Ann Thorac Surg 2006;82:722-724
© 2006 The Society of Thoracic Surgeons
Case report
Pulmonary Resection After Successful Downstaging with Photodynamic Therapy
Keith D. Mortman, MD*,
Kenneth M. Frankel, MD
Division of Thoracic Surgery, Baystate Medical Center, Springfield, Massachusetts
Accepted for publication December 1, 2005.
* Address correspondence to Dr Mortman, 2 Medical Center Dr, Suite 504, Springfield, MA. (Email: keith.mortman{at}bhs.org).
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Abstract
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Photodynamic therapy (PDT) is a treatment option for lung cancer that involves the administration of a photosensitizing agent and selective, bronchoscopic delivery of light to tumor tissue that has retained the agent. Currently, PDT is used either to treat microinvasive endobronchial nonsmall cell lung cancer (NSCLC) or to palliate patients with completely or partially obstructing endobronchial NSCLC. Herein is a case of PDT that successfully downstaged an obstructing endobronchial NSCLC, thereby enabling a complete resection. At 9 months postoperatively, the patient was treated for a chest wall recurrence with no evidence of disease in the airway or mediastinum.
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Introduction
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Photodynamic therapy is a local treatment option for lung cancer that involves the intravenous administration of a photosensitizing agent and selective, endoscopic delivery of light to the tumor tissue. Nonthermal laser light of a particular wavelength activates the photosensitizer that is retained in higher concentrations in the tumor compared with adjacent tissue. Localized cytotoxicity occurs secondary to the production of toxic oxygen radicals (ie, singlet oxygen, superoxide, and hydroxyl radicals). A second mechanism of tumor death is ischemic necrosis secondary to vascular occlusion, which is mediated by thromboxane A2 release. Currently, PDT is used either to treat microinvasive endobronchial NSCLC or to palliate patients with completely or partially obstructing endobronchial NSCLC [1]. There is evidence to support its use for small cell lung cancer as well [2]. This article reports the first known case of utilizing PDT to downstage an advanced primary bronchogenic carcinoma, thereby enabling subsequent resection with curative intent.
A 71-year-old man with a 60 pack-year smoking history initially presented in May 2004 with a 2-month history of mild, intermittent hemoptysis and chronic stable dyspnea on exertion. He had a history of hypertension, noninsulin dependent diabetes mellitus, atrial fibrillation, and a remote myocardial infarction. Chest computed tomography showed an ill-defined 3.2 cm right hilar mass. There were no pathologically enlarged mediastinal lymph nodes. Positron emission tomography revealed a solitary hypermetabolic focus in the right hilum. There was no evidence of hilar or mediastinal nodal involvement or distant metastatic disease by positron emission tomographic scan. Forced expiratory volume in 1 second was 2.06 L (60% of predicted) and increased to 2.56 L with bronchodilators. Bronchoscopy showed a polypoid tumor protruding from the right upper lobe orifice. Biopsy of the endobronchial mass revealed squamous cell carcinoma, and a biopsy of the carina showed no evidence of malignancy. Mediastinoscopy confirmed the absence of nodal metastatic disease. Preoperative cardiac stress testing showed evidence of reversible ischemia and coronary angiography demonstrated multivessel disease. Then the patient underwent coronary bypass grafting in August 2004. Due to deconditioning and the need for cardiac rehabilitation, the patient did not return until October 2004 at which time a chest computed tomographic scan showed that the right hilar mass had increased to 4.3 cm. In November 2004, he returned to the operating room for a planned right pneumonectomy. However, bronchoscopy documented progression of the endobronchial tumor along the lateral wall of the right mainstem bronchus to the level of the carina (Fig 1). Biopsy of the bronchial wall was not repeated at this time; however it was considered to be a T3 lesion due to its proximity to the carina. It was believed that tumor-free margins could not be obtained with a standard pneumonectomy, and that the operative risks of a sleeve pneumonectomy were too great. He was then referred for PDT to relieve his symptomatic endobronchial obstruction.
