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Transbronchial radioactive implantation using a Flexible Injector System. An improved technique for endobronchial brachytherapy
Radiotherapy and Oncology, 5 (t986) 11-13 Elsevier
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RTO00183
Transbronchial radioactive implantation using a Flexible* Injector System. An improved technique for endobronchial brachytherapy B h a r a t B. M i t t a l * * , J o h n P a r s o n s , J o h n W e b s t e r a n d M e l v i n D e u t s c h Department of Radiology (Radiation Oneology), Presbyterian University Hospital, Pittsburgh, PA 15213, U.S.A.
(Received 31 January 1985, revision received6 June 1985, accepted 3 September 1985)
Key words." Radioactive implantation; Flexible Injector System; Endobronchial brachytherapy
Summary A new implantation device for endobronchial brachytherapy is described. This implantation system is flexible and can be easily passed through the suction channel of a flexible bronchofiberscope (FBF) for radionucleide implantation of the tumor. All four patients implanted using this system, experienced excellent palliation of their symptoms. We think that the flexible system described is an improvement over the rigid system for endobronchial implantation in most patients.
Introduction Despite the widespread application of the flexible bronchofiberscope (FBF) in the diagnosis of lung cancer, its potential for the implantation of radioactive isotopes in tumors has not been fully recognized. In the past, endobronchial brachytherapy has mostly been carried out with a rigid bronchoscope [1~4,6]. In this publication, we will describe a Flexible
* Developed by Dr. D. Barlow and Associates, Olympus Corporation of America, Medical Instrument Division, 4 Nevada Dr., New Hyde Park, New York, NY 11042, U.S.A. ** Address for reprints: Bharat B. Mittal, Department of Radiology (Division of Radiation Oncology), Northwestern Memorial Hospital, 250 E. Superior Street University Hospital, Chicago, IL 60611, U.S.A.
Injector System (FIS) that employs an FBF* to implant radioactive isotopes in endobronchial tumors with minimal morbidity and far less discomfort to the patient than that associated with the rigid bronchoscope.
Methods and materials The i~IS consists of finger and thumb rings, exposure/retraction mechanisms, a flexible sheath and a sharp, beveledged needle (Fig. 1). The latch is released and, to avoid damage to the bronchoscope, the needle is retracted within the sheath prior to insertion through the wide suction channel of an FBF. The Flexible Injector S y s t e m ( F I S ) .
* Olympus FB-1TR bronchofiberscope.
12 SLIDER
(Exposes fhe needle)
FINGER RINGS
/
THUMB RING (Controls st ylef )
FLEXIBLE SHEATH
RETRACTABLE NEEDLE WITH STYLET
Fig. 1. Schematicdiagramshowingthe FlexibleInjector System.
slider is then used to expose the needle at the tip of the flexible sheath. A thumb ring is used to control the stylet which pushes the radioactive seeds into the tumor or submucosa. The FIS is reusable and can be sterilized with ethylene oxide gas.
Fig. 2. Chest radiograph shows endobronchial l~SAuimplant in patient no. 4 showingright lung collapse. bronchoscope. Therefore, partial suction of secretions and blood is still possible. Using this technique we implanted four patients.
