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Year : 2018  |  Volume : 14  |  Issue : 1  |  Page : 30-35

Three-dimensional-printed individual template-guided 125I seed implantation for the cervical lymph node metastasis: A dosimetric and security study

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

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. Juan Wang
Department of Oncology, The Hebei General Hospital, Shijiazhuang, Hebei Province 050051
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_619_17

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 > Abstract 

Objective: The objective of this study is to evaluate the dosimetric accuracy and pathway safety of the three-dimensional (3D)-printed individual template-guided 125I seed implantation for the treatment of cervical lymph node metastasis.
Materials and Methods: A total of 15 consecutive patients with cervical lymph node metastasis were enrolled during September 2015–July 2017 (12 patients had a history of external beam radiotherapy, with the mean dose of 63 Gy), who undergone radioactive seed implantation guided by the 3D-printed individual template. The preplan was completed based on contrast-enhanced computed tomography images, and then, the 3D-printed individual template was printed according to the preplan. After the operation, the real-time dose verification was completed: the D90 was ranged from 60 to 113 Gy with median of 93 Gy and the number of seeds was ranged from 21 to 76 with median of 53. To observe the intraoperative complications and postoperative complications in 3 days, we collected and compared the deviation of the number of seeds, target volume, and dosimetric parameters (D90, V90, V100, and V150) between preplan and postoperative plan.
Result: Intraoperatively, each template was observed to exactly fit and lock on the lamina, and the operation was successfully completed. No intraoperative complications and postoperative complications were observed in 3 days. There was no significant difference in P values between the two groups for all the parameters (P > 0.05).
Conclusion: The 3D-printed individual template-guided 125I seed implantation for the cervical lymph node metastasis has not only reduced the dosimetric differences between pre- and postplan but also lowered the difficulty of puncture, indicating that it was a safe and accurate guidance approach.

Keywords: Head and neck neoplasms, individual template, radioactive seed implantation, three-dimensional printed

How to cite this article:
Liang Y, Wang Z, Zhang H, Gao Z, Zhao J, Sui A, Zhao J, Liu Z, Wang J. Three-dimensional-printed individual template-guided 125I seed implantation for the cervical lymph node metastasis: A dosimetric and security study. J Can Res Ther 2018;14:30-5

How to cite this URL:
Liang Y, Wang Z, Zhang H, Gao Z, Zhao J, Sui A, Zhao J, Liu Z, Wang J. Three-dimensional-printed individual template-guided 125I seed implantation for the cervical lymph node metastasis: A dosimetric and security study. J Can Res Ther [serial online] 2018 [cited 2021 Jun 24];14:30-5. Available from: https://www.cancerjournal.net/text.asp?2018/14/1/30/226746

 > Introduction Top

Head and neck (HN) cancers have been a heterogeneous group with varying primary sites.[1] The annual global incidence of HN cancer has been more than 550,000 cases and around 300,000 deaths.[2] Moreover, 10% of HN squamous cell cancers (HNSCCs) were metastases while 60% of them were a locally advanced.[3] Furthermore, most of the locally advanced HNSCC would result in high rates of local recurrence or distant metastasis after treatment. The 5-year overall survival for patients with local, locally advanced, and metastatic diseases was 83%, 59%, and 36%, respectively.[4]

As one of the standard treatments for early-stage prostate cancer, permanent interstitial brachytherapy (PIBT) was parallel to that of surgery or external beam radiotherapy while it showed less trauma and side effects.[4] As a kind of PIBT, the radioactive 125I seed implantation has been considered to be one of the radical treatments for early low-risk prostate cancer, and a great number of scholars tried to apply this technology to treat malignant tumor on other parts of body, such as HN, thorax, abdomen, and pelvic cavity. The seed implantation was applied as monotherapy or combined with surgery, chemotherapy, or radiotherapy, achieving good therapeutic effects.[5],[6],[7],[8],[9] The target position, puncture path, and dose distribution were considered to be three important factors that affected the success rate of implantation and clinical effects. With the development of medical imageology, the advanced devices could position the target areas [10],[11] and guide the operators puncture accurately. Some seasoned operators have overcome the difficulties of puncture, but the unseasoned may not guarantee the consistency of the spatial distribution of needles of pre- and postplan. Thus, the dose distribution in target area and organs at risk (OARs) may be affected. As the core spirit of seed implantation, dosimetry was considered to be the most critical factor affecting the treatment efficacy. Until now, a good consistency could not be kept between the dose of post- and preplan.

