Invited commentary

Abstract

Endobronchial obstruction, either from primary bronchogenic carcinoma or, as detailed by Litle represents a life-threatening mechanical problem in patients with compromised performance status. With the advent of aggressive chemotherapeutic and biologic treatment options for these patients, it is crucial to assess these patients on an individual basis and tailor treatment options in a way which is durable, complementary, and minimally toxic. Certainly, photodynamic therapy (PDT) has assumed a role in this armamentarium. Photodynamic therapy can accomplish just about everything that other endobronchial techniques can, and in the randomized trials comparing PDT and YAG laser, the effects of PDT were more durable and clinical benefit was seen in a substantial number of patients. Thoracic surgeons, however, when referred with patients with endobronchial disease should not dismiss these patients as never having a surgical option. Photodynamic therapy can be used to clear the airway, and move the patient on to therapy as a “safer risk” for the multitude of interventions our oncologic colleagues are willing to use now. A cohort, albeit small, of these patients after their relief of obstruction will be found to have their palliated endobronchial site as the only residual of disease and thoracic oncologists should consider whether the patient may indeed have a resection option, which may even be sleeve-type resections to preserve function for future metastasectomies. Advances in PDT have plateaued over the last 5 years since it was approved by the Food and Drug Administration for the treatment of obstructing lung cancer and microinvasive lung cancer. Diode lasers are now as efficient as bulky, expensive, argon pump dye lasers, and the decrease in start up costs have made the technique more accessible to a greater number of patients. The real advances that must take place with this therapy, however, are timing and light photosensitivity issues. There are new sensitizers on the horizon which have the same or greater treatment depths as Photofrin II, but can be delivered 2–3 hours before the light therapy instead of 24–48 hours before. Moreover, their light sensitivity profile is measured in days, not weeks. Trials hopefully will begin soon which will investigate oncologic potential for these newer drugs, and with a little luck, PDT could assume less of a “stepchild” role in the evaluation, treatment and palliation of endobronchial obstruction.