Long-term follow-up of patients of intrahepatic malignancies treated with iodine-125 brachytherapy

Review of brachytherapy clinical trials: a cross-sectional analysis of ClinicalTrials.gov

INTRODUCTION

Characterizing the landscape of clinical trials including brachytherapy can provide an overview of the current status and research trends which may guide further areas of investigation.

METHOD

We queried 449,849 clinical trials from the ClinicalTrials.gov registry using brachytherapy-related keywords from 1980 to 2023, yielding 245 multi-arm and 201 single-arm, brachytherapy trials. Multi-arm and single-arm brachytherapy trials were compared using 12 trial protocol elements.

RESULTS

The number of trials including brachytherapy has increased over time, with over 60% of trials registered in 2010 onwards. The majority of clinical trials were Phase 2 or 3, evaluated both safety and efficacy, and were funded by academic sponsors. The most common tumor sites evaluated in brachytherapy clinical trials include prostate, cervix, liver, endometrium, and breast.

CONCLUSION

There remains continued interest in clinical trials including brachytherapy focused on evaluation of novel delivery systems, treatment planning, and new indications. More brachytherapy clinical trials are needed to define the optimal clinical utilization and advance prospective research in this field.

125I Radiotherapy combined with metronomic chemotherapy may boost the abscopal effect, leading to complete regression of liver metastasis in an SCLC patient with a 58.5-month OS: a case report

The liver is the most common and lethal metastatic site in patients with extensive-stage small-cell lung cancer (ES-SCLC), and median survival with current standard treatment is only 9-10 months from diagnosis. Clinical observations show that a complete response (CR) is extremely rare in ES-SCLC patients with liver metastasis. Moreover, to the best of our knowledge, complete regression of liver metastasis induced by the abscopal effect, boosted primarily by permanent radioactive iodine-125 seeds implantation (PRISI), combined with a low-dose metronomic temozolomide (TMZ) regimen, has not been recorded. Here, we present the case of a 54-year-old male patient who developed multiple liver metastases from ES-SCLC after multiple lines of chemotherapy. The patient was given partial PRISI therapy (two out of six tumor lesions; 38 iodine-125 seeds in one dorsal lesion and 26 seeds in one ventral lesion), which was combined with TMZ metronomic chemotherapy (50 mg/m²/day, days 1-21, every 28 days). The abscopal effect was observed for 1 month after PRISI treatment. After about 1 year, all the liver metastases had completely disappeared, and the patient experienced no relapse. The patient eventually died of malnutrition caused by a non-tumor intestinal obstruction and had an overall survival of 58.5 months after diagnosis. PRISI combined with TMZ metronomic chemotherapy might be considered a potential therapy to trigger the abscopal effect in patients with liver metastases.

Transarterial chemoembolisation plus I125 seeds implantation for people with unresectable hepatocellular carcinoma

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of transarterial chemoembolisation (TACE) plus I125 seeds implantation compared with TACE alone, regardless of chemotherapeutic drugs and vascular occlusive agents, for people with unresectable hepatocellular carcinoma. 

Local ablation of hepatocellular carcinoma by interstitial brachytherapy: prediction of outcome by diffusion-weighted imaging

BACKGROUND

Interstitial brachytherapy (iBT) has become a viable treatment option in the therapy of early and intermediate stage hepatocellular carcinoma (HCC). Prognostic imaging tools to predict patient outcome are missing.

PURPOSE

To assess the predictive value of baseline diffusion-weighted imaging in HCC before iBT with regard to local tumor control and overall survival (OS).

MATERIAL AND METHODS

We retrospectively identified 107 patients who underwent iBT for HCC from 2011 to 2018 from our database. Apparent diffusion coefficient (ADC) values for each treated lesion were analyzed in region of interest measurements. Additionally, explorative combined ratios adjusting total measured lesion area and mean measured lesion area per patient by ADC values were calculated. Measurements underwent a univariate and multivariate Cox regression analysis. The log rank test was then used to verify prognostic cutoff levels for median survival time.

RESULTS

A total of 189 lesions in 81 patients were measured. Median survival of patients was 46.0 months. Neither ADC parameter was indicative of local tumor control. Lesion size >5 cm was associated with lower local tumor control (hazard ratio [HR]=4.292, 95% confidence interval [CI]=1.285-14.331; P = 0.018). Average measured lesion area divided by ADC_min (ADC_{area mean, min}) was identified to independently predict OS (HR=1.994, 95% CI=1.172-3.392; P = 0.011). A cutoff based on the variable's median (0.29 × 10-4 AU) identified patients with poor outcome (OS 36 vs. 61 months) for lower ADC_{area mean, min} values as verified by the log-rank test (P = 0.040).

CONCLUSION

Pre-treatment ADC_{area mean, min} may serve as an independent predictor of OS in patients with HCC undergoing iBT.

Peritumoral abnormalities on dynamic-enhanced CT after brachytherapy for hepatic malignancies: local progression or benign changes?

Objectives

To determine if dynamic CT can differentiate local progression from radioactive seed-induced peritumoral reaction (RSIPR) after brachytherapy with iodine-125 radioactive seeds (BIRS) for advanced hepatic malignancies.

Methods

Enhanced CT images of seed-implanted lesions between 2006 and 2018 were retrospectively evaluated. Hounsfield units of peritumoral parenchyma were measured and assessed quantitatively. The classification, conversion, consequences, and serological indicators during follow-up were recorded and quantified. Statistical differences were analyzed using a Pearson χ² test.

Results

RSIPR was observed in 201 of 290 (69.3%) lesions (161 patients; median age, 55 years; range, 26–79 years), while local progression occurred in 53 lesions. The low density of local progression was much lower than that of RSIPR (p < 0.001), and the former did not exhibit iso-/high density in the portal or equilibrium phase. Ring-like enhancement in progressive lesions was also quite different from RSIPR. Local progression rate was lower for lesions with RSIPR than for those without RSIPR (14.9% vs 25.8%; p = 0.03), and their doses were different (397.2 Gy vs 120.3 Gy, p < 0.001).

Conclusions

Radioactive seed-induced peritumoral reaction has characteristic manifestations on CT images, which is associated with a higher dose of lesions and lower local progression rate. Notably, the enhancement pattern of local progression was distinct from RSIPR and was clearly distinguishable on dynamic-enhanced CT.

Key Points

• Radioactive seed-induced peritumoral reaction after brachytherapy with¹²⁵I seeds for liver malignancies has characteristic manifestations on CT images, which is associated with a higher dose of lesions (397.2 Gy vs 120.3 Gy, p < 0.001), as a focal radiation injury.

• Lesions with RSIPR were less likely to develop local progression, while those without RSIPR had a higher rate of local progression (14.9% vs 25.8%; p = 0.03).

• The enhancement pattern of local progression after brachytherapy was distinct from radioactive seed-induced peritumoral reaction and was clearly distinguishable on dynamic-enhanced CT.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-09074-x.

CalliSpheres® microsphere transarterial chemoembolization combined with 125I brachytherapy for patients with non–small‐cell lung cancer liver metastases

Objective

Poor prognosis and limited treatments of liver metastases from non–small‐cell lung cancer (NSCLC) after radical surgery are critical issues. The current study aimed to evaluate the efficacy and safety of CalliSpheres^® microsphere transarterial chemoembolization (CSM-TACE) plus ¹²⁵I brachytherapy in these patients.

Methods

A total of 23 patients with liver metastases from NSCLC after radical surgery were included. All patients received CSM-TACE 1–3 times, then ¹²⁵I brachytherapy was carried out following the last CSM-TACE. Complete response (CR), objective response rate (ORR), disease control rate (DCR), survival, and adverse events were evaluated.

