British Journal of Radiology (2006) 79, 522-527
© 2006 British Institute of Radiology
doi: 10.1259/bjr/31613651
Usefulness of mini-tracheostomy and torque controlled insertion of applicator in fractionated endobronchial brachytherapy
K Kishi, MD, PhD
T Yoshimasu, MD, PhD
S Shirai, MD
Y Minakata, MD, PhD
M Kimura, MD, PhD
T Sonomura, MD, PhD
Y Shioyama
and
M Sato, MD, PhD
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Abstract
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Endobronchial brachytherapy was developed as effective treatment of endobronchial cancer and fractionated schedule is applied to decrease late toxicity. However, repeated bronchofiberscopy is onerous to the patient and restricts the treatment schedule itself. We applied mini-tracheostomy for a ready access route, and a torque controlled technique for easy insertion of the endobronchial applicator. Eight patients with tracheobronchial cancer invasion were treated with endobronchial brachytherapy of 18–30 Gy/3–5 fractions/1.5–2.5 weeks (median 24 Gy/4 fractions/2 weeks) at reference points of 5 mm from the bronchial surface. The averaged individual irradiation and single session times were 4 min and 24 min, respectively. There were no procedure-related complications. These technical improvements may facilitate flexible fractionated dose prescriptions.
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Introduction
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Fractionated endobronchial brachytherapy was developed for both effective palliation of endobronchial cancer invasion [1–3], and eradication of localized superficial endobronchial cancers [4, 5]. This was performed with an endobronchial applicator inserted into the target lumen by a transoral or transnasal bronchofiberscopic approach [1–3, 5–8].
A shortcoming of this technique is the need to repeat the transoral or transnasal endobronchial approaches. Irrespective of possible fractionation patterns to decrease late radiation toxicity [9], a commonly used fractionation schedule has been once weekly [2, 4, 5, 7, 8, 10, 11].
To reduce the burden of this therapy we introduced a ready access procedure through a mini-tracheostomy, created without cartilage damage and maintained using a recently devised fast and less invasive device composed of a cannula-introducer assembly, which was originally devised for emergency use [12] and has been applied for various purposes [13, 14]. Usually the mini-stoma spontaneously closes in a few days. Additionally, the style of the applicator was curved to enable a torque control manoeuvre to insert it smoothly under fluoroscopy. The clinical feasibility and usefulness of these procedures were evaluated clinically.
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Patients
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Between January 1999 and June 2002, eight patients with inoperable advanced cancer growing into the endobronchial space, which developed 2.5–103.6 (median 46.7) months after disease onset, were subjected to this brachytherapy treatment (Table 1) in our department of radiation oncology, where 60–80 patients a year were treated (to #7). The cancer ingrowths were the only clinical manifestation at the time of the referral. The participants consisted of six males and two females aged 51–70 years (median 55.9 years). Karnofsky performance status of each patient was 80% or more. There were three tracheal cancers, three lung cancers, and one mediastinal cancer and metastatic cancer each. All had previously received external beam radiation therapy at doses of 50.4–70 Gy (median 60 Gy). Therapeutic goals of the brachytherapy included symptomatic relief from bronchial obstruction in four and prevention of further trachobronchial obstruction in all (Table 1). Patients were first evaluated by bronchofiberscopy to determine indications and target locations [11].
Informed consent was obtained prior to treatment. A choice of two treatment protocols had been offered to the patients: once a week 5 Gy brachytherapy for 4 weeks each with bronchofiberscopy according to many other reports [2, 4, 5, 7, 8, 10, 11], or the present protocol of twice a week less than 2.5 weeks after creation of a mini-stoma.
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Methods
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Mini-tracheostomy
Under local anaesthesia, according to the general insertion procedure [15], the cricothyroid membrane was penetrated with a needle-guidewire set of the Mini-Trach II system (Mini-Trach II; Portex Ltd, Kent, UK), and then a cannula-introducer assembly was introduced into the tracheal lumen with Seldinger's procedure. Thus, a mini-stoma was created and then maintained with the cannula (Figure 1a
).
