Endobronchial brachytherapy-A novel approach for the management of airway amyloidosis

High dose rate endoluminal brachytherapy in the treatment of endobronchial lesions - experience of a single institution and literature review

PURPOSE

To evaluate the efficacy and toxicity of Iridium-192 high-dose-rate endobronchial brachytherapy (HDR-EBT) for palliation of symptoms and for curative intent.

MATERIAL AND METHODS

This is a retrospective study of a prospectively registered cohort of 31 patients with endobronchial lesions treated with HDR-EBT at our institution between 2008 and 2020. Eighteen patients were treated with palliative intent and 13 curative intent; 4 of them as a boost to external radiation therapy (XRT). The primary objectives of the study were to analyze the symptomatic relief, endoscopic response, and treatment-related toxicity. As a secondary endpoint, survival analyses were performed.

RESULTS

In palliative setting, most of the symptomatic patients (80%) presented a significant clinical improvement and 75% presented endoscopic improvement of the lesions. In curative setting, all patients with visible lesions had endoscopic improvement and better survival than palliatively treated patients (median: 78 and 9 months, respectively; p = 0.002). There were no complications in 91.4% of the treatments: only one pneumonia, one pneumothorax and one bronchial stenosis occurred, all in palliative treatments. No fatal hemoptysis happened. Acute toxicity was mild (G ≤ 2) and transitory.

DISCUSSION

HDR-EBT is an excellent, safe, and inexpensive palliative treatment of symptoms caused by endobronchial growth of tumors in the proximal airway, either as a single treatment or in combination with XRT. It can also be an alternative in the treatment of initial malignant tumors when surgery or XRT is not possible, and it may also play a role in treating non-malignant bronchial obstructions.

Treatment of Localized Amyloid Light Chain Amyloidosis With External Beam Radiation Therapy

PURPOSE

Localized amyloidosis is a condition characterized by deposits of fibrillary proteins confined to a single organ. The most common subtype is amyloid light chain amyloidosis, which is caused by secretion of amyloidogenic light chain by a monoclonal population of plasma cells. We present a review and discussion of the literature in the context of a case presentation of localized amyloid light chain amyloidosis of the nasopharynx treated with radiation alone.

METHODS AND MATERIALS

We reviewed literature relevant to this topic from 1970 to the present. Relevant studies, reports, and articles were summarized in table form.

RESULTS

Surgical resection has historically been the primary therapeutic modality for these patients, with radiation being reserved for recurrent lesions or for those unfit for surgery. Although the data are limited to small retrospective series, radiation has been shown to provide good control with mild toxicity that is as good as or better than surgery. Doses range from 20 to 45 Gy, conventionally fractionated. There is no known risk of progression to systemic disease without local therapy.

CONCLUSIONS

We recommend local therapy for symptomatic patients after systemic disease has been excluded. We generally recommend radiation in the setting of recurrent lesions, unacceptable toxicity with surgery, poor surgical candidates, and as the initial modality in select patients (elderly individuals with bothersome but nonobstructive lesions).

Case Report: Management of Primary Tracheobronchial Light Chain Amyloidosis in a Patient With Biclonal Gammopathy Using a Systemic Bortezomib-Based Regimen

Primary tracheobronchial light chain (AL) amyloidosis is a rare and heterogeneous disease characterized by the buildup of amyloid deposits in the airway mucosa. Although its treatment remains challenging, the current view is that the localized form can be treated conservatively due to its slow progression. While radiotherapy has proven effective in treating localized form of the disease, some patients do not respond to local treatment and continue to experience poor quality of life, highlighting the need to explore additional treatment strategies. In this report, we discuss a case of primary tracheobronchial AL amyloidosis with biclonal gammopathy (IgA κ and IgG κ) in a 46-year-old man who was transferred to our hospital due to dyspnea progression over the preceding 3 years. Chest computed tomography revealed irregular tracheobronchial stenosis with wall thickening, and histological examination of the bronchial biopsies confirmed the diagnosis of endobronchial AL amyloidosis. Owing to the poor effect of radiation therapy and treatments for improving airway patency, he was treated with a systemic chemotherapy regimen [cyclophosphamide-bortezomib-dexamethasone (CyBorD)]. We observed substantial improvements in his dyspnea, highlighting the potential of systemic therapy to improve quality of life of patients with tracheobronchial AL amyloidosis. However, the long-term pathological changes associated with local bronchial lesions require further investigation.

Amyloidosis of the respiratory system: 16 patients with amyloidosis initially diagnosed ante mortem by pulmonologists

Background

Ante mortem diagnosis of amyloidosis of the respiratory system is rare. Few data are available regarding clinical presentation, precursor proteins, diagnostic procedures, comorbidities, complications, and outcome. We assessed clinical features of a series of patients with amyloidosis of the respiratory system in two Japanese centres.

Methods

Medical records of 16 patients with amyloidosis of the respiratory system were retrospectively analysed. Amyloid was diagnosed by polarisation microscopy using Congo red-stained tissue specimens and classified immunohistochemically.

Results

Median patient age was 71 years, and median follow-up period was 5 years. Immunoglobulin light-chain (AL)-λ amyloidosis was found in eight and AL-κ in five patients. Two patients harboured wild-type transthyretin and one harboured serum amyloid A-derived amyloid. Five different forms of amyloidosis of the respiratory system were observed: nodular pulmonary amyloidosis (seven patients), diffuse alveolar-septal amyloidosis (five), mediastinal lymph node amyloidosis (three), tracheobronchial amyloidosis (one), and pleural amyloidosis (one). One patient had diffuse alveolar-septal amyloidosis and mediastinal lymph node amyloidosis. Three of five patients with diffuse alveolar-septal amyloidosis were diagnosed by transbronchial lung biopsy as having concurrent diffuse alveolar haemorrhage or pneumocystis pneumonia. Two of three patients with mediastinal lymph node amyloidosis were diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration.

Conclusions

Not only nodular pulmonary amyloidosis, diffuse alveolar-septal amyloidosis, and tracheobronchial amyloidosis but also mediastinal lymph node amyloidosis and pleural amyloidosis should be considered in the differential diagnosis of amyloidosis of the respiratory system. Useful diagnostic methods include transbronchial lung biopsy for diffuse alveolar-septal amyloidosis and endobronchial ultrasound-guided transbronchial needle aspiration for mediastinal lymph node amyloidosis.

Not only nodular, diffuse alveolar-septal and tracheobronchial amyloidosis but also mediastinal lymph node and pleural amyloidosis should be considered in the differential diagnosis of amyloidosis of the respiratory systemhttps://bit.ly/2ZfZcxo