Interventional diagnosis and treatment of lung cancer is an important element in the interventional treatment of respiratory diseases.
I. Interventional diagnosis
1.Bronchoscopy: direct visualization and acquisition of tissues, cells, BALF and other specimens.
Transbronchoscopic direct view tracheobronchial biopsy: biopsy of tracheal and bronchial lesions at all levels of the trachea itself or lesions in the lung invading the trachea and bronchi that can be seen directly. The use of fluoroscopic bronchoscopy may reveal early lesions such as carcinoma in situ and precancerous lesions that cannot be detected by the naked eye under normal light sources.
Transbronchial needle aspiration biopsy: An invasive examination method that uses a specially designed puncture needle with a bendable catheter to enter the tracheobronchial tubes through the bronchoscopic operating channel, and then pass through the airway wall to obtain cytological or histological specimens from extra-airway lesions such as nodules, masses, lymph nodes and substantial lung lesions by puncture and suction according to the positioning of chest CT or endobronchial ultrasound.
Transbronchial X-ray guided transbronchial lung biopsy: The prerequisite for TBLB is that a substantial lesion is identified on the lung X-ray and then guided or positioned under X-ray fluoroscopy or CT. It can also be achieved based on preoperative chest X-ray positioning, and the diagnosis of lung lesions is extended to the surrounding lung tissue.
Indications.
(1) Unexplained cough, sputum, hemoptysis or blood in sputum.
(2) Hoarseness of unknown origin.
(3) Those with unexplained diagnosis of pulmonary masses or shadows, pulmonary atelectasis, obstructive pneumonia, etc. found on chest films or chest CT.
(4) Long-term shortness of breath or progressive dyspnea that has been treated as bronchitis or asthma with anti-inflammatory and anti-shortness of breath treatment.
(5) occult lung cancer in which cancer cells or suspected cancer cells are found in sputum, but no abnormality is found in chest X-ray, chest CT, chest MRI, etc.
(6) Pleural effusion (various kinds of pleural fluid) whose diagnosis is unknown
(7) Patients with chronic lung diseases such as chronic branch, tuberculosis, bronchial expansion, pneumoconiosis, etc., whose original symptoms recur, change or worsen or some new symptoms appear or some new lung lesions appear, and whose symptoms do not reduce or disappear after more than two weeks of anti-infection treatment, and whose lung lesions have no change or tend to increase in size.
(8) X-ray examination reveals intra-airway occupancy and airway narrowing.
(9) TBNA is mainly used for bronchoscopic biopsy of mediastinal and hilar lesions without visible lesions, such as paratracheal, subrhinal, aortopulmonary window nodules or lymph nodes, and also has diagnostic value for necrotic or submucosal lesions, intrapulmonary masses, and external pressure stenosis in the airway. and instead allows direct access to the viable tissue to obtain meaningful specimens.
In addition, it helps in the staging of lung cancer. For example, routine TBNA under augmentation is performed in patients with a proposed diagnosis of lung cancer.
(10) TBLB is mainly used in cases of unexplained peripheral lung mass shadows or diffuse infiltrative lung shadows or nodal shadows of unknown diagnosis.
Contraindications.
(1) Those who have severe cardiopulmonary insufficiency and patients who are extremely weak and cannot tolerate it.
(2) Those with severe coagulation dysfunction or active hemoptysis.
(3) Severe cardiac arrhythmias.
(4) Severe superior vena cava obstruction syndrome.
(6) Severe pulmonary hypertension.
(7) suspected aortic aneurysm.
2. Percutaneous lung aspiration biopsy
Although direct transbronchial lung biopsy, transbronchial needle aspiration biopsy and transbronchial X-ray guided lung biopsy have clarified the diagnosis of most pulmonary lesions, many peripheral pulmonary lesions cannot be clearly diagnosed because they cannot be biopsied under direct vision or cannot be accurately localized, or the biopsy forceps cannot reach the lesion after accurate localization or the biopsy results are negative. At this point, percutaneous lung biopsy (PBL) demonstrates its superiority.
