Percutaneous stenting and chemotherapy for unresectable pancreatic cancer: Comparison of irradiation stents vs conventional metal stents

CT-guided iodine-125 brachytherapy is an effective palliative treatment for the right lower paratracheal lymph nodes metastasis previously treatment failure

PURPOSE

This study aimed to evaluate the effectiveness and safety of iodine-125 brachytherapy as a treatment for right lower paratracheal lymph node metastasis following unsuccessful prior therapies.

METHODS

A retrospective review of patients who underwent iodine-125 brachytherapy for right lower paratracheal lymph node metastasis was conducted. The study included 24 patients who met the predefined criteria. Iodine-125 seeds were implanted under CT guidance, and treatment planning was performed using a treatment planning system. The primary endpoint was the objective response rate (ORR), while overall survival (OS) and complications were secondary endpoints.

RESULTS

The ORR was 87.5%, with 4 patients achieving complete response (CR) and 17 patients achieving partial response (PR). The mean diameter of metastatic lymph nodes significantly reduced from 40.21 ± 6.66 mm before treatment to 12.25 ± 9.27 mm at the last follow-up (p < 0.001). The median OS was 14.70 months, with 1-year and 2-year survival rates of 78.9% and 20.9%, respectively. Clinical symptoms significantly improved, as indicated by increased Karnofsky Performance Score (KPS) scores. Complications were manageable, with no procedure-related deaths.

CONCLUSION

Iodine-125 brachytherapy demonstrated promising efficacy and safety as an alternative treatment for right lower paratracheal lymph node metastasis after unsuccessful prior therapies.

Stereotactic ablative brachytherapy versus percutaneous microwave ablation for early-stage non-small cell lung cancer: a multicenter retrospective study

BACKGROUND

To analyze the efficacy of stereotactic ablative brachytherapy (SABT) and percutaneous microwave ablation (MWA) for the treatment of early-stage non-small cell lung cancer (NSCLC).

METHODS

Patients with early-stage (T1-T2aN0M0) NSCLC who underwent CT-guided SABT or MWA between October 2014 and March 2017 at four medical centers were retrospectively analyzed. Survival, treatment response, and procedure-related complications were assessed.

RESULTS

A total of 83 patients were included in this study. The median follow-up time was 55.2 months (range 7.2-76.8 months). The 1-, 3-, and 5-year overall survival (OS) rates were 96.4%, 82.3%, and 68.4% for the SABT group (n = 28), and 96.4%, 79.7%, and 63.2% for MWA group (n = 55), respectively. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 92.9%, 74.6%, and 54.1% for SABT, and 92.7%, 70.5%, and 50.5% for MWA, respectively. There were no significant differences between SABT and MWA in terms of OS (p = 0.631) or DFS (p = 0.836). The recurrence rate was also similar between the two groups (p = 0.809). No procedure-related deaths occurred. Pneumothorax was the most common adverse event in the two groups, with no significant difference. No radiation pneumonia was found in the SABT group.

CONCLUSIONS

SABT provided similar efficacy to MWA for the treatment of stage I NSCLC. SABT may be a treatment option for unresectable early-stage NSCLC. However, future prospective randomized studies are required to verify these results.

The Prognostic Value of Sarcopenia and Myosteatosis in Biliary Tract Cancer After Palliative Treatment With Radiation-Emitting Metallic Stent

Background:

Radiation-emitting metallic stent (REMS) placement is increasingly used for malignant biliary obstruction (MBO) caused by unresectable biliary tract carcinoma (UBTC) in clinical practice. The study is aimed to evaluate the prognostic value of sarcopenia, myosteatosis, and their combination on overall survival (OS) in patients treated with REMS for UBTC.

Methods

Patients diagnosed with UBTC who underwent REMS placement between January 2013 and May 2021 were included consecutively in this retrospective study. Sarcopenia and myosteatosis were defined based on skeletal muscle index (SMI) and skeletal muscle attenuation (SMA), respectively, which were measured by computer tomography (CT) images on the level of the third lumbar vertebral body before REMS placement. Patients were categorized into two groups by sex-specific cutoff value for sarcopenia and myosteatosis, and OS rates were compared between the groups. Univariate and multivariate cox regression analyses were used to assess factors associated with OS.

