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Thoraxklinik am Universitätsklinikum HeidelbergThoraxklinik am Universitätsklinikum HeidelbergInternistische Onkologie der Thoraxtumoren - ThoraxchirurgieInternistische Onkologie der Thoraxtumoren - Thoraxchirurgie
R Eberhardt Pneumologie Thoraxklinik Heidelberg gGmbH
1885 tuberculosis hospital1885 tuberculosis hospitalsince 1972 rebuild as a clinic forsince 1972 rebuild as a clinic forlung and thoracic diseaseslung and thoracic diseases
based on the dye-sensitized photooxidation of based on the dye-sensitized photooxidation of biological matter in the target tissue/tumorbiological matter in the target tissue/tumor
► high uptake in malignant tumorshigh uptake in malignant tumors► low uptake in benign tissuelow uptake in benign tissue► low phototoxicitylow phototoxicity► safe profilesafe profile► effective cytotoxicity at appropiate effective cytotoxicity at appropiate
wavelengthwavelength► stable and easy to prepare and to stable and easy to prepare and to
Carrol et al. Eur J Cancer Clin Oncol 1986;22:1352-56Carrol et al. Eur J Cancer Clin Oncol 1986;22:1352-56
Ernst et al. Respir Crit Care Med 2004; 169: 1278-1297Ernst et al. Respir Crit Care Med 2004; 169: 1278-1297
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► 57% 57% of the patients with non surgical tumors and of the patients with non surgical tumors and 36% 36% of of total will total will die for local problemsdie for local problems
► 20-30% of patients with lung cancer will develope 20-30% of patients with lung cancer will develope CAO and up to 40% of lung cancer deaths may be CAO and up to 40% of lung cancer deaths may be attributed tp locoregional diseaseattributed tp locoregional disease
Lam et al; Proc Spie Proc 1991: pp20-28Lam et al; Proc Spie Proc 1991: pp20-28
..
RadiotRadiothheraperapyy versus PDT versus PDT
► 41 patients41 patients► pdt+rdt: repermeabilization: 70% of pat.pdt+rdt: repermeabilization: 70% of pat.► rdt only: repermeabilization: 10% of pat.rdt only: repermeabilization: 10% of pat.► no response: 20% of pat.no response: 20% of pat.
► PDT PDT longer time until treatment failurelonger time until treatment failure longer medial survival (295 : 95 days)longer medial survival (295 : 95 days) but: differences in tumor stage between the groupsbut: differences in tumor stage between the groups
EstimationEstimation• effectiv in relatively non invasive, limited and effectiv in relatively non invasive, limited and superficial lesions with visible margins superficial lesions with visible margins
• suitable in: suitable in: • Carcinoma in situCarcinoma in situ• microinvasive cancermicroinvasive cancer• severe dysplasiasevere dysplasia
• clear indication in inoperable patientsclear indication in inoperable patients
• debatetable as first-line, when surgery is debatetable as first-line, when surgery is refusedrefused
Freitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HNFreitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HNThorax 2004; 59:790-793Thorax 2004; 59:790-793
..
Sequential photodynamic therapy (PDT) and high dose Sequential photodynamic therapy (PDT) and high dose brachytherapy for endobronchial tumour control in brachytherapy for endobronchial tumour control in
patients with limited bronchogenic carcinomapatients with limited bronchogenic carcinoma
PDT PDT 2 mg/kg Photofrin® i.v.
HDR-BrachytherapieHDR-Brachytherapieafter 5 – 6 weeksIridium 192 - 4 Gy weekly up to 20 Gy
Brachytherapy Brachytherapy • 31/32 Pat. without histological proof of tumor
• response rate 97 % • recurrence in 6/32 (19 %)• than lokal therapy or external radiation allowed
Follow Up Follow Up • all patients are living after 24 month (3-46 all patients are living after 24 month (3-46 month )month )Freitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HNFreitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HN
• results are surprisingly goodresults are surprisingly good
• long time survival and tumor controll seems to long time survival and tumor controll seems to bebe better than PDT or EBBT alone better than PDT or EBBT alone
• no severe complicationsno severe complications
• prospective randomized study necessaryprospective randomized study necessaryFreitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HNFreitag L, Ernst A, Thomas M, Prenzel R, Wahlers B, Macha HNThorax 2004; 59:790-793Thorax 2004; 59:790-793
..
