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

Interventional bronchoscopy in lung cancer treatment

Interventional bronchoscopy has seen significant advancements in recent decades, particularly in the context of lung cancer. This method has expanded not only diagnostic capabilities but also therapeutic options. In this article, we will outline various therapeutic approaches employed through either a rigid or flexible bronchoscope in multimodal lung cancer treatment. A pivotal focus lies in addressing central airway obstruction resulting from cancer. We will delve into the treatment of initial malignant changes in central airways and explore the rapidly evolving domain of early peripheral malignant lesions, increasingly discovered incidentally or through lung cancer screening programmes. A successful interventional bronchoscopic procedure not only alleviates severe symptoms but also enhances the patient's functional status, paving the way for subsequent multimodal treatments and thereby extending the possibilities for survival. Interventional bronchoscopy proves effective in treating initial cancerous changes in patients unsuitable for surgical or other aggressive treatments due to accompanying diseases. The key advantage of interventional bronchoscopy lies in its minimal invasiveness, effectiveness and favourable safety profile.

High-dose-rate brachytherapy for airway malignancy a single institution experience

PURPOSE

To evaluate clinical outcomes of endobronchial malignancy treated using high-dose-rate endobronchial brachytherapy (HDREB).

METHODS AND MATERIALS

A retrospective chart review was conducted for all patients treated with HDREB for malignant airway disease between 2010 and 2019 at a single institution. Most patients had a prescription of 14 Gy in two fractions given a week apart. The Wilcoxon signed rank test and paired samples t test were used to compare changes in mMRC dyspnea scale prior to and after brachytherapy at first followup appointment. Toxicity data were collected for dyspnea, hemoptysis, dysphagia, and cough.

RESULTS

A total of 58 patients were identified. Most (84.5%) had primary lung cancer with advanced cancers, stage III or IV (86%). Eight were treated while admitted in the ICU. Previous external beam radiotherapy (EBRT) was received by 52%. An improvement in dyspnea was seen in 72%, with an mMRC dyspnoea scale score improvement of 1.13 points (p < 0.001). Most (22, 88%) had an improvement in hemoptysis and 18 out of 37 (48.6%) had an improvement in cough. Grade four to five events occurred in 8 (13%) at the median time of 2.5 months from brachytherapy. Twenty-two patients (38%) had complete obstruction of the airway treated. Median progression free survival was 6.5 months and median survival was 10 months.

CONCLUSIONS

We report a significant symptomatic benefit among patients receiving brachytherapy with endobronchial malignancy, with rates of treatment related toxicities similar to prior studies. Our study identified new subgroups of patients, ICU patients & those with complete obstruction, who benefited from HDREB.

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.

BRACHY: A Randomized Trial to Evaluate Symptom Improvement in Advanced Non-Small Cell Lung Cancer Treated With External Beam Radiation With or Without High-Dose-Rate Intraluminal Brachytherapy

PURPOSE

Uncontrolled studies suggest that the addition of high-dose-rate intraluminal brachytherapy (HDRIB) to external beam radiation therapy (EBRT) may improve palliation for patients with advanced non-small cell lung cancer (NSCLC). The purpose of this study was to evaluate the potential clinical benefit of adding HDRIB to EBRT in a multicenter randomized trial.

METHODS AND MATERIALS

Patients with symptomatic stage III or IV NSCLC with endobronchial disease were randomized to EBRT (20 Gy in 5 daily fractions over 1 week or 30 Gy in 10 daily fractions over 2 weeks) or the same EBRT plus HDRIB (14 Gy in 2 fractions separated by 1 week). The primary outcome was the proportion of patients who achieved symptomatic improvement in patient-reported overall lung cancer symptoms on the Lung Cancer Symptom Scale (LCSS) at 6 weeks after randomization. Secondary outcomes included improvement in individual symptoms, symptom-progression-free survival, overall survival, and toxicity. The planned sample size was 250 patients based on detection of symptomatic improvement from 40% to 60% with a 2-sided α of .05 and 80% power.

