Name: endobronchial ultrasound-guided intratumoral injection of cisplatin for the treatment of isolated mediastinal recurrence of lung cancer
Uploaded: 2017-02-12T14:00:00
Description: Watch this Scientific Journal Video about Endobronchial Ultrasound-guided Intratumoral Injection of Cisplatin for the Treatment of Isolated Mediastinal Recurrence of Lung Cancer at JoVE.com

The authors have no acknowledgements.

Data on all patients treated with EBUS-guided cisplatin were reviewed. The institutional review board at the University of Florida approved this study (#IRB201400823). All data was prospectively collected and retrospectively analyzed. Use the following enrollment criteria.
1. Patient Selection
<ol>
	<li>Select patients between the ages of 18 and 80 years who have a biopsy-confirmed non-small cell lung cancer (NSCLC) or small cell lung carcinoma (SCLC) and have a pathologically-confirmed recu...

<ol>
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Our manuscript focuses on the management of isolated mediastinal and hilar recurrences of lung cancer for patients in whom more radiation is not an option. The incidence of IMHR is approximately 9%11. Different treatment options have been tried in these patients, including palliative chemotherapy, more external beam radiation therapy, or supportive care and surveillance. At our institution, we treat these patients with intratumoral cisplatin guided by bronchoscopy.
Ther...

Lung cancer is the most prevalent cancer worldwide in both men and women and accounts for 1 in 5 of all cancer-related deaths. It has a case fatality rate of 0.871,2. Recurrence after initial treatment accounts for most deaths in patients with lung cancer. Therapeutic options for recurrent lung cancer are limited. Recurrent lung cancer also leads to significant impairment in quality of life and to significant caregiver burnout and requires additional supportive care, all of which decrease the likelihood of acceptance and tolerance to further interventions3.
Nearly 30% of patients with NSCLC have locoregional recurrence after radiation4. Treatment options for these patients are limited and include systemic chemotherapy, which has an objective response rate of only 10%5,6. Although repeat chest radiation is feasible, it has been studied mainly for palliative purposes and symptom relief and has not been used for disease remission3.
At our institution, all patients with isolated mediastinal and hilar recurrence (IMHR) accessible through bronchoscopy were treated with an endobronchial ultrasound (EBUS)-guided transbronchial intratumoral injection of cisplatin (ITC). Concurrent treatment with systemic chemotherapy and/or external beam radiation therapy (EBRT) was allowed as per the treating oncologists&#39; discretions. This manuscript highlights the safety, efficacy, feasibility, and detailed methods of the protocol used at our institution.

<table border="0" cellpadding="0" cellspacing="0" width="261">
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			<td colspan="2" height="20" style="height:20px;width:261px;">Bronchoscope</td>
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			<td colspan="2" height="20" style="height:20px;">22 Guage olympus EBUS needle</td>
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			<td colspan="2" height="20" style="height:20px;">40 g of cisplatin in 40 mls of normal saline</td>
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	</tbody>
</table>

endobronchial ultrasound-guided intratumoral injection of cisplatin for the treatment of isolated mediastinal recurrence of lung cancer

Isolated hilar and mediastinal recurrence (IMHR) following external beam radiation therapy (EBRT) in patients with lung cancer is common. These patients do not have many treatment options and are usually offered palliative chemotherapy or best supportive care. Endobronchial ultrasound (EBUS)-guided intratumoral injection of cisplatin (ITC) is a novel approach for these patients. The procedure is performed under conscious sedation. The lesion is located with a bronchoscopy using EBUS, and a 22-gauge EBUS needle is advanced through the working channel of the scope and locked in position. Under ultrasound guidance, the wall of the tracheobronchial tree is punctured and the needle is moved into the target lesion. The needle stylet is then removed and cisplatin (40 mg/40 mL) is injected into the lesion. One to two sites are treated per session. Details of the procedure are described in the protocol section of paper. At our center, 50 sites were treated in 36 patients (19 males, 17 females). The mean age of our cohort was 61.9 &#177;8.5 years. We performed final analyses on 35 patients and 41 sites. 24/35 (69%) had complete or partial response (responders), whereas 11/35 (31%) had stable or progressive disease (non-responders). Overall, survival in our group was 8 months (95% CI of 6-11 months), with patients who responded having significantly better survival than the ones who did not.

