title: Risk factors for massive hemoptysis after endobronchial brachytherapy in patients with tracheobronchial malignancies.
abstract: BACKGROUND
  Massive and mostly fatal hemoptysis is a frequently reported morbidity after endobronchial brachytherapy (EBB) for tracheobronchial malignancies. However, to the authors' knowledge, it remains controversial whether this morbidity is related directly to EBB. To investigate whether massive hemoptysis is related to EBB, the authors retrospectively analyzed risk factors for massive hemoptysis after EBB.
  
  
  METHODS
  Thirty-six patients (30 men and 6 women) with a mean age of 70 years underwent high-dose rate EBB for tracheobronchial malignancy using a cobolt-60 (Co-60) afterloading machine. EBB was performed as primary therapy in 6 patients and as salvage treatment for recurrent disease in 30 patients. EBB was delivered to the tracheal lesions in 15 patients and to the main bronchial lesions in 21 patients. EBB was combined with external beam radiation therapy (EBRT) in 24 patients, with laser photocoagulation in 3 patients, and with EBRT plus laser photocoagulation in 5 patients. The dose of EBRT delivered with the EBB ranged from 16-69 grays (Gy), with a mean dose of 37 Gy.
  
  
  RESULTS
  At a mean follow-up of 18 months, 33 of the 36 patients had died. Eight of the 33 patients had no evidence of local disease at the time of death. Seven patients died of massive hemoptysis. The cumulative rate of massive hemoptysis was 29.4% at 2 years. According to univariate analysis, no statistically significant correlation with massive hemoptysis was observed for EBRT dose delivered in combination with EBB, EBB fractional and total doses, EBB length, and the sum of all the EBRT doses including that used for the initial treatment. Local failure or persistent malignancy (P = 0.033) and delivery of laser photocoagulation (P = 0.032) were found to be statistically significantly associated with massive hemoptysis. Direct contact between the EBB applicator and the tracheobronchial walls at the vicinity of the great vessels was observed in 16 patients and was found to be statistically significantly associated with massive hemoptysis (P = 0.003). In six patients, the applicator was in direct contact with two or more tracheobronchial walls at the vicinity of the great vessels; all these patients died of massive hemoptysis.
  
  
  CONCLUSIONS
  Direct contact between the EBB applicator and the tracheobronchial walls at the vicinity of the great vessels was one of the significant risk factors for massive hemoptysis. To prevent massive hemoptysis, a specific spacer should be employed to maintain a safe distance between the applicator and the bronchial wall.
authors.affiliation: Department of Radiation Therapy and Oncology, International Medical Center of Japan, Tokyo, Japan. rhara@imcj.hosp.go.jp
authors.forename: R
authors.initials: R
authors.lastname: Hara
authors.forename: J
authors.initials: J
authors.lastname: Itami
authors.forename: T
authors.initials: T
authors.lastname: Aruga
authors.forename: T
authors.initials: T
authors.lastname: Kozuka
authors.forename: K
authors.initials: K
authors.lastname: Nakajima
authors.forename: H
authors.initials: H
authors.lastname: Yamashita
authors.forename: T
authors.initials: T
authors.lastname: Uno
authors.forename: T
authors.initials: T
authors.lastname: Morita
authors.forename: H
authors.initials: H
authors.lastname: Itoh
authors.forename: T
authors.initials: T
authors.lastname: Nomura
mesh_terms: D000368:Aged; D001918:Brachytherapy / Q000009:adverse effects* / Q000295:instrumentation; D002423:Cause of Death; D004724:Endoscopy; D005260:Female; D005500:Follow-Up Studies; D006469:Hemoptysis / Q000209:etiology*; D006801:Humans; D008175:Lung Neoplasms / Q000532:radiotherapy*; D008297:Male; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis; D014134:Tracheal Neoplasms / Q000532:radiotherapy*