Locally advanced pancreatic carcinoma with jaundice: the benefit of a sequential treatment with stenting followed by CT-guided 125I seeds implantation

Guidelines for permanent iodine-125 seed interstitial brachytherapy for pancreatic cancer (2023 edition): The Chinese expert consensus workshop report

ABSTRACT

The incidence of pancreatic cancer is increasing worldwide. Approximately, 60% of patients with pancreatic cancer have distant metastases at the time of diagnosis, of which only 10% can be removed using standard resection. Further, patients derive limited benefits from chemotherapy or radiotherapy. As such, alternative methods to achieve local control have emerged, including permanent iodine-125 seed interstitial brachytherapy. In 2023, the Chinese College of Interventionalists, affiliated with the Chinese Medical Doctor Association, organized a group of multi-disciplinary experts to compose guidelines for this treatment modality. The aim of this conference was to standardize the procedure for permanent iodine-125 seed interstitial brachytherapy, including indications, contraindications, pre-procedural preparation, procedural operations, complications, efficacy evaluation, and follow-up.

Iodine-125 brachytherapy in inoperable duodenal papilla carcinoma: a case report series

Background

Duodenal papilla carcinoma (DPC) is a rare malignancy often diagnosed at an advanced stage. When surgery is not feasible in localized disease due to advanced age or comorbidities, there remains no consensus on optimal management for these patients.

Case summary

This case series details the therapeutic outcomes of 125I seed implantation in two elderly patients with DPC. A notable tumor reduction was achieved within two months after implantation. Furthermore, both patients demonstrated radiological tumor response and survived for over six months following the initial 125I seed treatment, marking the first reported instance of 125I seed implantation to effectively control DPC.

Conclusion

The anti-tumor activity of 125I seed implantation in the reported two cases of DPC underscores its potential as a viable treatment option for inoperable localized DPC.

Three-dimensional treatment-planning-based prediction of seed migration to chest after 125I seed brachytherapy for hepatic malignancy

PURPOSE

To develop and validate risk models incorporating clinical and/or imaging parameters based on three-dimensional treatment-planning systems (3D-TPS) to predict the occurrence of 125I seed migration and the number of migrated seeds <2/≥2 to the chest after brachytherapy for patients with malignant hepatic tumors.

METHODS AND MATERIALS

A total of 480 patients diagnosed with malignant liver tumors receiving 125I seed brachytherapy from July 2010 to May 2020 were retrospectively enrolled. Variables included 3D-TPS-based CT parameters, that is, the distance from the seed to the inferior vena cava (DSI), the distance from the seed to the second hepatic portal (DSP) and the angle from the seed to the second hepatic portal (ASP), and patients' clinical characteristics, that is, the number of seed implantation procedures (NSP), the maximum number of implanted seeds one time (MAX) and laboratory parameters within 1 week before treatment. Two sets of logistic regression models incorporating clinical and/or imaging variables were developed to predict the occurrence of seed migration and the number of migrated seeds <2/≥2. Model performance was assessed by ROC analysis and decision curve analysis.

RESULTS

Compared with the clinical models, the combined model showed a higher discriminative ability for both the prediction of migration occurrence and number of migrated seeds ≥ 2/<2 to the chest (AUC, 0.879 vs. 0.668, p < 0.05; 0.895 vs. 0.701, p < 0.05). The decision curve analysis results indicated higher net benefits of combined models than clinical models. Variables, including DSI, NSP and pretreatment lymphocyte-to-neutrophil ratio, acted as the most important predictors in combined models.

CONCLUSIONS

The proposed combined models based on 3D-TPS improved discriminative abilities for predicting 125I seed migration and number of migrated seeds <2/≥2 to the chest after hepatic brachytherapy, being promising to aid clinical decision-making.

