Percutaneous ablation of lymph node metastases using CT-guided high-dose-rate brachytherapy

Objective:

To assess the technical feasibility, safety and clinical outcome of CT-guided high-dose-rate brachytherapy (CT-HDRBT) for achieving local tumour control (LTC) in isolated lymph node metastases.

Methods:

From January 2008 to December 2011, 10 patients (six males and four females) with isolated nodal metastases were treated with CT-HDRBT. Five lymph node metastases were para-aortic, three were at the liver hilum, one at the coeliac trunk and one was a left iliac nodal metastasis. The mean lesion diameter was 36.5 mm (range 12.0–67.0 mm). Patients were followed up by either contrast-enhanced CT or MRI 6 weeks and then every 3 months after the end of treatment. The primary end point was LTC. Secondary end points included primary technical effectiveness rate, adverse events and progression-free survival.

Results:

The first follow-up examination after 6 weeks revealed complete coverage of all nodal metastases treated. There was no peri-interventional mortality or major complications. The mean follow-up period was 13.2 months (range 4–20 months). 2 out of 10 patients (20%) showed local tumour progression 9 and 10 months after ablation. 5 out of 10 patients (50%) showed systemic tumour progression. The mean progression-free interval was 9.2 months (range 2–20 months).

Conclusion:

CT-HDRBT is a safe and effective technique for minimally invasive ablation of nodal metastases.

Advances in knowledge:

CT-HDRBT of lymph node metastases is feasible and safe. CT-HDRBT might be a viable therapeutic alternative to obtain LTC in selected patients with isolated lymph node metastases.Metastatic spread to lymph nodes is a common event in the course of many thoracic and abdominal malignancies and has considerable clinical implications [1]. The management of metastatic disease is complex, and treatment modalities reported in the literature are heterogeneous, depending largely on the localisation of metastatic nodes as well as the patient’s performance status and treatment history. Hence, the optimal management for patients with isolated lymph node metastasis has not yet been established.Although the results of several studies suggest a potential benefit to the cytoreduction of isolated nodal disease among patients with ovarian, hepatocellular, renal or colorectal carcinoma, data on the role of repeated surgical resection of confined lymph node metastases are limited, and response rates of nodal metastases to chemotherapy are inconsistent [2–7].Over the past decades, interventional oncology has expanded its role, and minimally invasive tumour ablation techniques have become a cornerstone in the multimodal treatment of oncological patients. The clinical success of thermal ablation techniques, such as radiofrequency ablation (RFA), has generated a large body of literature on the treatment of liver and lung tumours, while data on its use for the treatment of lymph node metastases remain scarce. CT-guided high-dose-rate brachytherapy (CT-HDRBT) is a radio-ablative technique that was established about 10 years ago to overcome the limitations of thermal ablative techniques [8]. Features such as high accuracy in dose distribution and applicability regardless of tumour diameter and location have contributed to the attractiveness of this technique. In recent years, several studies have reported encouraging results for the treatment of lung and liver tumours as well as extrahepatic and extrapulmonary malignancies [9–12]. The purpose of the present study is to report the results of CT-HDRBT for achieving local tumour control (LTC) in the treatment of isolated lymph node metastases.     

Implant time and process efficiency for CT-guided high-dose-rate brachytherapy for cervical cancer

PurposeThis investigation details the time and teamwork required for CT-guided tandem and ring high-dose-rate brachytherapy.Methods and MaterialsFrom 2010 to 2012, 217 consecutive implantations were identified on 52 patients. We gathered key workflow times: preoperative, applicator insertion, CT image, treatment planning, treatment, patient recovery, and total time in clinic. Linear fixed-effects models were used, and key workflow times were the outcome variables and factors including age, body mass index, stage, outside referral, number of implant per patient, number of implants per day, and year of implantation were examined as fixed effects.ResultsOf the 52 patients, 62% of the patients were Fédération Internationale de Gynécologie et d'Obstétrique Stage 2B, 88% were treated with concurrent chemotherapy, and 23% were treated at an outside facility and referred for the procedure. The mean times (minutes) for each step were as follows: preoperative evaluation, 93; insertion, 23; imaging, 45; treatment planning, 137; treatment, removal, and recovery, 115; total clinic time, 401. For the insertion time, the greater implant number per patient was significantly associated with a decreased total insertion time, with and without adjusting for other covariates, p = 0.002 and p = 0.0005, respectively. Treatment planning time was expedited with increasing number of implant per patient and comparing treatment times in 2012 with those in 2010, p = 0.01 and p < 0.0001, respectively.ConclusionsGynecologic brachytherapy requires a skillfully coordinated and efficient team approach. Identifying critical components and the time required for each step in the process is needed to improve the safety and efficiency of brachytherapy. Continuous efforts should be made to enhance the optimal treatment delivery in high-dose-rate gynecologic brachytherapy.     

