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CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 2  |  Page : 397-400

125I brachytherapy seeds implantation for an inoperable large retroperitoneal leiomyosarcoma


Department of Oncology, The Hebei General Hospital, Shijiazhuang, Hebei Province, China

Date of Submission30-Jan-2018
Date of Decision11-Jul-2018
Date of Acceptance19-Nov-2018
Date of Web Publication28-May-2020

Correspondence Address:
Hongtao Zhang
No. 348, Peace West Road, Xinhua District, Shijiazhuang, Hebei Province
China
Juan Wang
No. 348, Peace West Road, Xinhua District, Shijiazhuang, Hebei Province
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_66_18

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 > Abstract 


Retroperitoneal leiomyosarcoma is relatively uncommon. Leiomyosarcoma has accounted for about 5%-10% of soft-tissue sarcoma, and 1/2–2/3 of the primary lesions were retroperitoneal, with a cumulative 5-year survival rate of only 35%.Leiomyosarcoma is one kind of soft-tissue sarcoma with the lowest survival rates due to the invasive growth, difficult treatment, and poor prognosis.The present study reported a case of a 78-year-old male diagnosed as left retroperitoneal leiomyosarcoma, who had received three operations. Computed tomography (CT) demonstrated a mass of approximately 12.9 cm × 6.9 cm × 6.6 cm in his retroperitoneal region. The Eastern cooperative oncology group and numerical rating scale scores of pain were 1 and 5, respectively. Multiple treatment strategies were administered, including the application of drainage and125I seed implantation. A total of 90125I seeds were implanted into the tumor through repetitious operations, with 30 seeds each time. Treatment planning system was involved to calculate the source distribution.125I seeds with the activity of 0.5 mCi were implanted under the guidance of CT, and dosimetric verification was performed after the operation. D90 (90% minimum prescription dose received by target volume) was 40 Gy. Follow-up was performed after 6 months, and complete response was achieved in the local lesions. However, there was no evidence-based treatment currently and the majority of our knowledge was based on results from case reports, thus further studies would be required.

Keywords: 125 I seed, brachytherapy, inoperable, retroperitoneal leiomyosarcoma


How to cite this article:
Di X, Liang Y, Yu H, Zhao J, Wang Z, Zhao J, Sui A, Zhang H, Wang J. 125I brachytherapy seeds implantation for an inoperable large retroperitoneal leiomyosarcoma. J Can Res Ther 2020;16:397-400

How to cite this URL:
Di X, Liang Y, Yu H, Zhao J, Wang Z, Zhao J, Sui A, Zhang H, Wang J. 125I brachytherapy seeds implantation for an inoperable large retroperitoneal leiomyosarcoma. J Can Res Ther [serial online] 2020 [cited 2020 Jul 16];16:397-400. Available from: http://www.cancerjournal.net/text.asp?2020/16/2/397/285196




 > Introduction Top


Leiomyosarcoma is common uterine, gastrointestinal and retroperitoneal tumors, with an annual incidence of 0.13/105 and a slight male preponderance.[1] The prognosis of leiomyosarcoma has been poor, with a reported 5-year survival rate of 28%–40%.[2],[3] Treatment options included surgery, radiation, and chemotherapy.[4],[5] In general, surgical resection has been considered as the main treatment for this disease. However, extensive resection was difficult because of invasive growth, or the combined parts of multiple critical organs and large vessels with the tumor were ≥10 cm. The effects of radiotherapy and chemotherapy were limited to the leiomyosarcoma. Currently, the literature reported that brachytherapy was an established approach, which could safely provide adjuvant local radiotherapy for leiomyosarcoma.[6] This patient experienced combined multiple organ resections, received three times of postoperative recurrence, and presented no surgery indications. The efficacy of radiotherapy and chemotherapy was limited, so the125 I particles implantation was selected. 125 I seeds interstitial brachytherapy has been used to treat tumors for over a century, which developed more extensive applications.[7],[8] Radioactive125 I seed is the most widely applied source for interstitial brachytherapy, providing with a 59.4-day half-life, 27.4–31.4 keV emitted photon energy, 0.0025-cm lead half-value layer. Compared with external beam radiotherapy,125 I seed interstitial brachytherapy generated higher doses of radiation in the target area at a continuous lower dose rate, while conserving the surrounding normal tissues due to the unique physical properties of125 I radionuclides.

This study reported a case of a patient with the left retroperitoneal leiomyosarcoma experiencing three times of postoperative recurrences, who received125 I particle implantations. In this case report, we discussed the unusual application of125 I particle implantations in leiomyosarcoma. The multiple therapeutic strategies and the difficulties in managing this disease were also demonstrated in this study.