For lesions close to the chest wall, larger peripulmonary lesions or lesions close to the mediastinum, ultrasound-guided lung puncture biopsy can also be performed, but for deeper lesions separated by lung tissue, ultrasound is often difficult to detect and localize and should not be used as a guidance method. Real-time CT fluoroscopy technology transforms CT imaging into a real-time, interactive tool that can simultaneously broadcast interventions, thus better improving puncture accuracy and reducing operative time. Some investigators have also performed PLB under the guidance of MRI fluoroscopy, which not only avoids radiation damage but also achieves satisfactory results. However, it has not yet become popular in China.
Automatic spring biopsy needles are gaining clinical popularity. The automatic spring biopsy needle consists of a spring-driven gun or needle sheath and a biopsy needle core. There is a clear depth scale marking, the ability to set the length of the biopsy tissue (15mm and 20mm) and select the thickness of the biopsy needle (14G~22G), the needle core enters the tissue in a circular groove shape, the needle sheath cuts quickly and keeps the biopsy tissue intact in the sheath, reducing the risk of tumor implantation in the needle tract, with the advantages of convenience, safety, biopsy sampling success rate (close to 100%) and correct biopsy rate ( 90% or more). However, the cutting action of the automatic spring biopsy needle is done automatically instantly after starting the trigger, which has no hand feeling and is not easy to control.
Indications
(1) For isolated nodules or masses in the lung, especially in the periphery, where the diagnosis is unknown.
(2) For lesions in the peri-pulmonary region or masses in the hilar region, where the diagnosis is still not confirmed by bronchoscopy and related examinations.
(3) Those with an undetermined diagnosis of a mass close to the pleura or chest wall
(4) Peripheral single or multiple lesions in the lung, which are expected to be difficult to detect and diagnose by bronchoscopy, may be preceded by percutaneous lung aspiration biopsy.
(5) Diffuse lesions or non-nodular or mass-limited lesions in the lung that are not clearly diagnosed by bronchoscopy and related examinations.
Contraindications
(1) Those who have severe cardiopulmonary insufficiency or whose patients are extremely debilitated and cannot tolerate it.
(2) Those with severe coagulation dysfunction or active hemoptysis.
(3) Lesions that may be vascular {such as arteriovenous malformations, aneurysms, etc.}
(4) Patients with severe pulmonary stasis or congestion (pulmonary hypertension).
(5) Patients who cannot maintain a constant position for a long time or cannot hold their breath and cannot cooperate with the procedure.
(6) Patients with severe airway obstruction.
(7) Patients with severe cardiac arrhythmias.
3.Thoracoscopic lung biopsy
For diffuse pulmonary lesions and limited lesions in the peripheral parts of the lung, TBLB and PLB have been able to clearly diagnose most of them. However, due to the small size of the specimens obtained by these methods (only 1-2 mm per piece of tissue), the scope and extent of the lesions cannot be observed comprehensively, or sometimes the diagnosis cannot be confirmed due to inaccurate positioning or difficulty in obtaining satisfactory histological specimens or even cytological specimens by puncture, especially in diffuse interstitial lung disease, where the confirmation rate is only 30%-40%. Therefore, methods that can obtain larger tissues under direct vision to meet clinical diagnosis and treatment needs have been proposed. Small incisional dissection lung biopsy can meet the need, but it is more invasive, requires higher anesthesia, and has more complications that are difficult for patients to accept. In contrast, thoracoscopic lung biopsy (TLB) is less invasive, requires less anesthesia (local anesthesia is available), has fewer complications, and is acceptable to patients, and can remove lung tissue over 2 cm × 2 crn in size, with a pathology rate of 90% to 100%, and can meet the needs of clinical management.
Indications.
(1) Diffuse or interstitial lung disease that has not been diagnosed by multiple tests.
(2) Peripheral pulmonary masses that have not been diagnosed by multiple tests.
Contraindications.
(1) Poor general condition, severe cardiac and pulmonary dysfunction, and inability to tolerate surgery.
(2) Extensive adhesions in the pleural cavity.
(3) Severe coagulation dysfunction or active hemoptysis.
Complications and their management.
(1) Pneumothorax due to air leakage from the stump of lung biopsy: careful intraoperative operation and careful inspection for air leakage is an effective method to prevent pneumothorax. If there is air leakage, medical biologic adhesive can be used to adhere to the lung section or needle eye. Postoperative pneumothorax can usually be cured by closed chest drainage, and if necessary, thoracoscopy or dissection is performed again to repair the stump.
(2) Intrathoracic hemorrhage: Intraoperative hemostasis should be carefully performed. The fluid drained from the closed chest drainage tube should be gradually reduced after surgery. If bleeding pleural fluid is drained, the patient should be advised to rest in bed, and while continuing closed drainage, hemostatic drugs, such as hemostat, hemostatic aromatic acid, lidostat, vitamin K1, etc., should be used if necessary to stop bleeding with posterior pituitary hormone and closely observe vital signs and other changes in condition. If the bleeding does not stop, thoracoscopy or dissection should be performed again to stop the bleeding.
(3) Intrathoracic infection, incisional infection or respiratory tract infection: strict aseptic operation should be performed, and antibiotics should be routinely given to prevent and treat infection after surgery.
(4) Postoperative respiratory failure: general anesthesia, tracheal intubation, postoperative pneumothorax or pleural effusion, and postoperative respiratory system infection can induce severe respiratory failure. In addition to the above treatment, oxygen should be given, and assisted breathing should be given if necessary.
4.Pleural biopsy
(1) Closed blind examination: Pleural biopsy needle is used for percutaneous puncture biopsy under B-ultrasound positioning, and positive results can be obtained for diffuse lesions.
(2) Transthoracoscopic direct view pleural biopsy: it can be combined with the microscopic view and targeted multi-point biopsy with higher accuracy and positivity rate.
5.Mediastinoscopy (treatment) is mostly performed by thoracic surgery.
Indications and clinical applications: pathological diagnosis and staging of lung cancer, lymph node dissection during lung cancer pneumonectomy (still controversial), guiding the establishment of lung cancer treatment plan.
II. Interventional treatment
1.Transvascular interventional therapy
Bronchial artery intubation and infusion chemotherapy (BAI). Basis: Central and peripheral lung cancer blood supply mainly comes from bronchial arteries. It is used for lung cancer without surgical indications or local chemotherapy before and after surgery to improve the success rate of surgery and prevent recurrence after surgery.
Pulmonary artery infusion chemotherapy (PAI). Basis: Lung cancer is a dual blood supply (bronchial artery and pulmonary artery), while metastatic lung cancer is mainly supplied by pulmonary artery.
Double arterial infusion chemotherapy (DAI). Yang Zhanggeng et al. concluded that the efficacy was better than that of single arterial infusion chemotherapy. Jin Gang et al. concluded that the efficacy was similar and there was no significant difference in survival.
Efficacy: The overall evaluation is that BAI or DAI is more effective than intravenous chemotherapy alone and has fewer adverse effects.
2. Transbronchoscopic intervention
(1) Transbronchoscopic microwave therapy for tumors. The mechanism of treating tumors is unknown. It may be related to the increase of lysosomes, activation, tumor tissue degeneration and necrosis; tumor vascular damage, stasis of blood and hypoxia, necrosis, etc. It is suitable for tumor tissue in the airway and can release airway obstruction. However, the effect is slow. Complications include: airway perforation, hemorrhage.
(2) Transbronchoscopic high-frequency electrosurgical tumor resection. High-frequency electricity can produce thermal effect on human tissues, causing denaturation, coagulation and necrosis due to the increase of local tissue temperature. It is used for those who have narrowed airway due to tumor in airway. It can be used to remove tumor tissues by electrodissection, trap and electrocoagulation with rapid action. The electrode is in direct contact with the tumor tissue. It is possible to cut too deep, resulting in perforation, bleeding, etc.
(3) Transbronchoscopic argon knife tumor resection. Based on high-frequency knife, ionized argon gas stream is used as electrode to remove tumor without direct contact with tumor tissue. There is no concern of cutting too deep.