Results

CR, ORR and DCR were 43.5%, 87.0%, and 100%, respectively, at three months; furthermore, they were 78.3%, 100%, and 100% accordingly at six months. Moreover, most European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (QLQ-C30) subscales of functions (including physical and emotional function) and symptoms (including pain, nausea, and vomiting) were generally improved at three months (all P < 0.05). Furthermore, median progression-free survival (PFS) was 14.0 [95% confidence interval (CI): 10.4–17.6] months, with a 1-year PFS rate of 62.9%, but the 2-year PFS rate was not reached. Moreover, the median overall survival (OS) was 22.0 (95% CI: 16.8–27.2) months, with a 1-year OS rate of 91.3% and a 2-year OS rate of 43.5%. Additionally, the main adverse events included fever (100%), pain (65.2%), liver function impairment (65.2%), fatigue (56.5%), and nausea and vomiting (52.2%), which were all categorized as grade 1–2.

Conclusion

CSM-TACE plus ¹²⁵I brachytherapy is effective and safe in patients with liver metastases from NSCLC after radical surgery, providing a potentially optimal option in these patients.

Salvage 125I brachytherapy for liver metastases of colorectal cancer in anatomically challenging locations after failure of systemic chemotherapy-A retrospective study

PURPSOE

Colorectal cancer liver metastasis (CCLM) in anatomically challenging locations is difficult to treat. This retrospective study aimed to evaluate the effectiveness and safety of permanent ¹²⁵I seeds implantation (ISI) for treatment of CCLM in anatomically challenging locations after failure of systemic chemotherapy.

METHODS AND MATERIALS

A total of 31 liver metastases (in 25 patients) were treated by ISI under computerized tomography guidance from January 2011 to December 2017. Post-treatment follow-up was for 40 months. Adverse events were classified using the National Cancer Institute's Common Terminology Criteria for Adverse Events. Tumor response was evaluated by the mRECIST criteria. Objective response rate, overall survival rate, and complications were retrospectively analyzed.

RESULTS

All ISI procedures were performed successfully. Most patients only complained of fatigue and mild pain after ISI. Only one patient had liver rupture during the procedure. Serum alanine aminotransferase and aspartate aminotransferase levels at 1 month after ISI were not significantly different from pre-procedure levels (p > 0.05). Computed tomography at 6 months after ISI treatment showed completed response in 11 (11/31, 35.5%) lesions, partial response in 14 (14/31, 45.2%) lesions, stable disease in 4 (4/31, 12.9%) lesions, and disease progression in 2 (2/31, 6.5%) lesions; thus, the objective response rate was 80.6%. Median survival was for 12 months. The 1 and 2 year overall survival rates were 52.0% and 20.0%, respectively.

CONCLUSIONS

¹²⁵I seeds implantation for CCLM in anatomically challenging locations is safe and effective. Survival benefit is limited in the salvage setting where patients have high intrahepatic tumor load after failed systemic chemotherapy.

Clinical Outcome of CT-Guided Iodine-125 Radioactive Seed Implantation for Intrahepatic Recurrent Hepatocellular Carcinoma: A Retrospective, Multicenter Study

The efficacy and safety of CT-Guided Iodine-125 Radioactive Seed Implantation (RSI) for the treatment of intrahepatic recurrent hepatocellular carcinoma (rHCC) were analyzed in this multicenter retrospective study. We reviewed the medical records of patients with rHCC treated with I-125 seed implantation at four different hospitals in China from December 2011 and January 2021. The local progression-free survival (LPFS),liver PFS, and overall survival (OS) were calculated, and the short-term efficacy and treatment-related toxicities were evaluated. A total of 82 patients were enrolled; the median follow-up time was 46 months (range, 3–80 months). The 1-, 3- and 5-year LPFS rates were 63.8%, 27.1%, and 7.9%, respectively, and the corresponding OS rates were 74.8%, 32.9%, and 12.6%, respectively. Univariate analysis showed that factors influencing LPFS included the maximum lesion diameter, Barcelona Clinic Liver Cancer (BCLC) stage, interval between treatment and recurrence, and D90. Multivariate analyses revealed that the BCLC stage, interval between treatment and recurrence, and D90 were independent factors influencing LPFS, whereas BCLC stage, D90, and short-term efficacy were independent factors influencing OS. In summary, I-125 seed implantation is a safe and effective treatment for rHCC. The BCLC stage, interval, and D90 were found to influence the local control. A larger, prospective study is required to confirm the dose-response curve for Iodine-125 RSI of rHCC.

Stereotactic Ablative Brachytherapy: Recent Advances in Optimization of Radiobiological Cancer Therapy

Brachytherapy (BT), a type of focal anti-cancer radiotherapy, delivers a highly focused radiation dose to localized tumors, sparing surrounding normal tissues. Recent technological advances have helped to increase the accuracy of BT and, thus, improve BT-based cancer treatment. Stereotactic ablative brachytherapy (SABT) was designed to improve the ablative effect of radiation, which was achieved via improved image guidance, and calculation of ablative dose, shorter treatment duration, and better organ preservation. Recently collected data characterized SABT as having the potential to cure various early-stage cancers. The method provides higher tumor control rate levels that were previously achievable only by surgical resection. Notably, SABT is suitable for application with unresectable malignancies. However, the pathological assessment of SABT irradiated tumors is limited due to difficulties in specimen acquisition. Prostate, lung, liver, and gynecological cancers are the most commonly reported SABT-treated malignancies. This study will give an overview of SABT, focusing on the advances in SABT optimization, and provide insights on the future benefits of the combined application of SABT with cancer immunotherapies.

Interventional Treatment for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most common type of primary liver malignancy. The latest classification includes intrahepatic cholangiocarcinoma and extrahepatic cholangiocarcinoma, with the latter one further categorized into perihilar and distal cholangiocarcinoma. Although surgical resection is the preferred treatment for CCA, less than half of the patients are actually eligible for radical surgical resection. Interventional treatment, such as intra-arterial therapies, ablation, and brachytherapy (iodine-125 seed implantation), has become an acceptable palliative treatment for patients with unresectable CCA. For these patients, interventional treatment is helpful for locoregional control, symptom relief, and improving quality of life. Herein, in a timely and topical manner, we will review these advances and highlight future directions of research in this article.

Combined Ultrasound and CT-Guided Iodine-125 Seeds Implantation for Treatment of Residual Hepatocellular Carcinoma Located at Complex Sites After Transcatheter Arterial Chemoembolization

Purpose

The purpose of this study was to evaluate the efficacy and safety of iodine-125 (¹²⁵I) seeds implantation under ultrasound and computed tomography (CT) guidance in the treatment of residual hepatocellular carcinoma (HCC) located at complex sites after transcatheter arterial chemoembolization (TACE).

Methods

This retrospective study analyzed the consecutive medical records of 31 HCC patients with residual tumors located at complex sites (such as large blood vessels, gallbladder, diaphragm dome, etc.) after TACE from May 2014 to December 2018, all of whom received ¹²⁵I seeds implantation therapy. Overall survival (OS), progression-free survival (PFS), recurrence, and complications were documented.

Results

A total of 607 seeds were implanted in 31 patients, with an average of 19.6±10.4 (range, 8–48) seeds per patient. Median OS and PFS were 33 months (95% CI: 27.1 months, 38.9 months) and 15 months (95% CI: 9.6 months, 20.4 months), respectively. Although univariate analysis showed that albumin, prothrombin time, alpha-fetoprotein level, Child-Pugh score, and lipiodol deposition in tumor were associated with OS, multivariate analysis showed that none of them was an independent prognostic factor for OS. Multivariate analysis showed that prothrombin time was an independent prognostic factor for PFS. No operation-related deaths in this study. Although pneumothorax was present in two patients and subcutaneous abscess in one patient, symptoms improved in all three patients with appropriate treatment. Common minor complications included fever, abdominal pain and leukopenia and no grade≥3 adverse events were observed.

Conclusions

¹²⁵I seeds implantation under the combined guidance of ultrasound and CT is safe and effective for patients with residual HCC located at complex sites after TACE. This is a promising treatment approach and deserves further discussion.

