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Iodine-125 seed implantation for synchronous pancreatic metastases from hepatocellular carcinoma: A case report and literature review

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Rationale The image-guided iodine-125 seed implantation has been widely used for a variety of tumors, including prostatic cancer, pulmonary cancer, hepatocellular carcinoma and pancreatic cancer. However, the clinical value of iodine-125 seed implantation for the treatment of pancreatic metastasis from hepatocellular carcinoma has not been reported. We presented the first case with ultrasound-guided iodine-125 seed implantation for this disease. Patient concerns We presented the case of a 48-year-old man patient with primary hepatocellular carcinoma and pancreatic metastasis who was managed with ultrasound-guided iodine-125 seeds implantation. Diagnoses She was diagnosed with synchronous pancreatic metastases from hepatocellular carcinoma. Interventions Puncture biopsy and ultrasound-guided iodine-125 seeds implantation. Outcomes The hepatic and pancreatic tumors were obviously reduced after 15 months. Moreover, the liver function test was mildly abnormal in glutamic-oxalacetic transaminase and glutamic-pyruvic transaminase. Lessons The image-guided iodine-125 seeds implantation was an important therapeutic approache to unresectable hepatocellular carcinoma with pancreatic metastasis. However, more related cases should be reported for further evaluating the value of the way.
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Iodine-125 seed implantation for synchronous
pancreatic metastases from hepatocellular
carcinoma
A case report and literature review
Junjie Xiong, MD
a
, Selina Kwong Chian, MBBS
b
, Jiao Li, BN
c
, Xubao Liu, MD PhD
a,
Abstract
Rationale: The image-guided iodine-125 seed implantation has been widely used for a variety of tumors, including prostatic
cancer, pulmonary cancer, hepatocellular carcinoma and pancreatic cancer. However, the clinical value of iodine-125 seed
implantation for the treatment of pancreatic metastasis from hepatocellular carcinoma has not been reported. We presented the rst
case with ultrasound-guided iodine-125 seed implantation for this disease.
Patient concerns: We presented the case of a 48-year-old man patient with primary hepatocellular carcinoma and pancreatic
metastasis who was managed with ultrasound-guided iodine-125 seeds implantation.
Diagnoses: She was diagnosed with synchronous pancreatic metastases from hepatocellular carcinoma.
Interventions: Puncture biopsy and ultrasound-guided iodine-125 seeds implantation.
Outcomes: The hepatic and pancreatic tumors were obviously reduced after 15 months. Moreover, the liver function test was
mildly abnormal in glutamic-oxalacetic transaminase and glutamic-pyruvic transaminase.
Lessons: The image-guided iodine-125 seeds implantation was an important therapeutic approache to unresectable hepatocellular
carcinoma with pancreatic metastasis. However, more related cases should be reported for further evaluating the value of the way.
Abbreviations: AFP =alpha-fetoprotein, ALB =albumin, ALT =glutamic-pyruvic transaminase, APTT =activated partial
thromboplastin time, AST =glutamic-oxalacetic transaminase, CA19-9 =carbohydrate antigen 19-9, CEA =carcinoembryonic
antigen, CT =computerized tomographic scanning, GGT =glutamyl transpeptidase, GPC3 =glypican 3, HbcAB =hepatitis B core
antibody, HbeAg =hepatitis B e antigen, HbsAg =hepatitis B surface antigen, HBV-DNA =hepatitis B virus deoxyribonucleic acid,
HCC =hepatocellular carcinoma, HCV =hepatitis C virus, HE =hematoxylin-eosin, HGB =hemoglobin, INR =International
Normalized Ratio, NEUT =neutrophil, PD =prescription dose, PLT =blood platelet, WBC =white blood cell, PT =prothrombin time,
PV =portal vein, RFA =radiofrequency ablation, SMA =superior mesenteric artery, SV =splenic vein, TACE =transcatheter arterial
chemoembolization.
