27 Bronchus Cancer

Bronchus Cancer

19

THE GEC ESTROHANDBOOKOF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 30/04/2017

EBRT, several brachytherapy fractions, the location of the tumour in the left upper lobe, long sections of irradiated bronchi (clinical stage).The rate of fatal haemoptysis reported in the literature varies from 0% to 32% (Table 29.7). However, it is recognised by most authors that most fatal haemorrhage is not due to brachytherapy, but to tumour progression [5,27] and the rate is comparable to the incidence of haemoptysis after laser coagulation alone. Hennequin [27] found no correlation with site of the treatment, technical factors, fraction size or association with external beam therapy as has been reported by others [21], but only with the length of endobronchial tumour spread. In the randomised trial conducted by the Munich group [31] however, fatal haemoptysis occurred more frequently after 2 x 4.8 Gy HDR boost than in patients who did not receive a boost after 60 Gy external beam RT (18.9% versus 14.2% fatal haemoptisis), but results were not statistically significance (p=0.53). The rate of tracheo-oesophageal fistula leading to death in theMacha [43] series is 5.3% (mean 3.5months after start of radiotherapy). To prevent fistula, it seems to be important to examine the bronchial wall (e.g. flat ulceration) and the oesophageal wall (oesophagoscopy) carefully in central tumours growing in this area. Oesophageal tumour infiltration carries a higher risk of developing fistula. Summarized observations are presented in Table 29.8.

Late effects such as chronic radiation bronchitis, bronchial stenosis and tracheomalacia are of course only seen in long term survivors, most of themwith lesions of the trachea or primary stembronchus [27]. The incidence rates reported in the literature vary between 4 and 13%. Speisser and Spratling [73] related chronic bronchitis to dose and dose rate. (9% inMDR and 13% inHDR). Hennequin et al [27] found a relation between chronic bronchitis and trachea and main stem sites (p=0.002), total dose (p= 0.04) and irradiated volume (p=0.02), the latter being the only significant parameter in multivariate analysis.

Table 29.7: Incidence of massive haemoptysis after HDR endobronchial brachytherapy

EQD2 of BT α/β 3 Gy

Reference point (mm)

Author

N

Dose HDR* (Gy)

EBRT** (n)

Haemoptisis (%)

Nori [54]

32

3-4 x 4-5

32

22.4-24 Gy

10

0

Speiser and Spratling [73] Chang [10] Gollins [22] Gustafson [23] Hennequin [27] Tredaniel [81] Ornadel [55] Taulelle [80] Huber [31]

295

3 x 10, 3 x 7.5

156

47.2-78 Gy

10

7

76

3 x 7

59 82 12 56 32 92

42 Gy 54 -92 42 Gy

10 10 10 10 10 10 10

4

406

1 x 15-20

7.9

46

3 x 7

7

149

4-6 x 7 2 x 4.8 1-6 x 7 1 x 15

112

56-84 Gy

5-15

7.4

56 51

15 Gy

18.9

14-84 Gy

10 11

117 189 175

54 Gy

3-4 x 8-10

117 160

70.4-78 Gy 54-216 Gy

7 5

Kelly [34]

1-4 x 15

6-7.5

Miller and Phillips [50]

88

3 x 10

(-)

78 Gy

10

0

Aygun [3]

62 38 31 31 20 17 12

3-5 x 5

62 38

24-40 Gy 32.4 Gy 22.4 Gy

10 10 20 10 10 10

15 32

Bedwinek [5] Mehta [47] Sutedja [78] Seagren [63] Roach [59]

3 x 6 4 x 4

9

3

3 x 10 1 x 10

31

78 Gy 26 Gy 30 Gy

32 28

(+) (+) (+)

30 Gy (LDR)

0

Khanavakar [35]

2-8 x 8

35.2-140.8 Gy

5

50

* number of fractions and fraction size in Gy, ** EBRT before BT or simultaneously, EBRT – external beam radiation therapy, BT – brachytherapy, LDR – low dose rate