Late Central Airway Toxicity after High-Dose Radiotherapy: Clinical Outcomes and a Proposed Bronchoscopic Classification
Abstract
:Simple Summary
Abstract
1. Introduction
2. Materials and Methods
2.1. Data Collecting and Classification System
2.2. Follow-Up
2.3. Statistical Analysis
3. Results
3.1. Patient and Treatment Characteristics
3.2. Bronchoscopic Findings and Proposed Classification System
3.3. Vascular Changes
3.4. Bronchial Stenosis
3.5. Combined Stenosis and Vascular Changes
4. Discussion
4.1. Mechanisms of Toxicity
4.2. Interventions to Reduce Airway Toxicity
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
Appendix A. Outcome for Patients with Stenosis Only
Stenosis Degree | Indication Bronchoscopy/Symptoms | Intervention | Follow-Up after Bronchoscopy | Status |
>70% | Post-treatment inspection | - | 42 months till last contact. | Alive |
>70% | Impending respiratory insufficiency | Dilatation and stent placement 5 months post-RT | Died 68 months after bronchoscopy. Probable cause of death related to heart problems, not airway stenosis. | Dead |
>70% | Severe tracheomalacia and stenosis, respiratory insufficiency | Tracheostomy, canula | Died 23 months after bronchoscopy. Repeated IC admissions for respiratory insufficiency. Palliative care for progressive dyspnea. | Dead |
>70% | Severe dyspnea | Stent placement 2 years after CRT and immuno-therapy | Died 9 days after bronchoscopy. Palliative care for progressive dyspnea. | Dead |
>70% | Post-treatment inspection. Dyspnea in combination with COPD exac-erbation. | Antibiotics | Died 3 months after bronchoscopy | Dead |
Appendix B. Post-Radiation Interventions for Airway Toxicity
No intervention No intervention necessary Deemed inoperable No bronchoscopic options left (e.g., recurrent stenosis) | 51 31 12 8 |
Dilatation | 2 |
Dilatation and stent placement | 7 |
Stent placement | 4 |
Pneumonectomy/lobectomy | 2 |
Reinforcement surgery | 2 |
Tracheostoma/canula | 2 |
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Characteristics | No. |
---|---|
Gender | |
Male | 42 |
Female | 28 |
Age (years) | |
Median (range) | 64 (42–80) |
Location of malignancy | |
Trachea | 8 |
Central (up to and segmental bronchi) | 21 |
Peripheral | 36 |
Esophagus | 3 |
Mediastinal lymph node | 1 |
Pathology | |
NSCLC | 64 |
Metastases | 2 |
Other | 4 |
Type of RT | |
SBRT | 10 |
Conventional | 14 |
Chemoradiotherapy (CRT) | 46 |
Indication for bronchoscopy | |
Airway symptoms | 28 |
Assessment post CRT/surgery | 12 |
Suspected tumor recurrence | 21 |
Radiological findings | 9 |
Recurrence at time of bronchoscopy | |
Free of recurrence | 47 |
High suspicion of recurrence on imaging | 9 |
Proven recurrence with biopsy | 14 |
Damage | Degree | SBRT | RT | CRT |
---|---|---|---|---|
Vascular changes | 0: None | 0 | 2 | 3 |
I: Telangiectasis only | 5 | 3 | 17 | |
II: Partial loss of vascularity | 3 | 3 | 12 | |
III: Extensive loss of vascularity | 1 | 4 | 6 | |
IV: Necrosis | 1 | 2 | 8 | |
Stenosis | 0: No stenosis | 3 | 5 | 17 |
I: Moderate stenosis (<70%) | 1 | 1 | 11 | |
II: Severe stenosis (>70%) | 6 | 8 | 18 | |
Total | 10 | 14 | 46 |
Indication for Bronchoscopy | Vascular Changes Only N = 25 | <70% Stenosis N = 13 | >70% Stenosis N = 32 |
---|---|---|---|
Hemoptysis | 5 | 3 | 3 |
Dyspnea | 1 | 1 | 9 |
Respiratory insufficiency | 1 | 1 | 2 |
Recurrent infections | 0 | 0 | 2 |
Assessment post-CRT or surgery | 3 | 2 | 7 |
Assessment (suspected) recurrence | 11 | 1 | 3 |
Intervention recurrence (diathermy/debulking) | 2 | 2 | 2 |
Assessment of radiological findings suspicious for RT damage | 2 | 3 | 4 |
Damage | Degree | RT-Toxicity | Follow-Up |
---|---|---|---|
Vascular changes | 0: None (N = 5) | 10.0 (4.0–23.5) | 23.0 (1.5–55.0) |
I: Telangiectasis only (N = 14) | 47.0 (26.0–88.0) | 10.0 (5.0–16.0) | |
II: Partial loss of vascularity (N = 10) | 23.0 (12.5–84.5) | 13.5 (4.0–31.0) | |
III: Extensive loss of vascularity (N = 9) | 19.0 (12.0–37.0) | 1.0 (0–11.0) | |
IV: Necrosis (N = 10) | 13.0 (6.0–23.0) | 5.0 (1.0–10.0) | |
Stenosis | 0: No stenosis (N = 19) | 29.0 (10.5–48.5) | 9.0 (2.5–19.5) |
I: Moderate stenosis (<70%) (N = 8) | 28.0 (14.5–70.0) | 5.0 (0–11.0) | |
II: Severe stenosis (>70%) (N = 21) | 22.5 (13.0–60.0) | 11.0 (2.0–23.0) |
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van Hoorn, J.E.; Dahele, M.; Daniels, J.M.A. Late Central Airway Toxicity after High-Dose Radiotherapy: Clinical Outcomes and a Proposed Bronchoscopic Classification. Cancers 2021, 13, 1313. https://doi.org/10.3390/cancers13061313
van Hoorn JE, Dahele M, Daniels JMA. Late Central Airway Toxicity after High-Dose Radiotherapy: Clinical Outcomes and a Proposed Bronchoscopic Classification. Cancers. 2021; 13(6):1313. https://doi.org/10.3390/cancers13061313
Chicago/Turabian Stylevan Hoorn, Juliët E., Max Dahele, and Johannes M. A. Daniels. 2021. "Late Central Airway Toxicity after High-Dose Radiotherapy: Clinical Outcomes and a Proposed Bronchoscopic Classification" Cancers 13, no. 6: 1313. https://doi.org/10.3390/cancers13061313