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 Table of Contents  
Year : 2018  |  Volume : 14  |  Issue : 7  |  Page : 1492-1496

Quality of life after I-125 seed implantation using computed tomography and three-dimensional-printed template guidance in patients with advanced malignant tumor

1 Department of Radiotherapy, Peking University Third Hospital, Beijing, China
2 Peking University School of Nursing, Beijing, China
3 Department of Neurology, Peking University Third Hospital, Beijing, China

Date of Web Publication19-Dec-2018

Correspondence Address:
Baohua Li
49 North Garden Road, Haidian District, Beijing 100191
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.JCRT_77_18

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 > Abstract 

Background: I-125 seed implantation has been widely applied in the local treatment of advanced malignant tumor. It has the advantages of providing a high dose of treatment to the target sites and low dose to normal tissues. It has been mostly applied as palliative treatment for recurrences in advanced malignant tumor (except for prostate cancer), suppressing tumor development and improving the quality of life of patients.
Objective: The objective of this study was to investigate changes in quality of life for patients with advanced malignant tumor after receiving I-125 seed implantation using a three-dimensional (3D)-printed individualized template and computed tomography (CT) guidance.
Materials and Methods: In this prospective study, convenience sampling was applied for patients with advanced tumors attending a tertiary hospital. The European Organization for Research on Treatment of Cancer Quality of Life Questionnaire-C30 was involved to assess quality of life. Patients completed the questionnaire before and 24 h after seed implantation. The questionnaire of 1 and 3 months after seed implantation was completed by telephonic follow-up.
Results: A total of 42 patients were included (24 males and 18 females), with an average age of 58.86 ± 14.13 years (ranged 25–91 years). The average scale score after seed implantation was higher than that of before implantation. The order was the average scale score 1 month after seed implantation >3 months after seed implantation >24 h after seed implantation.
Conclusion: The results suggested that the quality of life could be improved with I-125 seed implantation using a 3D-printed individualized template under CT guidance in patients with the advanced malignant tumor.

Keywords: I-125 seed implantation, patient with malignant tumor, quality of life

How to cite this article:
Wang P, Shen LQ, Zhang H, Zhang M, Ji Z, Jiang Y, Li B. Quality of life after I-125 seed implantation using computed tomography and three-dimensional-printed template guidance in patients with advanced malignant tumor. J Can Res Ther 2018;14:1492-6

How to cite this URL:
Wang P, Shen LQ, Zhang H, Zhang M, Ji Z, Jiang Y, Li B. Quality of life after I-125 seed implantation using computed tomography and three-dimensional-printed template guidance in patients with advanced malignant tumor. J Can Res Ther [serial online] 2018 [cited 2023 Jan 27];14:1492-6. Available from: https://www.cancerjournal.net/text.asp?2018/14/7/1492/247728

 > Introduction Top

Due to the increasing urbanization, aging, and global environmental pollution, malignant tumor has become one of the most serious public health issues all over the world. There were about 14 million new cancer cases in 2012, and the number of new cases was expected to rise by about 70% over the next two decades. The number of cancer-related deaths was 8.8 million in 2015, with about 70% occurred in low- and middle-income countries.[1] The incidence of malignant tumor tended to rise. The number of new malignant tumor cases worldwide was increased from 10.1 million in 2000 to 12.66 million in 2008, while the number of malignant tumor-related deaths rose from 6.2 million in 2000 to 7.56 million in 2008 globally.[2],[3] It is estimated that there would be 27 million new cases of malignant tumor and 17 million deaths globally by 2030, and the total number of patients with malignant tumors would reach 75 million.[4] The situation in China has been particularly grim. The China National Cancer Center released the latest data report on cancer in 2017, which showed that the number of new cancer cases continued to rise in China, from 3.58 million in 2012 to 3.68 million in 2013. The new cancer cases in China have accounted for a quarter of the world's total cases. Moreover, many cases of cancer were found at a late stage or unsuitable for surgical treatment, such as advanced pancreatic cancer, lung cancer and lung metastasis, recurrent gynecologic tumors, and prostate cancer.[5],[6]