Keywords: hepatocellular carcinoma, iodine-125, metastasis, pancreas
1. Introduction
Hepatocellular carcinoma (HCC) is one of the most common
malignant tumors in the world. Among primary liver cancers,
HCC is the major histological subtype and ranks fourth among
the organ-specic causes of cancer related deaths worldwide.
[1]
Extrahepatic metastases are commonly found during the
diagnosis of HCC. The most common sites of extrahepatic
metastatic HCC are the lungs, lymph nodes, bones, and adrenal
glands, respectively.
[2]
However, metastasis to the pancreas
occurs in only <1% of patients with HCC.
[3]
Currently, image-
guided iodine-125 seed implantation can achieve a necrotizing
dose of irradiation within the target volumes with a very sharp
falloff outside the implanted area, thus sparing the normal tissues
around the lesion. It has been widely used for a variety of tumors,
including prostatic cancer,
[4]
pulmonary cancer,
[5]
HCC,
[6]
and
pancreatic cancer.
[7]
However, the clinical value of iodine-125
seed implantation for the treatment of pancreatic metastasis of
HCC has not been reported. To the best of our knowledge, this is
the rst report of iodine-125 seed implantation as the treatment
of pancreatic metastasis from HCC. Using our experience, a
world literature review of all such cases was performed in order
to better recognize this rare pathology.
2. Case presentation
A 48-year-old man was admitted to West China Hospital of
Sichuan University as result of abdominal pain in the right upper
quadrant. He suffered from hypertension for 1 year and was
Editor: N/A.
Authorscontributions: XJ drafted the manuscript, and contributed to acquisition
of material; XJ and LJ collected material and patients information; LX revised the
manuscript and reviewed the literature; KCS revised the manuscript and modied
the language. All authors read and approved the nal manuscript.
The authors have no conicts of interest to disclose.
a
Department of Pancreatic Surgery,
b
West China School of Medicine,
c
Department of Emergency, West China Hospital, Sichuan University, Chengdu,
Sichuan Province, China.
Correspondence: Xubao Liu, Department of Pancreatic Surgery, West China
Hospital, Sichuan University, Guo Xue Rd 37, Chengdu, Sichuan, 610041, China
(e-mail: liuxb2011@126.com).
Copyright ©2017 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-
ND), where it is permissible to download and share the work provided it is
properly cited. The work cannot be changed in any way or used commercially
without permission from the journal.
Medicine (2017) 96:46(e8726)
Received: 8 October 2017 / Received in nal form: 20 October 2017 / Accepted:
23 October 2017
http://dx.doi.org/10.1097/MD.0000000000008726
Clinical Case Report Medicine®
OPEN
1
given oral medication. There was no remarkable family history.
On admission, the vital signs of the patients were within the
normal limits. On physical examination, the abdomen was soft,
but tender in the right upper quadrant. The blood examination
showed the following: hemoglobin (HGB) was 149 g/L (reference
range: 135175 g/L), blood platelet (PLT) was 134 10
9
/L
(reference range: 100300 10
9
/L), white blood cell (WBC)
was 4.99 10
9
/L (reference range: 3.59.5 10
9
/L), percentage
of neutrophil (NEUT) was 62.6% (reference range: 4075%).
The prothrombin time (PT) was 14.0 seconds (reference range:
9.612.8 seconds), activated partial thromboplastin time (APTT)
was 28.1 seconds (reference range: 2040 seconds), international
normalized ratio (INR) was 1.24 seconds (reference range: 0.86
1.14seconds). The patients liver function tests showed the
albumin (ALB) was 36.6 g/L (reference range: 4055 g/L), A/G
was 1.12 (reference range: 1.22.4), and glutamyl transpeptidase
(GGT) was 176 IU/L (reference range: <60IU/L). The hepatitis
serology was positive including hepatitis B surface antigen
(HbsAg), hepatitis B e antigen (HbeAg), and hepatitis B core
antibody (HbcAB). Hepatitis B virus deoxyribonucleic acid
(HBV-DNA) was 1.31E+05 copies/mL (reference range: <1.00E
+03 copies/mL). Tumor marker assays showed raised alpha-
fetoprotein (AFP) with 96.43 ng/mL (reference range: <8 ng/mL)
and carbohydrate antigen 199 (CA 199) with 34.54 IU/mL
(reference range: <22 IU/mL). However, carcinoembryonic
antigen (CEA) was 1.93 ng/mL (reference range: <5 ng/mL).
