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313 X-ray exposure of examiners: Comparison of CT-guided bronchoscopy (CT-BS) and CT-guided needle biopsy (CT-NB)
Therapy
I312
- Combined
Low-grade malignant tumors of the tracheobronchial tree: Nd-YAG laser treatment
A. Verna, E. Tassara, of Genoa, /fa/y
C. Mereu.
Cenfro
di Endoscopia
Joracica,
Modali
I314
University
K. Hanai. National
Cotugno
Hospital,
M.L. Cisternino, S. Orlando, and Thoracic Surgery Dept. of
Bari, lfaly
Cancer
Increasing number of minute peripheral pulmonary lesions which are visible on CT, but not on conventional x-ray films, have been detected because of wider spread of CT systems and the use of CT for lung cancer screening. The CT-NB method was developed, however, it was difficult to apply successfully in minute lesions because of the inability to compensate for respiratory movement. The development of CT-fluoroscopy which provides 6 imageslsec with a 0.67 second delay enabled other techniques, i.e., CT-BS, as well as CT-NE combined with CT-fluoroscopy. Although respiratory movement can be compensated for using CT fluoroscopy mode, the examiners must manipulate the needle with their hands in the radiation field in CT-NB, but not in CT-BS. To better assess the risks and indications of the examinations, x-ray exposure was measured using thermoluminescence dosimeters attached on the bilateral fingers, glabella, neck, chest, and abdomen. The x-ray exposures were measured in 8 CT-NB examinations and in 7 CT-BS examinations. The mean CT-fluoroscopy time was 191 seconds in CT-NB and 389 seconds in CT-ES with 432 seconds of fluoroscopy time. The results are as follows.
CT-NE (mGy) CT-BS (mGy)
Patterns of failure in patients affected with non small cell lung cancer (NSCLC) treated with neoadjuvant chemotherapy
Neoadjuvant chemotherapy (CT) is a novel combined modality approach for stage IIIA NSCLC with the aim of inducing a tumor shrinkage before operation and a longer progression free survival (PFS) and overall survival (OS) through possible destruction of micrometastases by early application of a systemic therapy. In our series of 30 patients (pts) affected with stage IIIA NSCLC and treated, from January to December 1994, with an accelerated regimen of CT consisting of three cycles of CDDP (80 ms/m’), lfosfamide (4,000 mg/m’) and Vinorelbine (30 ms/ma) administered on day 1 every two weeks with G-CSF support, an overall response rate of 73% (7% complete) with a resection rate of 66% were observed. Three cycles of the same chemotherapy without G-CSF were administered after surgery as adjuvant. At a median follow up of 30 months the PFS and OS were 23% and 33% respectively. The patterns of failure in our series were the following:3 pts (10%) died from drug related toxicity, 2 pts (7%) did not undergo surgery because of insufficient respiratory function and 4 pts (13%) because of insufficient response to chemotherapy. Moreover 1 pt (3%) refused to continue and quickly progressed. Of the twenty pts undergoing surgery, 5 pts (17%) relapsed in lung, 4 (13%) in brain, 2 (7%) in bone and 2 (7%) in liver respectively. In conclusion from our experience we have learned that if the failure of surgery alone is largely due to undetected spread of the disease, the effect of CT seems to be quite out of proportion to intuitive expectation. Until large well designed and well conducted randomized studies will demonstrate a clear advantage of preoperative CT on surgery or RT alone, neoadjuvant CT is still to be considered as an experimental approach in the treatment of stage IIIA NSCLC.
