High Dose-Rate Intraluminal Irradiation in Bronchogenic Carcinoma: Conclusion

High Dose-Rate Intraluminal Irradiation in Bronchogenic Carcinoma: ConclusionThe good results in published series have not been without associated morbidity and, at times, mortality. A discussion of complications for a procedure which, in many patients, is largely of palliative intent is essential. In general, the complication rates have varied, with the most common complications being radiation-induced bronchitis, fistulae, and pulmonary hemorrhage. All patients treated in our study tolerated irradiation treatments well. We encountered minimal and no acute or late complications attributable to the treatment. Following brachytherapy, two patients required extended observations for cardiac abnormalities; however, all patients were treated and sent home on the same day, and no patient required admission to the hospital as a result of endobronchial irradiation. One patient experienced persistent cough necessitating symptomatic management. In 15 patients, despite significant previous treatment for primary disease, there was no morbidity or mortality encountered. Overall, not a single patient in our entire series formed fistulae or hemorrhaged. buy antibiotics online

Analysis of serious complications, as reported in the literature, records a trend toward these occurring in patients with prior high-dose external-beam therapy or laser therapy (or both). Perhaps even more closely related to the risk of complications is the dose per fraction of the HDR brachytherapy. This is clearly demonstrated in Table 3, which summarizes the most widely quoted reports. The impact of fraction size is evident in the report of Seagren et al, where 1,000 cGy prescribed at a 1-cm distance from the center of the catheter resulted in a 25 percent incidence of fatal pulmonary hemorrhage. Bedwineck et al observed a 32 percent incidence of severe hemorrhage after delivering multiple 600-cGy HDR treatments prescribed at 1 cm from the source center. The majority of these patients received laser debulking as well. Interestingly, these authors noted the possibility of a significantly higher dose delivered in many patients during the brachytherapy. This was attributed to anatomic factors that lead to the placement of the source closer to the bronchial wall than originally planned. Theoretically, doses approaching 15,000 cGy could have been delivered with HDR. Importantly, Zajacs series demonstrated no difference in the tumor response rate to HDR brachytherapy of 500 cGy prescribed at 1 cm, compared to 700 cGy at 1 cm or 1,000 cGy at 1 cm; however, no serious complications were seen within the 500-cGy treatment arm, as opposed to the 10 percent fatalities experienced with 700 or 1,000 cGy.
Our reported series suggests that an excellent clinical response with minimal morbidity can be achieved by diminishing the dose per fraction delivered by HDR brachytherapy. Randomized controlled trials with different fractionation schedules on large numbers of patients are required to further clarify this issue regarding complications and overall effectiveness of HDR brachytherapy. Future investigation should also evaluate the value of HDR in conjunction with external-beam therapy in the treatment of patients with primary bronchogenic carcinoma. In our series, all patients were treated and sent home on the same day, and no patient required admission to the hospital as a result of endobronchial irradiation. One patient experienced persistent cough necessitating symptomatic management. In 15 patients, despite significant previous treatment for primary disease, there was no morbidity or mortality encountered. Overall, not a single patient in our entire series formed fistulae or hemorrhaged.
Analysis of serious complications, as reported in the literature, reveals a trend toward these occurring in patients with prior high-dose external-beam therapy or laser therapy (or both). Perhaps even more closely related to the risk of complications is the dose per fraction of the HDR brachytherapy.

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