New interventions for cancer have been continuously developing, one of which, seed implantation has been widely applied to treat many malignant tumors, such as prostate cancer, pancreatic cancer, and lung cancer. Seed implantation has achieved remarkable curative effects [7],[8],[9], and among them, I-125 seed implantation has become one of the most common types of distance therapy. Although these treatments present certain advantages, they also bring about side effects. In particular, there would be increased radiation risk from high-energy gamma rays for both patients and health-care personnel, without achieving adequate protection from these effects.[10] The introduction of three-dimensional (3D) printing technology has been a revolutionary technological innovation for individualized medicine. Applying a 3D-printed individualized template for computed tomography (CT)-guided seed implantation is a new therapeutic technique for malignant tumor. This technique introduces modern imaging, computer-aided technologies, and the navigation system of a fixed device. Before operative practices, a seed implantation plan can be accurately designed to effectively avoid blood vessels, bone, and other nondiseased tissue structures. The preoperative requirements could be met with real-time optimization during surgery and the immediate verification of the dose postoperatively.[11],[12] The study showed that 3D-printed individual template-guided 125I seed implantation for the cervical lymph node metastasis could not only reduce the dosimetric differences between pre-and post-plan but also lower the difficulty of puncture. It was a safe and accurate guidance approach.[13] New research showed that both surgery time and bleeding volume could be significantly reduced with the application of a 3D-printed template in lung cancer treatment.[14]

In the study of malignant tumor therapy, quality of life refers to an experience of satisfaction with the control of disease, or the treatment-related symptoms that reflect the functional, economic, social, psychological, and emotional aspects of the life of patients. It is the synthesis of multiple dimensions, including the physical, psychological, and social integrity of the individual. Measuring the quality of life for patients helps us to understand the impacts of disease on all aspects of the patient's life, reflecting their health situations, and requirements. Clinical oncologists are paying increased attention to improve the quality of life of patients with advanced cancer. A number of studies have investigated on the effects of 3D-printed individualized templates with CT-guided seed implantation to treat malignant tumor.[15],[16] A few studies have explored the effects of the technique on improving the quality of life of patients.[17] However, these studies have been limited to a certain type of malignant tumor. For patients with malignant tumor, the improvement of quality of life from 3D-printed individualized template with CT-guided seed implantation was not yet clear. Therefore, this study aimed to explore the effects of applying a 3D-printed individualized template for CT-guided seed implantation in improving the quality of life of cancer patients.

 > Materials and Methods Top


This prospective study applied convenience sampling to collect patient information. Advanced tumor patients received CT-and 3D-printed template-guided radiological I-125 seed implantation were enrolled in the cancer radiotherapy division of our hospital during July–November 2016.


A questionnaire was designed to investigate the situations of patients. It included questions on the patients' background, other disease conditions, current diseases, and a core quality of life scale from the European Organization for Research on Treatment of Cancer Quality of Life Questionnaire (EORTCQLQ-C30).[18] The questionnaire consisted of 30 items and included a self-report form with five functional scales (physical function, role function, cognitive function, emotional function, and social function); three symptom scales (fatigue, pain, and nausea/vomiting); six single measurement items; and one global quality of life scale. The questionnaire had been strictly tested in the Chinese language, and reliability, validity, and the evaluation indexes were within an acceptable range.[19]

Baseline data were collected before the seed implantation. An investigator issued the questionnaire to each patient, giving a detailed and unbiased explanation on how to complete it and encouraging the patient to complete it truthfully. Twenty-four hours after surgery, the patient completed the questionnaire again. The further information about the quality of life for patients was collected with questionnaires at 1 and 3 months after implantation.

Seed implantation method

For each patient receiving 3D-printed template CT-guided seed implantation, a preoperative disease assessment was performed. It aimed to ensure that the techniques were applicable, as well as assessing the safety and risks of surgery.

To simulate localization, an enhanced CT scan was performed on each patient 2 days before surgery. From this, a 5-mm thick fixed vacuum pad, patient body surface positioning markers, and template can be aligned with the reference line. The CT data were then transmitted to brachytherapy treatment planning system (BTPS) software to make a preoperative plan. It consisted of several steps: sketching the gross tumor volume (GTV) of the target lesion and the adjacent areas endangered by the tumor; setting the prescription dose and particle activity; determining the implantation needle path (direction, depth, and distribution); calculating the seed numbers; simulating the spatial position distribution of seeds; and calculating the dose distribution of the GTV and the peripheral endangered organs. This optimization ensured that the target dose was as close as possible to the prescribed dose.

The BTPS data were then imported to 3D-imaging and reverse engineering software to create an individualized template digital model. The 3D-printed template was printed with a 3D light-cured rapid-forming printer and medical optical curing resin material. The template contained information, such as the superficial characteristics of the patients' treatment area, positioning marks, and analog implantation needle tract.

