Helping Lung Cancer Patients Achieve Positive Outcomes at Montefiore
Tuesday, March 22, 2011
Maria Cirino-Marcano, M.D.
Photo: Maria Cirino-Marcano, M.D., Director of Interventional Pulmonology at Montefiore. Photo © Don Dempsey, White Light Photography
To effectively treat lung cancer, the disease must be caught in early stages, as the five-year survival rate for advanced, metastasized lung cancer is generally less than 5%. At Montefiore, several advanced bronchoscopy techniques, including autofluorescence bronchoscopy and navigational bronchoscopy, are used after an abnormal finding on a chest X-ray or CT scan is detected to allow for diagnosis at the earliest possible opportunity.
Autofluorescence bronchoscopy is used to detect early-stage abnormalities in the mucosa. Using blue wavelengths of light instead of traditional white light, abnormal mucosa is more easily distinguishable, as abnormal mucosa appears with a brownish or reddish hue instead of the bluish or greenish hue seen in patients with normal mucosa.
“Abnormal mucosal cells have increased levels of DNA, NADH and other substances, and will absorb and reflect wavelengths differently than normal cells,” says Maria Cirino-Marcano, M.D., Director of Interventional Pulmonology at Montefiore. “Autofluorescence bronchoscopy is advantageous because there are no associated risk factors. At Montefiore, we are using it during most bronchoscopies that are performed. Dr. Spivack [Simon Spivack, M.D., Chief of Pulmonology] and I are also working to biopsy areas that appear abnormal, and Dr. Spivack is combining this technique with different molecular methods to analyze airway cells collected in the bronchoscopy suite as part of a National Institutes of Health funded research project. We are also exploring to see if these molecular features are detectable in the patients’ breath, to see if this helps better detect lung cancer in earlier stages.” This is a very early stage of a potentially game-changing technology.
Navigational bronchoscopies allow physicians to better view and obtain biopsies of abnormalities located in the periphery of the lung. “Usually, the smaller the abnormality, the lesser the chance we will be able to reach it,” says Dr. Cirino-Marcano. “During navigational bronchoscopy, we are able to better reach the target regardless of size and location.”
“Traditional bronchoscopy has several limitations, as we are able to only look inside the central airways,” says Dr. Cirino-Marcano. “Using traditional bronchoscopy, diagnostic yield is only 15% for lesions present in the outer third periphery of the lung.”
Through the use of specialized computer software, a patient’s CT scan is used to create a map of the patient’s lungs, allowing physicians to more easily find the mass in question.
“Navigational bronchoscopy creates a customized map of each patient’s lungs and actually guides me to the lesion by telling me which way to turn my bronchoscope and alerting me when I am close to reaching the lesion,” says Dr. Cirino-Marcano. “This has allowed us to increase our diagnostic yield to 70%.”
Navigational bronchoscopy is indicated for patients with outlying lesions and patients with lesions that are small — generally 1 centimeter or less in size.
Staging Lung Cancer
Physicians at Montefiore follow national guidelines for the treatment and staging of lung cancer while keeping each patient’s wishes and functionality at the forefront of all medical decisions.
Lung cancer staging is done in two ways: clinical staging and pathological staging. During clinical staging, CT scans will be used to see if there are any areas indicative of metastases. If the patient has no areas suggestive of metastases, surgery is indicated.
When areas suggestive of metastases are present, endobronchial ultrasound can be helpful when evaluating lymph nodal involvement, which is one of the most important factors of lung cancer staging.
“Mediastinoscopy that is performed to determine lymph nodal involvement can be very beneficial with a high diagnostic yield,” says Dr. Cirino-Marcano. “However, it is less cost effective and has a higher morbidity than other noninvasive methods, such as endobronchial ultrasound.”
During an endobronchial ultrasound, physicians are able to visualize surrounding structures outside of the airways, including the heart and lymph nodes. This allows physicians to use fine-needle aspiration in real time during the endobronchial ultrasound to determine if cancer has spread to a patient’s lymph nodes.
“Endobronchial ultrasound can be used for both staging and diagnosis,” says Dr. Cirino-Marcano. “If you have a patient who has not yet received a diagnosis, you can use the endobronchial ultrasound to biopsy, stage and diagnose lesions during one procedure. This represents a significant advance, as pulmonologists traditionally have not done an adequate job when it comes to staging lung cancer. Pulmonologists will often overlook the lymph nodes, and clinical and pathological staging both rely heavily on the knowledge of lymph node involvement. Endobronchial ultrasound allows us to be more aggressive during staging, achieving a high diagnostic yield with a low risk of complications.”
A Multidisciplinary Approach to Lung Cancer Management
At Montefiore, patients benefit from the collaborative expertise of a wide range of physicians, including interventional pulmonologists, thoracic surgeons, radiologists, radiation oncologists, medical oncologists, pathologists and nuclear medicine physicians. These physicians routinely meet during thoracic oncology tumor boards that are held to discuss each patient who presents with a lung cancer diagnosis.
“During the thoracic oncology tumor boards, ideas are passed around to help make the best possible decision regarding treatment,” says Dr. Cirino-Marcano. “In that setting, we discuss the latest studies to see if the patient would benefit from an ongoing clinical trial or experimental treatment and also examine all available surgical, chemotherapeutic and radiation options. Minimally invasive surgical modalities are available, as well as radiation, chemotherapy or a combination of both. Our goal is to identify the treatment that will provide the highest success rate with the least amount of complications.”
