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MP 8.03.11 Endobronchial Brachytherapy

Medical Policy    
Section
Therapy 
Original Policy Date
3/15/99
Last Review Status/Date
Reviewed with literature search/2:2014
Issue
2:2014
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. 


Description

Endobronchial brachytherapy describes the delivery of radiation therapy directly to endobronchial lesions, using either permanent interstitial implantation of radioactive seeds or a temporary afterloading implant. The technique permits targeted radiation while minimizing exposure to surrounding radiosensitive structures, such as normal lung, heart, and spinal cord.

Endobronchial brachytherapy has been most investigated as a palliative treatment of obstructing primary or metastatic tumors, particularly in non-small cell lung cancer. There is also experience using endobronchial brachytherapy as a tool in curative treatment for some primary bronchial and tracheal tumors. Two to four fractions delivered weekly is a typical schedule. The most serious complications described for endobronchial brachytherapy are massive hemoptysis, formation of tracheoesophageal fistulas, bronchospasm, bronchial stenosis and radiation bronchitis (1).

In the outpatient setting, the patient receives local anesthesia and monitored sedation. A flexible bronchoscope is passed transnasally; a separate port on the bronchoscope allows passage of the afterloading catheter to the target lesion. Once the catheter is placed, the radioisotope can be administered by the high-dose radiotherapy afterloading machine. Patients with potential airway compromise due to bleeding may require treatment with a rigid bronchoscope, which requires general anesthesia and frequently an overnight stay.

Endobronchial brachytherapy represents one approach to the local treatment of endobronchial lesions. Other technologies include electrocoagulation, cryosurgery, laser resection, endosurgery and endobronchial stent placement. In some instances, the therapies may be used together, such as using laser therapy for initial debulking followed by brachytherapy.


Policy

Endobronchial brachytherapy may be considered medically necessary in the following clinical situations:

  • In patients with primary endobronchial tumors who are not otherwise candidates for surgical resection or external-beam radiation therapy due to comorbidities or location of the tumor
  • As a palliative therapy for airway obstruction or severe hemoptysis in patients with primary, metastatic, or recurrent endobronchial tumors

Other applications of endobronchial brachytherapy are investigational including, but not limited to, its use as a radiation “boost” to curative external-beam radiotherapy, as treatment for asymptomatic recurrences of non-small-cell lung cancer, or in the treatment of hyperplastic granulation tissue.


Policy Guidelines

Endobronchial brachytherapy is a multistep procedure requiring a series of radiation oncology CPT codes for radiation treatment planning, radiation physics, treatment delivery, and clinical treatment management. CPT codes 77761-77787 describe various types of radiation source application; these codes are used to describe the brachytherapy delivery. In contrast to other types of radiation therapy, endobronchial brachytherapy requires the services of a radiation oncologist, and a pulmonologist or other physician to perform the bronchoscopy and insert the catheter. In 1999, a new CPT code was introduced that specifically identified the catheter placement:

31643: Bronchoscopy (rigid or flexible); with placement of catheter(s) for intracavitary radioelement application.

Previously, the bronchoscopy component of endobronchial brachytherapy was probably coded with CPT code 31641 (bronchoscopy with destruction of tumor) or by using CPT codes 77761-77763 with a modifier –62 to indicate the participation of a surgeon/pulmonologist in addition to the radiation oncologist.


Benefit Application
BlueCard/National Account Issues

No applicable information.


Rationale

This policy was created in 1999 and updated with searches of MEDLINE through January 20, 2014. Following is a summary of the key literature to date.

Endobronchial brachytherapy is used as both palliative treatment and curative treatment; either alone or in combination with other modalities such as surgery, external-beam radiation, or other endoscopic interventions.

Endobronchial Brachytherapy as Palliative Treatment

Many patients with non-small-cell lung cancer (NSCLC) are initially treated with external-beam radiation therapy but ultimately experience local recurrence. Unfortunately, many are not candidates for further external-beam radiation therapy due to limited tolerance of normal tissue. If symptoms persist after external-beam radiation, endobronchial brachytherapy is well-accepted as short-term palliation for such symptoms as hemoptysis, cough, dyspnea, and resolution of obstructive atelectasis or pneumonitis. A 2008 European prospective study reported on 270 patients who had previously received radiation therapy and subsequently were given high-dose brachytherapy, resulting in a total response rate of 80% for symptoms of dyspnea, cough, hemoptysis, and postobstructive pneumonia with a median duration of palliation of 5 months with a range of 2 to 14 months.(2) In a summary of studies of palliative endobronchial brachytherapy between 1985 and 1994, Villanueva et al reported effective palliation in 60% to 100% of patients.(3) The median survival of these patients is typically less than 9 months.

