125I brachytherapy of locally advanced non-small-cell lung cancer after one cycle of first-line chemotherapy: a comparison with best supportive care

Prognostic value of pretreatment FDG PET-CT for short-term efficacy of radioactive iodine-125 seed implantation in patients with NSCLC

PURPOSE

To analyze the short-term clinical response of radioactive iodine-125 seed implantation (I125-SI) in patients of non-small-cell lung cancer (NSCLC) and explore possible correlations of various metabolic parameters of pretreatment FDG PET-CT with the short-term efficacy of this treatment modality.

METHODS AND MATERIALS

The present study is a retrospective analysis of treatment records of 46 NSCLC patients who were treated with I125-SI for lung tumors in Tianjin First Central Hospital from January 2016 to December 2018. The correlation among parameters D90, gender, pathological pattern, age, maximum tumor diameter, Metabolic Tumor Volume (MTV), SUVmax, SUVpeak, SUVmean, Total Lesion Glycolysis (TLG), High metabolic tumor cell ratio (HMR) and Carcinoembryonic antigen(CEA)with short-term efficacy of I125-SI was analyzed by two independent-sample t-test, Mann-Whitney U test or Chi-squared test and binary logistic regression.

RESULTS

After uneventful completion of treatment, patients were followed up at regular intervals. At the first month followup, none of cases showed complete response (CR), while 4 cases showed partial response (PR). After 3 months, there were 2 cases of CR, and 25 cases of PR; after 6 months, there were 5 cases of CR, and 27 cases of PR. D90 (p= 0.028, OR:1.075, 95% CI:1.008-1.147), MTV (p= 0.026, OR: 0.918, 95% CI: 0.851-0.990), HMR (p= 0.020, OR: 0.003, 95% CI: 0-0.407) were independent predictors for the short-term efficacy. The predictive accuracy of MTV was medium (AUC = 0.781; cutoff value = 44.58). However, the predictive accuracies of D90 and HMR were low, with the values of AUC being 0.650 for both the parameters, and their cutoff values being 127.8 Gy and 0.27 respectively.

CONCLUSIONS

I125-SI is an effective therapy with few complications in NSCLC patients. Small MTV, high D90 and low HRM were found to be linked with better local control at 6 months postimplantation.

Targeting Cell Signaling Pathways in Lung Cancer by Bioactive Phytocompounds

Lung cancer is a heterogeneous group of malignancies with high incidence worldwide. It is the most frequently occurring cancer in men and the second most common in women. Due to its frequent diagnosis and variable response to treatment, lung cancer was reported as the top cause of cancer-related deaths worldwide in 2020. Many aberrant signaling cascades are implicated in the pathogenesis of lung cancer, including those involved in apoptosis (B cell lymphoma protein, Bcl-2-associated X protein, first apoptosis signal ligand), growth inhibition (tumor suppressor protein or gene and serine/threonine kinase 11), and growth promotion (epidermal growth factor receptor/proto-oncogenes/phosphatidylinositol-3 kinase). Accordingly, these pathways and their signaling molecules have become promising targets for chemopreventive and chemotherapeutic agents. Recent research provides compelling evidence for the use of plant-based compounds, known collectively as phytochemicals, as anticancer agents. This review discusses major contributing signaling pathways involved in the pathophysiology of lung cancer, as well as currently available treatments and prospective drug candidates. The anticancer potential of naturally occurring bioactive compounds in the context of lung cancer is also discussed, with critical analysis of their mechanistic actions presented by preclinical and clinical studies.

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.

Efficacy and Safety Aiming at the Combined-Modality Therapy of External Beam Radiotherapy (40Gy) and Iodine-125 Seed Implantation for Locally Advanced NSCLC in the Elderly

Purpose

To evaluate the efficacy and safety of combined-modality therapy for elderly patients with locally advanced non-small-cell lung cancer (NSCLC) invading the chest wall.