Feasibility of 125I brachytherapy combined with arterial infusion chemotherapy in patients with advanced pancreatic cancer

To evaluation the feasibility of Iodine-125 (¹²5I) brachytherapy combined with arterial infusion chemotherapy in patients with advanced pancreatic cancer. A total of 72 cases with Stage III and IV were retrospectively reviewed. 23 cases receiving 125I brachytherapy were classified as Group A. 27 cases receiving arterial infusion chemotherapy (gemcitabine + cisplatin, GP) were classified as Group B and 22 cases receiving 125I brachytherapy combined with arterial infusion chemotherapy (GP) were classified as Group C. The evaluated indications were local control rate, survival rate, carbohydrate antigen 19-9, pain relief, and Karnofsky physical scores. Analysis of Variancep, Pearson chi-square test and Kaplan-Meier curves were used for analysis. The local control rate of group A and group C was significantly higher than group B (P < .001). Pearson chi-square test showed statistical difference of the 3 groups (χ2 = 12.969, P = .044). The median survival of group A,B and C was 9 months, 6 months and 13 months, respectively. The survival time of group C was significantly higher than group B (χ2 = 5.403, P = .020). The Log rank test showed statistical difference in the survival curve of the 3 groups (χ2 = 6.501, P = .039). The difference of carbohydrate antigen 19-9 decline percentage between group B and C group was statistically significant (χ2 = 5.959, P = .015). Patients in group A and group C relieved form pain after treatment with statistically significant (P < .001). Pain relief was much more effective in patients who received 125I brachytherapy. Karnofsky physical scores after treatment were statistically higher than those before treatment in each group (P < .001). 125I brachytherapy maybe one of the effective, safe and feasible alternative treatment of advanced pancreatic cancer. ¹²5I brachytherapy combined with arterial infusion chemotherapy was effective in the treatment of advanced pancreatic cancer.

Comparison of intraluminal brachytherapy combined with and without stent placement for treatment of obstructive jaundice induced by tumor thrombus

PURPOSE

To compare the safety and efficacy of intraluminal brachytherapy with iodine-125 (125I) seed strand implantation combined with and without stent placement to treat patients with obstructive jaundice induced by tumor thrombus.

METHODS

Between January 2018 and June 2022, 42 patients with malignant obstructive jaundice (MOJ) induced by tumor thrombus were included. 20 patients received 125I seed strand implantation and stent placement (group A). The remaining 22 patients, implanted 125I seed strands only, served as control (group B). The two groups' overall survival and jaundice-free survival were compared using the Kaplan-Meier method and log-rank test.

RESULTS

During the follow-up period, the mean survival time of group A was 38.0 ± 4.1 months (95%CI, 30.0-46.1 months), while that of group B was 25.1 ± 2.8 (95% CI, 19.5-30.6 months) (p = 0.406). The mean survival rates of 12 months for all patients, group A, and group B was 66.7%, 65%, and 68%, respectively. The mean jaundice-free survival of group A and group B were 34.0 ± 3.6 months (95% CI, 27.9-41.2months) and 22.9 ± 2.7 months (95%CI, 17.5-28.2months) (p = 0.254), respectively. Two PTBD drainage tube infection cases occurred in group A and group B separately.

CONCLUSIONS

125I intraluminal brachytherapy is an effective and safe therapy for treating patients with obstructive jaundice induced by tumor thrombus.

Intratumoral injection therapies for locally advanced pancreatic cancer: systematic review

INTRODUCTION

Pancreatic cancer has one of the worst prognoses of all cancers. Patients with locally advanced pancreatic cancer have a 12.7-20.2 per cent chance of receiving curative surgery after induction systemic chemotherapy. Intratumoral injection therapies have been studied as complementary treatment options for improved local tumour control. The aim of this systematic review was to provide an overview of intratumoral injection therapies, their safety, and oncological outcome in patients with locally advanced pancreatic cancer.

METHODS

A literature search was conducted in PubMed, Embase and the Cochrane Library for articles written in English up to 28 November 2022. All study designs involving at least five patients with locally advanced pancreatic cancer who were treated with an intratumoral injection therapy were included. Critical appraisal of the included studies was performed using the Newcastle-Ottawa scale.

