LUNG

Customized individual cancer treatment.

Cesium-131 Brachytherapy mesh provides conformal radiation to surgically managed patients with Non Small Cell Lung Cancer.

Brachytherapy is an established method to deliver a highly targeted dose of radiation therapy to soft tissue tumors. The procedure has become an accepted treatment for prostate cancer; however adoption of the procedure for other cancers has been slower. One opportunity where brachytherapy may provide additional benefit in the treatment of lung cancer, which is the number one cancer killer in the United States, killing more than the next three (colon, breast and prostate) cancers combined.

The current experience with brachytherapy in the treatment of lung cancer has been limited as there are limited commercially available products. However, Isoray’s Cesium-131 mesh has shown promise in the treatment of certain types/stages of lung cancer.

There are two primary types of lung cancer: Small Cell Lung Cancer (SCLC) and Non Small Cell Lung Cancer (NSCLC). NSCLC is the most prominent, representing 80-85% of diagnoses. The main challenge with lung cancer and the reason that it is so deadly is that because it is typically asymptomatic in early stages, it is not diagnosed until it is more advanced and has spread beyond its initial site.

The main treatment for NSCLC is surgery, with the type of surgery dependent on the size and location of the tumor, and the patient tolerance for the procedure. The gold standard is a lobectomy where the entire lobe where the primary tumor is located is surgically removed. Variations of lung surgery include a pneumonectomy where the entire lung is removed and a segmentectomy or wedge resection, where only a portion of a lobe is removed. Other potential treatments include external radiation and targeted ablation techniques.

However, even as surgery is the gold standard, “more than 20% of patients who are diagnosed with stage I or stage II NSCLC do not undergo operation.” This may be due a variety of reasons, including poor cardiopulmonary function that compromises the overall health of the patient. One drawback of a lobectomy is its potential impact on pulmonary function, which would further stress patients who present with poor functionality. These patients may benefit from less aggressive surgical treatment, such as segmentectomy.

WR plus Cs-131 is an excellent treatment option for patients with early stage non-small cell lung cancer that are not candidates for lobectomy. For high-risk WR we favor use of Cesium-131 brachytherapy.

Bhupesh Parashar, MD

“Analysis of stereotactic radiation vs wedge resection vs wedge resection plus Cesium-131 brachytherapy in early stage lung cancer., Brachytherapy 14 (2015) 648-654

Candidates for a sub-lobar resection wedge (WR) should consider Cesium-131.

  • Cesium-131 implants reach 90% of prescription does in 33 days. Six times faster than the Iodine-125 product used in historical studies.
  • Cesium-131 has delivered 99.8% of the prescription dose in 90 days when the bioabsorable sutures and mesh begin to break down.

Those patients who are not candidates for lobectomy should consider, with their physicians, a sub-lobar resection wedge resection (WR) or segmental resection with brachytherapy. To compensate for the less extensive surgical resection, brachytherapy has been combined with WR to achieve results equivalent to lobectomy. In reported retrospectives studies WR with brachytherapy report excellent local control (LC) rates in early stage lung cancer.

More information on non-small cell lung cancer treatments.

Resources

1. Allen MS, Darling GE, Pechet TT, et al. Morbidity and mortality of major pulmonary resections in patients with early-stage lung cancer; initial results of the randomized, prospective ACOSOG Z0030 trial. Ann Thorac Surg 2006;81:1013e1019.

2. Ginsberg RJ, Rubinstein LV. Lung Cancer Study Group. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Ann Thorac Surg 1995;60:615e622.

3. Chen A, Galloway M, Landreneau R, et al. Intraoperative 125I brachytherapy for high-risk stage I non-small cell lung carcinoma. Int J Radiat Oncol Biol Phys 1999;44:1057e1063.

4. Shibamoto Y, Hashizume C, Baba F, et al. Stereotactic body radiotherapy using a radiobiology-based regimen for stage I non- small cell lung cancer: A multicenter study. Cancer 2012;118:2078e2084.

5. Timmerman R, Paulus R, Galvin J, et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA 2010;303:

6. Haasbeek CJ, Lagerwaard FJ, Slotman BJ, Senan S. Outcomes of stereotactic ablative radiotherapy for centrally located early-stage lung cancer. J Thorac Oncol 2011;6:2036e2043.

7. Baumann P, Nyman J, Hoyer M, et al. Outcome in a prospective phase II trial of medically inoperable stage I non-small-cell lung cancer patients treated with stereotactic body radiotherapy. J Clin Oncol 2009;27:3290e3296.

8. Mohiuddin K, Haneuse S, Sofer T, et al. Relationship between margin distance and local recurrence among patients undergoing wedge resection for small (#2 cm) non-small cell lung cancer. J Thorac Cardiovasc Surg 2014;147:1169e1175.

9. Fernando HC, Landreneau RJ, Mandrekar SJ, et al. Impact of brachytherapy on local recurrence rates after sublobar resection: Results from ACOSOG Z4032 (Alliance), a phase III randomized trial for high-risk operable non-small-cell lung cancer. J Clin Oncol 2014;32:2456e2462.1070e1076.

10. Mery, Similar long term survival of elderly patients with Non small cell lung cancer treated with lobectomy or wedge resection within the surveillance, epidemiology, and end results database. chest, 2005, 128; 237-245.

11. Bach, Racial differences in the treatment of early stage non small cell lung cancer. NEJM, 1999, 341, 1198-205.

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