Implantation technique. A complete blood count and coagulation studies are performed prior to the procedure to confirm adequate hemostasis. After the patient has been NPO for at least 8 h, atropine (0.4-0.8 mg (IM) was given as premedication. Topical anesthesia of the naso and oropharnyx is then achieved with 2% lidocaine spray and jelly. After an IV line is started and electrocardiographic monitoring established, supplemental diazepam (2.5 mg increments) is given IV as needed during the procedure for mild sedation. A wide-channel bronchofiberscope is introduced transnasally. During the loading of radioactive seeds in the needle of the injector system, the styler should be fully retracted so that the bevelled edge of the needle is not blunted with the protruding seed. The needle tip is covered with a thin layer of Povidine-iodine ointment to prevent the seed from falling out. The flexible sheath of the FIS is passed through the suction channel of the FBF. Once the tip of the FIS reaches the tumor, the slider is pulled towards the finger rings to expose the needle. A quick jab causes the needle to pierce the tumor; the thumb ring is then pushed towards the finger rings to help the stylet expel and implant the seed in the tumor. This procedure is repeated until the desired number of seeds has been implanted. The flexible sheath of the FIS only partially occludes the suction channel of the
Results
In all four patients, we were able to implant 198Au seeds using FIS and FBF with minimal discomfort and bleeding. On the average, the procedure took approximately 30 min. It was somewhat difficult to implant seeds in the normal-looking submucosa due to the elasticity and retractibility of the bronchial mucosa and submucosa. During the procedure if a radioactive seed drops out of the needle Isodoses 5
10000 5000
50
4000 3000 2500 EO00 1500 1000 500
Fig. 3. Mid-plane isodose curves in patient no. 4.
13 into the bronchus; it can be retrieved using small biopsy forceps. Post-implant radiographs with computerized dosimetry in patient no. 4 is shown in Figs. 2 and 3. None of the patients coughed out any seeds. The patients stayed in the hospital 4-5 days for radiation monitoring. In order to decrease prolonged hospitalization, low energy radionuclides (125I) can be used for implanting tumors. After the procedure, all patients had slightly blood-stained sputum which cleared within 24-48 h. None of the patients had fever or any other complications. G o o d subjective and objective palliation was achieved in all the four patients as evidenced by improvement in dyspnea, resolution of hemoptysis, reexpansion of collapsed lung and marked tumor destruction on repeat bronchoscopy.
Discussion The feasibility of rigid bronchoscope for interstitial implantation of endobronchial tumors has been well established [14,6]. In recent years, FBF has been used for temporary 192Ir intraluminal brachytherapy [7]. The purpose of this publication is not to discuss the value of endobronchial implants; the merits of this technique have already been proven in a large number of patients [2,4,7]. In this paper, we have described a new flexible endobronchial implant system that can be used with an FBF for implanting endobronchial tumors with minimal discomfort and morbidity to the patient. Recently, Moylan et al. [5] used the same system to implant three patients with recurrent lung cancer; they achieved good results with no complications. We
think that with more experience, the FIS may prove to be more versatile and better suited for endobronchial implants than are the radioactive seed implanters used through the rigid bronchoscope, except in patients with highly vascular tumors who are at high risk of profuse bleeding. For these patients, a rigid scope would be superior providing better suction and cauterization.
Acknowledgement I am indebted to the physicians from Pulmonary Medicine for their cooperation.
References 1 Hilaris, B., Liskow, A., Bains, M. S. and Martini, N. A new endobronchial implanter. Clin. Bull. 9: 21-23, 1979. 2 Hilaris, B., Martini, N. and Loumanen, R. K. Endobronchial interstitial implantation. Clin. Bull. 9: 17-20, 1979. 3 Kernan, J. D. Carcinoma of the lung and bronchus: treatment with radon implantations and diathermy. Arch. Otolarynol. 17: 457-475, 1933. 4 Kernan, J. D. and Cracovaner, A.J. Carcinoma of the lung. Arch. Surg. 18: 315-321, 1929. 5 Moylan, D., Strubler, K., Unal, A. et al. Work in progress. Transbronchial brachytherapy of recurrent bronchogenic carcinoma: a new approach using the Flexible Fiberoptic Bronchoscope. Radiology 147: 253-254, 1983. 6 Pool, J. L. Bronchoscopyin the treatment of lung cancer. Ann. Otoot. Rhinool. Laryngol. 70: 1172-1178, 1961. 7 Shray, M. F., McDougall, J. C., Martinez, A., Edmundson, G. K. and Cortese, D. A. Managementof malignant airway obstruction: clinical and dosimetric considerations using an Iridium-192 afterloading technique in conjunction with the neodymium-YagLaser. Int. J. Radiat. Oncol. Biol. Phys. 1I: 403-409, 1985.
