Brachytherapy 12 (2013) 567e572

Case Report

Lung-conserving treatment of a pulmonary oligometastasis with a wedgeresection and 131Cs brachytherapy

A.Gabriella Wernicke1,*, Apurva Parikh1, Menachem Yondorf1, Samuel Trichter1,Divya Gupta2, Jeffrey Port3, Bhupesh Parashar1

1Department of Stich Radiation Oncology, Weill Medical College of Cornell University, New York, NY2Department of Gynecology, Weill Medical College of Cornell University, New York, NY

3Department of Surgery, Weill Medical College of Cornell University, New York, NY

ABSTRACT PURPOSE: Soft-tissue sarcomas most freque

Received 8 Febru

accepted 17 May 201

* Corresponding

Weill Medical Colleg

York, NY 10065. Tel.

E-mail address: g

1538-4721/$ - see fro

http://dx.doi.org/10

ntly metastasize to the lung. Surgical resection ofpulmonary metastases is the primary treatment modality. Although lobectomy is widely acknowl-edged as the standard procedure to treat primary pulmonary tumors, the standard for pulmonarymetastases is not well defined; furthermore, compromised lung function may tip the scales in favorof a less invasive approach. Here, we report the results of a patient treated with wedge resection andintraoperative cesium-131 (131Cs).METHODS AND MATERIALS: A 58-year-old African American female was diagnosed withthe American Joint Committee on Cancer Stage IIA mixed uterine leiomyosarcoma and underwenttotal abdominal hysterectomy and bilateral salpingo-oophorectomy followed by adjuvant externalbeam radiotherapy to a total dose of 45 Gy and vaginal brachytherapy to a total dose of 20 Gy.At 2 years, a routine CT scan of the chest revealed metastasis to right upper lobe of the lung.The patient’s poor pulmonary function, related to a 45 pack-year smoking history and chronicemphysema, precluded a lobectomy.RESULTS: After the patient underwent a lung-sparing wedge resection of the pulmonary rightupper lobe metastasis and intraoperative brachytherapy with 131Cs seeds to a total dose of80 Gy, she remained disease free in the implanted area. At a 2-year followup, imaging continuedto reveal 100% local control of the area treated with wedge resection and intraoperative 131Cs bra-chytherapy. The patient had no complications from this treatment.CONCLUSIONS: Such treatment approach may become an attractive option in patients with oli-gometastatic disease and compromised pulmonary function. � 2013 American BrachytherapySociety. Published by Elsevier Inc. All rights reserved.

Keywords: Pulmonary oligometastasis; Lung-conserving surgery; Wedge resection; Brachytherapy; Cesium-131

Introduction

Soft tissue sarcomas are a heterogeneous group of malig-nant tumors that arise in mesenchymal tissue and account forapproximately 1% of all malignancies in adults (1). Themostcommon site ofmetastases for soft tissue sarcomas is the lung(2). The appropriate surgical approach to treating pulmonarymetastases has inspired debate in the medical community

ary 2013; received in revised form 1 May 2013;

3.

author. Department of Stich Radiation Oncology,

e of Cornell University, 525 East 68th Street, New

: þ1-212-746-3641; fax: þ1-212-746-8749.

aw9008@med.cornell.edu (A.Gabriella Wernicke).

nt matter � 2013 American Brachytherapy Society. Publis

.1016/j.brachy.2013.05.001

with respect to the specific surgical approach: pneumonec-tomy, lobectomy, or a wedge resection (3, 4). In patientswhose lungs are amenable to complete resection, pneumo-nectomyhas proved to be a viable surgical approach, yieldingan operative mortality of 4% (4 of 112) and a 5-year survivalrate of 20% in 112 patients (5).However, several criteriamustbe met in order for surgical resection to be a viable approach:(1) the patient must be medically cleared for surgical inter-vention; (2) the primary malignancy must be controlled; (3)there should be absence of other extrapulmonary metastases;and (4) the pulmonary lesions should be deemed completelyresectable. The appropriate selection of candidates accordingto these criteria yields an overall 5-year survival after pulmo-nary metastasectomy of 30e40% (6e8). Furthermore,

hed by Elsevier Inc. All rights reserved.