X-ray exposure of examiners: Comparison of CT-guided bronchoscopy (CT-BS) and CT-guided needle biopsy (CT-NB)
M. Kaneko, T. Kobayashi, Y. Muramatsu, Center Hospital, Tokyo, Japan
81
V. Lorusso, F. Carpagnano, G. Di Rienzo, G. Napoli, M. De Lena. Oncology lnsfifufe
In our series 2 (both females) of 310 patients (less than 1%) with neoplastic tracheobronchial obstruction treated by laser (from October 1991 to December 1996) were affected by adenocystic carcinomas. In low-grade malignant tumors, such as carcinoids and adenocystic carcinomas, Nd-YAG laser destruction can be reserved in inoperable lesions. The first patient (M.A. - 61 years old) was classified surgically unresectable for the extension of tracheal disease. On October 1994, she received radiation therapy and than palliative single laser treatment to reduce symptoms (wheezing and cough). Good early result was obtained; eight months later a local recurrence developed that needed a second laser treatment and silicone stent position (12 mm diameter and 6 cm length). Up to date, we obtain symptomatic relief and recurrence control. The second one (P.L. - 46 years old) had surgical contraindication for a severe cardiac failure due to mitral stenosis, even though the lesion was limited to the right main bronchus. The patient required, from January 1995 to December 1996, 3 laser treatments because of the growth of the tumor with cough and hemoptysis. The last treatment was complicated by postoperative dyspnea and hypoxia, needed fiberoptic bronchoscopy to clean up endobronchial presence of fibrin. At today, the lesion spreads both the carina and the main bronchi. Although the number of patients is limited, the good results achieved makes the laser therapy an important tool in the non-surgical treatment of low-grade malignant tumors of the trachea and main-stem bronchi.
I313
Therapy
R-FIlW?E
L-Finoers
Glabella
Neck
Chest
Abdomen
13.6 0.38
1.7 0.30
0 06 0.20
0.007 0.02
0.019 0.02
0.0059 0.022
Considering these results and the recommendations of the International Commission on Radiological Protection which limit the exposure of the skin to 500 mGy/year and that of the crystalline lens (which was approximated by the glabella in this study) to 150 mGy/year, the limiting factor of CT-NB is the exposure to right fingers and that of CT-BS is the glabella. Therefore, performance of CT-NB is limited to 36 procedures/year, as opposed to 750 procedures/year in CT-BS In conclusion, CT-BS should be the first option for the diagnosis of minute peripheral pulmonary lesions and CT-NB should be reserved for cases in which diagnoses could not be obtained by CT-BS.
I
315
Plasma TGF-B levels during radiotherapy without carboplatin predicts pneumonitis non-small cell lung cancer (NSCLC)
with or in stage Ill
H.J.M. Groen ‘, M. van Waarden?, E. Fokkema’, A.H.D. van der Leest 3, A.W.T. Konings *, 2. Vujaskovic 2. Deparfmenf of’ Pulmonary Diseases; 3 Radiotherapy University Hospital Groningen; Department of ’ Radiobiology University Groningen, The Netherlands TGFfi is considered as a predictor of pneumonitis in patients (pts) receiving radiotherapy. Plasma TGF,9 levels were investigated in this ongoing study in 27 consecutive pts with NSCLC stage Ill, who were treated with 60 Gy (2 Gyiday) radiotherapy with or without carboplatin. TGFB was measured with bioassay using mink lung epithelial cells transfected with a plasminogen activator inhibitor-l promoter-luciferase construct (normal values (SD) 9.0 ngiml (1.9)). Mean (SD) pretreatment TGFfi value was 55.8 rig/ml (33). Only 3 pts had normal values, TGFB was not related to age, performance score (ECOG), or weight loss. High persistent TGFfl levels during treatment were observed in 9 pts who developed pneumonitis (CTC criteria). No relationship between pretreatment TGFB levels and pneumonitis was observed. There was no influence of carboplatin or radiation field size on the incidence of pneumonitis nor on TGFB levels during treatment. Pretreatment lung function values as % predicted of TLC, VC, FEV, and Kco (SD) were 87 (16) 86 (19) 66 (18). 116 (25), resp. Posttreatment values of TLC, VC, FEV, and Kco (n = 25) were 83 (16), 83 (13), 65 (13) 105 (25). Conclusion: elevated TGFfi levels during treatment may identify pts who develop pneumonitis after treatment. Lung function did not change significantly after treatment.
