Perkutane CT-gesteuerte Hochdosis-Brachytherapie (CT-HDRBT) von primären und metastatischen Lungentumoren in nicht chirurgischen Kandidaten

Zusammenfassung

Ziel: Evaluierung der CT-gesteuerten Hochdosis-Brachytherapie (CT-HDRBT) zur lokalen Tumorkontrolle bei primären und metastatischen Lungentumoren.

Material und Methoden: Es wurden alle konsekutiven Patienten mit Lungenmalignomen eingeschlossen, die zwischen November 2007 und Mai 2010 mittels CT-HDRBT behandelt wurden. Postinterventionelle Kontrollen erfolgten durch kontrastverstärkte CT-Untersuchungen erstmalig 6 Wochen nach Therapie, im Rahmen des Follow-ups einmalig nach 3 Monaten und anschließend alle 6 Monate. Als Endpunkte wurden die lokale Tumorkontrolle sowie das progressionsfreie Intervall untersucht. Zur Beurteilung der Überlebensfunktion sowie der lokalen Tumorprogression wurde eine Kaplan-Meier-Analyse durchgeführt.

Ergebnisse: Es wurden 34 Interventionen zur Behandlung von 33 Lungenläsionen bei 22 Patienten durchgeführt. Der mittlere Durchmesser der 33 Lungenherde betrug 33,3 mm (SD = 20,4). In allen Fällen konnte in der ersten CT-Kontrolle eine vollständige Umfassung der Läsionen nachgewiesen werden. Die mittlere minimale tumorumschließende Dosis betrug 18,9 Gy (SD = 2). 3 Patienten (13,6 %) entwickelten einen Pneumothorax nach der Behandlung. Die mittlere Verlaufskontrollzeit betrug 13,7 Monate (3 – 29 Monate). 2 von 32 Läsionen (6,25 %) entwickelten ein Lokalrezidiv. Bei 8 Patienten (36,3 %) zeigte sich im Verlauf ein Voranschreiten der Tumorerkrankung in Form eines nicht lokalen Tumorprogresses. Nach 17,7 Monaten lebten 13 Patienten, 9 waren zu diesem Zeitpunkt verstorben.

Schlussfolgerung: Die CT-HDRBT ist eine sichere und vielversprechende Behandlungsoption zur Ablation von Lungentumoren. Sie ermöglicht die gezielte Zerstörung des Tumorgewebes mit gleichzeitiger Erhaltung wichtiger Lungenstrukturen und ist dabei unabhängig von der Größe der Läsion und ihrer Lokalisation innerhalb des Lungenparenchyms.

Abstract

Purpose: To evaluate the safety and efficacy of CT-guided high-dose brachytherapy (CT-HDRBT) ablation of primary and metastatic lung tumors.

Materials and Methods: Between November 2007 and May 2010, all consecutive patients with primary or metastatic lung tumors, unsuitable for surgery, were treated with CT-HDRBT. Imaging follow-up after treatment was performed with contrast-enhanced CT at 6 weeks, 3 months and every 6 months after the procedure. The endpoints of the study were local tumor control and time to progression. The Kaplan-Meier method was used to estimate survival functions and local tumor progression rates.

Results: 34 procedures were carried out on 33 lesions in 22 patients. The mean diameter of the tumors was 33.3 mm (SD = 20.4). The first contrast-enhanced CT showed that complete ablation was achieved in all lesions. The mean minimal tumor enclosing dose was 18.9 Gy (SD = 2). Three patients developed a pneumothorax after the procedure. The mean follow-up time was 13.7 (3 – 29) months. 2 of 32 lesions (6.25 %) developed a local tumor progression. 8 patients (36.3 %) developed a distant tumor progression. After 17.7 months, 13 patients were alive and 9 patients had died.

Conclusion: CT-HDRBT ablation is a safe and attractive treatment option for patients with lung malignancies and allows targeted destruction of tumor tissue with simultaneous preservation of important lung structures. Furthermore, CT-HDRBT is independent of the size of the lesion and its location within the lung parenchyma.