 > Case Report Top


Presentation and diagnosis

A 78-year-old male was admitted to our hospital due to retroperitoneal leiomyoma with postoperative recurrence. The mass was noted in the left upper abdomen in physical examination. Intravenous contrast-enhanced computed tomography (CT) scan showed a mass of 12.9 cm × 6.9 cm × 6.6 cm in size, which located in the left retroperitoneum [Figure 1]a and [Figure 1]b. The Eastern Cooperative Oncology Group (ECOG)[7] and numerical rating scale (NRS) scores[8] of pain were 1 and 5, respectively. The patient described pain in his abdomen. In 2003, a mass was detected on the left lower quadrant of the abdomen of the patient. Then the patient received surgery, the mass and renal were removed, with the weight of the mass of 3 kg. Five years later, the patients presented to us with tumor recurrence in situ, a mass of 4 kg was removed in the second operation. In 2013, the patient received a third operation, a tumor with the weight of 5 kg was removed, as well as the left kidney, spleen, transverse colon, and descending colon. The postoperative pathological diagnosis was leiomyoma. However, according to the characteristics of the repeated recurrence and transfer, puncture biopsy was performed after the discussion for obtaining an exact diagnosis. Immunohistochemical stains showed that Vimentin, SMA, Caldesmon, Myogenin, CD34, P53 were positive; while Desmin, HMB45, S100 were negative. The results were all consistent with the diagnosis of low-grade malignant leiomyosarcoma [Figure 1]c and [Figure 1]d, and the diagnosis of retroperitoneal leiomyosarcoma was determined.
Figure 1:(a) Axial view, at level of renal demonstrates huge mass of preoperative computed tomography images. (b) Coronal reconstruction shows huge mass of preoperative computed tomography images. (c) A high-resolution version of this slide for use with the virtual microscope is available (H and E). (d) A high-resolution version of this slide for use with the virtual microscope is available (H and E). (e and f) Precontrast follow-up computed tomography 5 months after three sessions of125I implantation. Tumor size has markedly decreased and disappeared almost completely

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Treatment and progression

The informed consent was obtained from the patient, and this study was approved by the Ethics Committee of our hospital. Then, the125 I brachytherapy seeds implantation was performed under CT guidance. Due to the liquefaction necrosis of this tumor,125 I seeds were implanted by stages, and drainage tube was placed. The patients received three times of implantations, 30 seeds each time, about 14 days interval every time, a total of 90 seeds were finally implanted into the left retroperitoneal target, with an activity of 0.5 mCi. The space between seeds (center-to-center) was kept at 1–1.5 cm. A volume of 800 ml reddish liquid was drained out. A treatment plan was made with a treatment planning system (TPS) (Panther Brachy v5.0 TPS, Prowess Inc., USA) after three times operative generated a dose-volume histogram, and the minimum periphery dose (MPD) for this case was 40 Gy. The path of the needles was determined to avoid vital structures such as bone and large vessels. After 6 months, a follow-up CT examination showed that the size of the retroperitoneal tumor was decreased, only the shadow of the seeds could be observed, complete relief of the tumor was achieved [Figure 1]e and [Figure 1]f. Meanwhile, the quality life of the patient was improved, and NRS scores of pain were decreased to 0.125 I seeds implantation worked very well in this patient. At follow-up, the patient was free of symptoms, CT scan showed the disappearance of the tumor and no recurrence of retroperitoneal lesions for 33 months. Therefore, this treatment could be considered in the cases of many times of postoperative recurrence of retroperitoneal leiomyosarcoma.


 > Discussion Top


Based on the histology, leiomyosarcoma has been considered to be originated from benign progression, while characterized with an aggressive clinical course and relative insensitivity to chemotherapy.[9] Leiomyosarcomas demonstrated smooth muscle differentiation and accounted for up to 20% of all adult soft tissue sarcomas.[10],[11] In most cases of leiomyosarcoma, the reason for the treatment failure was the local recurrence. Furthermore, during the treatment of local recurrences, the radical approach was possible in 60%–70% of all cases withfirst or consecutive tumor recurrence. The resection of adjacent organs was generally well-founded, the literature reported that thefirst, the second and the third resection rates were 57%, 20%, and 10%, respectively.[12],[13] It seemed like that surgical resection was considered the main treatment for obtaining the longest distant survival rate during the primary surgery of retroperitoneal sarcoma.[14] However, surgery was not always possible, due to the large size of the tumor, advanced stages and frequent invasion of retroperitoneal adjacent structures and anatomic localization. Meanwhile, tumor of more than 10 cm tumor accounted for 60%, with poor prognosis.[12] Currently, external radiotherapy has been an approach for reducing the rate of local tumor reoccurrence. However, the small bowel, stomach, kidney often has a low radiation tolerance, which was radiosensitive.[15] The chemotherapy response rate was 20%–30% and the median overall survival was generally lower than 12 months. In addition, no consistent evidence has been shown on the disease-free survival benefit to the retroperitoneal sarcoma.[16],[17]