Furthermore, the abdominal enhanced computerized tomograph-
ic scanning (CT) scans found that there was a 4 3 cm mass in the
head of the pancreas (Fig. 1A). However, the imaging specialist
suspected the presence of a tumor in the left lobe of the cirrhosis
liver (Fig. 1B) which was conrmed by subsequent intraoperative
exploration. The chest x-ray scan was normal.
When all the preoperative examinations were completed, the
patient underwent exploratory laparotomy. We found a mass of
about 4 4 cm in the nodular cirrhosis liver, which was located in
segment IV, and a mass of about 4 3 cm in the pancreatic head.
The pancreatic neoplasm had broken through the capsule of the
pancreas, and invaded the superior mesenteric artery (SMA),
portal vein (PV), and splenic vein (SV). However, the main
pancreatic duct had no dilatation, and the duodenum had neither
invasion nor stricture. Therefore, primary pancreatic cancer with
hepatic metastasis was suspected. We conducted the puncture,
with 18-gauge needles, for hepatic and pancreatic masses under
ultrasonic guidance for frozen section. After that, considering the
liver cirrhosis and the patients condition, ultrasound-guided
iodine-125 seeds were implanted into the hepatic and pancreatic
tumors. The ethics committee of West China hospital approved
this study and the patient signed the informed consent form.
The iodine-125 seeds were provided by the Beijing ZHIBO
BioMedical Technology Company, China. Each particle was 0.8
mm in diameter and 4.5mm in length, with a radioactivity of 0.6
to 0.8 mCi, radioactive half-life of 60.2 days, and radiation
energy of 28 keV. Pre-procedural planning was conducted.
Tumor volume was measured during laparotomy by intra-
operative ultrasonography. The procedure for iodine-125 seed
implantation was carried out under the guidance of ultrasound.
18-gauge needles were inserted into the tumor mass at intervals of
1.0 cm in a parallel array, extending at least 0.5 to 1.0cm beyond
Figure 1. CT scan suggested a heterogeneous enhanced mass in the pancreatic head (A: white arrow) and an unobvious mass in the left of the liver (B: white
arrow). C T =computerized tomographic scanning.
Figure 2. Hematoxylin and eosin stains showed poorly differentiated malignant cells in the hepatic (A) and pancreatic masses (B) (400).
Xiong et al. Medicine (2017) 96:46 Medicine
2
the margins of pancreatic lesions. Penetration of the pancreatic
duct, small blood vessels, and adjacent transverse colon was
avoided. After the needles were placed, iodine-125 seeds were
implanted using a Mick applicator and the spacing was
maintained at 1.0 cm intervals. The prescription dose (PD) was
set to 140 Gy.
The postoperative hematoxylin-eosin (HE) staining suggested
that the hepatic tumor was poorly differentiated HCC, and
the pancreatic tumor was a metastasis of the HCC (Fig. 2). The
above diagnosis was further supported by immunohistochemical
staining. The immunocytochemical panel consisted of HepPar1,
glypican 3 (GPC3), AFP, CK8, CK18, CK7, and CK19. Of these,
the hepatic neoplastic cells were strongly and diffusely positive
for HepPar1, GPC3, CK8, and CK18 (Fig. 3). All other
immunocytochemical stains were negative. In comparison, the
GPC3, CK8, CK18, and CK19 were positive in the pancreatic
neoplastic cells. The nal diagnosis was pancreatic metastatic
tumor from HCC. The patients immediate postoperative course
was uneventful. A medical oncologist did not recommend
adjuvant systemic chemotherapy. After the operation, the patient
was followed up with routine CT scans performed every 3
months. Based on this, 15 months after the initial operation of the
patient, the CT examination suggested that the tumor size of the
hepatic and pancreatic tumors were obviously reduced (Fig. 4).
