Brachytherapy for Carcinoma of the Lung

Brachytherapy for Carcinoma of the Lung

An estimated 157,000 patients
died of lung cancer in the United States in the year 2000.[1] Although surgery can be curative, only about 20%
of patients are amenable to complete surgical resection. Most of the other
patients are treated with radiation therapy (external-beam irradiation and/or
brachytherapy) and/or chemotherapy, with less than 10% surviving to 5 years.

Most patients referred for radiation therapy have large tumor
volumes requiring high doses of radiation for control of locoregional disease.
Dose escalation with external-beam radiation therapy is limited by tolerance of
the surrounding normal structures. Brachytherapy is one method of delivering a
higher radiation dose to the tumor while sparing the surrounding normal tissues,
in an attempt to improve local control. Small or occult carcinomas of the lung
in medically inoperable patients are another subgroup in whom brachytherapy can
be used to boost the external-beam radiation dose.

The majority of lung cancer patients eventually have symptoms
related to local progression and subsequently die from locoregional failure.
Commonly reported symptoms from failure of local control include cough, dyspnea,
pain, and hemoptysis, with the majority related to endobronchial disease.
Therefore, management of the endobronchial and peribronchial component of lung
cancer is quite important, even in patients with metastatic disease.
Brachytherapy can be used for palliation in these patients.

Guideline Process

The use of brachytherapy for lung cancer is not new. Even as
early as 1922, Yankauer described two cases of lung cancer treated
endoscopically with radium (Ra)-226.[2] In 1933, Graham and Singer[3] implanted
radon-222 seeds into lung tumors, and Ormerod[4] performed transbronchial
brachytherapy in 1937. The use of low-energy iodine (I)-125 reduced the
radiation safety problems and regulations associated with the earlier
radionuclides. Subsequently, the advent of the fiberoptic bronchoscope and the
development of the high-activity iridium (Ir)-192 remote afterloader led to a
significant increase in the use of endobronchial brachytherapy.

Brachytherapy may be used alone, in combination with surgery, or
with external-beam radiation. The intent of treatment may be cure or palliation
of symptoms.

Lung brachytherapy techniques vary widely, and only limited
guidelines exist for their clinical use.[5] The American Brachytherapy Society
(ABS), therefore, formed a panel to issue guidelines specifically for the use of
brachytherapy for lung carcinoma.


Selected members of the ABS with expertise in lung brachytherapy
performed a literature review, which, supplemented by their clinical experience
and biomathematical modeling, allowed formulation of specific recommendations
and directions for future investigations in lung brachytherapy. These
recommendations were made by consensus and supported by evidence in the
literature, whenever possible. The consensus levels used by the ABS are similar
to those of the National Comprehensive Cancer Network and are defined as

  • Category 1: There is uniform panel consensus, based on
    published literature, that the recommendation is appropriate.

  • Category 2: Recommendation is based on low-level evidence,
    including nonpublished clinical experience. There is no major disagreement among
    panel members.

  • Category 3: There is major disagreement among panel members
    that the recommendation is appropriate.

This initial report was revised based on the comments of
external experts, including some who were ABS members and some who were not. The
board of directors of the ABS approved this final document.


The results of the deliberation of the panel and the ABS
recommendations are given in the following sections. Unless specifically noted,
these recommendations generally reflect a level 1 consensus.

Endobronchial Brachytherapy Techniques

Bronchoscopic and
Catheter Insertion

The ABS made the following recommendations regarding
bronchoscopic and catheter insertion techniques. Readers may refer to standard
textbooks for procedural details.[7-9]

The ABS recommends that brachytherapy be performed with flexible
fiberoptic bronchoscopy via the transnasal approach, with the patient under
conscious sedation. Sedation should be administered by individuals who are
properly trained and familiar with this approach. Intensive monitoring (eg, of
blood pressure, pulse oximetry, and cardiac status) is required, and appropriate
medical personnel and monitoring equipment (including electrocardiogram for
high-risk patients) must be available.

The tumor should be visualized through the bronchoscope and
photographed, if possible, for documentation and comparison on follow-up
examination. The tumor location in the tracheobronchial tree, percentage of
lumen occlusion, and length of airway involvement should all be recorded for
dose prescription purposes.

The catheter tip should be placed at least 2 cm beyond the most
distal aspect of the tumor, whenever possible. Localizing the tip in a segmental
bronchus helps to hold the catheter in place.[10] It should be noted that the
endobronchial lesion is usually well visualized under bronchoscopy but not under
fluoroscopy. Conversely, the catheter tip with the guidewire in place can
usually be clearly seen under fluoroscopy, but the tip’s position in relation
to the distal end of the tumor is harder to verify on bronchoscopy.

Graduated markings on the catheter help determine its location
relative to the tumor. If premarked catheters are not available, marking the
distal portion of the catheter at 5-cm intervals before insertion provides these
visual reference points for catheter placement and treatment planning (category
2). Although the exact length to be treated depends on the extent of bronchial
(or tracheal) involvement, lengths of
5 to 7 cm are commonly irradiated.

Centering devices (balloons, cages, and sheaths) can help to
reduce dose inhomogeneity in the bronchial wall (category 2).[11] The ABS deems
centering devices to be optional, depending on physician preference.

When required by the tumor location, two or more catheters
should be used to achieve adequate dosimetric coverage. In this situation, the
first catheter is placed through the bronchoscope into the desired location, and
the bronchoscope is withdrawn while the catheter remains in place. The
bronchoscope is subsequently reintroduced, and a second catheter is placed in
the desired location in the adjacent bronchus. Multiple catheters are commonly
used in tumors located at the major or minor carina.

Fluoroscopy should be used to visualize the guidewire during
insertion and to confirm that the catheter is not displaced as the bronchoscope
is removed. The external end of the catheter should be adequately secured to the
patient’s nose and marked with an ink pen at the nostril edge to allow an
additional visual check that the catheter has not migrated.

Upon treatment completion and catheter removal, the patient and
room should be surveyed to rule out any radioactive source misplacement. The
patient should be observed after the procedure and discharged only when stable.


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