- Email: [email protected]
Sequential interventional treatment of right-sided lung cancer with complete lung atelectasis: A case report
Accepted Manuscript Sequential interventional treatment of right-sided lung cancer with complete lung atelectasis: A case report Gang Wu, MD, Zongming Li, MD, Dechao Jiao, MD, Xinwei Han, MD PII:
S0022-5223(16)30320-8
DOI:
10.1016/j.jtcvs.2016.05.012
Reference:
YMTC 10606
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 20 March 2016 Revised Date:
3 May 2016
Accepted Date: 4 May 2016
Please cite this article as: Wu G, Li Z, Jiao D, Han X, Sequential interventional treatment of right-sided lung cancer with complete lung atelectasis: A case report, The Journal of Thoracic and Cardiovascular Surgery (2016), doi: 10.1016/j.jtcvs.2016.05.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Sequential interventional treatment of right-sided lung cancer with complete
2
lung atelectasis: A case report
3
Gang Wu, MD, Zongming Li, MD, Dechao Jiao, MD, Xinwei Han, MD*
5
Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou
6
University, Zhengzhou 450052, China
RI PT
4
Article word count: 736
9
Abstract word count: 96
10
M AN U
8
SC
7
Funding: This research received no specific grant from any funding agency in the
12
public, commercial or not-for-profit sectors
13
Conflict of Interest: The authors declare that they have no conflicts of interest in the
14
research.
EP
15
TE D
11
16
*
17
First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
18
E-mail: [email protected]; Tel: +8613803842129
AC C
Corresponding author: Xinwei Han, Department of Interventional Radiology, The
1
ACCEPTED MANUSCRIPT 19
Glossary of abbreviations: CT, computed tomography
20
Central Message: Sequential intervention is an effective and minimally invasive
22
treatment method for lung cancer with complete lung atelectasis.
RI PT
21
23
Central Picture:
M AN U
SC
24
25
Y-shaped stent placed in the right main bronchus, upper bronchus and intermediate
27
bronchus
AC C
EP
TE D
26
2
ACCEPTED MANUSCRIPT 28 29
Abstract Lung cancer with complete atelectasis is a medical emergency, and often difficult to treat with surgical resection, chemotherapy, and radiotherapy. Patients often
31
experience chronic dyspnea, thereby resulting in low quality of life and poor
32
prognosis. Here, we report a case of pulmonary adenocarcinoma and complete
33
atelectasis of the right lung (IIIA) that was successfully treated with placement of a
34
custom-made Y-shaped stent. The lung adenocarcinoma was further treated with
35
bronchial artery chemotherapy and subsequent radiotherapy. The patient’s breathing
36
was restored, and at 49 months of follow-up, the patient continued to feel healthy with
37
only a minor residual cough.
AC C
EP
TE D
M AN U
SC
RI PT
30
3
ACCEPTED MANUSCRIPT 38
Introduction Dyspnea due to lung cancer and concomitant atelectasis is a serious, acute
40
respiratory condition that can result in death secondary to asphyxiation.
41
Bronchoscopy and biopsy are difficult to perform in dyspneic patients with severe
42
airway stenosis or main bronchus blockage from atelectasis. The timely placement of
43
airway stents can release airway strictures and relieve dyspnea1. Herein, we present a
44
case of right lung cancer and atelectasis confirmed with airway imaging and biopsy
45
by interventional technique, and treatment with a Y-shaped airway stent to relieve
46
airway blockage, thus relieving the patient’s dyspnea.
M AN U
SC
RI PT
39
47
49
Case Report
A 66-year-old man presented to our department with a 1-month history of
TE D
48
productive cough. The patient did not benefit from symptomatic treatment. Six days
51
prior to admission, the patient became increasingly dyspneic, and a chest computed
52
tomography (CT) showed obstruction of the right lung hilum with right lung
53
atelectasis (Figure 1A,1B). The patient had grade 4 dyspnea, cyanosis, and
54
intermittent fever of 39℃. A repeat chest CT scan showed complete right lung
55
atelectasis, with plugging of the right main bronchus, and a right-shifted mediastinum.
