Value of perioperative brachytherapy in the management of non-oat cell carcinoma of the lung

Recommendations for intraoperative mesh brachytherapy: Report of AAPM Task Group No. 222

Mesh brachytherapy is a special type of a permanent brachytherapy implant: it uses low-energy radioactive seeds in an absorbable mesh that is sutured onto the tumor bed immediately after a surgical resection. This treatment offers low additional risk to the patient as the implant procedure is carried out as part of the tumor resection surgery. Mesh brachytherapy utilizes identification of the tumor bed through direct visual evaluation during surgery or medical imaging following surgery through radiographic imaging of radio-opaque markers within the sources located on the tumor bed. Thus, mesh brachytherapy is customizable for individual patients. Mesh brachytherapy is an intraoperative procedure involving mesh implantation and potentially real-time treatment planning while the patient is under general anesthesia. The procedure is multidisciplinary and requires the complex coordination of multiple medical specialties. The preimplant dosimetry calculation can be performed days beforehand or expediently in the operating room with the use of lookup tables. In this report, the guidelines of American Association of Physicists in Medicine (AAPM) are presented on the physics aspects of mesh brachytherapy. It describes the selection of radioactive sources, design and preparation of the mesh, preimplant treatment planning using a Task Group (TG) 43-based lookup table, and postimplant dosimetric evaluation using the TG-43 formalism or advanced algorithms. It introduces quality metrics for the mesh implant and presents an example of a risk analysis based on the AAPM TG-100 report. Recommendations include that the preimplant treatment plan be based upon the TG-43 dose calculation formalism with the point source approximation, and the postimplant dosimetric evaluation be performed by using either the TG-43 approach, or preferably the newer model-based algorithms (viz., TG-186 report) if available to account for effects of material heterogeneities. To comply with the written directive and regulations governing the medical use of radionuclides, this report recommends that the prescription and written directive be based upon the implanted source strength, not target-volume dose coverage. The dose delivered by mesh implants can vary and depends upon multiple factors, such as postsurgery recovery and distortions in the implant shape over time. For the sake of consistency necessary for outcome analysis, prescriptions based on the lookup table (with selection of the intended dose, depth, and treatment area) are recommended, but the use of more advanced techniques that can account for real situations, such as material heterogeneities, implant geometric perturbations, and changes in source orientations, is encouraged in the dosimetric evaluation. The clinical workflow, logistics, and precautions are also presented.

American Brachytherapy Society consensus guidelines for thoracic brachytherapy for lung cancer

PURPOSE

To update brachytherapy recommendations for pretreatment evaluation, treatment, and dosimetric issues for thoracic brachytherapy for lung cancer.

METHODS AND MATERIALS

Members of the American Brachytherapy Society with expertise in thoracic brachytherapy updated recommendations for thoracic brachytherapy based on literature review and clinical experience.

RESULTS

The American Brachytherapy Society consensus guidelines recommend the use of endobronchial brachytherapy for disease palliation in patients with central obstructing lesions, particularly in patients who have previously received external beam radiotherapy. The use of interstitial implants after incomplete resection may improve outcomes and provide enhanced palliation. Early reports support the use of CT-guided intratumoral volume implants within clinical studies. The use of brachytherapy routinely after sublobar resection is not generally recommended, unless within the confines of a clinical trial or a registry.

CONCLUSIONS

American Brachytherapy Society recommendations for thoracic brachytherapy are provided. Practitioners are encouraged to follow these guidelines and to develop further clinical trials to examine this treatment modality to increase the evidence base for its use.

Brachytherapy in the treatment of lung cancer - a valuable solution

The majority of patients with lung cancer are diagnosed with clinically advanced disease. Many of these patients have a short life expectancy and are treated with palliative aim. Because of uncontrolled local or recurrent disease, patients may have significant symptoms such as: cough, dyspnea, hemoptysis, obstructive pneumonia, or atelectasis. Brachytherapy is one of the most efficient methods in overcoming difficulties in breathing that is caused by endobronchial obstruction in palliative treatment of bronchus cancer. Efforts to relieve this obstructive process are worthwhile, because patients may experience improved quality of their life (QoL). Brachytherapy plays a limited but specific role in definitive treatment with curative intent in selected cases of early endobronchial disease as well as in the postoperative treatment of small residual peribronchial disease. Depending on the location of the lesion, in some cases brachytherapy is a treatment of choice. This option is fast, inexpensive, and easy to perform on an outpatient basis. Clinical indications, different techniques, results, and complications are presented in this work.

