Hepatobiliary brachytherapy is a niche area of research and this has been addressed in this slide set with opinion from discussants

1. Dr Ajeet Kumar Gandhi
MD (AIIMS); DNB; UICCF (MSKCC, USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow
Panel discussion: Common issues faced in
hepato-biliary brachytherapy

2. Hepato-biliary brachytherapy
 Hepatobiliary tumours consist of a constellation of
tumours with surgical resection as primary modality
of treatment
 Radiotherapy has emerged in past few decades as an
adjunct/bridge to surgical treatment
 While the use of EBRT has been on rise, the use of
brachytherapy is still limited to few centres across
the world: Physician/Institute centric

4. Common issues faced in H-B brachytherapy
 Awareness of BT as a modality for H-B
tumors
 Patient selection: EBRT vs. BT
 Procedural complexities and presumed
toxicities
 Skills/Invasiveness of procedure
 Sensitive organ/ limited tolerance
 Paucity of literature regarding
technique/results

5. H-B Brachytherapy Indications
 Radical
As a bridge to liver transplantation
In small inoperable tumors or in
combination with EBRT for un-resectable
patients
Hepato-cellular carcinoma
Cholangiocarcinoma
 Adjunctive (after non-radical excision,
possibly combined with EBRT)

6. Tumour
necrosis rates:
60-70% vs. 20-
30%

7. HDR-IBT in difficult case scenarios
 Large tumors >7-12 cm
 Hilar tumours
 Unresectable HCC
 Centrally located tumors
 HCC with portal vein thrombus

11. Gandhi AK, Chauhan A, Rastogi M et al. RMLIMS

12. Gandhi AK, Chauhan A, Rastogi M et al. RMLIMS

13. Neo-adjuvant treatment protocols for hilar
cholangiocarcinoma

14. EBRT combined with BT for biliary
tumors

16. H-B Brachytherapy Indications
 Palliative
 Metastatic lesions: Colo-rectal, breast, pancreatic,
neuro-endocrine, pancreatic, GI, RCC
 Malignant biliary obstruction
Primary cholangiocarcinoma
Tumoral obstruction: GB, Pancreas, nodes at
porta

18. Contemporary series on CT HDR-
IBT for liver lesions

21. Treatment Techniques: Trans-hepatic
1) Cholangiogram : Site and length of the
malignant stricture
2) Biliary drainage with minimum 10 French
diameter catheter
3) BT blind-ended catheter (usually
5 or 6 French) through the biliary drainage 10
French catheter
4) Marker wire is then passed into the
brachytherapy catheter
5) Treatment planning
procedure

22. Treatment Techniques: Trans-duodenal
endoscopic technique
 ERCP: Site, length of involvement, extent of
disease
 Sphincterotomy: Cannulation of bile duct
 Guide wire passed through and beyond
stricture
 Naso-biliary tube threaded over guide wire
beyond stricture
 Images acquired with radio-opaque markers
 Planning and delivery

23. Imaging for planning
 NCCT scan
 CECT scan
 CEMRI
 PET-CT

25. Target volume and planning
 2-D planning:
 Clinical target length (1 cm
proximal/distal)
 Dose prescribed at 1 cm
from source axis
 3-D planning:
 Image acquisition: CECT,
MRI, PET-CT
 Target delineation: GTV,
CTV,PTV
 OARs: Remaining liver,
stomach, duodenum, spinal
cord, small bowel

26. Dose prescription
 Liver brachytherapy
Radical: 15-20 Gray
Palliative: 10-25 Gray
 Biliary brachytherapy
Radical: EBRT (30-40 Gray) with
Brachytherapy (15-20 Gray)
Palliative: 15-20 Gray

27. Dosimetric advantage of Interstitial Brachytherapy
D4cm tumor shell>20Gy
D3.6cm tumor shell>25Gy
D3.2cm tumor shell >30Gy

28. