Canadian Neighbor Pharmacy: Results of Palliation of Bronchogenic Carcinoma with 198Au Implantation Using the Fiberoptic Bronchoscope

Demographic Data The study population consisted of 54 patients, 42 men and 12 women. The mean age was 62 years with a range from 35 to 84 years. Table 1 illustrates the distribution of cell types and their location. As expected, these are mainly central lesions with a squamous histology.

Radiation Therapy

Most patients received external beam radiotherapy at some point in their course. In 19 patients, this was concurrent with seed implantation. One hundred and eleven procedures were reviewed, a mean of two per patient (range one to ten). A mean of three seeds per procedure were implanted (range one to eight).

Therapy

Three patients with non-small cell carcinoma received chemotherapy, all three prior to seed implantation. Chemotherapy was used prior to implantation in three of four patients with small cell carcinoma (one patient refused). One patient was treated with endobronchial laser prior to gold seed use and one following gold seed use.

Response to Therapy

This was analyzed first in cohorts grouped by indication or anatomic location. As indications were often multiple, the same patients may have been analyzed in different cohorts with differing response to each indication. The latest issues on Canadian Neighbor Pharmacy are everything you need to be in touch with medical science.

Response was assessed by either a record of decreased symptoms, such as hemoptysis, shortness of breath, or pain, or an objective improvement in the chest x-ray film or bronchoscopic appearance. Observed responses are shown in Table 2. Any patient may have exhibited response in more than one category, and thus, the sum of the rows is greater than the n.

Occluding Endobronchial Lesion

Thirty one patients were given implants for this indication. Data were insufficient to assess benefit in two. Nineteen of the remaining 29 (66 percent) exhibited at least one form of benefit, 11 of these in the absence of any concurrent external beam radiation.

Hemoptysis or Other Symptoms

This occurred in 24 patients and follow-up notes did not permit assessment in two. Twenty one of the remaining 22 (91 percent) reported decrease in hemoptysis or other symptoms, 12 of these in the absence of concurrent external radiation.

Nonoccluding Endobronchial Lesion

Eight patients were implanted for this indication, one of whom was lost to follow-up. Three out of seven were assessed to have benefitted, all three in the absence of concurrent external radiation.

Tracheal Lesion

Six patients with lesions located in the trachea were implanted. All six benefitted from the procedure. Four of these six had no concurrent external beam radiation.

CA in Situ

One patient received an implant concurrent with external beam radiation for this indication. He is alive 20 months later. Multiple repeat bronchoscopies with biopsy of the same area have been negative.

Endobronchial Lesion with Significant Ipsilateral Pleural Effusion

Five patients could be analyzed in this subgroup, none of whom showed any objective improvement and all of whom had very short survival.

Assessment of Benefit by Anatomic Location

When the results were reassessed by objective response (chest x-ray film or bronchoscopic but excluding symptoms) according to the anatomic location of the lesion, it was noted that a progressive decrease in response rate was evident as lesions became more distal from the trachea (Table 3). Two peripheral tumors were not included in this table. Both have received implants recently and both showed improvement in chest x-ray film appearance.

Complications

Pneumothorax: There were no acute pneumothoraces. One patient developed a pneumothorax six weeks postimplantation following breakdown of a bronchial stump post lobectomy. As the seed activity declines to near zero at 14 days, we feel this was not related to the implant.

Displaced Seeds: Four seeds were lost at the time of implantation, three into the ipsilateral lung and one into the contralateral lung. In no case did this cause any significant problem. Following implantation, a majority of seeds are expectorated as the tumor necroses (the rest remain permanently embedded in the bronchial wall). We have not regarded this as a complication.

Tracheoesophageal Fistula: Three patients developed tracheoesophageal fistula. All three patients had completed maximum external radiotherapy (5,000 to 6,000 rads). One case occurred as an acute complication of YAG laser therapy, the other two following three months and five months after last implantation, and presumably due to tumor growth as the seeds were dormant at that point.

Hemoptysis: Four patients had hemoptysis. One had a slight increase for three days which then resolved completely, and one had massive exsanguinating hemoptysis four days after the last of five implantations over a period of 25 months. Two others died of massive hemoptysis, one six weeks later and the other 12 weeks later.

Airway Obstruction: One patient required temporary tracheostomy four days postinsertion of seeds into a tracheal lesion, and one required intubation for several hours after the procedure.

Early in the series, the tip of the introducer broke off into a patient. It was coughed out uneventfully. One patient developed a Bells palsy one month after insertion.

Table 1—Distribution of CeU Type and Site

Table 2—Responses

Table 3—Benefit of Gold Seed Implantation Assessed by Anatomic Location cf Tumor