IP Fellows Reading List

Therapies for Early Stage or Locally Invasive Lung Cancer

Cryotherapy

The application of cryosurgery in the treatment of lung cancer

https://pubmed.ncbi.nlm.nih.gov/14969682/

Clinical Trial

Reference: Maiwand MO, Evans JM, Beeson JE. The application of cryosurgery in the treatment of lung cancer. Cryobiology. 2004;48(1):55-61.

Background: This is a prospective study evaluating the use of endobronchial cryosurgery for relieving malignant central airway obstructions (MCAO).

PICO:

Population –

476 patients with symptomatic MCAO due to stage II-IV lung cancer. All patients were deemed inoperable due to the extent of disease or patient factors.

Intervention –

Cryosurgery for management of MCAOs.

Comparison –

None

Outcome –

Cryosurgery ameliorated hemoptysis in 76.4%, cough in 69.0%, dyspnea in 59.2%, and chest pain in 42.6% of symptomatic patients.
The mean Karnofsky performance status score improved from 59.6 to 75.2 and WHO performance status improved from 3.04 to 2.20.
Each patient underwent a mean of 2.4 cryosurgical treatments.
Complications were seen in 3.5% of treatments, which included bleeding, pneumothorax, and respiratory distress.

Take home: Cryosurgery is a relatively safe, rapid, and effective intervention in the management of MCAO due to inoperable lung cancer. This study demonstrates that it can improve symptoms and performance status.

Unimodality and multimodality cryodebridement for airway obstruction. A single-center experience with safety and efficacy

https://pubmed.ncbi.nlm.nih.gov/26999041/

Clinical Trial

Reference: Inaty H, Folch E, Berger R, et al. Unimodality and multimodality cryodebridement for airway obstruction. A single-center experience with safety and efficacy. Ann Am Thorac Soc. 2016;13(6):856-861.

Background: This retrospective analysis describes one institution’s experience with cryodebridement in the management of airway obstruction.

PICO:

Population –

156 patients who underwent bronchoscopic cryodebridement as the primary method to relieve airway obstruction.

Intervention –

Cryodebridement

Comparison –

None

Outcome –

56.4% of cases of airway obstructions were due to malignancies, most commonly NSCLC and metastatic renal cell carcinoma. 40% of lesions were localized to the central airways, 28% to the distal airways, and 42% were diffuse.
Cryodebridement was used either alone (27%) or with other tools, including forceps for mechanical debridement (51%), electrocautery (30%), and/or APC (17%). Interventions were successful in recanalizing the airway in 95% of cases. There was symptomatic improvement in 82% of patients. Of these, 62% reported substantial improvement, 20% reported little or no improvement, and 12% reported worsened symptoms.
Serious complications were reported in 11% of cases and included moderate bleeding controlled with iced saline, APC, and electrocautery, respiratory failure requiring ventilatory support, and hemodynamic instability. There were no procedure-related deaths.

Take home: Cryodebridement is a relatively safe and effective tool in managing both malignant and benign airway obstructions. This study took place at a single large-volume referral center so caution should be taken when generalizing these findings.

Endobronchial tumor debulking with a flexible cryoprobe for immediate treatment of malignant stenosis

https://pubmed.ncbi.nlm.nih.gov/19716140/

Clinical Trial

Reference: Schumann C, Hetzel M, Babiak AJ, et al. Endobronchial tumor debulking with a flexible cryoprobe for immediate treatment of malignant stenosis. J Thorac Cardiovasc Surg. 2010;139(4):997-1000.

Background: This is a retrospective analysis of the use of a cryosurgery in the management of malignant endobronchial disease at a single center in Germany.

PICO:

Population –

225 patients undergoing bronchoscopy for the management of symptomatic malignant airway obstruction.

Intervention –

Cryosurgery using an ERBE flexible cryoprobe in the management of a malignant airway obstruction. Other modalities (e.g., laser, APC, mechanical debulking) were available but rarely used.