1l
RTO00183
Transbronchial radioactive implantation using a Flexible* Injector System. An improved technique for endobronchial brachytherapy B h a r a t B. M i t t a l * * , J o h n P a r s o n s , J o h n W e b s t e r a n d M e l v i n D e u t s c h Department of Radiology (Radiation Oneology), Presbyterian University Hospital, Pittsburgh, PA 15213, U.S.A.
(Received 31 January 1985, revision received6 June 1985, accepted 3 September 1985)
Key words." Radioactive implantation; Flexible Injector System; Endobronchial brachytherapy
Summary A new implantation device for endobronchial brachytherapy is described. This implantation system is flexible and can be easily passed through the suction channel of a flexible bronchofiberscope (FBF) for radionucleide implantation of the tumor. All four patients implanted using this system, experienced excellent palliation of their symptoms. We think that the flexible system described is an improvement over the rigid system for endobronchial implantation in most patients.
Introduction Despite the widespread application of the flexible bronchofiberscope (FBF) in the diagnosis of lung cancer, its potential for the implantation of radioactive isotopes in tumors has not been fully recognized. In the past, endobronchial brachytherapy has mostly been carried out with a rigid bronchoscope [1~4,6]. In this publication, we will describe a Flexible
* Developed by Dr. D. Barlow and Associates, Olympus Corporation of America, Medical Instrument Division, 4 Nevada Dr., New Hyde Park, New York, NY 11042, U.S.A. ** Address for reprints: Bharat B. Mittal, Department of Radiology (Division of Radiation Oncology), Northwestern Memorial Hospital, 250 E. Superior Street University Hospital, Chicago, IL 60611, U.S.A.
Injector System (FIS) that employs an FBF* to implant radioactive isotopes in endobronchial tumors with minimal morbidity and far less discomfort to the patient than that associated with the rigid bronchoscope.
Methods and materials The i~IS consists of finger and thumb rings, exposure/retraction mechanisms, a flexible sheath and a sharp, beveledged needle (Fig. 1). The latch is released and, to avoid damage to the bronchoscope, the needle is retracted within the sheath prior to insertion through the wide suction channel of an FBF. The Flexible Injector S y s t e m ( F I S ) .
* Olympus FB-1TR bronchofiberscope.
12 SLIDER
(Exposes fhe needle)
FINGER RINGS
/
THUMB RING (Controls st ylef )
FLEXIBLE SHEATH
RETRACTABLE NEEDLE WITH STYLET
Fig. 1. Schematicdiagramshowingthe FlexibleInjector System.
slider is then used to expose the needle at the tip of the flexible sheath. A thumb ring is used to control the stylet which pushes the radioactive seeds into the tumor or submucosa. The FIS is reusable and can be sterilized with ethylene oxide gas.
Fig. 2. Chest radiograph shows endobronchial l~SAuimplant in patient no. 4 showingright lung collapse. bronchoscope. Therefore, partial suction of secretions and blood is still possible. Using this technique we implanted four patients.
Implantation technique. A complete blood count and coagulation studies are performed prior to the procedure to confirm adequate hemostasis. After the patient has been NPO for at least 8 h, atropine (0.4-0.8 mg (IM) was given as premedication. Topical anesthesia of the naso and oropharnyx is then achieved with 2% lidocaine spray and jelly. After an IV line is started and electrocardiographic monitoring established, supplemental diazepam (2.5 mg increments) is given IV as needed during the procedure for mild sedation. A wide-channel bronchofiberscope is introduced transnasally. During the loading of radioactive seeds in the needle of the injector system, the styler should be fully retracted so that the bevelled edge of the needle is not blunted with the protruding seed. The needle tip is covered with a thin layer of Povidine-iodine ointment to prevent the seed from falling out. The flexible sheath of the FIS is passed through the suction channel of the FBF. Once the tip of the FIS reaches the tumor, the slider is pulled towards the finger rings to expose the needle. A quick jab causes the needle to pierce the tumor; the thumb ring is then pushed towards the finger rings to help the stylet expel and implant the seed in the tumor. This procedure is repeated until the desired number of seeds has been implanted. The flexible sheath of the FIS only partially occludes the suction channel of the
Results
In all four patients, we were able to implant 198Au seeds using FIS and FBF with minimal discomfort and bleeding. On the average, the procedure took approximately 30 min. It was somewhat difficult to implant seeds in the normal-looking submucosa due to the elasticity and retractibility of the bronchial mucosa and submucosa. During the procedure if a radioactive seed drops out of the needle Isodoses 5
10000 5000
50
4000 3000 2500 EO00 1500 1000 500
Fig. 3. Mid-plane isodose curves in patient no. 4.
