Ann Thorac Surg 2008;85:e24-e26. doi:10.1016/j.athoracsur.2008.02.070
© 2008 The Society of Thoracic Surgeons
Case Reports
Photodynamic Therapy Followed by Thoracoscopic Sleeve Lobectomy for Locally Advanced Lung Cancer
Daniel T. DeArmond, MDa,*,
Ali Mahtabifard, MDb,
Clark B. Fuller, MDb,
Robert J. McKenna, Jr, MDb
a Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
b Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California
Accepted for publication February 18, 2008.
* Address correspondence to Dr DeArmond, Division of Thoracic Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78229 (Email: dearmond{at}uthscsa.edu).
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Abstract
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Photodynamic therapy is an effective technique for debulking endobronchial tumors over an acceptably short time-course; however, to be effective, numerous treatment cycles may be required to achieve the desired results. We present a case in which photodynamic therapy was used with curative intent to downsize an obstructing endobronchial non–small cell lung cancer in advance of resection via video-assisted thoracoscopic surgery with right upper lobe sleeve lobectomy.
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Introduction
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Photodynamic therapy (PDT) is a method of treatment of cancers in human beings that uses a photosensitizing agent preferentially retained in cancer cells along with absorbed light of a particular wavelength to elaborate a compound that is toxic to cancer cells, resulting in their necrosis. In lung cancer, though generally reserved for use in patients with locally advanced tumors requiring palliation via debulking of endobronchial tumor, PDT has been used in patients with early stage cancers who are not candidates for curative resection [1–3], preoperatively in an effort to downstage lung tumors in advance of resection [1, 2], and in other special circumstances such as bronchial stump recurrences after surgery [2, 4, 5]. We present a case in which PDT was administered for palliation in advance of curative resection via video-assisted thoracoscopic surgery (VATS) with sleeve lobectomy.
A 62-year-old woman came to our clinic with a 3-month history of worsening dyspnea on exertion. She reported a nearly constant, dry, hacking cough; diminished appetite; and an approximately 10-lb weight loss during the previous year. Her medical history was significant only for hypertension, and her surgical history was negative for thoracic operations. She reported a more than 30 pack-year history of cigarette smoking and was currently smoking 1 pack of cigarettes per day. At physical examination, the patient appeared profoundly cachectic and deconditioned, and manifested a nearly constant cough. She exhibited obvious dyspnea with ambulation in the hall of our clinic or with prolonged speaking. Breath sounds were absent in the entire right lung field. The remainder of the physical examination yielded findings within normal limits.
The patient had undergone a workup at an outside facility because of these symptoms, including plain films of the chest that demonstrated opacification of the right lung field with midline shift of the trachea to the right and cutoff of the right mainstem bronchus (Fig 1). Combined positron emission tomography and computed tomography were also performed at this outside facility and demonstrated a hypermetabolic soft tissue mass 2 cm in greatest dimension protruding into the right mainstem bronchus at approximately the level of the takeoff of the right upper lobe bronchus (Fig 2) but no evidence of mediastinal nodal disease or metastatic foci. At chest computed tomography, the right lung demonstrated near-total postobstructive atelectasis (Fig 2). Pulmonary function tests performed at the outside facility demonstrated a forced expiratory volume in 1second of 0.72 L (35% of predicted); the report noted that the diffusing capacity of the lung for carbon monoxide could not be obtained because of the patient's coughing and low lung volumes. Bronchoscopy performed at that facility demonstrated functional vocal cords and a pedunculated, obstructing right mainstem mass. The bronchoscope, according to the report, could not be passed distally into the bronchus intermedius because of the obstructing mass. Bronchoscopic brushings resulted in hemorrhage, which was controlled with cold saline solution and dilute epinephrine spray. A diagnosis of atypical cells consistent with non–small cell lung cancer was made. Hemorrhage precluded any additional attempts at biopsy. A thoracic surgery consultation at that facility determined that the patient was not a surgical candidate, and she was referred to medical oncology. She self-referred to our clinic for a second opinion.
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Fig 1. Chest radiograph demonstrates opacification of the right lung field with midline shift of the trachea to the right and cutoff of the right mainstem bronchus.
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Fig 2. Chest computed tomographic scan demonstrates a 2-cm soft tissue mass protruding into the right mainstem bronchus at approximately the level of the takeoff of the right upper lobe bronchus and near-total postobstructive atelectasis of the right lung.
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Both the patient and her family admitted to profound anxiety and depression over what they believed was a terminal condition in which the patient would suffer with shortness of breath and intractable coughing until her death. They conveyed a sense of resignation that there was nothing to be done to improve her condition.
Our initial goal was palliation of the dyspnea via tumor debridement. During a 15-day course of treatment, the patient was taken to the operating room 6 times for flexible and rigid bronchoscopy under general anesthesia, along with PDT and tumor debridement. At the first operation, neodymium-doped yttrium aluminum garnet laser debridement was attempted but was abandoned because of tumor hemorrhage. During the treatment course the tumor was gradually completely cleared from both the right mainstem bronchus and right upper lobe bronchus, resulting in restoration of complete right lung expansion (Fig 3). With reexpansion of the lung, the dyspnea greatly improved, coughing lessened, and in turn the patient's anxiety and depression were substantially relieved.
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Fig 3. Chest radiograph demonstrates restoration of complete right lung expansion after repeated treatment with photodynamic therapy.
