Implantation of 125I radioactive seeds via c-TBNA combined with chemotherapy in an advanced non-small-cell lung carcinoma patient
The critical management of advanced non-small-cell lung carcinoma (NSCLC), especially when complicated by severe airway stenosis, is difficult and often leads to high clinical risks and medical costs.
A 51-year-old previously healthy male was admitted to the Department of Respiratory and Critical Care Medicine, Taizhou People’s Hospital, in November 2018 for haemoptysis and difficulty breathing during a 15-d period. Following admission, chest computed tomography (CT) showed a large mass in the left hilum with atelectasis in the left upper lobe and obstructive pneumonia in the left lower lobe. Bronchoscopy revealed that the lesions occurred in the distal segment of the left main trachea, with occlusion of the left upper bronchus and significant narrowing of the lower bronchus. A basal mucosal biopsy of the lump tissue was performed after haemostasis treatment with sub-plasma coagulation (APC), and squamous lung carcinoma was confirmed. Following the final diagnosis, the patient was successfully treated with implantation of 125I radioactive seeds via transbronchial needle aspiration (c-TBNA) combined with chemotherapy.
We believe that implantation of 125I radioactive seeds via c-TBNA is an effective treatment for patients with advanced lung cancer and those presenting with severe and mixed main bronchus stenosis.
KeywordsNon-small-cell lung carcinoma 125I radioactive seed Transbronchial needle aspiration
transbronchial needle aspiration
Non-small-cell lung carcinoma
Non-small-cell lung carcinoma (NSCLC) is the most common type of cancer worldwide. Almost 70–75% of patients with NSCLC have advanced stage IIIB or IV disease when first diagnosed . Advanced NSCLC, particularly at the time where the central airway is involved, which often leads to severe airway stenosis, is a dangerous disease that is challenging to manage and has a poor prognosis . Although substantial progress has been made in terms of bronchoscopy interventional techniques, such as electrocoagulation, sub-plasma coagulation (APC), airway stenting, laser therapy and balloon dilatation in recent years , the critical management of some patients with airway stenosis is difficult and remains a focus of attention. The choice of therapy depends on the type of airway stenosis, pulmonary function and life expectancy of the patient. In recent years, studies have examined 125I radioactive seed implantation performed under CT or ultrasound guidance for the treatment of lung cancer, and many patients have been reported to benefit from this alternative technique . However, central bronchogenic carcinoma patients cannot benefit from this alternative technique because of a high risk of haemorrhage or pneumothorax [5, 6]. To the best of our knowledge, reports of 125I radioactive seed implantation via transbronchial needle aspiration (c-TBNA) are rare . The present study reports the diagnosis of an advanced NSCLC patient with severe airway stenosis and the outcomes of treatment with 125I radioactive seed implantation combined with chemotherapy.
This case report was carried out in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Taizhou People’s Hospital, Jiangsu, China. Written informed consent was obtained from the patient. A 51-year-old previously healthy male was admitted to the Department of Respiratory and Critical Care Medicine, Taizhou People’s Hospital, in November 2018 for haemoptysis and difficulty breathing during a 15-d period. Following admission, physical examinations revealed that vital signs were stable. Left-side respiratory movement was weakened and left upper lung tremor was significantly enhanced. Expiratory wheezing was heard throughout the left lung, and no moist rales were noted. The patient had a regular heart rhythm, and no oedema was observed in the lower extremities.
Discussion and conclusions
The critical management of advanced NSCLC, especially when complicated by severe airway stenosis, is difficult and often leads to high clinical risks and medical costs. Opening of the narrow trachea as soon as possible is one of the key factors affecting the prognosis of the disease . Although there has been considerable progress in recent years in terms of the development of bronchoscopy interventional techniques, including electrocoagulation, APC, airway stenting, balloon dilatation, laser therapy and cryoablation, the critical management of some patients with obstruction of the distal section of the central airway caused by intraluminal tumour growth or extrinsic compression is difficult and remains a focus of attention .