Enhanced therapeutic effect of transcatheter arterial chemoembolization combined with radioactive I-125 seed implantation on liver cancer

The present study aimed to evaluate the therapeutic effect of transcatheter arterial chemoembolization (TACE) combined with radioactive I-125 (iodine-125) seed implantation on liver cancer. A total of 38 liver cancer patients in the combined treatment group were treated with lobaplatin-TACE combined with radioactive I-125 seed implantation, while 45 patients in the TACE group were treated only with lobaplatin-TACE. Patients were followed up for survival time, and the liver function, change in α-fetoprotein (AFP) and side effects were evaluated. The average survival time of patients was 6.1 months in the TACE group and 8.2 months in the combined treatment group, and the overall survival was significantly different between the two groups (P<0.05). The response rate of lesions in the combined treatment group was superior to that observed in the TACE group, and the change in AFP in the TACE group was smaller than that in the combined treatment group. Improvement in the effects on most liver function indices in the combined treatment group were better than those in the TACE group. In addition, there were no differences in the side effects experienced between the two groups. Results of this study indicate that the effect of TACE combined with radioactive I-125 seed implantation is superior to that of TACE alone for the treatment of liver cancer, which can further benefit patients.

Computed tomography-guided iodine-125 brachytherapy for unresectable hepatocellular carcinoma

Purpose

This study aimed to retrospectively assess the outcome of interstitial iodine-125 brachytherapy for unresectable hepatocellular carcinoma (HCC).

Materials and Methods

Between February 2013 and March 2019, 57 patients with 108 unresectable HCC lesions treated with computed tomography (CT)-guided iodine-125 seed brachytherapy were retrospectively analyzed. The primary endpoint was overall survival (OS). The secondary endpoints included local tumor control and progression-free survival (PFS). Potential factors associated with OS were assessed.

Results

The mean follow-up duration was 24.3 ± 15.6 months (median, 20.5 months; range, 3.9-66.8 months). The median OS time was 23.6 months (95% confidence interval [CI], 18.4-28.8 months). The 1-, 2-, and 3-year actuarial OS rates were 80.0%, 46.1%, and 24.3%, respectively. The median PFS time was 12 months (95% CI, 9.9-14.5 months). The 1- and 2-year actuarial PFS rates were 50% and 20.1%, respectively. Local progression was noted in 11 (11.3%) of 108 lesions with mean local control time of 20.5 ± 8.8 months. The 1- and 2-year local control rates were 96.5% and 88.8%, respectively. Barcelona clinic liver cancer stage and Child-Pugh score were independent risk factors affecting the prognosis (hazard ratio [HR] = 0.330 [95% CI, 0.128-0.853] and HR = 0.303 [95% CI, 0.151-0.610], respectively). Hepatic artery pseudoaneurysm was found in 1 (1.8%) patient with lesion located in the porta hepatis. No other major complications developed during follow-up.

Conclusion

CT-guided iodine-125 brachytherapy may be an effective and safe alternative with promising survival and increased local control rate in unresectable HCC treatment.

Therapeutic efficacy of TACE 125I seed implantation and its combination with intra-tumor injection of cisplatin for the treatment of hepatocellular carcinoma

Background

This study aimed to compare the therapeutic efficacy of transcatheter arterial chemoembolization (TACE) combined with either ¹²⁵I seed implantation or ¹²⁵I seed implantation and intra-tumor injection of cisplatin in treating hepatocellular carcinoma (HCC).

Methods

A total of 100 patients with HCC were analyzed. The control group (n = 50) received TACE combined with ¹²⁵I seed implantation therapy. The therapy group (n = 50) was treated with an intra-tumor injection of cisplatin along with TACE and ¹²⁵I seed implantation therapy. After treatment, routine blood, liver and kidney function, tumor volume, T lymphocyte subset count (CD3, CD4, and CD8), implanted metastases, and survival were studied.

Results

The tumor volume decreased by 27.4% on average in the control group, and by 38.6% in the therapy group. Alpha fetoprotein (AFP) level decreased in all cases, and it was significantly lower in the therapy group than in the control group. Remote metastasis was observed in both groups (7 in the control group and 3 in the therapy group). No significant difference in routine blood, liver and kidney function, and T-lymphocyte subset counts were found between the two groups. Eight patients died of metastases in the control group and 2 in the therapy group at 1-year follow-up (P < 0.05).

Conclusion

TACE combined with either ¹²⁵I seed implantation or ¹²⁵I seed implantation and intra-tumor injection of cisplatin was effective for the treatment of HCC. Of the 2 combination therapies, TACE combined with ¹²⁵I seed implantation and intra-tumor injection of cisplatin was more effective for the treatment of HCC.

A meta-analysis of the efficacy and safety of iodine [131I] metuximab infusion combined with TACE for treatment of hepatocellular carcinoma

OBJECTIVES

To compare the efficacy and safety of combination iodine [¹³¹I] metuximab infusion and transcathether arterial chemoembolization (TACE) with those of TACE-alone for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

PubMed, Cochrane Library, Embase, Web of Science, China Biology Medicine, China Science and Technology Journal Database, Wan Fang Data, and Chinese knowledge resource integrated databases were used for the literature search regarding controlled clinical trials comparing combination TACE and iodine [¹³¹I] metuximab infusion with TACE-alone for HCC treatment before February 1, 2016. The Jadad system evaluation method for research quality and RevMan 5.0 software were used for the meta-analysis.

RESULTS

In total, 1302 patients from 10 studies were included. The meta-analysis showed that the combination TACE and iodine [¹³¹I] metuximab infusion treatment for HCC was more effective than TACE alone, including 6-month survival (odds ratio [OR] = 2.05, 95% confidence interval [CI]: 1.41-2.98, P = 0.0002), 1-year survival (OR = 1.90, 95% CI: 1.41-2.55, P < 0.00001), and the total response rate (OR = 2.91, 95% CI: 2.08-4.07, P < 0.00001). Nine studies reported adverse reactions, mainly comprising poor appetite, nausea, vomiting, and abdominal discomfort. Fever, chills, and bone marrow suppression were more common in the combined treatment group, but abnormal liver function was not different between the two treatment groups. There was no report on serious complications or death directly related to either treatment.

CONCLUSIONS

Compared with TACE alone, the combination of TACE with iodine [¹³¹I] metuximab infusion for treating unresectable HCC may improve local efficacy and overall survival in these types of patients.

Inflammation-based prognostic scores in patients with extrahepatic bile duct lesions treated by percutaneous transhepatic biliary stenting combined with 125I seeds intracavitary irradiation

PURPOSE

This study aimed at investigating the efficacy of percutaneous transhepatic biliary stenting (PTBS) combined with ¹²⁵I seeds intracavitary irradiation in the treatment of extrahepatic cholangiocarcinoma (EHC) and to preliminarily explore the prognostic values of inflammation-based scores in these patients.

METHODS

A total of 113 clinically/pathologically diagnosed cases of EHC who received PTBS combined with ¹²⁵I seeds implantation were retrospectively analyzed. The postoperative changes of clinical symptoms and serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), total serum bilirubin (TBIL), direct bilirubin (DBIL), and albumin (ALB) were observed. Preoperative clinical data were extracted to calculate inflammation-based scores, including systemic immune-inflammation index (SII), neutrophil-to-lymphocyte ratio (NLR), and platelets-to-lymphocyte ratio (PLR). Kaplan-Meier survival curves and Cox regression analyses were used to evaluate the prognostic significance of inflammation-based scores.

RESULTS

After operation, clinical symptoms such as jaundice and fever significantly improved in all patients. At 1 month and 3 months postoperatively, serum levels of ALT, AST, ALP, TBIL, and DBIL significantly reduced, and ALB significantly increased, compared with preoperative values. The median survival time of the patients was 12 months and the 1-year survival rate was 56.8%. Univariate analysis revealed that factors related to overall survival were CA19-9, TBIL, ALB, SII, and NLR. Multivariate analysis further identified SII and NLR as independent prognostic models.

CONCLUSION

The combination of PTBS and ¹²⁵I seeds intracavitary irradiation is an effective palliative treatment for advanced EHC. Elevated SII and NLR can be used to predict poor survival.

