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Photodynamic therapy for tracheal thyroid metastasis
Photodiagnosis and Photodynamic Therapy (2004) 1, 99—102
SHORT COMMUNICATION
Photodynamic therapy for tracheal thyroid metastasis P. Barber, FRCP*, A.K. Deiraniya, E. Allen North West Lung Centre, Wythenshawe Hospital, Manchester, UK
KEYWORDS Follicular carcinoma; Photodynamic therapy; Radiotherapy
Summary We report the case of a patient with recurrence of follicular carcinoma of the thyroid 8 years after surgical resection followed by external beam radiotherapy and radio-iodine treatment. The patient was treated by endoscopic photodynamic therapy (PDT) with complete endoscopic response after 12 months with good symptom relief. © 2004 Elsevier B.V. All rights reserved.
Introduction Malignant secondary tracheal tumours are rare and the majority are related to direct invasion from surrounding structures, notably thyroid and oesophageal cancer. Some may be amenable to surgical treatments [1]. In others cases interventional endoscopy is indicated in order to relieve the distressing airway obstruction [2]. In some cases, such as the one illustrated below, photodynamic therapy (PDT) appears to be the best option for provision of long-term clearance and palliation of symptoms.
Clinical history A 67-year-old man was referred in October 2001 from a radiotherapy clinic for advice on the management of a recurrent thyroid carcinoma invading the upper trachea. The condition presented in 1993, when a follicular carcinoma of the thyroid was surgically resected. He went on to receive external beam radiotherapy followed by radio-iodine ∗ Tel.:
+44-1612912721. E-mail address: [email protected] (P. Barber).
and was perfectly well for the next 8 years. He then re-presented with haemoptysis. At bronchoscopy (December 2001) the upper end of the trachea was found to be stenosed by nodules of tumour extending from the sub-glottic rim down the left side of the trachea for a distance of around 3 cm (Fig. 1). The trachea was around 70% stenosed. A further radio-iodine treatment was administered, without benefit. Enquiries were made as to the previous radiotherapy dose and it was concluded that further radiotherapy could not be given. The tumour was partially de-bulked by rigid bronchoscopy and diathermy in June 2002. There was substantial residual infiltration and stenosis (Fig. 2). On 10/9/2002, PDT was administered following intravenous porfimer sodium, 2 mg/kg. A 2.5 cm radial diffuser was used, 200 J of illumination at 630 nm delivered, using a diode laser power of 1 W for 500 seconds. At re-bronchoscopy on the following day, a marked and selective tumour necrosis effect was observed, with diffuse mucosal erythema in adjacent areas (Fig. 3). Small amounts of slough and attached secretions were removed without difficulty using the fibreoptic bronchoscope. There was no oedema or dysfunction of the vocal cords. A month later, there was still a marked necrotic reaction in the treated area, corresponding to
1572-1000/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/S1572-1000(04)00016-X
100
P. Barber et al.
Figure 1
Figure 2
Tumour stenosing upper trachea.
Appearance following endoscopic debulking.
Photodynamic therapy for tracheal thyroid metastasis
Figure 3
Tumour necrosis 24 h after PDT.
Figure 4
Appearances at 1 month.
101
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P. Barber et al.
Figure 5
Appearances at 12 months: mild sub-glottic stenosis.
the distribution of original disease (Fig. 4). By now, there was no major stenosis and no further de-bulking was required. At subsequent review in succeeding months, a continued abnormal and necrotic appearance on the right tracheal wall proved to be due to Candida infection, which responded well to systemic treatment with fluconazole. Bacteria were also identified in the same area, together with a slight foetor, responsive to treatment with cefixime and metronidazole. The most recent bronchoscopy at 12 months (September 2003) now shows a mild concentric sub-glottic stenosis (Fig. 5). The only evidence of possible residual disease is a tiny nodule at the left antero-lateral aspect of the upper trachea. The patient is perfectly well and asymptomatic (Fig. 3).
life-threatening metastatic obstruction of the upper trachea. Neither external beam radiotherapy nor brachytherapy could be administered because of previous radiotherapy to tolerance in 1993. The disease could not be surgically resected and endoscopic thermal laser or diathermy alone would have treated only the exophytic, not the infiltrative, component of his disease. Photodynamic therapy has achieved a selective tumour response with a potentially prolonged remission, the treatment complicated by transient secondary infection and a mild fibrotic stenosis. This case illustrates the unique benefit of photodynamic therapy in certain clinical situations.
Comment
[1] Hammoud ZT, Mathisen DJ. Surgical management of thyroid carcinoma invading the trachea. Chest Surg Clin N Am 2003;13(2):359—67. [2] Wood DE. Management of malignant tracheobronchial obstruction. Surg Clin N Am 2002;82(3):621—42.