Radioactive seeds are implanted directly into the lesion as a kind of brachytherapy, and these seeds kill the tumour cells by consistently releasing rays . 125I radioactive seeds represent the most common type of permanently implanted seed, which can continuously release low-power γ-rays, with a half-life of 59.6 days and an available irradiation range of 17 mm, thus continuously inhibiting cell proliferation and angiogenesis as well as inducing apoptosis and killing tumour cells . Percutaneous 125I radioactive seed implantation is usually performed under computed tomography (CT) or ultrasound guidance, and this technique has demonstrated effectiveness in local control and improvements of the OS time and rate [12, 13, 14, 15]. However, for central-type lung cancer, the technique of percutaneous puncture is associated with a great risk of haemorrhage and pneumothorax .
With the development of endoscopic interventional diagnosis and treatment techniques, trans-bronchoscopy 125I radioactive seed implantation has been reported for the treatment of central airway stenosis . This technique is mainly guided by bronchoscopy; 125I radioactive seeds are implanted into the tumour tissue via c-TBNA or EBUS-TBNA technology . After implantation, the 125I radioactive seeds inhibit cell proliferation and angiogenesis, induce apoptosis, and kill tumour cells . This technology provides a new and effective palliative treatment for patients with central lung cancer; it can permanently destroy tumour cells, maximize the patient’s lung function, improve the patient’s tracheal patency, and improve the patient’s quality of life.
The lesions in the reported patient occurred in the distal segment of the left main bronchus, with occlusion of the left upper bronchus and significant narrowing of the lower bronchus. To the best of our knowledge, traditional respiratory endoscopic intervention techniques, such as laser ablation and stent placement, which are considered the gold-standard treatments for narrowing of the trachea and main bronchus, were not effective and thus were not preferred methods for the specific site of bronchus narrowing in the presented patient. The site of bronchus narrowing was the real problem for the patient; thus, there was a need for a different type of therapy. Fortunately, the patient was successfully treated with trans-bronchoscopy with 125I radioactive seed implantation combined with chemotherapy. We believe that the treatment strategy used for this patient may have opened the respiratory tract in a short period of time, reduced the clinical symptoms, and thus improved the patient’s quality of life and survival time.
In conclusion, the majority of patients with advanced central lung cancer eventually require palliative treatment and individualized treatment strategies. Trans- bronchoscopy with 125I radioactive seed implantation combined with chemotherapy may be a potential and alternative treatment for some patients. It has been reported that 3 to 4 days after 125I radioactive seed implantation may be the best time for initial chemotherapy because the radioactive effect of the 125I radioactive seeds at this time result in an increase in vascular permeability and a facilitation of drug penetration . However, due to the limitation of the number of patients, a mature and feasible radioactive particle-based comprehensive program for these patients still requires further large-scale clinical research.
AGJ contributed to study design,data collection, and preparation of the manuscript. ZQD and HYL contributed to study design and data collection. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.
This work was supported by the “Six One Project” Top Talent Research Project of Jiangsu Commission of Health (GY2018033).
Ethics approval and consent to participate
This case report was approved by the Ethics Committee of Taizhou People’s Hospital, Jiangsu, China. Written informed consent was obtained from the patient.
Consent for publication
The patient provided written informed consent for the publication of any associated data and accompanying images.
The authors declare that they have no competing interests.
- 5.Niu L, Zhou L, Xu K, Mu F. Combination of cryosurgery and Iodine-125 seeds brachytherapy for lung cancer. J Thorac Dis. 2012;4(5):504–7. https://doi.org/10.3978/j.issn.2072-1439.2012.09.03.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Mao Y, Yang X, Li M, Guo W, Zhang W. Treating cancerous large airway stenosis with staging radioactive particle implantation guided by computed tomography and fiber bronchoscopy: a clinical study. World J Surg Oncol. 2017;15(1):149. https://doi.org/10.1186/s12957-017-1216-2.CrossRefPubMedPubMedCentralGoogle Scholar
- 14.Zhang T, Lu M, Peng S, Zhang W, Yang G, Liu Z, et al. CT-guided implantation of radioactive 125I seed in advanced non-small-cell lung cancer after failure of first-line chemotherapy. J Cancer Res Clin Oncol. 2014;140(8):1383–90. https://doi.org/10.1007/s00432-014-1655-x Epub 2014 Apr 11.CrossRefPubMedGoogle Scholar
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.