RESULTS

A total of 134 patients were randomized over 4.5 years: 67 to each arm. The study closed early owing to slow accrual. The mean age was 69.8 years, and 67% of patients had metastatic disease. At 6 weeks, 19 patients (28.4%) in the EBRT arm and 20 patients (29.9%) in the EBRT plus HDRIB arm experienced an improvement in lung cancer symptoms (P = .84). When limited to patients who completed the LCSS, percentages were 40.4% versus 47.6%, respectively (P = .49). Between group differences in mean change scores (0.3-0.5 standard deviations) in favor of EBRT plus HDRIB were observed for overall symptoms, but only hemoptysis was significantly improved (P = .03). No significant differences were observed in progression-free or overall survival. Grade 3/4 toxicities were similar between groups.

CONCLUSIONS

Small to moderate improvements were seen in symptom relief with the combined therapy, but they did not reach statistical significance. Further research is necessary before recommending HDRIB in addition to EBRT for palliation of lung cancer symptoms.

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.

Malignant Central Airway Obstruction: What's New?

Malignant central airway obstruction (MCAO) is a debilitating and life-limiting complication that occurs in an unfortunately large number of individuals with advanced intrathoracic cancer. Although the management of MCAO is multimodal and interdisciplinary, the task of providing patients with prompt palliation falls increasingly on the shoulders of interventional pulmonologists. While a variety of tools and techniques are available for the management of malignant obstructive lesions, advancements and evolution in this therapeutic venue have been somewhat sluggish and limited when compared with other branches of interventional pulmonary medicine (e.g., the early diagnosis of peripheral lung nodules). Indeed, one pragmatic, albeit somewhat uncharitable, reading of this article's title might suggest a wry smile and shug of the shoulders as to imply that relatively little has changed in recent years. That said, the spectrum of interventions for MCAO continues to expand, even if at a less impressive clip. Herein, we present on MCAO and its endoscopic and nonendoscopic management-that which is old, that which is new, and that which is still on the horizon.

Palliative treatment with high-dose-rate endobronchial interventional radiotherapy (Brachytherapy) for lung cancer patients

PURPOSE

to report on the use of high-dose-rate (HDR) endobronchial interventional radiotherapy (brachytherapy, EBIRT) for palliation of symptoms in patients with lung cancer.

PATIENTS AND METHODS

retrospective review of lung cancer patients treated with HDR-EBIRT at our institution (1995-2017). Treatment results and treatment related toxicity were recorded. Clinical response was subjectively evaluated within 3 months after treatment. Overall survival (OS) was analyzed.

RESULTS

347 patients were identified. The median age was 69 years and the median follow-up time was 13.4 months. Most patients received external beam radiation therapy during the primary treatment. Within 3 months, 87.7% of the patients had complete or major response of their presenting symptoms. OS was 55.2% at 1 year, 18.3% at 2 years. Patients who had complete or major response had a longer median survival than other patients (13 versus 7 months, p = 0.03). Chronic bronchitis was found in 26.8%, while 7.8% of the patients died due to uncontrollable hemoptysis.

CONCLUSION

HDR-EBIRT is a safe and effective treatment option for the palliative treatment of lung cancer patients. HDR-EBIRT is most suitable as a re-irradiation technique. Further clinical studies are needed to validate its role.

Early and Midtreatment Mortality in Palliative Radiotherapy: Emphasizing Patient Selection in High-Quality End-of-Life Care

BACKGROUND

Palliative radiotherapy (RT) is effective, but some patients die during treatment or too soon afterward to experience benefit. This study investigates end-of-life RT patterns to inform shared decision-making and facilitate treatment consistent with palliative goals.

MATERIALS AND METHODS

All patients who died ≤6 months after initiating palliative RT at an academic cancer center between 2015 and 2018 were identified. Associations with time-to-death, early mortality (≤30 days), and midtreatment mortality were analyzed.