A 2008 Cochrane review of palliative endobronchial brachytherapy for NSCLC, updated in 2012,(1,4) analyzed 13 randomized controlled trials (RCTs) but could not combine them into a meta-analysis because of heterogeneity in the doses of radiotherapy delivered, patient characteristics, and outcomes measured. The authors concluded that external-beam radiation therapy alone is still more effective for palliation of symptoms than endobronchial brachytherapy alone. Their findings did not provide conclusive evidence that endobronchial brachytherapy plus external-beam radiation therapy improved symptom relief over external-beam radiation alone, nor did it improve complication rates or extend survival. In summary, the authors were unable to provide conclusive evidence to recommend endobronchial brachytherapy as an add-on to first-line external-beam radiation therapy, chemotherapy, or Nd-YAG laser palliative treatment. For patients previously treated by external-beam radiation who are still symptomatic, endobronchial brachytherapy may be considered an option.

In agreement with the Cochrane review, a 2006 prospective randomized trial from India with 45 patients suggested that endobronchial brachytherapy alone and endobronchial brachytherapy with external radiation had similar efficacy and safety profiles in the palliative management of NSCLC.(5)

Also in agreement with the Cochrane review, Ung et al conducted a 2006 systematic review of endobronchial brachytherapy in the palliative treatment of NSCLC with 29 studies and 6 randomized trials.(6) The authors concluded that external-beam radiation therapy alone is more effective than endobronchial brachytherapy alone for symptom palliation in previously untreated patients. In contrast to the Cochrane review though, the Ung review concluded that endobronchial brachytherapy with external-beam radiation seems to provide better symptom relief than external-beam radiation alone, yet the final recommendation was to only use endobronchial brachytherapy for symptomatic recurrent endobronchial obstruction after external-beam radiation.

Most studies evaluated the use of endobronchial brachytherapy in lung cancer, but a 2007 French study reported on the use of endobronchial brachytherapy in a small number of patients with endobronchial metastases secondary to colorectal carcinomas.(7) All patients had primary resection of the colorectal carcinoma; then 7 received intrabronchial therapies including brachytherapy and 7 did not. Patients receiving intrabronchial therapies had a median survival of 55.7 months versus 12.7 months for controls. It is difficult to draw conclusions from this small study; larger trials are still needed.

Ozkok et al (2008) published a case series from Turkey on the use of high-dose-rate endobronchial brachytherapy for palliation of symptoms in 158 patients in 3 patient groups.(8) Group A comprised 43 patients with stage IIIA and IIIB NSCLC who received endobronchial brachytherapy in combination with external-beam radiation; group B comprised 74 previously untreated patients with incurable, locally advanced lung cancer; and group C comprised 41 patients with symptomatic endobronchial recurrences who had previously received full dose radiation therapy. Participants in group A were from a previously reported prospective trial(9); data from these participants were reanalyzed for symptom palliation in the Ozkok report. Not all patients received the intended number of fractions due to patient refusal or deterioration in performance status. A few patients required more than the prescribed doses due to repetitive obstructive symptoms. Response rates for cough, dyspnea, and hemoptysis were measured by the Speiser Symptom Index scoring system. Response rates in group A were 58% for cough (30% complete response, CR), 77% for dyspnea (76% CR), and 100% for hemoptysis (92% CR). Groups B and C had response rates of 57% and 55% for cough and 90% and 78% for dyspnea, respectively. Eighteen patients (11%) died of hemoptysis, with a median time to event of 7 months. Significant prognostic factors for fatal hemoptysis were use of brachytherapy intended as a treatment (as opposed to strictly palliation, p<0.001), total radiobiologic equivalent dose (p<0.001), and the number of high-dose-rate endobronchial brachytherapy fractions (p<0.001). The authors concluded that high-dose-rate endobronchial brachytherapy was effective for palliation of symptoms related to inoperable lung cancer, either alone or in combination with external-beam radiation. They cautioned that optimal dose, fractionation, and combination schedule with external-beam radiation were unknown. Further, they stated that any benefit must be weighed against potentially serious treatment-related morbidity or mortality. Without a comparison group, it is not possible to draw conclusions from this case series.