RESULTS

After evaluation of the 1680 articles yielded by the systematic search, 52 studies treating 1843 patients were included. Included intratumoral injection treatment modalities comprised iodine-125 (125I) seed brachytherapy (32 studies, 1283 patients), phosphorus-32 (32P) microbrachytherapy (5 studies, 133 patients), palladium-103 (103Pd) seed brachytherapy (2 studies, 26 patients), immunotherapy (9 studies, 330 patients), and chemotherapy (4 studies, 71 patients). Overall survival ranged between 7.0 and 16.0 months for 125I, 5.2 and 15.5 months for 32P, 6.9 and 10.0 months for 103Pd, 5.8 and 13.8 months for immunotherapy, and 9.0 and 16.2 months for chemotherapy. Severe complication (greater than or equal to grade III complications using Clavien-Dindo classification) rates were 6.2 per cent for 125I, 49.2 per cent for 32P, 15 per cent for 103Pd, 57.9 per cent for immunotherapy, and 0 per cent for chemotherapy.

CONCLUSION

Five intratumoral injection therapies are described and an overview is reported. Some intratumoral injection therapies for patients with locally advanced pancreatic cancer seem safe, although 32P microbrachytherapy and immunotherapy require additional evidence. Currently available data are insufficient to provide firm conclusions regarding the added value to survival. The potential advantage of intratumoral injection therapies complementary to conventional care should be studied in well designed RCTs.

Safety and efficacy of self-expandable metallic stent combined with 125I brachytherapy for the treatment of malignant obstructive jaundice

BACKGROUND

Several previous studies demonstrated that the combination of self-expandable metallic stents (SEMS) and ¹²⁵I seed implantation might prolong stent patency and obtain survival benefits for malignant obstructive jaundice (MOJ) patients. However, these studies rarely mentioned a comparison between CT-guided intratumoral ¹²⁵I seed implantation and intraluminal ¹²⁵I seed strand insertion combined with stenting for the management of MOJ. This study aimed to further evaluate the safety and efficacy of SEMS combined with ¹²⁵I brachytherapy in the management of unresectable MOJ.

METHODS

Fifty-nine patients with unresectable MOJ were retrospectively included from March 2018 to June 2021. The main therapeutic outcomes were evaluated in terms of stent patency, and overall survival. Cumulative stent patency and overall survival rates were calculated by Kaplan-Meier survival analysis. Both clinical and treatment factors associated with survival were analyzed.

RESULTS

Technical success was achieved in all patients. The clinical success rate was 94% (32/34) in the seeds group and 92% (23/25) in the control group, no significant difference was found (p =1.000). The median duration of stent patency was significantly longer in the ¹²⁵I brachytherapy group compared with the control group (289 days vs. 88 days, respectively, p =0.001). The ¹²⁵I brachytherapy group demonstrated a significantly better median overall survival rate than the control group (221 days vs. 78 days, respectively, p =0.001). In multivariate analysis, stents with ¹²⁵I brachytherapy (p =0.004) was a significant favorable prognostic factor that affected patient survival. No significant difference was observed between CT-guided ¹²⁵I seed implantation and ¹²⁵I seed strand insertion in stent patency (p =0.268), and overall survival (p =0.483).

CONCLUSION

SEMS combined with ¹²⁵I brachytherapy is safe and effective for treating MOJ. ¹²⁵I brachytherapy may help to maintain stent patency and prolong overall survival. There was no significant difference between CT-guided ¹²⁵I seed implantation with SEMS and ¹²⁵I seed strand insertion with SEMS in stent patency and overall survival.

Factors related to stent patency and early elimination of jaundice using bile duct stent combined with iodine-125 seed implantation in malignant obstructive jaundice

Purpose

Biliary stents combined with percutaneous or endoscopic ultrasound-guided iodine-125 seed implantation into primary tumor have been confirmed to relieve malignant obstructive jaundice (MOJ), and prolong patient's stent patency. The aim of the study was to evaluate meaningful clinical application indications and better guide the application of this technology.

Material and methods

Patients with MOJ, who have received bile duct stenting combined with iodine-125 (¹²⁵I) seed implantation from October, 2010 to April, 2022, were retrospectively analyzed. Univariate and multivariate analyses were adopted to indicate factors of stent patency in MOJ and influencing factors of jaundice reduction at one week after surgery.

Results

A total of 90 patients were enrolled into the study, including 52 males (57.8%) and 38 females (42.2%), with a mean age of 68.66 ±12.53 years. The median stent patency was 8 months. No serious adverse events occurred during follow-up. Multivariate analysis showed that Child-Pugh score (HR = 2.221, 95% CI: 1.081-4.562), biliary infection (HR = 1.901, 95% CI: 1.084-3.335), and pre-operative jaundice duration (HR = 1.977, 95% CI: 1.106-3.533) were the independent risk factors for stent patency. Child-Pugh B/C (OR = 4.647, 95% CI: 1.080-19.982) and bile duct infection (OR = 3.583, 95% CI: 1.095-11.725) were the independent risk factors for jaundice reduction at one week after surgery.