CT-guided 125I brachytherapy combined with chemotherapy for the treatment of unresectable or locally advanced pancreatic carcinoma

PURPOSEWe aimed to explore the feasibility and clinical effectiveness of percutaneous CT-guided iodine-125 (¹²⁵I) brachytherapy combined with chemotherapy for the treatment of patients with unresectable or locally advanced pancreatic carcinoma (PC).METHODSWe retrospectively reviewed 66 patients with Stage III and IV PC who had received chemotherapy. A total of 35 (53%) patients receiving ¹²⁵I brachytherapy and chemotherapy (gemcitabine + cisplatin, GP) were classified as Group A, and 31 (47%) patients who received GP chemotherapy alone were categorized as Group B. The evaluated indications were local control rate (LCR), local progression-free survival (LPFS), overall survival (OS), treatment-related complications, and the degree of symptom relief. Kaplan-Meier curves, log-rank test and Cox regression models were generated and used for further analysis to identify predictors of outcomes.RESULTSThe median follow-up time was 6.00±0.84 months. The 1-, 3-, 6-, 12- and 18-month LCRs for Group A were 100% (35/35), 89.3% (25/28), 71.4% (15/21), 37.5% (3/8) and 33.3% (1/3), respectively; and those for Group B were 87.1% (27/31), 69.6% (16/23), 41.2% (7/17), 14.3% (1/7) and 0% (0/3), respectively. The LCR differed at 1-, 3- and 6-months (p = 0.032; p = 0.009; p = 0.030; respectively). The median LPFS was 7.00±0.30 months and 5.00±0.75 months for Groups A and B (p = 0.023), respectively; however, the median OS of the groups were not significantly different (8.00±0.77 months vs. 6.00±1.04 months. p = 0.917). No life-threatening complications occurred during or after the procedures. Patients in Group A experienced better pain control and relief of abdominal distension than those in Group B.CONCLUSIONCT-guided ¹²⁵I brachytherapy is a feasible, safe, and valuable treatment for patients with unresectable PC.

