International Journal of Radiation Oncology*Biology*Physics
Clinical investigationsExternal irradiation and intraluminal irradiation using middle-dose-rate iridium in patients with roentgenographically occult lung cancer
Introduction
Intraluminal irradiation for lung cancer has come to be used widely in clinical cases only after the advent of the thin and highly flexible iridium sources. However, the primary objective of intraluminal irradiation has been alleviation of symptoms such as cough, bloody sputum, and dyspnea caused by tumors in the bronchi, and the procedure has been regarded as a palliative approach 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. Reports of intraluminal irradiation as a radical treatment have been limited 13, 14, 15, 16, 17, and its role as a radical treatment has not been sufficiently evaluated.
We started intraluminal therapy using middle-dose-rate iridium in 1987, and the first case was a patient with roentgenographically occult lung cancer (ROLC) inoperable due to reduced lung function. In this patient, intraluminal irradiation was performed using middle-dose rate iridium for a tumor that persisted in the bronchus after external irradiation at 77 Gy. Fortunately, the tumor was controlled by this additional intraluminal irradiation, but the respiratory function was further reduced due to the excessive external irradiation of 77 Gy, necessitating home oxygen therapy. In this case, the iridium source was placed in a 10Fr. aspiration tube, which was shown by bronchoscopy to be deviated from the center of the bronchus, suggesting uneven distribution of the dose in the bronchial mucosa. We thereafter developed our original catheter for intraluminal irradiation that would ensure even distribution of the dose in the bronchial mucosa; we have applied it clinically for radical treatment, primarily of ROLC (18).
In this report, the therapeutic results in 39 patients with ROLC were analyzed, and the significance of the catheter with a spacer that we developed, validity of the dose-monitoring points that we have used, optimal dose from the viewpoints of therapeutic effect and radiation injury, and clinical significance of bronchial intraluminal irradiation for the treatment of ROLC were evaluated.
Section snippets
Methods and materials
The subjects were 39 patients who underwent intraluminal irradiation at the Department of Radiotherapy, Aichi Cancer Center between May 1987 and August 1999 (Table 1). They consisted of 38 males and 1 female aged 54–82 years (median age 65 years). The lesions were confirmed by bronchoscopic biopsy in all patients. Bronchoscopy was performed due to bloody sputum in 22 patients, abnormal cytology of sputum on screening in 12, persistent cough and sputum in 3, and in periodic follow-up
Results
Treatments were completed as planned in 38 patients, except one case (poor general health). The doses were 22–66 Gy (median value 45 Gy) by external irradiation and 10–46 Gy (median value 28 Gy) by intraluminal irradiation. The therapeutic effect was a CR in 38 patients and a PR in 1, in whom additional treatments were reserved because of poor general health. Local recurrence was observed in the PR case, and 3 of the 38 patients who showed CR (follow-up period 3 months to 11 years and 5 months
Discussion
Since bronchial intraluminal irradiation has been used as a palliative 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, long-term survival after this therapy is not common. However, cases of long-term survival have been reported recently, when radical radiotherapy by a combination of bronchial intraluminal irradiation and external irradiation have been used in patients with ROLC 13, 14, 15, 17.
There are two requirements dictating the use of intraluminal radiotherapy for ROLC. One is irradiation at a
References (29)
- et al.
High dose rate afterloading intraluminal brachytherapy in malignant airway obstruction of lung cancer
Int J Radiat Oncol Biol Phys
(1994) - et al.
Inoperable endobronchial obstructing lung cancer treated with combined endobronchial and external beam irradiationA dosimetric analysis
Int J Radiat Oncol Biol Phys
(1993) - et al.
Endobronchial irradiation for malignant airway obstruction
Int J Radiat Oncol Biol Phys
(1989) - et al.
Management of malignant airway obstructionClinical and dosimetric considerations using an iridium-192 afterloading technique in conjunction with the neodymium-YAG laser
Int J Radiat Oncol Biol Phys
(1985) - et al.
High dose rate intraluminal irradiation in recurrent endobronchial carcinoma
Chest
(1985) - et al.
High dose rate brachytherapy in patients with local recurrences after radiotherapy of non-small-cell lung cancer
Int J Radiat Oncol Biol Phys
(1992) - et al.
Treatment of non-small cell lung cancer with external beam radiotherapy and high dose rate brachytherapy
Int J Radiat Oncol Biol Phys
(1992) - et al.
High-dose rate intraluminal irradiation in bronchogenic carcinomaTechnique and results
Chest
(1993) - et al.
Remote afterloading brachytherapy for the local control of endobronchial carcinoma
Int J Radiat Oncol Biol Phys
(1993) - et al.
Treatment of roentogenographically occult endobronchial carcinoma with external beam radiotherapy and intraluminal low dose rate brachytherapy
Int J Radiat Oncol Biol Phys
(1996)
Does additional brachytherapy improve the effect of external irradation? A prospective randomized study in central lung tumors
Int J Radiat Oncol Biol Phys
Curative irradiation of limited endobronchial carcinomas with high-dose rate brachytherapy. Results of a pilot study
Chest
Results of surgical treatment for roentgenographically occult bronchogenic squamous cell carcinoma
J Thorac Cardiovasc Surg
Roentgenographically occult lung cancer. A ten-year experience
J Thorac Cardiovasc Surg
Cited by (16)
Long-term results of endobronchial brachytherapy: A curative treatment?
2007, International Journal of Radiation Oncology Biology PhysicsCitation Excerpt :Some other techniques could be considered, including photodynamic therapy, cryotherapy, or laser therapy. A combination of EBRT and HDR-EBBT has also been proposed to treat radiographically occult endobronchial carcinomas as an alternative to surgery, with high response and survival rates (17–19). Physicians might also be reluctant to propose this intraluminal and uncomfortable technique for patients with a short life expectancy.
Endobronchial brachytherapy and optimization of local disease control in medically inoperable non-small cell lung carcinoma: A matched-pair analysis
2004, BrachytherapyCitation Excerpt :Despite these excellent palliative results, there exists relatively very little medical literature on the use of endobronchial brachytherapy as it pertains to disease control and survival for the potentially curable patient. The few studies that exist have investigated brachytherapy with or without EBRT in the management of radiographically occult lung cancer—an unusual diagnosis—and have reported local control rates of roughly 75–90% (19, 20). Japanese reports of EBRT followed by either LDR or HDR endobronchial boost for radiographically occult disease indicate nearly 100% clinical response rates after treatment and bronchial stenosis rates of 20–30% (21–23).
Endobronchial brachytherapy: Technique and indications
2003, Cancer/RadiotherapieBritish Thoracic Society guideline for advanced diagnostic and therapeutic flexible bronchoscopy in adults
2011, ThoraxCitation Excerpt :Survival has been related, unsurprisingly, to performance status. Brachytherapy has been used to treat radiologically-occult early-stage lung cancer.75 84 Complete endoscopic responses have been reported in 65-90% of patients, with partial responses in the remainder and 5-year survival of around 80%.
Brachytherapy in the treatment of lung cancer - a valuable solution
2015, Journal of Contemporary Brachytherapy