Iodine-125 seed implantation and allogenic natural killer cell immunotherapy for hepatocellular carcinoma after liver transplantation: a case report

For advanced hepatocellular carcinoma (HCC) patients, liver transplantation (LT) is an optimal treatment with limitation of high risk of tumor recurrence related to the immunosuppressive chemotherapy as usually recommended. In this study, a 29-year-old man suffered from HCC recurrence after LT. He underwent radiotherapy (total dose: 45 Gy) but had no significant response. Then, he received iodine-125 seed implantation combined with allogenic natural killer (NK) cell immunotherapy. Liver function, immune function, circulating tumor cell counts and computed tomography scans were evaluated to determine the clinical effect. We found that this combined treatment produced enhanced immune function of the patient and reduction in tumor size. This is the first report of an efficacy and safety study about clinical regimen comprising allogenic NK cell immunotherapy combined with iodine-125 seed implantation for the treatment of HCC recurrence after LT.

Transarterial chemoembolization plus iodine-125 implantation for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common malignancy in liver. Transarterial chemoembolization (TACE) is recommended as an effective treatment in advanced HCC patients. Recent studies showed iodine-125 seed (a low-energy radionuclide) can provide long-term local control and increase survival for HCC patients. The aim of the study was to evaluate the outcome of TACE plus iodine-125 seed in comparison with TACE alone for HCC.

METHODS

A comprehensive search of studies among PubMed, Embase, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews was conducted with published date from the earliest to January 10th, 2018. No language restrictions were applied, while only prospective randomized controlled trials (RCTs) or non-randomized controlled trials (non-RCTs) were eligible for a full-text review. The primary outcome was overall survival (OS), response rate (the rate of partial atrophy or complete clearance of the tumor lesion) and adverse events (AEs). The odds ratios (ORs) were combined using either fixed-effects model or random-effects model. All statistical analyses were performed using the Stata 12.0 software.

RESULTS

9 studies were included, involving 894 patients. Among them, 473 patients received combined therapy of TACE plus iodine-125 implantation, compared with 421 patients with TACE alone. Patients receiving combined therapy of TACE plus iodine-125 showed significantly improvement in 1-year OS (OR = 4.47, 95% confidence intervals (CI): 2.97-6.73; P < 0.001), 2-year OS (OR = 4.72, 95% CI: 2.63-8.47; P < 0.001). No significant publication bias was observed in any of the measured outcomes.

CONCLUSIONS

Based on these findings, TACE plus iodine-125 implantation achieves better clinical efficacy compared with TACE alone in the treatment of HCC.

Nutritional prognostic scores in patients with hilar cholangiocarcinoma treated by percutaneous transhepatic biliary stenting combined with 125I seed intracavitary irradiation: A retrospective observational study

We mainly aimed to preliminarily explore the prognostic values of nutrition-based prognostic scores in patients with advanced hilar cholangiocarcinoma (HCCA).We retrospectively analyzed 73 cases of HCCA, who underwent percutaneous transhepatic biliary stenting (PTBS) combined with I seed intracavitary irradiation from November 2012 to April 2017 in our department. The postoperative changes of total bilirubin (TBIL), direct bilirubin (DBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and albumin (ALB) were observed. The preoperative clinical data were collected to calculate the nutrition-based scores, including controlling nutritional status (CONUT), C-reactive protein/albumin ratio (CAR), and prognostic nutritional index (PNI). Kaplan-Meier curve and Cox regression model were used for overall survival (OS) analyses.The serum levels of TBIL, DBIL, ALT, AST, and ALP significantly reduced, and ALB significantly increased at 1 month and 3 months postoperatively. The median survival time of the cohort was 12 months and the 1-year survival rate was 53.1%. Univariate analysis revealed that the statistically significant factors related to OS were CA19-9, TBIL, ALB, CONUT, and PNI. Multivariate analysis further identified CA19-9, CONUT, and PNI as independent prognostic factors.Nutrition-based prognostic scores, CONUT and PNI in particular, can be used as predictors of survival in unresectable HCCA.

Preliminary clinical application of integrated 125I seeds stents in the therapy of malignant lower biliary tract obstruction

PURPOSE

To evaluate the clinical efficacy of percutaneous trans-hepatic integrated 125I seed stents implantation for malignant lower biliary tract obstruction.

METHODS

Thirty-two patients with malignant lower biliary obstruction were randomly divided into two groups. One group underwent the therapy with integrated 125I seed stents (Test group, n = 13), and another group received conventional metal stents implantation for treatment (Control group, n = 19). The pre- and post-operative changes in biochemical indices, white blood cell count, IgG level, stent patency, survival time, tumor size and complications were compared between the two groups. RECIST 1.1 (Response Evaluation Criteria In Solid Tumors) was used to evaluate therapeutic effects. The average follow-up time was 12.3 months.

RESULTS

The differences between pre- and post-operative (30 days) intragroup biochemical indices had statistically significant difference (P < 0.05), but there were no significant differences (P > 0.05) in leukocyte counts and IgG levels. As to the median time of stent patency and patients' survival, there were significant differences (P < 0.05) between Control and Test groups (3.9 months vs. 8.1 months, 139 days vs. 298 days, respectively). Three months after the operation, the average tumor size was reduced in the Test group, but was increased in the Control group (P < 0.05). There was no significant difference in the incidence of complications between the two groups. The evaluation results using RECIST 1.1 showed that there were statistically significant differences between the two groups in terms of the rates of remission, control, and progression (χ2 = 17.5, P < 0.05).

CONCLUSIONS

The study indicates that integrated 125I seed stents are effective in reducing jaundice symptoms, inhibiting tumor growth, improving stent patency and prolonging patient survival, which may serve as a safer and more feasible method in treating malignant lower biliary obstruction with minimal invasiveness.

Modified Fan-Shaped Distribution Technology for Computed Tomography (CT)-Guided Radioactive Seed Implantation in Lung Cancer Patients with Lung Dysfunction

Background

The aim of this study was to investigate the safety and effectiveness of fan-shaped distribution and coaxial puncture technology for radioactive iodine 125 (125I) seed implantation in treatment of lung cancer patients with lung dysfunction.

Material/Methods

We enrolled and analyzed 33 lung cancer patients with lung dysfunction diagnosed in our hospital from 2013 to 2014 in this study, all of which were implanted with radioactive 125I seed with technology of fan-shaped distribution and coaxial puncture. The matched peripheral dose (MPD) range was 90–140GY. The brachytherapy planning system (TPS) was used to draw up a preoperative seed implantation plan. The fan-shaped distribution system was applied to simulate a surgery program, and seed implantation pitch was 0.5–1.0 cm. Real-time adjustment was necessary during surgery. Dose distributions were verified by TPS immediately after implantation. Intraoperative and postoperative surgery-related complications were analyzed. All patients were followed up for 6 months, and the local control rate of cancer was evaluated through CT scan.

Results

All patients were operated on successfully. The main surgery-related complications were pulmonary hemorrhage, pleural cavity hemorrhage, and pneumothorax. The local control rates of 2-month, 4-month, and 6-month were 29%, 73%, and 85%, respectively. The total complete remission rate was 18%, the partial response rate was 67%, the stable disease rate was 12%, and the disease progression rate was 3%.

Conclusions

The fan-shaped distribution and coaxial puncture technology for radioactive 125I seed implantation was safe and effective in treating lung cancer patients with lung dysfunction.

CT-guided 125I brachytherapy for recurrent ovarian cancer

This retrospective study was to evaluate the local control and survival of ¹²⁵I brachytherapy for recurrent ovarian cancer. 52 ¹²⁵I brachytherapy procedures were performed in 47 patients with 51 recurrent ovarian cancer lesions. The follow-up period was 1-55 months (median 12 months). The local control rate (LC) of 3, 6, 12, 24 and 36 months was 93.3%, 77.7%, 58.9%, 38.7% and 19.3%, respectively. Patients with tumor size ≤ 4cm (85.7% vs 40.0%, P = 0.037) and actual D90 between 110 to 130Gy (47.4% vs 66.7% vs 62.5%, P = 0.029) had better LC. The 1, 2 and 3 years of overall survival (OS) was 79.3%, 63.0% and 52.5%, respectively. The poor performance status (HR 3.821, 95% CI 1.383-10.555; P = 0.010), concurrent distant metastasis (HR 9.222, 95% CI 1.710-49.737; P = 0.010) and large postoperative residual tumor size (HR 6.157, 95% CI 1.438-26.367; P = 0.014) were closely correlated with a poor OS. Our data indicate thatCT-guided ¹²⁵I brachytherapy is an effective and safe modality for the local treatment of recurrent ovarian cancer.

