J Korean Neurosurg Soc.  2013 Sep;54(3):175-182. 10.3340/jkns.2013.54.3.175.

Intracavitary Radiation Therapy for Recurrent Cystic Brain Tumors with Holmium-166-Chico : A Pilot Study

• Ha EJ
• Gwak HS
• Rhee CH
• Youn SM
• Choi CW
• Cheon GJ

• KMID: 2190894
• DOI: http://doi.org/10.3340/jkns.2013.54.3.175

Abstract

OBJECTIVE
Intracavitary injection of beta-emitting radiation source for control of cystic tumors has been tried with a benefit of localized internal radiation. The authors treated cystic brain tumor patients with Holmium-166-chitosan complex (Ho-166-chico), composed of a beta-emitting radionuclide Holmium-166 and biodegradable chit polymer, and evaluated the safety and effective measurement for response.
METHODS
Twenty-two patients with recurrent cystic brain tumor and/or located in a deep or eloquent area were enrolled in this pilot study. The cyst volume and wall thickness were determined on CT or MRI to assess radiological response. The activity of Ho-166-chico injected via Ommaya reservoir was prescribed to be 10-25 Gy to the cyst wall in a depth of 4 mm.
RESULTS
There was neither complications related to systemic absorption nor leakage of Ho-166-chico in all 22 patients. But, two cases of oculomotor paresis were observed in patients with recurrent craniopharyngioma. Radiological response was seen in 14 of 20 available follow-up images (70%). Seven patients of 'evident' radiological response experienced more than 25% decrease of both cyst volume and wall thickness. Another 7 patients with 'suggestive' response showed decrease of cyst volume without definitive change of the wall thickness or vice versa. All patients with benign tumors or low grade gliomas experienced symptomatic improvement.
CONCLUSION
Ho-166-chico intracavitary radiation therapy for cystic tumor is a safe method of palliation without serious complications. The determination of both minimal effective dosage and time interval of repeated injection through phase 1 trial could improve the results in the future.

Keyword

Holmium; Chitosan; Intracavitary radiation; Intracranial cyst

MeSH Terms

Absorption
Brain Neoplasms*
Brain*
Chitosan
Craniopharyngioma
Follow-Up Studies
Glioma
Holmium
Humans
Paresis
Pilot Projects*
Polymers
Chitosan
Holmium
Polymers

Figure

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  Fig. 1 Leakage test before Holmium-166-chitosan inject. Omnipaque® contrast agent is directly injected to the tumor cyst and CT scan reveals the exact tumor volume and any possible leakage.

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  Fig. 2 Calculated absorbed dose (Gy) to a 1 mm-thick cyst wall at a varying depth for each diameter cyst by Monte-Carlos simulation, when 10 mCi/mL of Holmium-166-chitosan uniformly distributed in the cystic fluid (empty bullet) and/or uniformly bound to the cyst wall surface (filled bullet).

• 

  Fig. 3 The distribution of injected Holmium-166-chitosan to the tumor cyst is confirmed by gamma camera.

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  Fig. 4 The proportion of wall bound form is depicted by time after Holmium-166-chitosan injection.

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  Fig. 5 Illustrative case of 'evident' radiological response. A : MRI before the treatment reveals cystic brain metastasis at motor cortex. The patients suffered from transient hemiparesis at 1st Holmium-166-chitosan (Ho-166-chico) injection of 15 mCi. However, he recovered completely with steroid treatment and underwent two more Ho-166-chico therapy. B : MRI follow-up 11 months later showed significant decrease of both cyst volume and wall thickness.

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  Fig. 6 Another illustrative case of 'evident' radiological response. A : Sagittal enhanced MRI before the treatment reveals enhancing cystic craniopharyngioma with mural nodule anteriorly. B : After 4 mCi of Holmium-166-chitosan intracavitary injection, MRI follow-up 3 months later showed definite decrease of the cyst volume and the mural nodule. Later, the cyst recurred at 36 months after the treatment.

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