Moreover, the liver function test was mildly abnormal except for
only a slight elevation in glutamic-oxalacetic transaminase (AST,
65IU/L) and glutamic-pyruvic transaminase (ALT, 60 IU/L).
3. Discussion
HCC is one of the most common and fatal cancers in the world.
[1]
It is a disease that is much more common in the Eastern world. In
China, most of the patients have underlying cirrhosis associated
with HBV or hepatitis C virus (HCV) viral hepatitis. Currently,
the symptoms of metastases conned to the pancreas at the time
of diagnosis are diagnostically unspecic, and imaging also rarely
Figure 3. Immunohistochemical stains showing positive staining of the tumor cells for HepPar1 (A), GPC3 (B), and CK8 (C) (400).
Figure 4. CT images at 15 months after I-125 seed implantation suggested that the tumors were largely reduced (A: hepatic tumor [white arrow], B: pancreatic
tumor [white arrow]). CT =computerized tomographic scanning
Table 1
Literature review for pancreatic metastasis from HCC.
Author Year Country Tumor location Diagnostic method Therapy Survival
Lowe 1997 USA Pancreatic head FNA Palliative surgery (Roux-en-y
cholecystojejunostomy, gastrojejunostomy)
Unknown
Texler 1998 Australia Pancreatic tail Postoperative pathological
examination
Surgical excision (hepatectomy,
distal pancreatectomy, splenectomy)
More than 16 months
Sugai 1999 Japan Pancreatic tail FNA TACE (HCC) and PEI (pancreatic metastasis) Unknown
Thirabanjasak 2009 Thailand Pancreatic body FNA Chemotherapy More than 9 months
FNA =ne needle aspiration, HCC=hepatocellular carcinoma, PEI =percutaneous ethanol injection, TACE=transcatheter arterial chemoembolizatio n.
Xiong et al. Medicine (2017) 96:46 www.md-journal.com
3
shows abnormalities seen only in primary neoplasms. In our
patient, the metastatic pancreatic tumor originating from the
HCC was a solitary tumor located in the pancreatic head.
However, the primary HCC was not clearly seen in the
preoperative CT. Therefore, pancreatic non-functioning neuro-
endocrine tumors with liver metastasis were also suspected.
Finally, the laparotomy was performed.
Although remote metastasis of HCC accounts for two-thirds of
cases, metastatic HCC to the pancreas is distinctly rare. Only 4
studies
[811]
have reported synchronous pancreatic metastases
from the HCC as a literature review (Table 1). However, only this
case was treated with iodine-125 seed implantation. Previously,
HCC had been conrmed to be a radiosensitive tumor. With the
development of new radiotherapy technology and facilities, the
iodine-125 seed implantation therapy has provoked more interest
throughout the world. The iodine-125 seed implantation is an
ideal technique that combines the ability to target tumor cells
under direct visualization and spare uninvolved liver parenchyma
due to the sharp dose falloff outside of the implanted volume.
Moreover, because of the livers natural regenerative capabilities,
a high dose of radiation can be delivered to restricted volumes by
brachytherapy. With the property of local conformal radiother-
apy, normal liver is spared. Hence, a potentially tumoricidal dose
of radiation can be administered with acceptable complications.
In 2009, Lv et al
[12]
reported that for patients with unresectable
HCC, 48 patients who had failed transcatheter arterial chemo-
embolization (TACE) underwent iodine-125 seed implantation.
