Simple, accurate, safe, and cost-effective percutaneous transperineal template technique for permanent 125iodine interstitial brachytherapy of prostate cancer

We present the technique, intraoperative and postoperative complications of percutaneous transperineal template permanent 125iodine interstitial brachytherapy of prostate cancer. The percutaneous transperineal template permanent iodine interstitial brachytherapy under "C-arm" fluoroscopic guidance is a simple, easily-learned, accurate and rapid procedure which can be performed without subjecting the patient to celiotomy. We have treated 58 patients by the transperineal percutaneous permanent interstitial brachytherapy. 33 of 58 patients also had a staging celiotomy just prior to the brachytherapy. In the group of 22 patients undergoing brachytherapy without celiotomy and without adjuvant external-beam pelvic radiotherapy, there were no major complications. Blood transfusions were not required by any patients who underwent percutaneous transperineal permanent iodine interstitial brachytherapy without celiotomy.     

Migration of prostate brachytherapy seeds to the vertebral venous plexus

PURPOSE: We report two cases of seed migration to the vertebral venous plexus after iodine-125 (I-125) transperineal interstitial permanent prostate brachytherapy. METHODS AND MATERIALS: Case 1: A 67-year-old Japanese man underwent percutaneous transperineal interstitial permanent prostate brachytherapy at our institution. Three months after brachytherapy, routine followup kidney-urinary bladder (KUB) radiography showed two seeds that had migrated to the pelvic area and were overlapped by sacral bone. It was very difficult to detect the seeds by visceral CT, because seeds were in contact with to vertebral bone, and seeds and bone were of the same CT value in visceral CT. But bone CT could distinguish seeds and bone, and it showed seed migration to the vertebral venous plexus in the sacral vertebral canal. Case 2: A 75-year-old Japanese man underwent percutaneous transperineal interstitial permanent prostate brachytherapy at our institution. The day after seed implantation, routine followup KUB radiography showed that a seed had migrated to the pelvic area and was overlapped by sacral bone. Bone CT clearly showed seed migration to the vertebral venous plexus in the vertebral canal in comparison with visceral CT. RESULTS: Seeds that have migrated to the vertebral venous plexus are difficult to be detected by visceral CT or KUB radiography. In visceral CT, it is difficult to distinguish seed and bone, especially when they are touching each other because they have the same CT value in visceral CT. It is therefore necessary to perform bone CT to detect such migrating seeds. CONCLUSIONS: To our knowledge, this is the first report of seed migration to the vertebral venous plexus after prostate brachytherapy. We thought that seeds migrate to the vertebral plexus via the pelvic venous pathway. If seed migration to the pelvic area and the overlapped sacral bone area is found after brachytherapy, bone CT should be performed, especially when it is difficult to detect the seed in visceral CT.     

Retreatment of recurrent pelvic tumors with iodine-125

We describe our experience with successful retreatment of common pelvic tumors including recurrent cervical and endometrial cancer, colorectal cancer, and soft tissue sarcomas. Two different permanent interstitial 125iodine (125I) endocurietherapy (ECT) techniques were employed. The first technique, percutaneous transperineal template 125I ECT, was used in the retreatment of recurrent tumors located within the true pelvis. The second technique, implantation of 125I in Vicryl carrier following celiotomy, was used for retreatment of recurrent tumors located outside the true pelvis within the false pelvis.     

A new method for treatment of unresectable, recurrent brain tumors with single permanent high-activity 125iodine brachytherapy

We describe a new method for treating unresectable recurrent brain tumors in previously-irradiated patients with localized high-dose intracranial brachytherapy of 10,000-30,000 rads using permanent implantation of a single high-activity 125Iodine seed. For unresectable recurrent previously-irradiated pituitary tumors, a single high-activity 125Iodine seed is permanently implanted into the center of the tumor with an interstitial needle inserted under fluoroscopic guidance via a transsphenoidal approach. For unresectable recurrent meningiomas, a single high-activity seed is permanently implanted into the tumor at craniotomy. The clinical course of five patients treated by this method is described. Excellent long-term local control was obtained in all implanted cases. There were no intraoperative, postoperative, or chronic complications.     