I
316
Response and toxicity of a phase II chemoradiation study for locally advanced non small cell lung cancer
N.K. Gogna’ , B.H. Burmeister ‘, G. Bryant’, J. Armstrong”, J. Mackintosh 3, K. Morton I. ’ Queens/and Radium Institute; ‘Princess Alexandra Hospital; 3 Mater Adult Hospital, South Brisbane, OLD, Australia A Phase II study was carried out to assess the response rate, toxicity and survival of patients with locally advanced non small cell lung cancer (NSCLC). The study was commenced in 1991 and forty-five patients were
I312
- Combined
Low-grade malignant tumors of the tracheobronchial tree: Nd-YAG laser treatment
A. Verna, E. Tassara, of Genoa, /fa/y
C. Mereu.
Cenfro
di Endoscopia
Joracica,
Modali
I314
University
K. Hanai. National
Cotugno
Hospital,
M.L. Cisternino, S. Orlando, and Thoracic Surgery Dept. of
Bari, lfaly
Cancer
Increasing number of minute peripheral pulmonary lesions which are visible on CT, but not on conventional x-ray films, have been detected because of wider spread of CT systems and the use of CT for lung cancer screening. The CT-NB method was developed, however, it was difficult to apply successfully in minute lesions because of the inability to compensate for respiratory movement. The development of CT-fluoroscopy which provides 6 imageslsec with a 0.67 second delay enabled other techniques, i.e., CT-BS, as well as CT-NE combined with CT-fluoroscopy. Although respiratory movement can be compensated for using CT fluoroscopy mode, the examiners must manipulate the needle with their hands in the radiation field in CT-NB, but not in CT-BS. To better assess the risks and indications of the examinations, x-ray exposure was measured using thermoluminescence dosimeters attached on the bilateral fingers, glabella, neck, chest, and abdomen. The x-ray exposures were measured in 8 CT-NB examinations and in 7 CT-BS examinations. The mean CT-fluoroscopy time was 191 seconds in CT-NB and 389 seconds in CT-ES with 432 seconds of fluoroscopy time. The results are as follows.
CT-NE (mGy) CT-BS (mGy)
Patterns of failure in patients affected with non small cell lung cancer (NSCLC) treated with neoadjuvant chemotherapy
Neoadjuvant chemotherapy (CT) is a novel combined modality approach for stage IIIA NSCLC with the aim of inducing a tumor shrinkage before operation and a longer progression free survival (PFS) and overall survival (OS) through possible destruction of micrometastases by early application of a systemic therapy. In our series of 30 patients (pts) affected with stage IIIA NSCLC and treated, from January to December 1994, with an accelerated regimen of CT consisting of three cycles of CDDP (80 ms/m’), lfosfamide (4,000 mg/m’) and Vinorelbine (30 ms/ma) administered on day 1 every two weeks with G-CSF support, an overall response rate of 73% (7% complete) with a resection rate of 66% were observed. Three cycles of the same chemotherapy without G-CSF were administered after surgery as adjuvant. At a median follow up of 30 months the PFS and OS were 23% and 33% respectively. The patterns of failure in our series were the following:3 pts (10%) died from drug related toxicity, 2 pts (7%) did not undergo surgery because of insufficient respiratory function and 4 pts (13%) because of insufficient response to chemotherapy. Moreover 1 pt (3%) refused to continue and quickly progressed. Of the twenty pts undergoing surgery, 5 pts (17%) relapsed in lung, 4 (13%) in brain, 2 (7%) in bone and 2 (7%) in liver respectively. In conclusion from our experience we have learned that if the failure of surgery alone is largely due to undetected spread of the disease, the effect of CT seems to be quite out of proportion to intuitive expectation. Until large well designed and well conducted randomized studies will demonstrate a clear advantage of preoperative CT on surgery or RT alone, neoadjuvant CT is still to be considered as an experimental approach in the treatment of stage IIIA NSCLC.