RESULTS

In total, 1,620 patients died ≤6 months from palliative RT initiation, including 574 (34%) deaths at ≤30 days and 222 (14%) midtreatment. Median survival was 43 days from RT start (95% CI, 41-45) and varied by site (P<.001), ranging from 36 (head and neck) to 53 days (dermal/soft tissue). On multivariable analysis, earlier time-to-death was associated with osseous (hazard ratio [HR], 1.33; P<.001) and head and neck (HR, 1.45; P<.001) sites, multiple RT courses ≤6 months (HR, 1.65; P<.001), and multisite treatments (HR, 1.40; P=.008), whereas stereotactic technique (HR, 0.77; P<.001) and more recent treatment year (HR, 0.82; P<.001) were associated with longer survival. No difference in time to death was noted among patients prescribed conventional RT in 1 to 10 versus >10 fractions (median, 40 vs 47 days; P=.272), although the latter entailed longer courses. The 30-day mortality group included 335 (58%) inpatients, who were 27% more likely to die midtreatment (P=.031). On multivariable analysis, midtreatment mortality among these inpatients was associated with thoracic (odds ratio [OR], 2.95; P=.002) and central nervous system (CNS; OR, 2.44; P=.002) indications, >5-fraction courses (OR, 3.27; P<.001), and performance status of 3 to 4 (OR, 1.63; P=.050). Conversely, palliative/supportive care consultation was associated with decreased midtreatment mortality (OR, 0.60; P=.045).

CONCLUSIONS

Earlier referrals and hypofractionated courses (≤5-10 treatments) should be routinely considered for palliative RT indications, given the short life expectancies of patients at this stage in their disease course. Providers should exercise caution for emergent thoracic and CNS indications among inpatients with poor prognoses due to high midtreatment mortality.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.

Endoluminal brachytherapy: Bronchus and oesophagus

Endobronchial brachytherapy could be proposed in case of endoluminal tumours either as a palliative or a curative treatment. As a curative treatment, endobronchial brachytherapy could obtain a high local control rate in case of limited disease. In palliative setting, endobronchial brachytherapy improved thoracic symptoms in more than 80% of cases, but it is less efficient than external beam radiation therapy for palliation. It could be also proposed to maintain the airway open after laser therapy. Oesophageal brachytherapy is a valuable option as a palliative treatment, underused at this time. It causes less side effects and a better quality of life compared to self-expanded metallic stents. For a curative aim, there is today no demonstration that a combination of external beam radiotherapy and oesophageal brachytherapy give better results than external beam radiotherapy alone in locally advanced tumours. For superficial diseases, the combination of external beam radiotherapy and oesophageal brachytherapy seems, on the contrary, promising.

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.

Endobronchial brachytherapy with curative intent: the impact of reference points setting according to the bronchial diameter

Endobronchial brachytherapy (EBB) is an effective treatment for endobronchial tumors. However, bronchial toxicity caused by over-irradiation remains problematic. To decrease bronchial toxicity, we developed a source-centralizing applicator for EBB. The purpose of the present study was to assess the efficacy and safety of EBB with varying reference dose points according to the bronchial diameter, using a source-centralizing applicator. We reviewed 15 patients with endobronchial carcinoma who were treated with curative intent using a combination of external beam radiotherapy (EBRT) and high-dose-rate EBB between 2005 and 2014. During each EBB session, we used a source-centralizing applicator that maintained the source-delivering catheter in the center of the bronchial lumen. Reference dose points were 5-7 mm from the source axis, depending on the bronchial diameter. The median radiation doses of EBRT and EBB were 40 Gy in 20 fractions and 18 Gy in 3 fractions, respectively. The median observation period was 36 months. The 3-year overall survival, progression-free survival and local control rates were 79%, 77% and 100%, respectively. Grade 2 radiation pneumonitis was observed in two cases. Bronchial toxicities, such as hemoptysis or the symptoms of chronic bronchitis, were not observed. EBB with varying reference dose points according to bronchial diameter, using a source-centralizing applicator, is a promising procedure that may be effective for tumor elimination and reducing toxicity to the bronchial wall.

Malignant central airway obstruction

This review comprehensively describes recent advances in the management of malignant central airway obstruction (CAO). Malignant CAO can be a dramatic and devastating manifestation of primary lung cancer or metastatic disease. A variety of diagnostic modalities are available to provide valuable information to plan a therapeutic intervention. Clinical heterogeneity in the presentation of malignant CAO provides opportunities to adapt and utilize endoscopic technology and tools in many ways. Mechanical debulking, thermal tools, cryotherapy and airway stents are methods and instruments used to rapidly restore airway patency. Delayed bronchoscopic methods, such as photodynamic therapy (PDT) and brachytherapy can also be utilized in specific non-emergent situations to establish airway patency. Although data regarding the success and complications of therapeutic interventions are retrospective and characterized by clinical and outcome measure variability, the symptoms of malignant CAO can often be successfully palliated. Assessment of risks and benefits of interventions in each individual patient during the decision-making process forms the critical foundation of the management of malignant CAO.