(4) Transbronchoscopic cryotherapy for tumors. Cryotherapy instrument, the cold source is liquid CO2, the temperature can reach -70℃, the effect of cryotomy is fast and easy to bleed, the effect of freeze-thaw method is slow.
(5) Transbronchoscopic laser resection of tumor. Nd-YAG (neodymium-doped-yttrium-aluminum-garnet) laser has a wavelength of 1.06nm, which is an invisible light of near-infrared light. It is mainly used for tumors in the airway. The effect is rapid and can be recurrent. Easy to cause airway perforation and bleeding.
Combined application of airway tumor resection and stent placement.
(6) Transbronchoscopic stent placement for tumor-induced large airway stenosis. There are silicone rubber stents, stainless steel mesh stents, and nickel-titanium memory alloy mesh stents. There are membrane and non-membrane stents. Most of the stents with membrane are made of nickel-titanium memory alloy mesh. It is used for narrowing of the airway due to lung cancer without surgical indication. The effect can be immediate, without serious complications, and there is a possibility of stent fracture, slippage and reocclusion.
(7) Transbronchoscopic endotracheal luminal post-loading radiation therapy (iridium 192). There are high device requirements, complex methods, slow onset of effect or temporary aggravation. It is appropriate to use with external irradiation.
Complications may include: fever, chest pain, pneumothorax, cartilage necrosis, airway stenosis, radiation pneumonia, etc. At present, it has been used less frequently.
3.Transthoracoscopic treatment is mainly performed by thoracic surgery, such as resection of early lung cancer.
4.Mediastinoscopic treatment is mainly performed by thoracic surgery, such as lymph node dissection in lung cancer pneumonectomy (still controversial).
5.Percutaneous percutaneous interventions.
(1) Chemical ablation (chemical knife): chemical agents (anhydrous ethanol, acetic acid, hydrochloric acid) are used for direct injection into tumor tissues to treat lung cancer. Almost all tumor cells are sensitive and there is no drug resistance. It is suitable for peripheral type lung cancer.
(2) Radioactive particle implantation brachytherapy (in vivo gamma knife): The treatment plan is determined by the treatment planning system, and the iodine 125 (125I) particles are pushed into the tumor tissue through the particle implantation system to achieve the purpose of intra-tumor brachytherapy. Compared with external irradiation, this method has higher accuracy and more accurate efficacy. It is suitable for both central type and peripheral type lung cancer.
(3) Radiofrequency ablation (RF knife) for lung cancer: local anesthesia, percutaneous puncture, no need for general anesthesia. Precise positioning, accurate puncture and conformal treatment. Insert the electrode needle into the center of tumor, open 10 very thin umbrella electrode needles inside the tumor, transmit the radiofrequency pulse electric wave into the tumor tissue, use the radiofrequency current to warm up the cancer tissue to 60~95℃, kill the tumor directly, precisely measure and control the temperature, and inactivate the cancer. Treatment for 10~30 minutes can kill 2~5cm tumor, extend the treatment time, the maximum can kill 10~12cm tumor, local injection after ablation to strengthen the treatment. It produces immune effect after tumor absorption and ablation. It is mostly applied to peripheral type lung cancer.
(4) Ar-He knife for lung cancer: Ar-He knife minimally invasive surgical operating system (Endocare Cryocare System), a minimally invasive targeted treatment system with multiple therapeutic effects such as ultra-low temperature freezing, interventional thermotherapy (rewarming) and immune enhancement. Tumor cell melting necrosis, cryoembolic effect, and immune enhancement. Mostly applied to peripheral type lung cancer. Risk of lung puncture, risk of damage to surrounding normal tissues, risk of tumor recurrence due to incomplete freezing.
Interventional therapy is mostly palliative, and it is advisable to apply with each other or with systemic chemotherapy, external radiation radiotherapy and immune supportive therapy, biologically targeted therapy, Chinese herbal medicine therapy, psychological intervention and other comprehensive treatments to achieve better results.