The seed implantation operation was performed under either local- or spinal-epidural anesthesia. The 3D-printed template on the treatment area of the patient's body was placed, using laser lines, the patient body surface positioning line, the template to the position of reference line, and external contour characteristics for accurate positioning. The template guide hole was applied to puncture the seed needle through the skin to a predetermined depth. During the process of puncture, the CT scanning was applied to verify the placement of the needles and to fine-tune the needle placements if necessary. Finally, the preoperative plan was referred, and the depth of each needle implanted in the target area was validated.

A postoperative CT scan was performed under similar conditions to the preoperative planning CT scan. The postoperative image was transmitted to the BTPS and the actual dose distribution was obtained according to a dose–volume histogram.

Statistical methods

After data collection, SPSS 17.0 (SPSS, Chicago, IL, USA) statistical software was included for the analysis. The results were expressed as mean ± standard deviation (x ± s).

 > Results Top

A total of 42 patients were enrolled, including 24 males and 18 females. The average age of these patients was 58.9 ± 14.13 years, ranged from 25 to 91 years. The EORTCQLQ-C30 scale score was higher at 1 month after seed implantation than at any other points. The average scale score was 1 month after seed implantation >3 months after seed implantation >24 h after seed implantation. The average scale score after seed implantation was higher than that of before implantation. Other specific results were shown in [Table 1] and [Table 2].
Table 1: Quality of life changes in patients

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Table 2: Subitem scores for each function

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 > Discussion Top

Somatic symptoms in patients relieved with seed implantation

With increasing developments in cancer treatment, the survival of the patient has been obviously improved. However, cancer patients may suffer from many symptoms, some of which would be caused by the cancer itself and some were related to treatment. When treating for symptoms caused by cancer itself, it is essential to avoid side effects of treatment as far as possible. The application of a 3D-printed individualized template for seed implantation has been an accurate treatment technique and characterized as minimally invasive approach, with little damage to surrounding tissues and few obvious local effects. With this technique, not only the somatic symptoms of the cancer itself could be effectively relieved but also the side effects of treatment would also be minimized. Our study showed that EORTCQLQ-C30-based somatic function scores were increased after applying 3D-printed individualized templates with CT-guided I-125 seed implantation. It indicated that the patients' somatic function was effectively improved after treatment, which may be related to the continuous release of radiation, effectively inhibiting the mitosis and hyperplasia of tumor cells, finally damaging tumor tissue.[20] Other studies have shown that side effects could also be reduced with 3D-printed individualized templates for seed implantation, such as the nausea, diarrhea, and fatigue.[21] In general, seed implantation can effectively relieve somatic symptoms in patients without leading to much side effects.

Improved quality of life of patients with advanced tumors after seed implantation

When I-125 seeds were implanted with 3D-printed individualized template, they are evenly spaced in the tumor. The shape of I-125 seeds could be accurately reflected by dose distribution. In addition, the prescribed dosage for tumor control can be achieved without affecting adjacent tissues, such as blood vessels and trachea. These tissues were well protected and the risk of damage to nondiseased tissue was minimized. There were many advantages provided by the 3D-printed individualized template for seed implantation, such as meeting the requirement of treatment dose matching, reducing toxicity and treatment side effects, conferring the advantages of safe seed implantation, and providing accurate curative effects and low complication rate.[22] In this study, EORTCQLQ-C30 scoring was significantly higher after treatment compared with that of before treatment, indicating that quality of life was significantly improved after treatment. This result was consistent with the results obtained from similar studies.[23] Using 3D printing of an individualized template for seed implantation enables accurate targeting of cancer cells, significant improving the patient's somatic functioning and effective reducing the incidence of various complications. Thus, this approach would assist in restoring social and role functions and improving quality of life in tumor patients.

 > Conclusion Top

Malignant tumor is a serious worldwide public health problem, with increasing incidence and mortality rate. Application of 3D-printed individualized template in CT-guided I-125 seed implantation therapy is a novel technique in the treatment of malignancy and advanced cancers. It enabled precisely targeting and killing cancer cells, presenting minimal damage to surrounding tissue. Patients' quality of life could be enhanced with this technique, through improving somatic and social functioning. It is expected to offer opportunities for improving quality of life toward early and advanced cancer patients.


We would like to acknowledge the individuals that participated in this research. We thank our colleagues for their helpful.

Financial support and sponsorship

We have staff support.

Conflicts of interest

There are no conflicts of interest.

 > References Top

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  [Table 1], [Table 2]

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