Bronchoscopic multimodality lung tumor treatment

Abstract

A minimally invasive medical technique for treating lung tumors includes use of multiple ablation modalities in a single procedure. Condensable vapor ablation and electrosurgical ablation are applied to treat the surface of the tumor and to debulk inner regions of the tumor, respectively.

Description

BACKGROUND OF THE INVENTION

The present invention relates to medical methods for treating lung tumors, and more specifically to minimally invasive medical methods for ablating lung tumors.

Bronchoscopic radio frequency ablation and bronchoscopic thermal vapor ablation are examples of minimally invasive techniques to treat lung tumors in a patient.

Bronchoscopic radio frequency ablation involves navigating an ablation catheter through the airways of the patient and to the lung tumor. The ablation catheter is activated, delivering radio frequency energy to the tumor. The physician targets or focuses the energy towards the center of the tumor to minimize damage to healthy tissue adjacent the tumor.

A drawback of radio frequency ablation is that targeting the center of the lung tumor risks allowing the margin of the tumor to remain untreated. This is undesirable.

Increasing the energy delivered to the tumor, however, is also undesirable due to the likelihood of overheating the healthy tissue adjacent the tumor.

Another drawback of bronchoscopic radio frequency ablation arises from the structural limitations of the ablation electrodes and the available spacing to maneuver the electrodes. To compensate, the physician may elect to increase the energy delivered to the target. Increasing the energy delivered to the target tissue, however, risks causing collateral damage to healthy adjacent tissue.

Bronchoscopic thermal vapor ablation is another technique to treat lung tumors. Bronchoscopic thermal ablation sends a condensable vapor across the lung tumor. The vapor, upon contact with tissue, changes phase from gas to liquid, heating the outside of the lung tumor and ultimately serving to ablate the tumor. Bronchoscopic thermal vapor ablation heats the tumor from the outside to the inside. A challenge with bronchoscopic thermal vapor ablation is to quickly reach the center or inside of the lung tumor. Increasing the thermal energy delivered via the vapor is undesirable for risking collateral damage to healthy adjacent tissue.

Notwithstanding the above, minimally invasive methods and systems are still desired that effectively ablate lung tumors in a patient, and to do so without damaging the healthy adjacent tissue and without putting the patient at any further risk of infection. Accordingly, a method that overcomes the above mentioned challenges is desirable.

SUMMARY OF THE INVENTION

The present invention is a method for treating a suspect tissue mass such as, for example, a lung tumor or metastasis.

A minimally invasive medical technique for treating lung tumors includes use of multiple ablation modalities in a single procedure. Condensable vapor ablation and electrosurgical ablation are applied to treat the surface of the tumor and to debulk inner regions of the tumor, respectively.

In embodiments, a method of treating a suspect tissue mass in a lung comprises uniformly applying heat to the margin or exterior of the suspect tissue mass and discretely applying heat to interior portions of the suspect tissue mass.

In embodiments, the step of uniformly applying heat to the margin of the suspect tissue mass comprises delivering a condensable vapor around the suspect tissue mass.

In embodiments, the step of discretely applying heat to the interior of the suspect tissue mass comprises advancing an electrosurgical instrument into direct contact with the suspect tissue mass, and activating the instrument.

In embodiments, the step of discretely applying heat to the interior of the suspect tissue mass comprises placing a heat source at a discrete internal location (e.g., the center of the suspect tissue mass), and radiating heat from the heat source towards the exterior of the mass.

In embodiments, the electrosurgical instrument is an RF energy catheter.

In embodiments, the method further comprises assessing an exterior of the suspect tissue mass for uniformity prior to the step of heating by the first modality, and assessing an interior of the suspect tissue mass for density prior to the step of heating by the second modality. The steps of assessing may be performed preoperatively using CT or other imaging data, and analysis. Additionally, the step of assessing may be performed using ultrasound, bronchoscope or other diagnostic and imaging techniques. Should the suspect tissue mass be non-uniform or lack symmetry, heating is performed by delivering condensable vapor. The second modality is then carried out to heat from the inside out. In embodiments, the method further comprises monitoring a first ablation region growing inward and a second ablation region growing outward arising from the first modality and second modality of heating, respectively, and confirming an overlap zone between the first ablation region and second ablation region.

