Treatment of hepatic pancreatic ductal adenocarcinoma metastases with high-dose-rate image-guided interstitial brachytherapy: a single center experience

Abstract

PurposeTo evaluate the efficacy and safety of image-guided (computed tomography/magnetic resonance imaging – CT/MRI) high-dose-rate (HDR) interstitial brachytherapy (iBT) as a salvage maneuver for the treatment of hepatic metastases originating from hepatic pancreatic ductal adenocarcinoma (PDAC). PDAC metastases present a major and unresolved problem, and any surgical approach or local therapeutic intervention remains extremely controversial.Material and methodsA cumulative number of 45 hepatic PDAC metastases in 16 patients were treated and retrospectively analyzed. Synchronous metastatic spread was observed in five patients, metachronous in eleven. 14 patients had resection of the pancreatic primary prior to iBT: eight Whipple/PPPD and six distal pancreatectomy procedures. The hepatic metastases were progressing under chemotherapy, thus iBT was applied as a salvage maneuver with the intention of local tumor control and prolonged survival. iBT is applied interstitially, with temporarily introduced 192Ir source in a single fraction HDR irradiation regime to eradicate vital tumor cells. Response to treatment was assessed clinically with CT/MRI every three months.ResultsLocal tumor control was achieved in 87% of all treated metastases. The median diameter of the irradiated lesions was 2.2 cm (range, 1-11.2 cm), the median irradiation dose was 21 Gy (range, 5-29.1 Gy). Median progression-free survival (PFS) after iBT was 3.4 months (range, 1.5-19.6 months), the median overall survival (OS) after iBT was 8.9 months (range, 3.1-29.3 months). Three major complications (CTCAE grade 3) occurred following iBT: three cases of liver abscess, which were successfully resolved with drainage and antibiotics.ConclusionsOverall, iBT is a safe procedure, which enables excellent rates of local tumor control and presents a viable anti-neoplastic treatment option as a salvage therapy for metastatic PDAC patients.

Defining oligometastatic pancreatic cancer: a systematic review and critical synthesis of consensus

“…Finally, 76 studies were identified, which provided a definition of OMD in PDAC and/or reported LCT of OMD ( Table 1 ). Most studies were retrospective ( n = 66, 87%), 2 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 ,…”

“… 41 , 45 , 50 , 51 , 53 , 84 Thirty (40%) studies encompassed synchronous metastasis, 29 , 31 , 33 , 34 , 40 , 42 , 43 , 44 , 46 , 47 , 48 , 49 , 51 , 52 , 56 , 60 , 61 , 64 , 69 , 70 , 72 , 73 , 75 , 80 , 83 , 88 , 89 , 90 , 91 , 92 whereas 21 (28%) involved metachronous metastases 13 , 27 , 35 , 37 , 53 , 57 , 58 , 59 , 63 , 65 , 67 , 71 , 74 , 76 , 77 , 79 , 93 , 94 , 95 , 96 and 16 (21%) studies involved both synchronous and metachronous metastases. 2 , 14 , 30 , 32 , 36 , 38 , 39 , 54 …”

Interstitial High-Dose-Rate Brachytherapy of Liver Metastases in Oligometastatic Patients

“…In a report of 16 patients with pancreatic cancer undergoing iBT for liver metastases, either disease progression under chemotherapy or discontinuation of chemotherapy due to drug-related toxicity were the two main reasons for referral to local treatment. This study reports a local tumor control of 87% and a median PFS of only 3.4 months [ 34 ].…”

Single-fraction high-dose-rate brachytherapy: a scoping review on outcomes and toxicities for all disease sites

“…Eighteen studies (7 primary, 11 metastasis) with 618 patients have been reported on receiving single-fraction treatment between 2004-2021 (Table 3). Seventeen studies were from Germany, and one was from Poland [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42]. Single-fraction high-dose brachytherapy dose delivered ranged from 8 to 25 Gy.…”

“…G3 toxicity was reported in 3 patients with liver abscesses post-interstitial brachytherapy in a study done by Drewes et al . [ 29 ]. Other serious complications were noted, including post-interventional abdominal hemorrhage, pneumothorax, biliary abscess [ 41 ], and Gram-negative septicemia [ 38 ]; however, only a few cases were reported with such complications ( Table 3 ).…”