Although endobronchial brachytherapy is often used to palliate hemoptysis, historically, there has been concern about an observed association between treatment with endobronchial brachytherapy and fatal hemoptysis. The largest study was a retrospective review of 938 patients treated with external irradiation and/or endobronchial brachytherapy for inoperable NSCLC.(10) In this study, 101 patients (10.8%) died from massive hemoptysis; 78 of those who died (77%) had clinical or radiologic evidence of tumor progression, and 23 (23%) did not. On multivariate analysis, intrabronchial tumor extension in the main bronchus, hemoptysis before radiotherapy, and tumor location in the upper bronchus were independently associated with massive hemoptysis. A dose-response relationship between fraction dose and massive hemoptysis also was found; in all subgroups, higher incidence of massive hemoptysis was seen after fraction dose of 15 Gy. These data were largely consistent with data published by Hennequin et al (1998) who reported that hemoptysis was most likely due to disease progression, with brachytherapy facilitating bleeding, rather than a direct complication of brachytherapy itself.(11) The authors noted that for tumors located in the upper lobes, brachytherapy may be causal. Tumor location was cited as the most important factor in predicting pulmonary hemoptysis in a 1991 case series reported by Bedwinek et al in which 32% of patients died of massive hemoptysis after brachytherapy.(12)

Dagnault et al (2010) reported a retrospective review of 81 patients who were treated with brachytherapy for symptom palliation due to endobronchial primary lung tumors or metastases.(13) Between 2002 and 2007, 81 patients who were not candidates for surgery or external radiation because of poor respiratory function, medical comorbidities, or previous treatment with thoracic radiation or surgery, were treated at a single institution. Mean patient age was 66 years (range, 39-87). Previous treatment comprised surgical resection of the primary tumor in 58% of patients, lung radiotherapy in 44%, and chemotherapy in 41%. After endobronchial brachytherapy, patients were followed until death or loss to follow-up. Patient characteristics included 59 (73%) with a lung primary and the remainder with metastatic disease, including primary colorectal cancer (13%), kidney, gynecologic, or head and neck cancers (4% each), and other cancers (2%). Presenting symptoms included dyspnea (66%), cough (47%), hemoptysis (28%), and no symptoms (6%). After brachytherapy, major symptomatic improvement was seen in most patients: Dyspnea improved during or shortly after the end of treatment in 85% of patients; hemoptysis stopped in all 23 patients; cough improved in 77% of patients; and 18% remained stable. At 6 weeks’ follow-up, 72% of tumors were evaluable for bronchoscopic response. A visible bronchoscopic response was evident in 77 patients; for 42 (52%) of 81 patients, the tumor shrank significantly during treatment. Median survival was 14.7 months; local progression-free survival was 77% at 12 months and 64% at 24 months. For comparison, the authors stated that survival for most patients with inoperable endobronchial tumors or metastasis was less than 6 months. The incidence of complications was low, and all complications resolved.

Guarnaschelli et al (2010) reviewed treatment outcomes of 52 patients with recurrent endobronchial tumors who underwent palliative high-dose-rate endobronchial brachytherapy between 1995 and 2005 at one institution.(14) Objective response was assessed by bronchoscopy and chest computed tomography, and subjective clinical response by patient reports. All patients had histologically proven bronchogenic carcinoma, recurrent or persistent symptoms (hemoptysis, cough, dyspnea, or postobstructive pneumonia), previous definitive external-beam radiotherapy, and bronchoscopic evidence of endobronchial obstruction. Mean patient age was 63 years (range, 41-83) and 37% of patients were women. Tumor histology was non-small cell in 77% of patients, small cell in 13%, adenoid cystic in 2%, and metastatic in 2%. Patient symptoms before brachytherapy included dyspnea upon exertion (79%), cough (89%), hemoptysis (62%), wheezing (52%), dysphagia (8%), chest pain (15%), and shortness of breath (83%). Symptomatic improvement was defined as significant if there was improvement in 2 or more symptoms and mild if only 1 symptom improved. Forty-eight patients (92%) showed symptomatic improvement, with 3 patients (60%) showing significant improvement and 18 patients (35%) showing mild improvement. One patient had worsening hemoptysis, and 2 patients (4%) did not return for assessment. Median time to symptomatic relapse after the first fraction of brachytherapy was 6 months (range, 1 to more than 6 months). Complete or partial tumor regression was demonstrated in 44 patients (85%) on repeat bronchoscopy. For the entire cohort, median follow-up was 31 months, and median overall actuarial survival from the first brachytherapy session was 7 months (range, 0-55). Fifty patients (96%) tolerated treatment without acute, treatment-related complications. Significant treatment-related complications (grade 3 or 4) were reported as possibly occurring in 2 patients (4%): 1 patient developed a pneumothorax 6 weeks after brachytherapy, and 1 patient died from hemoptysis 48 hours after treatment; however, it was unknown whether hemoptysis was due to brachytherapy or to erosion of tumor into a blood vessel.

A 2013 comparative effectiveness review prepared for the Agency for Healthcare Research and Quality reviewed local nonsurgical therapies for symptomatic obstructive NSCLC.(15) For patients with obstruction due to inoperable NSCLC, 4 RCTs (total N=268) examined endobronchial brachytherapy alone or in combination with external-beam radiation therapy or Nd-YAG laser therapy for palliative or curative intent. All RCTs were determined to be of poor quality. Seven single-arm studies (total N=740) examined endobronchial brachytherapy alone or in combination with external-beam radiation therapy, stent placement, or chemotherapy plus photodynamic therapy for palliative or curative intent. The evidence was considered “insufficient to permit conclusions on the comparative effectiveness of local nonsurgical therapies for…inoperable NSCLC patients with endoluminal tumor causing pulmonary symptoms.”

Endobronchial Brachytherapy as Primary Treatment

Candidates for primary treatment have principally included patients with early-stage endobronchial tumors who are not candidates for surgical resection or external-beam radiation due to comorbidities or tumor location. Most studies have been case series, which reported CR rates of 50% to 80%.(16-18)

There also have been early investigations of brachytherapy to deliver a focused radiation boost to patients undergoing curative external-beam radiation therapy. Because patients usually present with surgically unresectable disease and because NSCLC is unresponsive to chemotherapy, primary treatment for most patients with NSCLC is typically external-beam radiation therapy.

Aumont-le Guilcher et al (2011) reported on 226 patients with primary non-small-cell carcinoma (endobronchial only) who underwent high-dose-rate brachytherapy because of contraindications to surgery and external-beam radiation therapy.(19) The patient sample comprised 223 men and 3 women from 9 institutions; mean age was 62 years (range, 40-84). Tumor histology was squamous cell in 96%, adenocarcinoma in 2%, and other in 2%. Response to high-dose-rate brachytherapy at 2 to 3 months was classified as complete histologic response (disappearance of the lesion by bronchoscopy and negative biopsy), complete macroscopic response (disappearance of the lesion but no biopsy), partial response (greater than 50% decrease in endobronchial tumor volume), or progression (increase in endobronchial tumor volume or tumor visible on computed tomography scan). At 3 months, complete local response was observed in 213 patients (94%), and in 137 patients with biopsies, 126 (91%) had a CR. Seven patients had tumor progression, 5 had a partial response, and 1 had stable disease. Overall survival was 57% at 2 years and 29% at 5 years. Median survival was 28.6 months. Cancer-specific survival was 81% at 2 years and 56% at 5 years. Complications led to treatment interruption in 4.5% of patients. Fatal complications (most commonly fatal hemoptysis) occurred in 6% of patients.