Patients and Methods

We retrospectively enrolled 21 elderly patients (aged ≥60 years) with locally advanced NSCLC invading the chest wall. For external beam radiotherapy (EBRT) of the primary tumor, 40Gy was applied and supplemented with iodine-125 seed implantation while 60Gy was applied to the lymph nodes of the mediastinum. Follow-up was conducted every 3 months postoperatively. The related analytic parameters were change in tumor size, the objective response rate (ORR), the disease control rate (DCR), the degree of pain relief, the improvement of physical status, and toxicity.

Results

The combined-modality therapy significantly inhibited local growth of the tumor (from 7.84±1.20 to 4.69±1.90 cm) (P <0.0001), with 71.4% ORR and 90.5% DCR at 1 year. The cancer-related pain was significantly relieved (P <0.05) and physical status was significantly improved (P <0.05). No procedure-associated death or grade > 2 irradiation-related adverse effects were reported in this study.

Conclusion

The combined-modality therapy of EBRT with 40Gy and permanent iodine-125 seed implantation is an efficacious and safe treatment option for elderly patients with locally advanced NSCLC invading the chest wall.

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.

Automatic needle detection using improved random sample consensus in CT image-guided lung interstitial brachytherapy

Purpose

To develop a method for automatically detecting needles from CT images, which can be used in image‐guided lung interstitial brachytherapy to assist needle placement assessment and dose distribution optimization.

Material and Methods

Based on the preview model parameters evaluation, local optimization combining local random sample consensus, and principal component analysis, the needle shaft was detected quickly, accurately, and robustly through the modified random sample consensus algorithm. By tracing intensities along the axis, the needle tip was determined. Furthermore, multineedles in a single slice were segmented at once using successive inliers deletion.

Results

The simulation data show that the segmentation efficiency is much higher than the original random sample consensus and yet maintains a stable submillimeter accuracy. Experiments with physical phantom demonstrate that the segmentation accuracy of described algorithm depends on the needle insertion depth into the CT image. Application to permanent lung brachytherapy image is also validated, where manual segmentation is the counterparts of the estimated needle shape.

Conclusions

From the results, the mean errors in determining needle orientation and endpoint are regulated within 2° and 1 mm, respectively. The average segmentation time is 0.238 s per needle.

125I Seed Brachytherapy Combined with Single-Agent Chemotherapy in the Treatment of Non-Small-Cell Lung Cancer in the Elderly: A Valuable Solution

Purpose

The aim of this study was to compare the effectiveness and safety of CT-guided ¹²⁵I seed brachytherapy combined with single-agent chemotherapy versus combined chemotherapy in the treatment of elderly NSCLC.

Materials and Methods

We retrospectively analyzed 110 patients (64 men and 46 women; mean age=71.25±7.14 years) who were diagnosed with NSCLC without distant metastases between January 2015 and May 2020. A total of 50 patients received ¹²⁵I brachytherapy combined with single-agent chemotherapy (group A), whereas 60 patients received combined chemotherapy (group B). The response to therapy and adverse effect were compared between groups. The local response rate was evaluated by CT. Progression-free survival (PFS) and overall survival (OS) data were obtained through clinical follow-up.

Results

All patients had been treated and were followed-up for 3-60 months. The median OS and PFS were 23.71±1.41 months (95% CI=20.95-26.47) vs 16.12±0.93 months (95% CI=14.31-17.93) (P<0.05) and 15.08±0.85 months (95% CI=13.42-16.74) vs 10.03±0.53 months (95% CI=9.01-11.06) (P<0.05) in group A and group B, respectively. The local response rate and clinical symptoms of patients in group A were significantly relieved when compared with group B. Severe complications were not observed in either group.

Conclusion

CT-guided ¹²⁵I seed brachytherapy combined with single-agent chemotherapy is an effective and safe therapy and shows promising results compared to combined chemotherapy alone for NSCLC in the elderly. A randomized study will be needed to assess the superiority of this combined modality treatment.

