Endobronchial High Dose Rate Research Articles

Endobronchial HDR Brachytherapy for Post-Transplant or Wegener’s Granulomatosis Associated Bronchial Stenosis

Bronchial stenosis is a clinically challenging problem following lung transplant and in Wegener’s Granulomatosis. Despite laser, stenting, balloon dilation among other interventions, worsening of stenosis often occurs. Endobronchial brachytherapy has been implemented for treatment refractory stenotic areas based on limited data. We hypothesize that high dose rate (HDR) Brachytherapy using 3Gy x1 fraction is effective in alleviating treatment refractory stenosis of bronchus. Patients who underwent endobronchial HDR Ir-192 brachytherapy from January 2016 to January 2020 for bronchial stenosis were retrospectively reviewed. Patients were selected for HDR brachytherapy if they had treatment refractory symptomatic re-stenosis. On day of brachytherapy, a flexible bronchoscopy was performed and a brachytherapy catheter was inserted. Intraoperative fluoroscopic imaging confirmed catheter positioning. Treatment length ranged from 3-5cm. The dose of 3Gy in 1 fraction was prescribed 1cm from the catheter surface. Patients were followed with bronchoscopies and pulmonary function testing (PFTs). Four patients were included with median follow-up of 5.2m (range: 0.9-16.8). One patient received brachytherapy 12Gy in 4 fractions 12 years prior to re-treatment. The same patient received a second double lung transplant due to bronchiolitis obliterans. All patients had initial clinical & bronchoscopic improvement with brachytherapy. The one Wegener’s Granulomatosis patient required an additional two courses of brachytherapy due to residual granulation tissue found proximally outside of the prior radiation treatment fields. Median time to next endobronchial intervention after brachytherapy was 5.2m [0.9-18.8]. The median number of interventions pre and post brachytherapy are listed below (Table 1). FEV1 prior to brachytherapy was 33% predicted [27-65] and PFT after brachytherapy was 40% predicted [25-72]. The one Wegener granulomatosis patient had a balloon dilation procedure induced grade 4 bronchopulmonary hemorrhage three months after 3rd brachytherapy treatment, requiring bronchial artery embolization. They were subsequently discharged 36 hours after the initial bleed and remains free of stenosis. Table 1 Endobronchial HDR brachytherapy utilizing 3Gy x 1 fraction was safe and effective in resolving refractory re-stenotic areas of bronchus caused by granulation tissue. There were no toxicities associated with lung transplant patients. The Wegener’s Granulomatosis patient had a potential G4 toxicity after a third brachytherapy treatment. Caution needs to be applied in the setting of repeated endobronchial brachytherapy procedures. More robust follow up is needed to assess long term success.Abstract 2512; TablePatientNumber of Pre-Brachytherapy InterventionNumber of Post-Brachytherapy Intervention12-6 months6-0 months0-6 months6-12 months194191221311303442042900Median [range]6.5 [2-13]6.5 [4-11]2.5 [0-19]0 [0-12] Open table in a new tab

Endobronchial High-Dose Rate (HDR) Brachytherapy for the Treatment of Refractory Benign Endobronchial Obstruction in Lung Transplant Patients

Endobronchial High-Dose Rate (HDR) Brachytherapy for the Treatment of Refractory Benign Endobronchial Obstruction in Lung Transplant Patients

Multidisciplinary approach to endobronchial HDR brachytherapy as an alternative to external beam radiation for palliating malignant airway obstruction.

