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Lung cancer eight years after radioactive seed migration
2468-2942/ © 2016 Elsevier Ltd. All rights reserved.
Cancer Treatment and Research Communications 9 (2016) 124–125
Contents lists available at ScienceDirect
Cancer Treatment and Research Communications journal homepage: www.elsevier.com/locate/ctarc
Lung cancer eight years after radioactive seed migration a,c,⁎
a,c
a,c
a,c
crossmark
b,c
Angela Lin , Alexander Sun , Andrea Bezjak , Jean-Pierre Bissonnette , Jeffrey Tanguay , Shaf Keshavjeeb,c, Elantholi P. Saibishkumara,c a b c
Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada University Health Network, Toronto, ON, Canada University of Toronto, Toronto, ON, Canada
A R T I C L E I N F O
A BS T RAC T
Keywords: Seed migration Brachytherapy Lung cancer Radiation-induced cancer
We report here an occurrence of non-small cell lung cancer in a patient who had pulmonary radioactive seed emboli from his prostate brachytherapy 8 years post procedure. The potential etiological role of radiation carcinogenesis should be recognized.
Clinical practice points
•
Pulmonary seed emboli are known as potential complications of interstitial prostate brachytherapy. There have been a few reports of radiation pneumonitis as a result of seed emboli. We report here an occurrence of non-small cell lung cancer in a patient who had pulmonary radioactive seed emboli from his prostate brachytherapy 8 years post procedure. This is the second case report in the literature to date about this subject. The potential etiological role of radiation carcinogenesis should be recognized. Efforts, such as using stranded seeds, to reduce the risk of pulmonary seed migration may be of interest to clinicians. Known pulmonary radioactive seed emboli, in addition to heavy smoking history, may be considered as a risk factor to select highrisk population for lung cancer screening.
• • • •
Case In September 2007, a 65-year-old male, with a remote 40 pack-year smoking history (quit in 1997), underwent interstitial prostate brachytherapy for prostate adenocarcinoma. Percutaneous trans-perineal implantation of 96 loose Iodine-125 seeds was performed. Chest X-ray performed one month post-procedure revealed that five seeds migrated to the lung (Fig. 1A). The patient remained well until March 2015, when he presented with cough and hemoptysis and was found to have an 8.5 cm necrotic right lung mass (Fig. 1B). Biopsy showed poorly differentiated carcinoma; staging showed no evidence of lymphadenopathy or distant metastases. Discussion ensued as to whether the seeds ⁎
may have led to the development of this cancer, and whether there were any radiation safety precautions for the surgical or pathology teams if he proceeded with surgery. As there was no residual radioactivity of the seeds, we proceeded with surgical resection. Pathology reported a 13 cm sarcomatoid carcinoma, pleomorphic type. A brachytherapy seed was identified in the background lung parenchyma, 1.5 cm superior to the mass. Despite negative nodes and negative margin, the patient was found to have bilateral lung nodules, renal and adrenal metastases on restaging scans performed 10 weeks postoperatively. He went on to receive palliative chemotherapy. Discussion Seed migration is a well-recognized potential complication of interstitial prostate brachytherapy, with lungs being the most frequent site of migration [1]. The postulated mechanism of seed migration is through the periprostatic veins, to the iliac veins, right heart and ultimately to the lungs [1]. The incidence rates range from 0.7% to as high as 55%, depending on the type of seeds used (higher with loose seeds than with linked seeds) [2] and on the technique of seed placement (higher with extraprostatic than with intraprostatic techniques) [1]. Pulmonary seed emboli appear to be associated with little or no adverse effects, with only a few reports of radiation pneumonitis to date [3]. Radiation carcinogenesis is a potential long-term adverse sequela. Patients who have received external beam radiation for Hodgkin's disease have an increased risk of lung cancer; furthermore, smokers experience a significantly greater risk attributable to radiation than nonsmokers [4]. However, there has been only one reported case in the literature of the development of lung cancer in a non-smoker
Correspondence to: BC Cancer Agency, Centre for the Southern Interior, 399 Royal Avenue, Kelowna, BC, Canada V1Y 5L3. E-mail address: [email protected] (A. Lin).
http://dx.doi.org/10.1016/j.ctarc.2016.09.004 Received 7 June 2016; Accepted 6 September 2016