Pancreatic carcinoma (PC) is the fourth most common cause of cancer-related death in both males and females (1). Abdominal pain, distension and fatigue are relevant symptoms. However, these symptoms usually occur with advanced disease due to the deep located anatomy of the pancreas, making tumors difficult to detect (2). Tumors are inclined to invade vessels, nerves and lymphatic system, explaining its characteristics of being peripancreatic and extrapancreatic. Once these situation occur, unresectable disease is diagnosed based on certain criteria (3).For unresectable PC (UPC), some patients may refuse or give up their treatments because of its late stage when diagnosed, and poor general condition. An improvement of local control is an important part of disease management. The current treatment is multimodality therapy, including chemotherapy, irreversible electroporation, radiotherapy, and supportive care. However, the prognosis is poor, with a 1-year survival rate of 20% and a 5-year survival rate of less than 5% (4, 5). The first-line therapy for UPC with or without metastasis is chemotherapy, including gemcitabine with cisplatin or paclitaxel, FOLFIRINOX or FOLFOX. Despite advancements in chemotherapy, many patients are not able to tolerate treatment, mainly due to their poor mental and physical health at the time of diagnosis and the severe toxicities, including myelosuppression and vomiting. Irreversible electroporation, a local destructive therapy, is based on the transmission of high-voltage current pulses direct through the tumor tissue, leading to alteration of irreversible permeation in the integrity of cell membrane and cell death (6). Nevertheless, this procedure is often implemented under laparotomy and the expense is high. New technologies in external beam radiotherapy have also been developed, such as stereotactic body radiotherapy and cyberknife. However, PC is relatively insensitive to external radiation. Also, the higher the dose received, the higher the risk of severe adverse effects, especially to cardinal organs such as the intestine and liver. Thus, the dose has to be controlled and rapidly reduced, ultimately increasing the risk of residual tumor and treatment failure.Iodine-125 (¹²⁵I) brachytherapy, a treatment as internal radiotherapy, has been considered a useful and minimally invasive modality. It has been shown to be a safe and effective option for many types of tumors such as those on brain, thoracic, prostate and soft tissue (7–10), and remarkable advantage of few complications and side effects (11, 12). Under the real-time imaging guidance (CT or ultrasound), the ¹²⁵I seed-specific needle is used to insert the seed into the tumor tissue. When the needle reaches the target area according to the preoperative plan, the ¹²⁵I seed is released by a single use of implantation gun after pulling out the needle core. Each seed is implanted one by one within the tumor by drawing back the needle along the needle track. The ¹²⁵I seed continuously emits X-rays and γ-rays within the target area, with a half-life of 59.6 days and a radiation diameter of 1.7 cm. The miniature seed has higher local radiation energy than conventional radiotherapy, while decreasing rapidly with increasing distance from the target area. CT is characterized by clear images, real-time observations, thin slices, and good tissue contrast on enhancement scanning. These characteristics make it possible for CT-guided ¹²⁵I brachytherapy to safely and visibly cover the target lesion completely, avoiding injury to the adjacent tissues. However, there have been few reports about CT-guided ¹²⁵I brachytherapy combined with chemotherapy for this disease. The aim of our study was to evaluate and determine the effectiveness and feasibility of this combination treatment for UPC.     

Recurrent rectal carcinoma treated with high-dose-rate intraluminal brachytherapy

A 63-year-old man with recurrent rectal carcinoma was treated with high-dose-rate intraluminal brachytherapy (6 Gy x 4). After treatment, anal pain and bleeding were greatly improved. He died as a result of liver metastasis, but he was able to evacuate the bowels until death. bowels until death.     

Treatment of upper gum carcinoma with high-dose-rate customized-mold brachytherapy

PURPOSE: To design an applicator for the treatment of tumors of the upper gum (UGCs) with high-dose-rate (HDR) brachytherapy. METHODS AND MATERIALS: A customized mold with four 6-Fr catheters was built. The two halves of the paired catheters form a functional loop without sharp curves. RESULTS: An adequate dose to the surface of the tumor is ensured. CONCLUSIONS: Mold-based HDR brachytherapy seems ideally suited for UGCs.     

Reirradiation using high-dose-rate brachytherapy in recurrent carcinoma of uterine cervix

PurposeTo assess the feasibility of reirradiation with image-based high-dose-rate brachytherapy in previously irradiated patients with recurrent carcinoma of uterine cervix.Methods and MaterialsThirty previously irradiated patients diagnosed with central recurrence were treated with reirradiation. Martinez Universal Perineal Implant Template was used in 24 patients and Vienna applicator in 6 patients. Median interval between two radiation schedules was 25 months. Median delivered dose was 42 Gy equivalent dose at 2 Gy (EQD2; interquartile range, 37–46 Gy EQD2).ResultsAll 30 patients tolerated reirradiation well. Complete response was seen in 23 (76%) patients. With a median followup of 25 months, 2-year local control, disease-free survival, and overall survival were 44%, 42%, and 52%, respectively. Fifteen patients developed local recurrences; Local control rate was significantly higher with doses >40 Gy EQD2 (52% vs. 34%; p = 0.05). Disease-free survival was better for patients with longer interval (>25 months) between two radiotherapy schedules. Grade III radiation proctitis and cystitis was seen in 3 patients each, and Grade II small bowel toxicity was seen in 3 patients.ConclusionsReirradiation using high-dose-rate brachytherapy is feasible with acceptable outcomes in isolated local recurrence deemed unsuitable for surgery. The outcome is better with higher doses.     