Prostate brachytherapy seed migration to the right coronary artery associated with an acute myocardial infarction

PURPOSE: We report a case of prostate brachytherapy seed migration to the right coronary artery (RCA) associated with an acute myocardial infarction (AMI). METHODS AND MATERIALS: A 69-year-old male was diagnosed with Prostate Adenocarcinoma Stage II (T(1c)N0M0) in October 2003. He underwent percutaneous transperineal interstitial permanent prostate brachytherapy with the implantation of 94 loose iodine (125I) seeds under transrectal ultrasound guidance on 15 December, 2003. The implantation was designed to deliver a minimum dose of 144 Gy. RESULTS: Postimplant pelvic radiography at Day 30 showed five seeds missing. No chest radiography was done until hospital admission on October 10, 2005 for AMI. Cine radiography from cardiac catheterization revealed 86 metallic seeds remaining in the pelvic region, 4 that had migrated to the lungs (2 left and 2 right) and 2 to the heart. Two seeds were unaccounted for. Of the two cardiac seeds, one was lodged in the right ventricle endocardium and the other in the midsegment of the RCA at the site of a severely stenotic lesion that resulted in an AMI. CONCLUSIONS: To our knowledge, this is the first case of brachytherapy seed migration to the RCA associated with an AMI. Echocardiography before brachytherapy seed implantation might be considered in patients felt to be at high risk for cardiac shunting.     

Percutaneous laser disk decompression under CT and fluoroscopic guidance: indications, technique, and clinical experience.

The aim of percutaneous laser disk decompression (PLDD) is to vaporize a small portion of the nucleus pulposus of an intervertebral disk, thereby reducing the volume and pressure of a diseased disk. This minimally invasive technique can be performed in patients who need surgical intervention for disk herniation with leg pain. PLDD is usually performed under fluoroscopic guidance with or without diskoscopy. However, it can also be performed under dual computed tomographic (CT) and fluoroscopic guidance as an outpatient procedure. CT and fluoroscopic guidance increases the safety and accuracy of PLDD, with high precision of instrument guidance, direct visualization of nucleus pulposus vaporization, and reduced risk of complications. Of 119 patients with lumbar disk herniation treated with PLDD under CT and fluoroscopic guidance, 91 (76.5%) had a good or fair response. PLDD performed with CT and fluoroscopic guidance appears to be a safe and effective treatment for herniated intervertebral disks.     

C-arm cone beam computed tomography needle path overlay for image-guided procedures of the spine and pelvis

Introduction  

The aim of this study is to report our early clinical experience using C-arm cone beam computed tomography with fluoroscopic overlay for image guidance during percutaneous needle procedures of the spine and pelvis.     

Clinical role of guidance by C-arm CT for <Superscript>125</Superscript>I brachytherapy on pulmonary tumors

Purpose

To evaluate the clinical value of C-arm CT (CACT)-guided interstitial iodine-125 (¹²⁵I) brachytherapy on pulmonary tumors.

Materials and methods

30 patients with 40 solid pulmonary tumors were enrolled to undergo CACT-guided interstitial ¹²⁵I brachytherapy between November 2011 and November 2014. The needle path was planned on a CACT virtual navigation and real-time fluoroscopy system. Technical success, puncture score, procedure time, local control rate (LCR), radiation exposure, complications and survival were investigated.

Results

The technical success of interstitial ¹²⁵I brachytherapy under CACT guidance was 40/40 (100%). The performance score was 4.7 ± 0.5 with a mean total procedure time of 17.7 ± 5.6 min. LCR in small (≤2.0 cm), intermediate (2.1–4.9 cm) and large (≥5.0 cm) pulmonary tumors was 100, 89.5 and 72.7% at the 4-month follow-up, respectively. The mean effective dose was 10.1 ± 2.8 mSv. Major complications occurred in four patients (13.3%). The mean survival time was 28.4 ± 2.3 months.

Conclusion

CACT can provide virtual navigation and real-time fluoroscopy synchronously for interstitial ¹²⁵I seed implantation on pulmonary tumors.

     

C形臂X线机与CT联合导向在经皮椎体成形术中的应用

目的探讨在移动式C形臂X线机与16排CT联合导向下,经皮椎体成形术中在治疗骨质疏松性椎体压缩骨折的操作方法及优势。方法将移动式C形臂X线机与16排CT置于同一机房,组成组合机。16排CT扫描病变椎体及相邻椎体,确定穿刺点及穿刺路径,评价术后椎体情况;移动式C形臂X线机实时透视监视注射聚乙烯吡咯烷酮(骨水泥)。结果在组合机引导下对12例单椎体压缩骨折的患者行经皮椎体成形术成功率100%,无并发症发生。结论移动式C形臂X线机与16排CT联合导向在经皮椎体成形术中的操作简便、定位准确、监视实时、导向安全,特别提高了L4椎体平面以上各椎体行椎体成形术的安全性。     

Ultrasound-Guided Interstitial Brachytherapy in the Treatment of Advanced Vaginal Recurrences from Cervical and Endometrial Carcinoma