Still other descriptions, objects and advantages of the present invention will become apparent from the detailed description to follow, together with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 a flow chart illustrating a method in accordance with one embodiment of the present invention.

FIGS. 2 and 3 are illustrations of a method for delivering a condensable vapor to ablate a lung tumor in accordance with one embodiment of the invention.

FIG. 4 is an illustration of a method for ablating a lung tumor by applying radio frequency energy in accordance with one embodiment of the invention.

FIG. 5 is a flow chart illustrating another method to treat a lung tumor outside of an airway in the lung of a patient.

FIG. 6 is an illustration of a method for treating a lung tumor via a plurality of implants in accordance with one embodiment of the invention.

DETAILED DESCRIPTION OF THE INVENTION

Before the present invention is described in detail, it is to be understood that this invention is not limited to particular variations set forth herein as various changes or modifications may be made to the invention described and equivalents may be substituted without departing from the spirit and scope of the invention. As will be apparent to those of skill in the art upon reading this disclosure, each of the individual embodiments described and illustrated herein has discrete components and features which may be readily separated from or combined with the features of any of the other several embodiments without departing from the scope or spirit of the present invention. In addition, many modifications may be made to adapt a particular situation, material, composition of matter, process, process act(s) or step(s) to the objective(s), spirit or scope of the present invention. All such modifications are intended to be within the scope of the claims made herein.

Methods recited herein may be carried out in any order of the recited events which is logically possible, as well as the recited order of events. Furthermore, where a range of values is provided, it is understood that every intervening value, between the upper and lower limit of that range and any other stated or intervening value in that stated range is encompassed within the invention. Also, it is contemplated that any optional feature of the inventive variations described may be set forth and claimed independently, or in combination with any one or more of the features described herein.

All existing subject matter mentioned herein (e.g., publications, patents, patent applications and hardware) is incorporated by reference herein in its entirety except insofar as the subject matter may conflict with that of the present invention (in which case what is present herein shall prevail).

Reference to a singular item, includes the possibility that there are plural of the same items present. More specifically, as used herein and in the appended claims, the singular forms “a,” “an,” “said” and “the” include plural referents unless the context clearly dictates otherwise. It is further noted that the claims may be drafted to exclude any optional element. As such, this statement is intended to serve as antecedent basis for use of such exclusive terminology as “solely,” “only” and the like in connection with the recitation of claim elements, or use of a “negative” limitation.

Method Overview

An overview of a lung tumor treatment method 10 in accordance with embodiments of the present invention is illustrated in FIG. 1.

Step 12 states to identify a lung tumor or suspect tissue mass in the lung of the patient. By “suspect tissue mass”, it is meant a tissue mass whether diseased or otherwise a candidate for diagnosis, treatment or removal. Examples of a suspect tissue mass include, without limitation, a tumor, metastasis, growth, lymph node, tissue nodule, or other diseased tissue causing obstructions in the lung. Also, by “diseased lung tissue” it is meant a disorder or function in the lung tissue including, without limitation, emphysema, lung cancer or metastasis, TB, aspergillus, and pneumonia.

Physicians may identify the suspect tissue mass using imaging technology including, for example, CT scans, fluoroscopy, X-rays, and bronchoscopy.

Step 14 states to plan a route to the target tissue, e.g., the lung tumor. Though a physician may plan a route to the tumor by eye using the X-ray or video images of the lung and tumor, more sophisticated techniques automatically compute an optimal route to the target through the airways. Examples of airways include the trachea, bronchi, bronchial branches including, without limitation, the bronchioles and terminal bronchioles. Examples of route planning techniques are described in U.S. Pat. No. 9,037,215.

