Implanting Iodine-125 Seed Strand Inside the Portal Vein Stent: An Improved Approach to Endovascular Brachytherapy for Treatment of Patients with Hepatocellular Carcinoma and Main Portal Vein Tumor Thrombus

Figures & data

Figure 1 Study flowchart.

Abbreviations: mPVTT, main portal vein tumor thrombus; ECOG PS, Eastern Cooperative Oncology Group performance status; SMV, superior mesenteric vein; SV, splenic vein.

Figure 2 A 68-year-old male HCC patient with mPVTT underwent ¹²⁵I seed strand (30 seeds) implantation inside the portal vein stent. The patient underwent transarterial chemoembolization (TACE) 20 days later and died 6 months after the ¹²⁵I seed strand and portal vein stent implantation because of liver failure caused by progression of the tumor. (a) Portography shows a large filling defect in the main portal vein and the right branch of the portal vein with near-complete obstruction of the portal venous blood flow. (b) Portography after deployment of the portal vein stent shows restored blood flow in the main portal vein and the right branch. (c and d) Ultrasound images showing a portion of the ¹²⁵I seed strand in the liver parenchyma and the blood flow in the patent portal vein stent. (e) SPECT imaging shows homogeneous radiation dose distribution from the ¹²⁵I seed strand covering the range of the tumor thrombus. (f) Follow-up computed tomography at 3 months after the procedure shows the ¹²⁵I seed strand inside the stent without displacement, with steady blood flow in the stent.

Figure 3 A 67-year-old female patient with HCC and mPVTT underwent ¹²⁵I seed strand (26 seeds) implantation inside the portal vein stent. The patient had 3 transarterial chemoembolization (TACE) treatments during a 13-month follow-up, resulting in a stable partial response (PR). (a and b) Before treatment, the enhanced computed tomography shows the tumor thrombus in the main portal vein and the right branch of portal vein (arrow). (c) During the stent/strand placement, initial portography shows the filling defect in the portal vein with portal vein stenosis. (d) Portography following deployment of the portal vein stent shows restored blood flow in the main portal vein and the right branch. (e and f) Follow-up computed tomography at 1 year after the procedure shows the ¹²⁵I seed strand inside the stent without displacement, and steady blood flow in the stent (arrow).

Table 1 Characteristics of the Study Population

Characteristics	Group A (n = 12)	Group B (n = 11)	P value
Gender (male/female)	9/3	9/2	ns
Age (years)	61.33±+7.97	60.36±11.06	0.811
Maximum tumor diameter (cm)	8.05±2.77	7.96±2.82	0.942
Child-Pugh (A/B)	8/4	9/2	0.640
ECOG PS (1/2)	5/7	5/6	ns
Degree of mPVTT (stenosis/occlusive)^a	10/2	8/3	0.640
HBV (Yes/No)	12/0	11/0	ns
Ascites (Yes/No)	2/10	2/9	ns
AFP (≥400/<400)	6/6	5/6	ns
Previous treatment (Yes/No)^b	6/6	7/4	0.680
Post-operation TACE (Yes/No)	10/2	10/1	ns
Number of post-procedure TACE treatments	4.17±3.16	3.64±2.46	0.659
Sorafenib (Yes/No)	9/3	10/1	0.590

Notes: ^aIf the diameter of the filling defect exceeded 90% of the mPVTT on the transverse contrast-enhanced CT image or MRI before therapy, the mPVTT was defined as occlusive. ^bPrevious treatment, including resection, thermal ablation, TACE, or a combination of these therapies.

Abbreviations: EOCG PS, Eastern Cooperative Oncology Group performance status; mPVTT, main portal vein tumor thrombus; HCV, hepatitis C virus; AFP, alpha-fetoprotein; HBV, hepatitis B virus; TACE, transarterial chemoembolization.

Table 2 Pre- and Post-Procedure Liver Function

		Pre-Operation	One Week After Operation	P value
Group A	ALT (U/L)	58.09±41.02	78.27±72.24	0.319
	AST (U/L)	79.54±38.02	97.18±69.92	0.308
	TB (μmol/L)	27.01±9.68	27.29±9.82	0.922
Group B	ALT (U/L)	56.42±31.74	74.17±52.08	0.189
	AST (U/L)	69.17±20.34	94.41±60.48	0.159
	TB (μmol/L)	28.92±10.48	27.26±8.85	0.683

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; TB, total bilirubin.

Figure 4 Kaplan-Meier analysis for overall survival (left) and stent patency (right) in group A vs group B. The median survival was 12 months in group A and 13 months in group B (p = 0.822). The median duration of stent patency time was 9 months in group A and 12 months in group B (p = 0.670).