BACKGROUND: In advanced vaginal recurrences of cervical and endometrial carcinomas therapeutic options are rare because of preceding therapy. PATIENTS AND METHODS: 23 patients developing advanced vaginal recurrences of cervical and endometrial carcinomas were included. 15 patients started with external-beam therapy to the pelvis and eight patients after preceding radiotherapy underwent brachytherapy alone. All patients had ultrasound-guided implantation of transvaginal or transperineal interstitial needles for brachytherapy. Median prescribed total dose was 64 Gy. RESULTS: 18 patients (78%) achieved complete remission. Six patients are alive without tumor and one with tumor after a median follow-up of 64 months. 14 patients died of tumor and two of intercurrent disease. 5-year disease-specific survival and local control rate were 43% and 47%, respectively, in patients with complete remission. Univariate analysis found time to relapse > 2 years, initial diameter < or = 4 cm, initial volume < 15 cm(3), no extension to the pelvic side wall, volume before brachytherapy < 7.5 cm(3), brachytherapy coverage index > 0.8, and prescribed total dose > 64 Gy being positive predictors for local control and survival. CONCLUSION: The use of ultrasound guidance for placement of interstitial needles in template-based brachytherapy of advanced recurrent gynecologic malignancies is a feasible, safe, and cheap method with encouraging results. Today, ultrasound imaging can be also used to some extent for treatment planning which requires further development. Patient- and treatment-related prognostic factors can be defined.     

A Comparative Study of CT Fluoroscopy Combined with Fluoroscopy Versus Fluoroscopy Alone for Percutaneous Transhepatic Biliary Drainage

Purpose: We compared CT fluoroscopy (CTF) for the initial puncture of bile ducts with conventional fluoroscopic guidance in patients with malignant jaundice in whom percutaneous transhepatic biliary drainage (PTBD) was planned. Methods: Forty consecutive patients were randomized to two study groups: group A underwent PTBD under CTF and fluoroscopic guidance, group B underwent PTBD under fluoroscopic guidance alone. CTF-guided PTBD was performed using a combination of a helical CT scanner of the latest generation and a mobile C-arm; conventional PTBD was performed under fluoroscopic guidance in the angiographic unit. End points of the study were the success (a puncture that enabled safe placement of a guidewire in a suitable bile duct) and the complication rate (hemobilia, bile fistula, biliary peritonitis), the number of punctures required, the time needed for successful puncture of a suitable bile duct, and the patient's radiation exposure. Results: CTF-guided puncture of peripheral bile ducts suitable for PTBD was successful at the first attempt in 16 cases, under conventional fluoroscopic guidance, in only two cases. We found a significantly different number of punctures (1.2 in group A vs 2.9 in group B), a significantly shorter time for puncture in group A (mean 39 sec), but also a significantly higher skin exposure dosage in group A (mean 49.5 mSv surface dosage). There was no significant difference regarding the total procedure time. Only one complication occurred in group B (portobiliary fistula). Conclusion: CTF-guided initial puncture of bile ducts allowed a significantly reduced number of punctures and puncture times compared with puncture under conventional fluoroscopic guidance for placement of percutaneous transhepatic biliary drainage catheters.     

Percutaneous Relief of Tension Pneumomediastinum in a Child

The purpose of this article was to describe the experience of relieving tension pneumomediastinum by a fluoroscopic-guided percutaneous method. We inserted a percutaneous drainage catheter with a Heimlich valve under fluoroscopic guidance to relieve the tension pneumomediastinum in a 2-year-old girl who suffered from dermatomyositis with lung involvement. This allowed immediate relief without the need for surgery. The procedure was repeated for relapsed tension pneumomediastinum. Good immediate results were achieved in each attempt. We conclude that percutaneous relief of pneumomediastinum under fluoroscopic guidance can be performed safely and rapidly in patients not fit for surgery.     

经皮透视引导下胃造瘘和胃空肠造瘘术的临床应用

目的 评估经皮透视引导下胃造瘘和胃空肠造瘘术的临床应用,探讨影像导引下置管的技术操作及其适应证、禁忌证和并发症.方法 回顾性分析2002年5月 - 2010年6月在我院实施透视引导下胃造瘘和胃空肠造瘘术的40例患者的临床资料.采用Seldinger技术造痿,成功置入饲养管.分析手术指征,操作过程,技术成功率,手术相关并...     