Fig. 1. A routine CT scan of the chest performed on May 4, 2010 revealed

a new right upper lobe pulmonary nodule, measuring 1.9 � 1.6 cm.

568 A.Gabriella Wernicke et al. / Brachytherapy 12 (2013) 567e572

a study of patients with pulmonary metastases reporteda threefold increase in long-term survival in patients treatedwith surgical resection over those treated with nonoperativetherapy. Thus, surgical excision should remain the mainstayof treatment for pulmonary metastases of soft tissue sarcoma(2, 9, 10).

Although the ability to resect the entire tumor is themost favorable prognostic factor, in patients with compro-mised lung function (as per external factors), a less invasiveapproach, such as wedge resection, is preferred, and yieldsa higher long-term survival (11). A retrospective study ofpulmonary metastasectomy for colorectal cancer reporteda higher survival rate with wedge resection than with lobec-tomy (12). However, a study of 18 children with pulmonarymetastases treated with wedge resection reported an overallsurvival rate of 39% and a 50% local recurrence rate, sug-gesting that lobectomy or pneumonectomy is preferable inpatients without severe comorbidities. These results arestrongly linked to the histology of the disease; therefore,more data are needed before general conclusions being in-ferred. Still, wedge resection plays an important role inpatients with extensive comorbidities (13).

We present a case of a 58-year-old African Americanfemale with American Joint Committee on Cancer (AJCC)Stage IIA mixed uterine leiomyosarcoma metastatic to theright upper lobe (RUL). Chronic obstructive pulmonarydisease related to a 45 pack-year smoking precludeda lobectomy. Instead, she was treated with video-assistedthoracic surgery wedge resection and intraoperative brachy-therapy with cesium-131 (131Cs) seeds around the resectionmargin to minimize local recurrence.

Case report

A 58-year-old African American female with AJCCStage IIA mixed leiomyosarcoma status after total abdom-inal hysterectomy and bilateral salpingo-oophorectomy wastreated with external beam radiotherapy to a dose of 45 Gyin 25 fractions, 1.8 Gy per fraction to the pelvis with15 MV photons, and vaginal brachytherapy to a dose of20 Gy in four fractions of 5 Gy to the upper vagina overa length of 5 cm and a depth of 0.5 cm, completing thecourse of radiation on February 21, 2007. Subsequently,the patient was treated with five cycles of gemcitabine/do-cetaxel, completing therapy in May 14, 2007. A followupof the treatment consisted of surveillance CT scans of thechest, abdomen, and pelvis and an annual positron emissiontomographyeCT as per the gynecologic oncologistdall ofthem had no evidence of distant metastases.

A routine CT scan of the chest performed on June 24,2010 revealed a new RUL pulmonary nodule, measuring1.9 � 1.6 cm (Fig. 1). Further imaging as part of restagingconfirmed this as the only site of disease. The patient hada long-standing history of smoking (45 pack-years) andchronic emphysema that precluded lobectomy as a surgical

treatment option. The plan to address this only oligometa-stasis was to resect with a video-assisted wedge resectionand application of intraoperative brachytherapy. On August23, 2010, the patient underwent a right lung wedge resec-tion with intraoperative implantation of 20 stranded 131Csseeds. A video thoracoscopy was performed with three inci-sions 3 cm in transverse diameter at the fifth interspace inthe posterior axillary line, the seventh interspace in theposterior axillary line and the sixth interspace in the mid-scapular line. The lesion was palpated in the RUL andwas resected with a large wedge resection with multiplefires of the Endo GIA green load stapler (Covidien, Nor-walk, CT). No other lesions were appreciated. Meticuloushemostasis was achieved, and copious irrigation was used.131Cs brachytherapy seeds were sewn on each side of thestaple line with running 3e0 Vicryl sutures. The lungwas reexpanded under direct vision and noted to inflatewell. The patient tolerated the procedure well, was turnedover, awoken, extubated, and brought to the recovery roomin stable condition. The prescription was a total dose of80 Gy to the 5-mm depth from the resection edge (Fig. 2).

131Cs seeds are placed at 0.5e1 cm strand separationintervals along the surface of the cavity. Each seed has anactivity of 2.0e2.4 U. The 131Cs seeds are provided withina polyglycolic acid suture thread at 1-cm intervals along thesutures length. The thoracic surgeon configures the properorientation of the implant over the resection margin andthen secures the implant with tacking sutures of 3e0 silkor polyglycolic acid suture. The 131Cs seeds embedded inpolyglactin suture (Isoray, Richmond, VA) will be affixed0.5 cm on either side of the resection margin measuredfrom the base of the staple or suture line. The process iscontinued until both sides of each resection margin havea parallel row of seeds on each side. Suture seed placement,

Fig. 2. Wedge resection to right upper lobe. (aec) 100% isodose lines (orange: 120 Gy; blue: 80 Gy; and purple: 40 Gy). (a) Transverse CT image. (b)

Coronal CT image. (c) Sagittal CT image. (d) Radiation cloud of 100% isodose line corresponding to 80 Gy to a 5-mm depth. (For interpretation of references

to color in this figure legend, the reader is referred to the web version of this article.)

569A.Gabriella Wernicke et al. / Brachytherapy 12 (2013) 567e572

and thus dose prescriptions, were determined intraopera-tively and dependent on the length of the resection margin.A written dose prescription included the number of seeds,number of strands, activity of each seed, total activity ofthe implant, and strand separation. Final dosimetry was ob-tained after complete reinflation of the lung with CT-basedthree-dimensional planning a few days after the surgicalprocedure.

The patient sustained an uncomplicated postoperativecourse and had no side effects associated with the brachy-therapy. Pathology revealed metastatic high-grade sarcoma,histologically similar to the patient’s known leiomyosarco-ma of the uterus. The metastatic focus measured 2.8 cm ingreatest dimension. The surgical resection margins werefree of tumor. A followup CT of the chest on December6, 2010 revealed RUL wedge resection with 1.6 � 1.5 cmopacity observed adjacent to surgical clips in the RUL-reflected postoperative scarring and no evidence of localrecurrence (Fig. 3a), and no evidence of new lesions inthe lungs, bilaterally. There was no evidence for metastaticdisease in the abdomen or pelvis.

The patient was hospitalized with headaches persisted,and an MRI on August 10, 2011 demonstrated a 1.7 �1.4-cm tumor that compressed both aspects of the sagittaland transverse sinuses. The patient underwent a near total(95%) neurosurgical resection of the tumor and had a pro-longed hospital stay because of postoperative complications.

She was further staged and found to have increased bilobarhepatic metastases (since a CT scan on October 20, 2011)and stable postsurgical changes in the pulmonary RUL butno evidence of local pulmonary recurrence (Fig. 3b). OnFebruary 21, 2012, the patient was placed under the palliativecare of home hospice, and on October 04, 2012, she passedaway.

Discussion

Our approach to treat with wedge resection and 131Csbrachytherapy was largely influenced by the successfulresults of previous studies in treating both primary andmetastatic lung cancer with wedge resection alone andwedge resection with brachytherapy. Local recurrence afterlobectomy for a primary lung cancer ranges from 2.2% to5.1% and after wedge resection from 8.6% to 21.4% (14,15). However, the addition of local radiotherapy to thepatients with wedge resection reduces the risk of recurrencefrom approximately 19% (sublobar resection alone) to 2%(sublobar resection with iodine-125 [125I] brachytherapy)(16, 17). Various techniques of local or focal radiotherapyhave been used in patients undergoing a wedge resection.Brachytherapy renders a higher dose of radiation delivery(than external beam irradiation) to a tumor, while sparingnormal surrounding tissue. Radioactive isotope 125I has

Fig. 3. Followup imaging of the wedge resection site. (a) CT of the chest on November 22, 2010 revealed RUL wedge resection with 1.6 � 1.5 cm opacity

observed adjacent to surgical clips. (b) CT of the chest on January 12, 2012 revealed stable postsurgical changes in the pulmonary RUL but no evidence of

local pulmonary recurrence. RUL 5 right upper lobe.

