Neoadjuvant bronchoscopic photodynamic therapy to facilitate airway and parenchymal sparing lobectomies in two patients with central airway neuroendocrine tumors: A patient centered approach

Background

NCCN guidelines recommend surgical resection for well differentiated pulmonary neuroendocrine tumors (NETs), also known as carcinoid tumors, when they present in the lungs. Fortunately, most pulmonary NETs will not require extensive surgical resection beyond a lobectomy. We report two cases in which large pulmonary NETs would have required more extensive surgical resection, including a carinal pneumonectomy and a left lower lobe sleeve resection. However, after taking patient's preferences into account, neoadjuvant photodynamic therapy was able to decrease the overall tumor burden helping to facilitate airway and parenchymal sparing surgical lobectomies.

Materials

Interventional pulmonology (IP) and Cardiothoracic surgery (CTS) discussed options extensively with each patient and formulated a plan to perform neoadjuvant bronchoscopic followed by surgical resection if there were any remaining NET on follow up bronchoscopy. Both patients received infusions of porfimer sodium (Photofrin ®, Pinnacle Biologics) at 2mg/kg. Per standard protocol, they each underwent a series of bronchoscopies 48 h after infusion, in which endobronchial NET was illuminated with a fiberoptic catheter delivering up to 200J/cm per treatment. After the initial illumination bronchoscopy, a cryo probe was used to debulk necrotic tumor and allow for repeat illumination of residual tumor. Both patients received extensive education on avoiding phototoxicity.

Outcomes

Both patients underwent follow up restaging bronchoscopies revealing cleared central airways and only residual NET at the subsegmental level. As such, both underwent lobectomies, avoiding more extensive surgical resection. Both are free of disease at four years and 18 months follow up, respectively. Both patients were satisfied with their outcomes and the autonomy they were given in formulating their treatment plan.

Conclusions

While photodynamic therapy has been shown to be an effective stand alone, neoadjuvant, and adjuvant therapy for pulmonary NETs, surgical resection is still required in select patients. We present two cases of in which desired patient outcomes led to the use of neoadjuvant PDT to help facilitate airway and parenchymal sparing lobectomies, thus avoiding more extensive surgical resection and possible long-term morbidity.