In recent years, the three-dimensional (3D) printing technology has been applied to every subspecialty of the department of orthopedics, for guaranteeing the accuracy of location and operation in preoperative preparation and intraoperative procedure. Some scholars tried to implant the 125I seeds guided by 3D-printed individual template, for treating tumors of HN, thorax, abdomen, and pelvic cavity. They observed the 3D-printed template-guided seed implantation could ensure the consistency of the real-time needles and dose distribution with preplan precisely, resulted in a significantly reduced error.[12],[13],[14] However, the application of this operation to treat HN cancers was seldom reported. Hence, this study aimed to explore the dosimetric accuracy and pathway safety of the 3D-printed individual template-guided 125I seed implantation for the treatment of HN lymph node metastasis.

 > Materials and Methods Top

Informed consent

Approvals from the Ethics Committees of Hebei General Hospital were obtained before this investigation. Written informed consent was obtained from each patient after explanation of this study.


In this study, 15 patients with cervical lymph node metastasis received the 3D-printed individual template guided 125I seed implantation at Hebei General Hospital between September 2015 and May 2017 were enrolled in the study. The characteristics of the patients were summarized [Table 1]. The inclusion criteria were as follows: (1) age ≥18 years; (2) clinically or pathologically diagnosed as cervical lymph node metastasis, and no ulceration was observed on the surface of target area; (3) the short-axis diameter of the target area was ≥1 cm on computed tomography (CT) or ultrasonography; (4) Karnofsky performance status ≥70; (5) expected lifetime was ≥3 months; (6) patients were unsuitable for reoperation, chemotherapy, and radiotherapy or not willing to receive any chemotherapy or radiotherapy; and (7) no ulceration or infection was observed on the skin of puncture site. Patients with severe organ dysfunction, coagulation disorders, acute and chronic infection, and psychiatric history were excluded from the study. The seed activity was 0.3–0.6 mCi, and the prescriptive dose (PD) was 60–110 Gy.
Table 1: The characteristics of the patients and seed implantation details

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The model of 6711-99 radioactive 125I seed provided by Shanghai Xinke Pharmaceutical Company, Shanghai, China, and shaped as a cylindrical titanium package body, with a length of 4.5 mm, diameter of 0.8 mm, and wall thickness of 0.05 mm in titanium on its external shell. Vacuum cushion with the size of 120 cm × 80 cm × 4 cm was produced by Tiancheng Medical Instruments, China. Treatment planning system (TPS): Panther Brachy v5.0 TPS was provided by Prowess Inc., USA. Radioactivity meter was provided by RM-905a well-type ionization chamber, National Institute of Metrology, China. Mick 200-TPV Needle Applicator and 18G seed implantation needle were provided by Mick Radio-Nuclear Instruments, Inc., NY, USA; positron emission tomography-CT: MODEL Discovery CT750 HD provided by GENERAL EASTERN (GE) INSTRUMENTS CORP., USA. The 3D-printed template was provided by MODEL QL-QG-2 Beijing Unicom Science and Technology Ltd. The Statistic Package for the Social Science (SPSS) was version 21.0 SPSS, IL, USA.



A week before surgery, the vacuum cushion was applied to minimize patients' movement in the same body position; furthest, a position line and reset line had been marked on surface of patient's body according to the laser ray before scan, and then, 2 mark points were posted on the line in the direction of X-axis with the distance of 3–4 cm. Preoperative intensified CT images of the target area were obtained by a CT scanner with a slice thickness of 0.5 mm. The images were exported in Digital Imaging and Communications in Medicine format to TPS for preplan [Figure 1]a. The plan should ensure that the D90 of gross tumor volume meets the requirement of PD. The edge of OARs should be at least 1 cm away from isodose curve of D90, and the vessels that surrounded by tumor were excepted. Then, the plan was submitted, and the TPS would generate the dose-volume histogram (DVH) [Figure 2]a and a procedure, including the 3D spatial distribution of the needles [Figure 3] and other information which was applied for template printing. One day before the operation, the 3D printing template was sterilized. About 10% of the radioactive seeds were randomly sampled and tested with a radioactivity meter. The maximum error of the seeds not >5% was considered eligible.
Figure 1: (a) Preplan made by the treatment planning system to determine the needles and seed distribution. (b) Needle distribution of intraoperative guided by the template. (c) Seed distribution of postoperation

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Figure 2: (a) Dose-volume histogram of preplan calculated by treatment planning system. (b) Dose-volume histogram of postplan calculated by treatment planning system

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Figure 3: The three-dimensional spatial distribution of the needles of preplan

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The vacuum cushion was applied to fix the patients' body position as before. The disinfected 3D template was fixed according to the marks on the body surface. Then, 2 or 3 needles were inserted through the hole to stabilize the relative position of template, skin, and target area. The restoration accuracy was examined by CT scan, then, the needles were inserted, and the seeds were implanted [Figure 1]b.