Cancer Treatment and Research Communications 9 (2016) 124–125
A. Lin et al.
brachytherapy [5]. Radiation dose at distance of 1.5 cm from the seed source is estimated to be between 1.94 Gy and 7.86 Gy, based on dosimetric calculations for an anisotropic I-125 seed with lung density correction [6]. It was shown that radiation-associated risk for lung cancer increases with doses as low as 0.5 Gy, possibly due to the potentiating effect of radiation carcinogenesis at low to medium doses, without the mitigation of cell-killing effect of radiation at higher doses [7]. The lack of medical literature on carcinogenetic sequelae of seed emboli, despite the volume of brachytherapy procedures performed, could be owing to extreme rarity of such an adverse event, short followup periods in those studies or under-reporting. The development of lung cancer in our patient is likely multifactorial, but the potential etiological role of radiation carcinogenesis should increase awareness of such issues. The brachytherapy team at our institution made efforts to reduce the risk of seed migration by using linked or stranded seeds, which has been our standard practice since 2009. Acknowledgement We thank the patient for consenting to this publication, and the pathology assistants Martin Grealish, Sarah James and Amanda Chan from Toronto General Hospital for processing the gross specimen. References [1] K. Miyazawa, M. Matoba, H. Minato, et al., Seed migration after transperineal interstitial prostate brachytherapy with I-125 free seeds: analysis of its incidence and risk factors, Jpn. J. Radiol. 30 (8) (2012) 635–641. [2] P.P. Kumar, R.R. Good, Vicryl carrier for I-125 seeds: percutaneous transperineal insertion, Radiology 159 (1) (1986) 276. [3] N. Miura, Y. Kusuhara, K. Numata, et al., Radiation pneumonitis caused by a migrated brachytherapy seed lodged in the lung, Jpn. J. Clin. Oncol. 38 (9) (2008) 623–625. [4] F.E. van Leeuwen, W.J. Klokman, M. Stovall, et al., Roles of radiotherapy and smoking in lung cancer following Hodgkin’s disease, J. Natl. Cancer Inst. 87 (20) (1995) 1530–1537. [5] W.C. Chen, J. Katcher, C. Nunez, A.M. Tirgan, R.J. Ellis, Radioactive seed migration after transperineal interstitial prostate brachytherapy and associated development of small-cell lung cancer, Brachytherapy 11 (5) (2012) 354–358. [6] E.M. Tapen, J.C. Blasko, P.D. Grimm, et al., Reduction of radioactive seed embolization to the lung following prostate brachytherapy, Int. J. Radiat. Oncol. Biol. Phys. 42 (5) (1998) 1063–1067. [7] D.J. Brenner, R.E. Curtis, E.J. Hall, E. Ron, Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery, Cancer 88 (2) (2000) 398–406.
Fig. 1. (A) CXR performed one month after prostate brachytherapy revealed two migrated seeds in the right upper lobe, two in the right middle lobe, and one in the left lower lobe (red arrows). (B) CXR in 2015 showed a large right lung mass. In the surgical specimen, one brachytherapy seed (green arrow) was identified in the lung parenchyma, 1.5 cm superior to resected tumor. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article).
patient 7.5 years after pulmonary seed migration from his prostate
125
Cancer Treatment and Research Communications 9 (2016) 124–125
Contents lists available at ScienceDirect
Cancer Treatment and Research Communications journal homepage: www.elsevier.com/locate/ctarc
Lung cancer eight years after radioactive seed migration a,c,⁎
a,c
a,c
a,c
crossmark
b,c
Angela Lin , Alexander Sun , Andrea Bezjak , Jean-Pierre Bissonnette , Jeffrey Tanguay , Shaf Keshavjeeb,c, Elantholi P. Saibishkumara,c a b c
Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada University Health Network, Toronto, ON, Canada University of Toronto, Toronto, ON, Canada
A R T I C L E I N F O
A BS T RAC T
Keywords: Seed migration Brachytherapy Lung cancer Radiation-induced cancer
We report here an occurrence of non-small cell lung cancer in a patient who had pulmonary radioactive seed emboli from his prostate brachytherapy 8 years post procedure. The potential etiological role of radiation carcinogenesis should be recognized.
Clinical practice points
•
Pulmonary seed emboli are known as potential complications of interstitial prostate brachytherapy. There have been a few reports of radiation pneumonitis as a result of seed emboli. We report here an occurrence of non-small cell lung cancer in a patient who had pulmonary radioactive seed emboli from his prostate brachytherapy 8 years post procedure. This is the second case report in the literature to date about this subject. The potential etiological role of radiation carcinogenesis should be recognized. Efforts, such as using stranded seeds, to reduce the risk of pulmonary seed migration may be of interest to clinicians. Known pulmonary radioactive seed emboli, in addition to heavy smoking history, may be considered as a risk factor to select highrisk population for lung cancer screening.