The patientssurvival rates at 1, 2, and 3 years were 75%, 45.8%,
and 27.1%, respectively, with a median survival time of 15.5
months. The complications were acceptable and could be
managed with conservative treatment. One randomized con-
trolled trial study
[6]
suggested that iodine-125 seed implantation
plus radiofrequency ablation (RFA) could obtain better local and
intrahepatic tumor control as well as better long-term survival
compared with treatment with RFA alone. Furthermore, for
advanced tumors, Zhang et al
[13]
showed that CT-guided iodine-
125 implantation may be a safe and effective treatment option for
HCC patients with multiple pulmonary metastases. Their results
suggested that the rate of complete response and partial response
were 14.8% and 55.56%, respectively. The survival rates at 1
and 2 years were 67.0% and 30.8%, respectively, with a median
survival of 13.5 months. However, to our knowledge, this is the
rst case of pancreatic metastases of HCC treated with ultrasonic
guidance iodine-125 seed implantation. At 15 months follow-up,
the tumor size of the hepatic and pancreatic metastasis was
largely reduced. No complications occurred except for mild
abnormal liver function. The iodine-125 seed implantation has
some advantages, such as high-dosage in targeted organs,
minimal damage to normal tissue, and avoidance of organ
motion. It is a minimally invasive and accurate treatment method.
Therefore, image-guided iodine-125 seed implantation may be
a safe and effective treatment option for HCC patients with
pancreatic metastases.
In conclusion, this is the rst report with iodine-125 seed
implantation for the treatment of pancreatic metastasis from
HCC. Although there is presently no consensus on the optimal
treatment strategy for this rare disease, image-guided iodine-125
seed implantation has been regarded as an important therapeutic
approach to unresectable HCC or pancreatic tumor. For this
patient, ultrasound-guided iodine-125 implantation provided an
appropriate strategy for the patient with unresectable HCC
accompanied with pancreatic metastasis, and can be considered
by other hepatopancreatobiliary teams.
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Xiong et al. Medicine (2017) 96:46 Medicine
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... Meanwhile, the normal tissues around the tumor may be exposed to a sharp drop in the amount of radiation due to the low radioactive activity of particles, thus reducing the damage to the surrounding small intestine, blood vessels, and other pipelines. This low-dose, long-lasting radioactive source is more likely to damage tumor cells and inhibit tumor growth (34). Patients with pancreatic cancer often have intractable acute pain in the lower back or abdomen caused by tumor compression or invasion of the abdominal plexus, which can be prevented through the application of radioactive particles treatment, thus playing a better analgesic effect. ...
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Radioactive seed implantation, especially 125I seeds implantation, which has provided an effective method for treatment of hepatocellular carcimoma (HCC), is attracting more and more attention all over the world, but its dosimetry need standardizing. Therefore, it is necessary to perform the prospective study on the dosimetry of 125I radioactive seed implantation and seek for the best dosage and seed activity in order to enhance the therapeutic efficacy of 125I seeds implantation in HCC treatment and protect the normal tissues surrounding the tumors.
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Hepatocellular carcinoma (HCC) spreading to the pancreas is rare and, when it does occur, is most often detected as a late finding at autopsy. We report the first case of HCC initially presenting as a pancreatic mass. Computed tomography (CT) scan showed a 7-cm mass in the dome of the liver and a 3-cm pancreatic head mass causing biliary and duodenal obstruction. Palliative surgery was performed to bypass the pancreatic obstruction. During the operation, fine needle aspiration (FNA) was performed on the pancreatic mass. The liver mass was sampled by percutaneous ultrasound-guided biopsy. Postoperatively, the patient's obstructive symptoms were relieved. The histologic studies showed that both the liver and the pancreatic masses consisted of poorly differentiated HCC that stained positive for α-fetoprotein. The rarity and the implications of this presentation are discussed.