The response was measured by follow-up imaging 8-12 weeks after therapy. The response was classified as complete remission (CR), partial remission (PR), stable disease (SD), progressive disease (PD), or unable to assess response based on RECIST 1.1 criteria8. Patients with CR and PR were considered responders, and the others were classified as non-responders. Secondary outcomes included response based on tumor histology, size of recurrence, and concurrent systemic ...

Watch this Scientific Journal Video about Endobronchial Ultrasound-guided Intratumoral Injection of Cisplatin for the Treatment of Isolated Mediastinal Recurrence of Lung Cancer at JoVE.com

Endobronchial Ultrasound-guided Intratumoral Injection of Cisplatin for the Treatment of Isolated Mediastinal Recurrence of Lung Cancer

The management of isolated recurrent lung cancer in a previously-irradiated field is challenging. Here, we describe an endobronchial ultrasound (EBUS)-guided cisplatin injection for the management of patients with localized lung cancer recurrence in a previously-radiated field.

Isolated hilar and mediastinal recurrence (IMHR) following external beam radiation therapy (EBRT) in patients with lung cancer is common. These patients ...

The overall goal of this procedure is to describe an endobronchial ultrasound or EBUS-guided cisplatin injection for the management of patients with localized lung cancer recurrence in a previously radiated field. This method can help answer key questions in the field of lung cancer treatment about the safety and efficacy of EBUS-guided trans-bronchial intratumoral injection of cisplatin for recurrence of lung cancers in the post-radiated field. The main advantage of this technique is that it provides an alternative treatment option to systemic chemotherapy for patients with isolated, hilar, and mediastinal recurrence of lung cancer.For real-time visualization of hilar, mediastinal, and peribronchial structures for intratumoral cisplatin injection, first intravenously administer dexamethasone and ondansetron to a patient who has abstained from oral food and fluids for at least six hours. Next, induce conscious sedation with intravenous Midazolam and Fentanyl treatment, coupled with the topical application of five milliliters of Lidocaine. Use standard monitoring, including a continuous 3-lead electrocardiogram for heart rate monitoring, continuous pulse oximetry, and respiratory rate measurements.Now locate the target lesion using a convex probe EBUS with a built-in ultrasound probe on a flexible bronchoscope to advance the scope through the vocal cords. When the scope reaches the airways, turn on the EBUS processor and use one to two milliliters of normal saline to inflate the balloon at the tip of the scope. Flex the scope across the airway wall to locate the lesion.Then deploy the 22-gauge EBUS needle through the working channel of the scope and lock the needle into position. Under real-time ultrasound guidance, puncture the tracheobronchial wall and insert the needle into the target lesion. Remove the stylet within the needle and inject 10 milliliters of cisplatin into the lesion.Then retract the needle back into the sheath and inject the needle into a separate area of the lesion for the injection of another 10 milliliters of cisplatin. Remove the needle from the working channel of the scope and suction any additional drug from the distal airways. Then remove the bronchoscope.In this representative study, 8 to 12 weeks after therapy, 69%of the patients were classified as responders and 31%as non-responders, with a median survival of 8 months, 10 months for the responders, and six months for the non-responders, with a significantly higher progression-free survival rate observed in the responders group. While attempting this procedure, it is important to select appropriate patients, and to perform all of the steps in the protocol in a systematic manner. After its development, this technique paved the way for us and other researchers in the field of lung cancer to explore intratumoral chemo and other immunotherapies in animal models and in humans.After watching this video, you should have a good understanding of how to treat mediastinal and hilar recurrence of lung cancer with EBUS-guided intratumoral cisplatin injection.

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