132 Background: Concerns over the safety of high-dose-rate (HDR) endobronchial brachytherapy (EBB) has limited its widespread use in palliating pulmonary airway obstruction. Morbidity following EBB is commonly attributed to fatal hemoptysis and fistula formation. We implemented a procedure to deliver EBB under general anesthesia to minimize procedure risks, while maintaining treatment effectiveness. We hereby report outcomes of consecutive patients treated using this approach to palliate airway obstruction. Methods: We retrospectively reviewed charts of consecutive patients treated with EBB. Treated patients had obstructive lesions >2cm distal to the carina and central structures, who were deemed candidates for EBB by a multidisciplinary team of interventional pulmonologists (IP) and radiation oncologists (RO). All patients were treated under general anesthesia. Bronchoscopy and localization of target lesions was performed by IP. HDR catheters carrying a marker wire were advanced past obstructive lesion. CT simulation was performed to confirm catheter placement, and perform CT-based 3D treatment planning. A dose of 6 -7 Gy/fraction was prescribed at 1 cm from catheter surface. Results: 25 patients (ages 29 -71, mean 52 years) were treated with EPP. 5 had previously received external beam radiation (EBRT) and 3 had concurrent EBRT and EPP. Overall, a total of 76 EBB treatments were performed, with a median of 3 weekly fractions per patient (range 1-6) to total dose of 18Gy. There were no incidences of major bleeding (>50 mL) or fatal hemoptysis in the 30 days following EPP. Moreover, there were no cases of severe (Grade 3 or higher) CTCAE toxicity reported. After a median follow up of 30 months (range 4-42) only 1 out of 17 patients treated with EPP alone required additional EBRT for airway obstruction, 12 months following EPP. Conclusions: Our data suggest the safety and efficacy of an expert multidisciplinary approach to palliating pulmonary airway obstruction using EPP. This approach provides effective palliation of airway obstruction and decreased the need for additional EBRT in majority of treated patients.

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.

866 Poster Endobronchial high dose rate brachytherapy in the management of the malignant airway obstruction

866 Poster Endobronchial high dose rate brachytherapy in the management of the malignant airway obstruction

98 Endobronchial high dose rate brachytherapy (HDR-BT) in the treatment of patients with lung cancer and with histology positive margins after sleeve lobectomy (SL) or pneumonectomy (SP). Results on 14 patients

98 Endobronchial high dose rate brachytherapy (HDR-BT) in the treatment of patients with lung cancer and with histology positive margins after sleeve lobectomy (SL) or pneumonectomy (SP). Results on 14 patients

31 Morbidity and motality after exclusive endobronchial high dose rate brachytherapy (HDRBT) in a curative intent for small-sized bronchial carcinoma

31 Morbidity and motality after exclusive endobronchial high dose rate brachytherapy (HDRBT) in a curative intent for small-sized bronchial carcinoma

Radiation therapy for roentogenographically occult lung cancer by external beam irradiation and endobronchial high dose rate brachytherapy

Purpose: We investigated the clinical usefulness of radiation therapy by external beam irradiation and endobronchial brachytherapy for the treatment of roentogenographically occult lung cancer. Patients and methods: From 1995 to 1996, five patients were treated with radiation therapy. We analyzed their treatment outcomes. The follow-up period varied from 3.0 to 3.8 years or until death. External beam radiation (40 Gy/20 fractions/4 weeks) was delivered to the tumor site alone, and not prophylactically given to the mediastinum. Endobronchial brachytherapy using high dose rate iridium (Ir)-192 was concurrently administered principally to a total dose of 18 Gy on the bronchial mucosa in three weekly fractions of 6 Gy each. Results: Complete remission was obtained in all patients. Two patients died of intercurrent diseases at 12 and 21 months without any evidence of recurrence. The disease has been also controlled in the other three cases. With the above doses, three small tumors <1 cm were controlled without adverse effect. In two tumors, the dose reference points were set 2–7 mm beneath the mucosa, and larger doses were administered by brachytherapy. An applicator acting as a spacer was not used in these cases. The tumors were controlled, although the irradiated bronchi showed severe stenosis in 6 months following the treatment. However, the patients were asymptomatic and did not need further intervention. Conclusion: External beam irradiation combined with endobronchial brachytherapy was useful for the treatment of roentogenographically occult lung cancer as an alternative to surgery. Further investigation is needed to determine the optimal doses of radiation therapy.

499 Endobronchial high dose rate brachytherapy (HDRBT) in prior irradiated non small cell lung carcinoma: Is there a real benefit?

499 Endobronchial high dose rate brachytherapy (HDRBT) in prior irradiated non small cell lung carcinoma: Is there a real benefit?

