Intratumoral chemotherapy spread from Turkey to the world, is applied together with other treatment methods especially in lung cancer patients; eliminates side effects, strengthens the patient's immune system and helps the body to fight against cancer.

Smoking rates are still very high in our country. Among the causes of lung cancer, cigarette smoking takes the first place with 80%. Lung cancer symptoms such as cough and pain can be easily to ignored or dismissed, but if not ignored, these symptoms can be a precedent for making early diagnosis of lung cancer, which is mistaken to be untreated.The intratumoral chemotherapy technique developed and implemented by Professor Seyhan Celikoglu,MD in the late 1980s, used today in the USA and European countries, significantly increases the chance of successful treatment. Professor of Pulmonary Diseases Department at Bayindir Hospital, Prof. Firuz Çelikoğlu, MD, shares details about intratumoral chemotherapy with the diagnostic and treatment pathways of lung cancer.

What is lung cancer?
Lung cancer which develops as with most other cancers, is a type of cancer that starts in the lungs. However, lung cancer is a complex disease to understand and treat. Lung cancer is a mixture of cancers with very different course and clinical characteristics. Lung cancers are divided into two main groups: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC). These are clinical conditions with different characters in terms of treatment and clinical course. 80 percent of lung cancers occur due to airway obstruction. 20 percent are cancers that occur in the middle parts of the lung, that is, the parts we call alveoli, in the small air sacs.

What are the symptoms?
The most significant symptom is cough. If there is a dry cough that lasts for a month, this is a condition that must be identified. Second, there will be bleeding called hemoptysis. Thin streaks of red blood appears in the phlegm, or a completely bright blood comes out. This is a condition like cough that patients always ignore psychologically. Sometimes lung cancer may only manifest with local pain; such as back pain, shoulder pain. These are not very specific symptoms or certain signs for lung cancers. In other words, lung cancer is a cancer that develops very insidiously even though it gives small signs. When lung cancer spreads to other parts of the body such as bones and lung membrane, it may cause decisive pain which is late finding. Therefore, especially smokers need to be very vigilant. If identified at an early stage, it certainly can be treated effectively. However, since patients ignore the symptoms and we cannot catch them in time, lung cancer appears to be a disease without treatment.

Can you tell us about the risk factors for this type of cancer?
The first risk is genetic. In fact, cell mutations occur constantly in our bodies, but the P53 gene destroys these problematic cells and prevents the formation of cancers. The extinction of this gene triggers the formation of cancer. Smoking is the first reason for the decrease in activity of the P53 gene. Harmful substances in the cigarettes, toxic chemicals, conditions such as temperature, heat begin to reduce the activity of the body's P53 gene. A carcinogenic environment may occur as a result of the disturbance of balance. If the body is more susceptible to cancer, people who smoke are more likely to develop cancer faster. Secondly, there is a greater risk of developing cancer for those who have had lung-related inflammatory diseases continue smoking. Exposure to air pollution increases the cancer effect of cigarette smoking even more. In other words, living in the city centers increases the risk. Apart from these, exposure to chemicals is a factor. Therefore, the industrial workers are also at high risk. Asbestos exposure is one of the most common causes of cancer. This substance, which is currently under control to a large extent, is used extensively in the insulation also products including brake pads, pipe insulation. It is the chemical encountered at demolition of old buildings or sunken ship diving.

What are the diagnostic methods?
Lung CT the is first test used to diagnose lung cancer. Lung tomography shows us nodules that haven't reached 1 cm yet, which we are looking for, what we want is to see at this level. The second is to scan the inside of the airways. This is a visual inspection of the airways with the optical system called bronchoscopy. This is an extremely simple process. The procedure takes about 5-10 minutes while patient is asleep. The process itself does not cause a complication or change in disease. One of the most important finding is the examination of the bronchial washing process with sputum and bronchoscope, which we call cytology. These also enables us for early diagnosis at the cellular level. If lung cancer has been diagnosed, tests called PET-CT can be performed to screen other events.

Can you tell us about the treatment methods?
Chemotherapy is the first step in the treatment of a systemic cancer called small cell cancer. The diagnosis of this type of cancer must be determine with pathology. The other main group, which we call non-small cell, is divided into many groups. Chemotherapy and radiotherapy applications are different based on their treatments. There is also a very important third treatment that will contribute to treatment. Intratumoral chemotherapy (local chemotherapy) developed by Prof. Seyhan Çelikoğlu, MD at Cerrahpasa Medical Faculty in the late 1980s - early 1990s and now accepted in the world also increased the treatment opportunities of the patients. As a result of great research since then, intratumoral chemotherapy is currently being performed in the world. Intratumoral chemotherapy has taken its place as the treatment we accepted as the first step of immunotherapy in its future treatments. Intratumoral chemotherapy has been established as the first step of immunotherapy.

