Gregory P. LeMense, MD Pulmonary Specialists of Knoxville, PC Knoxville, TN

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16 Νοε 2013 (πριν από 3 χρόνια και 11 μήνες)

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Gregory P.
LeMense
, MD

Pulmonary Specialists of Knoxville, PC

Knoxville, TN

Introduction


New application of established treatment modality


Patients who are not good candidates for more
conventional treatment options


Previous radiation to same area


Severe emphysema with poor functional status

First Case


66 y/o WF,
dx

of limited stage small cell carcinoma
with RUL mass involving
mediastinum
.(2006)


Initial treatment of XRT and chemotherapy


New brain lesion in April, 2007, treated with XRT


Local recurrence in RUL in July, 2007 that was initially
treated with chemotherapy with no response.


Limbic encephalitis (also a presenting symptom) was
worsening.


Bronchoscopy

confirmed small cell carcinoma, with
obvious
endobronchial

component.


First Case


CT Image

Bronchoscopy

Findings

First Case


HDR
Brachytherapy

was recommended


Standard approach not feasible


Near complete occlusion of desired distal airway


Early branching of airway with acute angle


Brachytherapy

with EMN thought to be the only
option to deliver catheter to desired location.

First Case


Three HDR
brachytherapy

treatments, 1 week apart


500
cGy

delivered each treatment


9, 12, 12 dwell points


Maximal recommended dose in previous radiation
field


No procedure related complications


Treatment completed May, 2008


CT remains unchanged as of 10/2009

First Case


CT Image Comparison

Second Case


67 y/o WM with previous RLL
lobectomy

(1995) and
partial LUL
lobectomy

(2005) for two separate
adenocarcinomas


FEV1 1.07 DLCO 16%


Severe hypoxemia, requiring 4 l/m of O2.


New LUL nodule in
lingula


Patient desired biopsy, completed by EMN, confirming
new
NSCLCa


Not a candidate for standard XRT due to poor lung
function

Second Case


Three HDR
brachytherapy

treatments one week apart


700, 800, 800
cGy


5 dwell points each time


Well tolerated by the patient


Loculated

pneumothorax

with second case, resolved
with no chest tube


Different pathway used on last treatment to cover
inferolateral

portion of nodule


Treatment completed April, 2009


Second Case

Third Case


67 y/o WF smoker with new LUL nodule (1.1 cm)


CT scan showed severe emphysema


PET scan positive (SUV 5.8)


Sent for FNA, but refused when informed of risks of
pneumothorax


Repeat CT 3 months later, nodule now 1.3 cm


Patient seen in my office for second opinion, and
offered biopsy by EMN


Biopsy confirmed
adenocarcinoma

Third Case


CT Image


Super D image

Third Case


FEV1 0.67 (31%)


Severe
dyspnea

with minimal activity


Due to poor performance status, not offered
chemotherapy


Tomographic

radiation recommended


Expected 10% reduction in lung function


Patient/family refused


Offered
Brachytherapy





Third Case


800
cGy

x 3 treatments, one week apart


6,7,7 dwell points


“Definitive treatment” dosing


Well tolerated with no worsening of
dyspnea


Significant decrease in size of lesion at 3 months


Findings


Procedure well tolerated, even with marginal lung
function


No bleeding problems either immediate or delayed


Excellent early response to therapy


Prolonged effect in first two patients

Considerations


Bronchial sign helpful, not necessary


Diameter of 2.0 cm or less


Single lesion


Ability to pass probe distal to lesion at initial
diagnostic procedure


Adequate space beyond lesion to minimize migration

Technical Issues


“Three hands”


Advance LG distal to lesion before locking in position


Advance HDR catheter through EWC until tip reaches
tip of EWC


Pull EWC back over HDR catheter under fluoroscopic
guidance (sounds easy………)


Remove scope over HDR catheter


Unable to pull scope/EWC as one unit due to flexible
portion of EWC outside scope

Technical Issues


Migration of catheter after removal of scope has not
been an issue


Creation of pathway with needle to maximize catheter
location


Consider different catheter locations with each
treatment to allow overlap fields



??Simplify procedure by using HDR catheter as EWC??

Questions?