X-ray exposure of examiners: Comparison of CT-guided bronchoscopy (CT-BS) and CT-guided needle biopsy (CT-NB)
M. Kaneko, T. Kobayashi, Y. Muramatsu, Center Hospital, Tokyo, Japan
81
V. Lorusso, F. Carpagnano, G. Di Rienzo, G. Napoli, M. De Lena. Oncology lnsfifufe
In our series 2 (both females) of 310 patients (less than 1%) with neoplastic tracheobronchial obstruction treated by laser (from October 1991 to December 1996) were affected by adenocystic carcinomas. In low-grade malignant tumors, such as carcinoids and adenocystic carcinomas, Nd-YAG laser destruction can be reserved in inoperable lesions. The first patient (M.A. - 61 years old) was classified surgically unresectable for the extension of tracheal disease. On October 1994, she received radiation therapy and than palliative single laser treatment to reduce symptoms (wheezing and cough). Good early result was obtained; eight months later a local recurrence developed that needed a second laser treatment and silicone stent position (12 mm diameter and 6 cm length). Up to date, we obtain symptomatic relief and recurrence control. The second one (P.L. - 46 years old) had surgical contraindication for a severe cardiac failure due to mitral stenosis, even though the lesion was limited to the right main bronchus. The patient required, from January 1995 to December 1996, 3 laser treatments because of the growth of the tumor with cough and hemoptysis. The last treatment was complicated by postoperative dyspnea and hypoxia, needed fiberoptic bronchoscopy to clean up endobronchial presence of fibrin. At today, the lesion spreads both the carina and the main bronchi. Although the number of patients is limited, the good results achieved makes the laser therapy an important tool in the non-surgical treatment of low-grade malignant tumors of the trachea and main-stem bronchi.
I313
Therapy
R-FIlW?E
L-Finoers
Glabella
Neck
Chest
Abdomen
13.6 0.38
1.7 0.30
0 06 0.20
0.007 0.02
0.019 0.02
0.0059 0.022
Considering these results and the recommendations of the International Commission on Radiological Protection which limit the exposure of the skin to 500 mGy/year and that of the crystalline lens (which was approximated by the glabella in this study) to 150 mGy/year, the limiting factor of CT-NB is the exposure to right fingers and that of CT-BS is the glabella. Therefore, performance of CT-NB is limited to 36 procedures/year, as opposed to 750 procedures/year in CT-BS In conclusion, CT-BS should be the first option for the diagnosis of minute peripheral pulmonary lesions and CT-NB should be reserved for cases in which diagnoses could not be obtained by CT-BS.
I
315
Plasma TGF-B levels during radiotherapy without carboplatin predicts pneumonitis non-small cell lung cancer (NSCLC)
with or in stage Ill
H.J.M. Groen ‘, M. van Waarden?, E. Fokkema’, A.H.D. van der Leest 3, A.W.T. Konings *, 2. Vujaskovic 2. Deparfmenf of’ Pulmonary Diseases; 3 Radiotherapy University Hospital Groningen; Department of ’ Radiobiology University Groningen, The Netherlands TGFfi is considered as a predictor of pneumonitis in patients (pts) receiving radiotherapy. Plasma TGF,9 levels were investigated in this ongoing study in 27 consecutive pts with NSCLC stage Ill, who were treated with 60 Gy (2 Gyiday) radiotherapy with or without carboplatin. TGFB was measured with bioassay using mink lung epithelial cells transfected with a plasminogen activator inhibitor-l promoter-luciferase construct (normal values (SD) 9.0 ngiml (1.9)). Mean (SD) pretreatment TGFfi value was 55.8 rig/ml (33). Only 3 pts had normal values, TGFB was not related to age, performance score (ECOG), or weight loss. High persistent TGFfl levels during treatment were observed in 9 pts who developed pneumonitis (CTC criteria). No relationship between pretreatment TGFB levels and pneumonitis was observed. There was no influence of carboplatin or radiation field size on the incidence of pneumonitis nor on TGFB levels during treatment. Pretreatment lung function values as % predicted of TLC, VC, FEV, and Kco (SD) were 87 (16) 86 (19) 66 (18). 116 (25), resp. Posttreatment values of TLC, VC, FEV, and Kco (n = 25) were 83 (16), 83 (13), 65 (13) 105 (25). Conclusion: elevated TGFfi levels during treatment may identify pts who develop pneumonitis after treatment. Lung function did not change significantly after treatment.
I
316
Response and toxicity of a phase II chemoradiation study for locally advanced non small cell lung cancer
N.K. Gogna’ , B.H. Burmeister ‘, G. Bryant’, J. Armstrong”, J. Mackintosh 3, K. Morton I. ’ Queens/and Radium Institute; ‘Princess Alexandra Hospital; 3 Mater Adult Hospital, South Brisbane, OLD, Australia A Phase II study was carried out to assess the response rate, toxicity and survival of patients with locally advanced non small cell lung cancer (NSCLC). The study was commenced in 1991 and forty-five patients were