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Approximately 1 month after the initial treatment, the patient underwent video cervical mediastinoscopy for tumor staging. No nodal metastasis was identified at pathologic analysis. A clinical stage T3N0 tumor, or stage IIB non–small cell lung cancer, was diagnosed, which suggested that the patient was a candidate for curative resection. In the ensuing weeks she was taken to the operating room once more to undergo VATS right upper lobectomy and thoracic lymphadenectomy. Because of the proximity of the residual right upper lobe tumor to the right mainstem bronchus, this was performed as a VATS sleeve resection of the right upper lobe. The patient was discharged to home after this operation on postoperative day 3. Final pathologic analysis demonstrated a polypoid, moderately differentiated adenosquamous tumor 1.2 cm in greatest dimension, with no evidence of lymphatic, vascular, or pleural invasion and negative bronchial margins. The final pathologic staging was T3N0, or stage IIB non–small cell lung cancer. The final pathologic staging of the tumor as a T3 lesion was based in part on clinical information provided to the pathology service pertaining to the patient's previous complete lung collapse as a result of obstructing tumor. It could be argued, with the right lung nearly fully expanded at the time of resection, that PDT had resulted in tumor downstaging to a T2 lesion. At 1-year follow-up after surgery the patient is doing well with no evidence of recurrent disease.
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Comment
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Photodynamic therapy is a form of cancer treatment in human beings that uses a photosensitizing agent preferentially retained in cancer cells along with absorbed light of a particular wavelength to elaborate a compound that is toxic to cancer cells, resulting in their necrosis. This concept was initially demonstrated in 1978 by Dougherty and colleagues [6] and first translated to the treatment of lung cancer in 1980 as reported by Kato [1]. In the ensuing years, numerous publications have appeared reporting the use of PDT in treating cancers in human beings. In general, PDT has been reserved for the treatment of 2 specific groups of patients with lung cancer: those with stage III or IV disease in whom curative resection is not possible but who would receive palliative benefit from debulking of endobronchial tumor burden and patients with in situ or stage I lesions with medical comorbidities that preclude surgery [1–3] in whom PDT may produce a high complete response rate [3], though local recurrence has been reported [7]. Photodynamic therapy has also demonstrated some efficacy in special situations in non–small cell lung cancer, such as postsurgical bronchial stump tumor recurrence [2, 4, 5], and may be used, as in our patient, in conjunction with surgical resection in patients with extensive but relatively early stage lesions [1, 2]. Despite its demonstrated utility in these clinical scenarios, the side effect of photosensitivity, requiring patients to avoid sunlight and bright indoor lighting for up to 6 weeks, and its high monetary cost have prevented widespread adoption of PDT as a technique for lung cancer treatment [8], though newer photosensitizing agents may allow for a more favorable side effect profile [9].
In the current era of medical cost containment, this case raises some important issues. Photodynamic therapy is an effective method for debulking endobronchial tumors over an acceptably short time-course; however, to be effective, numerous treatment cycles may be required to achieve the desired result. The patient presented here required a total of 6 operations, each performed under general anesthesia, to achieve the endpoint of lung re-expansion, a seventh operation for mediastinal staging, and a final eighth operation for curative resection, spanning a treatment period of approximately two months. Clearly, the cost in terms of medical expenditures for this patient was high. On the other hand, this case demonstrates that lung cancer can be treated aggressively, in an effort to palliate or cure, with excellent results. It is difficult to imagine the patient who initially presented to our clinic in respiratory distress surviving and thriving as long as she has without the aggressive approach to her disease that was undertaken. Cases like this are helpful reminders that the laudable goal of reducing medical expenditures should not engender clinical nihilism on the part of those entrusted with the direct care of patients.
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References
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- Kato H. Photodynamic therapy for lung cancer: a review of 19 years' experience J Photochem Photobiol B 1998;42:96-99.[Medline]
- Usuda J, Kato H, Okunaka T, et al. Photodynamic therapy (PDT) for lung cancers J Thorac Oncol 2006;1:489-493.[Medline]
- Corti L, Toniolo L, Boso C, et al. Long-term survival of patients treated with photodynamic therapy for carcinoma in situ and early non-small-cell lung carcinoma Lasers Surg Med 2007;39:394-402.[Medline]
- Lam S. Photodynamic therapy of lung cancer Semin Oncol 1994;21:15-19.[Medline]
- Freitag L, Korupp A, Itzigehl I, et al. Experiences with fluorescence diagnosis and photodynamic therapy in a multimodality therapy concept of operated, recurrent bronchial carcinoma Pneumologie 1996;50:693-699.[Medline]
- Dougherty TJ, Kaufman JE, Goldfarb A, Weishaupt KR, Bouyle DG, Mitleman A. Photoradiation for the treatment of malignant tumours Cancer Res 1978;38:2628-2635.[Abstract/Free Full Text]
- Furukawa K, Kato H, Konaka C, et al. Locally recurrent type early-stage lung cancer less than 1.0 cm in diameter after complete remission by photodynamic therapy Chest 2006;128:3269-3275.
- Moro-Sibilot C, Brambilla C. Photodynamic therapy: where do we go from here? Eur Respir J 2003;22:399-400.[Free Full Text]
- Kato H, Furukawa K, Sato M, et al. Phase II clinical study of photodynamic therapy using mono-L-aspartyl chlorin e6 and diode laser for early superficial squamous cell carcinoma of the lung Lung Cancer 2003;42:103-111.[Medline]
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Abstract
Introduction
