Dosimetric comparison of CT-guided iodine-125 seed stereotactic brachytherapy and stereotactic body radiation therapy in the treatment of NSCLC

CT-guided palladium-103 seed brachytherapy for metastatic adenoid cystic carcinoma: a retrospective study to assess initial safety and effectiveness of percutaneous CT fluoroscopy-guided permanent seed brachytherapy

Purpose

Multiple pulmonary metastases present treatment difficulties in available treatment techniques, which are inconvenient or may damage sufficient pulmonary tissue to cause pulmonary crippling. This retrospective study of a single-community practice evaluated responses to computed tomography (CT)-guided ¹⁰³Pd permanent seed brachytherapy (CTGPSB) in adenoid cystic carcinoma (ACC) synchronous pulmonary metastases. The purpose of the current study was to document that metastatic pulmonary ACC lesions can be controlled with CTGPSB.

Material and methods

Twenty-nine discrete lesions in 14 patients were evaluated with serial CT scans. All were treated with CTGPSB. Lesions were tracked over serial CT scans and volumes measured. Primary endpoint was a reduction in tumor volume on subsequent CT scan. Secondary endpoint was occurrence of CTCAE grades 2-5.

Results

There was a 100% measured reduction in tumor volume (n = 29) at follow-up. Follow-up was a mean of 3.13 years. Baseline tumor volume was a mean of 1.85 ml (range, 0.69-9.15 ml). There were two grade 1 and one grade 2 adverse events, which did not require hospitalization.

Conclusions

CTGPSB for the treatment of multiple ACC pulmonary metastases is effective, with minimal acute complications, as shown in small cohort of subjects of the present study. Further studies evaluating specific dosimetry parameters in this free-hand technique are needed to specify minimal and maximal dose constraints.

Combined effects of low-dose gambogic acid and NaI131 in drug-resistant non-small cell lung cancer cells

Radioactive seed brachytherapy is a method for treating drug-resistant, late-stage non-small cell lung cancer (NSCLC). To elucidate the mechanism of low-dose gambogic acid (GA) and NaI¹³¹ in drug-resistant NSCLC cells, the human NSCLC A549 cell line and the drug-resistant A549/cisplatin (DDP) and A549/Taxol cell lines were treated with NaI¹³¹, low-dose GA or a combination of both in the present study; the control group of each cell line was treated with phosphate-buffered saline (PBS). Following treatment, cell proliferation, apoptosis and cell cycle analysis was performed. Apoptosis-related proteins, namely CDK1, cyclin B, mutant p53 (mtp53), heat shock protein 90 (HSP90), Bax and Bcl-2, and P-glycoprotein 1 (P-gp), which is known to confer resistance to chemotherapy, were detected using western blotting and immunofluorescence analysis. mRNA levels of p53 and HSP90 were measured using reverse transcription-quantitative PCR. Compared with the PBS control group, the A549, A549/DDP and A549/Taxol cells treated with NaI¹³¹, GA or a combination of the drugs exhibited G₂/M arrest and increased percentages of total apoptotic cells, as well as significantly decreased protein levels of CDK1, cyclin B, mtp53, HSP90, Bcl-2 and P-gp, increased protein levels of Bax and decreased mRNA levels of p53 and HSP90. The changes in the combination group were the most evident and were significantly different from the other groups (P<0.001). In conclusion, low-dose GA may be a potential radionuclide sensitizer.

Combination of Brachytherapy with Iodine-125 Seeds and Systemic Chemotherapy versus Systemic Chemotherapy Alone for Synchronous Extracranial Oligometastatic Non-Small Cell Lung Cancer

Background

A proportion of patients with synchronous oligometastatic non-small cell lung cancer (NSCLC) have poor survival, and currently no standard treatment is available, which poses a great challenge to physicians. This study aimed to assess and compare the efficacy and safety of the combination of brachytherapy with iodine-125 seeds and systemic chemotherapy versus systemic chemotherapy alone for synchronous extracranial oligometastatic NSCLC.

Materials and Methods

After a systematic retrospective review of the case database between 1st Mar 2014 and 30th Mar 2018, data were obtained on 69 NSCLC patients with extracranial oligometastatic NSCLC. Among them, 32 patients received brachytherapy with iodine-125 seeds combined with systemic chemotherapy (group A), and the remaining 37 patients received chemotherapy alone (group B). The primary endpoint was overall survival (OS), and the secondary endpoints included progression-free survival (PFS), objective response rate (ORR), and complications.

