Palliative Care

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TU_29_3023 - Multidisciplinary Approach to Endobronchial HDR Brachytherapy Provides a Safe and Effective Alternative to External Beam Radiation for Palliating Malignant Airway Obstruction

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Multidisciplinary Approach to Endobronchial HDR Brachytherapy Provides a Safe and Effective Alternative to External Beam Radiation for Palliating Malignant Airway Obstruction
H. Al-Halabi1, L. Shakibnia2, R. Bechara1,3, C. Parks1,3, K. Harpool4, P. N. Schantz1, T. Law4, W. Snyder4, J. W. Swanson4, and S. X. Cavanaugh1; 1Cancer Treatment Centers of America, Newnan, GA, 2McGill University Health Centre, Montreal, QC, Canada, 3Morehouse School of Medicine, Atlanta, GA, 4Landauer Medical Physics, Glenwood, IL

Purpose/Objective(s): Concerns over the safety of high-dose-rate (HDR) endobronchial brachytherapy (EBB) has limited its wide spread use in palliating pulmonary airway obstruction. Morbidity following EBB is commonly attributed to fatal hemoptysis and fistula formation. We have implemented a procedure to deliver EBB treatments under general anesthesia which minimize the procedure risks, while maintaining treatment effectiveness with accurate catheter localization, placement, and QA methods. We hereby report outcomes of consecutive patients treated using this approach to palliate airway obstruction.

Materials/Methods: We retrospectively reviewed the charts of consecutive patients treated with EBB for palliation of symptomatic malignant airway obstruction. Treated patients had obstructive lesions >2cm distal to the carina and central structures, who were deemed candidates for EBB by a multidisciplinary team of interventional pulmonologists (IP) and radiation oncologists (RO). All patients were treated under general anesthesia and monitored by anesthesia throughout the procedure. Bronchoscopy and localization of target lesions was performed by IP. HDR catheters carrying a marker wire were advanced past obstructive lesion, and in some cases, multiple catheters were used to treat multiple lesions simultaneously. CT simulation was performed to confirm catheter placement, and the target region on CT images corresponding to the obstructive lesion were identified by treating RO. All patients underwent CT-based 3D treatment planning. A dose of 6 -7 Gy/fraction was prescribed at 1 cm from catheter surface.

Results: Between 2014 and 2017, 24 patients (ages 29 -71, mean 52 years) were treated with EPP at our center. Of those, 5 had previously received external beam radiation (EBRT) and 3 had concurrent EBRT and EPP. Overall, a total of 76 EBB treatments were performed, with a median of 3 weekly fractions per patient (range 1-6 fractions) to total dose of 18Gy. Median CTV volume and length treated were 17.6 cm3 and 47mm, respectively. There were no incidences of major bleeding (>50 mL) or fatal hemoptysis in the 30 days following EPP. Moreover, there were no cases of severe (Grade 3 or higher) CTCAE toxicity reported. After a median follow up of 30 months (range 4-42 months) only 1 out of 16 patients treated with EPP alone required additional EBRT for airway obstruction, 12 months following EPP.

Conclusion: Our data suggest the safety and efficacy of an expert multidisciplinary approach to palliating pulmonary airway obstruction using EPP. Appropriate patient selection, the use bronchoscopy for primary target localization and CT based 3D treatment planning combined with a lower dose per fraction provide accurate target coverage while minimizing toxicity. This approach provides effective palliation of airway obstruction and decreased the need for additional EBRT in majority of treated patients. Prospective evaluation of this approach is warranted to better establish the role of EPP in this patient subgroup.

Author Disclosure: H. Al-Halabi: None. R. Bechara: None. C. Parks: None. T. Law: None. W. Snyder: None. S.X. Cavanaugh: None.

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