Skowronek et al (2013) reported on a small cohort of 34 patients in Poland who had stage IB-III lung cancer (74% squamous cell carcinoma histology; all distant metastasis-free) who had undergone lobar resection.(20) Thirteen patients (38%) developed postoperative recurrence in the bronchial stump, and 21 patients (72%) had histopathologically positive margins after nonradical resection. All patients had dyspnea and cough, and 8 patients (24%) had hemoptysis. Median patient age was 57 years (range, 47-73). Median time to recurrence after surgery was 11 months. It was not specified if patients were candidates for reoperation. Nine patients received high-dose-rate endobronchial brachytherapy (total dose, 12 Gy) in combination with external-beam radiation therapy (total dose, 50 Gy), and 25 patients received brachytherapy alone (total dose, 30 Gy). At 1 month, complete local and radiologic response was observed in 25 patients (74%), with 100% complete remission in the nonradical surgery group. All partial responses occurred in the recurrent tumor group (9 [69%] 13 patients). Median overall survival for the entire cohort was 19 months. With 2 years median follow-up, 2-year overall survival was 15% in the group with recurrent tumor and 48% in the nonradical resection group (Kaplan-Meier log-rank test, p=0.05). Adverse events were not reported.

Rochet et al (2013) reported on a cohort of 35 patients in Germany who had stage I-III (31% squamous cell carcinoma histology; all distant metastasis-free) inoperable NSCLC and received primary treatment with high-dose-rate endobronchial brachytherapy (median total dose, 15 Gy) in combination with external-beam radiation therapy (median total dose, 50 Gy).(21) Mean age was 64 years (range, 45-75). With 26 months median follow-up, median overall survival was 39 months. One-, 2-, and 5-year overall survival was 76%, 61%, and 28%, respectively. Median progression-free and local progression-free survival was 17 months and 42 months, respectively. In patients without mediastinal node involvement, 5-year local progression-free survival was 56% versus 11% with positive mediastinal nodes (Kaplan-Meier method log-rank test, p=0.008). Grade 3 adverse events were hemoptysis in 2 patients and necrosis in 1 patient. Fatal hemoptysis in 1 patient resulted from tumor recurrence.

Endobronchial Brachytherapy in the Treatment of Hyperplastic Granulation Tissue

Endobronchial brachytherapy has been investigated to treat hyperplastic granulation tissue causing recurrent airway stenosis after lung transplantation or stent placement. A 2008 case series reported on endobronchial brachytherapy in 8 patients after excision of obstructive granulation tissue; 6 patients (75%) had a good or excellent subjective early response for the first 6 months.(22) A 2006 case series used endobronchial brachytherapy in 5 patients with benign, postlung transplantation granulation tissue that was refractory to multiple other bronchoscopic interventions. After a median follow-up of 12 months, 3 (60%) of 5 patients had marked symptom improvement.(23) Although these case series reported positive outcomes, larger trials with adequate follow-up are needed to fully evaluate the potential role of endobronchial brachytherapy in the treatment of granulation tissue.

Rahman et al (2010) reported long-term follow-up of 115 patients who underwent various flexible bronchoscopic therapeutic modalities for the management of benign tracheal stenosis between 2001 and 2009.(24) High-dose-rate endobronchial brachytherapy was used in cases of refractory stent-related granulation tissue formation, defined as requiring 3 or more interventions within 6 months due to recurrent granulation tissue formation. All patients presented with signs and symptoms of upper airway obstruction, including shortness of breath, stridor, cough, dyspnea, and wheezing. Stents were placed in 33 patients to restore airway patency, and 28 of these patients underwent brachytherapy to prevent granulation tissue reformation. All 28 patients experienced a reduction in therapeutic bronchoscopic procedures after brachytherapy compared with the pretreatment period; no further details about response duration or other outcomes were reported. There were no treatment-related complications. Although this case series reported positive results, small sample size and concerns about outcome reporting limit conclusions that can be drawn.

National Cancer Institute Clinical Trials Database (PDQ®)

As of January 2014, 1 phase 3 trial addressing the use of endobronchial brachytherapy for NSCLC or metastases was identified. The BRACHY Trial to Evaluate the Improvement in Lung Cancer Patients Receiving Radiation With or Without Brachytherapy (NCT01351116) is an open-label, randomized trial by the Ontario Clinical Oncology Group. Eligible patients have stage III/IV or recurrent NSCLC and are candidates for palliative thoracic radiation therapy due to cough, shortness of breath or hemoptysis. Estimated enrollment is 250 patients, and the study completion date is December 2014.