Comparison –

None

Outcome –

Obstructing tumors involved central airways in 44.0% of cases, lobar bronchi in 41.3%, or both in 14.7%. The airway was recanalized in 91.1% of cases. Failure to recanalize was often due to a longer length (>2 cm) of complete bronchial obstruction.
Bleeding occurred in 12% of procedures (4% mild, 8% moderate, 0% severe). There was one case of pneumomediastinum after removal of a tracheal cystadenoma.

Take home: Tumor debulking with cryosurgery was found to be a safe and effective intervention in lesions <2 cm in length.

Treatment of pulmonary carcinoid tumors with bronchoscopic cryotherapy: a 28-year single-center experience

https://pubmed.ncbi.nlm.nih.gov/34261879/

Clinical Trial

Reference: Perikleous P, Mayer N, Finch J, Beddow E, Anikin V, Asadi N. Treatment of pulmonary carcinoid tumors with bronchoscopic cryotherapy: a 28-year single-center experience. J Bronchology Interv Pulmonol. 2022;29(1):71-82.

Background: The gold standard for managing pulmonary carcinoid tumors is resection. However, in inoperable cases with centrally-located intraluminal tumors, bronchoscopic management is a potential treatment option. This study is a retrospective review of bronchoscopic management of carcinoid tumors using cryotherapy at a single institution.

PICO:

Population –

63 patients with bronchial carcinoid tumors that were inoperable or the patient declined surgery.

Intervention –

Bronchoscopic treatment of carcinoid tumors using cryotherapy

Comparison –

None

Outcome –

A total of 243 cryotherapy procedures were performed with a median of 3 procedures per patient (range 1-18).
There was complete remission in 33.3% of patients over a median follow-up time of 33 months. All of these were typical carcinoid tumors <20 mm in diameter.
34.9% achieved sufficient cytoreduction to proceed with parenchymal-sparing resections.
92.1% of patients reported symptomatic improvement.
No immediate or late complications were reported.

Take home: Cryotherapy is a reasonable treatment option for patients with carcinoid tumors not amenable to surgical resection. This study has demonstrated that remission can be achieved in select patients treated with cryotherapy alone, although further study is needed prior to incorporation into standard practice.

Airway spray cryotherapy: initial outcomes from a multiinstitutional registry

https://pubmed.ncbi.nlm.nih.gov/22516831/

Clinical Trial

Reference: Finley DJ, Dycoco J, Sarkar S, et al. Airway spray cryotherapy: initial outcomes from a multiinstitutional registry. Ann Thorac Surg. 2012;94(1):199-203; discussion 203-204.

Background:

PICO:

Population –

80 patients with symptomatic airway tumors from 6 US hospitals

Intervention –

Treatment with spray cryotherapy. The duration and number of applications were deferred to the treating physician

Comparison –

None

Outcome –

114 SCT treatments were performed in 80 patients. 73.5% had stage IV carcinomas.
Most patients required an additional form of debridement (e.g., mechanical debridement with forceps).
19.3% of procedures had complications, which included hypotension (11.4%), desaturation (6.1%), bradycardia (5.3%). There was 1 significant bleeding with mechanical debulking that was controlled using SCT. There were 3 pneumothoraces with 1 requiring a chest tube. There were 5 deaths (4.4%): two occurred during the procedure ~5-30 minutes after application of SCT with the remainder occurring 1, 5, and 7 days after the procedure, all of whom were on comfort measures only. One of the intraprocedural deaths was due to a tension pneumothorax.

Take home: This study shows that SCT can be used to treat malignant airway tumors and has advantages of reduced bleeding complications. However, additional studies are needed to demonstrate clinically relevant outcomes. Furthermore, there was a significant number of deaths during and after the procedure for unclear reason (possibly due to high pressures from the spray) that need to be investigated prior to wider adoption of this intervention.