56
The patient was initially treated with oxygen to relieve the dyspnea, but his clinical
57
status worsened.
58 59
AC C
EP
50
The patient provided written consent for use of his medical records for subsequent publication. He underwent bronchography and right bronchial forceps 4
ACCEPTED MANUSCRIPT biopsy on day 3 of admission. Bronchography revealed complete blockage of the right
61
upper bronchial opening, the initial part of the right intermediate bronchus, and the
62
distal portion of the right main bronchus (Figure 2A). Under fluoroscopic guidance,
63
the biopsy forcep was introduced through a sheath, and three grain-sized specimens
64
were obtained from different parts of the stenosed area for histopathological analysis
65
(Figure 2B), which confirmed the diagnosis of right lung adenocarcinoma. The lung
66
cancer staging was IIIA (T3N2M0).
SC
An appropriate model of a Y-shaped airway stent (Micro-tech Co Ltd, Nanjing,
M AN U
67
RI PT
60
China) was custom-made in accordance with the bronchography and chest CT
69
findings. The intermediate portion of the stent measured 16 mm in diameter and 10
70
mm in length, the right upper bronchial part measured 8 mm in diameter and 12 mm
71
in length, and the intermediate bronchial portion measured 10 mm in diameter and 30
72
mm in length.
73
The self-expandable airway stent was implanted 6 days after admission (Figure 2C). A
74
repeat transcatheter bronchography showed appropriate stent location and patency of
75
the right bronchial lumen.
EP
AC C
76
TE D
68
Thirteen days after admission, the patient underwent regional perfusion
77
chemotherapy via the right bronchial artery. The angiography showed right bronchial
78
artery thickening with abnormal flaky staining in the right lung hilum (Figure 2D).
79
Chemotherapy was administered slowly via a catheter, which included 1000 mg
80
fluorouracil, 50 mg pirarubicin, and 60 mg cis-platinum, each in 160 ml of 5%
81
glucose. 5
ACCEPTED MANUSCRIPT 82
The patient’s breathing was normal 1 month after bronchial artery regional perfusion chemotherapy. A repeat chest CT at this time showed decreased obstruction
84
in the right hilum as compared to the preoperative imaging (Figure 1C,1D). The
85
second chemotherapy was administered 4 weeks later, after which the patient’s chest
86
tightness completely resolved. A further follow-up chest CT showed that the tumor
87
continued to decrease in size. Bronchoscopy revealed a small amount of granulation
88
tissue hyperplasia at the stent edges. Radiotherapy was performed 7 days after the
89
second chemotherapy session.
M AN U
SC
RI PT
83
90
Until now, the patient had completed 49 months of follow up. He claimed to
91
subjectively feeling better than before, and at the last follow-up, only experienced an
92
occasional cough productive of white sputum.
94
Discussion
TE D
93
Approximately 80% of patients with lung cancer are diagnosed with advanced
96
stage disease, leaving few, if any, surgical options2. We performed a forceps biopsy
97
with an interventional technique in our patient with severe airway stenosis. This
98
technique allowed us to effectively and rapidly obtain samples for histopathological
99
analysis with accurate localization, high technical success, and safety3. Simultaneous
100
airway imaging was used to identify specific parts of the tumor that involved the
101
airway, and this data was used to create a unique airway stent. The Y-shaped stent
102
successfully relieved the airway stenosis4. Bronchial artery regional perfusion
103
chemotherapy significantly reduced the tumor’s size, and further improved the
AC C
EP
95
6
ACCEPTED MANUSCRIPT patient’s dyspnea5. Finally, radiotherapy was used to destroy any residual neoplastic
105
lesions.
106
This case validates the use of a series of sequential interventional therapies to treat
107
severe airway stenosis secondary to a lung tumor. Not only did this therapy improve
108
the patient’s quality of life but it likely also prolonged his survival due to shrinkage of
109
the lung adenocarcinoma.
AC C
EP
TE D
M AN U
SC
RI PT
104
7
ACCEPTED MANUSCRIPT References
111
1. Andreetti C, D'Andrilli A, Ibrahim M, Rendina EA. Treatment of a complex
112
tracheobronchial malignant stenosis with a modified conical semicovered
113
self-expandingstent. J Thorac Cardiovasc Surg. 2013;146:488-9.
