A 75-year-old male, former smoker (50 pack-years), with a history of squamous cell lung carcinoma treated with right lower lobectomy 20 years earlier, presented with progressive dyspnea at rest (mMRC IV) and hypoxemic respiratory failure. Chest computed tomography revealed a 14mm nodular lesion in the left main bronchus. Bronchoscopy showed a lesion at the carina between the left upper and lower lobes, causing near-complete obstruction. Biopsy and partial endoscopic resection were performed, but follow-up demonstrated slight progression. Histopathology confirmed squamous cell carcinoma. Due to prior lobectomy, surgery was ruled out, and radical high-dose-rate endobronchial brachytherapy with Iridium-192 (30Gy in six weekly fractions) was administered. Complete endobronchial resolution was achieved and maintained at six months. Endobronchial brachytherapy is a well-tolerated technique that delivers high radiation doses with minimal damage to surrounding tissue and may represent a radical therapeutic option in selected patients with localized endobronchial tumors not eligible for surgery or external radiotherapy.
Varón de 75 años, exfumador (50 paquetes-año), con antecedentes de carcinoma epidermoide pulmonar tratado mediante lobectomía inferior derecha hace 20 años, consultó por disnea progresiva hasta hacerse de reposo (mMRC IV) e insuficiencia respiratoria hipoxémica. La tomografía computarizada torácica evidenció una lesión nodular de 14mm en el bronquio principal izquierdo. La broncoscopia mostró una lesión en la carina entre los lóbulos superior e inferior izquierdos, con obstrucción casi completa. Se realizaron biopsia y resección endoscópica parcial, con ligera progresión posterior. El estudio anatomopatológico confirmó carcinoma epidermoide. Dado el antecedente quirúrgico, se descartó cirugía y se indicó braquiterapia endobronquial de alta tasa de dosis con Iridio-192 (30Gy en seis fracciones). Se logró resolución completa mantenida a los seis meses. La braquiterapia endobronquial es una técnica bien tolerada que permite administrar altas dosis con mínima afectación del tejido sano y puede ser una alternativa terapéutica en pacientes seleccionados no candidatos a cirugía o radioterapia externa.
A 75-year-old male patient, former smoker (50 pack-years), with a previous history of chronic obstructive pulmonary disease (COPD) GOLD 2 A and squamous cell lung carcinoma treated with right lower lobectomy 20 years earlier, without subsequent recurrence, presented to the emergency department with a 1.5-month history of progressive dyspnea, eventually occurring at rest (mMRC grade IV), productive cough with whitish sputum, bilateral rhonchi on auscultation, and a baseline oxygen saturation of 88%. Arterial blood gas analysis confirmed de novo hypoxemic respiratory failure.
Chest computed tomography (CT) revealed a 14mm non-obstructive exophytic endoluminal lesion within the left main bronchus, located 4cm from the main carina, without evidence of significant extrabronchial invasion (Fig. 1A).
(A) Chest CT showing a 14mm solid-appearing nodular lesion within the left main bronchus (red arrow). (B) Bronchoscopy prior to brachytherapy: endobronchial lesion located at the carina between the left upper and lower lobes. (C) Follow-up bronchoscopy after 6 weeks of treatment: complete resolution of the lesion. (D) Bronchoscopy 6 months after treatment completion: post-radiation changes with no evidence of recurrence.
The patient was admitted to hospital, and a flexible bronchoscopy was performed in the operating room. The lesion was visualized at the carina separating the left upper and lower lobes, almost completely obstructing the entrance to the upper lobe and preventing passage of the therapeutic bronchoscope.
Biopsies were obtained, and partial resection was performed using a diathermy loop and electrocoagulation; however, access to the left upper lobe could not be achieved. The patient reported clinical improvement after the procedure, although respiratory failure persisted. A follow-up bronchoscopy 14 days later showed slight growth of the lesion (Fig. 1B).
An 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) staging study was performed, demonstrating no evidence of nodal or distant metastatic disease. Pulmonary function testing showed a forced vital capacity (FVC) of 3.52L (97% predicted), a forced expiratory volume in one second (FEV1) of 1.78L (65% predicted), an FEV1/FVC ratio of 51%, a diffusing capacity of the lung for carbon monoxide (DLCO) of 78% predicted, and a carbon monoxide transfer coefficient (KCO) of 101% predicted. Histopathological examination of the bronchoscopic biopsy confirmed squamous cell carcinoma, clinically staged as IA2 (cT1bN0M0) according to the 9th edition of the TNM staging system.
The case was presented and discussed at the Multidisciplinary Thoracic Tumor Board. Due to the location of the lesion, with complete involvement of the carina separating the left upper and lower lobes, pneumonectomy would have been required. However, considering the patient's age and previous history of right lower lobectomy surgical management was therefore ruled out.
Considering the patient's surgical risk and the localized endobronchial nature of the lesion, radical treatment with endobronchial brachytherapy was indicated.
Radical high-dose-rate endobronchial brachytherapy was administered using the Flexitron® afterloading system with Iridium-192, consisting of six weekly fractions of 5Gy per session, reaching a total dose of 30Gy.
A progressive reduction in lesion size was observed, leading to complete resolution (Fig. 1C), which persisted six months after completion of treatment (Fig. 1D).
The patient showed significant clinical improvement, with dyspnea decreasing from mMRC grade IV to grade I and resolution of respiratory failure. A new pulmonary function test was performed, showing no significant changes compared with the previous evaluation.
Brachytherapy enables highly localized and conformal radiation delivery with rapid dose fall-off, potentially improving target coverage while sparing surrounding normal tissues.1
It can be used as a radical oncological treatment in selected cases, as adjuvant therapy after surgery,2 for palliative purposes (e.g., hemoptysis, cough, or dyspnea due to airway obstruction),3 and even in certain benign conditions.4
This technique has shown encouraging rates of local tumor control in carefully selected endobronchial lesions and may offer an effective alternative for patients with localized disease who are ineligible for surgical resection or external beam radiotherapy.1
Ethical considerationsThis study did not require ethical approval because it did not involve experiments on humans or animals, nor did it include identifiable personal data.
Declaration of generative AI and AI-assisted technologies in the writing processNo AI software or tool was involved in this manuscript.
Informed consentInformed consent was obtained from the patient for the publication, clinical data and images submitted.
FundingWe declare that there is no funding received for this work.
Authors’ contributionsAll authors contributed to the conception, writing, and revision of the manuscript. All authors have read and approved the final version.
Conflicts of interestWe declare that there is no conflict of interest related to this work.
