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Effect of Endobronchial Radiation Therapy on Malignant Bronchial Obstruction
Effect of Endobronchial Radiation Therapy on Malignant Bronchial Obstruction* Minesh Mehta, M.D.;t Siamak Shahabi, Ph.D.;t Nizar ]arjour, M.D.;:j: Mark Steinmetz, M.D.;§ and Shrikant Kubsad, M.S.t
We evaluated the effect of endobronchial radiation therapy in 52 patients with malignant airway occlusion. Fifty-five endobronchial applications of the radioisotope iridium 192 were carried out. Response was assessed by change in performance status, symptom resolution, duration of symptom relief, roentgenographic reaeration, pulmonary function tests, and postimplant bronchoscopy. Thirty-three patients showed at least a one-level improvement in performance status. Of a total of 166 symptoms present prior to therapy, 131 resolved or improved. Approximately 70 percent of a patient's lifetime was rendered symptom improved or symptom free. A roentgenographic reaeration response of 30/41 (73 percent) was achieved. The average FEV, and FVC improved from 1.5 to 2.1 Land from 2.3 to
ith more than 150,000 cases every year, lung W cancer represents today's major oncologic chal-
lenge.1 There are more than 120,000 deaths annually 1 and most therapeutic approaches result in a high incidence of local failure2 that frequently manifests as malignant airway occlusion. According to one estimate, 20 to 30 percent of newly diagnosed lung malignant neoplasms will present with atelectasis and pneumonia due to endobronchial disease. 3 Other estimates• suggest that because of a high rate of local failure following conventional therapy, up to 50 percent of patients with lung cancer will eventually develop symptomatic endobronchial disease. Death from airway occlusion is often a painful process of slow asphyxiation, frequently complicated by obstructive pneumonia and hemoptysis. The majority of these patients have previously received high-dose radiation, and tissue tolerance concerns frequently preclude further external radiation. We report herein the results ofour experience with endobronchial radiation therapy (EBR1j for malignant airway occlusion. MATERIALS AND METHODS
Between October 1986 and March 1989, 52 patients underwent *From the Departments of Human Oncology and Medicine, University of Wisconsin Medical School, Wisconsin Clinical Cancer Center, Madison. tAssistant Professor of Human Oncology. *Pulmonary Fellow. §Radiation Oncology Resident. August 24. Manuscript received May 25; revision accep~ed Reprint requests: Dr: Mehta, K4/B 600 HlghltJnd Avenue, Madison.
WI53792
862
2.9 L, respectively. Posttherapy bronchoscopy was perfunned between one and two months fOllowing the implant in 15 patients who agreed to undergo the procedure. Eleven (73 percent) of 15 had complete tumor regression. Major long-term complications were noted in seven patients. Endobronchial radiation, therefOre, appears to be a safe and etl'ective technique to palliate malignant airway occlusion. (Cheat 1990; 97:66!-65) EBRT =endobronchial radiation therapy; ECOG =Eastern Cooperative Oncology Group; PS =performance status; RTOG=Radiation Thera~ Oncology G~=-dose delivered by estemal • • ; TEF= fistula; TVF tracheovascular 6stula; CMS =chronic mucosal sloughing
=
55 endobronchial procedures. The technical and dosimetric details have been published previously. ... Median age at presentation was 67 years with a male to female ratio of 42 to 10. FOrty-six patients had primary lung malignant neoplasms and six had nonpulmonary tumors. Twenty-three patients had metastatic disease at implantation. Eleven patients had received prior chemotherapy and 31 had undergone external radiation prior to implantation. The mean time to endobronchial occlusion from completion of prior external radiation was 26.5 months with a range of two to 150 months. Twenty three patients had received what was deemed to be tolerance level radiation (>6,000 rad). Of the 55 implants, eight presented with Eastern Cooperative Oncology Group (ECOG)7 performance status (PS) 4, 14 with PS 3, 23 with PS 2, nine with 1, and one with PS 0. The most common symptoms, in decreasing order of frequency, were cough (52), dyspnea (51), pneumonia (23~ hemoptysis (21), and chest pain (19). Of the 55 patients, 39 (71 percent) had at least three symptoms at presentation. Twelve patients underwent Nd:YAG laser excision of the tumor prior to EBRT. The median implant duration was 50 h, with a range from 11 to 115 h. The median dose at 1 and 2 em from the center of the source was 4, 700 and 2,000 rad, respectively. Several parameters were analyzed to assess response. These included change in PS, symptom resolution by Radiation Therapy Oncology Group (RTOG) criteria,• percentage of lifetime rendered symptom improved or symptom free, roentgenographic reaeration, change in pulmonary function, and bronchoscopic response. RESULTS
