Sequential comparison of low dose rate and hyperfractionated high dose rate endobronchial radiation for malignant airway occlusion

Systematic review of brachytherapy for symptom palliation

PURPOSE

Brachytherapy is most often applied in the curative or salvage setting, but many forms of brachytherapy can be helpful for symptom palliation. Declining utilization is seen, for multiple reasons, such as lack of awareness, insufficient expertise, or poor access to equipment. High level evidence for many types of palliative brachytherapy has been lacking. The objective of the current study was to review the evidence for utilization and efficacy of brachytherapy to palliate symptoms from cancer.

MATERIALS AND METHODS

We performed a systematic search in EMBASE and MEDLINE for English-language articles published from January 1980 to May 2022 that described brachytherapy used for a palliative indication in adults with a diagnosis of cancer (any subtype) and at least one symptom related outcome. Individual case reports and conference abstracts were excluded. All publications were independently screened by two investigators for eligibility.

RESULTS

The initial search identified 3637 abstracts of which 129 were selected for in-depth review. The number of studies (total number of patients) included in the final analysis varied widely by tumor site with the majority (68.2%) involving either lung or esophageal cancer. Despite a limited number of prospective trials that assessed the efficacy of brachytherapy for symptom management, there was a positive effect on palliation of symptoms across all tumor types. There was no clear trend in the number of publications over time. The most commonly cited symptom indications for palliation by brachytherapy were dysphagia, dyspnea, pain and bleeding.

CONCLUSIONS

Brachytherapy can provide palliation for patients with advanced cancer, across different tumor sites and clinical scenarios. However, high level evidence in the literature to support palliative applications of brachytherapy is lacking or limited for many tumor sites. There appears to be a strong publication bias towards positive studies in favor of brachytherapy. Beyond anecdotal reports and individual practices, outcomes research can further our understanding of the role of brachytherapy in palliating advanced cancers of all types, and should be encouraged.

Primary Radiotherapy with Endobronchial High-Dose-Rate Brachytherapy Boost for Inoperable Lung Cancer: Long-Term Results

Background

To retrospectively evaluate the outcome of patients with inoperable non-small-cell lung cancer treated with primary external beam radiotherapy combined with high-dose-rate endobronchial brachytherapy boost.

Patients and methods

Between 1988 and 2005, 35 patients with non-small-cell lung cancer (stage I-III) ineligible for surgical resection and/or chemotherapy, were primarily treated with external beam radiotherapy with a median total dose of 50 Gy (range, 46–60). A median of 3 fractions high-dose-rate endobronchial brachytherapy was applied as a boost after external beam radiotherapy, the median total dose was 15 Gy (range, 8–20). High-dose-rate endobronchial brachytherapy was carried out with iridium-192 sources (370 GBq) and prescribed to 1 cm distance from the source axis.

Results

With a median follow-up of 26 months from the first fraction of high-dose-rate endobronchial brachytherapy, the 1-, 2- and 5-year overall (local progression-free) survival rates were 76% (76%), 61% (57%) and 28% (42%), respectively. Complete or partial remission rates 6 to 8 weeks after treatment were 57% and 17%, respectively. Significant prognostic favorable factors were a complete remission 6–8 weeks after treatment and a negative nodal status. In patients without mediastinal node involvement, a long-term local control could be achieved with 56% 5-year local progression-free survival. Common Toxicity Criteria grade 3 toxicities were hemoptysis (n = 2) and necrosis (n = 1). One fatal hemoptysis occurred in combination with a local tumor recurrence.

Conclusions

The combination of external beam radiotherapy with high-dose-rate endobronchial brachytherapy boost is an effective primary treatment with acceptable toxicity in patients with non-small-cell lung cancer ineligible for surgical resection and/or chemotherapy.

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.

Palliative endobronchial brachytherapy for non-small cell lung cancer

BACKGROUND

This is an updated version of the original review published in Issue 2, 2008 of The Cochrane Library. Non-small cell lung cancers (NSCLC) constitute about 80% of all lung cancer cases. Although surgery is the only curative treatment of NSCLC, fewer than 20% of tumors can be radically resected. Radiotherapy is one of the main treatment modalities in lung cancer, contributing to both its cure and palliation. Endobronchial brachytherapy (EBB) has been used as one approach to improve local control either alone or in combination with other treatments.

OBJECTIVES

To assess the effectiveness of palliative EBB compared with external beam radiation therapy (EBRT) or other alternative endoluminal treatments in controlling thoracic symptoms and increasing survival in patients with advanced NSCLC.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL,The Cochrane Library, Issue 1 2012), MEDLINE (OvidSP) (1966 to January 2012), EMBASE (Ovid) (1974 to January 2012) and other databases as well as reference lists, and we handsearched selected journals and conference proceedings.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing different regimens of palliative EBB with EBRT or other endobronchial interventions in patients with advanced NSCLC.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and conducted risk of bias assessment.

MAIN RESULTS

We included fourteen RCTs involving 953 participants. We included a new study assessing a variety of different fractionation schedules of high dose rate palliative EBB in this update. There were important differences in the doses of radiotherapy investigated, in the patient characteristics and in the outcomes measured. We found trials comparing EBB to EBRT alone, EBB plus EBRT to EBRT alone, EBB plus chemotherapy to EBB alone, EBB to neodymium: yttrium-aluminum-garnet (Nd-YAG) laser and comparisons between various fractionation schedules of high dose rate EBB. From the heterogeneous information obtained from several small RCTs, we concluded that EBRT alone is more effective for palliation of NSCLC symptoms than EBB alone. Our findings did not provide conclusive evidence to recommend EBB plus EBRT to relieve symptoms compared to EBRT alone. Overall, for the primary endpoint of survival there was no evidence of benefit for EBB compared to EBRT and Nd-YAG laser or for the combination of EBB with chemotherapy. Additionally, findings from one trial suggested that twice 7.4 Gy was superior to the four times per week 3.8 Gy schedule for mean time of local control and fatal hemoptysis. No significant differences were found for fatal hemoptysis as an adverse event of EBB.

AUTHORS' CONCLUSIONS

The evidence did not provide conclusive results that EBB plus EBRT improved symptom relief over EBRT alone. We were not able to provide conclusive evidence to recommend EBB with EBRT, EBB in preference to EBRT, chemotherapy or Nd-YAG laser. From heterogeneous information obtained from several small RCTs, we conclude that EBRT alone is more effective for palliation than EBB alone. For patients previously treated by EBRT who are symptomatic from recurrent endobronchial central obstruction, EBB may be considered in selected cases.

Palliative endobronchial brachytherapy for non-small cell lung cancer

BACKGROUND

Non-small cell lung cancers (NSCLC) constitutes about 80% of all lung cancer cases. Although surgery is the only curative treatment of NSCLC, fewer than 20% of tumors can be radically resected. Radiotherapy is one of the main treatment modalities in lung cancer, contributing to both its cure and palliation. Endobronchial brachytherapy (EBB) has been used as one approach to improve local control either alone or in combination with other treatments.

OBJECTIVES

To assess the effectiveness of palliative EBB in increasing survival and to control thoracic symptoms in patients with advanced NSCLC compared with external beam radiation therapy (EBRT) or other alternative endoluminal treatments.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and other databases were searched, as were reference lists and handsearching of selected journals and conference proceedings.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing different regimens of palliative EBB with EBRT or other endobronchial interventions in patients with advanced NSCLC.

DATA COLLECTION AND ANALYSIS

Thirteen RCTs were included. There were important differences in the doses of radiotherapy investigated, patient characteristics and the outcomes measured. Because of this heterogeneity no meta-analysis was attempted.

MAIN RESULTS

We found trials comparing EBB to EBRT alone, EBB plus EBRT to EBRT alone, EBB plus chemotherapy to EBB alone, EBB to Nd-YAG laser and comparisons between diverse fractionation schedules of high dose rate EBB. From the heterogeneous information obtained from several small RCTs, we concluded that EBRT alone is more effective for palliation of NSCLC symptoms than EBB alone. Our findings did not provide conclusive evidence to recommend EBB plus EBRT to relieve symptoms compared to EBRT alone. Overall, for the primary endpoint of survival there was no evidence of benefit for EBB compared to EBRT and Nd-YAG laser or for the combination of EBB with chemotherapy. Additionally, findings from one trial suggested that twice 7.4 Gy was superior to the four times per week 3.8 Gy schedule for mean time of local control and fatal haemoptysis. No significant differences were found for fatal haemoptysis as an adverse event of EBB.

AUTHORS' CONCLUSIONS

The evidence did not provide conclusive results that EBB plus EBRT improved symptom relief over EBRT alone. We were not able to provide conclusive evidence to recommend EBB with EBRT, chemotherapy or Nd-YAG laser. For patients previously treated by EBRT who are symptomatic from recurrent endobronchial central obstruction, EBB may be considered in selected cases.

Brachytherapy for advanced prostate cancer bleeding

Advanced prostate cancer patients frequently deal with intractable prostatic bleeding which is a difficult problem to manage. Intraurethral high-dose rate (HDR) brachytherapy may palliate this condition. Advanced prostate cancer patients with intractable prostatic bleeding were offered brachytherapy with Iridium-192 using a Micro-selectron HDR machine. During a 5-year period, analysis was performed in 23 patients with a median age and Gleason score of 78 years and 9, respectively. Following brachytherapy, haematuria resolved in 19 of the 23 patients and was recurrence free at 6 months. Intraurethral HDR brachytherapy is a potentially effective modality for treating haematuria in patients with advanced prostate cancer.

Toward endobronchial Ir-192 high-dose-rate brachytherapy therapeutic optimization

A number of patients with lung cancer receive either palliative or curative high-dose-rate (HDR) endobronchial brachytherapy. Up to a third of patients treated with endobronchial HDR die from hemoptysis. Rather than accept hemoptysis as an expected potential consequence of HDR, we have calculated the radial dose distribution for an Ir-192 HDR source, rigorously examined the dose and prescription points recommended by the American Brachytherapy Society (ABS), and performed a radiobiological-based analysis. The radial dose rate of a commercially available Ir-192 source was calculated with a Monte Carlo simulation. Based on the linear quadratic model, the estimated palliative, curative and blood vessel rupture radii from the center of an Ir-192 source were obtained for the ABS recommendations and a series of customized HDR prescriptions. The estimated radius at risk for blood vessel perforation for the ABS recommendations ranges from 7 to 9 mm. An optimized prescription may in some situations reduce this radius to 4 mm. The estimated blood perforation radius is generally smaller than the palliative radius. Optimized and individualized endobronchial HDR prescriptions are currently feasible based on our current understanding of tumor and normal tissue radiobiology. Individualized prescriptions could minimize complications such as fatal hemoptysis without sacrificing efficacy. Fiducial stents, HDR catheter centering or spacers and the use of CT imaging to better assess the relationship between the catheter and blood vessels promise to be useful strategies for increasing the therapeutic index of this treatment modality. Prospective trials employing treatment optimization algorithms are needed.

Irradiated volume and the risk of fatal hemoptysis in patients submitted to high dose-rate endobronchial brachytherapy

To determine risk factors associated with fatal hemoptysis (FH) in endobronchial high dose-rate brachytherapy (EHDRB) 84 patients treated with EHDRB from January 1991 to June 2002 were studied. Clinical and technical parameters (including treatment volumes) were analyzed. Eight (9.5%) patients died of FH, all but one with recurrent or persistent local disease. Median interval until death due to FH was 4 months versus 6 months for the whole group. The only factor with significant correlation with FH was the 100% isodose volume (V100) (p=0.04). Larger irradiated volumes were related to FH. Analysis of volume parameters is suggested, together with the dose and number of fractions prescribed for each patient.

Palliative radiation therapy in oncology

Palliative radiation therapy is considered when the incurable cancer patient has symptoms specifically related to a malignancy that may be relieved by localized treatment of the primary tumor or metastatic lesions. Developing a treatment plan with radiation in the palliative setting may be more difficult than the curative setting, where there are clear guidelines for many situations. Radiation therapy has been used successfully in the management of a variety of pain syndromes. Radiation also has proven effective in the management of other tumor-related symptoms, including bleeding, neurologic compromise, dysphagia, and airway obstruction. Palliative radiation can be delivered using a variety of techniques: external beam radiation therapy, intraluminal brachytherapy (radioactive seed delivery), and systemic radionucleotides.

Palliative radiation therapy

Radiation is an effective modality to aid in symptom management of patients with metastatic disease. The type and duration of treatment depends on the Karnofsky performance status (KPS) of the patient and type and status of the cancer. Abbreviated treatment regimens may be favored in this patient population. They provide quick palliation without the patient and family spending significant time traveling back and forth to the treatment center. Hypofractionated regimens have been found effective in relieving pain from metastatic bone disease, relieving obstruction from locally advanced lung cancer, bleeding from gynecologic cancers, and hematuria from advanced bladder cancer. More aggressive regimens such as whole-brain radiation therapy (WBRT) and stereotactic radiosurgery may be appropriate for select patients with a good KPS. Radiation has also been found to be effective in palliating recurrent cancer that has already received definitive radiation.

Endobronchial brachytherapy and optimization of local disease control in medically inoperable non-small cell lung carcinoma: a matched-pair analysis

PURPOSE

External beam radiation therapy (EBRT) alone for early stage, medically inoperable non-small cell lung cancer (MILC) can produce local disease control and sometimes cure. We have previously reported that higher EBRT doses result in improved disease control and, for patients with tumors > or =3.0 cm, improved survival. This report describes the impact of dose escalation with endobronchial brachytherapy boost during or following EBRT upon local disease control.

METHODS AND MATERIALS

Medical records of 404 patients with MILC treated with radiotherapy alone were reviewed. Thirty-nine patients received a planned endobronchial brachytherapy boost during or following a course of EBRT. A matched-pair analysis of disease control and survival was performed by matching each brachytherapy patient to 2 EBRT patients from a reference group of the remaining patients.

RESULTS

Endobronchial brachytherapy boost significantly improved local disease control over EBRT alone (58% vs. 32% at 5 years). The local control benefit for brachytherapy was found to be limited to patients with T(1-2) disease or tumors < or =5.0 cm. Among these patients treated with endobronchial boost, EBRT doses of > or =6500 cGy were necessary to optimize local disease control. No overall survival differences were observed at 3 years. Excess toxicity with brachytherapy was not observed.

CONCLUSION

Endobronchial brachytherapy boost enhances local disease control rates in MILC treated with EBRT. Local control outcome is optimized when radical EBRT doses are used in conjunction with brachytherapy.

High dose rate brachytherapy: its clinical applications and treatment guidelines

Brachytherapy has the advantage of delivering a high dose to the tumor while sparing the surrounding normal tissues. With proper case selection and delivery technique, high-dose-rate (HDR) brachytherapy has great promise, because it eliminates radiation exposure, allows short treatment times, and can be performed on an outpatient basis. Additionally, use of a single-stepping source, allows optimization of dose distribution by varying the dwell time at each dwell position. However, when HDR brachytherapy is used, the treatments must be executed carefully, because the short treatment times do not allow any time for correction of errors, and mistakes can result in harm to patients. Hence, it is very important that all personnel involved in HDR brachytherapy be well trained and be constantly alert. It is expected that the use of HDR brachytherapy will greatly expand over the next decade and that refinements will occur primarily in the integration of imaging (computed tomography, magnetic resonance imaging, intraoperative ultrasonography) and optimization of dose distribution. It is anticipated that better tumor localization and normal tissue definition will help to optimize dose distribution to the tumor and reduce normal tissue exposure. The development of well-controlled randomized trials addressing issues of efficacy, toxicity, quality of life, and costs-versus-benefits will ultimately define the role of HDR brachytherapy in the therapeutic armamentarium.

High-Dose-Rate Brachytherapy in Combination with Stenting Offers a Rapid and Statistically Significant Improvement in Quality of Life for Patients with Endobronchial Recurrence

Symptomatic endobronchial recurrence after treatment failure is common in advanced non-small cell lung cancer. Optimal palliation has yet to be defined. We examined the combination of near-simultaneous, high-dose-rate (HDR) brachytherapy with stenting in this cohort of patients. Informed consent for intervention was obtained for 10 patients experiencing severely symptomatic (hemoptysis and oxygen-dependent shortness of breath), biopsy-proven endobronchial recurrence. All patients (eight men, two women, aged 52-77 years) had failed to respond to chemoradiotherapy for stage IIIB non-small cell lung cancer. Intervention consisted of placement of a self-expanding metallic stent (Nitinol/Ultraflex stent, Boston Scientific Co., Natick, MA) into the obstructing region. During that same bronchoscopy, HDR catheters were introduced. A dose of 6 Gy at 0.5 cm from the catheter was then delivered via an HDR unit. Two additional HDR sessions followed at weekly intervals for a total dose of 18 Gy. Patients under went follow-up bronchoscopes 1 month after the last HDR and when clinically indicated. All patients completed the prescribed therapy. No morbidity was noted from bronchoscopy, HDR, or stenting. All patients had rapid relief of signs and symptoms. At 1 week after stenting/first HDR, a statistically significant improvement in Karnofsky status was noted. Pulmonary palliation was maintained for the duration of their survival. The radio-opaque stent also offered significant advantages for catheter placement and verification during the HDR procedure. Although this series is small, the beneficial outcome obtained deserves further evaluation.

[Endobronchial brachytherapy: technique and indications]

The endobronchial brachytherapy procedure involves the insertion of an afterloading catheter into bronchus in close proximity to an endoluminal lesion, and to perform limited irradiation sparing as much as possible normal health tissues. The catheter is inserted during a classical flexible bronchoscopy. Three types of indications have been discussed: (i) palliative treatment of lung carcinoma, with or without laser desobstruction: an improvement in respiratory symptoms was observed in 60 to 80% of the cases; (ii) curative treatment for localised endobronchial carcinomas, in previously irradiated patients, or in case of contraindication of surgery or external beam irradiation; local control rate range from 60 to 70% at 2 years; (iii) combination of external irradiation and brachytherapy in the first line treatment of lung cancers. Two randomised trials did not show any improvement in survival for this approach; however, they have included advanced diseases. In the opposite, this association seems very effective for early stage lung carcinomas. Two major complications were regularly reported, haemoptysis and radiation bronchitis. Predictive factors for these toxicities are actually better known: haemoptysis could be due to a progressive disease more often than to brachytherapy itself; technical factors (dose, volume, fractionation), however, could explain a number of radiation bronchitis, and their incidence could decrease in the future.

High dose rate endobronchial brachytherapy in combination with external beam radiotherapy for stage III non-small cell lung cancer

INTRODUCTION

A phase-II study was planned to test the effect of external beam radiotherapy in combination with endobronchial brachytherapy on the local control and survival of stage-III non-small cell lung cancer patients.

MATERIALS AND METHODS

Thirty patients with stage-III non-small cell lung cancer have been treated with 60 Gy external beam radiotherapy and 3 x 5 Gy HDR endobronchial brachytherapy to control tumor and to prolong survival.

RESULTS

Therapy regimen was found to be very effective for the palliation of major symptoms, palliation rates were 42.8% for cough, 95.2% for hemoptysis, 88.2% for chest pain and 80.0% for dyspnea. There was a 76.7% tumor response (53.3% complete, 23.3% partial) verified by chest CT scans and bronchoscopy. However, median locoregional disease free survival was 9+/-4 months (95% CI: 1-17) and it was only 9.6% at 5 years. Major side effects were radiation bronchitis (70.0%), esophagitis (6.6%) in the acute period and bronchial fibrosis (25%), esophagial fibrosis (12.5%) and fatal hemoptysis (10.5%) in the late period. Median survival was 11+/-4 months (95% CI: 4-18),and 5-year actuarial survival was 10%. Locoregional disease free survival (P=0.008) and the overall survival was longer (P<0.001) in the patients younger than 60, survival was also improved in the patients with complete response (P=0.019). There were no major complications during catheterisation; early side effects were quite tolerable but severe late complications were around 10%.

CONCLUSIONS

It is concluded that endobronchial brachytherapy in combination with external irradiation provides a good rate of response, however does not eradicate locoregional disease and does not prolong survival except for some subgroups such as younger patients.

High-dose-rate endobronchial brachytherapy effectively palliates symptoms due to airway tumors: the 10-year M. D. Anderson cancer center experience

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.

The role of brachytherapy for palliation

The goal of palliative radiation is to alleviate symptoms in a short amount of time and maintain an optimal functional and quality-of-life level while minimizing toxicity and patient inconvenience. Despite advances in multimodality antineoplastic therapies, failure to control the tumor at its primary site frustratingly remains the predominant source of morbidity and mortality in many patients with cancer. Escalation of doses of radiation using external beam irradiation has been shown to improve local tumor control, but limits are imposed by the tolerance of normal surrounding structures. The highly conformal nature of brachytherapy enables the radiation oncologist to accomplish safe escalation of radiation doses to the tumor while minimizing doses to normal surrounding structures. Thus, by enhancing the potential for local control, brachytherapy used alone or as a supplement to external beam radiation therapy retains a significant and important role in achieving the goals of palliation. Proper patient selection, excellent technique, and adherence to implant rules will minimize the risk of complications. The advantages realized with the use of brachytherapy include good patient tolerance, short treatment time, and high rates of sustained palliation. This article reviews various aspects of palliative brachytherapy, including patient selection criteria, implant techniques, treatment planning, dose and fractionation schedules, results, and complications of treatment. Tumors of the head and neck, trachea and bronchi, esophagus, biliary tract, and brain, all in which local failure represents the predominant cause of morbidity and mortality, are highlighted.

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.

Predictive factors for late toxicity after endobronchial brachytherapy: a multivariate analysis

PURPOSE

To determine the predictive factors associated with hemoptysis and radiation bronchitis after endobronchial brachytherapy by univariate and multivariate analyses

METHODS AND MATERIALS

One hundred forty-nine patients underwent endobronchial brachytherapy and were divided into three therapeutic groups: group 1: patients treated with palliative intent (n=47); group 2: patients treated with curative intent (small endobronchial tumors without mediastinal or general dissemination: n=73); group 3: patients also receiving external irradiation (n=29). One hundred twelve patients had previously received external irradiation. Brachytherapy was delivered with a dose per fraction ranging from 4 to 7 Gy and a prescription point between 0.5 and 1.5 cm, usually 1 cm from the source center. Two to six fractions were delivered according to the therapeutic group and clinical situation. The influence of the following variables on the incidence of hemoptysis or radiation bronchitis was studied: age, sex, Karnofsky score, therapeutic group, histologic type, endoscopic tumor length, dose per fraction, total brachytherapy dose, total external beam irradiation dose, total dose (brachytherapy dose plus external irradiation dose), volumes of the 100% and 200% isodoses, and volumes of the 7 and 14 Gy isodoses.

RESULTS

We observed 11 hemoptyses (7.4%), 10 were lethal. All but one occurred in patients with progressive disease. Two clinical factors were significantly associated with hemoptysis by univariate analysis: palliative group (p=0.009) and endobronchial tumor length (p=0.004). No technical factors seem to be implicated in the occurrence of hemoptysis. Only endobronchial tumor length remained in the multivariate model (p=0.02). Radiation bronchitis was observed in 13 cases (8.7%). By univariate analysis, a good Karnofsky score (p=0.02), curative treatment (p=0.02), and tumor location on trachea and main stem bronchus (p=0.002) were significantly associated with this complication. Two technical factors were also incriminated: the total dose (p=0.04) and the 100% isodose volume (p=0.02). By multivariate analysis, only the tumor location retained statistical significance (p=0.009).

CONCLUSION

Hemoptysis is most likely due to disease progression, with the bleeding being facilitated by brachytherapy. Some rare cases could be a direct complication of brachytherapy itself, particularly when tumors are located in the upper lobes. In contrast, radiation bronchitis occurred more frequently in patients with controlled disease, and was significantly influenced by tumor location and technical factors (dose and volumes treated). Technical improvements should increase the therapeutic ratio.

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.

High dose rate endobronchial brachytherapy using a new applicator

BACKGROUND AND PURPOSE

To obtain adequate spatial dose distribution for endobronchial brachytherapy, we applied reference dose points according to the bronchial diameter. For this purpose, we devised a new applicator of which the source transfer tube is contained in the center of the lumen for high dose rate (HDR) brachytherapy.

MATERIALS AND METHODS

Thirty-nine patients with endobronchial cancer underwent endobronchial brachytherapy using an HDR afterloading machine with an Ir-192 source. In the nine patients treated with curative intent, treatment consisted of external beam radiotherapy with 40-60 Gy for 4-6 weeks and endobronchial brachytherapy with three fractions of 6 Gy. The 30 patients treated with palliative intent received one fraction of 10 Gy with or without external beam irradiation. The reference dose points were prescribed according to bronchial diameter, which was measured by the applicator's radiopaque wing expansion reflecting the bronchial caliber.

RESULTS

The new applicator could be placed at the intended site in 37 lesions. Of 12 lesions which were treated with curative intent, eight (67%) disappeared after brachytherapy. The overall survival at 3 years of all patients and of the patients treated with curative intent was 22 and 64%, respectively.

CONCLUSIONS

The source should be positioned in the center of the lumen; this technique is helpful in reducing side-effects caused by inhomogeneous dose distribution of endobronchial brachytherapy.

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.

Does additional brachytherapy improve the effect of external irradiation? A prospective, randomized study in central lung tumors

PURPOSE

Endobronchial brachytherapy has become more widely used to increase the total local dose of irradiation ("boost") applied for the treatment of lung cancer. Apart from treatment for local stenosis, endobronchial brachytherapy in combination with external irradiation (EI) has the potential to improve local tumor control and perhaps prolong survival, but the real benefit has not been proven yet. To evaluate the possible effects of external irradiation with an additional boost of high dose rate (HDR) brachytherapy, we conducted a prospective randomized study.

METHODS AND MATERIALS

Design-two groups were compared: Group 1 was treated with external radiotherapy alone (planned dose 60 Gy); Group 2 received an additional boost of HDR brachytherapy of scheduled 4.8 Gy each (at 10 mm from the source axis) before and after external irradiation. Patients-98 patients with advanced inoperable lung cancer were included in the study, 42 in Group 1 and 56 in Group 2. Both groups were comparable with respect to age, sex, tumor stage, Karnofsky performance status (KPS), and histology.

RESULTS

A mean total external irradiation dose of 50.5 +/- 14.1 Gy in Group 1 and 50 +/- 12.5 Gy in Group 2 was applied. Group 2 received an additional dose of 7.44 +/- 2.6 Gy (at 10 mm depth) through brachytherapy. The median survival time in both groups was comparable (28 weeks and 27 weeks, respectively). In patients with squamous cell carcinoma (68 patients) Group 2 showed an advantage in median survival with borderline significance (40 vs. 33 weeks, p = 0.09). Group 2 showed also a better local tumor control in all patients; patients with squamous cell carcinoma had a significantly longer period of local tumor control. Fatal hemoptysis was the cause of death in 6 (14.2%) patients in Group 1 and 11 (18.9%) in Group 2 (p = 0.53).

CONCLUSIONS

High dose rate brachytherapy in patients with inoperable lung cancer increased local control in our randomized study when used in combination with external irradiation. Survival time was also longer, but with no clear statistical significance. This applied especially to patients with squamous cell carcinomas. There was no statistically significant difference in the incidence of fatal hemoptysis between the two groups.

Palliative radiation therapy for non-small cell lung cancer

The palliative treatment of patients with NSCLC should be individualized. Treatment decisions should be directed by the goal of maximizing the patient's quality of life, and the patient's wishes should always be ascertained. The approaches to palliative radiation treatment of the chest, bones, and brain are quite similar. Treatment of the chest and bones is usually reserved until symptoms are significant. Brain metastases are generally treated soon after diagnosis. With respect to dose-fractionation schedules, the data are not conclusive. In theory, more protracted schedules of 40 to 50 Gy in 4 to 5 weeks are associated with more durable responses and less long-term morbidity than are shorter and lower-dose schedules. These regimens are therefore worth considering for the most favorable subset of palliative patients (i.e., those with good performance status and low burden of disease). At the other end of the spectrum, very ill patients with poor performance status may be best served by short hypofractionated schedules such as 20 Gy in five fractions, 17 Gy in two fractions, or possibly 8 to 10 Gy in one fraction. Response rates with these regimens are good, trips to the treatment facility are minimized, and these ill patients will probably not live long enough to experience the higher long-term toxicity rates associated with larger treatment fractions. The majority of patients, however, fall between these two extremes and are well served by schedules such as 30 Gy in 10 fractions. Radiation treatment fields should not be excessive but cover gross disease with a limited margin. (In the setting of brain metastases, treatment of the whole brain is recommended.) Further study of palliative treatment approaches should focus not only on assessments of response and toxicity but also on the impact of different treatments on overall quality of life.

The use of the covered Wallstent for the palliative treatment of inoperable tracheobronchial cancers. A prospective, multicenter study

STUDY OBJECTIVE

To investigate the safety, efficacy, and tolerance of the covered Wallstent for the palliative treatment of inoperable tracheobronchial cancer.

DESIGN

An 8-month prospective study employing either a rigid bronchoscope or a flexible delivery system for prosthesis insertion.

SETTING

Multicentric setting involving four teaching hospitals in Switzerland and Germany.

PATIENTS

Forty patients (29 men, 11 women), average age of 62 years, presenting with an inoperable tracheobronchial cancer.

INTERVENTIONS

After partial airway recanalization with an Nd-YAG laser, the covered Wallstent was inserted 23 times using a rigid bronchoscope (Rigidstep device), and 27 times using a flexible delivery system (Telestep device) under fluoroscopic and endoscopic visualization.

RESULTS

Clinical and endoscopic examination at 1, 30, and 90 days showed improvement in the bronchial lumen and in the dyspnea index. No serious complication (death, perforation, hemorrhage, inability to remove an improperly placed prosthesis) was observed during surgery. Late complications included migration (12%), inflammatory granulations or tumor regrowth at the tip of the prosthesis (36%), and symptomatic retention of secretion (38%).

CONCLUSIONS

Compared with other tracheobronchial prostheses, notably the Dumon stent, the covered Wallstent presents the following advantages: insertion with visual guidance, treatment of extrinsic compressions and esophagobronchial fistulas, and little chance of migration when the prosthesis diameter is chosen correctly. The following disadvantages can be noted: high price; both repositioning and extraction of the released stent are more difficult, though certainly possible; and risk of granulations at the tips of the prosthesis and retention of secretions. Suggestions are made for potential improvements to the stent and insertion system that may result in a significant decrease in early and late complications.

[High-dose rate endobronchial brachytherapy: results and complications in 189 patients]

Between September 1990 and March 1995, 189 patients were treated with high-dose-rate endobronchial brachytherapy. Most patients (70%) presented with either recurrent or persistent symptomatic endobronchial tumor after standard therapy. A minority of the patients (12%) had small endobronchial tumor and were unfit for surgical resection or radiotherapy. Treatment was delivered weekly and consisted of three to four 8- to 10-Gy radiotherapy fractions applied at 10 mm from the source. Major symptomatic improvement was obtained on hemoptysis (74%), dyspnea (54%), and cough (54%). Complete endoscopic response occurred in 54.5% of the cases. Median survival was 7 months for the entire group. For small strictly endobronchial tumors, complete response rate was 95.5%, median survival was 17 months, and 30-month survival was 46%, with a plateau starting at 18 months. The rate of late grade 3 to 4 toxicity was 17%, including hemoptysis (n = 13), stenosis (n = 12), local necrosis (n = 8), and bronchial fistula (n = 3). By univariate analysis, no factor was found to be predictive of late toxicity. Our study confirms the benefit of endobronchial brachytherapy in the palliative treatment of endobronchial recurrences and in the curative intent treatment of small endobronchial tumors in patients not suitable for other forms of therapy.

Treatment of unresectable lung cancer with brachytherapy

Endobronchial brachytherapy is an evolving treatment modality. Although standard clinical indications and dosage schedules have not yet been established, the wide range of individual experience overwhelmingly demonstrates its efficacy in palliating lung cancer patients who generally have limited treatment options. Although the exact complication rate is not known, it appears to be low and the potential benefits far outweigh the risks. The role of endobronchial brachytherapy for cure is less clear. For most instances "prolonged palliation" would be a more suitable term than "cure." Further data is needed to clarify the proper place of endobronchial brachytherapy as a boost to external beam radiation therapy. The dose, fractionation scheme, and timing relative to external beam radiation therapy are based on institutional preference at this time. The historical evolution, treatment technique, results, and complications of endobronchial brachytherapy are reviewed here.

High dose rate endobronchial brachytherapy in the management of primary and recurrent bronchogenic malignancies

BACKGROUND

The clinical, radiographic, and bronchoscopic records of patients treated with out-patient high dose rate (HDR) endobronchial brachytherapy were reviewed to determine its effectiveness in patients with malignant airway obstruction (with or without prior external beam radiation). In addition, quality of life and acute and chronic morbidity were evaluated.

METHODS

From January 1, 1989 to June 30, 1993, 46 patients received 128 HDR endobronchial treatments employing a high activity Ir-192 source with a remote afterloader. Patients treated had a total of 22 primary and 17 recurrent bronchogenic carcinomas, 7 of which were metastatic nonpulmonary tumors. Three separate fractions of 7.0 Gy were prescribed to a depth of 1.0 cm. and given 1 week apart. Twelve patients (30%) received prior external beam irradiation (median dose, 58 Gy).

RESULTS

Median follow-up for the entire group was 5 months (17.5 for surviving patients). Of the eight asymptomatic patients, five (62%) remained asymptomatic for the remainder of their lives. Of the 38 symptomatic patients, 28 (74%) had significant clinical improvement, and 12 of them remained improved for the duration of their lives. Of thirty-six (78%) patients examined for radiographic response, 25 (69%) had a partial or complete response to this treatment. In patients without prior irradiation, there was a tendency for a higher percentage of clinical and radiographic response. Two patients (4%) experienced mild, transient dysphagia, four patients developed self-limited radiation pneumonitis (9%), and three patients (7%) suffered fatal hemoptysis (all of these patients received prior or concurrent external beam radiotherapy). No factor (i.e., prior radiation therapy, number of catheters placed, surgery, or chemotherapy) predicted an increased risk of complications (P = NS).

CONCLUSIONS

Outpatient HDR endobronchial brachytherapy is effective in both preventing and relieving endobronchial obstruction in patients with or without prior irradiation, recurrent lesions, or metastatic nonpulmonary disease. A significant proportion of patients can be rendered asymptomatic for the duration of their lives, hence were provided with improved quality of life. These treatments are well tolerated and safe, and result in minimal long term morbidity.

Palliative endobronchial brachytherapy for central lung tumors. A prospective, randomized comparison of two fractionation schedules

AIM OF THE STUDY

Remote high dose rate brachytherapy is an effective local treatment modality for central lung tumors and has the potential to improve survival time. Optimal dose and fractionation schemes have not been identified yet. We conducted a prospective randomized study to compare two treatment schedules in terms of survival time, local tumor control, and possible complications.

DESIGN

Group 1 received 4 brachytherapies with a dose of 3.8 Gy (at a 10-mm depth) on a weekly basis, and group 2 received 2 treatments with 7.2 Gy (at a 10-mm depth) at a 3-week interval. At a depth of 5 mm, the calculated doses would be 8 and 15 Gy. This study is still ongoing. Here we report interim results.

PATIENTS

Ninety-three patients with advanced cancer were included in the study; 44 were in group 1 and 49, in group 2. Both groups were comparable regarding age, sex, tumor stage, Karnofsky performance status, and histologic findings.

INTERVENTIONS

A mean total irradiation dose of 13.4 +/- 5.2 Gy for group 1 and 13.7 +/- 4.4 for group 2 were applied (calculated at 10 mm from the source axis, equivalent to 27.9 Gy in group 1 and 28.5 Gy in group 2 at a 5-mm depth).

RESULTS

The 1-year survival rate was 11.4% in group 1 and 20.4% in group 2. No significant difference in survival time was found, but mean survival was longer in group 2 (49 weeks) than in group 1 (26 weeks). Local control after 3 months was comparable in both groups. Fatal hemoptysis occurred at a similar rate in group 1 (22.2%) and in group 2 (21.1%).

CONCLUSION

High-dose rate brachytherapy with 2 x 7.2 Gy with a 3-week interval is equivalent to a 4 x 3.8-Gy regimen on a weekly basis. The shorter treatment schedule is more convenient for patients, does not cause more side effects, and provides an equal local tumor control.

Endobronchial radiation therapy with or without neodymium yttrium aluminum garnet laser resection for managing malignant airway obstruction

BACKGROUND

Previous reports have shown low-dose-rate (LDR) afterloading Ir-192 endobronchial radiation therapy (EnBRT) to effectively palliate symptoms in patients with malignant airway obstruction. The authors retrospectively assessed the consequences of LDR EnBRT with or without neodymium yttrium aluminum garnet (Nd:YAG) laser resection in 37 patients.

METHODS

Between February 1986 and June 1991, 37 patients with malignant airway obstruction were treated with LDR EnBRT at The Cleveland Clinic Foundation. Inclusion criteria for LDR EnBRT with or without Nd:YAG laser resection were patients with recurrent, symptomatic endobronchial lesions treated previously with external beam irradiation. Of the 37 patients, 21 patients with endobronchial lesions underwent Nd:YAG laser resection; 16 patients with mainly extrinsic lesions received EnBRT only. Before EnBRT, selected patients (7 of 16 in the nonlaser-treatment group and 14 of 21 in the laser-treatment group) received additional external beam treatments of 2000 cGy/10 fractions. The LDR afterloading Ir-192 technique was used to deliver approximately 30 Gy to a 1.0-cm radius target.

RESULTS

All patients had one or more of the following symptoms: 1) dyspnea, 2) fever, 3) cough, and 4) hemoptysis. Good-to-excellent symptom relief was apparent in 16 of 21 (76.2%) laser-treated patients and in 12 of 16 (75%) nonlaser-treated patients. Follow-up bronchoscopy in 28 patients revealed tumor regression in 22 (79%). Median survival time was 16.3 weeks in the laser group and 11.7 weeks in the nonlaser group (P = 0.36). Longer median survival times were noted in laser-treated (22.8 weeks) and nonlaser-treated (16.4 weeks) patients receiving additional external beam treatments. Exsanguination occurred in 7 of 21 (33.3%) laser-treated patients and in 4 of 16 (25%) nonlaser-treated patients. The only factor affecting the exsanguination rate was implant location: 6 of 11 (54.5%) patients had lesions in the right or left upper lobe.

CONCLUSIONS

EnBRT alone or with Nd:YAG laser resection provided good-to-excellent symptom palliation in these patients although a high rate of exsanguination occurred in both groups.

Prolonged survival after high-dose rate endobronchial radiation for malignant airway obstruction

STUDY OBJECTIVE

To show that prolonged survival can be observed after high-dose rate (HDR) endobronchial brachytherapy as the sole treatment for some selected patients presenting with an endobronchial malignant obstruction.

PATIENTS

Twenty-nine patients (group 1) who presented with an endoluminal localized tumor without metastatic extension were treated by HDR endobronchial brachytherapy and are compared with 22 subjects who presented with extraluminal dissemination and were palliatively treated (group 2).

TREATMENT PROTOCOL

Treatment consisted of sessions of two exposures, delivering 7 Grays at a 10-mm radius from the center of the applicator each, and repeated every 15 days, to a maximum of six exposures. Endoscopic response and survival are the main criteria of assessment.

RESULTS

Follow-up bronchoscopies, performed 2 months after the end of the procedure, showed tumor regressions: macroscopic complete responses (CR) were observed in 21 of 25 patients evaluable in group 1, and 6 of 22 in group 2, with histologic CR in 18 and 2 patients, respectively. Median overall survival was not reached in group 1 after 23 months of follow-up; it was 5 months for group 2.

CONCLUSIONS

These results confirm that HDR brachytherapy can be used as a monotherapy for carefully selected patients who have small tumors to all appearances limited to the bronchial lumen and bronchial wall without adjacent parenchymal extension or metastatic disease.

Consensus guidelines for high dose rate remote brachytherapy in cervical, endometrial, and endobronchial tumors. Clinical Research Committee, American Endocurietherapy Society

PURPOSE

A large number of medical centers have recently instituted the use of High Dose-Rate Afterloading Brachytherapy (HDRAB). There is wide variation in treatment regimens, techniques, and dosimetry being used and there are no national standard protocols or guidelines for optimal therapy.

METHODS AND MATERIALS

The Clinical Research Committee (CRC) of the American Endocurietherapy Society (AES) met to formulate consensus guidelines for HDRAB in cervical, endometrial, and endobronchial tumors.

CONCLUSION

Each center is encouraged to follow a consistent treatment policy in a controlled fashion with complete documentation of treatment parameters and outcome including efficacy and morbidity. Until further clinical data becomes available, the linear quadratic model can be used as a guideline to formulate a new HDR regimen exercising caution when changing from a Low Dose Rate (LDR) to a HDRAB regimen. The treatments should be fractionated as much as practical to minimize long term morbidity. As more clinical data becomes available, the guidelines will mature and be updated by the Clinical Research Committee of the AES.

High dose-rate endobronchial irradiation in malignant airway obstruction

We evaluated the effectiveness of high dose rate (HDR) endobronchial irradiation for palliation of malignant airway obstruction. Between May 1989 and February 1992, 39 patients were treated in our department. Thirty-two patients (82 percent) had primary lung neoplasms and 7 (18 percent) had metastatic disease. Thirty-three patients (85 percent) had prior external irradiation (either alone or in combination with chemotherapy), and 9 patients (23 percent) received laser excision before treatment. Of the 39 patients, 14 (36 percent) presented with hemoptysis, 20 (51 percent) with cough, 15 (38.5 percent) had dyspnea, and 15 patients (38.5 percent) had pneumonia or atelectasis. There were 57 applications performed in the 39 patients. Patients with hemoptysis had 93 percent complete response (CR), 20 percent with cough had CR; 60 percent improved (partial response [PR]); no response was seen in 20 percent. Atelectasis and pneumonia resolved in 20 percent of patients. Eighteen patients (46 percent) underwent a second procedure and were evaluated for objective response; 34 percent had CR, 44 percent had PR, and 22 percent did not respond. There were two acute (one bronchospasm, one pneumothorax) and three late (two strictures, and one exsanguination) complications. In our experience, HDR was highly effective in the palliation of airway symptoms caused by malignant tumors, with acceptable toxicity.

Role of radiation therapy in the management of lung cancer

Most patients who have lung cancer will receive radiation therapy at some point during the course of their disease. For patients with non-small-cell lung cancer, radiation therapy is sometimes used after complete resection, particularly in patients with lymph node involvement. In addition, irradiation is commonly used after incomplete resection. In patients with unresectable non-small-cell lung cancer, radiation therapy alone is typically used, although recent studies of a combination of chemotherapy and radiation therapy, or radiation therapy given in twice-daily fractions, have yielded promising results. For patients with small-cell lung cancer who have limited (that is, nonmetastatic) disease, the addition of thoracic radiation therapy to chemotherapy has improved survival over that with chemotherapy only. The role of prophylactic cranial irradiation in small-cell lung cancer remains controversial. Radiation therapy has a major role in the management of locally recurrent and metastatic lung cancer. Both the bones and the brain are common metastatic sites in patients with lung cancer. Radiation therapy provides effective palliation of symptoms from these and other metastatic lesions.

Thoracic volume radiation sparing following endobronchial brachytherapy: a quantitative analysis

A retrospective analysis of patients with inoperable, Stage III non-small cell lung carcinoma presenting with malignant airway occlusion and treated with endobronchial brachytherapy boost prior to radical radiotherapy is reported. Of the 102 patients treated with endobronchial brachytherapy between October 1986 and January 1991, 22 were newly diagnosed, biopsy-proven Stage IIIA (14/22) or IIIB (8/22) non-small cell carcinoma with > 80% endoscopically demonstrated airway occlusion of the carina (1/22), mainstem bronchus (10/22) or lobar bronchus (11/22). Fifteen patients had complete lung or lobar atelectasis. Poor performance status (KPS < 70% in 13/22) and/or weight loss (> 10% in 9/22) rendered these patients ineligible for multi-institutional trials. Endobronchial boost was delivered using low dose rate (20 Gy at 2 cm) or high dose rate brachytherapy (16 Gy in 4 fractions over 2 days at 2 cm). Following a 10-14 day post-endobronchial period to allow for reaeration, patients underwent additional external beam radiotherapy (60 Gy in 30 fractions). Of the 15 patients with atelectasis, 6/15 (40%) reaerated completely, 4/15 (27%) partially, and 5/15 (33%) failed to reaerate. A new method, called "sequential volume integration" was used on the pre- and post-endobronchial films to analyze sparing of thoracic volume from external beam radiation as a consequence of reaeration. Patients with complete reaeration required 47% less and those patients with partial reaeration required 25% less ipsilateral thoracic volume radiation. There was a tend toward improved survival in reaerators (36 weeks) as compared to non-reaerators (24 weeks).