Radioablation of Upper Abdominal Malignancies by CT-Guided, Interstitial HDR Brachytherapy: A Multivariate Analysis of Catheter Placement Assisted by Ultrasound Imaging

Abstract

Purpose To evaluate the use of ultrasound (US) during catheter placement in interstitial brachytherapy (iBT) of abdominal malignancies as an alternative to computed tomography (CT) fluoroscopy.

Materials and Methods Catheter placement for CT-guided iBT was, if US visibility was sufficient, assisted by sonography in 52 consecutive patients with 82 lesions (liver N = 62; kidney N = 16; peritoneum N = 4) of various malignancies. We collected data on lesion visibility, location, depth, size, and dosimetry. Comparison of CT fluoroscopy versus US-assisted catheter placement was performed by Fisher’s exact test for frequencies and U-test for lesion visibility and dosimetric data. Factors predicting the utility of sonography were determined in a lesion-based multivariate regression analysis. A p-value < 0.05 was regarded as statistically significant.

Results 150 catheters (1 to 6 per lesion; mean diameter 3.6 ± 2.4 cm) were implanted. CT fluoroscopy was used for 44 catheters, and US was used for 106 catheters. Lesion visibility assessed by 5-point Likert scale was significantly better in US (median 2 vs. 3; p = 0.011) and effective dose was significantly reduced if US guidance was applicable (median 1.75 vs. 8.19 mSv; p = 0.014). In a multivariate regression analysis, we identified increased lesion size and caudal location within the target organ to independently predict the utility of ultrasound in catheter placement for iBT.

Conclusion Sonography is a helpful technique to assist CT-guided interstitial brachytherapy of upper abdominal malignancies. Especially for larger lesions localized in the lower liver segments or lower half of the kidney, superior visibility can be expected. As the effective dose of the patient is also reduced, radiation exposure of the medical staff may be indirectly lowered.

Key Points: 

• Ultrasound-assisted catheter placement in CT-guided brachytherapy of upper abdominal malignancies significantly improves lesion visibility.

• Predictors of successful ultrasound application are larger lesions within the lower portion of the liver and kidney.

• By reducing the need for CT fluoroscopy during intervention, radiation exposure to the medical staff may be indirectly lowered.

Citation Format

• Damm R, Damm R, Heinze C et al. Radioablation of Upper Abdominal Malignancies by CT-Guided, Interstitial HDR Brachytherapy: A Multivariate Analysis of Catheter Placement Assisted by Ultrasound Imaging. Fortschr Röntgenstr 2022; 194: 62 – 69

Zusammenfassung

Ziel Evaluierung der Ultraschallbildgebung (US) zur Katheterplatzierung bei der interstitiellen Brachytherapie (iBT) abdomineller Malignome als Alternative zur computertomografischen (CT) Fluoroskopie.

Material und Methoden Die Katheteranlage zur iBT erfolgte nach Möglichkeit mittels Sonografie bei 52 konsekutiven Patienten mit 82 abdominellen Tumoren (Leber n = 62, Niere n = 16, Peritoneum n = 4) unterschiedlicher Entitäten. Es wurden Läsionssichtbarkeit, Lokalisation, Tiefe und Größe sowie Dosimetrie erfasst. Der Vergleich zwischen CT- und ultraschallassistierter Katheteranlage erfolgte mittels Fisher’s exaktem Test für Häufigkeiten und U-Test für Sichtbarkeit und Dosimetrie. Faktoren für die Anwendung der Sonografie wurden in einer multivariaten Regression bestimmt. p < 0,05 wurde als signifikant betrachtet.

Ergebnisse 150 Katheter (1–6 pro Läsion, mittlerer Diameter 3,6 ± 2,4 cm) wurden eingebracht, CT-Fluoroskopie wurde bei 44 Kathetern und Ultraschall bei 106 Kathetern angewendet. Die Sichtbarkeit war anhand einer 5-Punkte-Likert-Skala signifikant besser (median 2 vs. 3; p = 0,011) und die effektive Dosis wurde signifikant reduziert, wenn Ultraschallführung anwendbar war (median 1,75 vs. 8,9mSv; p = 0,014). In der multivariaten Regressionsanalyse konnten ein größerer Läsionsdiameter sowie eine kaudale Lokalisation im Zielorgan als Faktoren zur Vorhersage der Ultraschallanwendung bei der iBT identifiziert werden.

Fazit Die Sonografie ist eine nützliche Bildgebungsmodalität bei der Katheteranlage zur CT-gesteuerten Brachytherapie abdomineller Malignome. Bei größeren Läsionen in den kaudalen Lebersegmenten oder der unteren Nierenhälfte können eine bessere Läsionssichtbarkeit und reduzierte Dosis erwartet werden.

Kernaussagen: 

• Die ultraschallgestützte Katheterplatzierung bei der CT-geführten Brachytherapie abdomineller Malignome erhöht signifikant die Läsionssichtbarkeit.

• Prädiktoren einer erfolgreichen Ultraschallanwendung sind größere Läsionen in den unteren Segmenten der Leber und Nieren.

• Durch die Reduzierung der CT-Fluoroskopie kann die Strahlenexposition des medizinischen Personals indirekt gesenkt werden.