Combination of Permanent Interstitial 125I-Seed Brachytherapy and Surgery for the Treatment of Large Hepatocellular Carcinoma

The treatment methods available for large primary hepatocellular carcinomas (diameter >5 cm) are inadequate. Here, we report the successful management of 80 cases of large hepatocellular carcinoma, using a combination of custom-designed permanent interstitial iodine-125 seed brachytherapy and palliative surgery. Patients were enrolled in the study between 2011 and 2014. All patients underwent surgical treatment along with permanent interstitial iodine-125 seed brachytherapy; for the latter, patients received minimum doses covering 90% of the target (D90 s) of iodine-125 seeds ranging from 100 to 160 Gy (median: 110 Gy). All patients received 6 cycles of chemotherapy and were followed up at 6, 12, 24, and 36 months postoperatively. The clinical symptom remission rate was 95.3% (61 of 64). Alanine aminotransferase and aspartate aminotransferase levels decreased to normal in 80% (50 of 60) and 75% of the patients (45 of 60), respectively. The posttreatment alpha-fetoprotein levels decreased by 50% in 80% of the patients (40 of 50). The effective therapy rates were 80% (76 of 95) for 95 tumor nodules (diameters 5-10 cm) and 78.6% (33 of 42) for 42 tumor nodules (diameters >10 cm). The 3-year disease-free survival rate was 66.6%. Palliative surgery plus permanent interstitial iodine-125 seed brachytherapy appears to be a reasonable therapeutic alternative for large hepatocellular carcinoma.

Efficacy and safety of endoscopic ultrasonography-guided interventional treatment for refractory malignant left-sided liver tumors: a case series of 26 patients

This study aimed to compare the efficacy and safety of EUS-guided ethanol injection and ¹²⁵I seed brachytherapy for malignant left-sided liver tumors which were difficult for trans-abdominal intervention. The study protocol was registered at Clinicaltrials.gov (NCT02816944). Twenty-six patients were consecutively and prospectively hospitalized for EUS-guided interventional treatment of refractory malignant left-sided liver tumors between June 2014 and June 2016. Liver masses were detected using EUS in 25 of 26 (96.2%) patients. EUS-guided interventional treatment was completed uneventfully in 23 of 26 (88.5%) patients using anhydrous ethanol injection (n = 10) or iodine-125 seed implantation (n = 13). Six months later, complete response was achieved in 15 of 23 (65.2%) patients and partial response in 8 of 23 (34.8%) patients. Patients with tumor residual have second-look EUS-guided interventional treatment (n = 5), radiotherapy (n = 2) or surgical resection (n = 1). Complete response was achieved after repeated interventional treatment in 3 of 5 patients who underwent second EUS-guided intervention; 2 patients required additional surgical resection but one succeed. No significant complications occurred. Therefore EUS-guided ¹²⁵I seed brachytherapy is an effective and safe treatment modality for radical operation or promising palliative control of malignant left-sided liver tumors refractory to trans-abdominal intervention.

Iodine-125 implantation plus transarterial chemoembolization for the treatment of hepatocellular carcinoma of 3-5cm: A propensity score matching study

BACKGROUND

Both iodine-125 implantation and transarterial chemoembolization (TACE) are feasible options for hepatocellular carcinoma (HCC). The aim of the research is to investigate whether iodine-125 implantation combined with TACE could improve the overall survival of patients with HCC of 3-5cm.

METHODS

144 patients with HCC of 3-5cm who underwent iodine-125 implantation plus TACE and TACE alone were retrospectively enrolled in this study. To reduce the selection bias, 55 matched pairs of patients were generated by propensity score matching (PSM). Their overall survival was compared by the Kaplan-Meier method. Independent prognostic factors were identified by Cox proportional hazards regression model.

RESULTS

patients receiving iodine-125 implantation plus TACE have significantly better overall survival than patients receiving TACE alone (P<0.001). After PSM, treatment of iodine-125 plus TACE still provide better survival (1-year, 89.1% vs. 65.5%; 3-year, 51.0% vs. 7.4%; P<0.001). In multivariate analysis, BCLC stage, vascular invasion and treatment modality independently predicted the prognosis. No severe adverse events occurred in both groups.

CONCLUSION

for HCC patients of 3-5cm for whom surgical intervention is not an option, iodine-125 implantation combined with TACE might be an effective and viable alternative to provide better overall survival.

125I Brachytherapy in Locally Advanced Nonsmall Cell Lung Cancer After Progression of Concurrent Radiochemotherapy

To investigate the safety and effectiveness of computed tomography (CT)-guided I seed implantation for locally advanced nonsmall cell lung cancer (NSCLC) after progression of concurrent radiochemotherapy (CCRT).We reviewed 78 locally advanced NSCLC patients who had each one cycle of first-line CCRT but had progressive disease identified from January 2006 to February 2015 at our institution. A total of 37 patients with 44 lesions received CT-guided percutaneous I seed implantation and second-line chemotherapy (group A), while 41 with 41 lesions received second-line chemotherapy (group B).Patients in group A and B received a total of 37 and 41 first cycle of CCRT treatment. The median follow-up was 19 (range 3-36) months. After the second treatment, the total response rate (RR) in tumor response accounted for 63.6% in group A, which was significantly higher than that of group B (41.5%) (P = 0.033). The median progression-free survival time (PFST) was 8.00 ± 1.09 months and 5.00 ± 0.64 months in groups A and B (P = 0.011). The 1-, 2-, and 3-year overall survival (OS) rates for group A were 56.8%, 16.2%, and 2.7%, respectively. For group B, OS rates were 36.6%, 9.8%, and 2.4%, respectively. The median OS time was 14.00 ± 1.82 months and 10.00 ± 1.37 months for groups A and B, respectively (P = 0.059). Similar toxicity reactions were found in both groups. Tumor-related clinical symptoms were significantly reduced and the patients' quality of life was obviously improved.CT-guided I seed implantation proved to be potentially beneficial in treating localized advanced NSCLC; it achieved good local control rates and relieved clinical symptoms without increasing side effects.

Radiation oncology approaches in liver malignancies

Radiation therapy plays an increasingly important role in the treatment of hepatic malignancies. There is convincing evidence of safety and efficacy employing brachytherapy (yttrium-90), three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy (SBRT), and proton beam therapy (PBT) in all stages of primary and metastatic involvement in the liver. Technologic advances in tumor imaging, real-time tracking of moving targets during radiotherapy delivery, and superb radiation dose deposition control have enabled treatment of previously unapproachable lesions. Recently completed and ongoing clinical trials are refining optimal dose fractionation schedules for SBRT as monotherapy. Radioembolization as part of first-line therapy in metastatic colorectal tumors is being tested in large international trials combined with FOLFOX6 and bevacizumab, as well as in hepatocellular carcinoma with sorafenib. PBT is becoming more available as new facilities open in many countries providing particle beam therapy, which delivers unparalleled control of radiation dose close to critical structures. A major point of research is understanding how best to safely destroy tumors in the background of often fragile hepatic function from cirrhosis or heavily pretreated chemotherapy liver parenchyma. Fortunately, serious complications from radiotherapy are rare, acute toxicities are typically Common Terminology Criteria for Adverse Events v4.0 grade 1-2, with consistent response rates of 50% to 97% in the modern era.

Spectral CT with monochromatic imaging and metal artifacts reduction software for artifacts reduction of ¹²⁵I radioactive seeds in liver brachytherapy

PURPOSE

To investigate the optimal monochromatic energy for artifacts reduction from (125)I seeds as well as image improvement in the vicinity of seeds on monochromatic images with and without metal artifacts reduction software (MARS) and to compare this with traditional 120-kVp images, so as to evaluate the application value of gemstone spectral imaging for reducing artifacts from (125)I seeds in liver brachytherapy.