Summary

Patients with non-small-cell lung cancer (NSCLC) may be treated with external-beam radiation therapy but ultimately experience local recurrence; many are not candidates for further external-beam radiation therapy due to limited tolerance of normal tissue. If symptoms persist after external-beam radiation, endobronchial brachytherapy is well-accepted as short-term palliation for such symptoms as hemoptysis, cough, dyspnea, and resolution of obstructive atelectasis or pneumonitis.

Candidates for primary treatment principally have included patients with early-stage endobronchial tumors who are not candidates for surgical resection or external-beam radiation due to comorbidities or tumor location. Most studies have been case series, which reported complete response rates of 50% to 80%. Comparative trials are needed to determine if survival or quality-of-life outcomes are improved compared with no treatment in these patients.

Endobronchial brachytherapy has been investigated to treat hyperplastic granulation tissue causing recurrent airway stenosis after lung transplantation or stent placement. Case series reported positive outcomes; larger trials with adequate follow-up are needed to fully evaluate the potential role of endobronchial brachytherapy to treat granulation tissue.

Practice Guidelines and Position Statements

National Comprehensive Cancer Network (NCCN) Guidelines, version 2.2014

NCCN guidelines recommend endobronchial brachytherapy for locoregional recurrence of non-small-cell carcinoma with endobronchial obstruction or severe hemoptysis (category 2A).(25)

The American College of Radiology (ACR) Appropriateness Criteria

ACR Appropriateness Criteria are developed by expert consensus and literature review. Several publications address radiation and nonsurgical treatments of lung cancer.

  • For nonsurgical treatment of NSCLC in patients with poor performance status or for palliative intent, the expert panel considered endobronchial brachytherapy “useful for patients with symptomatic endobronchial tumors.”(26)
  • For nonsurgical treatment of NSCLC in patients with good performance status or for definitive intent (no distant metastases), the panel considered endobronchial brachytherapy not appropriate, except in combination with external-beam radiation therapy for patients who are symptomatic due to endoluminal obstruction, eg, postobstructive pneumonia.(27)
  • Endobronchial brachytherapy is not included in appropriateness criteria for radiation therapy of small cell lung cancer.(28)

Third International Lung Cancer Consensus Workshop

The Workshop generated consensus statements on palliative radiotherapy and symptom control. For endobronchial brachytherapy, experts concluded that there was no evidence to routinely recommend endobronchial brachytherapy alone or in combination with other palliative maneuvers in the initial palliative management of endobronchial obstruction resulting from lung cancer. However, for palliative management of patients with recurrent endobronchial obstruction after external radiation therapy or to treat a central obstruction before definitive radiation therapy to re-establish airway patency, endobronchial brachytherapy may be a reasonable option.(29)