570 A.Gabriella Wernicke et al. / Brachytherapy 12 (2013) 567e572

frequently been used in conjunction with sublobar resectionto treat T1 nonesmall-cell lung cancer (NSCLC) inpatients who are unfit to undergo lobectomy.

Some studies have demonstrated that adjuvant brachy-therapy with wedge resection may reduce local recurrence(18). Santos et al. (16) compared the efficacy of sublobarresection without subsequent brachytherapy to that with125I brachytherapy. A total of 101 patients, who presentedwith AJCC clinical Stage I NSCLC and marginal lung func-tion, were treated with wedge resection and brachytherapy,whereas 102 patients were treatedwith onlywedge resection.Postoperative morbidity, mortality, and survival in bothgroups were similar, whereas local recurrence in the brachy-therapy group was significantly lower (2% in brachytherapygroup vs. 19% in thewedge-only group). Although this studywas limited to patients with primary lung cancer, it demon-strates that local recurrence is significantly reduced withthe addition of brachytherapy to wedge resection (16). Simi-larly, in a multicenter study of 291 patients with Stage IANSCLC, Fernando et al. (18) reported a significantly reducedlocal recurrence rate in the group (n5 23) treatedwithwedgeresection and 125I brachytherapy over the group (n 5 28)treated with isolated wedge resection (3.3% vs. 17.2%).Johnson et al. (19) reported that sublobar resection inconjunction with 125I brachytherapy is associated with recur-rence rates of 2.0% comparedwith 18.6%with surgery alone.Like the aforementioned study, this study demonstrates thatadjuvant brachytherapywith sublobar resection reduces localrecurrence.

131Cs radioactive isotope was cleared by the FederalDrug Administration in 2003 for the application in multiplesites of prostate, gastrointestinal, gynecologic, brain, andlung cancer, to name a few (20). 131Cs has substantialradiobiologic and physical advantages over 125I: a shorthalf-life (t1/2) of 9.69 vs. 60.2 days, high dose rate of

0.342 Gy/h vs. 0.069 Gy/h, and a similar mean energy of29.8 vs. 28.0 KeV. This means that 131Cs delivers 90% ofthe intended dose 33 days postimplant, as compared with32% of the 125I dose. Therefore, 131Cs has less exposureto the hospital staff and family than 125I. In 2011, Parasharet al. (21) treated 28 patients for early stage lung and recur-rent head and neck cancers as well as reported both anacceptable dosage and a lower prescription volume for131Cs as compared with 125I. Furthermore, systemic therapycan be initiated in 1 month after surgery when most of theradiation dose has been delivered. Having a higher doserate is superior in attaining superior local control in rapidlydividing and aggressive tumors such as sarcoma.

125I has traditionally been used for permanent lungimplants. The prescription doses have not been standard-ized by any randomized prospective trial, but a dose of80e120 Gy at 0.5e1 cm from the wedge line has been usedwith success and minimal toxicity (17, 22, 23). Because131Cs is a new source to be used in clinical practice, nostandard of prescriptions for lung brachytherapy has beenestablished. Radiobiologic data suggest that tumors withshort doubling times would respond better with radiationsources with shorter t1/2 (24).

131Cs seeds have a dose rateconstant of 1.06 cGy h�1 U�1 in water, dose penetrationcharacteristics similar to 125I and palladium-103 (103Pd),anisotropy function values on the order of 0.71 at shortdistances and small angles, and an average anisotropyfactor of 0.964 (20). The overall dosimetric characteristicsare similar to 125I and 103Pd seeds with the exception of t1/2,which is 9.7 days, as compared with 17 days for 103Pd and60 days for 125I (20). The working assumption of the studywas that as far as the radial dose distribution is concerned,this source is very similar to 125I. Therefore, the technicalplacement of seeds, that is, the needle positions and numberof seeds should be very similar to 125I seed placement (25).

