Minimally Invasive Tumor Therapy (MITT) 

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Brachytherapy

Brachytherapy involves local radiation of tumours within the liver (hepatocellular carcinoma) and of bile duct carcinomas, as well as liver metastases.

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Brachytherapy (here: high-dose brachytherapy / HDRBT)

The procedure was developed at the Charité hospital, based on an intra-operative radiation technique used as early as the 1980s. Compared to conventional radiation techniques, it provides significant benefits in terms of accuracy and depth of effectiveness (invasivity).

How does brachytherapy work?

Figure 1: Irradiation of a tumour (shown as CTV (clinical target volume)) using two after-loading catheters. The total tumour volume (dark area) is irradiated in one session with 20 Gray (Gy).

Brachytherapy is a form of internal radiotherapy. A solid source of radiation (iridium-192) is inserted into the tumour, under the control of computer tomography. It irradiates the surrounding tumour tissue with gamma rays and destroys it (Figure 1). In this way, very high doses of radiation can be achieved inside the tumour, while the surrounding liver tissue and other organs are protected as much as possible.

What are the aims of brachytherapy?

The aim of brachytherapy is to achieve local tumour control, i.e. to create a biologically inactive tumour which no longer presents the risk of further spread or progression of the disease.

For which patients do we recommend brachytherapy?

Brachytherapy is suitable for patients with inoperable liver tumours. This treatment can also be of benefit if the tumours are already quite large (> 3 cm) and therefore less susceptible to thermal destruction ("blation", e.g. through RFA).

How is brachytherapy carried out?

Beforehand

We admit the patient to our unit for around three to four days for the treatment.

We generally avoid using general anaesthesia. Based on our experience of over 3,000 procedures, brachytherapy of the liver is tolerated very well by most patients under local anaesthetic and a strong painkiller.

We initially introduce one or more special catheters directly into the tumour under CT guidance. Once the catheter is in place, we carry out a CT scan of the liver. This provides accurate details for the planning of the actual irradiation.
The radiation source is then activated. The actual irradiation process lasts between 10 and 45 minutes.

After the treatment, the catheter is removed and the incision channel is sealed with tissue glue.

To avoid radiation-related complications such as burns to the skin or inflammation of the lining of the stomach, radiation-sensitive structures (such as the stomach and bowel) are taken into account during the treatment planning and during the actual radiation delivery itself.

After

After the treatment, the patient can continue with their normal lives.

After six to eight weeks, and then every three months, we recommend an outpatient MRI scan of the liver, ideally with liver-specific contrast medium. This will check the success of the treatment and identify any recurrences or new liver tumours.

You can have this MRI scan done as an outpatient either at our facility or elsewhere. If the MRI scan is carried out elsewhere, we would be grateful if you could send us the image data via CD-ROM for further assessment.

Generally speaking, a single session of therapy is sufficient to treat the tumour. Only in individual cases, e.g. very large tumours or numerous tumour nodes, must the procedure be carried out several times. If the development of new liver tumours is picked up at later follow-up, the procedure can usually be carried out again without any problems.

What complications should patients be aware of?

The entire procedure can be carried out with any large skin incisions. The procedure is similar to that of taking a biopsy of the tumour.

The complication rate for HDRBT is very low. Treatment-related complications can however occur while the catheter is being positioned through the skin. Injuries to surrounding organs (e.g. lungs, stomach, bowel) or bleeding are usually avoided thanks to the CT guidance.

When very large tumours are irradiated, the body’s own response to the tumour destruction approximately four to six hours after the procedure can cause fever, chills and nausea. The symptoms generally last around a few hours and can usually be relieved with suitable medication.

Case example

Figure 2: Treatment of a hepatocellular carcinoma more than 5 cm in size with CT-HDRBT. The MRI image before treatment shows the large tumour (a). For the irradiation, three catheters are positioned in the tumour (b) via CT guidance. The 3D planning of the tumour irradiation (c) is then carried out. The follow-up MRI scan shows virtually complete shrinkage of the treated tumour 12 months after CT-HDRBT (d). (Modified from Collettini et al. (2))
Figure 3: Treatment of a large liver metastasis from a breast cancer with CT-HDRBT. The MRI image prior to treatment shows migration of the tumour (metastasis) to the right liver lobe (arrow) (A). 3D planning of the tumour irradiation (B). The MRI investigations as part of the follow-up show a significant reduction in the size of the liver metastasis 3 months (E) and 32 months (F) after CT-HDRBT. (Modified from Collettini et al. (4))
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Bibliography

  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.