Thoracic surgeons, medical oncologists and interventional pulmonologists also hold clinics together, allowing patients to see all of their physicians at the same time in the same place.
Perhaps one of the best examples of the collaboration that occurs between physicians at Montefiore is in the area of radiation oncology. Dr. Cirino-Marcano and her team work to place fiducials prior to radiation treatment, which help radiation oncologists account for tumor movements that occur during respiration.
“During a navigational bronchoscopy procedure, we are able to place fiducials around the tumor prior to radiation therapy,” says Dr. Cirino-Marcano. “Because of respiration, the lung is not static during radiation treatment, so we must calculate how much the tumor will move prior to treatment to minimize radiation exposure to healthy tissues.”
Brachytherapy is also beneficial for cancer of the airways and can be performed during bronchoscopy. Brachytherapy delivers a dose of radiation directly to the tumor, sparing healthy tissue from radiation exposure and increasing efficacy.
In terms of other treatment modalities, new chemotherapeutic agents have been developed that use tumor markers to determine how a patient will respond to a particular chemotherapeutic agent.
“Depending on the type and the biomarkers present in that particular cancer, medical oncologists can now determine the chemotherapeutic agent that will be most effective in treating the cancer,” says Dr. Cirino-Marcano. “Because of this, it becomes highly important for interventional pulmonologists to provide oncologists with enough tissue and enough information to make this determination.”
Interventional pulmonologists also routinely work with thoracic surgeons to help them better track small nodules during thoracotomy. This can be achieved by placing fiducials around the nodule or by placing dye around the nodule.
“Fiducial placement can be performed in cases of very small nodules that are difficult to detect during thoracotomy,” says Dr. Cirino-Marcano. “Placement of dye is also useful in instances where small nodules are located around the periphery of the lung. This can be done during navigational bronchoscopy and allows surgeons to be able to follow the dye to more easily detect abnormalities. In many cases, this helps decrease the time of surgery.”
Palliation for Lung Cancer Patients
“A major aspect of lung cancer treatment is helping improve patients’ quality of life,” says Dr. Cirino-Marcano. “Because of this, interventional pulmonologists, thoracic surgeons, medical oncologists and radiation oncologists are involved in the palliation of lung cancer patients.”
Chief complaints of patients with lung cancer include shortness of breath and hemoptysis. Because cancer can also spread to the airways of the lungs, obstruction can occur, contributing to patients’ shortness of breath.
According to the National Lung Cancer Partnership, more people in the United States die from lung cancer than breast, colon and prostate cancers combined. To help offset this startling statistic, Montefiore is committed to staying on the forefront of advances in diagnostic testing and treatment.
Tools available for palliation that help aid patients’ symptoms include brachytherapy, cryotherapy, the use of stents or lasers to help open obstructed airways and the use of pleural catheters to manage pleural effusion, which is often characterized by chest pain and shortness of breath.
Previously, patients with pleural effusion required surgery to drain the fluid that surrounded their lungs. Using a special adhesive, the patient’s lung would then be glued to the chest wall after draining to prevent further fluid build up; however, many patients with lung cancer are poor surgical candidates, which prevent them from receiving this treatment and achieving symptom relief.
“Many lung cancer patients have smoked for a very long time and suffer from other serious comorbidities, including chronic obstructive pulmonary disease and emphysema, which make surgery dangerous,” says Dr. Cirino-Marcano. “Using chronic pleural catheters, we can help patients find relief without surgery.”
Chronic pleural catheters are catheters that patients can use to drain the fluid from their lungs at home whenever they are experiencing symptoms. The catheters are discreet, and patients can travel, dress normally and carry on daily activities while the catheters are in place. In 40% of patients, the catheters can eventually be removed, as long-term use of chronic pleural catheters can have the same effect as a pleural fluid adhesive procedure.
“Through use of the pleural catheters, we can give patients control over their own symptoms,” says Dr. Cirino-Marcano. “This way patients can drain the fluid whenever they are feeling discomfort rather than having to have an extra procedure or come in for an additional appointment. Montefiore Home Care is instrumental in the success of this modality, as the nurses who perform home visits are generally responsible for training patients and their caregivers in using this technique.”
Partnering for Success
Enhancing patient access to research, clinical trials and the latest development in cutting-edge techniques, Montefiore is the university hospital and academic partner of Albert Einstein College of Medicine, one of the nation’s premier centers for research. Through this partnership, patients and physicians have increased access to resources needed to perform clinical and scientific research to accelerate the application of new discoveries into treatments and therapies. Current research being performed includes analyzing tumor markers to customize chemotherapy, DNA methylation in lung cancer patients and use of a breathalyzer test to detect lung cancer.
“All physicians in the lung cancer program are experts in their fields and are involved in research, which is a tremendous asset to our program,” says Dr. Cirino-Marcano. “Through ongoing research in the areas of medical, surgical and radiation oncology, we are able to provide patients with the latest techniques and technologies. We are all also professors at Albert Einstein College of Medicine, and by being in this environment, we can concentrate solely on lung cancer and cancers affecting the lung. In other places, the oncology treatment teams often work with patients suffering from many different types of malignancies. Here, we have professionals dedicated solely to this diagnosis, which allows us to devote all of our time both clinically and in terms of research to our lung cancer patients.”
For more information about the interventional pulmonology services available through Montefiore, visit www.montefiore.org.
The Interventional Pulmonology Team
Photos © Don Dempsey, White Light Photography
MD News March 2011, Lower Hudson Bronx