Thirty-three patients showed at least a one-level improvement in PS, 17 remained unchanged, and five showed at least a one-level deterioration one month following EBRT ('!able 1A). A total of 166 symptoms were present prior to therapy; 131 of these resolved or improved, 20 remained unchanged, and 15 worsened ('!able 1C). When measured as an average Eudobrouchlal Radiation Therapy In MaJignllnl Bronchial Obalructlon (Mehta et 81)
Table 1-Respome to Endobronchial
~iotion
A. Change in Perfonnance Status PS (ECOG) 0 1 234 14 Pretherapy 19 23 Posttherapy 8 23 12 66 B. Roentgenographic Response Reaeration No. (%) Partial 12 (29) Complete 18 (44) Overall 30 (73) C . Change in Symptoms No. of Patients Symptom Cough Dyspnea Pneumonia Hemoptysis Chest pain Total
Improved 39 41 19 17 15 131
Pretherapy 52 51 23 21 19 166
8
Worse 4 5 2 4
Same 9 5 2 0 31 19
16
average FVC improved from 2.3 to 2.9 L . Of the 15 patients undergoing postimplant bronchoscopy, 11 had a complete bronchoscopic response, with no evidence of endobronchial tumor. Of the 52 patients, 13 are currently alive. The median surviv.J of the entire group is five months, with a range of one to 29 months. Other than one case of acute local edema resulting in immediate postbronchoscopy lung collapse that reaerated completely within 48 h, no significant acute complications related to catheter placement or EBRT were noted. Seven long-term radiation-associated or radiation-exacerbated complications were encountered . These are summarized in Table 2. One intraoperative death secondary to hemorrhage was directly attributable to laser vaporization as this patient had not even undergone catheter placement for implantation. DISCUSSION
parameter, approximately 70 percent of a patient's lifetime was rendered symptom free or symptom improved (Fig 1). Fourteen patients were roentgenographically not assessable because neither pretherapy pulmonary atelectasis nor collapse was present. Of the remaining 41 implants, complete roentgenographic reaeration, as illustrated in Figure 2, was achieved in 18 and partial reaeration in 12, for an overall roentgenographic reaeration rate of 30 of 41 or 73 percent (Table 1B). Postimplant pulmonary function studies and bronchoscopy were not performed in all patients principally because of patient reluctance to undergo more procedures in their advanced disease state. In the 14 patients who underwent pulmonary function testing, the average FEV 1 improved from 1.5 to 2.1 Land the
/o Lifetime Symptom-Free
0
cG)
~
G)
61 50
D.
25
o u-
----
~ ----
~~
Hemoptysis Pneumonia
I'm FIGURE
proved.
Asymptomatic
--
~~
Dyspnea
--
--~----~
Chest Pain •
Cough
Symptomatic
1. Percentage of lifetime rendered symptom free or im-
Several therapeutic modalities are currently available for malignant airway occlusion. These include external beam radiation,s- 11 laser therapy, 12 · 13 and endobronchial radiation.l 4 • 15 To our knowledge, no randomized study has evaluated these modalities prospectively. Although laser therapy achieves immediate airway recanalization, the duration of response is unlikely to be long, as considerable endobronchial as well as extrabronchial tumor is likely to be left untreated. A recent study9 suggested that when compared with external beam radiation, "faster palliation with fewer side effects is probably achieved with laser therapy;' but no supporting data were presented . External beam radiation can successfully reverse atelectasis and pneumonitis in 21 to 61 percent9- 11 of patients. In the largest series reported to date, 10 23 percent of330 patients had improvement of atelectasis following external radiation. In a recent study9 of 57 patients, 21 percent achieved resolution of atelectasis and a clear dose response relationship was discerned. However, at follow-up bronchoscopy, none of 14 patients had clearance of endobronchial tumor. These authors therefore concluded that high doses of external radiation are required for reaeration and despite this, the response rate is poor and complications are frequent . Endobronchial radiation, on the other hand, as seen in our study, is very successful in achieving roentgenographic reaeration and in patients undergoing repeated bronchoscopy, a high complete response rate is noted . This is probably a function of the high tumor dose delivered in a relatively short time interval. The complication rate is acceptable and can be further lowered by excluding very-high-risk patients. Other studies 14 have combined endobronchial radiation and laser excision, but the results are not superior to the endobronchial radiation series reported by us. CHEST 197 I 3 I MARCH, 1990
~
Fl!:tiHE 2. Pre-implant and postimplant chest oJ.:raphk reaeration.