The potential role of brachytherapy in the irradiation of patients with lung cancer: a systematic review

To review the use of brachytherapy as an adjuvant therapy to reduce recurrences after sublobar resections and as a palliation to patients with inoperable disease. Α review of all published studies was performed to identify the recurrence rate after brachytherapy adjuvant to sublobar resection and assess the palliation of symptoms and the complications of brachytherapy as a palliative treatment. Most of the studies that we found about brachytherapy as an adjuvant therapy to sublobar resection due to patient's poor cardiopulmonary reserve showed that brachytherapy offered low recurrence rate with low toxicity. Ten studies concerning palliative brachytherapy showed improvement of symptoms with good tolerance and good endoscopic response rates. Literature suggests that brachytherapy for inoperable symptomatic disease can be delivered for symptom improvement with acceptable toxicity. Brachytherapy as an alternative treatment option for lung cancer needs more investigation with more prospective trials.

Interventional bronchoscopy in the management of thoracic malignancy

Educational Aims

Interventional bronchoscopy is a rapidly expanding field in respiratory medicine offering minimally invasive therapeutic and palliative procedures for all types of lung neoplasms. This field has progressed over the last couple of decades with the application of new technology. The HERMES European curriculum recommendations include interventional bronchoscopy skills in the modules of thoracic tumours and bronchoscopy [1]. However, interventional bronchoscopy is not available in all training centres and consequently, not all trainees will obtain experience unless they rotate to centres specifically offering such training.

In this review, we give an overview of interventional bronchoscopic procedures used for the treatment and palliation of thoracic malignancy. These can be applied either with flexible or rigid bronchoscopy or a combination of both depending on the anatomical location of the tumour, the complexity of the case, bleeding risk, the operator’s expertise and preference as well as local availability. Specialised anaesthetic support and appropriately trained endoscopy staff are essential, allowing a multimodality approach to meet the high complexity of these cases.

Interventional bronchoscopy is integral to the treatment and palliation of lung cancerhttp://ow.ly/R25w0

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.

Interventional pulmonology approaches in the diagnosis and treatment of early stage non small cell lung cancer

Lung cancer management is complex and requires a multi-disciplinary approach to provide comprehensive care. Interventional pulmonology (IP) is an evolving field that utilizes minimally invasive modalities for the initial diagnosis and staging of suspected lung cancers. Endobronchial ultrasound guided sampling of mediastinal lymph nodes for staging and detection of driver mutations is instrumental for prognosis and treatment of early and later stage lung cancers. Advances in navigational bronchoscopy allow for histological sampling of suspicious peripheral lesions with minimal complication rates, as well as assisting with fiducial marker placements for stereotactic radiation therapy. Furthermore, IP can also offer palliation for inoperable cancers and those with late stage diseases. As the trend towards early lung cancer detection with low dose computed tomography is developing, it is paramount for the pulmonary physician with expertise in lung nodule management, minimally invasive sampling and staging to integrate into the paradigm of multi-specialty care.

Integrating stereotactic body radiation therapy in stage II/III non-small cell lung cancer: is local control important?

Local control for advanced non-small cell lung cancer (NSCLC) remains a significant problem with chemoradiation local failure rates in the chest of 30-50%. Despite attempts at dose escalation with conventional radiation therapy techniques, toxicities limit the amount of radiation that can be delivered. For stage I NSCLC, mounting evidence supports the use of hypofractionated radiation therapy (SBRT) to gain high local control rates with acceptable toxicity. For healthy patients with stage II/III NSCLC, the National Comprehensive Cancer Network guidelines suggest surgery is the preferred standard of care for patients with <N2 nodes or T3 tumors. In select patients who are surgical candidates or have more extensive disease, guidelines may include pre-operative chemoradiation followed by surgery, although this remains controversial and is the subject of a current national clinical trial (RTOG 0839). Dose escalation through conventional radiation therapy planning suggests that we can improve outcomes in stage III patients, but toxicity remains problematic. It follows that with improvements in imaging and delivery of radiotherapy, dose escalation with SBRT incorporation may improve local control in stage II/III NSCLC for medically inoperable patients. The rationale for dose escalation and some of the considerations for incorporation of SBRT dose escalation in stage III lung cancer are reviewed here.

