PowerPoint presentation on the topic Endobronchial Brachytherapy.

1. ENDOBRONCHIAL
BRACHYTHERAPY
Dr.Tinku Joseph
MD, DM, FCCP
Consultant Pulmonologist
AIMS, Kochi
Lecture given at Hospital
Serdang, Malaysia

2. Contents
 Overview
 Technique
 Types
 Indications
 Complications

3. Endobronchial Brachytherapy (EBBT)
 Placement of a radioactive source within or in
close proximity to a malignancy in order to provide
high doses of radiation in close proximity to the
tumor.
 Palliative therapy
 Recently-: need for this technique has declined.

4. Goal-:
 Reduction in tumor size so that airway symptoms can
be relieved.
 Compared with (EBRT), EBBT - local radiation is
provided to the lesion (spares other tissues).
Technique

5. 1. Selection of patients
2. Planning phase
3. FOB/Rigid with or without MV
support
4. Placement of Radioactive source
(Ir-192)
5. Fluroscopy
6. HDR/LDR given
Technique

6. Technique (step 1)

7. Technique (step 2)

8. Technique (step 3)

10. Technique (step 4)

11. 1
2

12. Radiation Type
 Dose rate of brachytherapy depends upon the energy
and rate of decay of the radionuclide used.
 Commonly used-: Iridium192
• According to dose rate
1) High dose rate (HDR)-
- >12 Gy/Hr
2) Medium dose rate (MDR)
- 2-12 Gy/Hr
3)Low dose rate (LDR) -
- 0.4 -2 Gy/Hr
4)Ultra low dose rate (ULDR)-
-0.01-0.3 Gy/Hr

13. ISOTOPES USED IN BRACHYTHERAPY
can be embedded in
 Surface Applicator- placed directly on surface of tumor eg. Hard
palate, skin, ocular
 Intracavitory- inserted into specially designed apparatus that is
placed into body cavity eg. Gynec.malign, nasopharynx
 Intraluminal- Various organs with lumen
 (Oesophagus, endobronchial, biliary etc.)
 Interstitial- Directly through tissues encompassing tumor
 Intravascular- coronaries, peripheral art. internal mammary etc.

14.  10 to 12 Gray (Gy)/hour,
 Total dose - ranging from 5 to 40 Gy,
 Dose per session (fraction) varying from 3 to 10 Gy.
 Treated every 1-2 weeks (takes few mins)
HDR/LDR:
 Treatment times are shorter
 outpatient procedure.
 Increase procedure efficiency,
 Reduce treatment cost.
 Simpler and safer therapy.
Radiation Type- HDR

16. Radiation Type- LDR
 Delivers less than 2 Gy/hour
 Total dose of 1500 to 5000 Gy,
 Given over a few days (usually up to three days)
Disadvantages:
 Manual manipulation of the radionuclide
 30 to 70 hours of continuous treatment,
 Cumbersome radiation protection measures
 Catheter has to be left in place for the few days of
administration.

17.  Inpatient procedure
 Catheter displacement
 More costly than HDR EBBT
 Largely fallen out of favor.
Radiation Type- LDR

18. Indications
1. palliative treatment of large
obstructing central airway tumors
(NSCLC).
2. Metastatic airway tumors.
3. Early NSCLC that is limited to the
airway.
4. Benign tracheal stenosis

19. Palliation of central obstructing airway
tumors
 Palliation of obstructive symptoms caused by large
central airway tumors that are not amenable to
surgical resection and/orEBRT.
 Patients cannot tolerate or fail other local ablative
therapies (Nd:YAG laser, APC, or cryotherapy).

20. Types of cancer that are responsive to EBBT
 Biopsy proven NSCLC
 Early NSCLC localized to the airway.
 Positive resection margins or a stump
 Recurrence following surgery.
 Extrathoracic malignancy metastatic to lung
 Small cell carcinoma/carcinoid (no response)
Palliation of central obstructing airway
tumors

21. EBBT - patient or tumor criteria

23. Acute life threatening symptoms of airway obstruction
 First-: local ablative therapies or EBRT
 Followed by EBBT
• Efficacy:
 Subjective and objective improvement following
EBBT (20 to 100 % of patients).
 No survival benefit associated with EBBT or EBBT in
combination with chemotherapy.
 EBBT + Coventional methods (beneficial)
Palliation of central obstructing airway
tumors

24.  Hemoptysis improve most readily (90% response
rate)
 Cough and dyspnea may improve less reliably,
(underlying conditions such as COPD or radiation
fibrosis).
 Responses in tumor size and the degree of airway
obstruction are most commonly evaluated by chest
radiography and bronchoscopy.
 70 % of patients have greater than 50% improvement
in patency that persists for at least six months.
Palliation of central obstructing airway
tumors

25. Benign airway stenosis
Recurrent tracheal stenosis
 Following repeated attempts at dilation and stenting,
HDR EBBT (eg, a single 3 to 10Gray [Gy] dose of
Iridium192) is beneficial.
 Prevents formation of granulation tissue and reduce
the recurrence rate of restenosis.
 Role in post TB stenosis ???

28. Contraindications- Absolute
1) presence of fistulas between bronchi and
other structures.
 (EBBT increases the risk of viscus rupture and
fatal hemorrhage)
2) Presence of high grade airway obstruction.
 Try other modalities first
 use of brachytherapy will not immediately
shrink tumor size
 (maximal effect is after three weeks)
 may result in postradiation tissue edema and
complete airway obstruction.

29.  Moribund patients.
 Other absolute
contraindications to
bronchoscopy in general.
Contraindications- Absolute

30. 1. Lesions in close proximity to large
vessels
2. Malignant involvement of the major
arteries
3. Significant destruction of the bronchial
wall
4. Mediastinal invasion
Contraindications- Relative
High risk of fistula formation and fatal hemorrhage

31. Complications
 <5%. Range (5-40%)
 Early (hours to days) or late (days
to weeks).
Early:
 Infrequent
 Usually due to bronchoscopy or
catheter insertion.
 Hemoptysis
 Catheter displacement
 Early complications of
bronchoscopy

32. Late:
 Radiation bronchitis
 Airway stenosis.
 Massive hemoptysis
 Fistula formation
Complications

33. Conclusions (EBBT)
 Placement of a radioactive source
within or in close proximity to a
malignancy in order to provide high
doses of radiation close to the tumor.
 EBBT is a good palliative treatment
for endoluminal neoplasms of the
lungs, either alone or in combination
with other procedures.

34.  Used in benign airway stenosis.
 HDR/LDR EBBT
 Bronchoscopy guided procedure.
 Combined with EBRT/APC/Nd YAG
(better results)
 Good tolerance and low
complication rate.
Conclusions