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Figure 1. (a) A cannula of Mini-Trach II was inserted to maintain a mini-stoma. (b) At fractionated endotracheobronchial radiotherapy, the cannula was temporarily withdrawn and the endobronchial or endotracheal mini-applicator was gently inserted through the mini-stoma (arrow) using a curved stylet (long arrow) under fluoroscopic monitoring. The soft elastic wings were stretched during insertion (shadowed arch indicated with a broken arrow). (c) Measuring wire with dots at 1 cm intervals was inserted in the bronchial applicator, the wings of which were opened to support the applicator position (Note the different opened width of the soft wings). Reference points were determined according to the vertical distance from the bronchial surface (one reference point is shown by an asterisk, the depth: vertical line).
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Applicator deployment
Patients were pre-medicated with inhalation of 0.2 g lidocaine via a nebulizer and intramuscular injection of 0.5 mg of atropine sulphate and 25 mg of hydroxyzine. An endobronchial mini-applicator (Clinical Supply, Tokyo, Japan) composed of a stylet, an elastic hard polyethylene inner tube and a soft silicone outer tube with self-expandable wings stretched by the inner tube (Figure 1b
) [5, 7, 8], was introduced into the trachea via the stoma and inserted to the target lumen under fluoroscopic guidance, paying attention not to stimulate the tracheobronchical wall. The inner tube was curved to enable torque manipulation to reach the lesion more easily (Figure 1c) [16]. Then the inner tube was withdrawn to allow the wings to open softly and hold the catheter position in the centre of the lumen. Routine lidocaine spray topical anaesthesia, which is an irritant, was not necessary during the procedure because of the smooth insertion.
Before each session, the cannula was temporarily withdrawn, and after each session the cannula was re-inserted to maintain the stoma until the final session, after which the stoma was left for spontaneous obliteration.
Dose prescription
Treatment was scheduled twice weekly to a total dose of 18–30 Gy (median 24 Gy) in 3–6 fractions (median 4 fractions) with a single fraction dose of 5–6 Gy (median 6 Gy) for 1.5–2.5 weeks. These prescriptions were determined based on the necessity of treatment and previously irradiated dose at the reference point of the brachytherapy. In case no. 6, it was vital to suppress the widespread intratracheal tumour relapse, even though the total dose came to surpass the tolerance level of the normal tissue. The reference point was at 5 mm depth from the bronchial (tumour) surface (Figure 1c).
The mean volume with the prescribed dose was 11 cm3, ranging from 4.3 cm3 to 18.3 cm3. The biological effective doses (BED) of the present schedules were the same as those corresponding to the once weekly schedules both at a/b ratio 3 and at 10.
Follow-up
Patients were followed up at our out-patient clinic. Bronchofiberscopic follow-up study and X-ray CT study were scheduled for the third month, and every sixth month thereafter.
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Results
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Mini-tracheostomy was successfully performed and maintained in all patients. In the fractionated endobronchial treatment, the mean time from insertion to the targeted location of the applicator under fluoroscopic guidance was 8 s (range 6–18 s). The mean dwelling time of source in the irradiating position and the averaged single session time of each fractionated brachytherapy were 3.1 min (range 1 min 57 s to 8 min 6 s) and 24 min (range 14–35 min), respectively, excluding the time for treatment planning using the PLATO system. There were no procedure-related complications. The stomas closed in 3 days.
All patients obtained symptomatic improvement, and four patients showed histologically negative bronchofiberscopic biopsy specimens.
During the mean follow-up period of 18.9 months, no patient developed local relapse on the irradiated lesion. Three patients died of metastatic disease and two patients died of aggravated respiratory distress due to disease progression. One patient died of pneumonia due to tracheal fistula. Another died of haematoemesis at home. One patient is alive at 31 months presently without disease.
