Massive haemoptysis after radiotherapy in inoperable non-small cell lung carcinoma: is endobronchial brachytherapy really a risk factor?
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.
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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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2018, Lung CancerCitation Excerpt :However, fatal lung haemorrhage may not necessarily be a treatment complication as it is often tumor-related, and a common cause of death in patients with NSCLC [22]. Tumor-related factors associated with haemoptysis or fatal lung haemorrhage have been identified in a number of prospective, retrospective, and autopsy studies, and these include central tumor location, squamous cell carcinoma histology, baseline tumor cavitation, and endobronchial tumor involvement [23–26]. Haemoptysis has been reported after chemotherapy, brachytherapy, and conventional radiotherapy.