A Case of Radiation Bronchitis Induced Massive Hemoptysis after High-Dose-Rate Endobronchial Brachytherapy
A 67-year-old man visited for cough and sputum lasting for 5 months. He was a current smoker with a history of 40 pack-year smoking and had a coronary arterial disease. Right pleural effusion was seen in a chest X-ray (). The character of pleural effusion was exudates with many lymphocytes and low level of adenosine deaminase. A consolidation was seen in computed tomography (CT) after the effusion had been drained () and no endobronchial lesion was found on left upper lobe in chest CT (). Bronchoscopy was performed to differentiate causes of the right lung lesion. There was no endobronchial lesion in right bronchial tree. Incidentally, mucosal nodularity was observed in the left upper lobe bronchus () and was diagnosed with squamous cell carcinoma with biopsy (). A pulmonary wedge resection and pleural biopsy were performed to evaluate right lower lobe and pleural lesions through video assisted thoracoscopic surgery, and the results were chronic organizing pneumonia and subpleural fibrosis with chronic inflammation. The lesions of right lower lobe and right pleura were remained without progression until the last follow-up radiologic examination. Lymph node involvement and distant metastasis were not observed in the staging work-up. Despite the clinical stage was IA, the patient had moderate chronic obstructive pulmonary disease (post-bronchodilator forced expiratory volume in 1 second, 1.74 L) and his endobronchial cancer involved the left main bronchus. The patient might be intolerable for surgical treatment, such as pneumonectomy or sleeve lobectomy, and we decided to do curative local therapy.\nHDREB was performed with 6 fractions of 5 Gy for 6 weeks. After the treatment, the patient complained of persistent cough, but bronchoscopy and chest CT had not shown the progression of lung cancer until 4 weeks after HDREB. Further follow-up bronchoscopies were performed at 34, 50, 54, and 59 weeks after the HDREB. Grade 1 radiation bronchitis was observed in the left upper lobe bronchus which was previous cancer lesion at 34 weeks () and was also observed in the medial wall of the left mainstem bronchus which was not cancer lesion but contact area of guide sheath for radiation source at 50 weeks after HDREB (). On the bronchoscopic finding at 54 weeks (12 months), mucosal necrosis of the left upper lobe bronchus was advanced () and ulcer lesions began to appear in the left main bronchus (). The patient started taking oral steroids at 55 weeks, but the area of the left upper bronchial lesions extended () and left main bronchus ulcers also increased in the depth and extent at 59 weeks (14 months) (). Bronchial biopsies for the bronchitis were performed four times among five follow-up bronchoscopic examinations, and it showed acute or chronic inflammation and no cancer cells were observed. The patient died suddenly due to massive hemoptysis at 15 months after HDREB.