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Hepatobiliary brachytherapy

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Hepatobiliary brachytherapy

  1. 1. Dr Ajeet Kumar Gandhi MD (AIIMS); DNB; UICCF (MSKCC, USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow Panel discussion: Common issues faced in hepato-biliary brachytherapy
  2. 2. Hepato-biliary brachytherapy  Hepatobiliary tumours consist of a constellation of tumours with surgical resection as primary modality of treatment  Radiotherapy has emerged in past few decades as an adjunct/bridge to surgical treatment  While the use of EBRT has been on rise, the use of brachytherapy is still limited to few centres across the world: Physician/Institute centric
  3. 3. Common issues faced in H-B brachytherapy  Awareness of BT as a modality for H-B tumors  Patient selection: EBRT vs. BT  Procedural complexities and presumed toxicities  Skills/Invasiveness of procedure  Sensitive organ/ limited tolerance  Paucity of literature regarding technique/results
  4. 4. H-B Brachytherapy Indications  Radical As a bridge to liver transplantation In small inoperable tumors or in combination with EBRT for un-resectable patients Hepato-cellular carcinoma Cholangiocarcinoma  Adjunctive (after non-radical excision, possibly combined with EBRT)
  5. 5. Tumour necrosis rates: 60-70% vs. 20- 30%
  6. 6. HDR-IBT in difficult case scenarios  Large tumors >7-12 cm  Hilar tumours  Unresectable HCC  Centrally located tumors  HCC with portal vein thrombus
  7. 7. Gandhi AK, Chauhan A, Rastogi M et al. RMLIMS
  8. 8. Gandhi AK, Chauhan A, Rastogi M et al. RMLIMS
  9. 9. Neo-adjuvant treatment protocols for hilar cholangiocarcinoma
  10. 10. EBRT combined with BT for biliary tumors
  11. 11. H-B Brachytherapy Indications  Palliative  Metastatic lesions: Colo-rectal, breast, pancreatic, neuro-endocrine, pancreatic, GI, RCC  Malignant biliary obstruction Primary cholangiocarcinoma Tumoral obstruction: GB, Pancreas, nodes at porta
  12. 12. Contemporary series on CT HDR- IBT for liver lesions
  13. 13. Treatment Techniques: Trans-hepatic 1) Cholangiogram : Site and length of the malignant stricture 2) Biliary drainage with minimum 10 French diameter catheter 3) BT blind-ended catheter (usually 5 or 6 French) through the biliary drainage 10 French catheter 4) Marker wire is then passed into the brachytherapy catheter 5) Treatment planning procedure
  14. 14. Treatment Techniques: Trans-duodenal endoscopic technique  ERCP: Site, length of involvement, extent of disease  Sphincterotomy: Cannulation of bile duct  Guide wire passed through and beyond stricture  Naso-biliary tube threaded over guide wire beyond stricture  Images acquired with radio-opaque markers  Planning and delivery
  15. 15. Imaging for planning  NCCT scan  CECT scan  CEMRI  PET-CT
  16. 16. Target volume and planning  2-D planning:  Clinical target length (1 cm proximal/distal)  Dose prescribed at 1 cm from source axis  3-D planning:  Image acquisition: CECT, MRI, PET-CT  Target delineation: GTV, CTV,PTV  OARs: Remaining liver, stomach, duodenum, spinal cord, small bowel
  17. 17. Dose prescription  Liver brachytherapy Radical: 15-20 Gray Palliative: 10-25 Gray  Biliary brachytherapy Radical: EBRT (30-40 Gray) with Brachytherapy (15-20 Gray) Palliative: 15-20 Gray
  18. 18. Dosimetric advantage of Interstitial Brachytherapy D4cm tumor shell>20Gy D3.6cm tumor shell>25Gy D3.2cm tumor shell >30Gy
  19. 19. Dose constraints for the OARs  Liver:  V5< 30-60% [Ricke 2016]  V10<30% [Colletini 2014]  Stomach  D1ml<12 Gray [Colletini 2014]  D1ml<15.5 Gy [Ricke 2006]  Hilar Structures  D1ml<12 Gray [Colletini 2014]  Duodenum, Small Bowel, Lung, Kidneys
  20. 20. Response Evaluation  Criteria: RECIST/PERCIST  Time of evaluation  Imaging modality: CECT MRI PET-CT
  21. 21. Take home message  Hepato-biliary brachytherapy is a safe, effective and applicable technique  The indications have expanded over the period of time  Volume delineation, dose constraints need to be better defined  In difficult to treat situations, HDR-IBT could be useful competitive modality  Prospective and multi-institutional studies are warranted  Teaching workshops would propagate knowledge and promote its use
  22. 22. Thank you!!

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