Right after the brachytherapy, a CT scan was performed to verify the distribution of seeds. Postplan was performed according to the postoperative CT images and DVH were printed [Figure 1]c and [Figure 2]b.

Quality assessment standards and codes

The success criteria of this procedure were defined as “the seeds were implanted into target area guided by the 3D individual template; the postprocedural dosimetry verification meets the requirement of preprocedural plan.” The quality assessment (QA) with reference to the British Columbia Cancer Agency Provincial Prostate Brachytherapy Quality Assurance Program,[15] and the detail were as follows: Excellent (E): V100≥90%, 125% PD ≥D90≥100% PD; Good (G): 90% > V100>85% and 100% PD > D90>90% PD; Suboptimal (S): 85%≥ V100≥75%, 90% PD ≥ D90≥80% PD, or D90>125% PD; and (4) Poor (P): V100<75% and D90<80% PD.

Observation indexes

The complications such as hemorrhage, ache at the point of puncture, hoarseness, and dyspepsia were observed for 3 days. The D90, V90, V100, and V150 values of pre- and postoperation were compared.

Statistical analysis

The SPSS version 21.0 statistical software was applied for data analysis. The paired t-test was applied to analyze the statistical difference in pre- and postoperation D90, V90, V100, and V150 values, the amount of seeds, and target volume. P < 0.05 was considered statistically significant.

 > Result Top

Intraoperatively, each template was found to exactly fit and lock on the body surface, and the operation was completed successfully. Minor hemorrhage with the amount of 1–2 ml was observed in 3 patients. No hemostatic treatment and no other complications were observed. The QA of postprocedural was listed in [Table 1]. The number of seeds of pre- and postoperation was 51.67 ± 15.24 and 53.13 ± 16.01, the target volume of pre- and postoperation was 58.87 ± 33.59 cc and 60.98 ± 32.12 cc; the values of preplan dosimetric parameters, D90, V90, V100, and V150, were 8982.03 ± 2031.39 cGy, 94.66% ± 1.7%, 91.11% ± 1.56%, and 61.82% ±6.15%, respectively, and postplan were 8895.19 ± 1998.94 cGy, 94.43% ± 2.49%, 90.61% ± 3.14%, and 60.97% ± 10.03%, respectively. No significant difference was observed between the two groups for all the parameters. The values of all the parameters of two groups were summarized [Table 2].
Table 2: Comparison of preoperative and postoperative dosimetry parameters in target volume of 15 cases

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 > Discussion Top

125I seeds have showed obvious advantages in treating recurrent or metastatic malignancy.[6],[16] Hongtao et al.[12] took the lead in treating malignancy with 125I seeds guided by the 3D-printed individual templates. He proved that the postplan and preplan dose parameters of 3D-printed template-guided seed implantation were nearly consistent. However, some professional surgeons considered that the HN was unique and complex in anatomical structure, so this kind of operation should be applied cautiously. In this study, we summarized that the experience of 15 patients with HN malignancy received the 125I seed implantation guided by the 3D-printed individual templates.

The seeds implantation guided by 3D-printed individual templates reduced the difficulty in puncture. Rembowska et al.[17] reported that the spatial distribution of needles was the precondition of dose accuracy. The traditional technique of puncture may be affected by skill and experiences of operators. The seasoned operators may overcome the difficulties of puncture while the unseasoned operators cannot guarantee the consistency of the spatial distribution of needles of pre- and postplan, further influencing on the dose distribution in target area and OARs.[7],[18] Comparing to traditional technique of puncture, the guidance of templates showed its unique advantages, such as efficient preoperative preparation and the restoration, fixation of templates guaranteed the reticle of templates and body surface closely coincident, and even, the unseasoned operators could control the errors between pre- and postplan in degree of millimeter. On the other hand, the altered seed distribution would also affect the dose directly, so the application of 3D templates guaranteed the accuracy and safety of operation. Our center has never offered any opportunities for the unseasoned operators during the traditional seed implantation for treating the cervical lymph node metastasis. However, in this study, 11 of the 16 operations were completed by the unseasoned operators after the application of 3D templates. So, the templates could greatly make up for the inexperience of the unseasoned operators. Moreover, the homogeneity of operations could be increased.

