to cure cancer, and consecutive patients were treated with photodynamic therapy (n = 5), Nd:YAG laser therapy (n = 1), electrocautery (n = 24), and argon plasma coagulation (n = 2). Follow-up evaluation at 3 to 4 months interval included high-resolution computed tomographic scans, both conventional and autofluorescence bronchoscopy, including biopsy specimens and brush cytology for histologic evaluation. The average follow-up period was 5 years (range, 2–10 years). In three patients local recurrence was again successfully treated with electrocautery. Sixteen patients (50%) died during follow-up. Eight of the nine patients who died as a result of lung cancer had a previous resection of a more advanced stage lung cancer as long as 5 years before BT of the ROLC. In the remaining seven patients, the cause of death was not related to lung cancer. Sixteen patients are still alive without any tumor recurrence. Based on these observations, the authors conclude that BT is an effective treatment modality for high-risk patients with ROLC who are not eligible for surgical resection. Early detection of lung cancer by currently available methods such as low-dose spiral computed tomography, screening sputum cytology, autofluorescence bronchoscopy, and other techniques may enable surgical cure in a number of patients. However, not all patients are surgical candidates because of various reasons. One of the main reasons is the presence of cancer in the major airways (trachea and within 2.0 cm of the main carina), which upgrades the cancer stage. More commonly, surgery and anesthesia are contraindicated because of underlying medical conditions such as severe chronic obstructive pulmonary disease, severe malnutrition, and other conditions. When such patients develop intraluminal microinvasive ROLC in the central part of the tracheabronchial tree, various types of BT described in this publication may benefit them. Nonetheless, as noted by the authors of this study, early detection of lung cancer and BT in such patients is questionable because this expensive and time-consuming exercise may have little or no impact on mortality. Death from lung cancer occurred in 9 patients (28%), and death from other causes was noted in 7 patients (22%). The positive outcome of this study is that 50% of patients were still alive after BT, with an average follow-up of 5 years (range, 2–10 years).