Results

The demographic and clinical characteristics were not significantly different between the groups (all p>0.05). The overall 3-month ORR was significantly higher in group A (65.6% vs 37.8%, p=0.030) than in group B. With a median follow-up time of 23 months, the PFS and OS were 11.6 (95% CI: 7.0–16.2) months vs 6.3 (95% CI: 3.4–9.2) months (p=0.036) and 17.6 (95% CI: 13.9–21.3) months vs 11.2 (95% CI: 7.7–14.7) months (p=0.042) in groups A and B, respectively. Furthermore, in Cox regression analysis, local brachytherapy was an independent prognostic factor for both PFS (HR=0.416, 95% CI: 0.246–0.702, p=0.001) and OS (HR=0.375, 95% CI: 0.216–0.653, p=0.001). Severe complications were not observed in either of the groups.

Conclusion

The combination of brachytherapy with iodine-125 seeds and systemic chemotherapy is superior to chemotherapy alone for synchronous extracranial oligometastatic NSCLC.

Iodine-125 seed implantation treatment of lung metastases < 2.5 cm using 5-ml syringe as a guide

PURPOSE

Small lung metastases change their location with respiration, making difficult to localize, therefore, increasing the number of punctures. Accurate puncture can reduce trauma to lung tissue and accelerate patient's recovery. The aim of the study was to present our experience with the technique of using local anesthesia 5-ml syringe as a guide for computerized tomography-guided iodine-125 seed implantation (CT-ISI).

MATERIAL AND METHODS

This was a retrospective study, including patients with small metastatic tumors in the lung, treated with CT-ISI between December 2013 and March 2018 at the Affiliated Hospital of the University. The patients were divided according to whether a 5-ml syringe was used as a guide during CT-ISI or not. The final follow-up was on March 31st, 2018. Implantation success and complications were examined.

RESULTS

Nineteen patients were included. A total of 840 seeds were used, with 44.2 ±33.6 (range, 10-160) seeds per patient. The mean D90 for CT-ISI was 134.5 ±7.5 Gy. Treatment intervention for eleven patients was performed using a 5-ml syringe as a guide during CT-ISI. There were no differences in total dose and number of implanted seeds between the two groups, but the number of punctures per lesion was lower in the syringe group than in the no-syringe group (1.9 ±0.5 vs. 2.9 ±0.6, p < 0.001), suggesting a higher puncture accuracy. The total number of SMTIL was 50 (median, 2; range, 1-10), and the median size was 1.9 cm (range, 0.8-2.4 cm). All SMTIL were well-controlled at 6-months follow-up (response rate [RR] = 100%). One patient in the no-syringe group experienced grade 2 chest tightness, chest pain, intraoperative needle tract bleeding, and post-operative blood in sputum.

CONCLUSIONS

Puncture with a 5-ml syringe as a guide during CT-ISI seems to be a more accurate option for patients with small (< 2.5 cm) lung metastasis.

A novel approach for salvage treatment of non-small-cell lung cancer: percutaneous CT fluoroscopy-guided permanent seed brachytherapy for salvage treatment of lung cancer: long-term results of a case series

Purpose

We sought a curative technique to treat recurrent or primary non-small cell lung cancer (NSCLC) with a minimally invasive outpatient technique that could be repeated multiple times, had minimal pulmonary toxicity, and was readily available in the community setting. Percutaneous outpatient computed tomography (CT) fluoroscopy-guided permanent seed brachytherapy fits these criteria.

Material and methods

Eight lesions in five patients (three patients had two lesions each) with NSCLC were treated using outpatient percutaneous CT fluoroscopy-guided palladium-103 seed brachytherapy. At initial presentation, seven lesions had recurred following external beam radiation therapy (EBRT) and initial chemotherapy, and one lesion was treated with brachytherapy as a primary treatment.

