Minimally Invasive Tumor Therapy (MITT)

Department of Radiology, Charité – Universitätsmedizin Berlin

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References

  1. Mohnike K, Wieners G, Schwartz F, et al. Computed tomography-guided high-dose-rate brachytherapy in hepatocellular carcinoma: safety, efficacy, and effect on survival. Int J Radiat Oncol Biol Phys. 2010;78:172-9.
  2. Collettini F, Schnapauff D, Poellinger A, et al. Hepatocellular carcinoma: computed-tomography-guided high-dose-rate brachytherapy (CT-HDRBT) ablation of large (5-7 cm) and very large (>7 cm) tumours. Eur Radiol. 2012;22:1101-9.
  3. Schnapauff D, Denecke T, Grieser C, et al. Computed tomography-guided interstitial HDR brachytherapy (CT-HDRBT) of the liver in patients with irresectable intrahepatic cholangiocarcinoma. Cardiovasc Intervent Radiol. 2012;35(3):581-7.
  4. Collettini F, Golenia M, Schnapauff D, et al. Percutaneous computed tomography-guided high-dose-rate brachytherapy ablation of breast cancer liver metastases: initial experience with 80 lesions. J Vasc Interv Radiol. 2012;23(5):618-26.
  5. Ricke J, Wust P, Stohlmann A, et al. CT-Guided brachytherapy. A novel percutaneous technique for interstitial ablation of liver metastases. Strahlenther Onkol. 2004; 180:274-80.
  6. Collettini F, Singh A, Schnapauff D, et al. Computed-Tomography-Guided High-Dose-Rate Brachytherapy (CT-HDRBT) Ablation of Metastases Adjacent to the Liver Hilum. Eur J Radiol. 2013;82(10):509-14.
  7. Ricke J, Wust P, Wieners G, et al. Liver malignancies: CT-guided interstitial brachytherapy in patients with unfavorable lesions for thermal ablation. J Vasc Interv Radiol. 2004;15(11):1279-86.

High-Dose Rate Brachytherapy (CT-HDRBT) for the Treatment of Liver Tumors

 

High-dose rate brachytherapy guided by computed tomography (CT-HDRBT) is a form of local radiation treatment for both primary liver tumors (hepatocellular carcinoma (HCC) and cholangiocellular carcinoma (CCC)) and secondary liver tumors (metastases).

 

CT-HDRBT was jointly developed by radiologists and radiation oncologists of the Charité about a decade ago. It is based on an internal radiation technique that was introduced in the 1980s to deliver radiotherapy during surgery. CT-HDRBT is superior to conventional radiotherapy because it allows precise local delivery of radiation to cancer tissue while sparing surrounding healthy tissue.

 

In our department, CT-HDRBT is routinely and successfully used as a minimally invasive treatment in a large number of patients with inoperable primary and secondary liver tumors.

 

How Does CT-HDRBT Work?

 

Brachytherapy is delivered through one or more so-called afterloading catheters, which are tubes that are inserted into the liver tumor through the skin. The afterloading catheters are positioned using computed tomography (CT) for guidance. This step is similar to a CT-guided liver puncture or biopsy. Next, a CT scan of the liver is obtained with the catheter in place before a solid source of radiation (iridium-192) is introduced into the catheter and positioned inside the tumor (Figure 1). With the radioactive source inside the tumor, a very high dose can be delivered to cancer tissue while minimizing exposure to healthy liver tissue and neighboring organs. Internal radiotherapy is delivered for 10 to 45 minutes.

 

At the end of treatment, the catheter is removed and the puncture tract is sealed with tissue glue. The procedure is minimally invasive because it requires only small skin incisions (cuts). Our experience in over 3000 cases shows that most patients tolerate CT-HDRBT very well with local anesthesia and a strong painkiller delivered intravenously. There is no need for general anesthesia. Most liver tumors can be treated with a single session of CT-HDRBT. Only a few patients with very large tumors or many tumor nodules require several sessions of internal radiation therapy. In most patients, CT-HDRBT can be repeated if the tumor starts to grow again or a new tumor develops.