Efficacy and safety of CT-guided 125I brachytherapy in elderly patients with non-small cell lung cancer

Non-small cell lung cancer (NSCLC) has become the most common cancer type and the leading cause of cancer-associated mortality worldwide. The aim of the present retrospective study was to evaluate the efficacy and safety of computed tomography (CT)-guided ¹²⁵I brachytherapy alone in elderly patients with NSCLC. A total of 26 elderly patients with NSCLC stage I–III who had an inoperable lesion or progressive disease following radio-chemotherapy were treated with CT-guided ¹²⁵I seed implantation for lung lesions and included in the present study. The prescribed dose of ¹²⁵I brachytherapy was 80–140 Gy, and dosimetric verification was performed immediately after the procedure. The response rate (RR) and local control rate (LCR) were analyzed according to the Response Evaluation Criteria in Solid Tumors (version 1.1). Survival was estimated using the Kaplan-Meier method. Safety and complications were also documented. All patients were aged 65–85 years (median age, 77 years) and successfully completed the procedure, and the median follow-up time was 9.4 months (range, 3–31 months). After a 6-month follow-up, for pulmonary lesions, complete response (CR) was achieved in 11 (42.3%) cases, partial response in 9 (34.6%) cases, stable disease in 4 (15.4%) cases and progressive disease in 2 (7.7%) cases. The 6-month RR and LCR were 76.9 (20/26) and 92.3% (24/26), respectively. The mean overall survival (OS) time was 11.7±7.6 months and the 0.5- and 1-year OS rates were 90.1 and 73.3%, respectively. Tumor-related symptoms in patients were significantly alleviated following the procedure. No severe complications occurred during and after the procedure of ¹²⁵I seed implantation. In conclusion, CT-guided ¹²⁵I brachytherapy is a feasible, effective and safe therapy and may be considered as an alternative option to surgery and radiotherapy for elderly patients with NSCLC.

Chinese Expert Consensus Workshop Report: Guideline for permanent iodine-125 seed implantation of primary and metastatic lung tumors

Surgery remains the first choice of cure for early stage lung cancer. However, many patients are diagnosed at advanced stage, and thus miss the opportunity to undergo surgery. As such patients derive limited benefits from chemotherapy or radiotherapy, alternatives focusing on local control have emerged, including iodine-125 seed implantation. The Interstitial Brachytherapy Society, Committee of Minimally Invasive Therapy in Oncology, Chinese Anti-Cancer Association organized a group of multidisciplinary experts to develop guidelines for this treatment modality. These guidelines aim to standardize iodine-125 seed implantation procedures, inclusion criteria, and outcome assessment to prevent and manage procedure-related complications.

A Real-Time Tracking and Visualization System for Robot-Assisted Template Location Method Applied to Lung Cancer Brachytherapy

Accurate location of the puncture-guiding template, including the position and orientation, is essential for surgeons to implant radioactive seeds into an internal tumor in lung cancer brachytherapy. The objective of this paper is to establish a real-time tracking and visualization system (RTVS) to monitor the robot-assisted location process distantly and confirm the ultimate location accuracy without redundant computed tomography (CT) scans. RTVS consists of tracking and visualization components. A quaternion-based iterative closest point (QICP) algorithm for higher accuracy was proposed for the premised module of spatial registration. Arithmetic accuracy of QICP and clinical performance of RTVS were both validated by a series of experiments in a CT room. Spatial registration experiment shows that QICP consistently presents a distinctly higher degree of accuracy of 0.87±0.11 mm compared with other two conventional algorithms. RTVS, evaluated by tracking and visualization experiments, achieves a tracking accuracy of 1.05±0.05 mm position and (0.29±0.14) deg orientation. In addition, the time cost for template location is greatly reduced, so are the CT scan times. RTVS has the potential on lessening the workload of surgeons, reducing the CT radiation injury to the patient, and accelerating the progress of a brachytherapy surgery. The system presented means a new contribution to the lung cancer brachytherapy.