Recently, brachytherapy has been gradually applied to the retroperitoneal malignant tumor and obtained a certain effect.[18],[19] The therapeutic effects of radioactive125 I seeds implantation were already confirmed for many malignant tumors, which increased the dose compared to external radiotherapy and lowered the dose to surrounding normal tissues. In addition, the occurrence rate of complications and sustained release of γ rays could be managed by repeated implant of125 I seeds.[20],[21] Biao reported that the125 I seeds implantation for the inoperable retroperitoneal sarcoma could provide a local control rate of 87.0%. The median overall survival was 21.56 ± 14.16 months, and no serious complications were detected. Li also reported good results could be achieved with125 I seeds implantation for inoperable low-grade leiomyosarcoma.[18],[22] In this study, we reported a case of a 78-year-old male diagnosed with the left retroperitoneal leiomyosarcoma experiencing three postoperative recurrences. CT demonstrated a mass of approximately 12.9 cm × 6.9 cm × 6.6 cm in his retroperitoneum. Multiple treatment strategies were administered, including the application of drainage and125 I particle implantations. Reexamination was employed 6 months after the treatment, complete response (CR) was achieved in the local lesions. At the same time, metastatic masses including the iliac lymph nodes, the chest, the abdominal aortic left lymph nodes, the gastric small lymph nodes also applied125 I particle implantation and obtained a certain effect.

125 I seed implantation was an established approach, providing simplicity, safety, and effectiveness in the treatment of primary leiomyosarcoma. We presented a rare case of retroperitoneal leiomyosarcoma, with liquefaction necrosis and multiple metastases in tumor. In this case, the surgical procedure was impossible. Based on our previous experiences on125 I seeds implantation in malignant tumors,125 I seeds were implanted by stages, combining with the drainage tube approach, and excellent results were obtained in this case. The literature reported that the MPD of patients was verified to reach 160 Gy. However, in this research, MPD was verified to reach only 40 Gy which achieved excellent results.

The present results suggested that125 I implantation was effective. However, this study was only an individual patient. Additional large-scale and multicenter studies should be required.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Toro JR, Travis LB, Wu HJ, Zhu K, Fletcher CD, Devesa SS, et al. Incidence patterns of soft tissue sarcomas, regardless of primary site, in the surveillance, epidemiology and end results program, 1978-2001: An analysis of 26,758 cases. Int J Cancer 2006;119:2922-30.  Back to cited text no. 11
    
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Lewis JJ, Leung D, Woodruff JM, Brennan MF. Retroperitoneal soft-tissue sarcoma: Analysis of 500 patients treated and followed at a single institution. Ann Surg 1998;228:355-65.  Back to cited text no. 12
    
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Gronchi A, Casali PG, Fiore M, Mariani L, Lo Vullo S, Bertulli R, et al. Retroperitoneal soft tissue sarcomas: Patterns of recurrence in 167 patients treated at a single institution. Cancer 2004;100:2448-55.  Back to cited text no. 14
    
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Classen J, Hehr T, Lamprecht U, Zumbrägel A, Bamberg M, Budach W, et al. Hyperfractionated 192Ir brachytherapy for recurrent retroperitoneal sarcoma: A technique for delivery of local tumor boost dose. Strahlenther Onkol 2003;179:118-22.  Back to cited text no. 15
    
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Yang B, Guo WH, Lan T, Yuan F, Liu GJ, Zan RY, et al. CT-guided 125I seed implantation for inoperable retroperitoneal sarcoma: A technique for delivery of local tumor brachytherapy. Exp Ther Med 2016;12:3843-50.  Back to cited text no. 18
    
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Ni RH, Wang G, Zhang ZM, Ma JG. Iodine-125 seed implantation in the treatment of sacrococcygeal chordoma: A case report. Cell Biochem Biophys 2012;64:107-13.  Back to cited text no. 19
    
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Han T, Yang X, Xu Y, Zheng Z, Yan Y, Wang N, et al. Therapeutic value of 3-D printing template-assisted 125I-seed implantation in the treatment of malignant liver tumors. Onco Targets Ther 2017;10:3277-83.  Back to cited text no. 20
    
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Maki S, Itoh Y, Kubota S, Okada T, Nakahara R, Ito J, et al. Clinical outcomes of 125I brachytherapy with and without external-beam radiation therapy for localized prostate cancer: Results from 300 patients at a single institution in Japan. J Radiat Res 2017;58:870-80.  Back to cited text no. 21
    
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