Elsevier

Radiotherapy and Oncology

Volume 49, Issue 2, November 1998, Pages 175-183
Radiotherapy and Oncology

Massive haemoptysis after radiotherapy in inoperable non-small cell lung carcinoma: is endobronchial brachytherapy really a risk factor?

https://doi.org/10.1016/S0167-8140(98)00103-0Get rights and content

Abstract

Background and purpose: This retrospective study was conducted to investigate whether endobronchial brachytherapy (EBB) is a risk factor for massive haemoptysis in patients primarily treated by a combination of EBB and external irradiation (XRT) for NSCLC.

Materials and methods: The records of 938 patients with inoperable NSCLC who were treated with XRT and/or EBB were reviewed. The patients were divided into five groups as follows: group XRT, treated by XRT alone (n=421); group XRTelig, treated by XRT but eligible for EBB (n=419); group XRTEBB, primarily treated with EBB+XRT (n=62); group EBBrec, treated by EBB for recurrence after XRT (n=23); and group EBB, treated by EBB alone (n=13). EBB was delivered using HDR. Patients with bronchoscopy-proven endobronchial tumour in the proximal airways, i.e. the trachea, the main bronchus or lobar bronchus were considered eligible for EBB.

Results: One hundred one out of 938 patients (10.8%) died from massive haemoptysis. The incidence was 4.3% in group XRT, 13.1% in group XRTelig and 25.4% in group XRTEBB. The differences between groups XRT and XRTelig as well as between groups XRTelig and XRTEBB were statistically significant (P<0.01). The incidence of massive haemoptysis depended significantly on the fraction size of brachytherapy. When two fractions of 7.5 Gy or a single fraction of 10 Gy were used, 11.1% of the patients died from massive haemoptysis. However, when a single dose of 15 Gy was used, 47.8% died from massive haemoptysis. In the multivariate analysis, a single dose of 15 Gy EBB was the most important prognostic factor for massive haemoptysis.

Conclusion: XRT+EBB as primary treatment for NSCLC does not lead to a higher risk of massive haemoptysis as compared to XRT alone when fraction sizes for EBB of 7.5 or 10 Gy are used. However, the risk of massive haemoptysis increases dramatically when a fraction size of 15 Gy is used.

Introduction

Reports regarding massive haemoptysis after external beam radiotherapy are scarce. However, massive haemoptysis after endobronchial brachytherapy (EBB) is a frequently described fatal complication in non-small cell lung carcinoma (NSCLC). A number of studies reported on the results of endobronchial brachytherapy in bronchial carcinoma and in these series incidence rates for massive haemoptysis range from 0 to 50% [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [17], [18], [19], [20], [21], [22], [23], [24], [25]. The question arises whether EBB itself plays a causative role in the development of this fatal complication. However, the high incidence of massive haemoptysis after EBB may be explained by the selection of patients with centrally localized tumours in the proximal airways in the vicinity of the great vessels and thus at risk for massive haemoptysis. In the past 10 years, the treatment policy of patients with inoperable centrally localized tumours referred for radiotherapy to our department has changed. When HDR afterloading equipment became available, this category of patients was more frequently treated with a combination of external irradiation (XRT) and EBB. This allowed us to compare the incidence of massive haemoptysis in subsets of patients treated with XRT alone and XRT in combination with EBB.

The objectives of this retrospective study were (1) to assess pre-treatment risk factors for massive haemoptysis, (2) to investigate if patients treated with (XRT) but who were eligible for EBB were at risk for massive haemoptysis, (3) to investigate whether massive haemoptysis was more frequently observed in patients actually treated with a combination of EBB and XRT as compared to patients eligible for EBB but treated with XRT alone and (4) to investigate the role of treatment-related factors, such as the fraction size of EBB.

Section snippets

Patients

Patients who were referred for radiotherapy to the RTIL in the period from 1987 to 1996 with inoperable NSCLC were included. The diagnosis had to be confirmed by cytology and/or histology and patients had to be treated with XRT and/or EBB. Initially, a total number of 966 patients fulfilled these inclusion criteria. The endpoint of this study was whether the patient died of massive haemoptysis or not. Massive haemoptysis was defined as an unmistakable event characterized by the coughing up of

Incidence of massive haemoptysis

Of the 938 patients included in the study a total number of 101 patients (10.8%) died from massive haemoptysis. Forty-eight patients (5.1%) were alive at the time of the final analysis, meaning that 11.3% of the patients died from massive haemoptysis. Seventy-three patients (72%) suddenly died at home, the remaining patients expiring during admission in the hospital. In 78 cases (77%), there was clinical or radiological evidence of local tumour progression, while in 23 patients there were no

Discussion

First, the incidence of massive haemoptysis after XRT alone (groups XRT and XRTelig) was 8.7%. This incidence rate is comparable with the results of other investigators reporting on the incidence of massive haemoptysis in NSCLC treated with XRT alone. Miller and McGregor [16] reported on the incidence of massive haemorrhage in 877 lung cancer patients treated with different modalities. Twenty-nine patients (3.3%) died from massive haemorrhage. In the group of patients treated with XRT, 13 out

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