roent~enogram
With the need for general anesthesia, the possible risk of intraoperative death, the intrinsic limitation of laser to have no impact on extrabronchial disease, and lack of proven superiority to endobronchial radiation, we question the need for laser excision in these patients. The recent availability of high-dose rate remote afterloading machines 15 has tremendously simplified endobronchial radiation and made it very safe for personnel. This technology also has the added advantage of being performed in an outpatient setting and thereby results in considerable savings of health care dollars. In our series of 55 implants, seven major long-term complications were encountered. The exact quantification of tracheovascular fistulae is difficult in patients not undergoing autopsies. Hemoptysis as the terminal event is not an uncommon occurrence in these paTable 2-Complications of Endobronchial Radiation* EBRT(rad) Typt• I 2 3
4 .5 6 7
TEF TVF TVF TVF CMS CMS CMS
Interval
XRT. rad
3
5500 7200 6000 6700 6400 6000 6000
.5 6 9 10
4
.5
Laser
2cm
I em
r
2400 2200 2000 2000 2000 .5300 1600
5800
N Yx4
N
r
Yx3
N
4300
4400
.5000 6000 9600 3900
*TEF = tracheoesopha)::eal fistula (this patient had a preexisting TEF that was exacerhated hy therapy); TVF = tracheova.~cular fistula; CMS =chronic mu<..,sal slouJ::hinJ.:; interval= numher of months from t."rnplt'lion of implant to l1>11lplkation; and XRT= total dose delin•red hy external radiation.
664
showin~
an example of complete
roent~en-
tients, even without implantation. We have scored all deaths secondary to hemoptysis as complications of our therapy. A total of three tracheovascular fistulae in 55 implants (3155 = 5.5 percent) in 52 patients (3/ 52=5.8 percent) were noted. These resulted in the immediate death of the three patients. An additional patient also died of hemoptysis during laser vaporization and is not scored as a complication of radiation therapy. Interestingly, of the seven major complications, four patients had laser vaporization in addition to the other therapies. Since only 12 patients had laser+ EBRT, our study suggests that the combination of external radiation, EBRT, and laser may possibly lead to a higher complication rate. However, these patients had multiple courses of therapy because of advanced tumor that could also have been responsible for the increased complication rate . Preimplant laser therapy should probably be reserved for only those patients in whom EBRT would not be feasible without first creating a channel with laser. In the setting of recurrent disease, malignant airway occlusion results in a median survival of only five months.5 Most patients have progression at distant sites and, therefore, endobronchial therapeutic maneuvers are unlikely to significantly impact overall survival. We conclude that endobronchial radiation is a highly effective palliative modality that provides excellent control of local symptoms for a significant duration of a patient's remaining life span. ACKNOWLEDGMENTS: The authors wish to thank Susan Higgins for manuscript preparation. Endobronchial Radiation Therapy in Malignant Bronchial Obstruction (Mehta et al)
REFERENCES 1 Silverberg E, Lubera JA. Cancer statistics. CA 1989; 39:3-20 2 Perez CA, Bauer M, Edelstein S, Gillespie BW, Birch R. Impact of tuinor control on survival in carcinoma of the lung treated with irradiation. Int J Radiat Oncol Bioi Phys Ui86; 12:539-47 3 Minna JD, Higgins GA, Glatstein EJ. Cancer of the lung. In: DeVita VI', Hellman S, Rosenberg SA, eds. Cancer principles and practice of oncology, 2nd ed. Philadelphia: JB Lippincott Co; 1985:518 4 Moylan D. Overview of endobronchial brachytherapy and review of literature. AER-ALTS II. New Orleans, La; 1987 5 Mehta MP, Shahabi S, Jarjour NN, Kinsella TK. Endobronchial irradiation for malignant airway obstruction. Int J Radiat Oncol . Bioi Phys (in press) 6 Shahabi S, Mehta MP, Wiley AL, Thomadsen BR, Olson MH. The role of computed tomography in dosimetric evaluation of endobronchial implants. Endocurietherapy!Hyperthermia Oncology 1988; 4:187-91 7 Beahrs OH, Henson DE, Kutler RVP, Myers MM. Manual for staging of cancer, 3rd ed. Philadelphia: JB Lippincott Co, 1988:9 8 RTOG Data Managers Handbook. Radiation Therapy Oncology Group Headquarters: Philadelphia, 1983:4.12-4.38