On the other hand, the application of 3D templates could dramatically reduce the radiation exposure of the patients as well as relieving tension and stress of both operators and patients. In this study, only three of the patients were minimal bleeding with spontaneous hemostasis without hemodynamic instability, and the average scan number of CT was only 5.7. The application of 3D templates could also guarantee the accuracy of dosimetry; Huang et al. and Zhang et al.[13],[19] proved the advantage of 3D templates in guaranteeing the dose consistency of pre- and postplan. Our study also enrolled 15 patients and the result was parallel to the previous, which could also prove the advantages of 3D templates in guaranteeing the dose consistency. Compared to the results in Ming-Wei Huang's study, the target area of 15 patients was under the hyoideum, which filled the gaps in the field of the application history of 3D-printed template-guided seed implantation.

 > Conclusion Top

Our initial experience showed that the complexity and particularity of anatomical structure of HN provided the possibility for the application of 125I seed implantation guided by the 3D-printed individual templates for treating the cervical lymph node metastasis. It would not only reduce the dosimetric differences between pre- and postplan but also lower the difficulty of puncture.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 > References Top

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da Costa AA, D'Almeida Costa F, Ribeiro AR, Guimarães AP, Chinen LT, Lopes CA, et al. Low PTEN expression is associated with worse overall survival in head and neck squamous cell carcinoma patients treated with chemotherapy and cetuximab. Int J Clin Oncol 2015;20:282-9.  Back to cited text no. 3
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Gao F, Li C, Gu Y, Huang J, Wu P. CT-guided 125I brachytherapy for mediastinal metastatic lymph nodes recurrence from esophageal carcinoma: Effectiveness and safety in 16 patients. Eur J Radiol 2013;82:e70-5.  Back to cited text no. 7
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[PUBMED]  [Full text]  
Hongtao Z, Xuemin D, Huimin Y, Zeyang W, Lijuan Z, Jinxin Z, et al. Dosimetry study of three-dimensional print template-guided precision 125 I seed implantation. J Cancer Res Ther 2016;12:C159-C165.  Back to cited text no. 12
Huang MW, Zhang JG, Zheng L, Liu SM, Yu GY. Accuracy evaluation of a 3D-printed individual template for needle guidance in head and neck brachytherapy. J Radiat Res 2016;57:662-7.  Back to cited text no. 13
Ji Z, Jiang Y, Guo F, Sun H, Fan J, Zhang L, et al. Dosimetry verification of radioactive seed implantation for malignant tumors assisted by 3D printing individual templates and CT guidance. Appl Radiat Isot 2017;124:68-74.  Back to cited text no. 14
Keyes M, Morris WJ, Spadinger I, Araujo C, Cheung A, Chng N, et al. Radiation oncology and medical physicists quality assurance in British Columbia cancer agency provincial prostate brachytherapy program. Brachytherapy 2013;12:343-55.  Back to cited text no. 15
Jiang P, Liu C, Wang J, Yang R, Jiang Y, Tian S, et al. Computed tomography (CT)-guided interstitial permanent implantation of (125) I seeds for refractory chest wall metastasis or recurrence. Technol Cancer Res Treat 2015;14:11-8.  Back to cited text no. 16
Rembowska AM, Cook M, Hoskin PJ, Mahdevan A. The stepping source dosimetry system as an extension of the manchester system. Radiother Oncol 1996;39:25.  Back to cited text no. 17
Zhang J, Zhang JG, Song TL, Zhen L, Zhang Y, Zhang KH, et al. 125I seed implant brachytherapy-assisted surgery with preservation of the facial nerve for treatment of malignant parotid gland tumors. Int J Oral Maxillofac Surg 2008;37:515-20.  Back to cited text no. 18
Zhang HT, Di XM, Yu HM, Zhao XZ, Zhang LJ, Zhao JX, et al. Dose comparison between pre and post operation of 125I seeds implantation guided by 3D print tamplate. Zhonghua Yi Xue Za Zhi 2016;96:712-5.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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