Clinical Case Report Medicine ®

Iodine-125 seed implantation combined

chemotherapy for metastatic pancreatic
adenocarcinoma with primary colon cancer
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A case report
wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/17/2023

Yinghui Songa,b, Yuchen Qic, Zhangtao Yua, Zhihua Zhanga, Yuhang Lia, Junkai Huanga, Sulai Liua,b,* 

Abstract
Rationale: Colon cancer has a distinct migration aptitude. However, pancreatic metastasis is rare and treatment of inoperable
pancreatic cancers is seldom seen.
Patient concerns: A 47-year-old woman presented 2-month history of abdominal pain and abdominal distention, with anal
cessation of exhaust and defecation for 4 days. A colon cancer radical resection was performed when she diagnosed with colon
cancer. After 26 months, the patient complained shoulder and back pain. Multiple intraperitoneal metastases and nonisolated
pancreatic metastasis of colon cancer were diagnosed.
Diagnosis: Metastatic pancreatic adenocarcinoma (MPA) with primary colon cancer.
Intervention: Iodine-125 seed implantation combined chemotherapy.
Outcomes: She remains free of cancer metastasis and recurrence, and has a good quality of life during the period.
Lessons subsections: Iodine-125 seed implantation is an effective and safe strategy for unresectable metastatic pancreatic
cancer. Iodine-125 seed implantation combined with chemotherapy improve survival for advanced pancreatic metastasis of colon
cancer.
Abbreviations: CA19-9 = carbohydrate antigen (CA) 19-9, MPA = metastatic pancreatic adenocarcinoma, PA = pancreatic
adenocarcinoma.
Keywords: chemotherapy, colon cancer, FOLFOX, iodine-125, metastasis, pancreas

1. Introduction 2. Case report

Pancreatic adenocarcinoma (PA) is an aggressive and lethal dis-
ease, divided into metastatic pancreatic adenocarcinoma (MPA)
and locally advanced pancreatic carcinoma. MPAs are rare, only
accounting for 2% of all pancreatic tumors.[1] These metasta-
ses include 2 clinicopathological types: a widespread systemic
disease or an isolated lesion of pancreas. However, most pan-
creatic cancers are diagnosed at an advanced stage.[2] Thus, we
have to deal with the inoperable pancreatic cancers. There is no
recommended standard treatment for unresectable metastatic
pancreatic cancer currently. Herein, we described a case with
pathologically confirmed MPA, who presented a good effect by
Iodine-125 seed implantation combined with chemotherapy.
On January 14, 2017, a 47-year-old woman presented 2-month
history of abdominal pain and abdominal distention, with anal
cessation of exhaust and defecation for 4  days. The patient
was in good health, with no history of disease and smoking
and drinking habits. On physical examination, the patient had
tenderness and rebound pain in the upper and right abdomen
with hyperactive bowel sounds. Further examinations includ-
ing enhanced abdominal and thoracic computed tomography
(CT) scans, electrocardiogram, colonoscopy and blood test
were performed. CT showed that transverse colonic had occu-
pying lesions complicated with upper colonic intestinal obstruc-
tion, infection, ascending colon intestinal fistula, and intestinal

This work was financially supported by following funds: National Natural Science
Foundation of China (No.81902017)/ Youth Talent of Hunan (2020RC3066);
Hunan Natural Science Fund for Excellent Young Scholars (2021JJ20003); Hunan
Provincial Natural Science Foundation of China (2020JJ5610); China Postdoctoral
Science Foundation (2020M68115/2021T140197)and The Project of Improving
the Diagnosis and Treatment Capacity of Hepatobiliary, Pancreas and Intestine in
Hunan Province (Xiangwei [2019] No. 118).
Written informed consent for publication was obtained from all participants.
The authors have no conflicts of interest to disclose.
*Correspondence: Sulai Liu, Department of Hepatobiliary Surgery, Hunan
Provincial People’s Hospital/The First Affiliated Hospital of Hunan Normal
University Changsha, Hunan Province 410005, China (e-mail: liusulai@hunnu.
edu.cn).
Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly
cited.

