Intraoperative 125I Vicryl mesh brachytherapy after sublobar resection for high-risk stage I nonsmall cell lung cancer

doi:10.1016/j.brachy.2005.03.007

Brachytherapy

Volume 4, Issue 4, 2005, Pages 278-285

https://doi.org/10.1016/j.brachy.2005.03.007 Get rights and content

Abstract

Purpose

To assess the feasibility and outcomes of ¹²⁵I Vicryl mesh brachytherapy after sublobar resection in stage I nonsmall cell lung cancer (NSCLC) patients with poor pulmonary function.

Methods and materials

Between January 1997 and July 2004, patients with poor cardiopulmonary reserve who had stage IA and IB (T1-2 N0 M0) NSCLC and a forced expiratory volume in 1 s (FEV₁) of ≥0.6 L were considered for limited surgical resection either by an open or video-assisted thoracoscopic procedure and for a subsequent ¹²⁵I Vicryl mesh brachytherapy implant. Mediastinal and hilar lymph node staging was performed routinely in all patients. After clear margins were obtained grossly and on frozen section, a single-plane ¹²⁵I implant was designed to encompass a plane consisting of the staple line and a 2-cm margin of surrounding visceral pleura. The implant was introduced through the surgical incision and sutured to the visceral pleura. A prescribed dose of 100–120 Gy was delivered to a volume within 0.5 cm from the plane of the implant. Follow-up orthogonal films or CTs were obtained for dosimetric analysis. Kaplan–Meier analyses were used to estimate the local control, locoregional control, and overall survival rates.

Results

Of the 110 patients, 65 had stage IA and 45 had stage IB NSCLC. The mean preoperative FEV₁ was 47% of the predicted volume. With a median follow-up of 11 months (range 1–68 months), there were four recurrences within the radiation volume. The estimated 5-year local (in-field) control, locoregional control, and overall survival rates were 90%, 61%, and 18%, respectively.

Conclusion

Vicryl mesh brachytherapy after sublobar resection for high-risk stage I NSCLC patients is a feasible procedure, which results in an excellent local (in-field) control rate.

Introduction

The management of high-risk patients with stage I nonsmall cell lung cancer (NSCLC) is controversial. Whereas lobectomy remains the standard of care in operable patients with good performance status (1), high-risk patients have been managed with sublobar resection alone, sublobar resection followed by adjuvant external beam radiation or intraoperative brachytherapy, external beam radiation alone, and, more recently, extracranial stereotactic radiosurgery [2], [3], [4], [5], [6], [7]. Outside a randomized phase III trial, it is difficult to compare the outcomes of these different modalities due to multiple biases associated with patient selection, operability criteria, inadequate lymph node staging, and the patient's choice of treatment. This is further complicated by the limited availability of stereotactic body radiosurgery and the unique expertise of each treatment center in the management of this high-risk population.

We have previously reported the results of a phase II study of intraoperative radioactive Iodine-125 (¹²⁵I) brachytherapy after segmentectomy or wedge resection in high-risk patients with stage I NSCLC [4], [5]. The procedure was well tolerated, without an increase in intraoperative or postoperative complications, and with no radiation-related toxicity. The updated results and an in-depth analysis of recurrence rates, survival rates, and prognostic factors are presented in this retrospective study.

Section snippets

Patient selection

Preoperative evaluation and procedures included the following: a

Patient characteristics

There were 130 patients included in the raw data. After excluding 20 patients who had no follow-up data, the final study cohort comprised 110 patients. Of these 110 patients, there were 58 males and 52 females. Most patients were elderly (median age, 71 years; range, 47–89 years). All patients had severe cardiopulmonary comorbidities. Sixty-five patients had stage IA whereas 45 patients had stage IB NSCLC. The median primary tumor size was 2.5 cm (range 0.8–7.0 cm). Forty-three percent of the

Discussion

To enhance local control, various radiation modalities have been explored in the adjuvant setting after sublobar resection of early stage NSCLC. Shennib et al. (3) reported on the use of postoperative radiotherapy in a group of 28 patients with T1 N0 NSCLC from CALGB and ECOG institutions after video-assisted thoracoscopic wedge resection. Radiation fields encompassed the staple line and ranged from 5 × 6 to 11 × 9 cm. Median failure-free and overall survival rates were 19.1 and 30.4 months,