Results

Data of 135 patients included were retrospectively reviewed and analyzed. Median OS was 7.17 months in total cohort. Patients in the sarcopenia group had significant poorer OS than those in the non-sarcopenia group (median: 3.23 vs. 11.60 months, p < 0.001). OS was shorter in patients with myosteatosis than those without myosteatosis (median: 4.40 vs. 9.17 months, p < 0.001). Sarcopenia (odds ratio [OR] = 9.61; 95% CI = 5.41–17.09; p < 0.001) and myosteatosis (OR = 1.70; 95% CI = 1.13–2.57; p = 0.012) were significantly associated with OS. Combining sarcopenia and myosteatosis (CSM) showed a better predictive accuracy in OS than either one (area under curves: CSM vs. sarcopenia = 0.760 vs. 0.698, p = 0.049; CSM vs. myosteatosis = 0.760 vs. 0.671, p = 0.006).

Conclusion

Sarcopenia and myosteatosis are negative predictors of survival in patients who underwent REMS placement for UBTC. CSM seemed to show a better prognostic value than either sarcopenia or myosteatosis alone. They can be used preoperatively for risk evaluation.

Radioactive Iodine-125 in Tumor Therapy: Advances and Future Directions

Radioactive iodine-125 (I-125) is the most widely used radioactive sealed source for interstitial permanent brachytherapy (BT). BT has the exceptional ability to deliver extremely high doses that external beam radiotherapy (EBRT) could never achieve within treated lesions, with the added benefit that doses drop off rapidly outside the target lesion by minimizing the exposure of uninvolved surrounding normal tissue. Spurred by multiple biological and technological advances, BT application has experienced substantial alteration over the past few decades. The procedure of I-125 radioactive seed implantation evolved from ultrasound guidance to computed tomography guidance. Compellingly, the creative introduction of 3D-printed individual templates, BT treatment planning systems, and artificial intelligence navigator systems remarkably increased the accuracy of I-125 BT and individualized I-125 ablative radiotherapy. Of note, utilizing I-125 to treat carcinoma in hollow cavity organs was enabled by the utility of self-expandable metal stents (SEMSs). Initially, I-125 BT was only used in the treatment of rare tumors. However, an increasing number of clinical trials upheld the efficacy and safety of I-125 BT in almost all tumors. Therefore, this study aims to summarize the recent advances of I-125 BT in cancer therapy, which cover experimental research to clinical investigations, including the development of novel techniques. This review also raises unanswered questions that may prompt future clinical trials and experimental work.

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

OBJECTIVES

To evaluate the role of sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation for locally advanced pancreatic carcinoma with concomitant obstructive jaundice.

METHODS

Between January 2016 and December 2018, 42 patients diagnosed with locally advanced pancreatic carcinoma with concomitant obstructive jaundice were enrolled retrospectively. All patients received biliary stenting via percutaneous transhepatic biliary drainage (PTBD) to alleviate obstructive jaundice. Thereafter, twenty-two patients underwent CT-guided iodine-125 seed implantation (treatment group), and 20 did not (control group). The prescribed dose in the treatment group was 110-130 Gy. The clinical data, duration of biliary stent patency, and overall survival (OS) were evaluated.

RESULTS

Overall, the total bilirubin level decreased from 275.89 ± 115.44 to 43.08 ± 43.35 μmol/L (p < 0.001) 1 month after percutaneous biliary stenting. In the treatment group, the postoperative median dose covering 90% of the target volume was 129.71 Gy. Compared with the control group, the treatment group had a long mean duration of biliary stent patency and median OS (11.42 vs. 8.57 months, p < 0.01; 11.67 vs. 9.40 months, p < 0.01, respectively). The overall positive response rates 6 months post-treatment in the treatment and control groups were 72.7% (16/22) and 30% (6/20), respectively. Adverse events of more than grade 3 were not observed during the follow-up.

CONCLUSION

Sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation is an effective and safe treatment alternative for locally advanced pancreatic carcinoma with concomitant obstructive jaundice, which is worthy of clinical application.

KEY POINTS

• Obstructive jaundice was alleviated after biliary stent placement in all patients, and the total bilirubin level decreased. • The overall positive response rates at 6 months post-treatment were higher in the treatment group than in the control group, and adverse events of more than grade 3 were not observed during the follow-up period. • Sequential therapy with percutaneous biliary stenting and CT-guided iodine-125 seed implantation can prolong biliary stent patency and improve survival.

CT-guided iodine-125 brachytherapy as salvage therapy for recurrent mediastinal lymph node metastasis

Background

The treatment of recurrent mediastinal lymph node metastasis (MLNMs) is challenging. We conducted this study to evaluate the effectiveness and safety of computed tomography (CT)‐guided percutaneous iodine‐125 brachytherapy for MLNMs.