13 into the bronchus; it can be retrieved using small biopsy forceps. Post-implant radiographs with computerized dosimetry in patient no. 4 is shown in Figs. 2 and 3. None of the patients coughed out any seeds. The patients stayed in the hospital 4-5 days for radiation monitoring. In order to decrease prolonged hospitalization, low energy radionuclides (125I) can be used for implanting tumors. After the procedure, all patients had slightly blood-stained sputum which cleared within 24-48 h. None of the patients had fever or any other complications. G o o d subjective and objective palliation was achieved in all the four patients as evidenced by improvement in dyspnea, resolution of hemoptysis, reexpansion of collapsed lung and marked tumor destruction on repeat bronchoscopy.
Discussion The feasibility of rigid bronchoscope for interstitial implantation of endobronchial tumors has been well established [14,6]. In recent years, FBF has been used for temporary 192Ir intraluminal brachytherapy [7]. The purpose of this publication is not to discuss the value of endobronchial implants; the merits of this technique have already been proven in a large number of patients [2,4,7]. In this paper, we have described a new flexible endobronchial implant system that can be used with an FBF for implanting endobronchial tumors with minimal discomfort and morbidity to the patient. Recently, Moylan et al. [5] used the same system to implant three patients with recurrent lung cancer; they achieved good results with no complications. We
think that with more experience, the FIS may prove to be more versatile and better suited for endobronchial implants than are the radioactive seed implanters used through the rigid bronchoscope, except in patients with highly vascular tumors who are at high risk of profuse bleeding. For these patients, a rigid scope would be superior providing better suction and cauterization.
Acknowledgement I am indebted to the physicians from Pulmonary Medicine for their cooperation.
References 1 Hilaris, B., Liskow, A., Bains, M. S. and Martini, N. A new endobronchial implanter. Clin. Bull. 9: 21-23, 1979. 2 Hilaris, B., Martini, N. and Loumanen, R. K. Endobronchial interstitial implantation. Clin. Bull. 9: 17-20, 1979. 3 Kernan, J. D. Carcinoma of the lung and bronchus: treatment with radon implantations and diathermy. Arch. Otolarynol. 17: 457-475, 1933. 4 Kernan, J. D. and Cracovaner, A.J. Carcinoma of the lung. Arch. Surg. 18: 315-321, 1929. 5 Moylan, D., Strubler, K., Unal, A. et al. Work in progress. Transbronchial brachytherapy of recurrent bronchogenic carcinoma: a new approach using the Flexible Fiberoptic Bronchoscope. Radiology 147: 253-254, 1983. 6 Pool, J. L. Bronchoscopyin the treatment of lung cancer. Ann. Otoot. Rhinool. Laryngol. 70: 1172-1178, 1961. 7 Shray, M. F., McDougall, J. C., Martinez, A., Edmundson, G. K. and Cortese, D. A. Managementof malignant airway obstruction: clinical and dosimetric considerations using an Iridium-192 afterloading technique in conjunction with the neodymium-YagLaser. Int. J. Radiat. Oncol. Biol. Phys. 1I: 403-409, 1985.