Intraoperative brachytherapy in non-small cell lung cancer

High-dose rate brachytherapy of bronchial cancer: treatment optimization using three schemes of therapy

PURPOSE

Our aim is to demonstrate that a fractionated high-dose rate endobronchial brachytherapy (HDRBT) treatment is tolerable for patients with advanced (IIIA-IIIB) non-small cell lung cancer and gives an improvement of symptoms. Patients and Methods. From January 1992 to July 1997, we treated 320 patients with external beam radiotherapy (EBRT) and concomitant HDRBT with Ir192. Eighty-four patients received 10 Gy in one fraction from January 1992 to March 1993 (Group A); 47 patients received two fractions of 7 Gy each from April 1993 to December 1993 (Group B), and 189 patients received three fractions of 5 Gy each from January 1994 to July 1997 (Group C).

RESULTS

Mean survival from diagnosis is 11.1 months and mean survival from last HDRBT is 9.7 months. The symptomatic response rate is 90% for dyspnea, 82% for cough, 94% for hemoptysis and 90% for obstructive pneumonia. Performance status was improved in 70% of patients. Follow-up is in the range of 5-36 months with 280/320 evaluable patients (87.5%) (40 patients were lost to follow-up). For the patients treated with three fractions of HDRBT plus EBRT, a smaller number of side effects occurred while relief from symptoms linked to bronchial obstruction and survival was similar for the three groups.

CONCLUSIONS

A three-fraction brachytherapy results in fewer side effects, such as bronchial fibrosis with or without stenosis, while survival and symptomatic relief are similar in the three groups treated.

Intraoperative 125I brachytherapy for high-risk stage I non-small cell lung carcinoma

PURPOSE

Preliminary assessment of feasibility, efficacy, acute and chronic side effects associated with permanent intraoperative placement of 125I vicryl mesh brachytherapy in a select group of high-risk Stage I NSCLC who have undergone video-assisted thoracoscopic resection (VATR).

METHODS AND MATERIALS

From January 8, 1997 to March 16, 1998, 23 patients with Stage I NSCLC at high risk for conventional surgery due to cardiopulmonary compromise underwent combined VATR and intraoperative placement of 125I seeds embedded in vicryl mesh. Seeds embedded in vicryl suture were attached with surgical clips to a sheet of vicryl mesh, and thoracoscopically inserted over the target area (tumor bed and staple line) with nonabsorbable suture or surgical clips. A total dose of 100-120 Gy prescribed to the periphery of the target area (defined as the staple line and tumor bed with a 1-cm margin) was delivered.

RESULTS

The mean target area covered was 48 cm2 (range 40-72) and mean total activity was 22 mCi (range 17.2-28.2). The median length of postoperative stay was 7 days. The median follow-up was 11 months (range 2-20). Postoperative CT scans of the chest revealed no dislodgement of the seeds and no local recurrence in any patient. Three patients developed distant metastasis (1 died 6 months postoperatively; the other 2 are currently alive with disease). One patient developed an ipsilateral recurrence in the right lower lobe after having had a right upper lobe resection. There were 3 postoperative deaths due to medical comorbid conditions or surgical complications (1 in the immediate postoperative period). Pulmonary function testing performed 3 months after implantation revealed no significant difference between preoperative and postoperative values: mean preoperative FVC was 2.3 L (range 1.31-3.0) and postoperative FVC was 2.2 L (range 1.1-3.9), p = 0.42; mean preoperative FEV1 was 1.2 L (range 0.71-2.2), and postoperative FEV1 was 1.5 L (range 0.8-2.9), p = 0.28.

CONCLUSION

Review of early data suggests that intraoperative 125I vicryl mesh brachytherapy in high-risk Stage I NSCLC is potentially effective and well tolerated, with no significant decline in measurable pulmonary function studies and no increase in postoperative complications. Longer follow-up is needed to determine ultimate local control and survival.

Brachytherapy for non-small cell lung cancer and selected neoplasms of the chest

This article reviews the indications, techniques, and results of brachytherapy in the treatment of non-small cell lung cancer (NSCLC) and selected chest neoplasms. Various isotopes and techniques are used to place radioactive sources directly into a tumor, tumor bed, or the chest. Brachytherapy techniques can be tailored to the clinical situation and can be in the form of permanent interstitial volume or planar implants (radioactive sources permanently imbedded into the tumor or tumor bed) or in the form of temporary interstitial or endoluminal implants (where radioactive sources irradiate a tumor bed over a certain length of time and then are removed). These treatments can be delivered over a short interval (high-dose rate [HDR]) or over a more protracted time (low-dose rate). HDR treatments can be used intraoperatively to deliver a large dose of radiation to a determined target area with selective sparing of surrounding normal structures. Different methods of delivering HDR intraoperative radiation are under investigation. Most reports on brachytherapy for chest malignancies are retrospective and come from a few single institutions. Most of the published data relate to the treatment of NSCLC, but other intrathoracic malignancies, such as malignant pleural mesothelioma and malignant thymoma, have been treated with brachytherapy. To our knowledge, no major randomized trials accurately assess or confirm these retrospective studies yet, complicating the interpretation of these results. Nevertheless, brachytherapy is of value in selected situations and offers the clinician and the patient an innovative method of delivering conformal high-dose radiation to a defined target with preferential sparing of normal surrounding structures. With continued innovations in the development of radioactive isotopes, computerized treatment planning and targeting, and source delivery, brachytherapy should continue to offer an attractive alternative and complement to conventional treatment approaches, and may offer patients improved local control and survival.

Intraoperative brachytherapy using Gelfoam radioactive plaque implants for resected stage III non-small cell lung cancer with positive margin: a pilot study

Complete surgical resection of stage III non-small cell lung cancer (NSCLC) is at times impossible. Adjuvant radiation therapy is required to sterilize the residual tumor. This study is to investigate the safety, reproducibility, and effectiveness of intraoperative I-125 or Pd-103 Gelfoam plaque implant technique as an adjuvant treatment for resected stage III NSCLC with positive surgical margin. Between 1989 and 1993, 12 patients with stage III NSCLC received intraoperative lung implant with radioactive I-125 or Pd-103 pellets. All 12 patients underwent tumor resection, but either gross or microscopic positive margin was found during operation. Radioactive I-125 or Pd-103 seeds were embedded in the Gelfoam plaque. After surgical resection was completed, the radioactive Gelfoam plaque was secured onto the tumor bed either by clips or suture. Either preoperative or postoperative external beam radiation of 45-60 Gy was given to all of the 12 patients. Four patients received chemotherapy. No patient has developed any early or late complications attributable to implant procedure or radiation. The local control rate at last follow-up is 82%. The 2-year overall and cause-specific survival rates are 45% and 56%, respectively. The intraoperative Gelfoam I-125 or Pd-103 planar implant technique is a safe, reproducible, and effective technique of treatment for stage III NSCLC with a positive surgical margin. Encouraging local control and survival are achieved in patients treated with this technique. This technique will compliment standard adjuvant treatments to further improve local control in resected state III lung cancer.