CT-guided radiofrequency ablation after with transarterial chemoembolization in treating unresectable hepatocellular carcinoma with long overall survival improvement

Purpose

To assess the time to disease progression (TTP), long-term survival benefit and safety of patients with unresectable hepatocellular carcinoma (HCC) treated with computed tomography (CT)-guided radiofrequency ablation (RFA) with transarterial chemoembolization chemoembolization (TACE).

Methods

This study was approved by the institutional review board. We reviewed the records of patients with intermediate and advanced HCC treated with CT-guided RFA with TACE between January 2000 and December 2009. Median TTP, overall survival (OS) and hepatic function were analyzed with the Kaplan–Meier method and log-rank tests.

Results

One hundred and twenty-two patients (112 men and 10 women, mean age 53 years, range 18–86 years) were included in the study. The median follow-up time was 42 months (range 6–89 months), TTP was 6.8 months, the median OS was 31 months, and the 1-, 3-, and 5-year OS were 88.5%, 41.0%, and 10.7%. The results of the univariate analysis revealed that intrahepatic lesion, AJCC stage, and Child-Pugh stage were predictors of OS (P < 0.01). In the multivariate analysis, the AJCC stage system showed a statistically significant difference for prognosis. Procedure-related death was 0.21% (1/470) within 1 month, and a statistical difference was found between the TACE and RFA of liver decompensation and Child-Pugh stage (P < 0.05).

Conclusions

The survival probabilities of OS increased with CT-guided RFA with TACE, as observed in randomized studies from Europe and Asia. The longest TTP was observed for the intermediate stage HCC. The procedures were well tolerated with acceptable minor and major complications in unresectable HCC patients.     

Efficacy of high-dose-rate interstitial brachytherapy in patients with oral tongue carcinoma

PurposeTo evaluate the results of high-dose-rate (HDR)-interstitial brachytherapy (ISBT) in oral tongue carcinomas.Methods and MaterialsBetween September 1999 and August 2007, 50 patients were treated for oral tongue carcinoma with HDR-ISBT. The patient's mean age was 58 years. Forty-two patients were in T1–2 stage and 8 patients were in T3 stage; 16 patients were in N+ stage and 34 patients in N0 stage. Exclusive ISBT was given to 17 patients (34%) in T1–2 N0 stage and complementary to external beam radiotherapy (EBRT) to 33 patients (66%). A perioperative technique was performed on 14 patients. The median total dose was 44 Gy when HDR was used alone (4 Gy per fraction) and 18 Gy when complementary to 50 Gy EBRT (3 Gy per fraction).ResultsThe median followup was 44 months. Actuarial disease-free survival rates at 3 and 5 years were 81% and 74%, respectively. Local failure developed in 7 patients. Actuarial local control (LC) rates were 87% and 79% at 3 and 5 years in T1–2 stage 94.5% and 91% and T3 stage 43% and 43% (with salvage surgery). Exclusive HDR cases showed LC in 100% of the cases, and the combined group (EBRT + HDR) showed LC in 80% and 69% of the cases at 3 and 5 years (p = 0.044). Soft-tissue necrosis developed in 16% and bone necrosis in 4% of the cases.ConclusionsHDR brachytherapy is an effective method for the treatment of oral tongue carcinoma in low-risk cases. Doses per fraction between 3 and 4 Gy yield LC and complication rates similar to low-dose rate. The perioperative technique promises encouraging results.     

Transcatheter arterial embolization in unresectable hepatocellular carcinoma

Seven hundred thirty-nine patients with unresectable hepatocellular carcinoma have been treated by transcatheter arterial chemoembolization using gelatin sponge particles soaked in a solution of Mitomycin C and Adriamycin. This therapy can be equal, or superior to surgical resection and serves both as embolic therapy and targeted chemotherapy.     

