Unresectable Colorectal Liver Metastases: Percutaneous Ablation Using CT-Guided High-Dose-Rate Brachytherapy (CT-HDBRT)

Abstract

Purpose: To evaluate the clinical outcome of CT-guided high-dose-rate brachytherapy (CT-HDRBT) of unresectable colorectal liver metastases (CRLMs).

Materials and Methods: Retrospective analysis of all consecutive patients with unresectable CRLMs treated with CT-HDRBT between January 2008 and November 2012. Treatment was performed by CT-guided catheter placement and high-dose-rate brachytherapy with an iridium-192 source. MRI follow-up was performed after 6 weeks and then every 3 months post-intervention. The primary endpoint was local tumor control (LTC); secondary endpoints included time to progression (TTP) and overall survival (OS).

Results: 80 heavily pretreated patients with 179 metastases were available for MRI evaluation for a mean follow-up time of 16.9 months. The mean tumor diameter was 28.5 mm (range: 8 – 107 mm). No major complications were observed. A total of 23 (12.9 %) local tumor progressions were observed. Lesions ≥ 4 cm in diameter showed significantly more local progression than smaller lesions (< 4 cm). 50 patients (62.5 %) experienced systemic tumor progression. The median TTP was 6 months. 28 (43 %) patients died during the follow-up period. The median OS after ablation was 18 months.

Conclusion: CT-HDRBT is an effective technique for the treatment of unresectable CRLMs and warrants promising LTC rates compared to thermal ablative techniques. A combination with other local and systemic therapies should be evaluated in patients with lesions > 4 cm in diameter, in which higher progression rates are expected.

Key Points:

• CT-HDRBT enables a highly cytotoxic irradiation of colorectal liver metastases with simultaneous conservation of important neighboring structures (eg liver parenchyma, bile ducts and bowel)

• The local tumor control rates obtained by CT-HDRBT in patients with colorectal liver metastases are promising, also compared to the local tumor control rates after RFA

• Metastases with a diameter of 4 cm or abow, display a higher local progression rate after CT-HDRBT, therefor a combination therapy with other locoregional or systemic treatments should be investigated in prospective studies

Citation Format:

• Collettini F, Lutter A, Schnapauff D et al. Unresectable Colorectal Liver Metastases: Percutaneous Ablation Using CT-Guided High-Dose-Rate Brachytherapy (CT-HDBRT). Fortschr Röntgenstr 2014; 186: 606 – 612

Zusammenfassung

Ziel: Evaluierung der Behandlungsergebnisse der CT-gesteuerten Hochdosisbrachytherapie (CT-HDRBT) bei irresektablen kolorektalen Lebermetastasen (CRLM).

Material und Methoden: Retrospektive Analyse von allen konsekutiven Patienten mit irresektablen CRLM, die zwischen Januar 2008 und November 2012 mittels CT-HDRBT behandelt wurden. Die Behandlung erfolgte über eine CT-gesteuerte Hochdosisbrachytherapie mittels einer Iridium-192-Quelle. Post interventionelle Kontrollen erfolgten durch kontrastverstärkte MRT-Untersuchungen nach 6 Wochen nach Ablation und anschließend alle 3 Monate. Als primärer Endpunkt wurde die lokale Tumorkontrolle festgelegt. Als sekundäre Endpunkte wurden das progressionsfreie Intervall und das Gesamtüberleben nach Ablation untersucht.

Ergebnisse: 80 zumeist intensiv vorbehandelte Patienten mit 179 irresektablen Lebermetastasen konnten eingeschlossen werden. Die mittlere Verlaufskontrollzeit betrug 16,9 Monate. Der mittlere Durchmesser der Metastasen betrug 28,5 mm (8 – 107 mm). Es traten keinerlei Komplikationen auf. 23 Metastasen (12,8 %) entwickelten eine lokale Progression. Metastasen ≥ 4 cm im Diameter zeigten eine signifikant höhere lokale Progressionsrate als kleinere Metastasen (< 4 cm). Bei 50 Patienten (62,5 %) zeigte sich im Verlauf ein Voranschreiten der Tumorerkrankung in Form eines nicht lokalen intrahepatischen oder extrahepatischen Tumorprogress. Das mediane progressionsfreie Überleben lag bei 6 Monaten. 28 Patienten (43 %) starben während des Follow-ups. Das mediane Gesamtüberleben nach Ablation betrug 18 Monate.

Schlussfolgerungen: Die CT-HDRBT ist eine aussichtsreiche Technik zur Ablation von CRLM mit der man, im Vergleich zu den thermischen Ablationsverfahren, sehr vielversprechende lokale Tumorkontrollraten erzielen kann. Bei Läsionen mit einem Durchmesser > 4 cm, bei denen höhere Progressionsrate zu erwarten sind, sollte eine Kombination mit anderen lokalen oder systemischen Therapien erwogen werden. Dies gilt es in weiteren klinischen Studien zu untersuchen.

Key words

abdomen - ablation procedures - interventional procedures - metastases - radiofrequency (RF) ablation

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