Intraoperative seed placement for thoracic malignancy-A review of technique, indications, and published literature

PURPOSE

This review examines the role of permanent radioactive seed implantation in thoracic malignancy. This technique can be used intraoperatively to provide additional highly localized radiation therapy in cases where optimal oncologic margins are unattainable or to palliate unresectable disease.

METHODS AND MATERIALS

Relevant trials were identified through a systematic literature search using Pubmed.

RESULTS

The intraoperative placement of brachytherapy seeds has been described after sublobar resection for non-small-cell lung cancer (NSCLC), where surgical margins are close or microscopically positive and in the presence of macroscopic residual disease. This brachytherapy technique is currently the focus of a randomized prospective trial in the USA in patients unfit for lobectomy for early-stage NSCLC.

CONCLUSIONS

This review summarizes the methods of brachytherapy seed placement and the published experience of brachytherapy implants within the thorax, also examining radiation safety and postoperative dosimetry. This technique has the potential to improve local control with optimal sparing of normal tissue owing to its highly conformal radiotherapy delivery.

Severe toxicity after permanent radioactive seed implantation for mediastinal carcinoid tumors

PURPOSE

Permanent implantation of 125I seeds may be used when uninvolved surgical margins are unobtainable or close. Two cases of mediastinal carcinoid tumors with prior chemoradiation had tumors adherent to esophageal muscularis. Both underwent intraoperative permanent seed implantation and developed esophageal fistulas requiring surgical correction.

METHODS AND MATERIALS

Custom permanent 125I seed mesh implants were fashioned intraoperatively in a geometrically coherent pattern. The implants were directly sutured to the partially resected esophageal wall. The postimplant CT scans were fused with the postfistula scans to provide dosimetric information at the fistula site. Doses were calculated from time of insertion to time of fistula formation. Neither patient showed evidence of disease recurrence at the time of fistula repair.

RESULTS

Patient 1 developed an esophageal-pleural fistula 83 days after seed implantation. Patient 2 developed a broncho-pleural fistula 300 days after seed implantation.

CONCLUSIONS

These cases demonstrated that implantation in the setting of extensive subcarinal space dissection and partial esophageal wall resection could cause fistula formation and the need for additional surgery. The high mucosal dose, despite the relatively low activity implant, was due to lack of geometric sparing of the mucosa. We recommend that extensive subcarinal space dissection be considered a contraindication to permanent seed implantation.

Hemithoracic radiation therapy after pleurectomy/decortication for malignant pleural mesothelioma

PURPOSE

To evaluate pleurectomy/decortication (P/D) and adjuvant radiotherapy (RT) in the treatment of malignant pleural mesothelioma (MPM).

METHODS AND MATERIALS

In a retrospective review, we included MPM patients treated with P/D and adjuvant RT at Memorial Sloan-Kettering Cancer Center from 1974 to 2003. When indicated, patients received intraoperative brachytherapy to residual tumor.

RESULTS

All 123 patients received external beam RT (median dose, 42.5 Gy; range, 7.2-67.8 Gy) to the ipsilateral hemithorax postoperatively. Fifty-four patients underwent brachytherapy (matched peripheral dose, 160 Gy). The median and 2-year overall survival for all patients was 13.5 months (range, 1-199 months) and 23%, respectively. One-year actuarial local control for all patients was 42%. Multivariate analysis for overall survival revealed radiation dose <40 Gy (p = 0.001), nonepithelioid histology (p = 0.002), left-sided disease (p = 0.01), and the use of an implant (p = 0.02) to be unfavorable. Two patients (1.6%) died from Grade 5 toxicity within 1 month of treatment.

CONCLUSIONS

Pleurectomy/decortication with adjuvant radiotherapy is not an effective treatment option for patients with MPM. Our results imply that residual disease cannot be eradicated with external RT with or without brachytherapy and that a more extensive surgery followed by external RT might be required to improve local control and overall survival.