Article
Cancer constitutes an enormous burden on society in more and less economically developed countries alike. The occurrence of cancer is increasing because of the growth and aging of the population, as well as an increasing prevalence of established risk factors such as smoking, overweight, physical inactivity, and changing reproductive patterns associated with urbanization and economic development. Based on GLOBOCAN estimates, about 14.1 million new cancer cases and 8.2 million deaths occurred in 2012 worldwide. Over the years, the burden has shifted to less developed countries, which currently account for about 57% of cases and 65% of cancer deaths worldwide. Lung cancer is the leading cause of cancer death among males in both more and less developed countries, and has surpassed breast cancer as the leading cause of cancer death among females in more developed countries; breast cancer remains the leading cause of cancer death among females in less developed countries. Other leading causes of cancer death in more developed countries include colorectal cancer among males and females and prostate cancer among males. In less developed countries, liver and stomach cancer among males and cervical cancer among females are also leading causes of cancer death. Although incidence rates for all cancers combined are nearly twice as high in more developed than in less developed countries in both males and females, mortality rates are only 8% to 15% higher in more developed countries. This disparity reflects regional differences in the mix of cancers, which is affected by risk factors and detection practices, and/or the availability of treatment. Risk factors associated with the leading causes of cancer death include tobacco use (lung, colorectal, stomach, and liver cancer), overweight/obesity and physical inactivity (breast and colorectal cancer), and infection (liver, stomach, and cervical cancer). A substantial portion of cancer cases and deaths could be prevented by broadly applying effective prevention measures, such as tobacco control, vaccination, and the use of early detection tests. CA Cancer J Clin 2015;65: 87-108. (c) 2015 American Cancer Society.
Article
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.
Article
To investigate the clinical value of computed tomography (CT)-guided radioactive (125)I seed implantation for the treatment of multiple pulmonary metastases of hepatocellular carcinoma (HCC). From March 2007 to August 2010, 27 HCC patients with pulmonary metastases who had received computed tomography (CT)-guided radioactive (125)I seed implantation were enrolled in the study. All patients had ≥2 metastatic lesions (mean diameter 2 ± 0.6 cm). Under CT-guidance, (125)I seeds were implanted into the pulmonary metastases using the plane implantation technique. Among 27 cases, complete response, partial response, stable disease, and progressive disease were observed in four, 15, six, and two cases, respectively, during 6-48 months (mean 20.1 ± 2.2 months) of follow-up CT. The response rate was 92.6%. The mean follow-up time after (125)I implantation was 20.1 months (range 6-48 months). The survival rates at 1 and 2 years were 67% and 30.8%, respectively, with a median survival of 13.5 months. Side effects during the procedure included minor pulmonary effusions and pneumothorax. Pulmonary haemorrhage was observed in 18 cases and haemoptysis occurred in five patients. Radial shadows were observed in three cases on follow-up CT images, and seed migration in two cases on follow-up spiral CT images. CT-guided radioactive (125)I seed implantation may be a safe and effective treatment option for HCC patients with multiple pulmonary metastases.
Article
Objective To report the outcomes of >1000 men with low-risk prostate cancer treated with low-dose-rate (LDR) brachytherapy at three large UK cancer centres. Patients and MethodsA total of 1038 patients with low-risk prostate cancer (prostate-specific antigen [PSA] ≤10 ng/mL, Gleason score 6, ≤T2b disease) were treated with LDR iodine 125 (I-125) brachytherapy between 2002 and 2007.Patients were treated at three UK centres.PSA and clinical follow-up was performed at each centre.Biochemical recurrence-free survival was reported for the cohort. ResultsThe median (range) PSA follow-up for the whole group was 5 years (4 months to 9 years).A total of 79 patients had biochemical failure, defined by a rise in PSA level: 16 patients fulfilled the ASTRO definition of biochemical failure, 25 patients fulfilled the Phoenix definition and 38 patients fulfilled both definitions.The 5-year biochemical relapse-free survival (bRFS) rate was 94.1% by the ASTRO definition and 94.2% by the Phoenix definition.The absence of neoadjuvant hormone therapy was predictive of inferior biochemical control as defined by the Phoenix definition (P = 0.033). Conclusions Our prospective multicentre series showed excellent bRFS with LDR I-125 brachytherapy for patients with low-risk prostate cancer.Further work is necessary to define the role of neoadjuvant androgen deprivation therapy in combination with brachytherapy.
