Pulmonologists frequently encounter lung nodules, >50% of which are benign. This poses a diagnostic challenge when nodules with worrisome features are found in areas of the lung that are not easily accessible by conventional bronchoscopy or transthoracic biopsy. Triage of nodules to observation, biopsy, and/or resection is influenced by nodule location and size, patient comorbidities, and technological limitations. Conventional bronchoscopy can reach the fifth generation bronchi, but nodules in the peripheral third of the lung are inaccessible. Diagnostic yield with conventional bronchoscopy is poor for small peripheral lesions, especially those <2cm in size. While the advent of electromagnetic navigation bronchoscopy significantly improved this yield, it has been further augmented with the use of robotic-assisted navigation bronchoscopy. Here, we describe our experience evaluating high-risk lesions using the Ion platform, specifically to prove malignancy or definitive benign disease. Proving benign disease avoids unnecessary resection, alleviates concern for cancer, and minimizes the need for follow up imaging.METHODS: All patients undergoing robotic navigation bronchoscopy using the Ion platform beginning August 1 st , 2020 were enrolled in an IRB-approved registry. Radial EBUS and fluoroscopy were used for all cases to confirm proximity to the nodule. Patient demographics, nodule characteristics, diagnostic yield, complications, and pathology were recorded for all patients. RESULTS:The Ion was used to evaluate 64 nodules in 51 patients. Median number of nodules per person was 1 (range 1-3). Median size of nodules was 14mm (range 5-44mm). A total of 34 benign nodules with a mean size of 16mm were diagnosed in 25 patients. Twenty-one nodules were solid, 9 were subsolid, and 4 were groundglass. Seventeen patients (26 nodules) were evaluated with PET/CT, 20 nodules were PET-avid. Definitive diagnoses included the following: granulomatous disease (7), inflammation (6), fibrosis (2), necrosis (1), organizing pneumonia (1), multinucleated giant cells (1), radiation effect (1), and infection (3), including Streptococcus, Aspergillus, and NTM. Benign tissue was isolated from the remaining 12 nodules, but for our purposes this was considered non-diagnostic and ongoing surveillance was recommended.CONCLUSIONS: Small peripheral nodules are increasingly identified, especially with new lung cancer screening guidelines that capture a larger patient cohort. Many have high-risk features despite being benign, therefore it is essential to have a safe method of tissue sampling that allows both access to and accuracy in diagnosing these lesions. Using the Ion we were able to definitively prove benign disease in 34% of nodules, thus alleviating patient anxiety and eliminating the need for future surveillance and resection.CLINICAL IMPLICATIONS: Using the Ion we were able to definitively prove benign disease in 34% of nodules, thus alleviating patient anxiety and eliminating the need for future surveillance and resection.
PURPOSE: Photodynamic therapy (PDT) has been used successfully in patients with endobronchial non-small cell lung cancer (NSCLC) with curative and palliative intent. We assessed outcomes of PDT in patients with endobronchial carcinoid. METHODS: This is a records review using a multi-center registry that consists of patients who received endobronchial PDT for curative intent or for management of pulmonary symptoms. We evaluated adverse events and clinical outcomes including survival. All patients received porfimer sodium at 1-2 mg/kg intravenously as the photosensitizer. Light was administered at 630 nm for a total dose of 200 J, except for one case as noted below. RESULTS: 1998 and 2014, 893 patients were treated with 1061 courses of PDT for esophageal and lung malignancies at 5 centers. Endobronchial PDT accounted for 530 of the cases. 9 patients received PDT for treatment of endobronchial carcinoid. Endobronchial therapy was offered when surgical resection could not be performed. 7/9 patients responded to PDT, and 4/9 exhibited patholocial complete responses with absence of tumor on repeat bronchoscopy. 1 patient with bulky disease at the carina was treated with 500J, responded poorly, and developed tracheoesophageal fistula postoperatively. 1 patient with multifocal disease required short term ventilator support. There were no post procedure deaths. Massive hemoptysis was not observed. CONCLUSIONS: Endobronchial carcinoid can be ablated with PDT. Endobronchial PDT with porfimer sodium is generally welltolerated with minimal morbidity. Significant hemoptysis was not observed even in the setting of multiple endobronchial manipulations of the tumor. Light dosage greater than 200J should be avoided. Tumor response to PDT was seen in 7/9 cases (77%), and this led to a pathological complete response in 4/9 (44%). CLINICAL IMPLICATIONS: Carcinoid tumors are responsive to treatment with PDT. PDT should be considered for endobronchial treatment of carcinoid when surgical resection is not an option.
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