Sequential transarterial chemoembolization for unresectable advanced hepatocellular carcinoma

Purpose The aim of this prospective study was to evaluate the feasibility, safety, and efficacy of sequential transarterial chemoembolization (TACE) for patients with unresectable advanced hepatocellular carcinoma (HCC). Methods Twenty-one consecutive patients with unresectable T3 and T4 HCC were treated by sequential TACE (median time interval between treatments 7 weeks) up to six times with an emulsion of lipiodol, epirubicin, and cisplatin. All TACE procedures were performed as unilobar or whole-liver chemoembolization. Results An average of 3.9 TACE procedures were performed per patient. One primary and two secondary technical failures occurred. No procedural death was observed. After exclusion of the patient with the primary technical failure and 3 patients with extrahepatic disease, the survival rates for the remaining 17 patients at 6, 12, 18, and 24 months were 70.6%, 52.9%, 44.1%, and 33.1%, respectively. Conclusion Sequential TACE is a safe procedure in patients with unresectable advanced HCC and feasible in most cases. It seems to prolong the survival time compared with historical series of untreated patients.     

CT-guided placement of iodine-125 seeds for unresectable carcinoma of the lung

To avoid thoracotomy, we recently placed 70 125I seeds percutaneously with the aid of CT guidance for treatment of an unresectable carcinoma of the lung. We achieved a successful distribution of seeds without complications.     

Dosimetry errors in endovascular high-dose-rate brachytherapy

Monte Carlo data were used to demonstrate the dosimetry of the microSelectron high-dose-rate (HDR) iridium 192 (¹⁹²Ir) stepping source. These data were used to assess the accuracy of the Nucletron brachytherapy planning system (BPS version 13) for peripheral vessel endovascular brachytherapy. Dose rates from the high-dose-rate (HDR) source are calculated using the Monte Carlo code MCNP4A. Calculations are made at 0.25-cm intervals in the longitudinal direction on sleeves of radii of 1 and 0.25 cm. The Monte Carlo data are summed and weighted to simulate the longitudinal dose distribution at a distance of 1 and 0.25 cm from an ¹⁹²Ir source stepping through a straight pathway. A comparison is made between the simulated Monte Carlo dosimetry and the Nucletron brachytherapy planning system’s dosimetry. This study illustrates and quantifies the dosimetric errors at small distances associated with a point source dose calculation algorithm. The effects of step size, dwell time optimization, and active length on the accuracy of BPS v.13 for HDR endovascular brachytherapy are demonstrated.     

CT引导下125I放射性粒子组织间植入治疗纵隔转移性淋巴结

目的 探讨CT引导下经皮穿刺125I放射性粒子植入治疗纵隔转移性淋巴结的技术方法、安全性及临床价值.方法 应用125I放射性粒子组织间种植治疗纵隔淋巴结转移患者8例,所有患者采用前路进针途径穿刺,按照病灶与体表穿刺点的位置设定CT机架的角度,采用多方位重组技术及平头针芯捻压分离主动脉、上腔静脉间隙进针法植入125I放射性粒子.疗效评价采用术后治疗计划系统(TPS),验证放射性粒子种植后剂量分布,观察治疗后患者局部压迫症状(气短、咳嗽、吞咽困难等)的改善情况及粒子植入术后2个月靶淋巴结的局部反应,并记录并发症情况.结果 植入术后粒子覆盖率为(93.5 ±1.5)％.术后2个月复查,其中完全缓解(CR)3例,部分缓解(PR)4例,病灶稳定(SD)1例.5例气短、4例咳嗽和吞咽困难等局部压迫症状均有不同程度减轻,未出现头颈部及上肢水肿.术后无严重并发症发生;无大血管、气管、食管损伤,1例出现少量气胸.结论 CT引导下经皮穿刺组织间放射性粒子植入治疗纵隔4R区肿瘤转移性淋巴结,疗效肯定、安全可靠,为常规治疗局部压迫症状较严重的复杂部位淋巴结转移,提供了一种新的微创治疗方法.     