Bronchoscopic management of malignant airway obstruction

Approximately one-third of patients with lung cancer will develop airway obstruction and many cancers lead to airway obstruction through meta stases. The treatment of malignant airway obstruction is often a multimodality approach and is usually performed for palliation of symptoms in advanced lung cancer. Removal of airway obstruction is associated with improvement in symptoms, quality of life, and lung function. Patient selection should exclude patients with short life expectancy, limited symptoms, and an inability to visualize beyond the obstruction. This review outlines both the immediate and delayed bronchoscopic effect options for the removal of airway obstruction and preservation of airway patency with endobronchial stenting.

High-dose-rate brachytherapy in symptom palliation due to malignant endobronchial obstruction: a quantitative assessment

PURPOSE

This study was performed to objectively evaluate the effect of high-dose-rate endobronchial brachytherapy (HDREB) in symptom palliation of patients with malignant airway obstruction and treatment-related toxicity.

METHODS AND MATERIALS

Seventy-eight patients were treated with palliative intent according to a prospective observational protocol. HDREB was delivered in three fractions of 7.5 Gy at weekly or fortnightly intervals, associated or not with external beam irradiation. Most patients presented with lung cancer primaries and were treated because of lesions located in the trachea and/or main bronchi. Performance status, degree of obstruction, and symptom palliation were graded according to an objective score index, defined before and after HDREB at the last followup visit. Survival was considered from the end of HDREB for at least 3 years or until death.

RESULTS

Overall, there was a 70% improvement, with migration of patients from lower to higher performance status. Bronchial obstruction was improved in 73.4% of the patients. The symptom that presented the better response was hemoptysis (100% complete relief) followed by postobstructive pneumonia (80%), dyspnea (57.4%), and cough (33.9%). Median survival was 6 months and improved in patients with complete response at bronchoscopy (9 months). There were two (2.6%) cases of bronchial fistulae and eight cases (10.2%) of fatal hemoptysis.

CONCLUSIONS

HDREB is an excellent modality for palliating malignant airway obstruction resulting in quality of life improvement, with a good tolerance, patient compliance, and low rate of complications.

Mature results of a randomized trial comparing two fractionation schedules of high dose rate endoluminal brachytherapy for the treatment of endobronchial tumors

Purpose

To determine the efficacy of high dose rate endobronchial brachytherapy (HDR-BT) for the treatment of centrally located lung tumors, two different fractionation schedules were compared regarding local tumor response, side effects and survival. Mature retrospective results with longer follow-up and more patients were analyzed. Initial results were published by Huber et al. in 1995.

Methods and materials

142 patients with advanced, centrally located malignant tumors with preferential endoluminal growth were randomized to receive 4 fractions of 3.8 Gy (time interval: 1 week, n = 60, group I) or 2 fractions of 7.2 Gy (time interval: 3 weeks, n = 82, group II) endobronchial HDR-BT.

Age, gender, tumor stage, Karnofsky Performance Score and histology were equally distributed between both groups.

Results

Local tumor response with 2 fractions of 7.2 Gy was significantly higher as compared to 4 fractions of 3.8 Gy (median 12 vs. 6 weeks; p ≤ 0.015). Median survival was similar in both groups (19 weeks in the 4 fractions group vs. 18 weeks in the 2 fractions group). Fatal hemoptysis was less frequent following irradiation with 2 × 7.2 Gy than with 4 × 3.8 Gy, although the difference did not achieve statistical significance (12.2% vs. 18.3%, respectively. p = 0,345). Patients presenting with squamous cell carcinoma were at higher risk of bleeding compared to other histology (21.9% vs. 9%, p = 0,035).