9 Chetty KG, Sassoon CSM, Viravathana T, Light RW. Effect of radiation therapy on bronchial obstruction due to bronchogenic carciiloma. Chest 1989; 95:582-84 10 Slawson RG, Scott RM. Radiation therapy in bronchogenic carcinoma. Ther Radiol1979; 132:175-76 11 Majid DA, Lee S, Khushalani S, Seydel M. The response of atelectasis from lung cancer to radiation therapy. Int J Radiat Oncol Bioi Phys 1986; 12:231-32 12 Personne C, Colchen A, Leroy M, Vourch G, Toty L. Indications and technique for endoscopic laser resections in bronchology: a critical analysis based upon 2,284 resections. J Thorac Cardiovasc Surg 1986; 91:71Q-15 13 Wolfe WG, Sabiston DC Jr. Management of benign and malignant lesions of the trachea and bronchi with the neodyniumyttrium-aluminium-gamet laser. j Thorac Cardiovasc Surg 1986; 91:4o-5 14 Schray MF, McDougall JC, Martinez A, Cortese DA, Brutinel MW. Management of malignant airway compromise with laser and low dose rate brachytherapy. Chest 1988; 93:264-69 15 Jackson SM. Fourth international Selectron users meeting. Vancouver: Abstracts 1986:13-157
CHEST I 97 I 3 I MARCH, 1990
665
We evaluated the effect of endobronchial radiation therapy in 52 patients with malignant airway occlusion. Fifty-five endobronchial applications of the radioisotope iridium 192 were carried out. Response was assessed by change in performance status, symptom resolution, duration of symptom relief, roentgenographic reaeration, pulmonary function tests, and postimplant bronchoscopy. Thirty-three patients showed at least a one-level improvement in performance status. Of a total of 166 symptoms present prior to therapy, 131 resolved or improved. Approximately 70 percent of a patient's lifetime was rendered symptom improved or symptom free. A roentgenographic reaeration response of 30/41 (73 percent) was achieved. The average FEV, and FVC improved from 1.5 to 2.1 Land from 2.3 to
ith more than 150,000 cases every year, lung W cancer represents today's major oncologic chal-
lenge.1 There are more than 120,000 deaths annually 1 and most therapeutic approaches result in a high incidence of local failure2 that frequently manifests as malignant airway occlusion. According to one estimate, 20 to 30 percent of newly diagnosed lung malignant neoplasms will present with atelectasis and pneumonia due to endobronchial disease. 3 Other estimates• suggest that because of a high rate of local failure following conventional therapy, up to 50 percent of patients with lung cancer will eventually develop symptomatic endobronchial disease. Death from airway occlusion is often a painful process of slow asphyxiation, frequently complicated by obstructive pneumonia and hemoptysis. The majority of these patients have previously received high-dose radiation, and tissue tolerance concerns frequently preclude further external radiation. We report herein the results ofour experience with endobronchial radiation therapy (EBR1j for malignant airway occlusion. MATERIALS AND METHODS
Between October 1986 and March 1989, 52 patients underwent *From the Departments of Human Oncology and Medicine, University of Wisconsin Medical School, Wisconsin Clinical Cancer Center, Madison. tAssistant Professor of Human Oncology. *Pulmonary Fellow. §Radiation Oncology Resident. August 24. Manuscript received May 25; revision accep~ed Reprint requests: Dr: Mehta, K4/B 600 HlghltJnd Avenue, Madison.