Article
The aim of this study was to assess the technical feasibility, efficacy, and complications of CT-guided interstitial brachytherapy for treating inoperable non-small cell lung cancer (NSCLC). Twenty one patients were included in this prospective study. The median age was 72.6 years (57-85). Tumors were treated with brachytherapy that was positioned under CT-fluoroscopy. The treatment planning system (TPS) was used preoperatively to reconstruct three dimensional images of the tumor and to calculate the estimated seed number and distribution. The median matched peripheral dose (MPD) was 130 Gy (range, 100-160 Gy). All procedures were performed under local anesthesia. A follow-up CT was performed 6 weeks later and every 3 months post implantation. Follow-up period was 2-30 months. The mean diameter of the 21 lung tumors was 4.6 cm (range, 2.8-6.5 cm). The response rate of pain relief was 83.3% (10/12). The pain-free duration was 0-12 months (median: 6 months; 95% CI: 3-9 months). Overall responding rate (CR+PR) for this group of patients was 71.4%. Local tumor control rate was 85.7%. Six (28.6%) patients died as a result of primary tumor progression; thirteen (61.9%) patients died of multi-organ failure or other metastases. Two (9.5%) patients survived to follow-up. At the time of analysis, the median survival time for all patients was 10 months (95% CI: 6.6-13.4 months), with 1 year and 2 year survival rates were 42.4% and 6.5%, respectively. Median survival time for stage II, stage III, and stage IV was 20 months, 9 months, and 8 months, respectively. No major complications were observed. Minor complications (19%) included mild pneumothorax (n=1), hemosputum (n=1), pleural effusion (n=1), and localized skin erythema (n=1). None of these complications required further treatment, although hospital discharge was delayed. No (125)I seeds migrated to other tissues or organs. Minimally invasive CT-guided interstitial brachytherapy is safe, useful, less complicated and considered as a palliative treatment option for inoperable non-small cell lung cancer.
Article
Despite significant advances in the treatment of intrahepatic lesions, the prognosis for patients with hepatocellular carcinoma (HCC) who have extrahepatic metastasis remains poor. The objective of this study was to further elucidate the clinical course and prognostic determinants of patients with this disease. In total, 342 patients who had HCC with extrahepatic metastasis were enrolled. The metastases were diagnosed at initial presentation with HCC in 28 patients and during follow-up in the remaining patients. The authors analyzed clinical features, prognoses, and treatments and established a scoring system to predict prognosis using a split-sample method with a testing set and a training set. The most frequent site of extrahepatic metastasis was the lung followed by lymph nodes, bone, and adrenal glands. These metastases were related directly to death in only 23 patients (7.6%). The median survival after diagnosis of extrahepatic metastasis was 8.1 months (range, 0.03-108.7 months). In univariate analysis of the training set (n = 171), performance status, Child-Pugh classification, the number and size of intrahepatic lesions, macroscopic vascular invasion, symptomatic extrahepatic metastases, α-fetoprotein levels, and complete responses to treatment were associated significantly with prognosis. On the basis of multivariate analysis, a scoring system was developed to predict prognosis that assessed uncontrollable intrahepatic lesions, extent of vascular invasion, and performance status. This scoring system was validated in the testing set (n = 171) and produced a concordance index of 0.73. The controllability of intrahepatic lesions and performance status were identified as important prognostic factors in patients with advanced HCC who had extrahepatic metastasis.