The patient was injected with porfimer sodium (Photofrin [Axcan Pharma, Birmingham, AL]) 2 mg/kg intravenously 60 hours before light irradiation (Diomed 630). A 2.5-cm diffusing quartz tip fiber was used to deliver the light at a tissue dose of 200 J/cm for 500 seconds. The patient was returned to the operating room 48 hours later for airway debridement through a rigid bronchoscopy and for repeat PDT. A final airway debridement was performed 48 hours after the previous session. At that time, all of the tumor in the right main stem bronchus and at the ostium of the right upper lobe bronchus was removed (Fig 2). Residual disease was noted in the anterior segmental bronchus of the right upper lobe. Three weeks later a follow-up bronchoscopy was performed. Stable disease in the right upper lobe anterior segment was visualized. Biopsies of the carina, bronchus intermedius, and ostium of the right upper lobe bronchus showed no evidence of malignancy. In December 2004, he had an en bloc right upper lobectomy with bronchoplasty and a right lower lobe superior segmentectomy. The final pathology confirmed the presence of a 4.0 x 4.0 x 4.0 cm moderately differentiated squamous cell carcinoma. Bronchial and vascular margins were negative for tumor. Thoracic lymphadenectomy, which included peribronchial, hilar, subcarinal, and paratracheal lymph nodes, showed no evidence of nodal metastasis. Final staging was pT2N0M0 or stage IB [3]. Adjuvant chemotherapy consisting of carboplatin and paclitaxel was discontinued after one cycle secondary to moderate neuropathic symptoms.
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Fig 2. After photodynamic therapy and mechanical debridement, no tumor remains in the right mainstem bronchus or at the orifice of the right upper lobe bronchus.
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At his 6-month follow-up visit, he had mild persistent peripheral neuropathy and mild dyspnea on exertion. There was no coughing or wheezing. His physical examination was unremarkable. A chest computed tomographic showed no evidence of recurrent disease. Bronchoscopy demonstrated a well-healed bronchial suture line, and biopsies of the carina, right mainstem bronchus, and bronchus intermedius remained negative for malignancy. However, 3 months later the patient complained of right chest wall pain. A repeat chest computed tomographic scan revealed a 5-cm mass in the lateral chest wall with destructive changes of the fifth rib, but no evidence of recurrent disease in the airway or mediastinum. This local recurrence was at the site of his prior thoracotomy. Fine-needle aspiration of the chest wall mass confirmed the presence of squamous cell carcinoma (consistent with his primary lung cancer), and he was treated with chemoradiation.
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Comment
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Photodynamic therapy was first used for the treatment of lung cancer in the early 1980s [4]. Since that time its use has been well described for both early superficial bronchogenic carcinoma of the central airways and for more advanced, obstructing tumors that are surgically unresectable [5–7]. A systematic review of the results of such treatment was recently published [1]. However, there is no known use of PDT in combination with surgical resection for curative intent. This case report illustrates a successful resection with curative intent for an advanced squamous cell carcinoma that was downstaged with PDT. At the time of his initial presentation, the patient had a cT2N0M0(stage IB) tumor. The need for coronary revascularization resulted in a 4-month delay in his return to the operating room. At that time, the tumor was noted to extend to the carina, upstaging it to a cT3N0M0 (stage IIB). A standard pneumonectomy was unlikely to afford a complete resection, and the risks of a sleeve pneumonectomy were deemed to be greater than the benefits. Therefore he underwent PDT, which successfully downstaged the tumor back to a cT2N0M0. Absence of microscopic invasion of the carina and right mainstem bronchus by the tumor was confirmed with brochoscopic biopsies. This allowed a complete (R0) resection by right upper lobectomy with bronchoplasty and en bloc superior segmentectomy of the right lower lobe (due to the proximity of the tumor to the major fissure).
Surgical resection of NSCLC remains the gold standard for treatment in operable patients that present with early stage disease. Newer techniques such as PDT, radiofrequency ablation, tracheobronchial stenting, and intrapleural, or endoluminal brachytherapy have extended the thoracic surgeon's ability to care for patients with NSCLC. Their precise role in treating patients with NSCLC continues to evolve.
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References
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Abstract
Introduction
