INTERVENTIONAL PULMONOLOGY IN OTHER JOURNALS: Commentary on Selected Publications
Autofluorescence bronchoscopy improves staging of radiographically occult lung cancer and has an impact on therapeutic strategy.
Chest 2001;120:1327–32. Sutedja TG, Codrington H, Risse EK, Breuer RH, van Mourik JC, Golding RP, Postmus PE. Departments of Pulmonology, Pathology, Surgery, and Radiology, Academic Hospital Vrije Universiteit, Amsterdam, The Netherlands.
This prospective study evaluated the role of high-resolution CT (HRCT) and AFB in the assessment of radiographically occult lung cancer (ROLC) before the most appropriate therapy could be considered. The study included 23 patients with ROLC, who were referred for intraluminal bronchoscopic treatment (IBT) with curative intent. Of these, there were 20 male patients, 9 patients had first primary cancers, and 14 patients had second primary cancers or synchronous cancers. Additional staging with HRCT and AFB was performed before treatment. HRCT revealed that 19 patients (83%) had no visible tumor or enlarged lymph nodes. With AFB, only 6 of the 19 patients (32%) were found to have tumors ≤ 1 cm2 with visible distal margins. They were treated with IBT. In the remaining 13 patients, abnormal fluorescence indicated more extensive tumor infiltration than could be seen with conventional bronchoscopy alone. Six patients underwent radical surgery for stage T1–2N0 (n = 5) and stage T2N1 (n = 1) tumors. Surgically resected specimens showed that tumors were more invasive than initially expected. The remaining seven patients did not have operable conditions, so they were treated with external irradiation (n = 4) and IBT (n = 3). The range for the time of follow-up for all patients was 4 to 58 months (median, 40 months). The authors conclude that these data show that 70% of patients presenting with ROLC had a more advanced cancer than initially suspected, which precluded IBT with curative intent. The authors also indicate that additional staging with HRCT and AFB enabled better classification of true occult cancers, and their approach enabled the choice of the most appropriate therapy for each individual patient with ROLC. The detection of the smallest lung cancer implies diagnosis at an early stage, before the cancer has invaded deep into the mucosa. Patients with such cancers, when detected and treated by appropriate surgical resection, enjoy a good long-term prognosis. In patients with severe cardiopulmonary problems or other medical conditions, surgical therapy may not be feasible even when the cancer is detected during its early stages. Such patients may benefit from IBT. The ability to detect the bronchogenic cancer during its earlier stages is difficult despite the newer techniques that are available. When such cancers are not detected on chest roentgenography, the term ROLC is used to describe them. The types of IBT currently available include photodynamic therapy, electrocautery, argon plasma therapy, or laser therapy. As noted by Sutedja et al., the most difficult aspect of IBT with curative intent is to select patients who are really candidates for cure by these methods. Furthermore, IBT with curative intent is only possible in areas accessible by the fiberoptic bronchoscope in the visible part of the tracheobronchial tree. The discouraging finding in this study is that 70% of patients with ROLC had more advanced malignancy that expected. The only potential technology that is currently available to assess depth of infiltration of bronchial mucosa is bronchoscopic ultrasound. However, there are not enough studies to document its role in this. A combination of HRCT, AFB, and ultrasound evaluation may provide a better means of staging patients accurately with ROLC so that more appropriate therapy can be planned.