WI53792
862
2.9 L, respectively. Posttherapy bronchoscopy was perfunned between one and two months fOllowing the implant in 15 patients who agreed to undergo the procedure. Eleven (73 percent) of 15 had complete tumor regression. Major long-term complications were noted in seven patients. Endobronchial radiation, therefOre, appears to be a safe and etl'ective technique to palliate malignant airway occlusion. (Cheat 1990; 97:66!-65) EBRT =endobronchial radiation therapy; ECOG =Eastern Cooperative Oncology Group; PS =performance status; RTOG=Radiation Thera~ Oncology G~=-dose delivered by estemal • • ; TEF= fistula; TVF tracheovascular 6stula; CMS =chronic mucosal sloughing
=
55 endobronchial procedures. The technical and dosimetric details have been published previously. ... Median age at presentation was 67 years with a male to female ratio of 42 to 10. FOrty-six patients had primary lung malignant neoplasms and six had nonpulmonary tumors. Twenty-three patients had metastatic disease at implantation. Eleven patients had received prior chemotherapy and 31 had undergone external radiation prior to implantation. The mean time to endobronchial occlusion from completion of prior external radiation was 26.5 months with a range of two to 150 months. Twenty three patients had received what was deemed to be tolerance level radiation (>6,000 rad). Of the 55 implants, eight presented with Eastern Cooperative Oncology Group (ECOG)7 performance status (PS) 4, 14 with PS 3, 23 with PS 2, nine with 1, and one with PS 0. The most common symptoms, in decreasing order of frequency, were cough (52), dyspnea (51), pneumonia (23~ hemoptysis (21), and chest pain (19). Of the 55 patients, 39 (71 percent) had at least three symptoms at presentation. Twelve patients underwent Nd:YAG laser excision of the tumor prior to EBRT. The median implant duration was 50 h, with a range from 11 to 115 h. The median dose at 1 and 2 em from the center of the source was 4, 700 and 2,000 rad, respectively. Several parameters were analyzed to assess response. These included change in PS, symptom resolution by Radiation Therapy Oncology Group (RTOG) criteria,• percentage of lifetime rendered symptom improved or symptom free, roentgenographic reaeration, change in pulmonary function, and bronchoscopic response. RESULTS
Thirty-three patients showed at least a one-level improvement in PS, 17 remained unchanged, and five showed at least a one-level deterioration one month following EBRT ('!able 1A). A total of 166 symptoms were present prior to therapy; 131 of these resolved or improved, 20 remained unchanged, and 15 worsened ('!able 1C). When measured as an average Eudobrouchlal Radiation Therapy In MaJignllnl Bronchial Obalructlon (Mehta et 81)
Table 1-Respome to Endobronchial
~iotion
A. Change in Perfonnance Status PS (ECOG) 0 1 234 14 Pretherapy 19 23 Posttherapy 8 23 12 66 B. Roentgenographic Response Reaeration No. (%) Partial 12 (29) Complete 18 (44) Overall 30 (73) C . Change in Symptoms No. of Patients Symptom Cough Dyspnea Pneumonia Hemoptysis Chest pain Total
Improved 39 41 19 17 15 131
Pretherapy 52 51 23 21 19 166
8
Worse 4 5 2 4
Same 9 5 2 0 31 19
16
average FVC improved from 2.3 to 2.9 L . Of the 15 patients undergoing postimplant bronchoscopy, 11 had a complete bronchoscopic response, with no evidence of endobronchial tumor. Of the 52 patients, 13 are currently alive. The median surviv.J of the entire group is five months, with a range of one to 29 months. Other than one case of acute local edema resulting in immediate postbronchoscopy lung collapse that reaerated completely within 48 h, no significant acute complications related to catheter placement or EBRT were noted. Seven long-term radiation-associated or radiation-exacerbated complications were encountered . These are summarized in Table 2. One intraoperative death secondary to hemorrhage was directly attributable to laser vaporization as this patient had not even undergone catheter placement for implantation. DISCUSSION
parameter, approximately 70 percent of a patient's lifetime was rendered symptom free or symptom improved (Fig 1). Fourteen patients were roentgenographically not assessable because neither pretherapy pulmonary atelectasis nor collapse was present. Of the remaining 41 implants, complete roentgenographic reaeration, as illustrated in Figure 2, was achieved in 18 and partial reaeration in 12, for an overall roentgenographic reaeration rate of 30 of 41 or 73 percent (Table 1B). Postimplant pulmonary function studies and bronchoscopy were not performed in all patients principally because of patient reluctance to undergo more procedures in their advanced disease state. In the 14 patients who underwent pulmonary function testing, the average FEV 1 improved from 1.5 to 2.1 Land the
/o Lifetime Symptom-Free
0
cG)
~
G)
61 50
D.