Comparison of C-arm CT fluoroscopy and conventional fluoroscopy for percutaneous biliary drainage procedures

PURPOSE: To conduct a prospective randomized evaluation of C-arm computed tomography (CT) fluoroscopy for external biliary drainage procedures in comparison with conventional fluoroscopic guidance to reduce the number of transhepatic punctures as a primary endpoint. MATERIALS AND METHODS: In 18 patients with biliary obstructions, 20 external percutaneous biliary drainage procedures were prospectively performed with use of either C-arm CT fluoroscopy or conventional fluoroscopy alone. The number of hepatic punctures, procedure time, and fluoroscopy time, were analyzed separately for both methods. RESULTS: C-arm CT fluoroscopy resulted in a reduced number of transhepatic punctures, with decreased procedure and fluoroscopy times (P < .05; t test). When compared with conventional external biliary drainage procedures, a mean of 1.8+/-1 versus 4.8+/-2.8 hepatic punctures at a fluoroscopy time of 3.4+/-1.5 versus 11.4+/-7.4 minutes was required for C-arm CT fluoroscopy, while procedure times were 11+/-3.6 versus 16.2+/-9.3 minutes. CONCLUSIONS: C-arm CT fluoroscopy is associated with decreased procedure and fluoroscopy times, while fewer transhepatic punctures are required to establish external biliary drainage.     

Modified Radiology-Guided Percutaneous Gastrostomy (MRPG) for Patients with Complete Obstruction of the Upper Digestive Tract and Who are without Endoscopic or Nasogastric Access

Objective

We wanted to report on our experience with modified radiology-guided percutaneous gastrostomy (MRPG) without endoscopic or nasogastric access for treating patients with complete obstruction of the upper digestive tract.

Materials and Methods

Fourteen oncology patients (13 had hypopharyngeal cancer and 1 had upper esophageal cancer) with complete obstruction of the upper digestive tract were recruited. Conventional percutaneous endoscopic gastrostomy (PEG) and radiologic (fluoroscopy-guided) percutaneous gastrostomy (RPG) were not feasible in all the patients. An MRPG technique (with a combination of ultrasound, an air enema and fluoroscopic guidance) was performed in these patients.

Results

We achieved successfully percutaneous gastrostomy using the modified technique in all patients without any major or minor complications after the procedure.

Conclusion

A modified radiology-guided percutaneous gastrostomy technique can be safely performed in patients who failed to receive conventional PEG or RPG due to the absence of nasogastric access in the completely obstructed upper digestive tract.     

Radiation exposure to operating room personnel during transperineal interstitial permanent prostate brachytherapy

PURPOSE: To identify factors associated with radiation exposure (RE) to operating room personnel during transperineal interstitial permanent prostate brachytherapy (TIPPB). METHODS AND MATERIALS: Between May 1998 and December 2000, 155 patients underwent TIPPB with fluoroscopic and ultrasound guidance. Data for each case included: operating room time (OT), anesthesia time (AT), fluoroscopy time (FT), number and type of seed implanted, total seed activity, and resident participation. RESULTS: Personnel RE per case, FT, OT, and AT decreased as case number increased. Whole body badge dose per case decreased from a mean of 0.15+/-0.01 mSv (15+/-1 mrem) in 1998 to 0.074+/-0.011 mSv (7+/-1 mrem) in 2000. Average FT per case decreased from a mean of 17:27 min (range, 10:40-28:23) in 1998 to 12:08 min (range, 6:40-31:00) in 2000. Resident participation was associated with increased FT. Mean whole body and ring badge doses for the treating radiation oncologist were 0.0076 mSv/min (0.76 mrem/min) and 0.05 mSv/min (5.26 mrem/min) of FT, respectively. CONCLUSIONS: FT was the predominant factor that related to RE during TIPPB. Treating radiation oncologists were exposed to less than 20 mSv per 100 cases, significantly less than other fluoroscopically guided procedures. Nonetheless, appropriate radiation exposure precautions during TIPPB should continue.     

Seed migration after transperineal interstitial prostate brachytherapy with I-125 free seeds: analysis of its incidence and risk factors

Purpose

The purpose of this study was to evaluate the incidence and predictors of seed migration after transperineal interstitial prostate brachytherapy.

Materials and methods

From March 2007 to March 2011, 121 patients with stage T1?CT2 prostate cancer underwent transperineal interstitial prostate brachytherapy. Pre-planning was performed 3?weeks prior to implantation, and the implants were inserted using the standard parallel needle insertion technique. All patients underwent a series of radiographs [chest radiography, kidney?Cureter?Cbladder (KUB) radiography, and a CT scan] to assess whether seed migration had occurred on postoperative days?1 and 30, and 12?months.