Brachytherapy in the treatment of thoracic tumors. Lung and esophageal

Brachytherapy for carcinoma of the lung is most often performed using HDR remote afterloading equipment which delivers the treatment within the tracheal-bronchial tree in an outpatient setting. It provides excellent palliation, rapidly, and can also be selectively used with for curative intent. Permanent implantation using iodine seeds at the time of surgery improves the local control rate for those patients. Esophageal brachytherapy is performed as an intraluminal technique, most often using HDR equipment in an outpatient setting, and is used for palliation as a single modality and as a boost following chemo/radiation for curative patients. In this latter situation, the more aggressive therapy provides significantly better palliation than is possible with single-modality therapy.

Contemporary brachytherapy approaches in non-small-cell lung cancer

Brachytherapy has the ability to deliver a higher tumor dose compared to external beam irradiation, while sparing normal tissue outside the tumor; it is the most effective means of delivering conformal radiation and can be tailored to clinical circumstances, either at open surgery or in an ambulatory setting, which is currently the preferred method. Intraoperative lung and/or endobronchial brachytherapy in the management of non-small-cell lung cancer offers a good curative potential in patients with accessible localized tumors, well defined and small to moderate in size, that have not metastasized to the lymph nodes and are technically or medically inoperable. Effective palliation can be frequently obtained by endobronchial brachytherapy on an outpatient procedure basis. Brachytherapy administered simultaneously with chemotherapy is better tolerated than a course of external beam irradiation and chemotherapy.

Brachytherapy in lung cancer

Brachytherapy, the direct application of a radioactive isotope into the tumor bed, delivers a high dose to the tumor as compared to the surrounding normal tissue. Interstitial brachytherapy, the placement of the isotope into a tumor bed where no lumen exists, has been described but is utilized infrequently in clinical practice. Endobronchial brachytherapy, the placement of the source within the airway lumen, as a boost to conventional external beam radiation has not yet demonstrated improved local tumor control or overall survival as compared to external beam alone in the definitive treatment of inoperable lung cancer. In the palliative setting, brachytherapy can provide prompt relief of obstructive symptoms and hemoptysis in the majority of patients.

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.

Absorbable mesh in placement of temporary implants

PURPOSE

To evaluate absorbable mesh for the suturing of afterloading catheters in patients with tumors involving the chest wall.

METHODS AND MATERIALS

Patients underwent thoracotomy and resection of tumor; a layer of absorbable mesh was then sutured to the tumor bed. Nylon flexiguide afterloading catheters were sutured into the mesh at about 1.5 cm distance from each other. A second layer of mesh was then sutured on top of the catheters. The chest wall was closed. Orthogonal radiographs and CT scans of the area of implants were done to verify catheter position in each patient on day 1 and on the last day of implant. Computer dosimetry by digitization of dummy sources was performed on each set of radiographs. The same seed for both sets of films was chosen as the origin of digitization. All seed coordinates were compared directly to offset for any rotation of the patient during the two sets of films. The distances were calculated from all seed positions to the origin, then tabulated and compared.

RESULTS

The distances agreed within a few millimeters (7-8 mm). The differences may be attributed to the patient's breathing and to the localization uncertainty. The resulting dose alteration was negligible.

CONCLUSION

This technique appears to provide adequate anchorage of catheters with resulting constant seed position and dose distribution in areas of scant tissues or in surgical beds of considerable size.

Extending the limits of lung cancer resection

Patients with locally advanced bronchogenic carcinoma are often considered to have unresectable disease because of invasion into vital structures, or they undergo resection with questionable or involved margins, which results in local recurrence later. Brachytherapy (direct application of radioactive sources to the tumor bed) offers the potential to provide tumoricidal doses of radiation to the target area with minimal toxicity to surrounding structures. In this study, one of two different techniques of brachytherapy was utilized to treat 15 highly selected patients with histologically positive (n = 8) or suspicious (n = 7) margins after resection. The techniques were easy to apply and were not associated with any complications directly related to their use. One postoperative death resulted from a perforated peptic ulcer. In the remaining 14 patients, at a mean follow-up of 38 months, local control was complete in 12 (86%) patients, and 8 patients are alive, with 7 free of disease. Thoracic brachytherapy may offer the potential for cure to patients whose disease would otherwise be considered inoperable.