Multivariate analysis with regard to overall survival, revealed histology (p = 0.02), Karnofsky Performance Score (p < 0.0001) and response to therapy (p < 0.0001) as significant prognostic factors. For patients showing complete response the median survival was 57 weeks, while for patients with progressive disease median survival time was 8 weeks, p < 0.0001.

The KPS at the start of the treatment was significantly correlated with survival. Patients presenting with a KPS ≤ 60 at the start had a significantly (p = 0,032) shorter survival time (10 weeks) than patients with a KPS > 60 (29 weeks).

Moreover, the Karnofsky Performance Score of most patients improved during therapy (p = 0,001), suggesting successful palliation of cancer associated symptoms.

Multivariate analysis with regard to local tumor control found no significant factors.

Conclusion

Endobronchial HDR-BT is an effective local treatment for advanced centrally located malignant tumors with endoluminal tumor growth. Local tumor response was significantly higher after HDR-BT with 2 × 7.2 Gy.

Surgical and endoscopic palliation of advanced lung cancer

Pulmonary symptoms from advanced-stage lung cancer often require palliative treatments for compassionate patient care. Although many of these symptoms can result from complications of advanced lung cancer treatment regimens (ie, radiation/chemotherapy-induced lung toxicity) or the patient's underlying comorbid conditions and poor constitution, a significant number of patients have symptoms that originate from the primary tumor itself or from locoregional metastases within the thoracic cavity. These complications from advanced-stage lung cancer can be a serious threat to life and require appropriate intervention.

NCIC Clinical Trials Group experience of employing patient-reported outcomes in clinical trials: an illustrative study in a palliative setting

In this article we briefly review the experience of the National Cancer Institute of Canada (NCIC) Clinical Trials Group (CTG) with respect to the assessment of patient reported outcomes in clinical trials, and illustrate issues important to assessing symptom palliation in clinical trials of cancer therapy. We highlight a standard approach taken by the NCIC CTG, and illustrate how this approach may be applied to the complex problem of symptom control analysis in patients with locally advanced NSCLC. We further illustrate how variations in this analysis yield different apparent rates of palliation. Apparent rates of palliation critically depended on the outcome measures used: single symptom response across patients (5-32%, depending on the symptom of interest), symptom response in specific symptomatic patients (37-100%), symptom control (45-82%), index symptom response (60%), proportion of patients experiencing improvement in all symptoms (21%), or health-related quality of life (HRQoL) improvement (23%, global). Rates also varied substantively depending on which cohort of patients was considered relevant to each analysis (i.e., was included in the respective denominator). Substantive discordance in patients' apparent palliation was seen when HRQoL data were compared with symptom diary data. Appropriate and valid descriptions of palliative outcomes in clinical trials are complex undertakings. We conclude that several measures are required for a textured clinical description of outcome, and recommend reporting palliation according to individual symptom response rates and HRQoL response rates, in order to address each construct of palliation success.

High-Dose-Rate Endobronchial Brachytherapy for Recurrent Airway Obstruction From Hyperplastic Granulation Tissue

PURPOSE

Benign endobronchial granulation tissue causes airway obstruction in up to 20% of patients after lung transplantation or stent placement. High-dose-rate endobronchial brachytherapy (HDR-EB) has been successful in some cases refractory to standard bronchoscopic interventions.

METHODS AND MATERIALS

Between September 2004 and May 2005, 8 patients with refractory benign airway obstruction were treated with HDR-EB, using one to two fractions of Ir-192 prescribed to 7.1 Gy at a radius of 1 cm. Charts were retrospectively reviewed to evaluate subjective clinical response, forced expiratory volume in 1 second (FEV(1)), and frequency of therapeutic bronchoscopies over 6-month periods before and after HDR-EB.

RESULTS

The median follow-up was 14.6 months, and median survival was 10.5 months. The mean number of bronchoscopic interventions improved from 3.1 procedures in the 6-month pretreatment period to 1.8 after HDR-EB. Mean FEV(1) improved from 36% predicted to 46% predicted. Six patients had a good-to-excellent subjective early response, but only one maintained this response beyond 6 months, and this was the only patient treated with HDR-EB within 24 h from the most recent bronchoscopic intervention. Five patients have expired from causes related to their chronic pulmonary disease, including one from hemoptysis resulting from a bronchoarterial fistula.