The next step shown in FIG. 1 is the first treatment procedure 15. By “first treatment procedure”, it is meant a single continuous medical operation or intervention without interruption (such as by patient discharge from the OR, hospital, or surgery center) and regardless of how many individual treatment modalities, described below, are performed on the patient during her first treatment procedure.

Step 16 states to apply a first treatment modality to ablate the tissue margin. The first treatment modality serves to ablate across the exterior surface of the lung tumor. As will be described further herein, an exemplary first modality treatment for ablating the tumor margin includes, without limitation, condensable vapor ablation. By “margin of the tumor” it is meant the outer region or boundary of the tumor. Examples of the margin of the tumor include the outer limits, boundary, outside, and periphery of the tumor.

Step 18 states to apply a second treatment modality to debulk target tissue. As will described further herein, an instrument is advanced along the route to the target tissue. Once the position of the working tip is confirmed, energy is applied to debulk the lung tumor. Exemplary techniques to debulk the lung tumor include, without limitation, electro-surgery, microwave ablation, and cryosurgery.

With reference to FIGS. 2 and 3 aspects of the invention are described in further detail. Particularly, FIG. 2 shows the respiratory system including the trachea 36, left lung lobe 32 and right lung lobe 34, left bronchi 24 and right bronchi 22 and lobar bronchial branches. The lobar bronchial branches further break off into segmental and sub-segmental branches. A lung tumor 400 is shown in the left lobe 32 in the vicinity of the left secondary bronchi 42 or segmental bronchi.

Bronchoscopic Condensable Vapor Ablation

FIG. 2 also illustrates a bronchoscope 100 having a working channel extending through the trachea 36 and into the left bronchi 24. Guidance of the bronchoscope to the target area in the lung may be performed by eye using the video monitor (not shown), under fluoroscopy, or using navigation or guidance systems. Examples of guidance and navigation systems are described in the U.S. Pat. Nos. 7,889,905 and 7,756,563.

Vapor ablation catheter 200 is shown advanced through the bronchoscope 100 and into the bronchi branch upstream or proximal to the lung tumor 400. Balloon 202 is inflated to isolate the target airways and tumor.

With reference to FIG. 3, a condensable vapor 210 is delivered from the end of the catheter 200 into the airways and tumor 400. The vapor surrounds or engulfs the tumor, quickly heating the tumor as the vapor changes to liquid phase. The margin of the tumor is initially heated by thermal convection, and then heat thermally conducts towards the center of the tumor until the tumor is ablated. In a sense, the tumor 400 is heated from the outside to the inside (namely, “outside in”).

An advantage of vapor ablation is that a wide range of tissue geometries may be treated because of the gaseous nature of the vapor. The catheter is not required to contact the target tissue. The vapor crosses any gaps present in the tissue until the tumor is completely engulfed or encapsulated by the vapor. Additionally, porous tissues near the tumor margin can be permeated by the vapor, and ablated.

The energy delivery or vapor ablation catheter 200 may have various configurations. Examples of vapor ablation catheters, energy generators and controllers are described in U.S. Pat. Nos. 7,913,698; 8,585,645, and US Patent Publication No. 2016/0151103. In some embodiments, the catheter is adapted to detachably couple to an energy generator (not shown).

Electrosurgical Ablation

As stated above, embodiments of the invention include treatment of a lung tumor with a second treatment modality such as, for example, radio frequency ablation. With reference to FIG. 4, a radio frequency probe 300 is shown advanced beyond the end of a sheath 302, and into the lung tumor 400. Although the distal tip of the electrosurgical instrument 300 is shown penetrating the tumor 400, the invention is not so limited. Embodiments of the invention include, without limitation, making mere contact with the tumor, or partially inserting the tip, or contacting a pole or edge of the tumor.

Once the physician confirms the catheter tip 300 or RF electrode is properly positioned, the radio frequency catheter is activated. Position confirmation or tracking of the catheters can be performed by a wide range of guidance and location techniques including, without limitation, fluoroscopy or use of electromagnetic sensors. Examples of tracking and guidance techniques are described in U.S. Pat. Nos. 6,380,732 and 9,265,468 and US Patent Publication no. 2016/0180529.