Intraoperative brachytherapy in non-small cell lung cancer

The lung cancer incidence and mortality rates have risen steadily each year. Survival rates during the same period have improved marginally even by the best treatment approaches. A small proportion of patients with limited disease can be offered surgical resection as the primary curative treatment. In a significant number of cases, complete resection of cancer is not possible either because the patient could not tolerate radical surgical approach or because the tumor is attached to important structures in the mediastinum precluding any surgical intervention. Intraoperative brachytherapy by various techniques offers the greatest advantage in these patients to deliver higher doses of radiation to the tumor without damage to the normal lung. Numerous intraoperative brachytherapy techniques are described to adapt to different clinical situations. Experience over the past 30 years has shown that these procedures are safe and well tolerated and can be used alone or as a boost in conjunction with external beam radiation. Published data show encouraging local control rates and survival compared with treatment by external radiation to higher doses.

Endobronchial interstitial Au-198 implantation in the treatment of recurrent bronchogenic carcinoma

Nineteen patients with non-small-cell bronchogenic carcinoma, recurrent following initial conventional external beam radiotherapy, were treated with endobronchial implantation of Au-198 seeds. Seventeen patients were symptomatic with primary symptoms of persistent hemoptysis (9), bronchial obstruction (2), or worsening dyspnea (6). Two patients were asymptomatic and implanted for bronchoscopic evidence of tumor recurrence. The dose delivered was described by three dosimetric parameters: 1) the total activity implanted (m Ci); 2) the midbronchial dose point; and 3) the volume of tissue that received greater than 20 Gy. Response was determined based on a system reflecting the primary indication for the implant. Seven of nine (78%) presenting with hemoptysis, four of six (67%) with increasing dyspnea, and one of two with bronchial obstruction responded. The overall median survival was 5.25 months (2.5-10 months 95% confidence interval). There was no clear correlation between any of the dosimetric parameters evaluated and a clinical response to therapy. Technical complications related to the inability to penetrate the scirrhous tumor surface adequately often led to less than optimal dose distribution. Endobronchial Au-198 implantation is associated with a poor calculated dose distribution but is, nonetheless, a relatively simple and comparatively inexpensive technique that often produces a clinical response and can be a useful option in the management of patients with recurrent bronchogenic carcinoma.

Iodine125 interstitial brachytherapy in the treatment of carcinoma of the lung

In a prospective study, 14 patients with primary non-oat cell lung carcinoma were treated with intraoperative Iodine125 (I125) implantation of the lung tumor via lateral thoracotomy or median sternotomy. Staging mediastinal node dissection was performed in each case. Patients were selected when wedge or segmental resections were not technically feasible, such that lobectomy or completion pneumonectomy would have been required or pulmonary function studies were poor. Doses ranged from 8,000 cGy at the periphery to 20,000 cGy at the center. With a minimum 12 month follow-up, mean and median survivals were 16.7 and 15.1 months, respectively. Local control was achieved in 10 of 14 patients (71%) with all local failures occurring in pathologic stage III patients. When separated according to tumor size, local control was obtained in six of seven tumors of less than 3 cm and four of five tumors of 3-5 cm. Both cases with masses greater than 5 cm failed locally. There was one operative mortality and two postoperative complications. All other patients were discharged within one week of surgery. There was no radiation pneumonitis. I125 lung brachytherapy is an excellent alternative treatment for T1 and T2 tumors when medical conditions preclude curative resection.

The relative biological effectiveness of photon radiation from encapsulated iodine-125, assessed in cells of human origin: I. Normal diploid fibroblasts

The relative biological effectiveness (RBE) of photon radiation from encapsulated Iodine-125 "seed" sources has not previously been investigated in human cells. The RBE of 125I photons relative to 137Cs gamma rays was examined in normal diploid human fibroblasts derived from lung and skin. The cells were irradiated in plateau phase using a specially designed incubator-irradiator which permitted simultaneous 125I and 137Cs irradiation. The cells were irradiated at various dose rates ranging from 7 to 70 cGy/hr. Dosimetry was performed using Monte Carlo computer calculations to simulate the 125I irradiations and the exposure-standardization measurements made by the U.S. National Bureau of Standards which are the basis for the specified strengths of 125I seeds. Simulation of the exposure standardization measurements revealed systematic errors due to the unrecognized presence of low-energy fluorescence X rays. The specified activity of the type of seeds used for this study (high-activity, no radiographic marker) was found to be too high by more than 10%. The RBE of 125I assessed with both lung fibroblast lines was found to be 1.2 and was 1.3 for the skin fibroblasts. The RBE did not change over the range of dose rates tested. In fact, for both 125I and 137Cs, the dose response curves did not change with dose rate over the range tested, implying full repair of sublethal damage at dose rates below 70 cGy/hr in these non-dividing cells.