Key words

brachytherapy - local ablative treatment - sonography

Publication History

Received: 15 April 2021

Accepted: 29 June 2021

Article published online:
14 October 2021

• References

• 1 Escudier B, Porta C, Schmidinger M. et al. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-updagger. Ann Oncol 2019; 30: 706-720 DOI: 10.1093/annonc/mdz056.
• 2 Van Cutsem E, Cervantes A, Adam R. et al. ESMO consensus guidelines for the management of patients with metastatic colorectal cancer. Ann Oncol 2016; 27: 1386-1422 DOI: 10.1093/annonc/mdw235.
• 3 Vogel A, Cervantes A, Chau I. et al. Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2018; 29 (Suppl. 04) iv238-iv255 DOI: 10.1093/annonc/mdy308.
• 4 Crocetti L, de Baere T, Pereira PL. et al. CIRSE Standards of Practice on Thermal Ablation of Liver Tumours. Cardiovasc Intervent Radiol 2020; 43: 951-962 DOI: 10.1007/s00270-020-02471-z.
• 5 Hao G, Hao Y, Cheng Z. et al. Local tumor progression after ultrasound-guided percutaneous microwave ablation of stage T1a renal cell carcinoma: risk factors analysis of 171 tumors. Int J Hyperthermia 2018; 35: 62-70 DOI: 10.1080/02656736.2018.1475684.
• 6 Lin ZY, Li GL, Chen J. et al. Effect of heat sink on the recurrence of small malignant hepatic tumors after radiofrequency ablation. J Cancer Res Ther 2016; 12: C153-C158 DOI: 10.4103/jcrt.JCRT_959_16.
• 7 Liu J, Wu Y, Xu E. et al. Risk factors of intrahepatic biloma and secondary infection after thermal ablation for malignant hepatic tumors. Int J Hyperthermia 2019; 36: 980-985 DOI: 10.1080/02656736.2019.1660422.
• 8 Ricke J, Wust P. Computed tomography-guided brachytherapy for liver cancer. Semin Radiat Oncol 2011; 21: 287-293 DOI: 10.1016/j.semradonc.2011.05.005.
• 9 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: 1279-1286 DOI: 10.1097/01.RVI.0000141343.43441.06.
• 10 Sommer CM, Sommer SA, Sommer WO. et al. Optimisation of the coagulation zone for thermal ablation procedures: a theoretical approach with considerations for practical use. Int J Hyperthermia 2013; 29: 620-628 DOI: 10.3109/02656736.2013.828103.
• 11 Damm R, El-Sanosy S, Omari J. et al. Ultrasound-assisted catheter placement in CT-guided HDR brachytherapy for the local ablation of abdominal malignancies: Initial experience. Rofo 2019; 191: 48-53 DOI: 10.1055/a-0636-4055.
• 12 Ludemann L, Wybranski C, Seidensticker M. et al. In vivo assessment of catheter positioning accuracy and prolonged irradiation time on liver tolerance dose after single-fraction 192Ir high-dose-rate brachytherapy. Radiat Oncol 2011; 6: 107 DOI: 10.1186/1748-717X-6-107.
• 13 Mohnike K, Steffen IG, Seidensticker M. et al. Radioablation by Image-Guided (HDR) Brachytherapy and Transarterial Chemoembolization in Hepatocellular Carcinoma: A Randomized Phase II Trial. Cardiovasc Intervent Radiol 2019; 42: 239-249 DOI: 10.1007/s00270-018-2127-5.
• 14 Ricke J, Mohnike K, Pech M. et al. Local response and impact on survival after local ablation of liver metastases from colorectal carcinoma by computed tomography-guided high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 2010; 78: 479-485 DOI: 10.1016/j.ijrobp.2009.09.026.
• 15 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: 581-587 DOI: 10.1007/s00270-011-0249-0.
• 16 Grosser OS, Wybranski C, Kupitz D. et al. Improvement of image quality and dose management in CT fluoroscopy by iterative 3D image reconstruction. Eur Radiol 2017; 27: 3625-3634 DOI: 10.1007/s00330-017-4754-7.
• 17 Shakeri S, Afshari Mirak S, Mohammadian Bajgiran A. et al. The effect of tumor size and location on efficacy and safety of US- and CT- guided percutaneous microwave ablation in renal cell carcinomas. Abdom Radiol (NY) 2019; 44: 2308-2315 DOI: 10.1007/s00261-019-01967-8.
• 18 Yuan C, Yuan Z, Cui X. et al. Efficacy of ultrasound-, computed tomography-, and magnetic resonance imaging-guided radiofrequency ablation for hepatocellular carcinoma. J Cancer Res Ther 2019; 15: 784-792 DOI: 10.4103/jcrt.JCRT_836_18.
• 19 Clasen S, Rempp H, Hoffmann R. et al. Image-guided radiofrequency ablation of hepatocellular carcinoma (HCC): is MR guidance more effective than CT guidance?. Eur J Radiol 2014; 83: 111-116 DOI: 10.1016/j.ejrad.2013.09.018.
• 20 Lee LH, Hwang JI, Cheng YC. et al. Comparable Outcomes of Ultrasound versus Computed Tomography in the Guidance of Radiofrequency Ablation for Hepatocellular Carcinoma. PLoS One 2017; 12: e0169655 DOI: 10.1371/journal.pone.0169655.
• 21 Wu J, Chen P, Xie YG. et al. Comparison of the effectiveness and safety of ultrasound- and CT-guided percutaneous radiofrequency ablation of non-operation hepatocellular carcinoma. Pathol Oncol Res 2015; 21: 637-642 DOI: 10.1007/s12253-014-9868-5.
• 22 McGahan JP, Loh S, Fitzgerald E. et al. Pretreatment imaging can be used to select imaging guidance, ultrasound alone versus CT plus ultrasound, for percutaneous renal radiofrequency ablation. Am J Roentgenol 2011; 197: 1244-1250 DOI: 10.2214/Am J Roentgenol.10.6071.
• 23 Kan X, Wang Y, Han P. et al. Combined ultrasound/computed tomography guidance in percutaneous radiofrequency ablation after transarterial chemoembolization for hepatocellular carcinoma in the hepatic dome. Cancer Manag Res 2019; 11: 7751-7757 DOI: 10.2147/CMAR.S212127.