Key words

thorax - ablation procedures - interventional procedures - percutaneous - neoplasms

• Literatur

• 1 Van’t Westeinde SC, van Klaveren RJ. Screening and early detection of lung cancer. Cancer J 2011; 17: 3-10
• 2 Mountain CF, McMurtrey MJ, Hermes KE. Surgery for pulmonary metastasis: a 20-year experience. Ann Thorac Surg 1984; 38: 323-330
• 3 D’Addario G, Felip E , ESMO Guidelines Working Group Non-small-cell lung cancer: ESMO clinical recommendations for diagnosis, treatment and followup. Ann Oncol 2008; 19 (Suppl. 02) ii39-ii40
• 4 Scott WJ, Howington J, Feigenberg S et al. American College of Chest Physicians. Treatment of non-small cell lung cancer stage I and stage II: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132: 234S-42S
• 5 Pollock RE. Manual of clinical oncology. 7th ed. New York, NY: Wiley-Liss; 1999
• 6 Ihde DC, Minna JD. Non-small cell lung cancer. II. Treatment. Curr Probl Cancer 1991; 15: 105-154
• 7 Licker M, Spiliopoulos A, Frey JG et al. Risk factors for early mortality and major complications following pneumonectomy for nonsmall cell lung carcinoma of the lung. Chest 2002; 121: 1890-1897
• 8 Marino P, Preatoni A, Cantoni A. Randomized trials of radiotherapy alone versus combined chemotherapy and radiotherapy in stage IIIa and IIIb non-small cell lung cancer: a meta-analysis. Cancer 1995; 76: 593-601
• 9 Finkelstein DM, Ettinger DS, Ruckdeschel JC. Long-term survivors in metastatic non-small cell lung cancer: an eastern cooperative oncology group study. J Clin Oncol 1986; 4: 702-709
• 10 Lee JM, Jin GY, Goldberg SN et al. Percutaneous radiofrequency ablation for inoperable non-small cell lung cancer and metastases: preliminary report. Radiology 2004; 230: 125-134
• 11 Graham PH, Gebski VJ, Lnglands AO. Radical radiotherapy for early-stage non-small cell cancer. Int J Radiat Oncol Biol Phys 1996; 31: 261-266
• 12 Kaskowitz L, Graham MV, Emani B et al. Radiation therapy for stage I non-small cell lung cancer. Int J Radiat Oncol Biol Phys 1993; 27: 517-523
• 13 Goldberg SN, Gazelle GS, Compton CC et al. Radiofrequency tissue ablation in the rabbit lung: efficacy and complications. Acad Radiol 1995; 2: 776-784
• 14 Goldberg SN, Gazelle GS, Compton CC et al. Radio-frequency tissue ablation of VX2 tumor nodules in the rabbit lung. Acad Radiol 1996; 3: 929-935
• 15 Ricke J, Wust P, Wieners G et al. CT-guided interstitial single-fraction brachytherapy of lung tumors – phase I results of a novel technique. Chest 2005; 127: 2237-2242
• 16 Goldberg SN, Grassi CJ, Cardella JF et al. for the Society of Interventional Radiology Technology Assessment Committee and the International Working Group on Image-guided Tumor Ablation. Image-guided tumor ablation: standardization of terminology and reporting criteria. J Vasc Interv Radiol 2009; 20 (Suppl. 07) S377-S390
• 17 Chua TC, Sarkar A, Saxena A et al. Long-term outcome of image-guided percutaneous radiofrequency ablation of lung metastases: an open-labeled prospective trial of 148 patients. Ann Oncol 2010; 21: 2017-2022
• 18 Douillard JY, Cunningham D, Roth AD et al. Irinotecan combined with fluorouracil compared with fluorouracil alone as first-line treatment for metastatic colorectal cancer: a multicenter randomized trial. Lancet 2000; 355: 1041-1047
• 19 Giacchetti S, Perpoint B, Zidani R et al. Phase III multicenter randomized trial of oxaliplatin added to chronomodulated fluorouracil-leucovorin as first-line treatment of metastatic colorectal cancer. J Clin Oncol 2000; 18: 136-147