In embodiments, and with reference to FIG. 4, the tip 300 is a sharp needle pair and penetrates the lung tumor 400. The electrodes act as a heat source and initially heat the tissue where the electrodes make contact. The heat thermally conducts through the tumor from the heat source. When the tip is positioned within the tumor, the tumor is ablated from the heat source (or point) to the exterior (namely, “inside out”).

An advantage of RF ablation is that the central denser portion of the tumor can be efficiently ablated. This is particularly useful for larger tumors where the heat from the vapor ablation, described above, may take longer to reach the dense central portions of the tumor. RF ablation is effective to ablate dense tissues and to debulk large volumes of tissue compared to other modalities. In contrast, condensable vapor ablation is effective to ablate across an entire surface where the geometry of the surface may be non-uniform and less dense than the central portions of the tumor.

The radio frequency energy delivery catheter may take a wide range of configurations and the electrode shape itself may also vary widely. Examples of electrode shapes include, without limitation, needle, hook, basket, loop, helix, coil, forceps or clamp, tubular, and snare or lasso. The electrode distal section may also be configured to flex, turn, and steer using mechanical or thermal action. Examples of RF ablation catheters, energy generators, and controllers are described in U.S. Pat. Nos. 6,692,494; 7,022,088 and US Patent Publication No. 2013/0046296.

Additional modalities to abate the tumor may include catheters and probes configured to deliver microwave energy, cryo-energy, or other types of energy suited to ablate lung tumors.

FIG. 5 is a flow chart of another method 500 for treating tumors in accordance with embodiments of the present invention.

Similar to the method described above, step 510 states to identify the tumor in the lung of a patient. Step 510 may be performed as described above.

Step 520 queries whether the target is within an airway. If yes, the procedure may proceed substantially as outlined above in connection with the methods described above.

Particularly, step 530 states to plan the bronchoscopic route to the target tissue.

Step 540 states to advance the bronchoscope to a position along the airway in the vicinity of the target tissue, preferably with a clear view of the target to be ablated.

Step 550 states to advance the vapor ablation catheter through the bronchoscope and into position at the target tissue. The position of the catheter may be confirmed as described above.

Step 560 states to deliver condensable vapor to the exterior of the target tissue to ablate the target tissue. After treatment with the vapor, the vapor catheter is withdrawn from the patient.

Step 570 states to advance the electrosurgical ablation catheter through the bronchoscope and into contact with the target tissue. Position of the catheter may be confirmed as described above.

Step 580 states to activate the electrosurgical ablation catheter to ablate the target tissue. After ablation, the catheter is retracted from the patient.

Step 590 states to confirm target tissue ablation. The physician may monitor and confirm ablation of the tumor in real time using the bronchoscope, sensors including electrodes and thermocouples, or other imaging techniques. Ablation duration, tissue temperature, energy delivered, may also be monitored and the procedure may be terminated when a threshold level is attained.

Tumor Outside the Airway—Create Access Channel

With reference again to step 520, in the event the target is determined to be outside of the airway (e.g., in the parenchymal lung tissue), method 500 proceeds to step 522.

Step 522 states to plan the bronchoscopic route to an exit or egress opening along the airway and in the vicinity of the target tissue, and to plan a route extension from the egress opening to the target tissue.

In embodiments, planning an exit or egress opening from the airway and to the target tissue outside of the airway is performed based on a number of constraints. Examples of constraints include, without limitation, proximity to the target tissue, avoiding obstacles such as blood vessels, and physical limitations of the instruments to be used during the procedure such as size, flexibility, and bend constraints. Exemplary techniques to plan the route are descried in U.S. Pat. Nos. 8,709,034 and 9,037,215.

Step 524 states to advance the bronchoscope to a position along the airway in the vicinity of the candidate exit opening.