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Growing data supports the role of radiation therapy in the treatment of soft tissue sarcoma (STS). Brachytherapy has been used for decades in the management of STS and can be utilized as monotherapy or as a boost to external beam radiation. We present updated guidelines from the American Brachytherapy Society regarding the utilization of brachytherapy in the management of STS.
Members of the American Brachytherapy Society with expertise in STS and STS brachytherapy created an updated clinical practice guideline including step-by-step details for performing STS brachytherapy based on a literature review and clinical experience.
Brachytherapy monotherapy should be considered for lower-recurrence risk patients or after a local recurrence following previous external beam radiation; a brachytherapy boost can be considered in higher-risk patents meeting implant criteria. Multiple dose/fractionation regimens are available, with determination based on tumor location and treatment intent. Techniques to limit wound complications are based on the type of wound closure; wound complication can be mitigated with a delay in the start of brachytherapy with immediate wound closure or by utilizing a staged reconstruction technique, which allows an earlier treatment start with a delayed wound closure.
These updated guidelines provide clinicians with data on indications for STS brachytherapy as well as guidelines on how to perform and deliver high quality STS brachytherapy safely with minimal toxicity.
Brachytherapy for lung cancer
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Brachytherapy (BT) is a minimally invasive anticancer radiotherapeutic modality where the tumor is directly irradiated via a radioactive source that is precisely implanted in or adjacent to the tumor. BT for lung cancer may be conducted in the form of endobronchial BT and radioactive seed implantation (RSI-BT), mainly for nonsmall cell lung cancer (NSCLC). For patients with early-stage lung cancer who are not suitable for surgery or external beam radiotherapy (EBRT), BT may be used as an alternative treatment, and curative results could be achieved in certain patients with cancer confined to the trachea lumen. For patients with locally advanced/metastatic lung cancer, BT could be selectively applied alone or as a boost to EBRT, which could improve the local tumor control and patient’s survival. In addition, BT is also useful as a salvage treatment in select patients with locally recurrent/residual lung cancer that failed other treatments (e.g., surgery, chemotherapy, and EBRT). However, clinical outcomes are mainly obtained from retrospective studies. Prospective studies are limited and needed. In recent years, the introduction of modern image guidance, novel radioactive seeds, BT treatment planning systems (BT-TPS), after-loading technique, and three-dimensional printing template (3D-PT) assistance, among others, have potentially improved the clinical outcomes of BT. However, a comprehensive review of BT with newly published literature was lacking. This review is to discuss BT for NSCLC based on recent literature published in PubMed.
American Brachytherapy Society consensus statement for soft tissue sarcoma brachytherapy
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Citation Excerpt :
The ability to conform the HDR dose has the potential to minimize radiation dose to the incision and skin, which may improve wound healing. The use of iodine-125 (125I) permanent seed implants is a recognized form of LDR BT, which has been described in thoracic malignancies (57,58), with limited evidence of efficacy in STS. The use of permanent seeds has been described in adult STS of the extremity (59), deep irregular cavities (60), and the retroperitoneum (61).
Radiation therapy represents an essential treatment option in the management of soft tissue sarcomas (STS). Brachytherapy represents an important subset of radiation therapy techniques used for STS, with evolving indications and applications. Therefore, the purpose of this guideline was to update clinicians regarding the data surrounding brachytherapy (BT) and provide recommendations for the utilization of BT in patients with STS.
Members of the American Brachytherapy Society with expertise in STS, and STS BT in particular, created an updated guideline for the use of BT in STS based on a literature review and clinical experience.
Guidelines are presented with respect to dose and fractionation and technical features to improve outcomes and potentially reduce the risk of toxicity. Brachytherapy as monotherapy can be considered in low-risk cases or in situations where re-irradiation is being considered. Brachytherapy boost can be considered in cases at higher risk of recurrence or where BT alone cannot adequately cover the target volume. To limit wound complications, the start of BT delivery should be delayed until final wound closure, or if after immediate reconstruction, started after postoperative Day 5.
The current guidelines have been created to provide clinicians with a review of the data supporting BT in the management of STS as well as providing indications and technique guidelines to ensure optimal patient selection and clinical outcomes.
American Brachytherapy Society consensus guidelines for thoracic brachytherapy for lung cancer
