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Biliary duct stenosis after image-guided high-dose-rate interstitial brachytherapy of central and hilar liver tumors

A systematic analysis of 102 cases

Gallengangstenosen nach bildgeführter interstitieller Hochdosis-Brachytherapie zentraler und hilusnaher Lebertumore

Eine systematische Analyse von 102 Fällen

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Abstract

Objective

Image-guided high-dose-rate interstitial brachytherapy (iBT) with iridium-192 is an effective treatment option for patients with liver malignancies. Little is known about long-term radiation effects on the bile duct system when central hepatic structures are exposed to iBT. This retrospective analysis investigates the occurrence of posthepatic cholestasis (PHC) and associated complications in patients undergoing iBT.

Materials and methods

We identified patients who underwent iBT of hepatic malignancies and had point doses of ≥1 Gy to central bile duct structures. Patients with known bile duct-related diseases or prior bile duct manipulation were excluded.

Results

102 patients were retrospectively included. Twenty-two patients (22%) developed morphologic PHC after a median of 17 (3–54) months; 18 of them were treated using percutaneous transhepatic cholangiopancreatography drainage or endoscopic retrograde cholangiopancreatography. The median point dose was 24.8 (4.4–80) Gy in patients with PHC versus 14.2 (1.8–61.7) Gy in those without PHC (p = 0.028). A dose of 20.8 Gy (biological effective dose, BED3/10 = 165/64.1 Gy) was identified to be the optimal cutoff dose (p = 0.028; 59% sensitivity, 24% specificity). Abscess/cholangitis was more common in patients with PHC compared to those without (4 of 22 vs. 2 of 80; p = 0.029). Median survival did not differ between patients with and without PHC (43 vs. 36 months; p = 0.571).

Conclusion

iBT of liver malignancies located near the hilum can cause PHC when the central bile ducts are exposed to high point doses. Given the long latency and absence of impact of iBT-induced PHC on median survival, the rate of cholestasis and complications seen in our patients appears to be acceptable.

Zusammenfassung

Zielsetzung

Die bildgestützte interstitielle Hochdosis-Brachytherapie (iBT) mit Iridium-192 ist eine effektive Methode zur Ablation hepatischer Malignome. Unklar ist die Langzeitauswirkung auf das Gallengangsystem bei Bestrahlung zentraler Leberstrukturen. Die vorgestellte retrospektive Studie eruiert den Einfluss der iBT auf die Entstehung posthepatischer Cholestasen (PHC) und vergesellschafteter Komplikationen.

Material und Methoden

Eingeschlossen wurden Patienten mit iBT hepatischer/hilusnaher Malignome mit Punktdosen ≥1 Gy an zentralen Gallengangstrukturen. Ausschlusskriterien waren gallengangassoziierte Erkrankungen oder vorherige Manipulationen an den Gallenwegen.

Ergebnisse

In die Studie konnten 102 Patienten eingeschlossen werden. Von diesen entwickelten 22 (22 %) nach im Median 17 Monaten (Spanne 3–54 Monate) eine morphologische PHC, die in 18 Fällen (18 %) mit perkutaner transhepatischer Cholangiodrainage oder endoskopischer retrograder Cholangiopankreatikographie abgeleitet werden musste. Die Punktdosis der Patienten mit PHC lag im Median bei 24,8 Gy (Spanne 4,4–80 Gy), derjenigen ohne PHC bei 14,2 Gy (Spanne 1,8–61,7 Gy; p = 0,028). Bei 20,8 Gy (biologische effektive Dosis, BED3/10 = 165/64,1 Gy) konnte ein optimaler Cut-off-Wert (Schwellendosis) ermittelt werden (p = 0,028; Sensitivität 59 %, Spezifität 24 %). Abszesse/Cholangitiden traten bei Patienten mit PHC signifikant häufiger auf als ohne (4 von 22 vs. 2 von 80; p = 0,029). Im medianen Überleben zwischen Patienten mit und ohne PHC zeigte sich kein Unterschied (43 vs. 36 Monate; p = 0,571).

Schlussfolgerung

Die iBT hilusnaher Lebertumore kann bei hohen Punktdosen an zentralen Gallengängen zu einer klinisch relevanten PHC führen. In Anbetracht der langen Latenzzeit und der fehlenden Auswirkung iBT-assoziierter PHC auf das mediane Überleben halten wir die ermittelte Rate an Strikturen und Komplikationen für akzeptabel.

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Authors and Affiliations

  1. Klinik für Radiologie und Nuklearmedizin, Otto-von-Guericke University, Leipziger Straße 44, 39120, Magdeburg, Germany

    Maciej Powerski MD, Susanne Penzlin MD, Robert Damm MD & Maciej Pech MD

  2. Klinik für Strahlentherapie, Otto-von-Guericke University, Leipziger Straße 44, 39120, Magdeburg, Germany

    Peter Hass MD & Günther Gademann MD

  3. Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Marchioninistraße 15, 81377, München, Germany

    Ricarda Seidensticker MD, Jens Ricke MD & Max Seidensticker MD

  4. Diagnostisch Therapeutisches Zentrum Berlin, Kadiner Straße 23, 10243, Berlin, Germany

    Konrad Mohnike MD

  5. Klinik für Nuklearmedizin, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany

    Ingo Steffen MD

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  1. Maciej Powerski MD
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Correspondence to Maciej Powerski MD.

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Conflict of interest

M. Powerski, S. Penzlin, P. Hass, R. Seidensticker, K. Mohnike, R. Damm, I. Steffen, M. Pech, G. Gademann, J. Ricke, and M. Seidensticker declare that they have no competing interests.

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Powerski, M., Penzlin, S., Hass, P. et al. Biliary duct stenosis after image-guided high-dose-rate interstitial brachytherapy of central and hilar liver tumors. Strahlenther Onkol 195, 265–273 (2019). https://doi.org/10.1007/s00066-018-1404-1

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