MASSIVE HEMOPTYSIS DEATH AND OTHER MORBIDITY ASSOCIATED WITH HIGH-DOSE-RATE INTRALUMINAL RADIOTHERAPY FOR CARCINOMA OF THE BRONCHUS

Four hundred and six patients with primary non-small cell carcinoma of the bronchus causing symptoms due to endobronchial disease, were trea ted with intraluminal radiotherapy (ILT) using the microSelectron-HDR machine at the Christie Hospital, Manchester, between April 1988 and t he end of 1992. An assessment of morbidity for this treatment is prese nted, particularly with regard to the risk factors and causes of massi ve haemoptysis death, The most common early side-effect was a mild tra nsient exacerbation of cough which usually resolved within 2-3 weeks. At various times following ILT treatment 83 bronchoscopies were carrie d out randomly in 55 patients. In bronchoscopies carried out within th e first 3 months following ILT, no tumour was visible in 80% of cases. A mucosal radiation reaction score (RRS) was used to grade bronchosco pic appearance after ILT treatment. Overall, 55% of bronchoscopic exam inations showed some degree of mucosal radiation reaction. The majorit y of radiation reactions from 6 months onwards after ILT demonstrated a degree of fibrosis. A radiation reaction was seen more frequently af ter treatment with 2000 cGy as opposed to 1500 cGy at 1 cm from the ce ntral axis of the radiation source. Thirty-two patients were identifie d who had died from massive haemoptysis (MH) as a terminal event. A Co x multivariate regression analysis showed that the treatment-related f actors of increased dose at first ILT (P = 0.004), prior laser treatme nt at the site of ILT (P = 0.020) and second ILT treatment in the same location as the first ILT treatment (P = 0.047), all significantly in creased the relative risk of MH death compared with their effect on th e relative risk of death from other causes (OC). (In addition a fourth treatment-related factor, namely the concurrent use of ILT and extern al beam radiotherapy (EB) had a P value of 0.08). Twenty out of 25 ass essable MH-death patients (80%) had evidence of recurrent or residual tumour before death but 5 patients (20%) did not. For surviving patien ts the instantaneous risk of death at any one time (the cause-specific death rate expressed as deaths per 100 cases per month), showed a sha rp peak for MH deaths between 9 and 12 months post ILT in contradistin ction to OC death where the peak was between 3 and 6 months post ILT. These findings may imply a role for late radiation reaction in the tre atment-related risk factors identified as increasing the relative risk of MH death and possible mechanisms are discussed. The results have i mplications for treatment regimes that use a dose of 2000 cGy at 1 cm in a single fraction technique, that have a high frequency of previous laser treatment, that use multiple, repeated ILT treatments in the sa me location and that use ILT concurrently with EB.