References:
  1. Cardona AF, Reveiz L, Ospina EG et al. Palliative endobronchial brachytherapy for non-small cell lung cancer. Cochrane Database Syst Rev 2008; (2):CD004284.
  2. Kubaszewska M, Skowronek J, Chichel A et al. The use of high dose rate endobronchial brachytherapy to palliate symptomatic recurrence of previously irradiated lung cancer. Neoplasma 2008; 55(3):239-45.
  3. Villanueva AG, Lo TC, Beamis JF. Endobronchial brachytherapy. Clin Chest Med 1995; 16(3):445-54.
  4. Reveiz L, Rueda JR, Cardona AF. Palliative endobronchial brachytherapy for non-small cell lung cancer. Cochrane Database Syst Rev 2012; 12:CD004284.
  5. Mallick I, Sharma SC, Behera D et al. Optimization of dose and fractionation of endobronchial brachytherapy with or without external radiation in the palliative management of non-small cell lung cancer: a prospective randomized study. J Cancer Res Ther 2006; 2(3):119-25.
  6. Ung YC, Yu E, Falkson CLCDSGoCCOsPiE-BC et al. The role of high-dose-rate brachytherapy in the palliation of symptoms in patients with non-small-cell lung cancer: a systematic review. Brachytherapy 2006; 5(3):189-202.
  7. Coriat R, Diaz O, de lFC et al. Endobronchial metastases from colorectal adenocarcinomas: clinical and endoscopic characteristics and patient prognosis. Oncology 2007; 73(6-May):395-400.
  8. Ozkok S, Karakoyun-Celik O, Goksel T et al. High dose rate endobronchial brachytherapy in the management of lung cancer: response and toxicity evaluation in 158 patients. Lung Cancer 2008; 62(3):326-33.
  9. Gejerman G, Mullokandov EA, Bagiella E et al. Endobronchial brachytherapy and external-beam radiotherapy in patients with endobronchial obstruction and extrabronchial extension. Brachytherapy 2002; 1(4-Jan):204-10.
  10. Langendijk JA, Tjwa MK, de Jong JM et al. Massive haemoptysis after radiotherapy in inoperable non-small cell lung carcinoma: is endobronchial brachytherapy really a risk factor? Radiother Oncol 1998; 49(2):175-83.
  11. Hennequin C, Tredaniel J, Chervret S et al. Predictive factors for late toxicity after endobronchial brachytherapy: a multivariate analysis. Int J Radiat Oncol Biol Phys 1998; 42(1):21-7.
  12. Bedwinek J, Petty A, Bruton C. The use of high dose rate endobronchial brachytherapy to palliate symptomatic endobronchial recurrence of previously irradiated bronchogenic carcinoma. Int J Radiat Oncol Biol Phys 1991; 22(1):23-30.
  13. Dagnault A, Ebacher A, Vigneault E et al. Retrospective study of 81 patients treated with brachytherapy for endobronchial primary tumor or metastasis. Brachytherapy 2010; 9(3):243-7.
  14. Guarnaschelli JN, Jose BO. Palliative high-dose-rate endobronchial brachytherapy for recurrent carcinoma: the University of Louisville experience. J Palliat Med 2010; 13(8):981-9.
  15. Ratko TA, Vats V, Brock J et al. Local Nonsurgical Therapies for Stage I and Symptomatic Obstructive Non-Small-Cell Lung Cancer, June 2013 . Rockville MD: Agency for Healthcare Research and Quality 2013.
  16. Hennequin C, Bleichner O, Tredaniel J et al. Long-term results of endobronchial brachytherapy: A curative treatment? Int J Radiat Oncol Biol Phys 2007; 67(2):425-30.
  17. Perol M, Caliandro R, Pommier PCiolecwh-d-rb et al. Results of a pilot study. Chest 1997; 111(5):1417-23.
  18. Raben A, Mychalczak B. Brachytherapy for non-small cell lung cancer and selected neoplasms of the chest. Chest 1997; 112(4 suppl):276S-86S.
  19. Aumont-le GM, Prevost B, Sunyach MP et al. High-dose-rate brachytherapy for non-small-cell lung carcinoma: a retrospective study of 226 patients. Int J Radiat Oncol Biol Phys 2011; 79(4):1112-6.
  20. Skowronek J, Piorunek T, Kanikowski M et al. Definitive high-dose-rate endobronchial brachytherapy of bronchial stump for lung cancer after surgery. Brachytherapy 2013; 12(6):560-6.
  21. Rochet N, Hauswald H, Stoiber EM et al. Primary radiotherapy with endobronchial high-dose-rate brachytherapy boost for inoperable lung cancer: long-term results. Tumori 2013; 99(2):183-90.
  22. Tendulkar RD, Fleming PA, Reddy CA et al. High-dose-rate endobronchial brachytherapy for recurrent airway obstruction from hyperplastic granulation tissue. Int J Radiat Oncol Biol Phys 2008; 70(3-Jan):701-6.
  23. Madu CN, Machuzak MS, Sterman DH et al. High-dose-rate (HDR) brachytherapy for the treatment of benign obstructive endobronchial granulation tissue. Int J Radiat Oncol Biol Phys 2006; 66(5):1450-6.
  24. Rahman NA, Fruchter O, Shitrit D et al. Flexible bronchoscopic management of benign tracheal stenosis: long term follow-up of 115 patients. J Cardiothoracic Surg 2010; 5(1):2.
  25. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-small cell lung cancer, version 2.2014 (discussion update in progress). Available online at: http://www.nccn.org/professionals/physician_gls/PDF/nscl.pdf. Last accessed January, 2014.
  26. Rosenzweig KE, Chang JY, Chetty IJ et al. ACR Appropriateness Criteria Nonsurgical Treatment for Non–Small-Cell Lung Cancer: Poor Performance Status or Palliative Intent. J Am Coll Radiol 2013; 10(9):654-64.
  27. Gewanter RM, Rosenzweig KE, Chang JY et al. ACR Appropriateness Criteria® Nonsurgical Treatment for Non-Small-Cell Lung Cancer: Good Performance Status/Definitive Intent. Curr Probl Cancer 2010; 34(3):228-49.
  28. Kong FM, Lally BE, Chang JY et al. ACR Appropriateness Criteria(R) radiation therapy for small-cell lung cancer. Am J Clin Oncol 2013; 36(2):206-13.
  29. Rodrigues G, Macbeth F, Burmeister B et al. Consensus statement on palliative lung radiotherapy: third international consensus workshop on palliative radiotherapy and symptom control. Clin Lung Cancer 2012; 13(1):1-5. 