MATERIALS AND METHODS

A total of 45 tumors from 25 patients treated with (125)I seed brachytherapy in the liver were enrolled in this study. Multiphasic spectral computed tomography (CT) scanning was performed for each patient. After a delay time of 15 s of portal vein phase, a traditional 120-kVp scan was performed, focusing on several planes of (125)I seeds only. The artifact index (AI) in the vicinity of seeds and the standard deviation (SD) of the CT density of region of interest in the outside liver parenchyma were calculated. Artifact appearance was evaluated and classified on reconstructed monochromatic S and 120-kVp images. Image quality in the vicinity of seeds of three data sets were evaluated using a 1-5 scale scoring method. The Friedman rank-sum test was used to estimate the scoring results of image quality.

RESULTS

The greatest noise in monochromatic images was found at 40 keV (SD = 27.38, AI = 206.40). The optimal monochromatic energy was found at 75 keV, which provided almost the least image noise (SD = 10.01) and good performance in artifact reduction (AI = 102.73). Image noise and AI reduction at 75 keV was decreased by 63.44 and 50.23%, compared with at 40 keV. Near-field thick artifacts were obvious in all 45 lesions, in 120-kVp images, and 75-keV images, but basically reduced in 75 keV MARS images and artifacts completely invisible in 7 lesions. The number of diagnosable images (score ≥3) was significantly more in the 75-keV MARS group (28/45), and the 75-keV group (22/45) than in the 120-kVp group (11/45) (p < 0.0167 for both). Compared with 120-kVp images alone, 75-keV images plus 75-keV MARS images can increase tumor visibility around seeds and increase the proportion of diagnostic images to 84.4% (38/45).

CONCLUSION

Spectral CT producing 75-keV MARS images could substantially reduce near-field thick artifacts caused by (125)I seeds and improve image quality, even to a state of being completely free from artifacts. Spectral CT imaging (with and without MARS) can provide more accurate CT images for estimating efficacy after (125)I seed brachytherapy in the liver.

Chemoembolization and stenting combined with iodine-125 seed strands for the treatment of hepatocellular carcinoma with inferior vena cava obstruction

The aim of the present study was to investigate the efficacy and safety of stenting combined with radioactive iodine-125 seed strands following chemoembolization for the treatment of patients with hepatocellular carcinoma and inferior vena cava (IVC) obstruction. A retrospective analysis was conducted of 52 hepatocellular carcinoma patients with IVC obstruction. All patients received chemoembolization of tumor-supplying arteries and IVC stents, and 18 patients additionally received iodine-125 seed strands, which were fixed to the stents. Improvement of IVC obstruction and the tumor response rates were compared between the two groups with a median follow-up time of 2.5 months. In both groups the stents were successfully deployed. At the 2-month post-procedural follow-up, the mean diameter of the IVC obstruction site, the mean pressure difference between the distal IVC obstructive segment and the right atrium as well as the obstruction scoring did not differ significantly between the two groups. By contrast, the tumor response rate of the iodine-125 seed strand group was 94.4%, whereas for the group without iodine-125 seed strands it was 35.3% (P<0.001). The combination of stent and iodine-125 seed strands was effective and safe for the treatment of hepatocellular carcinoma with IVC obstruction.

Sodium glycididazole enhances the efficacy of combined iodine-125 seed implantation and chemotherapy in patients with non small-cell lung cancer

The aim of the present study was to investigate the efficacy and safety of combined therapy with iodine-125 seed implantation and the gemcitabine plus cisplatin chemotherapeutic regimen, as well as treatment with the radiosensitizer sodium glycididazole (CMNa), in patients with non-small cell lung cancer (NSCLC). The 40 patients with NSCLC in the experimental group (19 females; mean age, 52.3±11.5 years; age range, 34-74 years) received the combined therapy and CMNa, and the 41 controls (13 females; mean age, 53.7±10.7 years; age range, 8-79 years) received the combined therapy only. The response rate in the experimental group was significantly higher than in the control group (85.5 vs. 63.4%; P=0.027), with no apparent complications. Therefore, it was concluded that such therapy may be reliable and well-tolerated for the treatment of patients with NSCLC.

Increased survival in hepatocellular carcinoma with iodine-125 implantation plus radiofrequency ablation: a prospective randomized controlled trial

BACKGROUND & AIMS

The purpose of this study was to evaluate whether use of combined radiofrequency ablation (RFA) and percutaneous iodine-125 ((125)I) seed implantation results in better progression-free survival compared with the use of RFA alone in patients with hepatocellular carcinoma.

METHODS

136 patients were randomly assigned to undergo HCC treatment with RFA and percutaneous iodine-125 seed implantation (RFA-(125)I, n=68) or RFA-only (n=68). A total of 91 patients had hepatitis B viral infection in both groups. Rates of tumour recurrence and overall survival were evaluated.

RESULTS

The probabilities of recurrence at 1-, 3-, and 5-years were 4.5%, 22.1%, and 39.8% in the RFA-(125)I group; and 14.8%, 35.3%, and 57.4% in the RFA-only group, respectively. The recurrence rate in the RFA-(125)I group was significantly lower than in the RFA-only group (HR, 0.508; 95% CI, 0.317-0.815; p=0.004 by log-rank test). Local and intrahepatic recurrence was significantly lower in the RFA-(125)I group than in the RFA-only group (7.3% vs. 22.0%, p=0.012 by log-rank test; 17.6% vs. 32.3%, p=0.041 by log-rank test). The probabilities of survival at 1-, 3-, and 5-years were 100%, 86.7%, and 66.1% in the RFA-(125)I group and 95.6%, 75.0%, and 47.0% in the RFA-only group, respectively. The survival rate in the RFA-(125)I group was significantly better than in the RFA-only group (HR, 0.502; 95% CI, 0.313-0.806; p=0.003 by log-rank test). Cox regression model indicated that the treatment group and tumour size were both recurrence-related and overall survival-related prognostic factors.

CONCLUSIONS

There were significant differences in overall survival and cumulative recurrence between RFA-(125)I and RFA-only for patients with small HCCs (⩽3 cm). Treatment with RFA-(125)I facilitated better local and intrahepatic tumour control and long-term survival compared with treatment of RFA alone. ClinicalTrials.gov Identifier: NCT01717729.

Efficacy of permanent iodine-125 seed implants and gemcitabine chemotherapy in patients with platinum- resistant recurrent ovarian carcinoma

BACKGROUND

The aim of this study was to explore the efficacy and adverse reactions of CT-guided radioactive 125I-seed implantation treatment combined with chemotherapy for platinum-resistant recurrent ovarian carcinoma.

MATERIALS AND METHODS

From September 2010 to December 2012, 23 patients with platinum-resistant recurrent ovarian carcinoma were enrolled. All the patients refused, could not bear, or were not suitable for surgery. They all had no more than 3 lesions, which were detected and could also be measured by CT. All were clarified as single-lesion or multiple-lesion groups. A total of 41 lesions underwent implantation of from 8 to 106 125I seeds (median=43). Multi-plane implanting was adopted and 125I-seeds of (0.4-0.7)mCi were placed at intervals of (0.5-1.0) cm. After implantation treatment, all patients underwent 4 cycles of chemotherapy with gemcitabine 800 mg/m2 (days 1, 8 and 15).

RESULTS

The outcome was evaluated with CT 3 weeks and every 3 months after implantation treatment. After 6 months, the volume of 32 out of 41 lesions (78.0%) was reduced at least 30%, within which 9 lesions completely disappeared(22.0%). Complete response was observed in 7 cases (30.4%), with a partial response in 4 cases (17.4%),4 cases stable(17.4%)and 8 cases showing progression (34.8%). The total clinical remission rate was 47.8% (11/23). The clinical remission rate was 77.8% (7/9) in the single-lesion group and 28.6% (4/14) in the multiple-lesion group with a significant difference between the two(P=0.036). The common side effects observed were mild gastrointestinal reactions.

