Recent Advances in Bronchoscopic Treatment of Peripheral Lung Cancers

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Recent Advances in Bronchoscopic Treatment of Peripheral Lung Cancers Kassem Harris, MD, FCCP, Jonathan Puchalski, MD, FCCP, Daniel Sterman, MD, FCCP CHEST Volume 151, Issue 3, Pages 674-685 (March 2017) DOI: 10.1016/j.chest.2016.05.025 Copyright © 2016 The Authors Terms and Conditions

Figure 1 A, Navigational bronchoscopy image showing the bronchial tree with airway (pink) leading to the peripheral lung nodule in the apical segment of the right upper lobe (white arrow). B, Image showing the tip of the guide sheath proximal to the target. The green ball represents the right upper nodule in the apical segment. The red arrow shows the alignment of the guide sheath with the target at a 0.3-cm distance. CHEST 2017 151, 674-685DOI: (10.1016/j.chest.2016.05.025) Copyright © 2016 The Authors Terms and Conditions

Figure 2 CT-assisted transbronchial brachytherapy for small peripheral lung cancer. A, Peripheral lung lesions (adenocarcinoma). B, A dummy source was inserted into the lesion. C, An applicator with a dummy source was stabilized between the pleura and the orifice of a tracheal tube to preserve accurate positioning of the radiation center throughout the procedure. D, CT scan after brachytherapy shows radiation fibrosis without apparent changes in the surrounding lung tissue. (Reprinted with permission from Kobayashi et al.31) CHEST 2017 151, 674-685DOI: (10.1016/j.chest.2016.05.025) Copyright © 2016 The Authors Terms and Conditions

Figure 3 Salvage: postradiotherapy ablation. A, PET and corresponding axial CT scans demonstrate a hypermetabolic lesion (black arrows) within the left upper lobe with surrounding radiation change—a difficult lesion to treat surgically. B, Radiofrequency electrode within target lesion (black arrow). C, PET and corresponding axial CT images after treatment demonstrating cavity in the region of prior ablation with smooth surrounding hypermetabolic rim—corresponding to expected postablation changes (black arrows). (Reprinted with permission from Pua et al.33.) CHEST 2017 151, 674-685DOI: (10.1016/j.chest.2016.05.025) Copyright © 2016 The Authors Terms and Conditions

Figure 4 CyberKnife robotic radiosurgery for early-stage non-small cell lung cancer (NSCLC). A-C, Example of radiation dose distribution in axial, sagittal, and coronal images, respectively, of a chest CT scan for a left peripheral lung cancer. D, Beam configuration. A typical treatment plan for a 13-cm3 NSCLC lesion. Treatment would deliver 60 Gy in three fractions to the 65% isodose level using 60 beams, resulting in a V(15) of 4.6%. (Reprinted with permission from Brown et al.55.) CHEST 2017 151, 674-685DOI: (10.1016/j.chest.2016.05.025) Copyright © 2016 The Authors Terms and Conditions

Figure 5 Cryotherapy for lung cancer. A, Preprocedural (left) and procedural (right) images of a 2-cm primary lung cancer in a patient who was not eligible for surgery show the initial needle placement (arrow). The tip was subsequently advanced to the far tumor margin. B, Image on left was obtained 10 weeks after percutaneous cryotherapy (PCT) and shows resolution of the cavitary effect that developed (not shown), with a residual parenchymal reaction but a minimal underlying soft-tissue component. Image on the right was obtained 6 months after PCT and shows nearly complete resolution of the parenchymal reaction and minimal residual scarring. (Reprinted with permission from Wang et al.57). CHEST 2017 151, 674-685DOI: (10.1016/j.chest.2016.05.025) Copyright © 2016 The Authors Terms and Conditions