114
2. Videtic GM, Chang JY, Chetty IJ, Ginsburg ME, Kestin LL, Kong FM, et al. ACR
115
appropriateness Criteria early-stage non-small-cell lung cancer. Am J Clin Oncol.
116
2014;37:201-7.
117
3. Li ZM, Wu G, Han XW, Ren KW, Zhu M. Radiology-guided forceps biopsy and
118
airway stenting in severe airway stenosis. Diagn Interv Radiol. 2014;20:349-52.
119
4. Han XW, Wu G, Li YD, Zhang QX, Guan S, Ma N, et al. Overcoming the delivery
120
limitation: results of an approach to implanting an integrated self-expanding Y-shaped
121
metallic stent in the carina. J Vasc Interv Radiol. 2008;19:742-7.
122
5. Nakanishi M, Demura Y, Umeda Y, Mizuno S, Ameshima S, Chiba Y, Ishizaki T.
123
Multi-arterial infusion chemotherapy for non-small cell lung carcinoma-significance
124
of detecting feeding arteries and tumor staining. Lung Cancer. 2008;61:227-34.
AC C
EP
TE D
M AN U
SC
RI PT
110
8
ACCEPTED MANUSCRIPT Figure Legends
126
Figure 1: Chest computed tomography (CT) on admission, shows complete atelecasis
127
in the (A) lung window and (B) mediastinum window. A repeat CT in the (C) lung
128
window and (D) mediastinum window shows reduction in size of the tumor in the
129
right lung hilum 1 month after bronchial artery regional perfusion chemotherapy.
RI PT
125
130
Figure 2: Bronchography (A) shows complete blockage of the right upper bronchus,
132
initial segment of the right intermediate bronchus, and distal right main bronchus.
133
Fluoroscopic guidance (B) to reach the blocked right bronchus using biopsy forceps
134
inserted through the sheath’s canal. Fluoroscopy (C) shows release of the Y-shaped
135
stent. Right bronchial artery angiography (D) shows thickening of the artery, with
136
abnormally stained areas in the right lung hilum.
AC C
EP
TE D
M AN U
SC
131
9
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0022-5223(16)30320-8
DOI:
10.1016/j.jtcvs.2016.05.012
Reference:
YMTC 10606
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 20 March 2016 Revised Date:
3 May 2016
Accepted Date: 4 May 2016
Please cite this article as: Wu G, Li Z, Jiao D, Han X, Sequential interventional treatment of right-sided lung cancer with complete lung atelectasis: A case report, The Journal of Thoracic and Cardiovascular Surgery (2016), doi: 10.1016/j.jtcvs.2016.05.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Sequential interventional treatment of right-sided lung cancer with complete
2
lung atelectasis: A case report
3
Gang Wu, MD, Zongming Li, MD, Dechao Jiao, MD, Xinwei Han, MD*
5
Department of Interventional Radiology, The First Affiliated Hospital of Zhengzhou
6
University, Zhengzhou 450052, China
RI PT
4
Article word count: 736
9
Abstract word count: 96
10
M AN U
8
SC
7
Funding: This research received no specific grant from any funding agency in the
12
public, commercial or not-for-profit sectors
13
Conflict of Interest: The authors declare that they have no conflicts of interest in the
14
research.
EP
15
TE D
11
16
*
17
First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
18
E-mail: [email protected]; Tel: +8613803842129
AC C
Corresponding author: Xinwei Han, Department of Interventional Radiology, The
1
ACCEPTED MANUSCRIPT 19
Glossary of abbreviations: CT, computed tomography
20
Central Message: Sequential intervention is an effective and minimally invasive
22
treatment method for lung cancer with complete lung atelectasis.
