title: Severe toxicity after permanent radioactive seed implantation for mediastinal carcinoid tumors.
abstract: OBJECTIVE
  Permanent implantation of 125I seeds may be used when uninvolved surgical margins are unobtainable or close. Two cases of mediastinal carcinoid tumors with prior chemoradiation had tumors adherent to esophageal muscularis. Both underwent intraoperative permanent seed implantation and developed esophageal fistulas requiring surgical correction.
  
  
  METHODS
  Custom permanent 125I seed mesh implants were fashioned intraoperatively in a geometrically coherent pattern. The implants were directly sutured to the partially resected esophageal wall. The postimplant CT scans were fused with the postfistula scans to provide dosimetric information at the fistula site. Doses were calculated from time of insertion to time of fistula formation. Neither patient showed evidence of disease recurrence at the time of fistula repair.
  
  
  RESULTS
  Patient 1 developed an esophageal-pleural fistula 83 days after seed implantation. Patient 2 developed a broncho-pleural fistula 300 days after seed implantation.
  
  
  CONCLUSIONS
  These cases demonstrated that implantation in the setting of extensive subcarinal space dissection and partial esophageal wall resection could cause fistula formation and the need for additional surgery. The high mucosal dose, despite the relatively low activity implant, was due to lack of geometric sparing of the mucosa. We recommend that extensive subcarinal space dissection be considered a contraindication to permanent seed implantation.
authors.affiliation: Department of Clinical Oncology, Royal Marsden Hospital, Sutton, Surrey, United Kingdom. alexandra.stewart@rmh.nhs.uk
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Stewart
authors.forename: Desmond A
authors.initials: DA
authors.lastname: O'Farrell
authors.forename: Subhakar
authors.initials: S
authors.lastname: Mutyala
authors.forename: Raphael
authors.initials: R
authors.lastname: Bueno
authors.forename: David J
authors.initials: DJ
authors.lastname: Sugarbaker
authors.forename: Robert A
authors.initials: RA
authors.lastname: Cormack
authors.forename: Phillip M
authors.initials: PM
authors.lastname: Devlin
mesh_terms: D000328:Adult; D000368:Aged; D001918:Brachytherapy / Q000009:adverse effects / Q000379:methods; D002276:Carcinoid Tumor / Q000188:drug therapy / Q000532:radiotherapy*; D017024:Chemotherapy, Adjuvant; D006801:Humans; D007457:Iodine Radioisotopes / Q000627:therapeutic use; D008297:Male; D008479:Mediastinal Neoplasms / Q000188:drug therapy / Q000532:radiotherapy*; D011879:Radiotherapy Dosage
chemical_list: D007457:Iodine Radioisotopes