CONCLUSION

High-dose-rate-EB may be an effective treatment for select patients with refractory hyperplastic granulation tissue causing recurrent airway stenosis. Performing HDR-EB within 24-48 h after excision of obstructive granulation tissue could further improve outcomes. Careful patient selection is important to maximize therapeutic benefit and minimize toxicity. The optimal patient population, dose, and timing of HDR-EB should be investigated prospectively.

State of the art: interventional pulmonology

Interventional pulmonology (IP) provides comprehensive care to patients with structural airway disorders and pleural diseases. A growing armamentarium of diagnostic and therapeutic tools has expanded the interventional pulmonologist's ability to care for pulmonary patients with complex abnormalities, often in concert and close collaboration with physicians in other specialties, such as thoracic surgery. Innovative technologies promise to have an impact on diseases and clinical entities not traditionally treated by invasive pulmonary interventions, such as asthma, COPD, and the solitary pulmonary nodule. Training, credentialing, reimbursement, and scientific validation remain key necessities for the continued growth of IP, and require a concerted effort by chest physicians and their professional organizations.

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.

Endobronchial Brachytherapy: An Effective Option for Palliation of Malignant Bronchial Obstruction

Symptoms resulting from tumors extending to the endobronchial wall are common in patients with lung cancer and significantly impact quality of life. A number of treatment options are available for palliation, including endobronchial brachytherapy, stent placement, laser photoresection, external-beam radiation therapy, and photodynamic therapy. This review will focus on the methodology and role of endobronchial brachytherapy while discussing benefits of other treatment options as additions or alternatives to brachytherapy.

High-dose-rate (HDR) brachytherapy for the treatment of benign obstructive endobronchial granulation tissue

BACKGROUND

Severe airway obstruction can occur in the setting of benign granulation tissue forming at bronchial anastomotic sites after lung transplantation in up to 20% of patients. Many of these benign lesions respond to stent placement, laser ablation, or balloon bronchoplasty. However, in certain cases, proliferation of granulation tissue may persist despite all therapeutic attempts. This study describes a series of refractory patients treated with high-dose-rate (HDR) brachytherapy for benign proliferation of granulation tissue, causing airway compromise.

METHODS AND MATERIALS

Between April 2002 and June 2005, 5 patients with significant airway compromise from recurrent granulation tissue were treated with HDR brachytherapy. All patients had previously failed to maintain a patent airway despite multiple bronchoscopic interventions. Treatment was delivered using an HDR brachytherapy afterloader with (192)Ir. Dose prescription was to a depth of 1 cm. All patients were treated weekly, with total doses ranging from 10 Gy to 21 Gy in two to three fractions.

RESULTS

The median follow-up was 12 months. All patients experienced a reduction in therapeutic bronchoscopic procedures after HDR brachytherapy compared with the pretreatment period. With the exception of possible radiation-induced bronchitis in 1 patient, there were no other treatment related complications. At the time of this report, 2 patients have died and the other 3 are alive with marked symptomatic improvement and reduced bronchoscopic procedures.

CONCLUSION

High-dose-rate brachytherapy is an effective treatment for benign proliferation of granulation tissue causing airway obstruction. The early response to therapy is encouraging and further follow-up is necessary to determine long-term durability and late effects.

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 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.

Preparation and characterization of radioactive Co/188Re stents intended for lung cancer treatment using an electrodeposition method

A procedure for electroplating a Co/(188)Re alloy layer on metal coils (stents) at room temperature was developed. The electroplating of the Co/(188)Re alloy layer was carried out at a current density of 93 A m(-2) and produced a physically strong Co/(188)Re alloy layer that adhered well to a thin gold strike layer on top of the stent material. The final gold layer was also stable. An empirically-found equation correlates the radioactive electroplating efficiency factor to the concentration of the radioisotope and was used to deposit predetermined amounts of radioactivity on the stent surface. Radioactive stents can be prepared and quality control performed within 2 hours using an automated electroplater and dosimetric quality control system. The radioactivity was homogeneously distributed on the stent surface. The in vitro stability in human plasma at 37 degrees C was found to be greater than 95% for both Wallstent and Ultraflex stent after 72 hours of incubation. A clinical pilot trial is planned after successful completion of animal testing.