571A.Gabriella Wernicke et al. / Brachytherapy 12 (2013) 567e572

The 131Cs prescribed dose determination is based on thelinearequadratic formulation where assumptions are maderegarding the a/b ratios for late responding and lung tissue,tissue repair constant, average tumor doubling time, repo-pulation rates, and so on. If they are similar to 125I (almostsimilar energy), and radiobiological effectiveness similar to125I is assumed (1.0e1.45), then matched tumor effects canbe expected in the range of 80e120 Gy. If the a/b ratio forlung cancer is less than five as assumed, and given the rela-tive effectiveness of 125I in lung cancer cell killing in theliterature, then a prescribed dose of 60e80 Gy (60e70Gy used for lesions less than 1 cm) is assumed to be reason-able especially because of significantly higher dose rate(24).

A nomogram was developed using the variseed softwarewith source data from American Association of Physicistsin Medicine Task Group no. 43 report (26). As the row orcolumn spacing is changed, activity and number of seedsare changed to maintain the prescribed dose. Doses areachieved with infinite source decay. The reduction in theprescribed dose was based on clinical judgment, especiallythe location of the implant to critical structures such aspulmonary vessels and aorta. The nomogram was devel-oped for a prescription dose at 0.5 cm from the wedge line.Additionally, dosimetric analysis between 131Cs has beenshown to deliver the effective dose to a smaller tissuevolume and has shown no Radiation Therapy OncologyGroup grade 1eIV radiation toxicity (21).

Given her comorbidities, we approached our patient’spulmonary oligometastasis from a uterine sarcoma primarywith a wedge resection and 131Cs intraoperative brachyther-apy. As evidenced by all the followup imaging, the patientsustained 100% local control in the treated RUL. Further-more, she had no acute or late sequelae reported in associ-ation with this treatment. She ultimately succumbed tobrain metastases 2 years subsequent to the application of131Cs brachytherapy but still with no evidence of localrecurrence.

Another major treatment option for patients with lungoligometastasis is that of stereotactic body radiationtherapy (SBRT). The results of Phase II trials using SBRTfor the treatment of oligometastatic (five lesions or less)disease have recently been reported by showing 2-yearlocal control rates between 67% and 96% (27e30). Anal-yses of the results have showed that the use of higher moreintense dose of SBRT yielded higher rates of local control.At the same time, with the increasing dose of SBRT, theremust be adequate monitoring of associated toxicities.Because of differences in baseline prognostic featuresbetween patients in these studies and others in the literaturethere are limitations between the comparisons, just as notedwithin this case as well.

To our knowledge, this is the first case report in the liter-ature in which 131Cs brachytherapy was used in conjunctionwith wedge resection to treat pulmonary oligometastasis.Although lobectomy is widely accepted as the mainstay

of treatment for pulmonary neoplasms (31e33), our caseillustrates the potential benefits of using wedge resectionand 131Cs brachytherapy to treat pulmonary metastases inpatients with a compromised lung function. Previousstudies have demonstrated the effectiveness of wedgeresection with 125I brachytherapy to treat patients withprimary lung cancer (16e18, 34e36). However, scarceliterature exists on the surgical treatment of pulmonarymetastases with this approach.

Conclusions

We report the application of 131Cs brachytherapy in thesetting of a wedge resection of a pulmonary oligometastasisfrom a uterine sarcoma. A 2-year followup demonstrated100% local control and no acute or chronic complicationsafter surgery. Although further research is required, wethought that in patients with compromised pulmonary func-tion and a pulmonary oligometastasis, such approach mayrender durable local control without significant complica-tions. Thus, the combination of wedge resection and131Cs brachytherapy offers a promising future to selectpatients with compromised lung function and pulmonaryoligometastasis.

Acknowledgment

Written consent was obtained from the patient.

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