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Treatment of Early Stage Non-small Cell Lung Cancer*
Section snippets
Materials and Methods
Published guidelines on lung cancer diagnosis and management were identified by a systematic review of the literature and evaluated by the Appraisal of Guidelines for Research and Evaluation method (see Section on Methods and Grading). Those guidelines including recommendations specific to the treatment of early stage lung cancer were identified for inclusion in this section. Supplemental material appropriate to this topic was obtained by literature search of a computerized database (MEDLINE)
Review of Data
Roentgenographically occult lung cancers can be detected in high-risk patients with either sputum cytology or bronchoscopic inspection. Traditionally, the only treatment available for these cancers was surgical resection. Even though these cancers are small, 70% of cases require a lobectomy, and in the remaining 30%, either a bilobectomy or pneumonectomy is required.1 There are patients with reduced cardiopulmonary reserve who are not candidates for any of these surgical options. Additionally,
PDT
PDT is based on the interaction of tumor-selective photosensitizer and laser light. This interaction causes selective death of tumor cells. The majority of clinical data using PDT in early lung cancer has been for treatment of patients who were deemed nonsurgical candidates. The greatest experience has emerged from Japan in the last 2 decades.27131415161718192021 One hundred forty-five patients (191 cancers) with early non-small cell lung cancer have been treated with PDT since 1980. This
Electrocautery
Electrocautery is the less expensive treatment for endobronchial tumors. Bronchoscopic electrocautery is the use of high-frequency electrical current that generates heat due to tissue resistance, resulting in destruction of tissue. A small study in early lung cancer of 13 patients (15 cancers) showed a complete response in 80% of lesions with no recurrence at 22 months of follow-up.8
Cryotherapy
Cryotherapy is a technique where tissue is destroyed by freezing and is the least expensive for treatment. A recent report included 35 patients (41 cancers) with early stage lung cancer. A complete response was obtained 91% of the patients with a recurrence rate of 28% within 4 years. A long-term response of 63% was achieved, similar to that of PDT.5
Brachytherapy
Brachytherapy refers to the placement of a radioactive source within or near an endobronchial malignancy to deliver local irradiation. This requires the insertion of an afterloading polyurethane catheter into the airway adjacent to the tumor during fiberoptic bronchoscopy. Iridium 192 is generally used. In two small studies, the use of high-dose brachytherapy in three to six sessions reported response rates similar to PDT.3435 Marsiglia et al34 reported 34 patients with early stage lung cancer
Nd-YAG Laser Therapy
Nd-YAG laser therapy is used for direct thermal ablation of tissue in endobronchial malignancy. It has been used extensively as a palliative measure to relieve airway obstruction. The use of laser treatment for early lung cancer has not been widely studied. A study by Cavaliere et al9 showed a complete response rate of 100% in 22 patients with small bronchial cancers. The long-term outcome of these patients was not reported. Yttrium-aluminum-garnet laser therapy is not indicated for tumors that
Follow-up/Surveillance
Following treatment, patients should be closely monitored for recurrent disease and development of metachronous lesions. These patients should undergo bronchoscopic examination every 3 to 6 months with both white light and fluorescence bronchoscopy if available. Please refer to the chapter of Follow-up/Surveillance in this guideline publication.
Conclusion
PDT is the most extensively studied endobronchial treatment for early lung cancer for patients who are not candidates for surgical resection. Suitable lesions (< 1 cm) require careful assessment bronchoscopically and radiographically. The data for use of PDT for patients who are surgical candidates appears encouraging. Other endobronchial treatments such as electrocautery, cryotherapy, and brachytherapy are not as well studied, but appear to have similar response rates to PDT. The best response
Summary of Recommendations
- 1.
For patients with early superficial squamous cell carcinoma who are not surgical candidates, PDT should be considered as a treatment option. Level of evidence, fair; benefit, moderate; grade of recommendation, B
- 2.
For patients with early superficial squamous cell carcinoma who are surgical candidates, the use of PDT appears to be a promising treatment, but more experience is needed to compare PDT to surgical outcomes. Level of evidence, poor; benefit, none/negative; grade of recommendation, I
- 3.
In
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