| Objective:Gynecological tumors are mainly treated with surgery,radiotherapy,and chemotherapy.Due to the unique anatomical relationship of the prone site of gynecological tumors,especially when the lesion scope is enormous or the infiltration is deep,the surgical removal becomes challenging,the recurrence rate is high,and the quality of postoperative life is compromised.Radiotherapy is a significant treatment method that mainly combines external irradiation with brachytherapy.The local control rate of intraluminal brachytherapy for small gynecological tumors is promising.However,with poor anatomical conditions,retroperitoneal lymph node metastasis,and extensive adhesion in the pelvic cavity,the target area of intraluminal radiotherapy is not covered completely,the dose distribution is uneven,and the effect is not appropriate.Foreign research associations suggest that inter tissue implantation can be used to make up for the deficiency of endovascular radiotherapy.However,during the tumor recurrence and metastasis,the adjacent organs at risk are compressed and infiltrated.It is not easy to achieve the desired effects with the conventional treatment.Radioactive iodine-125 seeds implantation has been frequently applied in treating patients with recurrent and metastatic gynecological tumors,providing a new therapeutic direction in this field.Permanent interstitial implantation of radioactive seeds can give higher radiation doses within the limits of organs at risk,making it possible to cure.Seeds implantation in China has been widely used in tumors as an effective treatment.However,no standard method exists,and the postsurgical dosage is nonuniform,making it difficult to be repeated and popularized.Currently,freehand implantation is the main method.The flexibility of the insertion angle is improved with the3D printed template,which can accurately avoid the organs at risk around the tumor,reduce the incidence of error,make dosiology more accurate,and achieve a higher degree of consistency with the preoperative plan.This study aimed to analyze the difference in dosimetry and clinical efficacy between 3D printed templates and freehand implantation in treating gynecological tumors with iodine-125 seeds.The preliminary efficacy of radioiodine 125 seeds combined with immunotherapy in gynecological tumors was also analyzed and discussed.Methods:The data of gynecological tumor patients treated with radioactive seeds implantation in Hebei General Hospital from January 2014to December 2021 were screened,including 39 patients treated with a 3D printed template(template group)and 54 patients treated with freehand particle implantation(freehand group).The treatment plan was formulated using the Treatment Planning System(TPS)before surgery.In the template group,3D templates were printed,and seeds were implanted under the guidance of template and CT.In the freehand group,the operation was completed directly according to the preoperative plan with CT guidance alone.A postoperative TPS verification plan was applied in the first part to obtain D80,D90,V90,V100,and V150 of the DVH graph.The differences between D80,D90,V90,V100,and V150 were compared between the two groups.According to the formula of,andThe dosage was calculated to determine the statistical differences.The quality of the seeds implants was assessed using the British Columbia Cancer Research Centre quality Assessment Criteria.The efficacy evaluation was completed according to RECISIT 1.1.The local control rate and effective rates of 2,6,and 12 months post-operation were compared between the two groups.The survival analysis was completed by the Kaplan-Meier method.In the second part,the clinical value of iodine-125 seeds implantation combined with immunotherapy in treating gynecological tumors was discussed.From January 2018 to December 2021,four patients with gynecological tumors who received immunotherapy combined with iodine-125 seeds brachytherapy were retrospectively analyzed in the oncology department of Hebei General Hospital.All patients were pathologically confirmed to have gynecological tumors.Mutation tests in driver genes such as ALK,ROS1,and BRAF were negative.All the selected cases underwent iodine-125 seeds implantation and were treated with immunotherapy.The clinical efficacy was evaluated by the efficacy evaluation criteria for solid tumors(RECIST version 1.1).Tolerance was assessed by monitoring the adverse events such as bleeding,fever,bone marrow suppression,hepatic and renal insufficiency,radiation dermatitis and mucosal reactions,radiation pneumonia,particle displacement,and other symptoms.Results:All 39 patients in the template group and all 54 patients in the freehand group were successfully operated on.The preoperative and postoperative D90 values of the template group were(111.66±15.00)Gy and(111.61±16.18)Gy,respectively.The difference was not statistically significant(P=0.997).While the preoperative and postoperative D90 values of the freehand group were(105.92±20.20)Gy and(105.21±18.57)Gy,respectively,the difference was not statistically significant(P=0.660).The D80 values were(133.05±13.18)Gy and(130.19±15.10)Gy,respectively,and there was no statistically significant difference(P=0.803).The D80 values of the freehand group were(123.87±26.20)Gy and(123.33±23.66)Gy,and the difference was statistically significant(P=0.000).The V90 values of the template group was(94.36%±1.42%),and the freehand group was(84.59%±3.14%).The difference between the two groups was not statistically significant.The V100values was(90.23%±3.42%)and(80.94%±6.71%),respectively.The difference was not statistically significant.The V150 values was(65.50±5.64%)and(63.47±9.09%),respectively.The difference was also not statistically significant.The difference and percentage difference of D80,D90,V90,V100,and V150 between the two groups before and after surgery was statistically significant.The proportions of"excellent","good","medium"and"poor"in the validation quality assessment template group were:excellent:61.5%(24/39);good:33.3%(13/39);medium:5.2%(2/39);poor:0(0).The freehand group was excellent:50%(27/54);good:25.9%(14/54);medium:18.5%(10/54);poor:5.6%(3/54).Template group D90 reached the standard rate of 84.6%(33/39).The rate of V100 reached the standard of 82.1%(32/39).The D90 in the freehand group was 38.9%(21/54).The rate of V100was 44.4%(24/54).The effective rate of the template group was 46.2%(18/39),and the local control rate was 100%(39/39)two months after the operation.The effective rate of the freehand group was 46.3%(25/54),and the local control rate was 100%(54/54).The effective rate was 66.7%(26/39),and the local control rate was 94.9%(37/39)in the template group six months after the operation.The effective rate of the hands-free group was 61.1%(33/54),and the local control rate was 94.4%(51/54).The effective rate was69.2%(27/39),and the local control rate was 94.9%(37/39)in the template group 12 months after the operation.The effective rate of the freehand group was 59.3%(32/54),and the local control rate was 90.7%(49/54).There was no statistically significant difference in efficacy data between the two groups.There were complications in the two groups.Postoperative pain was transient,and there was no significant difference in postoperative fevers.Bleeding due to puncture occurred in two cases in the freehand group.There was one case in the template group and two cases in the freehand group,and the difference was not statistically significant.Patients were followed up for 6-27 months,with a median follow-up of 12 months.The median survival time was 36(18-54)months in the template group and 23(9-37)months in the freehand group,and the overall survival rates(OS)at 6,12,18,and 24 months were80.9%vs 79.5%,62.7%vs 60.5%,59.7%vs 50.5%,and 55.7%vs 41.5%,respectively,(X~2=0.249,P=0.618).All the patients with radioiodine-125 seeds combined immunotherapy achieved a complete or partial response with the stable condition and significantly prolonged their progression-free survival.Conclusions:Iodine-125 seeds implantation guided by a 3D printed template for treating gynecological tumors is safe and feasible.The im plantation guided by 3D printed template can make the pre-implantation plan more accurate than the freehand group.The consistency of dose parameters before and after the operation can improve the quality of the operation.Radioactive iodine 125 seeds combined with immunotherapy in the treatment of gynecological tumors is worth popularizing. |
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