CONCLUSIONS

125I-seed implantation combined with chemotherapy applies an effective way in the treatment of platinum-resistant recurrent ovarian epithelial carcinoma with the advantages of high local control rates, good short-term effects, little trauma and less side effects.

The assistant function of three-dimensional information for I125 particle implantation

The purpose of this study was to explore the assistant function of 3-D information for I125 particle implantation of multineedle intervention under the guidance of ultrasound. The assistant function of 3-D information was verified by a simulation experiment system which consists of an ultrasound probe, an abdominal phantom, the preoperative computed tomography image of a patient, the electromagnetic tracking device, and the self-developed 3-D image navigation software with a practical and friendly graphical user interface. The simulation particle implantation experiments were divided into the two groups. The first group of experiments was performed with the aid of 3-D information. Seven days later, the second group of experiments was carried out with the aid of 2-D information. We made the statistical analysis of the experimental results obtained by nine medical students, nine interventional radiologists, and nine attending physicians. With the assistance of 3-D information, the percentage of tumor coverage increased (p < 0.01), the operation time shortened (p < 0.01), and the number of insertions reduced (p < 0.01). The assistant function of 3-D information for particle implantation of multineedle intervention under the guidance of ultrasound was technically feasible and effective.

Brachytherapy with iodine-125 seeds for hepatocellular carcinoma

¹²⁵I seeds have good physical and radiobiological characteristics. Interstitial brachytherapy has advantages of minimal invasive, precise stereotactic treatment and high local control rate and plays an important role in the treatment of hepatocellular carcinoma (HCC). Brachytherapy with ¹²⁵I seeds has been used in unresectable HCC, HCC with portal vein tumor thrombus, intrahepatic cholangiocarcinoma, hepatic metastases, and some other tumors, providing encouraging survival rates. Radiation-related complications are rare in highly selected patients. In a word, ¹²⁵I brachytherapy is a safe and effective treatment for newly diagnosed or recurrent unresectable intrahepatic malignancies and can provide better survival rates and decent quality of life.

Computed tomography-guided interstitial high dose rate brachytherapy for centrally located liver tumours: a single institution study

OBJECTIVES

To evaluate the clinical outcome of computed tomography (CT)-guided interstitial (IRT) high-dose-rate (HDR) brachytherapy (BRT) in the treatment of unresectable primary and secondary liver malignancies. This report updates and expands our previously described experience with this treatment technique.

METHODS

Forty-one patients with 50 tumours adjacent to the liver hilum and bile duct bifurcation were treated in 59 interventions of CT-guided IRT HDR BRT. The tumours were larger than 4 cm with a median volume of 84 cm(3) (38-1,348 cm(3)). The IRT HDR BRT delivered a median total physical dose of 20.0 Gy (7.0-32.0 Gy) in twice daily fractions of median 7.0 Gy (4.0-10.0 Gy) in 19 patients and in once daily fractions of median 8.0 Gy (7.0-14.0 Gy) in 22 patients.

RESULTS

With a median follow-up of 12.4 months, the local control for metastatic hepatic tumours was 89 %, 73 % and 63 % at 6, 12 and 18 months respectively. The local control for primary hepatic tumours was 90 %, 81 % and 50 % at 6, 12 and 18 months respectively. Severe side effects occurred in 5.0 % of interventions with no treatment-related deaths.

CONCLUSIONS

CT-guided IRT HDR BRT is a promising procedure for the radiation treatment of centrally located liver malignancies.

KEY POINTS

• Interstitial high-dose-rate brachytherapy (IRT HDR BRT) is a promising treatment for central liver tumours • CT-guided IRT HDR BRT is safe for treating extensive tumours • CT-guided IRT HDR BRT could play a role in managing unresectable hepatic malignancies.

Adjuvant iodine-125 brachytherapy for hepatocellular carcinoma after complete hepatectomy: a randomized controlled trial

BACKGROUND

Tumor recurrence is a major problem after curative resection of hepatocellular carcinoma (HCC). The current study evaluated the effects of adjuvant iodine-125 ((125)I) brachytherapy on postoperative recurrence of HCC.

METHODOLOGY/PRINCIPAL FINDINGS

From July 2000 to June 2004, 68 HCC patients undergoing curative hepatectomy were randomly assigned into a (125)I adjuvant brachytherapy group (n = 34) and a group of best care (n = 34). Patients in the (125)I adjuvant brachytherapy group received (125)I seed implantation on the raw surface of resection. Patients in the best care control group received identical treatments except for the (125)I seed implantation. Time to recurrence (TTR) and 1-, 3- and 5-year overall survival (OS) were compared between the two groups. The follow-up ended in January 2010, and lasted for 7.7-106.4 months with a median of 47.6 months. TTR was significantly longer in the (125)I group (mean of 60.0 months vs. 36.7 months in the control). The 1-, 3- and 5-year recurrence-free rates of the (125)I group were 94.12%, 76.42%, and 73.65% vs. 88.24%, 50.00%, and 29.41% compared with the control group, respectively. The 1-, 3- and 5-year OS rates of the (125)I group were 94.12%, 73.53%, and 55.88% vs. 88.24%, 52.94%, and 29.41% compared with the control group, respectively. The (125)I brachytherapy decreased the risk of recurrence (HR = 0.310) and the risk of death (HR = 0.364). Most frequent adverse events in the (125)I group included nausea, vomiting, arrhythmia, decreased white blood cell and/or platelet counts, and were generally mild and manageable.

CONCLUSIONS/SIGNIFICANCE

Adjuvant (125)I brachytherapy significantly prolonged TTR and increased the OS rate after curative resection of HCC.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12610000081011.

Advances in treatment of liver metastases of colorectal cancer

Liver metastasis of colorectal cancer has a high incidence and mortality and is the main factor affecting prognosis, which necessitates the development of more reasonable therapeutic strategy for this condition. Nowadays, surgical resection is the only probable curative method; however, surgical intervention is indicated in only a few patients. The development of medical technology and accumulation of clinical experience have led to the wide use of multimodal treatment for liver metastases of colorectal cancer. Multimodal treatment includes surgical resection, neoadjuvant chemotherapy, transcatheter hepatic arterial chemoembolization, radiation therapy, radiofrequency ablation, cryotherapy, percutaneous ethanol injection, and Chinese medicine treatment. The combined application of the above treatments can improve the survival rate and the quality of life of patients. This article summarizes the advances in comprehensive treatment for colorectal liver metastases.

A novel biliary stent loaded with (125)I seeds in patients with malignant biliary obstruction: preliminary results versus a conventional biliary stent

BACKGROUND & AIMS

Stenting is a palliative therapy method for relieving malignant biliary obstruction. The aim of this study was to evaluate the safety and effectiveness of an irradiation stent compared to a conventional biliary stent in patients with biliary obstruction caused by both primary and metastatic adenocarcinomas.

METHODS

Participants were randomly assigned to receive treatment with a biliary irradiation stent (irradiation stent group) or a conventional biliary stent (control group). After stent implantation, the outcomes were measured in terms of relief of obstructive jaundice, survival time, complications related to the procedure. A p value of less than 0.05 indicated a significant difference.

RESULTS

The stents were successfully placed in all the 23 patients. The obstructive jaundice was relieved in all patients except three in the control group. The median and mean overall survivals in the irradiation stent group were higher than those in the control group (7.40 months versus 2.50 months, 8.03 months versus 3.36 months, p=0.006). The patients with stent patent at 3, 6, and 12 months in the irradiation stent group were 11 (91.7%), 7 (58.3%), and 1 (8.3%), respectively. While in the control group, 4 (36.4%), 1 (9.1%), and 0 (0%), respectively. There were no significant differences in the complications related to stent insertion between the two groups.

CONCLUSIONS

This interim analysis shows that treatment with the biliary intraluminal irradiation stent in patients with biliary obstruction caused by adenocarcinomas appears safe and technically feasible, has benefits in relieving jaundice, and seems to extend survival when compared to a conventional biliary stent.

125I radioactive seed interstitial brachytherapy for liver metastases

AIM: To detect the efficacy of ¹²⁵I radioactive seed interstitial brachytherapy for liver metastases.