Implementation of high-dose-rate brachytherapy for prostatic carcinoma in an unshielded operating room facility

PurposeThe purpose of the study was to describe our approach towards safe delivery of single-fraction high-dose-rate (HDR) brachytherapy (BT) boost in patients with prostate cancer in the setting of an unshielded operating room (OR).Methods and MaterialsA total of 95 patients received 15 Gy HDR BT boost. The procedure involved transrectal ultrasound–based catheter insertion and planning in the OR, after which the patient was moved to a shielded treatment room for radiation. This required three vital components: (1) an OR table capable of transporting the patient in lithotomy position, (2) robust motion management checks to ensure reproducibility of prostate and catheter positions in the treatment room before radiation delivery, (3) remote monitoring of patient vitals while under anesthesia, during the radiation. Initial viability of this approach was confirmed by assessing acute toxicities using the Common Terminology Criteria for Adverse Events v4.0 and American Urologic Association symptom scores.ResultsWe found good stability in prostate and catheter position, with less than 1 mm shifts in each direction due to patient transfer. The median baseline American Urologic Association score was 7 (3–11), which increased to 12 (7–17) at 4 weeks and 9 (5–14) at 3 months (p = 0.003). Common Terminology Criteria for Adverse Events ≥ grade 2 genitourinary and gastrointestinal toxicities were experienced by 7% and 0% patients, respectively, at 3 months posttreatment completion.ConclusionsSingle-fraction HDR prostate BT can be delivered safely in an unshielded OR facility with a distant shielded treatment room using rigorous motion management checks and supplementary procedural equipment.     

Survival after C-arm CT-assisted chemoembolization of unresectable hepatocellular carcinoma

Purpose

To compare patient survival after transarterial chemoembolization with and without intraprocedural C-arm computed tomography (CT) in patients with unresectable hepatocellular carcinoma.

Materials and methods

We retrospectively reviewed the records of 130 patients with unresectable hepatocellular carcinoma who underwent lipiodol-based chemoembolization using a C-arm cone-beam system. We compared patients who underwent chemoembolization with angiography alone (69 patients; April 2005–July 2007) to those who underwent C-arm CT-assisted chemoembolization (61 patients; July 2007–April 2010). Overall and local progression-free survivals were compared using the Kaplan–Meier estimator with log-rank testing. Univariate and multivariate analyses were performed using the Cox proportional hazards model.

Results

Overall survival rates of patients who underwent chemoembolization with and without C-arm CT assistance were 94% and 79%, 81% and 65%, and 71% and 44% at 1, 2, and 3 years, respectively. Local progression-free survival rates of these patients were 43% and 27%, 31% and 10%, and 26% and 5% at 1, 2, and 3 years, respectively. Patients receiving C-arm CT-assisted chemoembolization had significantly higher overall (P = 0.005) and local progression-free (P = 0.003) survival rates than those receiving chemoembolization with angiography alone. Multivariate analysis showed that C-arm CT assistance was an independent factor associated with longer overall survival (hazard ratio, 0.40; P = 0.033) and local progression-free survival (hazard ratio, 0.25; P = 0.003).

Conclusion

C-arm CT usage in addition to angiography during transarterial chemoembolization prolongs survival in patients with unresectable hepatocellular carcinoma.     

高剂量率近距离放射治疗剂量学研究进展

近年来高剂量率近距放射治疗技术(high dose rate brachytherapy, HDR-BT)及设备均有较大发展,剂量分布及治疗计划系统的改善提高了HDR-BT治疗的准确性,从而推动其成为多种肿瘤的放射治疗的重要组成部分.本文介绍了HDR-BT所用的放射源、剂量分布、施源器、剂量优化、辐射生物效应等,探讨了HDR-BT剂量学未来的研究方向.     

Australian high-dose-rate brachytherapy protocols for gynaecological malignancy

There is no consensus over the optimal dose fractionation schedules for high-dose-rate (HDR) brachytherapy used for gynaecological malignancy. In Australian public hospital departments of radiation oncology, HDR brachytherapy for gynaecological cancer is being more commonly used. A survey of public departments that are using this technology, or that plan to introduce this technology, was performed. Their current protocols are presented. In general, protocols are similar biologically; however, the practical aspects such as the number of fractions given do vary and may reflect resource restrictions or, alternatively, differences in interpretations of the literature and of the best protocols by clinicians.