This patient presented a difficult problem, in excellent general health but with a potentially
References
SHORT COMMUNICATION
Photodynamic therapy for tracheal thyroid metastasis P. Barber, FRCP*, A.K. Deiraniya, E. Allen North West Lung Centre, Wythenshawe Hospital, Manchester, UK
KEYWORDS Follicular carcinoma; Photodynamic therapy; Radiotherapy
Summary We report the case of a patient with recurrence of follicular carcinoma of the thyroid 8 years after surgical resection followed by external beam radiotherapy and radio-iodine treatment. The patient was treated by endoscopic photodynamic therapy (PDT) with complete endoscopic response after 12 months with good symptom relief. © 2004 Elsevier B.V. All rights reserved.
Introduction Malignant secondary tracheal tumours are rare and the majority are related to direct invasion from surrounding structures, notably thyroid and oesophageal cancer. Some may be amenable to surgical treatments [1]. In others cases interventional endoscopy is indicated in order to relieve the distressing airway obstruction [2]. In some cases, such as the one illustrated below, photodynamic therapy (PDT) appears to be the best option for provision of long-term clearance and palliation of symptoms.
Clinical history A 67-year-old man was referred in October 2001 from a radiotherapy clinic for advice on the management of a recurrent thyroid carcinoma invading the upper trachea. The condition presented in 1993, when a follicular carcinoma of the thyroid was surgically resected. He went on to receive external beam radiotherapy followed by radio-iodine ∗ Tel.:
+44-1612912721. E-mail address: [email protected] (P. Barber).
and was perfectly well for the next 8 years. He then re-presented with haemoptysis. At bronchoscopy (December 2001) the upper end of the trachea was found to be stenosed by nodules of tumour extending from the sub-glottic rim down the left side of the trachea for a distance of around 3 cm (Fig. 1). The trachea was around 70% stenosed. A further radio-iodine treatment was administered, without benefit. Enquiries were made as to the previous radiotherapy dose and it was concluded that further radiotherapy could not be given. The tumour was partially de-bulked by rigid bronchoscopy and diathermy in June 2002. There was substantial residual infiltration and stenosis (Fig. 2). On 10/9/2002, PDT was administered following intravenous porfimer sodium, 2 mg/kg. A 2.5 cm radial diffuser was used, 200 J of illumination at 630 nm delivered, using a diode laser power of 1 W for 500 seconds. At re-bronchoscopy on the following day, a marked and selective tumour necrosis effect was observed, with diffuse mucosal erythema in adjacent areas (Fig. 3). Small amounts of slough and attached secretions were removed without difficulty using the fibreoptic bronchoscope. There was no oedema or dysfunction of the vocal cords. A month later, there was still a marked necrotic reaction in the treated area, corresponding to
1572-1000/$ – see front matter © 2004 Elsevier B.V. All rights reserved. doi:10.1016/S1572-1000(04)00016-X
100
P. Barber et al.
Figure 1
Figure 2
Tumour stenosing upper trachea.
Appearance following endoscopic debulking.
Photodynamic therapy for tracheal thyroid metastasis
Figure 3
Tumour necrosis 24 h after PDT.
Figure 4
Appearances at 1 month.
101
102
P. Barber et al.
Figure 5
Appearances at 12 months: mild sub-glottic stenosis.
the distribution of original disease (Fig. 4). By now, there was no major stenosis and no further de-bulking was required. At subsequent review in succeeding months, a continued abnormal and necrotic appearance on the right tracheal wall proved to be due to Candida infection, which responded well to systemic treatment with fluconazole. Bacteria were also identified in the same area, together with a slight foetor, responsive to treatment with cefixime and metronidazole. The most recent bronchoscopy at 12 months (September 2003) now shows a mild concentric sub-glottic stenosis (Fig. 5). The only evidence of possible residual disease is a tiny nodule at the left antero-lateral aspect of the upper trachea. The patient is perfectly well and asymptomatic (Fig. 3).
life-threatening metastatic obstruction of the upper trachea. Neither external beam radiotherapy nor brachytherapy could be administered because of previous radiotherapy to tolerance in 1993. The disease could not be surgically resected and endoscopic thermal laser or diathermy alone would have treated only the exophytic, not the infiltrative, component of his disease. Photodynamic therapy has achieved a selective tumour response with a potentially prolonged remission, the treatment complicated by transient secondary infection and a mild fibrotic stenosis. This case illustrates the unique benefit of photodynamic therapy in certain clinical situations.
Comment
[1] Hammoud ZT, Mathisen DJ. Surgical management of thyroid carcinoma invading the trachea. Chest Surg Clin N Am 2003;13(2):359—67. [2] Wood DE. Management of malignant tracheobronchial obstruction. Surg Clin N Am 2002;82(3):621—42.
This patient presented a difficult problem, in excellent general health but with a potentially
References