 

Figure 1: Diagram of the liver with two afterloading catheters placed for brachytherapy (internal radiotherapy). “CTV” stands for “clinical target volume” and indicates the tumor. The entire tumor volume (encircled by the interrupted blue line) is irradiated with 20 Gray (Gy) in one session.

 

What are the Advantages of CT-HDRBT over other Ablation Treatments?

 

CT-HDRBT has some important advantages over minimally invasive techniques that use heat to destroy cancer tissue (thermal ablation techniques like radiofrequency ablation (RFA)).

 

Large tumors cannot be treated with RFA or other thermal ablation techniques. Scientific studies have shown that it is much more difficult to kill all tumor cells with heat when a tumor is larger than 3 cm.

 

CT-HDRBT has no limitations regarding the tumor size that can be treated. Several studies, including studies by our group, suggest that CT-HDRBT is also suitable for the treatment of very large liver tumors. Another drawback of thermal ablation treatment is that it is less effective when a tumor has high blood flow or is close to a large blood vessel (>3 mm in diameter). In these cases, the blood carries away the heat too fast, and the treatment temperature may be too low to effectively destroy the tumor cells. This problem of heat dissipation does not occur with CT-HDRBT. Therefore, high tumor blood flow and nearby larger blood vessels do not affect the success of CT-HDRBT.

 

What are Possible Complications of CT-HDRBT?

 

CT-HDRBT has a very low complication rate. Some possible complications are related to the insertion and positioning of the afterloading catheter(s). The risk of injury to surrounding organs (like the lungs, stomach, and intestines) and of bleeding is minimized by using CT to guide the procedure.

 

Brachytherapy lessens radiation damage to healthy tissue. Precise targeting reduces side effects such as skin burns or inflammation of the mucosal lining of the stomach (gastritis). The delivery of radiation is planned in such a way as to protect radiosensitive organs like the stomach or intestines.

 

After internal radiation of a very large tumor, the body’s reaction to the dying tissue may cause fever, chills, and nausea. These side effects develop about 4 – 6 hours after the intervention. In most patients, they can be relieved by medications and will disappear after a couple of hours.

 

Aftercare

 

We offer CT-HDRBT in an inpatient setting. You will be admitted to our ward for about 3 – 4 days. There are no restrictions on daily activities after the procedure. You should have a follow-up magnetic resonance imaging (MRI) examination of the liver as an outpatient 6 – 8 weeks after treatment and then every 3 months. Ideally, the MRI examinations should be performed with a liver-specific contrast agent. Follow-up MRI is done to assess the success of treatment and to detect returning or new liver tumors. You can have follow-up MRI as an outpatient in our department or elsewhere. If the MRI is done at another site, we kindly ask you to send us a CD with the images for evaluation.

 

For further information on CT-HDRBT of the liver, please do not hesitate to contact us. We will be happy to answer any questions you may have.

 

  • Contact:

Minimally Invasive Tumor Therapy (MITT)

Charité, Campus Virchow-Klinikum

Department of Radiology

Augustenburger Platz 1

13353 Berlin, Germany

Phone: +49 (0)30/450-557309

Fax: +49 (0)30/450-557947

minimal-invasive-ambulanz@charite.de oder mia@charite.de

 

Case Examples

 

Figure 2: CT-HDRBT treatment of a large hepatocellular carcinoma (>5 cm). The MRI examination performed before treatment shows a large tumor in the liver (a). Three catheters are placed within the tumor using CT guidance (b). After positioning of the catheters, three-dimensional (3D) image-based treatment planning is performed (c). The follow-up MRI examination 12 months after CT-HDRBT shows almost complete shrinkage of the tumor (d). (Modified from Collettini et al. (2))

 

Figure 3: CT-HDRBT treatment of a large liver metastasis from breast cancer. The MRI examination performed before treatment shows a metastasis in the right liver lobe (arrow) (A). Image for 3D planning of local radiotherapy of the liver metastasis (B). Follow-up MRI examinations performed 3 months (E) and 32 months (F) after treatment show marked shrinkage of the metastasis (arrow). (Modified from Collettini et al. (4))