25
o u-
----
~ ----
~~
Hemoptysis Pneumonia
I'm FIGURE
proved.
Asymptomatic
--
~~
Dyspnea
--
--~----~
Chest Pain •
Cough
Symptomatic
1. Percentage of lifetime rendered symptom free or im-
Several therapeutic modalities are currently available for malignant airway occlusion. These include external beam radiation,s- 11 laser therapy, 12 · 13 and endobronchial radiation.l 4 • 15 To our knowledge, no randomized study has evaluated these modalities prospectively. Although laser therapy achieves immediate airway recanalization, the duration of response is unlikely to be long, as considerable endobronchial as well as extrabronchial tumor is likely to be left untreated. A recent study9 suggested that when compared with external beam radiation, "faster palliation with fewer side effects is probably achieved with laser therapy;' but no supporting data were presented . External beam radiation can successfully reverse atelectasis and pneumonitis in 21 to 61 percent9- 11 of patients. In the largest series reported to date, 10 23 percent of330 patients had improvement of atelectasis following external radiation. In a recent study9 of 57 patients, 21 percent achieved resolution of atelectasis and a clear dose response relationship was discerned. However, at follow-up bronchoscopy, none of 14 patients had clearance of endobronchial tumor. These authors therefore concluded that high doses of external radiation are required for reaeration and despite this, the response rate is poor and complications are frequent . Endobronchial radiation, on the other hand, as seen in our study, is very successful in achieving roentgenographic reaeration and in patients undergoing repeated bronchoscopy, a high complete response rate is noted . This is probably a function of the high tumor dose delivered in a relatively short time interval. The complication rate is acceptable and can be further lowered by excluding very-high-risk patients. Other studies 14 have combined endobronchial radiation and laser excision, but the results are not superior to the endobronchial radiation series reported by us. CHEST 197 I 3 I MARCH, 1990
~
Fl!:tiHE 2. Pre-implant and postimplant chest oJ.:raphk reaeration.
roent~enogram
With the need for general anesthesia, the possible risk of intraoperative death, the intrinsic limitation of laser to have no impact on extrabronchial disease, and lack of proven superiority to endobronchial radiation, we question the need for laser excision in these patients. The recent availability of high-dose rate remote afterloading machines 15 has tremendously simplified endobronchial radiation and made it very safe for personnel. This technology also has the added advantage of being performed in an outpatient setting and thereby results in considerable savings of health care dollars. In our series of 55 implants, seven major long-term complications were encountered. The exact quantification of tracheovascular fistulae is difficult in patients not undergoing autopsies. Hemoptysis as the terminal event is not an uncommon occurrence in these paTable 2-Complications of Endobronchial Radiation* EBRT(rad) Typt• I 2 3
4 .5 6 7
TEF TVF TVF TVF CMS CMS CMS
Interval
XRT. rad
3
5500 7200 6000 6700 6400 6000 6000
.5 6 9 10
4
.5
Laser
2cm
I em
r
2400 2200 2000 2000 2000 .5300 1600
5800
N Yx4
N
r
Yx3
N
4300
4400
.5000 6000 9600 3900
*TEF = tracheoesopha)::eal fistula (this patient had a preexisting TEF that was exacerhated hy therapy); TVF = tracheova.~cular fistula; CMS =chronic mu<..,sal slouJ::hinJ.:; interval= numher of months from t."rnplt'lion of implant to l1>11lplkation; and XRT= total dose delin•red hy external radiation.
