Salim Aisen

High-dose-rate brachytherapy in symptom palliation due to malignant endobronchial obstruction: A quantitative assessment

PURPOSE This study was performed to objectively evaluate the effect of high-dose-rate endobronchial brachytherapy (HDREB) in symptom palliation of patients with malignant airway obstruction and treatment-related toxicity. METHODS AND MATERIALS Seventy-eight patients were treated with palliative intent according to a prospective observational protocol. HDREB was delivered in three fractions of 7.5 Gy at weekly or fortnightly intervals, associated or not with external beam irradiation. Most patients presented with lung cancer primaries and were treated because of lesions located in the trachea and/or main bronchi. Performance status, degree of obstruction, and symptom palliation were graded according to an objective score index, defined before and after HDREB at the last followup visit. Survival was considered from the end of HDREB for at least 3 years or until death. RESULTS Overall, there was a 70% improvement, with migration of patients from lower to higher performance status. Bronchial obstruction was improved in 73.4% of the patients. The symptom that presented the better response was hemoptysis (100% complete relief) followed by postobstructive pneumonia (80%), dyspnea (57.4%), and cough (33.9%). Median survival was 6 months and improved in patients with complete response at bronchoscopy (9 months). There were two (2.6%) cases of bronchial fistulae and eight cases (10.2%) of fatal hemoptysis. CONCLUSIONS HDREB is an excellent modality for palliating malignant airway obstruction resulting in quality of life improvement, with a good tolerance, patient compliance, and low rate of complications.

High dose-rate brachytherapy as a treatment option in primary tracheal tumors

PURPOSE To present experience with high dose-rate endobronchial brachytherapy in the treatment of primary tracheal tumors. PATIENTS AND METHODS Four patients with nonresected primary tracheal tumors are presented: 2 cases of squamous cell carcinoma of the trachea, 1 of recurrent adenoid cystic carcinoma, and 1 with recurrent plasmacytoma. All received brachytherapy, alone or as a boost for primary irradiation, in 3 or 4 fractions of 7.5 Gy, calculated at a depth of 1 cm. Follow-up was considered to start from the end of brachytherapy. RESULTS Local control was achieved in all cases at the time of first bronchoscopic evaluation. Two patients with squamous cell carcinoma died at 6th and 33rd months after brachytherapy, respectively. The first had no evidence of disease, and the latter had local recurrence. The other 2 patients were alive after 64 and 110 months of follow-up, respectively, both with no evidence of disease. Tracheal stenosis developed in these 2 cases, 22 and 69 months after brachytherapy. Tracheal stent placement was needed only for the patient with an adenoid cystic carcinoma. CONCLUSIONS Endobronchial high dose-rate brachytherapy may be used for tracheal tumors, even as a boost for external beam irradiation, or in recurrences. Local control in 3 out of 4 patients indicates that individual cases may benefit from the treatment. Long-term survival may also be expected, mainly for tumors with adenoid cystic histology.

Radiation therapy as an option for upper airway obstruction due to Wegener's granulomatosis

A 42-year-old white woman presented with pain, bleeding, and erosions of the nasal cavity. The diagnosis of Wegener’s granulomatosis was confirmed with a nasal biopsy in 1987. Six years later, in 1993, nasal inflammatory obstruction began, and in August 1994, the patient underwent her first surgical resection of granulomatous hypertrophic tissue of the nasal cavity. Obstruction recurred in 11 months, and an additional 4 surgical procedures were performed through July 1998, with recurrence intervals ranging from 6 to 18 months. During the course of her disease, the patient also received clinical therapy, with alternation of the classic drugs cyclophosphamide, prednisone, clotrimazole, and methotrexate. Mild cutaneous vasculitis, subglottic and bronchial stenosis, arthralgia, and hypoacusis with tympanic membrane retraction were the main systemic manifestations of her disease. She always maintained a high performance status, and organ failure never developed. Radiotherapy to the nasal cavity started in October 1998, 1 month after the last operation. At that time, plastic tubes were placed in her nasal cavities to prevent restenosis and airway obstruction. Two courses of radiation were delivered at a 1month interval: 20 and 26 Gy, respectively, in conventional fractionation (2 Gy per fraction, 5 days per week). The patient developed acute grade III mucositis with candidiasis in the nasal cavity, nasopharynx, and high oropharynx, with severe pain relieved only with morphine chlorhydrate (30 mg/d) and fluconazole (50 mg/d). Mucositis disappeared 2 months after irradiation. Methotrexate therapy was used continuously during the treatment and recovery phases. No clinical or radiological (sequential computed tomography scans) signs of recurrence were observed within 2 years of follow-up after radiotherapy. Since then, no surgical nasal interventions have been necessary. The patient continues to have mild rhinorrhea and pain, and the plastic tubes are maintained in situ until longer follow-up is achieved.