Codes

Number

Description

CPT  31643  Bronchoscopy; with placement of catheter(s) for intracavitary radioelement application 
  77326 - 77328  Brachytherapy isodose calculation; code range 
  77761 - 77763  Intracavitary radioelement application; code range 
  7785 - 77787 Remote afterloading high dose rate radionuclide source
  77790  Supervision, handling, loading of radio elements
ICD-9 Procedure  92.27  Implantation or insertion of radioactive element 
ICD-9 Diagnosis  162.2 – 162.9  Primary neoplasm of bronchus, code range 
  197.0  Secondary malignant neoplasm of lung (bronchus) 
  231.2  Carcinoma in situ of bronchus and lung 
HCPCS  No code   
ICD-10-CM (effective 10/1/15) C34.00-C34.92 Malignant neoplasm of bronchus lung, code range
   C78.00-C78.02 Secondary malignant neoplasm of lung, code range
   D02.20-D02.22 Carcinoma in situ of bronchus and lung, code range
ICD-10-PCS (effective 10/1/15)    ICD-10-PCS codes are only used for inpatient services. There is no specific ICD-10-PCS code for this procedure.
  0BH001Z, 0BH031Z,
0BH041Z, 0BH071Z,
0BH081Z
Surgical, respiratory system, insertion, tracheobronchial tree, radioactive element, code by approach (open, percutaneous, percutaneous endoscopic, via natural or artificial opening, or via natural or artificial opening endoscopic)
   0BHK01Z, 0BHK31Z, 0BHK41Z, 0BHK71Z, 0BHK81Z, 0BHL01Z, 0BHL31Z, 0BHL41Z, 0BHL71Z, 0BHL81Z Surgical, respiratory system, insertion, radioactive element, code by body part (right lung or left lung) and approach (open, percutaneous, percutaneous endoscopic, via natural or artificial opening, or via natural or artificial opening endoscopic)
Type of Service  Radiation Therapy 
Place of Service  Inpatient
Outpatient
 


Index

Brachytherapy, Endobronchial
Endobronchial Bachytherapy
Lung Cancer, Brachytherapy  


Policy History

Date Action Reason
03/15/99 Add to Therapy section New policy
04/15/02 Replace policy Policy reviewed without literature review; new review date only
10/3/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy
03/15/05 Replace policy Policy updated with literature search; no change in policy statement
03/7/06 Replace policy Policy reviewed with literature search; no change in policy statement. Policy Guideline section coding updated
08/14/08 Replace policy  Policy updated and rewritten with literature search through July 2008; reference numbers 1,2,4 to 6, 9 to 12 added. Policy statements unchanged. 
10/06/09 Replace policy Policy updated with literature search through July 2009; policy statements changed to add that use as palliative treatment for severe hemoptysis and in recurrent tumors may be considered medically necessary and that use in asymptomatic recurrent disease is considered investigational. References 13–19 added
2/10/11 Replace policy Policy updated with literature search; no change to policy statements. References 20-24 added
2/09/12 Replace policy Policy updated with literature search; no change to policy statements. No references added.
02/14/13 Replace policy Policy updated with literature search; no change to policy statements. References 4 and 24 added; reference 22 updated.
2/13/14 Replace policy Policy updated with literature search through January 20, 2014; references 15, 20-21, and 27-28 added; reference 25 updated. No changes to policy statements.