664
showin~
an example of complete
roent~en-
tients, even without implantation. We have scored all deaths secondary to hemoptysis as complications of our therapy. A total of three tracheovascular fistulae in 55 implants (3155 = 5.5 percent) in 52 patients (3/ 52=5.8 percent) were noted. These resulted in the immediate death of the three patients. An additional patient also died of hemoptysis during laser vaporization and is not scored as a complication of radiation therapy. Interestingly, of the seven major complications, four patients had laser vaporization in addition to the other therapies. Since only 12 patients had laser+ EBRT, our study suggests that the combination of external radiation, EBRT, and laser may possibly lead to a higher complication rate. However, these patients had multiple courses of therapy because of advanced tumor that could also have been responsible for the increased complication rate . Preimplant laser therapy should probably be reserved for only those patients in whom EBRT would not be feasible without first creating a channel with laser. In the setting of recurrent disease, malignant airway occlusion results in a median survival of only five months.5 Most patients have progression at distant sites and, therefore, endobronchial therapeutic maneuvers are unlikely to significantly impact overall survival. We conclude that endobronchial radiation is a highly effective palliative modality that provides excellent control of local symptoms for a significant duration of a patient's remaining life span. ACKNOWLEDGMENTS: The authors wish to thank Susan Higgins for manuscript preparation. Endobronchial Radiation Therapy in Malignant Bronchial Obstruction (Mehta et al)
REFERENCES 1 Silverberg E, Lubera JA. Cancer statistics. CA 1989; 39:3-20 2 Perez CA, Bauer M, Edelstein S, Gillespie BW, Birch R. Impact of tuinor control on survival in carcinoma of the lung treated with irradiation. Int J Radiat Oncol Bioi Phys Ui86; 12:539-47 3 Minna JD, Higgins GA, Glatstein EJ. Cancer of the lung. In: DeVita VI', Hellman S, Rosenberg SA, eds. Cancer principles and practice of oncology, 2nd ed. Philadelphia: JB Lippincott Co; 1985:518 4 Moylan D. Overview of endobronchial brachytherapy and review of literature. AER-ALTS II. New Orleans, La; 1987 5 Mehta MP, Shahabi S, Jarjour NN, Kinsella TK. Endobronchial irradiation for malignant airway obstruction. Int J Radiat Oncol . Bioi Phys (in press) 6 Shahabi S, Mehta MP, Wiley AL, Thomadsen BR, Olson MH. The role of computed tomography in dosimetric evaluation of endobronchial implants. Endocurietherapy!Hyperthermia Oncology 1988; 4:187-91 7 Beahrs OH, Henson DE, Kutler RVP, Myers MM. Manual for staging of cancer, 3rd ed. Philadelphia: JB Lippincott Co, 1988:9 8 RTOG Data Managers Handbook. Radiation Therapy Oncology Group Headquarters: Philadelphia, 1983:4.12-4.38
9 Chetty KG, Sassoon CSM, Viravathana T, Light RW. Effect of radiation therapy on bronchial obstruction due to bronchogenic carciiloma. Chest 1989; 95:582-84 10 Slawson RG, Scott RM. Radiation therapy in bronchogenic carcinoma. Ther Radiol1979; 132:175-76 11 Majid DA, Lee S, Khushalani S, Seydel M. The response of atelectasis from lung cancer to radiation therapy. Int J Radiat Oncol Bioi Phys 1986; 12:231-32 12 Personne C, Colchen A, Leroy M, Vourch G, Toty L. Indications and technique for endoscopic laser resections in bronchology: a critical analysis based upon 2,284 resections. J Thorac Cardiovasc Surg 1986; 91:71Q-15 13 Wolfe WG, Sabiston DC Jr. Management of benign and malignant lesions of the trachea and bronchi with the neodyniumyttrium-aluminium-gamet laser. j Thorac Cardiovasc Surg 1986; 91:4o-5 14 Schray MF, McDougall JC, Martinez A, Cortese DA, Brutinel MW. Management of malignant airway compromise with laser and low dose rate brachytherapy. Chest 1988; 93:264-69 15 Jackson SM. Fourth international Selectron users meeting. Vancouver: Abstracts 1986:13-157
CHEST I 97 I 3 I MARCH, 1990
665