Clinical investigation: lung
High-dose-rate endobronchial brachytherapy effectively palliates symptoms due to airway tumors: The 10-year M. D. Anderson Cancer Center experience

Presented at the 84th Scientific Assembly, Radiological Society of North America, Chicago, IL, November 29, 1998.
https://doi.org/10.1016/S0360-3016(00)00693-3Get rights and content

Abstract

Purpose: To evaluate the toxicity and efficacy of Iridium-192 high-dose-rate (HDR) endobronchial brachytherapy (EBBT) for the palliation of symptoms caused by relapsed or persistent endobronchial tumors.

Methods and Materials: We reviewed the treatment outcomes between 1988 and 1997 in 175 lung cancer patients who underwent HDR EBBT for recurrent or metastatic tumors at The University of Texas M. D. Anderson Cancer Center. One hundred sixty of these patients had previously received thoracic external-beam irradiation. This updated report includes 74 patients from a previous series. Most patients received 3,000-cGy EBBT delivered at a distance of 6 mm and divided into 2 fractions over 2 weeks. Subjective response was assessed by questionnaire at follow-up. Objective response was assessed by physical examination, bronchoscopy, and chest radiograph.

Results: The median actuarial survival for the entire group was 6 months from the time of the first EBBT treatment session. Of the 115 patients (66%) who showed symptomatic improvement, 32% were much improved and 34% were slightly improved. Patients showing improvement survived for significantly longer than those who showed no change or worsening symptoms (7 vs. 4 months, p = 0.0032). Repeat bronchoscopy demonstrated a 78% overall objective response rate that correlated significantly with subjective response and symptom relief. Complications occurred in 19 patients (11% crude rate) with an actuarial complication rate of 13% at 1 year from the time of the first EBBT treatment session. The actuarial hazard for fatal hemoptysis due to EBBT was 5%.

Conclusion: HDR EBBT effectively palliates most patients’ symptoms caused by endobronchial lesions. This relief correlates significantly with an overall survival benefit. Treatment complications appear to be few, even for patients who have received prior external-beam irradiation.

Introduction

The potential to use radioactive sources in or near airway tumors has long been recognized. For example, reports from as early as 1922 describe the implantation of radon seeds in a pulmonary lesion via a rigid bronchoscope (1). Unfortunately, these initial attempts were limited by the fact that physicians and personnel were exposed to high levels of radiation, dosimetry was nonuniform, and tumor access was restricted. With the development of more advanced techniques, such as flexible fiberoptic bronchoscopy and the remote afterloading of high-activity sources, endobronchial brachytherapy (EBBT) has now emerged as a safe and effective treatment (2).

The majority of lung cancer patients are diagnosed with clinically advanced disease. These are tumors that have invaded local tissues or spread to regional lymph nodes, which makes them either inoperable or unlikely to be eradicated by surgical resection alone. The patients, who then undergo combined chemotherapy and radiotherapy or radiotherapy alone, are at substantial risk for intrathoracic relapse or metastasis. Indeed, clinical relapse rates of 30–50% have been noted in prospective trials (3). When local tumor control was defined by the pathological complete response, a rate of 17% has been reported (4). Retreatment options in these patients are often limited because the doses prescribed for definitive external-beam radiotherapy usually preclude the administration of additional external radiation due to the increased risk of severe toxicity to other organs such as the heart or to structures such as the esophagus and spinal cord.

An advantage of EBBT in patients with airway tumors is that it allows the delivery of a potentially tumoricidal radiation dose to the site of recurrent disease with less overall risk of substantial injury to the surrounding organs and tissues. An additional particular strength of EBBT lies in its ability to relieve debilitating symptoms, such as dyspnea and hemoptysis. EBBT may also alleviate postobstructive pneumonitis, thereby enabling patients to receive chemotherapy without increased risk of neutropenic sepsis.

At The University of Texas M. D. Anderson Cancer Center, high-dose-rate (HDR), remote-afterloaded, Iridium-192 EBBT has been applied over the past 10 years to palliate patients’ symptoms from recurrent or metastatic endobronchial tumors. In this review, we report on this therapy’s efficacy and toxicity in a series of 175 consecutive patients with lung carcinoma treated during this past decade at our institution.

Section snippets

Methods and materials

One hundred ninety-eight consecutive patients who underwent palliative (EBBT) HDR for endobronchial tumors at M.D. Anderson between November 1988 and December 1997 were identified from a Division of Radiation Oncology database. Twenty-three of these patients received treatment for nonpulmonary primary tumors and were excluded from the analysis. The remaining 175 patients included 74 patients who were included in a previous report (5). Patients’ hospital and radiotherapy charts were reviewed to

Results

The patients ranged in age from 28 to 79 years (median 60); 119 were men and 56 were women (Table 1). The median KPS before treatment was 70, with the score ranging from 50 to 100. One hundred forty-nine patients (85%) had dyspnea, while 133 (76%) had cough, and 60 (34%) had hemoptysis. Forty-seven patients (27%) reported wheezing prior to EBBT. Sixteen patients (9%) reported other symptoms, such as dysphagia, chest pain, and hoarseness. Non-small cell lung carcinoma was the prevalent

Discussion

HDR EBBT provides prompt relief of symptoms in patients with intraluminal airway tumors. Although external-beam radiation therapy could also be used for this purpose, often it cannot be used because patients have already received definitive irradiation, where additional dose to normal intrathoracic tissues and organs would risk severe and debilitating chronic complications. For patients who have not had prior thoracic radiation therapy, a combination of external-beam and endobronchial radiation

References (29)

Cited by (102)

View all citing articles on Scopus
View full text