Central Airway Obstruction

Central airway obstruction is a problem facing all medical and surgical subspecialists caring for patients with chest diseases. The incidence of this disorder appears to be rising because of the epidemic of lung cancer; however, benign causes of central airway obstruction are being seen more frequently as well. The morbidity is significant and if left untreated, death from suffocation is a frequent outcome. Management of these patients is difficult, but therapeutic and diagnostic tools are now available that are beneficial to most patients and almost all airway obstruction can be relieved expeditiously. This review examines current approaches in the workup and treatment of patients suffering from airway impairment. Although large, randomized, comparative studies are not available, data show significant improvement in patient outcomes and quality of life with treatment of central airway obstruction. Clearly, more studies assessing the relative utility of specific airway interventions and their impact on morbidity and mortality are needed. Currently, the most comprehensive approach can be offered at centers with expertise in the management of complex airway disorders and availability of all endoscopic and surgical options.

Radiation therapy

RT is an indispensable part of current treatment approaches of locally advanced and metastatic NSCLC. It can be used alone or in combination with surgery or CHT. Because RT can potentially cure some patients, prolong the life of others, and reduce symptoms in the majority of them, it is a unique treatment modality in this disease. Radiation oncologists have learned how to deal with RT-induced toxicities and how to improve quality of life of lung cancer patients. Although recent technologic advances made sophisticated RT somewhat more expensive than before (demanding more manpower and being more time-consuming), it is still an inexpensive treatment modality, which is important in the era of focusing on cost-effectiveness. Although newer RT technologies are used to enable effective dose-escalation-a clear must for the community of radiation oncologists--optimization of RT must also include clear identification of various pretreatment, patient, and tumor-related characteristics that may influence treatment outcome. Regardless of the current therapeutic/technologic potential, we still lack some basic knowledge to better understand the process of, for example, combining RT and CHT. There is recognized need for better translational research that ultimately should be seen as a "two-way road," from laboratory to clinic and vice versa, preferably in a continuous way. The National Cancer Institute in the United States recently organized a workshop on translational research in radiation oncology, which has identified RT-CHT interactions as one of its major areas of research. Research topics include development of the methods of imaging the results of RT/ CHT interactions (confirmed by biopsy), development of new radiation modifiers, and identification of factors other than genetic ones that may influence the response of tumors to RT/CHT interactions. Tumor microenvironment was also clearly addressed as one of the targets for research, indicating as special tasks the development of new, microenvironmentally activated cytotoxic or cytostatic drugs, development and validation of more user-friendly methods for determining tumor oxygenation, and answering whether hypoxia predicts for radioresistance to CHT in treatment and whether it causes increased tumor aggression and metastasis. The future may, therefore, be quite simple: technology meets biology.

Treatment of recurrent disease in lung cancer

Recurrence is a common event after treatment of lung cancer. Retreatment options depend on previous therapies, location of recurrence, and physical condition of the patient. Locoregional relapse can be treated the same way as initial lung cancer, including surgery, radiotherapy (RT), and chemotherapy (CHT), or combined treatment. Approximately 1% to 2% of all recurrent lung cancer is treated with curative reoperation, with somewhat dismal results. RT has been used for either postsurgical or post-RT locoregional recurrences. In the former case, external beam RT was particularly effective in isolated bronchial stump recurrences, with median survival time of approximately 28.5 months and a 5-year survival of approximately 31.5%. In the latter case, reirradiation, generally with endobronchial brachytherapy, was successful in palliation of intrathoracic symptoms (in at least two-thirds of cases), carrying a low incidence of radiation pneumonitis (up to 5%) although cumulative doses went up to 120-150 Gy. Besides external beam RT, endobronchial RT was used to treat symptomatic intraluminal recurrences, with the vast majority of studies using high-dose rate brachytherapy. Finally, CHT has been used in relapsed/refractory advanced or metastatic non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) with the major emphasis on the third-generation drugs that show good response after previously used platinum-based CHT.