Percutaneous and endobronchial high dose rate brachytherapy for lung cancer

Endobronchial and percutaneous high dose rate (HDR) brachytherapy was performed with a microSelectron HDR using iridium-192 as a radiation source. As spontaneous pain was uncontrollable by external beam radiation (EBR), chemotherapy, hyperthermia or a combination of these treatment methods, three patients with lung cancer infiltration into the chest wall underwent percutaneous HDR brachytherapy for palliation of severe pain. Selectron needles were inserted under CT guidance and the irradiation dose was set to 10 or 12 Gy at the point 1 cm from the center of the radiation source. A total of 2-4 selectron needles was introduced by means of a template. Irradiation was performed once a week for 1-2 weeks depending on the degree of alleviation of spontaneous pain. In all 3 cases, alleviation of spontaneous pain occured within 7 days after the completion of HDR brachytherapy, and the mean pain score decreased from a value of 2 to 1 within 2 weeks. After discharge from the hospital, the pain score remained between 1-4 in all 3 patients. One problem in percutaneous brachytherapy is the possible hindrance of multiple selectron needle insertion through the template by the ribs depending on the location of the lesion. Six patients aged 51-75 years were subjected to endobronchial HDR brachytherapy. Two of these patients had postoperative recurrence of lung cancer, and 3 patients received concomitant chemotherapy. Brachytherapy was performed 3.4 months (average) after the administartion of 40-70 Gy of EBR. Endobronchial irradiation was performed at a dose of 7 Gy, measured at 1 cm from the center of the radiation source, once a week over a 3 week period for a total of 21 Gy. With the exception of 2 patients who died due to systemic exacerbation, local control of the illness has been good. In endobronchial HDR brachytherapy, it is important to develop a system for altering radiation dose in response to changes in the caliber of the tracheobronchial tree and the degree of the tumor invasion under the bronchial mucosa.

2151 Stratagies and technical aspects of endobronchial high dose rate irradiation in the treatment of malignant airway occlusion

2151 Stratagies and technical aspects of endobronchial high dose rate irradiation in the treatment of malignant airway occlusion

196 Endobronchial HDR brachytherapy: A curative approach for very limited non-small cell carcinomas

Endobronchial high dose rate brachytherapy (BT) is an alternative treatment for very small and limited bronchial carcinomas in patients with chronic respiratory deficiency after past history of lung cancer treated by surgery and/or external radiotherapy. Study of toxicity and results of high dose rate B.T. in 18 patients with 21 limited and endoscopically visible lesions. Patients Medium age: 65—Sex Ratio: 16 M/2 F—OMS: 2. Localization of tumors: main bronchus = 9, lobar and segmental bronchus = 12. No adenopathy on CT-scan. No other therapy possible because of respiratory deficiency. The treatment was 6 sessions of 5 Gy with a 7-day interval with one or two catheter applicators. A CT-scan with catheter was perforated to have a better visualization ofthe tumor and to assess the relation between the tumor, the normal structures and the applicator. In 12 treatments, the dose prescription point was at With a mean follow-up of 9 months, toxicity on bronchus was nil; 18 tumors were locally controlled, 3 failures were observed and 1 peribronchial recurrence suspected. The 3 treatment failures were in relation with a wrong evaluation of the distance between the tumor and the applicator.

99 Endobronchial high-dose rate brachytherapy (HDR-BT) for lung carcinoma: results and complications in 111 patients (PTS)

99 Endobronchial high-dose rate brachytherapy (HDR-BT) for lung carcinoma: results and complications in 111 patients (PTS)

High Dose Rate Intraluminal Irradiation in Recurrent Endobronchial Carcinoma

Palliative therapy for previously irradiated patients with symptomatic recurrent endobronchial malignancy is a difficult problem. We have had the opportunity to treat 20 such patients with high dose rate (50-100 rad/min) endobronchial brachytherapy. Eligible patients had received previous high dose thoracic irradiation (TDF greater than or equal to 90), a performance status of greater than or equal to 50, and symptoms caused by a bronchoscopically defined and implantable lesion. The radiation is produced by a small cobalt-60 source (0.7 Ci) remotely afterloaded by cable control. The source is fed into a 4 mm diameter catheter which is placed with bronchoscopic guidance; it may oscillate if necessary to cover the lesion. A dose of 1,000 rad at 1 cm from the source is delivered. We have performed 22 procedures in 20 patients, four following YAG laser debulking. Most had cough, some with hemoptysis. Eight had dyspnea secondary to obstruction and three had obstructive pneumonitis. In 12, symptoms recurred with a mean time to recurrence of 4.3 months (range 1-9 months). Eighteen patients were followed-up and reexamined via bronchoscope 1-2.5 months following the procedure; two were lost to follow-up. All had at least 50 percent clearance of tumor, and six had complete clearance; most regressions were documented on film or videotape. In six, the palliation was durable. The procedure has been well tolerated with no toxicity. We conclude that palliative endobronchial high dose rate brachytherapy is a useful palliative modality in patients with recurrent endobronchial symptomatic carcinoma.