Role of brachytherapy in the management of pulmonary and mediastinal malignancies

Brachytherapy, the permanent or temporary implantation of radioactive sources, has been performed in limited numbers of patients with lung cancer over the last 50 years. Because of renewed interest in this modality, we reviewed our experience with 103 patients treated over a 7-year period. The mean age of this group was 55.5 years (range, 1 to 84 years). Primary lung cancer accounted for 82 patients (79.6%); metastatic lesions to the lung, 13 (12.6%); and mediastinal malignancies, 8 (7.8%). Indications for brachytherapy included mediastinal and chest wall invasion in 42 patients (40.8%), unresectable tumors and mediastinal adenopathy in 30 (29.1%), medical contraindications to extensive pulmonary resection in 20 (19.4%), and irradiation of excised lymph node beds in 11 (10.7%). Seeds labeled with radioactive iodine 125 alone were used in 65 patients (63.1%), afterloading catheters containing iridium 192 sources in 25 (24.3%), and both in 13 (12.6%). There were no operative deaths. With a mean follow-up of 18.6 months, the mean and median survivals for the entire group were 17.3 and 14.0 months, respectively. The 1-year, 2-year, and 3-year survivals for the entire group were 67.9%, 38.7%, and 27.8%, respectively. In summary, brachytherapy offers a useful surgical approach in patients in whom unresectable pulmonary or mediastinal malignancies are found at the time of thoracotomy or in patients previously treated with other modalities for whom limited therapeutic alternatives exist.

Interstitial 192Ir flexible catheter radiofrequency hyperthermia treatments of head and neck and recurrent pelvic carcinomas

Since September 1983, five patients with head and neck cancers and five patients with pelvic or perineal recurrences of colorectal neoplasms received 192Ir interstitial implants through flexible afterloading catheters that were modified to allow RF hyperthermia treatments of the tumor within 1 hr pre- and post-brachytherapy. Local control in the implant volume was obtained in three of the patients with head and neck cancers (base tongue--2/4; floor of mouth--1/1) with follow-up of 9 to 42 months. Two patients had local recurrences after disease-free periods of 8 and 24 months. Two of the five patients treated for pelvic recurrences had complete responses lasting less than 3 months; prolonged stabilization (12 months) of a presacral mass in a third patient also occurred, but the neoplasm eventually regrew. Average temperatures of 39.2 degrees C to 43.7 degrees C were obtained in the implant volumes of these patients during the 45 minute heating periods which took place prior to loading, and just after removal, of the 192Ir seeds in each patient. No instances of intra or post-operative hemorrhage or necrosis of bone or soft tissues occurred in these patients. However, one individual required a permanent tracheostomy for persistent epiglottic edema after implantation as part of a base-tongue brachytherapy procedure. Interstitial RF hyperthermia in conjunction with brachytherapy appears to be a relatively safe and effective modality, but must be tested prospectively to compare its efficacy to interstitial irradiation alone.

New intraoperative brachytherapy techniques for positive or close surgical margins

Tumors attached or adjacent to critical structures can often not be completely resected or resected with adequate surgical margins. Sites involving major blood vessels, the paravertebral spaces, or critical abdominal structures often present technical difficulties for standard brachytherapy procedures using I-125 or Ir-192 implants. These techniques allow for a high-dose delivery to the tumor bed with minimal normal tissue toxicity. A relatively simple and accurate method is described using I-125 seeds in Vicryl suture threaded through Gelfoam. These permanent implant procedures with radioactive I-125 seeds effectively treat small residual tumors or suspicious margins where standard brachytherapy techniques may be unsatisfactory and technically difficult to perform.

The current state of intraoperative interstitial brachytherapy in lung cancer

Low dose-rate intraoperative brachytherapy allows for a more precise tumor localization of the delivered radiation and its easier adaptation to the tumor shape than it is possible with external radiation. As a result a higher dose is usually delivered to the tumor volume and the damage to the normal lung is less. In an attempt to determine the value of lung brachytherapy we provide in this article a complete review of the evolution of brachytherapy in lung cancer at Memorial Sloan-Kettering Cancer Center, an experience which exceeds 1,000 patients. The use of encapsulated sources of I-125, greatly reduced radiation outside the treatment volume and simplified medical and nursing staff radiation protection. Lung brachytherapy in combination with surgery and postoperative external radiation, improved local tumor control in advanced tumors (from 63% to 76%) with no increase in late pulmonary morbidity, but only a modest survival advantage. The results of brachytherapy in patients with early lung cancer who had limited pulmonary reserve, suggest that intraoperative brachytherapy is an effective alternative treatment option. The limited experience with interstitial brachytherapy under fluoroscopic and CT guidance is encouraging, but needs more investigation.