Step 526 states to create an access pathway to the target tissue. Particularly, step 526 states to create the opening through the airway wall, and tunnel to the tumor to create an access passage along the pre-planned route extension.

In an embodiment, the egress hole is created with a catheter fed through the bronchoscope having a sharp tip. An example of a needle catheter suitable to create the hole is described in U.S. Pat. No. 8,517,955.

In an embodiment, the hole is dilated. Openings may be enlarged using, for example, enlargeable members (e.g., balloon) or fixed tapered dilators.

An elongate tube is advanced through the hole and to the tumor. The tube may be advanced over a wire or needle, or the tube may be navigated to the tumor. In embodiments, the tube includes a removable obturator to prohibit the tube from becoming filled with tissue as the tube is advanced through the tissue.

Once the tube is in position, and the position is confirmed, the intermediate instruments such as an obturator, dilator, guidewire, or needles are retracted leaving an open channel through the tube. Position confirmation, or tracking, of the instruments for accessing the tumor can be performed by a wide range of guidance and location techniques including, without limitation, fluoroscopy or use of electromagnetic sensors. Examples of tracking and guidance techniques are described in U.S. Pat. Nos. 6,380,732 and 9,265,468 and US Patent Publication no. 2016/0180529.

Although a route extension has been described above, various techniques to create and install an access passageway to the tumor are described in the following patent publications including, without limitation, U.S. Pat. Nos. 8,784,400 and 8,709,034. See also, Anciano et al., Going Off Road The First Case Reports of the Use of the Transbronchial Access Tool With Electromagnetic Navigational Bronchoscopy, J Bronchol Intervent Pulmonol, Vol. 24, No. 3, July 2017.

Once the access passageway is installed (such as, e.g., the sheath 302 shown in FIG. 4), the procedure to treat the tumor may be performed as described herein with reference to steps 550-590, except the ablation instruments are advanced to the tumor through the access passageway instead of solely along the airway.

Therapeutic Agent Delivery Via Microspheres

FIG. 6 illustrates ablation of a lung tumor 620 by implanting a plurality of therapeutic agent delivery vehicles 612 in accordance with another embodiment of the invention.

Particularly, a number of particles or microspheres 612 are shown implanted in the vicinity of the tumor 620 and a condensable vapor 600 is delivered from the end of the catheter 610 into the target region.

The microspheres are adapted to temporarily hold and deliver a therapeutic agent to the tumor. The microspheres may be preloaded with the agent, and then implanted in the lung. The position of the microspheres may be detected under imaging such as, for example, radiography or MRI.

The size of the microspheres may vary. In embodiments, the microspheres range from between 0.1 and 1000 μm.

The material of the microspheres may also vary. Exemplary materials of the microspheres include, without limitation, polymer, glass, ceramic. Examples of microspheres are FluoSpheres (manufactured by Thermo Fisher, Eugene, Oreg.).

Examples of therapeutic agents to be delivered by the microspheres include, without limitation, chemotherapy drugs, checkpoint inhibitor, immunotherapy agents, antibiotics or antiseptic agents.

In embodiments, the microspheres release the therapeutic agent over time. In embodiments, the therapeutic agent is heat activated, and treats the tumor.

Optionally, additional energy (e.g., RF ablation) or other treatment and ablation modalities may be applied to the tumor. Preferably, multiple modalities are applied in only one first treatment procedure.

Alternative Embodiments

A wide range of energy modalities may be employed in accordance with the present invention. Examples of suitable energy modalities include RF, laser, microwave, cryogenic fluid, resistive heating, ultrasound and other energy delivery mechanisms for heating a target lung volume.

In another embodiment, a method of treating a suspect tissue mass comprises: delivering a heat activated therapeutic agent to the suspect tissue mass; delivering a condensable vapor comprising water to the suspect tissue mass to activate the heat activated therapeutic agent; and delivering energy to heat the suspect tissue mass to destroy the suspect tissue mass from the inside out.

In embodiments, the heat activated therapeutic agent can be delivered systemically and only activated in the suspect tissue mass where the vapor is delivered.