Data sharing not applicable to this article as no datasets were generated or
analyzed during the current study.
a
Department of Hepatobiliary Surgery, Hunan Provincial People’s Hospital/The
First Affiliated Hospital of Hunan Normal University, Changsha, China, b Central
Laboratory of The First Affiliated Hospital of Hunan Normal University, Changsha,
China, c Xiangdong Hospital Affiliated to Hunan Normal University, Liling, Hunan
Province, China.
How to cite this article: Song Y, Qi Y, Yu Z, Zhang Z, Li Y, Huang J, Liu
S. Iodine-125 seed implantation combined chemotherapy for metastatic
pancreatic adenocarcinoma with primary colon cancer: A case report. Medicine
2022;101:36(e30349).
Received: 26 April 2022 / Received in final form: 31 May 2022 / Accepted:
8 July 2022
http://dx.doi.org/10.1097/MD.0000000000030349

1
 Song et al.  •  Medicine (2022) 101:36Medicine
contents entered into left perirenal, left retroperitoneal and
left iliac fossa (Fig. 1). Colonoscopy revealed a circumferential
mass 40 cm away from the anus. The laboratory data were as
follows: white blood cell count, 24.54 × 109/L (normal: 4.0–
10.0 × 109/L); Neu 21.88 × 109/L, N 89.2%; blood gas analysis:
corrected pH 7.584↑, corrected pCO2 27.5 mm Hg; Alb: 28 g/L;
total bilirubin: 74.6 μmol/L (normal: 5.0–21.0 μmol/L); direct
bilirubin, 40.2  μmol/L (normal: 0–6.8  μmol/L). Coagulation
function: prothrombin time 13.2 seconds, prothrombin activity
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69.7%, quantitative fibrinogen 5.70 g/L.
Based on these results, on January 15, the patient received
radical resection of right colon cancer and removal of retroper-
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itoneal abscess. The pathological findings revealed poorly dif-
ferentiated adenocarcinoma, ulcerative type with 3 × 3 × 1 cm
size, with direct cancer cell invasion the whole layer of intes-
tinal wall to the extraintestinal adipose tissue, focal coagula-
tive necrosis; tumor thrombus can be seen in the vascular, the
resection margin of the 2 broken ends is clear and no metastatic
carcinoma found in parenteral lymph nodes (0/9) (Fig.  2A).
The dissected tissue margin was positive. The immunohisto-
chemistry results showed CK7 (–), CK20 (+), Villin (+), CDX2
(Scattered+), Syn (–), CgA (–), p53 (1+), Ki-67 (+30%), CD34
(vasculation+), D2-40 (Lymph gland+), Special staining: PAS(–)
(Fig. 2B). The pathological tumor-node-metastasis classification
was defined according to the criteria of the 2010 American Joint
Commission on Cancer/International Union Against Cancer, the
surgical-pathological staging was T4aN2aM0 stage IIIC.
Since March 17, 2017, the patient received postoperative adju-
vant chemotherapy of XELOX regimen contained oxaliplatin
(100 mg/m2 d1) plus capecitabine (1000 mg/m2 bid d1–14), every
3 weeks in 8 doses for a total of 6 months. In the follow-up after
therapy, the colonoscopy and imaging examination showed no
tumor recurrence. Until March 6, 2019, the patient complained
Figure 1.  Abdominal computed tomography. (A) Transverse plane of colon mass and (B) coronal plane of colon mass.
Figure 2.  (A) Gross pathology of colon mass, (B) colon poorly differentiated adenocarcinoma, and (C) pancreatic metastatic adenocarcinoma.
2
shoulder and back pain. The patient’s CT showed low-density
nodules in the pancreatic neck (Fig. 3B) compared with no metas-
tasis at the initial diagnosis (Fig. 3A) on January 14, 2017. Then
puncture biopsy guided by B-mode ultrasound showed metastatic
adenocarcinoma of colonic origin (Fig.  2C). The immunohisto-
chemistry results showed CK7 (–), CK19 (+), CEA (+), CA19-9
(+), CK20 (+), CDX2 (±), Ki-67 (+40%), CD34 Vessel (+); VG (+).
Due to multiple intraperitoneal metastases, the patient
received chemotherapy of FOLFOX-6 regimen contained oxal-
iplatin (100 mg/m2 d1) plus folinic acid (400 mg/m2 d1) and
5-fluorouracil (400 mg/m2 d1, 2400 mg/m2 d1–2).[3] On March
25, 2019, the patient received pancreatic mass iodine-125 par-
ticle implantation under the guidance of B ultrasound guided
by laparoscopy. Under the guidance of B ultrasound, pancre-