• 20 Rossi S, Garbagnati F, Lencioni R et al. Percutaneous radiofrequency thermal ablation of nonresectable hepatocellular carcinoma after occlusion of tumor blood supply. Radiology 2000; 217: 119-126
• 21 Murakami R, Yoshimatsu S, Yamashita Y et al. Treatment of hepatocellular carcinoma: value of percutaneous microwave coagulation. Am J Roentgenol 1995; 164: 1159-1164
• 22 Vogl TJ, Eichler K, Straub R et al. Laser-induced thermotherapy of malignant liver tumors: general principals, equipments, procedures side effects, complications and results. Eur J Ultrasound 2001; 13: 117-127
• 23 Goldberg SN, Gazelle GS, Mueller PR. Thermal ablation therapy for focal malignancy: a unified approach to underlying principles, techniques, and diagnostic imaging guidance. Am J Roentgenol 2000; 174: 323
• 24 Bangard C. Radiofrequenzablation der Leber – eine aktuelle Übersicht. Fortschr Röntgenstr 2011; 183: 703-713
• 25 Stoffner R, Schullian P, Widmann G et al. Magnetresonanztomografie von durch Radiofrequenzablation erzeugten Koagulationszonen in der Ex-vivo-Rinderleber. Fortschr Röntgenstr 2010; 182: 690-697
• 26 Bruners P, Schmitz-Rode T, Günther RW et al. Multipolare Radiofrequenzablation der Leber mit bis zu sechs Applikatoren: erste Ergebnisse. Fortschr Röntgenstr 2008; 180: 216-222
• 27 Kühn JP, Puls R, Wallaschowski H et al. Charakteristik von Koagulationsnekrosen nach laserinduzierter Thermotherapie in der kontrastmittelverstärkten Magnetresonanztomografie und deren Einfluss auf den Therapieerfolg. Fortschr Röntgenstr 2008; 180: 816-820
• 28 Isfort P, Bruners P, Penzkofer T et al. In-vitro-Experimente zur flüssigkeitsmodulierten Mikrowellenablation. Fortschr Röntgenstr 2010; 182: 518-524
• 29 Goldberg SN, Hahn PF, Halpern EF et al. Radiofrequency tissue ablation: effect of pharmacologic modulation of blood flow on coagulation diameter. Radiology 1998; 209: 761-767
• 30 Livraghi T, Goldberg SN, Monti F et al. Saline-enhanced radiofrequency tissue ablation in the treatment of liver metastases. Radiology 1997; 202: 205-210
• 31 Lee JM, Jin GY, Goldberg SN et al. Percutaneous radiofrequency ablation for inoperable non-small cell lung cancer and metastases: preliminary report. Radiology 2004; 230: 125-134
• 32 Yan TD, King J, Sjarif A et al. Percutaneous radiofrequency ablation of pulmonary metastases from colorectal carcinoma: prognostic determinants for survival. Ann Surg Oncol 2006; 13: 1529-1537
• 33 Haasbeek CJ, Lagerwaard FJ, Antonisse ME et al. Stage I nonsmall cell lung cancer in patients aged > or = 75 years: outcomes after stereotactic radiotherapy. Cancer 2010; 116: 406-414
• 34 Timmerman R, Paulus R, Galvin J et al. Stereotactic body radiation therapy for inoperable early stage lung cancer. JAMA 2010; 303: 1070-1076
• 35 Vahdat S, Oermann EK, Collins SP et al. CyberKnife radiosurgery for inoperable stage IA non-small cell lung cancer: 18F-fluorodeoxyglucose positron emission tomography/computed tomography serial tumor response assessment. J Hematol Oncol 2010; 3: 6
• 36 Ricke J, Wust P, Stohlmann A et al. CT-guided brachytherapy. A novel percutaneous technique for interstitial ablation of liver malignancies. Strahlenther Onkol 2004; 180: 274-280
• 37 Simon CJ, Dupuy DE, DiPetrillo TA et al. Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients. Radiology 2007; 243: 268-275
• 38 von Meyenfeldt EM, Prevoo W, Peyrot D et al. Local progression after radiofrequency ablation for pulmonary metastases. Cancer 2011; 117: 3781-3787
• 39 Larici AR, del Ciello A, Maggi F et al. Lung abnormalities at multimodality imaging after radiation therapy for non-small cell lung cancer. Radiographics 2011; 31: 771-789 . Review.