In embodiments, the heat activated therapeutic agent is delivered via a bronchoscopic aerosol.

The agents delivered in the method may vary widely. Examples of heat activated therapeutic agents include, without limitation, a chemotherapy drug, immunotherapy agent, or a checkpoint inhibitor.

Additionally, it is to be understood that the order of the modalities may vary. In embodiments, the vapor ablation may be performed prior to the second modality or vice versa.

The invention has been discussed in terms of certain embodiments. One of skill in the art, however, will recognize that various modifications may be made without departing from the scope of the invention. For example, numerous variations, changes, and substitutions will now occur to those skilled in the art without departing from the invention. Moreover, while certain features may be shown or discussed in relation to a particular embodiment, such individual features may be used on the various other embodiments of the invention.

Claims

1. A method of treating a lung nodule in a lung, the lung nodule comprising a periphery and an interior, the method comprising: assessing the periphery of the lung nodule for symmetry, and distributing heat across the periphery of the lung nodule based on assessing the periphery of the lung nodule for symmetry, wherein the step of distributing heat is performed by advancing a catheter along an airway in the lung to a location proximal to a lung region surrounding the lung nodule and delivering a condensable vapor from the catheter into the lung region surrounding the lung nodule such that the lung nodule is engulfed or encapsulated by the condensable vapor; andassessing the interior of the lung nodule for increased tissue density for whether to apply a second ablation modality; anddirectly applying heat from a point source to the interior of the lung nodule based on the density of the interior of the lung nodule; and wherein the steps of distributing heat and directly applying heat are performed in a first treatment procedure.

2. The method of claim 1 wherein the step of directly applying heat to the interior of the lung nodule comprises advancing an electrosurgical instrument into direct contact with the lung nodule, and activating the instrument.

3. The method of claim 2 wherein the electrosurgical instrument is an RF energy catheter.

4. The method of claim 1, further comprising delivering a therapeutic agent to the lung nodule.

5. The method of claim 4 wherein the therapeutic agent is selected from the group consisting of an immunotherapy agent, sclerosing agent, and chemotherapy drug.

6. The method of claim 4 wherein the therapeutic agent is an antibiotic or antiseptic agent.

7. The method of claim 4 further comprising implanting microspheres in the vicinity of the lung nodule, and wherein the microspheres comprise the therapeutic agent and the therapeutic agent is released to the lung nodule from the microspheres.

8. The method of claim 7 further comprising detecting the microspheres under imaging.

9. The method of claim 8 wherein the imaging comprises radiography or MRI.

10. The method of claim 1 wherein the condensable vapor is delivered sufficient to fill the lung region, and wherein the lung region is a segment or sub-segment of a lobe of the lung.

11. A method of treating a lung nodule in a lung, the lung nodule comprising a solid mass comprising an exterior and an interior, the method comprising: identifying the exterior and interior of the solid mass;assessing tissue density of the interior relative to the exterior of the solid mass for increased tissue density;heating the lung nodule by a first modality from the whole exterior of the lung nodule inwards if the exterior of the lung nodule is less dense than the interior;heating by a second modality different than the first modality the lung nodule from the interior outwards if the interior of the lung nodule is more dense than the interior;monitoring a first ablation region and a second ablation region arising from the first modality and second modality of heating, andconfirming an overlap zone between the first ablation region and second ablation region.

12. The method of claim 11 wherein the heating by the first modality comprises delivering a condensable vapor to the lung nodule.

13. The method of claim 12 wherein the heating by the second modality comprises applying electrosurgical energy to the lung nodule.

14. The method of claim 13 wherein the first modality is performed prior to the second modality.

15. The method of claim 14 wherein the second modality is bronchoscopic radio frequency ablation.

16. The method of claim 11 further comprising assessing the exterior of the lung nodule for non-uniformity prior to the step of heating by the first modality and heating by the first modality based on the assessing the exterior of the lung nodule.

17. The method of claim 11 wherein the second ablation region grows outward.