2016, Brachytherapy
To update brachytherapy recommendations for pretreatment evaluation, treatment, and dosimetric issues for thoracic brachytherapy for lung cancer.
Members of the American Brachytherapy Society with expertise in thoracic brachytherapy updated recommendations for thoracic brachytherapy based on literature review and clinical experience.
The American Brachytherapy Society consensus guidelines recommend the use of endobronchial brachytherapy for disease palliation in patients with central obstructing lesions, particularly in patients who have previously received external beam radiotherapy. The use of interstitial implants after incomplete resection may improve outcomes and provide enhanced palliation. Early reports support the use of CT-guided intratumoral volume implants within clinical studies. The use of brachytherapy routinely after sublobar resection is not generally recommended, unless within the confines of a clinical trial or a registry.
American Brachytherapy Society recommendations for thoracic brachytherapy are provided. Practitioners are encouraged to follow these guidelines and to develop further clinical trials to examine this treatment modality to increase the evidence base for its use.
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2015, Clinical Lung Cancer
Lung cancer is among the most common cancers worldwide and is the leading cause of cancer death in both men and women. For patients with early stage (American Joint Committee on Cancer T1-2, N0) non–small-cell lung cancer, the current standard of care is lobectomy with systematic lymph node evaluation. Unfortunately, patients with lung cancer often have medical comorbities, which may preclude the option of surgical resection. In such cases, a number of minimally invasive to noninvasive treatment options have gained popularity in the treatment of these high-risk patients. These modalities provide significant advantages, including patient convenience, treatment in an outpatient setting, and acceptable toxicities, including reduced impact on lung function and a modest risk of postprocedure chest wall pain. We provide a comprehensive review of the literature, including reported outcomes, complications, and limitations of sublobar resection with or without intraoperative brachytherapy, radiofrequency ablation, microwave ablation, percutaneous cryoablation, photodynamic therapy, and stereotactic body radiotherapy.
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Although lobectomy is widely accepted as the mainstay of treatment for pulmonary neoplasms (31–33), our case illustrates the potential benefits of using wedge resection and 131Cs brachytherapy to treat pulmonary metastases in patients with a compromised lung function. Previous studies have demonstrated the effectiveness of wedge resection with 125I brachytherapy to treat patients with primary lung cancer (16–18, 34–36). However, scarce literature exists on the surgical treatment of pulmonary metastases with this approach.
Soft-tissue sarcomas most frequently metastasize to the lung. Surgical resection of pulmonary metastases is the primary treatment modality. Although lobectomy is widely acknowledged as the standard procedure to treat primary pulmonary tumors, the standard for pulmonary metastases is not well defined; furthermore, compromised lung function may tip the scales in favor of a less invasive approach. Here, we report the results of a patient treated with wedge resection and intraoperative cesium-131 (¹³¹Cs).
A 58-year-old African American female was diagnosed with the American Joint Committee on Cancer Stage IIA mixed uterine leiomyosarcoma and underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy followed by adjuvant external beam radiotherapy to a total dose of 45 Gy and vaginal brachytherapy to a total dose of 20 Gy. At 2 years, a routine CT scan of the chest revealed metastasis to right upper lobe of the lung. The patient's poor pulmonary function, related to a 45 pack-year smoking history and chronic emphysema, precluded a lobectomy.
After the patient underwent a lung-sparing wedge resection of the pulmonary right upper lobe metastasis and intraoperative brachytherapy with ¹³¹Cs seeds to a total dose of 80 Gy, she remained disease free in the implanted area. At a 2-year followup, imaging continued to reveal 100% local control of the area treated with wedge resection and intraoperative ¹³¹Cs brachytherapy. The patient had no complications from this treatment.
Such treatment approach may become an attractive option in patients with oligometastatic disease and compromised pulmonary function.

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: Oral presentation at the 2004 ASTRO Meeting, Atlanta, GA.

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Intraoperative 125I Vicryl mesh brachytherapy after sublobar resection for high-risk stage I nonsmall cell lung cancer

Abstract

Purpose

Methods and materials

Results

Conclusion

Introduction

Section snippets

Patient selection

Patient characteristics

Discussion

Ann Thorac Surg

Int J Radiat Oncol Biol Phys

Int J Radiat Oncol Biol Phys

Surgery

Chest

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Intraoperative ¹²⁵I Vicryl mesh brachytherapy after sublobar resection for high-risk stage I nonsmall cell lung cancer