Where can it be applied?
It is a treatment applied in our country. This method is used in Germany, also there are groups that receive treatment in the United States. However, this treatment cannot be administered in every center because oncologists treating cancer cannot administer this therapy directly since they are not bronchoscopist at the same time.

How is intratumoral chemotherapy administered?
In this treatment, the specialist inserts the bronchoscope directly into the pathological zone in the lung, if the airways are obstructed due to tumor expansion, special drug is applied to melt the blockage, which allows the lung to ventilate again. Secondly, these drugs go directly to the lymph glands and clean up the cancer cells in the lymph. This prevents spreading of cancer cells beyond the lymph glands. This prevents it from spreading out of the area. In early stages of cancers, the first option is surgery, i.e. removing the tumor locally. Intratumoral chemotherapy is a method that can support this treatment, because even if it looks very small, what we call lung cancer micrometastases can spread to lymph glands and form an early-stage cancer. In this regard, in cases that are caught in early stage, the drug is injected directly into the tumor with a needle, in this way drug is sent early in the lymph glands where cancer can spread, and then it is removed surgically. The studies showed that the patients after intratumoral injections had much better respond to radiotherapy treatment. Intratumoral injection increases the effect of the beam. The third benefit of this treatment is the possibility to minimize the size of the tumor in advanced lung cancer, which allows surgery. It gives us the chance to turn even advanced cancer into an early stage cancer. We have had patients who were at this level and survived after operation. The most crucial aspect of this treatment in emergency cases is the ability to stop bleeding.

AN EFFECTIVE TREATMENT WITHOUT SIDE EFFECTS

What are the advantages of intratumoral chemotherapy in comparison with other methods?
The intratumoral chemotherapy cannot be applied alone; it should be put in practice in combination with other treatments. During chemotherapy, when the patient's general condition deteriorates and blockage of airway occurs, intratumoral chemotherapy is applied to eliminate the obstruction and facilitate breathing process. Also because it is locally delivered directly into the cell, we are able to reach high doses that we cannot reach in classical chemotherapy. Since this high dose is not released into bloodstream, it does not have a systemic adverse effect. It can also be applied together with radiotherapy. The radiotherapy treatment can continue up to a certain extent, otherwise the lung might be damaged. However, cancer treatment is a treatment that demands continuity. Since intratumoral chemotherapy is local, we can continue. Thirdly, it is a motivated treatment alongside other treatments. In the treatment of cancer that is caught very early and to be operated, when we give intratumoral chemotherapy a week in advance, we will already clean the micrometastases prior to surgery. We boost the patient's immune system in order to activate the immunotherapy.

What's immunotherapy?
What is currently desired in cancer treatment is that the body removes cancer with its own cells. It is called immunotherapy. Currently, most of the research is based on this. The purpose of immunotherapy is to boost immune system that can start to perceive cancer tissue as foreign to the body and fight against it with its own resources. When we present cancer cells as foreign invaders with the help of immunotherapy, the body attacks it with its own macrophages and destroys the cancer cells. With the cellular treatment we apply in our method, the body begins to recognize the cancer cell, stimulates the immune system and attacks to kill the cancer cells. in this regard, we achieve very fast results. If we can start the treatment in the early stages, both the effect of chemotherapy and radiotherapy with the support of immunotherapy will increase the success rate.

Who can apply this treatment?
The treatment implies participation of different professionals such as pulmonologist, physician trained in the performance of bronchoscopy which we call bronchoscopist, in cooperation with oncologist.

Can it be used in other types of cancer?
Apart from lung cancer patients those with airway obstruction, this method can also be applied to brain tumors as the effect of chemotherapy treatment remains poor reaching the tumor located in the brain. It can be used to treat pancreatic cancers, colorectal cancers (i.e. rectal cancers), stomach cancers, liver cancers and cancer metastases.

Does intratumoral chemotherapy have a side effect?
The side effect seems almost non-existent. The existing side effects are positive. First, it stops bleeding, opens the airways, eases shortness of breath. Perhaps fever may occur as a side effect in some patients on the first day of procedure. The treatment is done on an outpatient basis as daycase. The patient returns home on the same day.  Side effects such as hair loss, low blood cell counts or weakness are not associated with intratumoral chemotherapy.

Prof. FIRUZ CELIKOGLU, M.D.
Pulmonary Diseases Department,  Bayındır Hospital Icerenkoy