INTRODUCTION: Intraoperative brachytherapy is one of the new approaches being utilized to decrease the local recurrence of lung cancer following surgical resection.We report a unique case where brachytherapy resulted in a residual cavity formation and subsequent dislocation of the radiation seeds. The patient subsequently developed hemoptysis that proved fatal.
CASE PRESENTATION: An 80-year-old man with history of CAD, CABG and gastric cancer treated with partial gastrectomy, was noted at follow-up to have a left upper lobe lung mass four years ago. He had a metastatic workup that was negative and subsequently underwent a thoracotomy and segmentectomy with intraoperative placement of a brachytherapy mesh. His course during the following months was associated with occasional cough and expectoration with exertional dyspnea. Follow-up radiography (five months later) showed the development of a 6 cm cavitary lesion at the site of brachytherapy mesh placement. The cavity persisted over the next three years without any increase in size. Dislocation (with disappearance) of the brachytherapy seeds was noted over the last year. Laboratory work for fungal , mycobacterial and other conditions that would have caused a cavity were all negative. Uncontrolled hemoptysis from the cavity bed ultimately proved fatal to the patient.
DISCUSSIONS: Local recurrence of lung cancer following surgery for stage I disease showed a 6% incidence following lobectomy and 22% incidence following wedge resection. Routine radiation therapy is not indicated in patients, provided the tumor margins are clear. However in patients with questionable clearance of margins at time of surgery, intraoperative brachytherapy remains an option to decrease local recurrence and possibly improve survival. Brachytherapy involves placement of I 125 seeds in a Vicryl mesh that is sutured and stapled to the resected margin. The low energy seeds tend to target the tumor bed with minimal radiation hazard. No significant side effects including radiation pneumonitis have been reported so far. We however noticed the development of a cavitary lesion five months after placement of the mesh. The cavity itself persisted without change in size over the ensuing three years. Of interest was also the loss of all the radiation seeds following development of the cavity. Though the patient doesn't recollect coughing them up, the possible explanation for the missing seeds remains the same due to a potential communication of cavity with a bronchus. Though no major untoward incidents have been reported so far, the formation of a cavity itself may need close follow-up for potential complications like infection and hemorrhage. Our patient was unfortunate as uncontrolled hemoptysis resulted in his death. An autopsy performed confirmed the communication of the cavity with a bronchus indicating the site of hemoptysis.
CONCLUSION: Brachytherapy has been utilised as an option to decrease local recurrence and improve survival for early stage lung cancer. We report an interesting finding of cavity formation and expulsion of the radiation seeds that ultimately resulted in fatal hemorrhage from the cavity bed. Observation for this potential complication should be considered in patients treated with lung brachytherapy.
DISCLOSURE: Rajashekar Adurty, None.