Efficacy and safety of iodine-125 brachytherapy combined with chemotherapy in the treatment of advanced NSCLC in the elderly

Background

Advanced non-small-cell lung cancer (NSCLC) is a huge challenge for physicians. Traditional chemoradiotherapy is associated with high rates of toxicities, especially when treating gerontal patients. Our study was focused on investigating the safety and efficacy of permanent iodine-125 seed implantation and chemotherapy for the treatment of advanced NSCLC in the elderly.

Methods

Fifty elderly patients with stage III or IV NSCLC at our hospital from January 2011 to June 2017 were treated with the chemotherapy regimens (paclitaxel/cisplatin) and computed tomography (CT)-guided iodine-125 brachytherapy (group A), 50 patients who received chemotherapy consisting of paclitaxel and cisplatin only (group B) were matched-up with the patients in group A. The local response rate was evaluated by CT. Progression-free survival (PFS) and overall survival (OS) data were obtained through clinical follow-up.

Results

The patients were followed-up for 3-46 months. With a median follow-up time of 20 months, the OS and PFS were 20 months (95% CI: 19.09-20.90 months) vs 15 months (95% CI: 14.48-15.51 months) (P<0.05) and 13 months (95% CI: 11.96-14.04 months) vs 8 months (95% CI: 7.63-8.37 months) (P<0.05) in group A and group B, respectively. The symptoms of patients in group A were significantly relieved when compared with group B. Severe complications were not observed in either of the groups.

Conclusion

The combination of iodine-125 seed brachytherapy and chemotherapy is an effective and safe therapy and is superior to chemotherapy alone for advanced NSCLC in the elderly.

DTI and pathological changes in a rabbit model of radiation injury to the spinal cord after 125I radioactive seed implantation

Excessive radiation exposure may lead to edema of the spinal cord and deterioration of the nervous system. Magnetic resonance imaging can be used to judge and assess the extent of edema and to evaluate pathological changes and thus may be used for the evaluation of spinal cord injuries caused by radiation therapy. Radioactive ¹²⁵I seeds to irradiate 90% of the spinal cord tissue at doses of 40–100 Gy (D90) were implanted in rabbits at T₁₀ to induce radiation injury, and we evaluated their safety for use in the spinal cord. Diffusion tensor imaging showed that with increased D90, the apparent diffusion coefficient and fractional anisotropy values were increased. Moreover, pathological damage of neurons and microvessels in the gray matter and white matter was aggravated. At 2 months after implantation, obvious pathological injury was visible in the spinal cords of each group. Magnetic resonance diffusion tensor imaging revealed the radiation injury to the spinal cord, and we quantified the degree of spinal cord injury through apparent diffusion coefficient and fractional anisotropy.

Age Is Not a Limiting Factor in Interventional Radiotherapy (Brachytherapy) for Patients with Localized Cancer

This review examines the role of interventional radiotherapy (IRT otherwise known as brachytherapy) in cancer treatment for elderly patients. Despite their advanced age and associated comorbidities, elderly patients should receive definitive cancer therapies, including surgery and radiotherapy (RT). In fact, RT becomes first-line option for patients who are not eligible for surgery (due to comorbidities, anticoagulant drugs, and risk of disfigurement) or those who refuse it. It emerged from this review of the literature as effective, simple, safe, and comfortable and was associated with good local control, low toxicity rates, and excellent cosmesis and provided a cost benefit. IRT may be used as sole treatment for small cancers or as a useful adjunct to surgery or external beam radiotherapy (EBRT) in more advanced (or lymph node positive) cases, especially when the aim is local control with adequate preservation of normal tissue function. As palliative treatment, IRT preserves quality of life and/or improves survival. It is to be hoped that this review will serve as a helpful guide for members of multidisciplinary teams that are involved in treating elderly patients with cancer.