Sequential photodynamic therapy (PDT) and high Sequential photodynamic therapy (PDT) and high dose brachytherapy for endobronchial tumour dose brachytherapy for endobronchial tumour control in patients with limited bronchogenic control in patients with limited bronchogenic
► effect depends on rapidity of freezing and thawingeffect depends on rapidity of freezing and thawing rapid coolingrapid cooling slow thawingslow thawing
► the lowest temperature achievedthe lowest temperature achieved
Cryotherapy in advanced Cryotherapy in advanced bronchial carcinomabronchial carcinoma
► 33 patients/81 sessions33 patients/81 sessions improvement in lung function 58%improvement in lung function 58% relief of bronchial obstruction 77%relief of bronchial obstruction 77%Walsh DA et al. Thorax 1990Walsh DA et al. Thorax 1990
► 172 patients/344 sessions172 patients/344 sessions improvement in dyspnoe 50,5%improvement in dyspnoe 50,5% 10% increase in Karnofsky index all over10% increase in Karnofsky index all overAsimakopoulus G Chest 2005Asimakopoulus G Chest 2005
Cryotherapy in early superficial Cryotherapy in early superficial bronchogenic carcinomabronchogenic carcinoma
► 35 patients35 patients► 41 cancers41 cancers
► complete response in 91%complete response in 91%► recurrence rate of 28% within 4 yearsrecurrence rate of 28% within 4 years► long term response of 63%long term response of 63%
► results comparable to PDT?? results comparable to PDT??
Deygas N Chest 2001; 120: 26-31Deygas N Chest 2001; 120: 26-31
► Delayed effect – no emergencies Delayed effect – no emergencies
► Depth of effect is limited – several sessionsDepth of effect is limited – several sessions
► Cannot achieve vaporisation of tissue Cannot achieve vaporisation of tissue
► Coagulation of highly vascularised tissue is notCoagulation of highly vascularised tissue is not achieved as quickly as with the laser or with achieved as quickly as with the laser or with electrocautery electrocautery
► Section of webs (PITS) is impossibleSection of webs (PITS) is impossible
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Early cancerEarly cancer
R Eberhardt Pneumologie Thoraxklinik Heidelberg gGmbH
Data inhomogenous, but ...Data inhomogenous, but ...
if operableif operable resectionresection if not or refusedif not or refused PDTPDT if largerif larger PDT + brachytherapyPDT + brachytherapy alternativesalternatives cryotherapycryotherapy
► the best therpeutic approach will be the best therpeutic approach will be thethe combination of several treatment combination of several treatment approaches approaches
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Thank you for your attention …Thank you for your attention …
R Eberhardt Pneumologie Thoraxklinik Heidelberg gGmbH
► Chlorofluoracarbons (CFCs) damage the ozone layer
► Carbon dioxide (CO2) CO2 snow obstructs the cryoprobe
► Lliquid nitrogen (LN2)
► Nitrous oxide (NO2) commonest used agent
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n = 95, unbehandelte Patienten mit NSCLC, Stadium I - IIIB 30 oder 60 Gy perkutan ± 2 x 7,5 Gy endoluminal
randomisiert
Langendijk-JA et al, Radiotherapy and Oncology 2001
Brachytherapie + externe Radiatio
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PDT und Brachytherapie bei PDT und Brachytherapie bei limitiertem BClimitiertem BC
► zwischen 4/95 und 11/98 32 Patientenzwischen 4/95 und 11/98 32 Patienten► mit mit
► primärem inoperablen Bronchialkarzinom (n=15) primärem inoperablen Bronchialkarzinom (n=15) ► oder einem Rezidiv (n=17)oder einem Rezidiv (n=17)► begrenzt auf zentrale Atemwegebegrenzt auf zentrale Atemwege
CT und CT und Bronchoskopie mit Weißlicht und Autofluoreszenz sowieBronchoskopie mit Weißlicht und Autofluoreszenz sowie Biopsien vom Tumor und den GrenzenBiopsien vom Tumor und den Grenzen
► Ausdehnung nach Länge, Weite und Erhabenheit über Ausdehnung nach Länge, Weite und Erhabenheit über die Oberflächedie Oberfläche
► histologisch ganz überwiegend Plattenepithelkarzinome histologisch ganz überwiegend Plattenepithelkarzinome (30 von 32)(30 von 32)