RI PT
21
23
Central Picture:
M AN U
SC
24
25
Y-shaped stent placed in the right main bronchus, upper bronchus and intermediate
27
bronchus
AC C
EP
TE D
26
2
ACCEPTED MANUSCRIPT 28 29
Abstract Lung cancer with complete atelectasis is a medical emergency, and often difficult to treat with surgical resection, chemotherapy, and radiotherapy. Patients often
31
experience chronic dyspnea, thereby resulting in low quality of life and poor
32
prognosis. Here, we report a case of pulmonary adenocarcinoma and complete
33
atelectasis of the right lung (IIIA) that was successfully treated with placement of a
34
custom-made Y-shaped stent. The lung adenocarcinoma was further treated with
35
bronchial artery chemotherapy and subsequent radiotherapy. The patient’s breathing
36
was restored, and at 49 months of follow-up, the patient continued to feel healthy with
37
only a minor residual cough.
AC C
EP
TE D
M AN U
SC
RI PT
30
3
ACCEPTED MANUSCRIPT 38
Introduction Dyspnea due to lung cancer and concomitant atelectasis is a serious, acute
40
respiratory condition that can result in death secondary to asphyxiation.
41
Bronchoscopy and biopsy are difficult to perform in dyspneic patients with severe
42
airway stenosis or main bronchus blockage from atelectasis. The timely placement of
43
airway stents can release airway strictures and relieve dyspnea1. Herein, we present a
44
case of right lung cancer and atelectasis confirmed with airway imaging and biopsy
45
by interventional technique, and treatment with a Y-shaped airway stent to relieve
46
airway blockage, thus relieving the patient’s dyspnea.
M AN U
SC
RI PT
39
47
49
Case Report
A 66-year-old man presented to our department with a 1-month history of
TE D
48
productive cough. The patient did not benefit from symptomatic treatment. Six days
51
prior to admission, the patient became increasingly dyspneic, and a chest computed
52
tomography (CT) showed obstruction of the right lung hilum with right lung
53
atelectasis (Figure 1A,1B). The patient had grade 4 dyspnea, cyanosis, and
54
intermittent fever of 39℃. A repeat chest CT scan showed complete right lung
55
atelectasis, with plugging of the right main bronchus, and a right-shifted mediastinum.
56
The patient was initially treated with oxygen to relieve the dyspnea, but his clinical
57
status worsened.
58 59
AC C
EP
50
The patient provided written consent for use of his medical records for subsequent publication. He underwent bronchography and right bronchial forceps 4
ACCEPTED MANUSCRIPT biopsy on day 3 of admission. Bronchography revealed complete blockage of the right
61
upper bronchial opening, the initial part of the right intermediate bronchus, and the
62
distal portion of the right main bronchus (Figure 2A). Under fluoroscopic guidance,
63
the biopsy forcep was introduced through a sheath, and three grain-sized specimens
64
were obtained from different parts of the stenosed area for histopathological analysis
65
(Figure 2B), which confirmed the diagnosis of right lung adenocarcinoma. The lung
66
cancer staging was IIIA (T3N2M0).
SC
An appropriate model of a Y-shaped airway stent (Micro-tech Co Ltd, Nanjing,
M AN U
67
RI PT
60
China) was custom-made in accordance with the bronchography and chest CT
69
findings. The intermediate portion of the stent measured 16 mm in diameter and 10
70
mm in length, the right upper bronchial part measured 8 mm in diameter and 12 mm
71
in length, and the intermediate bronchial portion measured 10 mm in diameter and 30
72
mm in length.
73
The self-expandable airway stent was implanted 6 days after admission (Figure 2C). A
74
repeat transcatheter bronchography showed appropriate stent location and patency of
75
the right bronchial lumen.
EP
AC C
76
TE D
68
Thirteen days after admission, the patient underwent regional perfusion
77
chemotherapy via the right bronchial artery. The angiography showed right bronchial
78
artery thickening with abnormal flaky staining in the right lung hilum (Figure 2D).
79
Chemotherapy was administered slowly via a catheter, which included 1000 mg
80
fluorouracil, 50 mg pirarubicin, and 60 mg cis-platinum, each in 160 ml of 5%
81
glucose. 5
ACCEPTED MANUSCRIPT 82
The patient’s breathing was normal 1 month after bronchial artery regional perfusion chemotherapy. A repeat chest CT at this time showed decreased obstruction
84
in the right hilum as compared to the preoperative imaging (Figure 1C,1D). The
85
second chemotherapy was administered 4 weeks later, after which the patient’s chest
86
tightness completely resolved. A further follow-up chest CT showed that the tumor
87
continued to decrease in size. Bronchoscopy revealed a small amount of granulation
88
tissue hyperplasia at the stent edges. Radiotherapy was performed 7 days after the
89
second chemotherapy session.