Results

Seed migration occurred in 31 (25.6?%) of 121 patients. A total of 51 of 7,883 (0.65?%) implanted seeds migrated. Migration was detected on postoperative day?1 in 16 patients, day?30 in 13 patients and at 12?months in 4 patients (migration occurred at different times in 2 patients). The migrated seeds were found in the lungs, pelvis, heart, mediastinum, kidney, inguinal canal, liver and sacrum. The number of needles was a statistically significant factor in seed migration.

Conclusions

The seeds migrated to many organs. No decrease in the dose administered to the prostate or adverse effects associated with seed migration were noted.     

Prostate brachytherapy seed embolization to the right renal artery

PurposeWe report three cases of seed embolization to the right renal artery after iodine-125 (I-125) transperineal interstitial permanent prostate brachytherapy.Methods and materialsCase 1: A 65-year-old man presented with right flank and back pain less than 4 months after prostatic seed implantation. CT evaluation for renal stone showed a seed embedded in the lower aspect of the right kidney. Case 2: A 73-year-old man complained of painless hematuria 3 years after prostatic seed brachytherapy. CT and subsequent abdominal angiography showed a seed embolization to a lower branch of the right renal artery. Case 3: An 84-year-old man presented with gross hematuria 7 months after prostatic seed implantation. Excretory urogram and subsequent CT demonstrated the right lower renal seed migration.ResultsProstatic seed embolization to the right renal artery may cause pain and hematuria. This pattern of seed migration may be easily overlooked by imagers because it mimics renal lithiasis on cross-sectional imaging. Knowledge of prior history of permanent interstitial prostate brachytherapy and careful radiologic interpretation may help to achieve the correct diagnosis of rare renal seed migration.ConclusionsWe present an additional atypical site of brachytherapy seed relocation in the right renal artery in 3 patients. This type of migration is probably secondary to pulmonary arteriovenous malformation or right-to-left cardiac shunts. Awareness of the propensity of seeds to dislodge and vigilance in imaging interpretation of prostatic brachytherapy recipients are necessary for the correct diagnosis of seed embolization.     

Patient and operator exposure during percutaneous vertebroplasty

Purpose

The purpose of this study was to compare exposure of patient and operator to ionising radiation during percutaneous vertebroplasty performed under combined computed tomography (CT) and fluoroscopic guidance or fluoroscopic guidance alone.

Materials and methods

With the collaboration of our physics department, we measured exposure on ten patients undergoing vertebroplasty with combined CT and fluoroscopic guidance and on ten undergoing vertebroplasty with fluoroscopic guidance alone.

Results

Mean operator dose was approximately 0.8 microSv during vertebroplasty done with combined CT and fluoroscopic guidance and 5.8 microSv in procedures with fluoroscopic guidance alone. Mean patient dose was approximately 6 mSv for combined guidance and 8 mSv for fluoroscopic guidance, a difference that was not found to be statistically significant.

Conclusions

Although combined CT and fluoroscopic guidance is normally preferred for difficult areas such as the cervical and upper thoracic vertebrae, to ensure operator radiation protection, the technique should also be considered for areas normally treated under fluoroscopic guidance alone. However, a larger patient series is needed to correctly evaluate the real contribution of low-dose CT to patient exposure.     

Radioactive seed migration after transperineal interstitial prostate brachytherapy and associated development of small-cell lung cancer

PurposeWe report a case of lung carcinoma developing in the location of a migrated prostate brachytherapy seed.Methods and MaterialsA 57-year-old male nonsmoker was originally diagnosed with prostate adenocarcinoma Group IIB in October 1999. Treatment was completed at an outside local hospital and consisted of hormone suppression, pelvic external beam radiation, and transperineal interstitial permanent prostate brachytherapy with loose iodine-125 seeds.ResultsThe treatment was unremarkable for any complications, and immediate postimplant evaluation did not reveal any loose seeds. The patient remained clinically without evidence of disease and was asymptomatic until an isolated episode of hematuria in December 2009. Radiographic evaluation noted an incidental right lower lobe lung mass with a 4-mm hyperdensity slightly off-center. Biopsy confirmed Stage IB limited-stage small-cell lung cancer, and he underwent thoracic radiation with concurrent systemic chemotherapy. The mass remained mildly avid on a positron emission tomographic scan after treatment, and he underwent surgical evaluation with final pathology demonstrating no residual tumor but a metal rod-like implant consistent with a migrated radioactive brachytherapy seed.ConclusionsTo our knowledge, this is the first case of a long-term adverse sequela seen in the location of a migrated brachytherapy seed. Although reported incidence of pulmonary seed emboli remains low with little measurable consequence on pulmonary function, we must appreciate that a theoretical risk for secondary malignancy remains not only locally within the periprostatic region but also at any site of seed migration.