atic masses were implanted with iodine-125 particles. B ultra-
sound was used to locate the hypoechoic mass in the neck of
the pancreas. 4 needles were inserted from the center of the
mass and the upper and lower edges of the pancreas, and 19
iodine-125 particles were placed (Fig. 3C). B-ultrasound again
revealed a large number of hyperechoic areas of the pancre-
atic mass. The whole operation went very smoothly. Then the
patient received 2 cycles of FOLFOX-6 regimen. After that
the patient felt no discomfort and did not want chemotherapy
any more. There was no sign of progression in the patient’s
conditions until we reported this case and now the PFS was
28 months (until June, 2021) (Fig. 3D). The treatment sched-
ule is given in Figure 4.
We confirm that written informed consent was provided
by the patient to have the case details and any accompanying
images published. Institutional approval was not required to
publish the case details. This study was approved by the ethical
committee of Hunan Normal University. Informed consent was
obtained from this patient in the study.
 Song et al.  •  Medicine (2022) 101:36www.md-journal.com
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Figure 3.  Abdominal computed tomography. (A) Normal image of the pancreas during initial colon cancer, (B) image of pancreatic metastasis when tumor
relapses, (C) imaging of pancreatic metastatic cancer immediately after particle implantation, and (D) latest image of pancreatic metastases.
Figure 4.  The treatment schedule of the patient.
3. Discussion and Conclusion
PA is currently the fifth cause of cancer-related death in Europe
with an overall 5-year survival rate of only about 6%.[4] PA con-
sists of MPA and locally advanced pancreatic carcinoma. Most
patients with metastases to the pancreas have extensive meta-
static disease and are not suitable for excision. Consequently,
less of 4% have chance to pancreatic resection.[5] It was reported
that the most common tumors with pancreatic metastasis
include renal cell cancer, colon cancer, melanoma, sarcoma,
breast, and lung cancer.[6,7]
Metastatic pancreatic tumors lack of specific imaging fea-
tures, and the imaging manifestations of pancreatic metasta-
ses vary among different types of primary tumors. Differential
diagnosis between metastatic pancreatic tumors and primary
pancreatic tumors is difficult. Fine needle aspiration biopsy
guided by CT or B-ultrasound can be performed for cytological
examination. This case is a fine needle aspiration biopsy guided
by B-mode ultrasonography. Pathological examination showed
that the type of pancreatic cancer cells was identical to that of
colon adenocarcinoma. The concentration of the serum tumor
3
marker carbohydrate antigen (CA) 19-9 is increased in more
than 80% of patients with advanced pancreatic carcinoma,
and is routinely used to monitor disease processes, whether in
treatment or closure.[8] In primary pancreatic cancer, the positive
rate of tumor marker CA199 is up to 80%, while in metastatic
pancreatic cancer, CA199 is mostly within the normal range.
Therefore, detection of CA199 is of certain significance in differ-
entiating pancreatic metastases from primary tumors.[9,10]
According to the biological characteristics of the primary
tumor, different modes of comprehensive treatment were selected.
For isolated metastatic pancreatic tumor, especially the survival
time of the primary tumor is relatively long after treatment. An
increasing number of literatures suggest that patients with met-
astatic colorectal cancer, renal cell carcinoma, melanoma and
neuroendocrine cancer have a better prognosis when metastatic
tumors are removed.[11–14] Therefore we often choose pancreatic
lesion resection for isolated metastatic pancreatic tumors. In the
absence of metastasis to other sites, surgical resection can be
the first choice, including pancreaticoduodenectomy, pancreati-
cocaudal resection and total pancreatectomy. Nevertheless, for
 Song et al.  •  Medicine (2022) 101:36Medicine
widespread metastatic lesions, because of the metastasis of other