METHODS: Thirty-two tumors in 24 patients with liver metastases were treated by ¹²⁵I radioactivity seed interstitial brachytherapy. The tumor diameter ranged from 4.5 to 12.8 cm, with an average value of 7.8 cm. The treatment response, local control rate and survival rate were evaluated and adverse events observed.

RESULTS: Complete remission (CR) was achieved in 7 tumors, and partial remission (PR) was achieved in 16 tumors. Five tumors had no remission (NR), and 4 tumors had progressive deterioration (PD). The response rate was 71.9%. The patients were followed up for 7 to 22months (median 16 mo). The local control rate was 65.9%, and total survival rate 70.1%. No serious side effects were observed.

CONCLUSION: Radioactive seed interstitial brachytherapy is an effective form of treatment for patients with liver metastases.

The combined treatment of CT-guided percutaneous 125I seed implantation and chemotherapy for non-small-cell lung cancer

PURPOSE

Gemcitabine plus cisplatin (GP) is a first-line treatment for advanced non-small-cell lung cancer (NSCLC). In this study, we evaluated the efficacy and safety of a combined treatment consisting of CT-guided percutaneous (125)I seed implantation with GP chemotherapy for advanced NSCLC.

METHODS

Fifty-three patients with advanced NSCLC were enrolled in a nonrandomized, two-armed clinical trial. Of these patients, 24 received a combination treatment of CT-guided percutaneous (125) I seed implantation and GP (the combo group), while 29 were treated with GP only (the control group).

RESULTS

Patients in the combo group received (125)I seed implantation with prescription dose of 100-140 Gy and a total of 55 cycles of GP, and patients in the control group received a total of 73 cycles of GP. The overall response rate was 79.2% in the combo group and 41.4% in the control group. The median overall survival time was 13.5 ± 1.5 months in the combo group and 9.0 ± 1.8 months in the control group. The progression-free survival time was 8.0 ± 1.2 months in the combo group and 5.0 ± 0.8 months in the control group. The 1- and 2-year survival rates were 62.5 and 16.7% in the combo group, respectively, and 41.4 and 13.8% in the control group. The interventional complications in the combo group included 5 cases of pneumothorax and 4 cases of hemoptysis. There were no complications due to radiation pneumonia or radiation esophagitis in the combo group, and no patients had lethal hemoptysis or esophagotracheal fistula. Chemotherapy treatment-related toxicities, including Grade 3/4 myelosuppression and Grade 3 gastrointestinal toxicity, were similar in both groups.

CONCLUSIONS

Our initial experience showed that combined CT-guided (125)I radioactive seed implantation and GP chemotherapy are effective and safe for treating advanced NCSLC.

Endovascular placement of iodine-125 seed strand and stent combined with chemoembolization for treatment of hepatocellular carcinoma with tumor thrombus in main portal vein

PURPOSE

To study the safety and feasibility of endovascular placement of an iodine-125 ((125)I) seed strand and stent combined with chemoembolization to treat hepatocellular carcinoma (HCC) with tumor thrombus in the main portal vein (MPV).

MATERIALS AND METHODS

From February 2008 to October 2009, 32 patients with HCC complicated by tumor thrombus in MPV were enrolled into this study (28 men and 4 women, mean age 53.2 years ± 8.8). After (125)I seed strand and self-expandable stent had been placed in the obstructed MPV, chemoembolization was performed. All patients were followed up every 30 days. Patency of stent and response of HCC were evaluated by abdominal contrast-enhanced computed tomography (CT) scan.

RESULTS

The technical success rate was 100% for placement of the (125)I seed strand and stent in the obstructed MPV. No serious procedure-related complications occurred. During a mean follow-up of 217.5 days ± 151.6, the objective response rate of HCC to chemoembolization was 37.5%. The 90-day, 180-day, and 360-day cumulative survival rates were 96.4%, 67.4%, and 39.3%, and the cumulative stent patency rates were 96.7%, 83.4%, and 83.4%.

CONCLUSIONS

Endovascular placement of (125)I seed strand and stent combined with chemoembolization was safe and feasible to treat HCC with tumor thrombus in the MPV.

1.5T conventional MR-guided iodine-125 interstitial implants for hepatocellular carcinoma: feasibility and preliminary clinical experience

PURPOSE

To evaluate the feasibility and therapeutic efficacy of 1.5 T conventional MR-guided percutaneous interstitial implantation of I-125 radioactive seeds in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

The institutional ethics committee approved this study. After imformed consent was obtained, twenty-three patients suffering from a total of 65 HCC lesions were treated with I-125 seed permanent interstitial implantation under the guidance of a 1.5T conventional magnetic resonance imaging (MRI) system. The FSE T2WI, T1 FSPGR, FIESTA 2D, 3D Dyn T1WI sequences were used to guide an 18 G MR-compatible needle inserted into the lesions to introduce the I-125 seeds. The response evaluation criteria in solid tumors (RECIST) were used to evaluate the curative effect.

RESULTS

The needle and I-125 seed were seen clearly on MRI images. The final dose delivered to total decay was 173.46 ± 32.44 Gy (range, 110-270 Gy) as calculated by postoperative TPS. The complete response (CR) was seen in 22 lesions (33.8%), partial response (PR) in 24 lesions (36.9%), stable disease (SD) in 9 lesions (13.8%), and progressive disease (PD) in 10 lesions (15.4%). The post-operative alpha-fetoprotein (AFP) was decreased (t = 3.117, P = 0.005<0.05). Two patients were observed a small area of subcapsular bleeding that did not lead to any symptoms or clinical sequelae.

CONCLUSION

MR-guided I-125 implantation for HCC is technically feasible and effective.

Cholangiocarcinoma--controversies and challenges

Cholangiocarcinomas are a diverse group of tumors that are presumed to originate from the biliary tract epithelium either within the liver or the biliary tract. These cancers are often difficult to diagnose, their pathogenesis is poorly understood, and their dismal prognosis has resulted in a nihilistic approach to their management. The two major clinical phenotypes are intrahepatic, mass-forming tumors and large ductal tumors. Among the ductal cancers, lesions at the liver hilum are most prevalent. The risk factors, clinical presentation, natural history and management of these two types of cholangiocarcinoma are distinct. Efforts to improve outcomes for patients with these diseases are affected by several challenges to effective management. For example, designations based on anatomical characteristics have been inconsistently applied, which has confounded analysis of epidemiological trends and assessment of risk factors. The evaluation of therapeutic options, particularly systemic therapies, has been limited by a lack of appreciation of the different phenotypes. Controversies exist regarding the appropriate workup and choice of management approach. However, new and emerging tools for improved diagnosis, expanded indications for surgical approaches, an emerging role for locoregional and intrabiliary therapies and improved systemic therapies provide optimism and hope for improved outcomes in the future.

Treatment of portal vein tumor thrombus using 125Iodine seed implantation brachytherapy

We reported two cases of liver metastasis with portal vein tumor thrombus that developed after liver transplantation for hepatocellular carcinoma (HCC). Both the patients were women aged 43 and 55 years, who had liver metastasis and portal vein tumor thrombus formation after liver transplantations for HCC. For the treatment of portal vein tumor thrombus, ¹²⁵I seeds were implanted into the hepatic tissue under the guidance of preoperative computed tomography (CT) images with a total radiation dose of 130 Gy. Enhanced spiral CT scan was performed for evaluation of the liver at 12 and 16 wk after treatment. Thereafter, upper abdominal CT examination was performed every 2-3 mo. No severe complications associated with the ¹²⁵I seeds were seen in these two patients. The upper abdominal CT images (obtained after 3 and 4 mo of treatment) showed that the thrombosis reactions were complete reaction and restoration of the patency of the partially obstructed portal vein with partial obstruction. In the case with complete obstruction of the portal vein, the thrombosis was resolved completely, but blood flow could not be restored. After this treatment, one of the patients is still alive, while the other died within 6 mo after the treatment due to lung metastasis complicated with lung infection, leading to respiratory failure.