Intraoperative ¹²⁵I brachytherapy for high-risk stage I non-small cell lung carcinoma

Purpose: Preliminary assessment of feasibility, efficacy, acute and chronic side effects associated with permanent intraoperative placement of ¹²⁵I vicryl mesh brachytherapy in a select group of high-risk Stage I NSCLC who have undergone video-assisted thoracoscopic resection (VATR). Methods and Materials: From January 8, 1997 to March 16, 1998, 23 patients with Stage I NSCLC at high risk for conventional surgery due to cardiopulmonary compromise underwent combined VATR and intraoperative placement of ¹²⁵I seeds embedded in vicryl mesh. Seeds embedded in vicryl suture were attached with surgical clips to a sheet of vicryl mesh, and thoracoscopically inserted over the target area (tumor bed and staple line) with nonabsorbable suture or surgical clips. A total dose of 100-120 Gy prescribed to the periphery of the target area (defined as the staple line and tumor bed with a 1-cm margin) was delivered. Results: The mean target area covered was 48 cm² (range 40-72) and mean total activity was 22 mCi (range 17.2-28.2). The median length of postoperative stay was 7 days. The median follow-up was 11 months (range 2-20). Postoperative CT scans of the chest revealed no dislodgement of the seeds and no local recurrence in any patient. Three patients developed distant metastasis (1 died 6 months postoperatively; the other 2 are currently alive with disease). One patient developed an ipsilateral recurrence in the right lower lobe after having had a right upper lobe resection. There were 3 postoperative deaths due to medical comorbid conditions or surgical complications (1 in the immediate postoperative period). Pulmonary function testing performed 3 months after implantation revealed no significant difference between preoperative and postoperative values: mean preoperative FVC was 2.3 L (range 1.31-3.0) and postoperative FVC was 2.2 L (range 1.1-3.9), p = 0.42; mean preoperative FEV₁ was 1.2 L (range 0.71-2.2), and postoperative FEV₁ was 1.5 L (range 0.8-2.9), p = 0.28. Conclusion: Review of early data suggests that intraoperative ¹²⁵I vicryl mesh brachytherapy in high-risk Stage I NSCLC is potentially effective and well tolerated, with no significant decline in measurable pulmonary function studies and no increase in postoperative complications. Longer follow-up is needed to determine ultimate local control and survival.