sites, radiotherapy and chemotherapy are often used to treat the
tumors. This case is a nonisolated metastatic pancreatic tumor,
which is difficult to be resected surgically.
There is no recommended standard treatment for unresectable
metastatic pancreatic cancer currently. Theoretically, combining
different treatment methods should work in synergy to enhance
locoregional disease control and improve survival. Interstitial
brachytherapy has been considered as a useful method for local
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control of pancreatic malignant tumors.[15] Clinically, the tech-
nique also has been used to control malignancies of the prostate,
the breast, the rectum, etc.[16–18] The radioactive seeds recom-
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mended in brachytherapy are iodine-125, iridium-192, or palla-
dium-103. Compared with the latter 2 sources, iodine-125 has
a longer half-life of 59.7 days, which is appropriate in targeting
pancreatic cancer.[19] The treatment mechanism of radioactive
particles implantation for pancreatic cancer can be summa-
rized briefly as an anticancer cell action of γ-rays emitted by
the particles with therapeutic purposes. A continuous low-dose
irradiation with iodine-125 seeds causes Panc-1 cell-cycle arrest
in the G2/M phase and induces apoptosis.[20] Furthermore,
implantation of iodine-125 seeds as irradiation promotes the
permeability of the surrounding vasculature and increases the
efficacy of chemotherapy.[21] So far, an optimal therapeutic dose
has not been clearly recommended to be utilized to treat patients
suffering from pancreatic cancer with intratumorally particle
implantation. The consensus recommended 80 to 145  Gy of
tumor matching peripheral dose and 145 Gy of matched periph-
eral dose during radical treatment and both are superior to the
external radiotherapy dose recommended by the NCCN guide-
lines.[22] In this case, we used 19 particles of 0.4 mCi iodine-125
according to the tumor size. The patient only suffered a little
nausea and the symptom disappeared quickly after application
of gastric mucosal protective agent and proton pump inhibi-
tor. It was confirmed that iodine-125 is effective in relieving
symptoms of pancreatic cancer.[23] This patient also felt the pain
of shoulder and back nearly gone away after implantation of
iodine-125. All of this indicated that interstitial implantation of
iodine-125 seeds was an effective and safe strategy for unresect-
able metastatic pancreatic cancer.
FOLFOX has been a standard treatment with metastatic col-
orectal cancer. The research showed no significant interaction
between the stage of disease and the treatment, indicating that
FL plus oxaliplatin benefited both stage II and stage III colorectal
cancer.[3] As a result, FOLFOX regime can be seen as a potentially
effective therapeutic schedule for metastatic pancreatic tumor.
This patient was diagnosed as metastatic pancreatic cancer with
puncture biopsy guided by B-mode ultrasound. After the treatment
with FOLFOX, the patient has no special discomfort and her CT
showed the metastasis is not enlarged, which proved that FOLFOX
regime have played an important role in the antineoplastic pro-
cess. It is very regrettable that the patient did not complete all the
courses of treatment because she did not feel uncomfortable.
In summary, this report describes a unique patient who has
been treated with endoscopic ultrasonography-guided intersti-
tial implantation of iodine-125 seeds combined FOLFOX regi-
men with MPA accompanied by distant metastasis from colon
cancer. She remains free of cancer metastasis and recurrence,
and has a good quality of life during the period.
Author contributions
Conceptualization: Yinghui Song, Sulai Liu.
Data curation: Yinghui Song, Yuchen Qi, Zhangtao Yu, Zhihua
Zhang, Yuhang Li, Junkai Huang, Sulai Liu.
Formal analysis: Yinghui Song, Yuchen Qi, Zhangtao Yu,
Zhihua Zhang, Yuhang Li, Junkai Huang, Sulai Liu.
Writing – original draft: Yinghui Song, Sulai Liu.
Writing – review & editing: Yinghui Song, Sulai Liu.
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