Case presentations
A 53-year-old-man (patient no. 4) complaining of severe dyspnoea due to obstruction of the trachea and bilateral main bronchi was admitted to our hospital. He underwent 60 Gy in 30 fractions of external beam radiotherapy combined with intravenous administration of cisplatinum and doxorubicin. To the persisting tumour, an endobronchial brachytherapy of 24 Gy in four fractions was scheduled. 1 month after the brachytherapy, no tumour or viable cells were found in the trachea. He was asymptomatic for 12 months.
A 52-year-old-woman (patient no. 7) complaining of mild dyspnoea due to metastatic left bronchial tumour obstruction was indicated for endobronchial brachytherapy. Since undergoing low anterior resection for rectal cancer 6.7 years previously, she had experienced gamma-knife therapy for brain metastases, conformal radiotherapy for pelvic relapse and right mediastinum mass, and stereotactic body irradiation for lung metastases. She underwent endobronchial irradiation of 24 Gy in four fractions at the outpatient clinic. The dyspnoea disappeared in 2 weeks. She survived 43.8 months after the brachytherapy.
A 57-year-old-woman (patient no. 8) suffered from dyspnoea and obstinate cough due to relapsed tracheal cancer. 8 years previously she had undergone non-curative surgical resection of the tumour followed by 70 Gy in 35 fractions of external beam radiotherapy. During the recent 2 years, two metastatic nodules, both in the left lung, were excised and one nodule in the right lung was treated with stereotactic radiotherapy. A laser treatment and stent placement were attempted to relieve the present symptoms but were ineffective. The previous dose in the relapsed lesion was 40 Gy. An endobronchial irradiation of 24 Gy in four fractions was planned. She continues to maintain a good performance status for over 30.4 months after the brachytherapy.
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Discussion
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The safety and less invasive nature of the mini-tracheostomy procedure have been well established [12]. The insertion procedure was fast and simple, and the reported mean procedural time was only 6.7 s from incision to removal of the guidewire [17]. During the endobronchial treatment, the mini-stoma was safely used as a ready access route. Through the mini-stoma, the applicator was inserted quickly and smoothly under fluoroscopy to the target position using a torque control technique. The patients were freed from the repeated burden of transoral or transnasal endobronchial manipulation under bronchofiberscopy. Thus, this fast fluoroscopic procedure would save time, cost and effort of the patients.
Furthermore, the fast and convenient fluoroscopic procedure allows flexible schedules of fractionation unrestricted by bronchofiberscopy availability. Despite biological knowledge that fractionation decreases the late radiation toxicity [9], most of the reported schedules have been restricted to once a week: for instance, 30 Gy in two fractions [18], 30 Gy in 6 fractions [19], 22.5 Gy in three or 10 Gy in two [11], 20 Gy in five [10], 10 Gy in one or 18 Gy in three [8] and 14 Gy in 2 weeks as a boost. To our knowledge, only one schedule has been described in which 25 Gy for weekly five fractions was given [20].
Another merit of this procedure was that the applicator insertion to deployment was carried out under smooth fluoroscopic guidance, and anaesthesia such as local lidocaine spray, which is irritating to the airway, was not necessary.
It is difficult to discuss the precise effects, including late toxicity, because of the limited number of observations in the present study and dosimetric inconsistency between reports due to different depth of reference points [1, 5]. However, efforts to control late radiation toxicity should be continued.
Some patients survived for relatively long periods, suggesting that an appropriate selection of patients might result in a good outcome of the endotracheal brachytherapy in some cases, but at present any such conclusion is unwarranted due to the small number of cases studied. The possible benefits of well-fractionated endobronchial brachytherapy need to be determined in future investigations.
Received for publication May 18, 2005.
Revision received January 14, 2005.
Accepted for publication January 24, 2006.
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Abstract
Introduction