A new catheter system with remote tip guidance for endobronchial brachytherapy

Endobronchial brachytherapy is being used with increased frequency in the treatment of recurrent neoplastic obstruction of the major airways, alone or in combination with Nd-YAG laser ablation of the occluding tumor mass. Currently available catheter systems are not reliable with respect to accurate and simple bronchoscopic guidance during placement. Flexibility, wall strength and radiation transmission characteristics are not optimized. We describe a system that meets these goals which has been designed and tested in our department. It is composed of an external handle, deflecting guidewire, and catheter specially modified for endobronchial brachytherapy, with a tip that can be maneuvered in any direction with one hand from outside the patient. Major advantages of the system are ease of concurrent bronchoscopy and catheter guidance, good dosimetric characteristics of the catheter, reasonable cost, and ready availability for adaptation to various techniques of endobronchial brachytherapy.

Multimodality treatment of non-small cell lung cancer: response to cisplatin, VP-16, and 5-FU chemotherapy and to surgery and radiation therapy

Twenty-one patients with unresectable non-small cell lung cancer (NSCLC), 11 with stage III M0, five with malignant pleural effusion, and five with a single resectable metastasis were treated with multimodality therapy. All received two to three cycles of preoperative chemotherapy with a new sequential combination of cisplatin (50 mg/m2 IV X 1) followed by 5-FU infusion (40 mg/m2/hr X 72) and etoposide (80 mg/m2/day X 3). Thirteen of 21 (62%) had a partial response, and three (14%) had a minor response to chemotherapy. Of the 19 who underwent surgical exploration, 17 were confirmed to have NSCLC. Ten patients with NSCLC and one with choriocarcinoma were rendered disease free by resection of the primary tumor and lymph nodes. Six received intra- and/or perioperative interstitial therapy with 125I and/or 192Ir. Another patient was treated with 32P. Postoperative external radiotherapy was administered in 15 patients, and adjuvant chemotherapy was administered in ten. This multimodality therapy was well tolerated, safe, and highly effective, resulting in excellent palliation even in patients with pleural effusion and metastasis. The most promising results were in unresectable stage III M0 with a partial response rate of 82% following neoadjuvant chemotherapy and a complete response rate of 73% after surgery. In this group, median survival has not yet been reached and will exceed 12 months.

Results of surgical treatment of stage III lung cancer invading the mediastinum

From 1974 to 1984, 225 patients underwent thoracotomy at Memorial Sloan-Kettering Cancer Center for primary non-small cell lung cancer invading only the mediastinum (T3). The perioperative mortality was 2.7 per cent, and the nonfatal complication rate 13 per cent. Forty-nine patients underwent complete resection of all intrathoracic disease, with a median survival of 17 months, 3-year survival of 21 per cent, and 5-year survival of 9 per cent. Thirty-three patients underwent pulmonary resection with simultaneous iodine-125 interstitial implantation or iridium-192 delayed afterloading to areas of unresectable primary or nodal disease, with a median survival of 12 months, 3-year survival of 22 per cent, and 5-year survival of 22 per cent. One hundred and one patients underwent interstitial implantation without resection, with a median survival of 11 months, 3-year survival of 9 per cent, and no 5-year survivors. Forty-two patients had incomplete resection without intraoperative radiation therapy and fared no better than a cohort group of 44 unoperated patients with clinical evidence of mediastinal invasion--both groups had a median survival of 8 months and no 3-year survivors. An aggressive surgical approach with pulmonary resection and/or brachytherapy appears to offer some survival advantage to this group of patients. In particular, 5-year survival rates ranging from 7 to 15 per cent were observed in subsets of intraoperatively treated patients with invasion of pulmonary vein, phrenic nerve, esophagus, or pericardium and in those with clinically occult T3 disease.

The role of external radiation and brachytherapy in unresectable non-small cell lung cancer

The role of radiation therapy in the management of non-small cell lung cancer is rapidly changing. Preoperative radiation, with the exception of the superior sulcus tumor, has not been found to benefit patients. The issue of postoperative radiation in completely resected patients with non-small cell lung cancer remains controversial. Current postoperative trials suggest, however, that postoperative radiation in these patients prevents local recurrence and, in combination with chemotherapy, prolongs survival. Primary radiation therapy in inoperable non-small cell lung cancer is associated with a small but definite cure rate. Better definition of treatment volume, proper selection of dose-time, state-of-art treatment planning, and, whenever possible, intraoperative radiation have improved local control rates and decreased severe complications.

Role of brachytherapy in the management of desmoid tumors

From 1977 to 1982, fourteen patients with desmoid tumors underwent surgery and brachytherapy. Surgery ranged from biopsy to complete or partial excision of the tumor. Most of these patients had locally advanced tumor or positive margins. A high recurrence rate is expected in such a group if treated by surgery alone. In twelve out of fourteen patients the treatment was considered curative when all disease sites could be encompassed. In the remaining two patients the treatment was considered palliative because the tumor encroaching on to the spinal cord was left untreated. Ten out of twelve curatively treated patients have remained free of recurrence at a minimum of 2 year follow-up. Five of them were followed from 4-6 years. In the palliatively treated group, one patient is alive with active disease at 18 months. Three patients developed complications with wound healing. This experience suggests that surgery and brachytherapy treatment for desmoid tumor results in higher local control than expected from surgery alone in this selected group of patients.

Combined surgery, intraoperative brachytherapy, and postoperative external radiation in stage III non-small cell lung cancer

From March 1977 to December 1980, 318 patients with Stage III non-small cell lung cancer underwent thoracotomy at Memorial Sloan-Kettering Cancer Center. One hundred of these patients, considered for this study, were treated by a multimodality approach consisting of resection and/or intraoperative brachytherapy followed by postoperative external irradiation. The criteria for utilizing intraoperative brachytherapy and postoperative external irradiation were either the presence of residual gross disease (47%) or close resection margins suspected to be involved by the tumor (53%). The intraoperative brachytherapy consisted of a temporary iridium 192 implant for subclinical disease in the mediastinum (median dose, 30 Gy in 3-5 days) and a permanent iodine 125 implant for residual gross disease usually at the primary site (median dose, 160 Gy). All patients received postoperative external beam irradiation consisting of 30 to 40 Gy in 2 to 4 weeks. Seven patients (7%) experienced mild to severe complications after these treatments. The local control, when all gross disease had been removed, was influenced by the presence or absence of tumor at the margins of resection (53% and 89%, respectively). The local control in the patients with gross residual disease treated by brachytherapy and postoperative external irradiation, (40 Gy in 4 weeks) was 72%. The actuarial overall 5-year survival was 22%. The 5-year survival was better in patients who had all gross disease removed as compared with patients who had gross residual disease (30% versus 13%). The disease-free survival in these two groups was 27% and 12%, respectively. This review shows that complete resection and moderate doses of postoperative external irradiation achieves a satisfactory local control and improves survival. When all gross disease cannot be removed, then brachytherapy and postoperative external irradiation may achieve similar local control. Distant metastases still remain a major problem in these patients.

Pleurectomy and intraoperative brachytherapy and postoperative radiation in the treatment of malignant pleural mesothelioma

Forty-one patients with diffuse, pleural mesothelioma limited to one hemi-thorax underwent a thoracotomy at Memorial Sloan-Kettering Cancer Center from January 1976 to July 1982. Treatment at thoracotomy consisted of as complete a parietal pleurectomy as was possible to remove the bulk of the tumor. Measurable gross residual disease was treated whenever feasible, with permanent 125I implantation; residual diffuse disease was treated by a temporary 192Ir implantation or by postoperative instillation of 32P. External radiation therapy was given 4-6 weeks postoperatively to the involved hemi-thorax, shielding the lung and utilizing a combination of electron and a photon beam. A dose of 4500 rad in 4.5 weeks was given to the pleural surface by the mixed beam. There was no postoperative mortality in this group of 41 patients. Complications developed in 6 patients (15%). The median survival was 21 months; the one year survival was 65% and the two year survival was 40%. The median disease-free survival was 11 months and the one and two year disease-free survival 44 and 13% respectively. This study suggests that the combination of pleurectomy, intraoperative brachytherapy and postoperative external radiation increased the local control of the tumor and prolonged the survival.