Methods

We retrospectively analyzed 33 patients with recurrent MLNMs treated with CT‐guided interstitial implantation of iodine‐125 seeds. Regular contrast‐enhanced CT was conducted to evaluate the tumor response. Follow‐up survival, quality of life, and adverse events were analyzed.

Results

The number of implanted seeds was 16–85 (median, 40). The matched peripheral dose was 110–160 Gy. The patients were followed up for 5–24 months (median, 14 months). At the last follow‐up or death, complete response to therapy was achieved in 11 patients (33.3%) and partial response in 18 patients (54.5%). The median survival time of this cohort was 15.2 months (95% confidence interval [CI], 9.9–20.5 months); the estimated one‐ and two‐year survival rates were 68.6% and 31.1%, respectively. The Karnofsky performance score increased significantly after the procedure (p = 0.007). Pneumothorax with pulmonary compression of 30% to 40% occurred in five (15.2%) patients and was cured after drainage. No severe complications occurred.

Conclusions

CT‐guided iodine‐125 brachytherapy provided a safe and effective choice for recurrent mediastinal lymph node metastasis with significant local therapeutic effects and minor complications, especially for patients who were not eligible for surgical resection and had failed to benefit from systemic therapy.

Advances in stent therapy for malignant biliary obstruction

Malignant biliary obstruction (MBO), result of pancreatobiliary diseases is a challenging condition. Most patients with MBO are inoperable at the time of diagnosis, and the disease is poorly controlled using external-beam radiotherapy and chemotherapy. Biliary stent therapy emerged as a promising strategy for alleviating MBO and prolonging life. However, physicians find it difficult to determine the optimal type of biliary stent for the palliation of MBO. Here, we review the safety and efficacy of available biliary stents, used alone or in combination with brachytherapy, photodynamic therapy and advanced chemotherapeutics, in patients with pancreatobiliary malignancies and put forward countermeasures involving stent obstruction. Furthermore, 3D-printing stents and nanoparticle-loaded stents have broad application prospects for fabricating tailor-made biliary stents.

A novel combination of percutaneous stenting with iodine-125 seed implantation and chemotherapy for the treatment of pancreatic head cancer with obstructive jaundice

PURPOSE

Insertion of radioactive strips through the biliary stent has been reported to offer longer survival and patency than an uncovered conventional self-expanding metal stent in patients with unresectable malignant biliary obstruction. The aim of this study was to investigate the safety and effectiveness of intraluminal brachytherapy combined with ¹²⁵I seed implantation and transarterial infusion chemotherapy for the treatment of pancreatic head cancer with obstructive jaundice.

METHOD

From October 2012 to January 2018, 21 consecutive patients diagnosed with biliary obstruction caused by locally advanced, nonmetastatic pancreatic cancer with cytologically or histologically confirmed by biopsy were enrolled and receive treatment with intraluminal brachytherapy using ¹²⁵I seed strand and CT-guided percutaneous radioactive seed implantation therapy. The procedure-related and radiation complications were assessed. The outcomes were measured in terms of stent patency, patient survival, complications related to the procedure.

RESULT

One of the 22 patients (4.5%, 1/22) with pancreatic head cancer failed to perform the above procedure because the guidewire was unable to pass through the obstruction segment. The remaining 21 patients (95.5%, 21/22) with pancreatic head cancer with obstructive jaundice were successfully placed with biliary stents and radioactive strips through drainage tubes. The median number of ¹²⁵I seeds loaded was 15, ranging from 12 to 17. After the chemotherapy with gemcitabine and cisplatin, no adverse reaction of Grade Ⅲ ∼ Ⅳ occurred in all cases. Median stent patency was 12.50 months (95% CI: 10.26, 14.74). By May 2019, all 21 patients had died, with overall survival of 5.2-23.3 months, with a median survival of 13.20 months (95% CI: 10.96, 15.44).

CONCLUSION

Percutaneous ¹²⁵I seed implantation combined with insertion of radioactive strips through the biliary stent has the characteristics of less trauma, fewer complications, simple operation, and so on. These procedures bring remission of obstructive jaundice combined with the increased survival for the treatment of obstructive jaundice caused by unresectable pancreatic head cancer if follow-up chemotherapy is carried out. The long-term efficacy of this treatment combination needs to be confirmed by further multicenter, large sample size prospective randomized controlled studies.