Results

In five patients with eight lesions, there were no recurrences at follow-up from final implant, average follow-up of 58.1 months (range, 15-145 months). There were no acute complications requiring intervention and no long-term complications. One lesion required a second salvage implant 10 months after first implant. This lesion’s original salvage D₉₀ was but 90% and repeat implant achieved a D₉₀ of 273%. This salvaged site had not recurred at 43-month follow-up after the second salvage implant.

Conclusions

Percutaneous CT fluoroscopy-guided permanent seed brachytherapy is a safe, efficacious, and cost effective primary and salvage treatment for lung cancer. CT-fluoroscopy resources are readily available in the community and are an effective alternative to stereotactic body radiation therapy (SBRT), intensity-modulated radiation therapy (IMRT)/proton beam, radiofrequency ablation (RFA), and cryoablation (CA). Percutaneous CT fluoroscopy-guided permanent seed brachytherapy has an equivalent or better local control rate, a lower resource cost, and a far lower integral radiation dose than other therapies. We believe this is the first published article documenting the curative potential of percutaneous CT fluoroscopy-guided permanent seed brachytherapy for recurrent NSCLC with long-term follow-up. High D₉₀ doses appear to be required to achieve complete response. Further studies are essential to confirm these findings.

How many times 125I seed implantation brachytherapy can be repeated for pulmonary metastases: clinical efficacy and complications

Purpose

The aim of the study was to determine how many times iodine-125 (¹²⁵I) seed brachytherapy (ISB) for recurrent pulmonary metastases (RPM) can be done, and the clinical efficacy and complications of repeated ISB in RPM treatment.

Material and methods

Between September 2013 and August 2018, 18 patients with RPM, after conventional chemotherapy, radiotherapy, and trans-arterial chemoembolization, received CT-guided repeated ISB. Patients were followed up, and local control, survival, and post-operative complications were analyzed retrospectively. The Kaplan-Meier method was used for survival analyses.

Results

Eighty-two metastases in 18 patients were treated with ISB, with 71 implantations (mean number of implantations per patient, 4; range, 3-8). The total number of implanted ¹²⁵I seeds was 1,220 (mean number per patient, 68; minimum, 40; maximum, 110). The mean value of D₉₀ for ISB was 138 Gy. Local control was 91.46%, 90.24%, and 89.02% at 1, 3, and 6 months after ISB, respectively. After repeated ISB, good local control was achieved, and all patients were discharged from hospital within 3 days. One month after, six metastases of large diameter were treated with ISB; computed tomography revealed level 1 radioactive injury to the lungs, but special treatment was not administered. Post-operative renal, hepatic, and vascular functions were normal.

Conclusions

ISB for RPM is safe and efficacious. RPM treatment seems not to be limited by number of times ISB could be repeated; at least up to 8 times for different sites of lung.

Subdermal injection of hyaluronic acid to decrease skin toxicity from radiation delivered with low-dose-rate brachytherapy for cancer patients

Purpose

To study the feasibility of hyaluronic acid (HA) injection to increase the distance between skin and radioactive sources, and dose reduction of skin during low-dose-rate (LDR) brachytherapy.

Material and methods: A total of 11 patients with subdermal malignant tumors were enrolled in this study. HA was injected after I-125 seed implantation, and dosimetric parameters were calculated by a brachytherapy treatment planning system (BTPS). The distance of the new space between radioactive sources and skin was measured on computed tomography (CT) and magnetic resonance imaging (MRI). Clinical signs were observed and followed up for every patient.

Results

After HA injection, the average of newly generated maximum distance was 1.0 cm along the entire length of the tumor. The D₉₀ and V₁₀₀ did not significantly change for tumors before or after injection (p = 0.39, p = 0.50, respectively). The maximum dose to a relatively small volume (0.1 cc) of the skin (OAR-Max) decreased from 100.66 Gy to 61.20 Gy (p < 0.05), and the mean skin dose (OAR-Mean) decreased from 49.20 Gy to 17.27 Gy (p < 0.05) after injection. On follow-up CT and MRI, HA was quite stable in shape and position for nearly 6 months.

Conclusions

Our study results showed that an additional 1.0 cm distance between the radioactive source and skin could be induced by HA injection in patients with subdermal tumor, and this distance could significantly decrease the skin dose in LDR brachytherapy. In addition, no obvious toxicity and side effects were produced by HA injection. Therefore, hyaluronic acid injection is a safe and effective technique.