• • • •
Case In September 2007, a 65-year-old male, with a remote 40 pack-year smoking history (quit in 1997), underwent interstitial prostate brachytherapy for prostate adenocarcinoma. Percutaneous trans-perineal implantation of 96 loose Iodine-125 seeds was performed. Chest X-ray performed one month post-procedure revealed that five seeds migrated to the lung (Fig. 1A). The patient remained well until March 2015, when he presented with cough and hemoptysis and was found to have an 8.5 cm necrotic right lung mass (Fig. 1B). Biopsy showed poorly differentiated carcinoma; staging showed no evidence of lymphadenopathy or distant metastases. Discussion ensued as to whether the seeds ⁎
may have led to the development of this cancer, and whether there were any radiation safety precautions for the surgical or pathology teams if he proceeded with surgery. As there was no residual radioactivity of the seeds, we proceeded with surgical resection. Pathology reported a 13 cm sarcomatoid carcinoma, pleomorphic type. A brachytherapy seed was identified in the background lung parenchyma, 1.5 cm superior to the mass. Despite negative nodes and negative margin, the patient was found to have bilateral lung nodules, renal and adrenal metastases on restaging scans performed 10 weeks postoperatively. He went on to receive palliative chemotherapy. Discussion Seed migration is a well-recognized potential complication of interstitial prostate brachytherapy, with lungs being the most frequent site of migration [1]. The postulated mechanism of seed migration is through the periprostatic veins, to the iliac veins, right heart and ultimately to the lungs [1]. The incidence rates range from 0.7% to as high as 55%, depending on the type of seeds used (higher with loose seeds than with linked seeds) [2] and on the technique of seed placement (higher with extraprostatic than with intraprostatic techniques) [1]. Pulmonary seed emboli appear to be associated with little or no adverse effects, with only a few reports of radiation pneumonitis to date [3]. Radiation carcinogenesis is a potential long-term adverse sequela. Patients who have received external beam radiation for Hodgkin's disease have an increased risk of lung cancer; furthermore, smokers experience a significantly greater risk attributable to radiation than nonsmokers [4]. However, there has been only one reported case in the literature of the development of lung cancer in a non-smoker
Correspondence to: BC Cancer Agency, Centre for the Southern Interior, 399 Royal Avenue, Kelowna, BC, Canada V1Y 5L3. E-mail address: [email protected] (A. Lin).
http://dx.doi.org/10.1016/j.ctarc.2016.09.004 Received 7 June 2016; Accepted 6 September 2016
Cancer Treatment and Research Communications 9 (2016) 124–125
A. Lin et al.
brachytherapy [5]. Radiation dose at distance of 1.5 cm from the seed source is estimated to be between 1.94 Gy and 7.86 Gy, based on dosimetric calculations for an anisotropic I-125 seed with lung density correction [6]. It was shown that radiation-associated risk for lung cancer increases with doses as low as 0.5 Gy, possibly due to the potentiating effect of radiation carcinogenesis at low to medium doses, without the mitigation of cell-killing effect of radiation at higher doses [7]. The lack of medical literature on carcinogenetic sequelae of seed emboli, despite the volume of brachytherapy procedures performed, could be owing to extreme rarity of such an adverse event, short followup periods in those studies or under-reporting. The development of lung cancer in our patient is likely multifactorial, but the potential etiological role of radiation carcinogenesis should increase awareness of such issues. The brachytherapy team at our institution made efforts to reduce the risk of seed migration by using linked or stranded seeds, which has been our standard practice since 2009. Acknowledgement We thank the patient for consenting to this publication, and the pathology assistants Martin Grealish, Sarah James and Amanda Chan from Toronto General Hospital for processing the gross specimen. References [1] K. Miyazawa, M. Matoba, H. Minato, et al., Seed migration after transperineal interstitial prostate brachytherapy with I-125 free seeds: analysis of its incidence and risk factors, Jpn. J. Radiol. 30 (8) (2012) 635–641. [2] P.P. Kumar, R.R. Good, Vicryl carrier for I-125 seeds: percutaneous transperineal insertion, Radiology 159 (1) (1986) 276. [3] N. Miura, Y. Kusuhara, K. Numata, et al., Radiation pneumonitis caused by a migrated brachytherapy seed lodged in the lung, Jpn. J. Clin. Oncol. 38 (9) (2008) 623–625. [4] F.E. van Leeuwen, W.J. Klokman, M. Stovall, et al., Roles of radiotherapy and smoking in lung cancer following Hodgkin’s disease, J. Natl. Cancer Inst. 87 (20) (1995) 1530–1537. [5] W.C. Chen, J. Katcher, C. Nunez, A.M. Tirgan, R.J. Ellis, Radioactive seed migration after transperineal interstitial prostate brachytherapy and associated development of small-cell lung cancer, Brachytherapy 11 (5) (2012) 354–358. [6] E.M. Tapen, J.C. Blasko, P.D. Grimm, et al., Reduction of radioactive seed embolization to the lung following prostate brachytherapy, Int. J. Radiat. Oncol. Biol. Phys. 42 (5) (1998) 1063–1067. [7] D.J. Brenner, R.E. Curtis, E.J. Hall, E. Ron, Second malignancies in prostate carcinoma patients after radiotherapy compared with surgery, Cancer 88 (2) (2000) 398–406.
Fig. 1. (A) CXR performed one month after prostate brachytherapy revealed two migrated seeds in the right upper lobe, two in the right middle lobe, and one in the left lower lobe (red arrows). (B) CXR in 2015 showed a large right lung mass. In the surgical specimen, one brachytherapy seed (green arrow) was identified in the lung parenchyma, 1.5 cm superior to resected tumor. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article).
patient 7.5 years after pulmonary seed migration from his prostate
125