Alternative bone cancer treatment

We describe a patient who suffered from a bacterial pneumonia and had a left-sided infiltrate on his chest radiograph. He was found to be cytopenic and acute myeloid leukemia was diagnosed. A complete remission was achieved after chemotherapy, and the patient was scheduled to have autologous bone marrow transplantation. Bronchoscopy was performed because of persistent hemoptysis and a squamous cell carcinoma in the right upper lobe bronchus was found. This small tumor was successfully treated with photodynamic therapy preventing any delay in the treatment of his leukemia, which would have occurred if surgery had been the treatment of choice. The patient is still in complete remission after a follow-up period of 12 months.

Photodynamic therapy (PDT) is laser illumination of malignant tissue containing photosensitizers such as Photofrin II (PII, Cyanamid Pearl River, NJ).[1-4] Photodynamic therapy leads to selective damage because tumor stroma retains PII at a higher concentration than the normal surrounding tissue and because the light can be delivered directly to the tumor via fiberoptics. Previous reports indicate that PDT is especially effective in the treatment of "small" endobronchial tumors without a major loss of functioning lung tissue.[5,6] We have performed PDT in a patient who was scheduled to have an autologous bone marrow transplantation (ABMT) for acute myelogenous leukemia (AML); a second primary non-small cell lung cancer (NSCLC) was found in this patient.

CASE REPORT

A 47-year-old man was admitted to a hospital in the United States because of fever, hemoptysis, and dyspnea. The chest radiograph showed a left-sided infiltrate. He was found to be cytopenic and further analysis revealed the diagnosis of AML. He was treated with broad-spectrum antibiotics for bacterial pneumonia and a complete remission of the leukemia was achieved with combination chemotherapy (Ara-C/Daunorubicin). He was subsequently transferred to the University Hospital Leiden-The Netherlands, for consolidation chemotherapy and ABMT. Although chest radiographs and computed tomographic (CT) scan of the chest were normal, bronchoscopy was performed because of a persistent hemoptysis. A circumscript intraluminal tumor, with a diameter of 1.5 cm, was seen on the trifurcation of the right upper lobe (Fig 1: left, during treatment; and right, 1 year after treatment). Biopsy specimens showed squamous cell carcinoma. Since surgical treatment of this T1N0M0 tumor would have delayed further chemotherapy and ABMT, PDT was considered as an alternative treatment. After obtaining informed consent, the patient received 2mg/kg PII intravenously. Two days later, intraluminal illumination with laser light of 628-nm wavelength (argon-dye laser, Spectra Physics) was performed, using a laser fiber with a 2-cm cylindrical diffusing tip. The patient was advised to avoid sunlight exposure for a period of 4 weeks following PII injection to prevent skin photosensitivity. Consolidation chemotheraphy and ABMT could be performed successfully after PDT without any delay within 3 months as scheduled. The follow-up period to date is 14 months and he has remained disease free with regard to both his leukemia and lung cancer.

DISCUSSION

Illumination of malignant tissue containing photosensitizers such as PII with light of an appropriate wavelength initiates a "selective" photochemical reaction with the formation of reactive oxygen species and other radicals, leading to selective tumor necrosis.[2,3] Skin photosensitivity is the only potential side effect, as current sensitizers are also retained in the skin and strongly absorb UV light.[4]

This case report confirms earlier reports that PDT can achieve a complete response of early-stage intraluminal lesions.[5,6] The extent of PDT necrosis is known to be <9 mm deep, as penetration of 628-nm wavelength in tissue is limited.[1,7] Considering the circumstances of this patient, PDT provided him with an alternative treatment for NSCLC, without causing delay in the treatment schedule of his leukemia.

REFERENCES

[1] Dougherty TJ. Photodynamic therapy: new approaches. Semin Surg Oncol 1989; 5:6-16

[2] Ash D, Brown SB. Photodynamic therapy: achievements and prospects. Br J Cancer 1989; 60:151-52

[3] Gomer CJ, Rucker N, Ferrario A, Wong S. Review: properties and applications of photodynamic therapy. Radiat Res 1989; 120:1-18

[4] Dougherty TJ, Cooper MT, Mang TS. Cutaneous phototoxic occurrences in patients receiving Photofrin. Lasers Surg Med 1990; 10:485-88

[5] Horai T, Nakamura SI, Nishio H, Sakuma T, Ikegami H, Matsuda M. A 5-year disease-free survivor of multiple unresectable lung cancer treated by photoradiation therapy with haematoprophyrin derivative. Lasers Med Sci 1989; 4:1-5

[6] Konaka C, Kato H, Hayata Y. Lung cancer treated by photodynamic therapy alone: survival for more than 3 years. Lasers Med Sci 1987; 2:17-9

[7] Van Gemert JC, Berenbauw MC, Gijsbers GH. Wavelength and light-dose dependence in tumor phototherapy with haematoporphyrin porphyrin derivative. Br J Cancer 1985; 52:43-9