M AN U
SC
RI PT
83
90
Until now, the patient had completed 49 months of follow up. He claimed to
91
subjectively feeling better than before, and at the last follow-up, only experienced an
92
occasional cough productive of white sputum.
94
Discussion
TE D
93
Approximately 80% of patients with lung cancer are diagnosed with advanced
96
stage disease, leaving few, if any, surgical options2. We performed a forceps biopsy
97
with an interventional technique in our patient with severe airway stenosis. This
98
technique allowed us to effectively and rapidly obtain samples for histopathological
99
analysis with accurate localization, high technical success, and safety3. Simultaneous
100
airway imaging was used to identify specific parts of the tumor that involved the
101
airway, and this data was used to create a unique airway stent. The Y-shaped stent
102
successfully relieved the airway stenosis4. Bronchial artery regional perfusion
103
chemotherapy significantly reduced the tumor’s size, and further improved the
AC C
EP
95
6
ACCEPTED MANUSCRIPT patient’s dyspnea5. Finally, radiotherapy was used to destroy any residual neoplastic
105
lesions.
106
This case validates the use of a series of sequential interventional therapies to treat
107
severe airway stenosis secondary to a lung tumor. Not only did this therapy improve
108
the patient’s quality of life but it likely also prolonged his survival due to shrinkage of
109
the lung adenocarcinoma.
AC C
EP
TE D
M AN U
SC
RI PT
104
7
ACCEPTED MANUSCRIPT References
111
1. Andreetti C, D'Andrilli A, Ibrahim M, Rendina EA. Treatment of a complex
112
tracheobronchial malignant stenosis with a modified conical semicovered
113
self-expandingstent. J Thorac Cardiovasc Surg. 2013;146:488-9.
114
2. Videtic GM, Chang JY, Chetty IJ, Ginsburg ME, Kestin LL, Kong FM, et al. ACR
115
appropriateness Criteria early-stage non-small-cell lung cancer. Am J Clin Oncol.
116
2014;37:201-7.
117
3. Li ZM, Wu G, Han XW, Ren KW, Zhu M. Radiology-guided forceps biopsy and
118
airway stenting in severe airway stenosis. Diagn Interv Radiol. 2014;20:349-52.
119
4. Han XW, Wu G, Li YD, Zhang QX, Guan S, Ma N, et al. Overcoming the delivery
120
limitation: results of an approach to implanting an integrated self-expanding Y-shaped
121
metallic stent in the carina. J Vasc Interv Radiol. 2008;19:742-7.
122
5. Nakanishi M, Demura Y, Umeda Y, Mizuno S, Ameshima S, Chiba Y, Ishizaki T.
123
Multi-arterial infusion chemotherapy for non-small cell lung carcinoma-significance
124
of detecting feeding arteries and tumor staining. Lung Cancer. 2008;61:227-34.
AC C
EP
TE D
M AN U
SC
RI PT
110
8
ACCEPTED MANUSCRIPT Figure Legends
126
Figure 1: Chest computed tomography (CT) on admission, shows complete atelecasis
127
in the (A) lung window and (B) mediastinum window. A repeat CT in the (C) lung
128
window and (D) mediastinum window shows reduction in size of the tumor in the
129
right lung hilum 1 month after bronchial artery regional perfusion chemotherapy.
RI PT
125
130
Figure 2: Bronchography (A) shows complete blockage of the right upper bronchus,
132
initial segment of the right intermediate bronchus, and distal right main bronchus.
133
Fluoroscopic guidance (B) to reach the blocked right bronchus using biopsy forceps
134
inserted through the sheath’s canal. Fluoroscopy (C) shows release of the Y-shaped
135
stent. Right bronchial artery angiography (D) shows thickening of the artery, with
136
abnormally stained areas in the right lung hilum.
AC C
EP
TE D
M AN U
SC
131
9
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT