High-Dose-Rate Brachytherapy for Non–Small-Cell Lung Carcinoma: A Retrospective Study of 226 Patients

doi:10.1016/j.ijrobp.2009.12.041

International Journal of Radiation OncologyBiologyPhysics

Volume 79, Issue 4, 15 March 2011, Pages 1112-1116

Presented at the 47th Annual Meeting of the American Society for Therapeutic Radiation Oncology, Denver, CO, Oct 16–20, 2005.

https://doi.org/10.1016/j.ijrobp.2009.12.041 Get rights and content

Purpose

To evaluate the efficacy and toxicity of high-dose-rate (HDR) brachytherapy in patients with inoperable endobronchial carcinoma.

Methods and Materials

We retrospectively reviewed the records (April 1991—May 2004) of patients with non–small-cell carcinoma, with no extrabronchial spread on computed tomography scans, who underwent HDR brachytherapy because of contraindications to surgery and external beam radiation therapy. Kaplan-Meier survival curves were compared by the log-rank test. Prognostic factors were analyzed by multivariate analysis.

Results

226 patients (223 men, 3 women, mean age: 62.2 years (range, 40–84)) were included. Of those, 217 (97%) had squamous cell carcinoma (Tis/T1/T2/Tx: 60/153/9/4). Dose was prescribed at 1 cm from the radius (24–35 Gy in 4–6 fractions). Mean follow-up was 30.4 months (range, 9–116). Complete endoscopic response rate was 93.6% at 3 months. One hundred twenty-eight patients (56%) died of intercurrent disease (n = 45), local failure (n = 36), metastasis (n = 10), local failure and metastasis (n = 11), complications (n = 13), and other causes (n = 12). The 2-year and 5-year survival rates were, respectively, 57% and 29% (overall) (median, 28.6 months), 81% and 56% (cancer-specific), and 68% and 50% (local disease-free). Acute toxicity included pneumothorax (1.5%) and mucosal inflammation (10%). Late complications were hemoptysis (6.6% with 5% of fatalities), bronchitis (19.5%), and necrosis (3.5%). In multivariate analysis, a distal tumor location and the use of two catheters were associated with improved local disease-free survival (p = 0.003 and p = 0.007, respectively) and a distal tumor location with improved overall survival (p = 0.0001).

Conclusions

This large retrospective study confirms that HDR brachytherapy is an efficient and safe treatment in patients with inoperable endobronchial carcinoma.

Introduction

In the early 1990s, the scaling down of radioactivity sources led to the development of palliative high-dose-rate (HDR) brachytherapy for lung cancer. It successfully alleviated symptoms (hemoptysis, cough, and dyspnea) in 60–88% of cases and provided an endoscopic response rate ranging from 30% to 100% depending on the extent of bronchial obstruction, tumor type according to the World Health Organisation classification, and concurrent treatment: external beam radiotherapy (EBRT) or laser resection 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. The combination of HDR brachytherapy with EBRT in locally advanced forms of lung cancer has improved the local control of squamous cell carcinomas but has provided no gain in survival 1, 13, 14, 15, 16. High-dose-rate brachytherapy has also been studied for curative purposes in the treatment of radiooccult carcinomas that are inoperable for medical reasons, either in combination with EBRT or alone. Good outcomes have been obtained in terms of local control, survival, and toxicity 4, 17, 18, 19, 20, 21, 22.

The aim of the present study was to assess retrospectively the efficacy and tolerance of HDR brachytherapy alone in the treatment of patients with endobronchial tumors that cannot be removed surgically or benefit from EBRT.

Section snippets

Patient selection

The medical records of patients in nine centers of the French National Federation of Cancer Centers who had undergone HDR brachytherapy between 1991 and 2004 were retrospectively reviewed. Inclusion criteria were as follows: histologically proven non–small-cell lung carcinoma, endobronchial carcinomas only, a normal chest computed tomography (CT) scan, no metastases, a contraindication to surgical removal and EBRT, and able, in the opinion of the anesthetist, to undergo diazepam-induced

Results

Overall, 226 patients met the inclusion criteria. Their characteristics are shown in Table 1.

The treatment schedule was at the discretion of each department, but a trend was observed from 1995 to reduce dose per fraction and increase number of fractions as advised in the literature (23). Until 1995, 4 or 5 fractions of 7 Gy were given, then after this date either 5 fractions of 6 Gy, or more often 6 fractions of 5 Gy (40% of patients), were delivered once weekly. Mean total dose was 28.7 Gy

Discussion

The present series of endobronchial cancers treated by HDR brachytherapy is by far the largest reported so far. The very low number of women was probably related to the high rate of squamous-cell histology, which is predominant in male individuals with smoke exposure. The results for local control at 2 to 3 months and overall survival at 2 years are similar to those already published (Table 3). The main prognostic factor in terms of local control and overall survival was tumor site, with

Conclusion

High-doses-rate brachytherapy is a useful technique in patients with endobronchial tumors in whom surgery and EBRT are contraindicated. It requires appropriate patient selection (distal lesions) and selection of the best dose prescription point (CT scan to determine proximity of at-risk organs, in particular of the large mediastinal vessels). Prospective trials are needed to compare HDR brachytherapy with the more recent EBRT and interventional techniques.

References (33)

C. Aygun et al.
Treatment of non-small cell lung cancer with external beam radiotherapy and high dose rate brachytherapy
Int J Radiat Oncol Biol Phys
(1992)
S.W. Gollins et al.
Massive haemoptysis death and other morbidity associated with high dose rate intraluminal radiotherapy for carcinoma of the bronchus
Radiother Oncol
(1996)
B.L. Speiser et al.
Remote afterloading brachytherapy for the local control of endobronchial carcinoma
Int J Radiat Oncol Biol Phys
(1993)
D. Ornadel et al.
Defining the roles of high dose rate endobronchial brachytherapy and laser resection for recurrent bronchial malignancy
Lung Cancer
(1997)
R.M. Huber et al.
Palliative endobronchial brachytherapy for central lung tumors: A prospective, randomized comparison of two fractionation schedules
Chest
(1995)
J. Bedwinek et al.
The use of high dose rate endobronchial brachytherapy to palliate symptomatic endobronchial recurrence of previously irradiated bronchogenic carcinoma
Int J Radiat Oncol Biol Phys
(1992)
J.F. Kelly et al.
High-dose-rate endobronchial brachytherapy effectively palliates symptoms due to airway tumors: The 10-year M.D. Anderson cancer center experience
Int J Radiat Oncol Biol Phys
(2000)
T.D. Nguyen et al.
Non-metastatic advanced non-small cell lung carcinoma: Systemic high-dose brachytherapy following curative external radiotherapy
Cancer Radiother
(1999)
Y. Anacak et al.
High dose rate endobronchial brachytherapy in combination with external beam radiotherapy for stage III non-small cell lung cancer
Lung Cancer
(2001)
H. Langendijk et al.
External irradiation versus external irradiation plus endobronchial brachytherapy in inoperable non-small cell lung cancer: A prospective randomized study
Radiother Oncol
(2001)

R.M. Huber et al.

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

Int J Radiat Oncol Biol Phys

(1997)

M. Saito et al.

Treatment of roentgenographically occult endobronchial carcinoma with external beam radiotherapy and intraluminal low-dose-rate brachytherapy: Second report

Int J Radiat Oncol Biol Phys

(2000)

N. Fuwa et al.

The treatment results of 40 patients with localized endobronchial cancer with external beam irradiation and intraluminal irradiation using low dose rate (192) Ir thin wires with a new catheter

Radiother Oncol

(2000)

D. Peiffert et al.

High dose endobronchial brachytherapy: A curative treatment

Cancer Radiother

(2000)

M. Perol et al.

Curative irradiation of limited endobronchial carcinomas with high-dose rate brachytherapy: Results of a pilot study

Chest

(1997)

H. Marsiglia et al.

High-dose-rate brachytherapy as sole modality for early-stage endobronchial carcinoma

Int J Radiat Oncol Biol Phys

(2000)

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: Conflict of interest: None.

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Clinical InvestigationHigh-Dose-Rate Brachytherapy for Non–Small-Cell Lung Carcinoma: A Retrospective Study of 226 Patients

Purpose

Methods and Materials

Results

Conclusions

Introduction

Section snippets

Patient selection

Results

Discussion

Conclusion

Int J Radiat Oncol Biol Phys

Radiother Oncol

Int J Radiat Oncol Biol Phys

Lung Cancer

Chest

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Cancer Radiother

Lung Cancer

Radiother Oncol

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Radiother Oncol

Cancer Radiother

Chest

Int J Radiat Oncol Biol Phys

Clinical Investigation
High-Dose-Rate Brachytherapy for Non–Small-Cell Lung Carcinoma: A Retrospective Study of 226 Patients