Conclusions

MOJ patients treated with biliary stents combined with ¹²⁵I seed implantation, and patients with better pre-operative liver function and no biliary tract infection, present not only longer biliary stent patency, but also better early jaundice reduction.

Systematic review of brachytherapy for symptom palliation

PURPOSE

Brachytherapy is most often applied in the curative or salvage setting, but many forms of brachytherapy can be helpful for symptom palliation. Declining utilization is seen, for multiple reasons, such as lack of awareness, insufficient expertise, or poor access to equipment. High level evidence for many types of palliative brachytherapy has been lacking. The objective of the current study was to review the evidence for utilization and efficacy of brachytherapy to palliate symptoms from cancer.

MATERIALS AND METHODS

We performed a systematic search in EMBASE and MEDLINE for English-language articles published from January 1980 to May 2022 that described brachytherapy used for a palliative indication in adults with a diagnosis of cancer (any subtype) and at least one symptom related outcome. Individual case reports and conference abstracts were excluded. All publications were independently screened by two investigators for eligibility.

RESULTS

The initial search identified 3637 abstracts of which 129 were selected for in-depth review. The number of studies (total number of patients) included in the final analysis varied widely by tumor site with the majority (68.2%) involving either lung or esophageal cancer. Despite a limited number of prospective trials that assessed the efficacy of brachytherapy for symptom management, there was a positive effect on palliation of symptoms across all tumor types. There was no clear trend in the number of publications over time. The most commonly cited symptom indications for palliation by brachytherapy were dysphagia, dyspnea, pain and bleeding.

CONCLUSIONS

Brachytherapy can provide palliation for patients with advanced cancer, across different tumor sites and clinical scenarios. However, high level evidence in the literature to support palliative applications of brachytherapy is lacking or limited for many tumor sites. There appears to be a strong publication bias towards positive studies in favor of brachytherapy. Beyond anecdotal reports and individual practices, outcomes research can further our understanding of the role of brachytherapy in palliating advanced cancers of all types, and should be encouraged.

Prognosis of adenoid cystic carcinoma in head and neck region treated with different regimens-A single-centre study

BACKGROUND

No study has evaluated the impact of regimen on recurrence, metastasis and survival in patients with adenoid cystic carcinoma (ACC). The present study aimed to compare the efficacy of radioactive seed implantation and other regimens in treating ACC, so as to investigate the clinical applicability of radioactive seed implantation and determine the indications for this regimen.

METHODS

A total of 188 patients with ACC in oromaxillofacial region were allocated to four groups according to the treatment regimen: group 1 was treated with a combination of surgery and ¹²⁵ I seed therapy, group 2 with a combination of surgery and external radiotherapy, group 3 with surgery, whereas group 4 was untreated. The Kaplan-Meier method was used to assess the survival rates, and the Cox regression analyses were used to identify the associated prognostic factors.

RESULTS

The overall survival rates of 188 patients and groups 1, 2, 3 and 4 were 85.7%, 75%, 68.2% and 37.5%, respectively. Cox regression analysis revealed that age, T stage, N stage and regimen were independent prognostic factors of survival. Amongst patients with primary ACC, the efficacy of radioactive seed implantation was higher in those with perineural invasion than in those without.

CONCLUSION

Patient age, T stage, N stage and regimen are independent prognostic factors of survival in patients with ACC. Patients treated with surgery combined with postoperative ¹²⁵ I seed radiotherapy have a higher overall survival rate, and those with perineural invasion are more suitable for radioactive seed implantation therapy.

Clinical practice guidelines for the interventional treatment of advanced pancreatic cancer (5th edition)

Pancreatic cancer has become a major disease affecting people's health because of its insidiousness, rapid progression and poor prognosis. Based on the practical needs of clinical work, combined with domestic multi-center research and experience, this guideline provides constructive suggestions for the interventional treatment of pancreatic cancer.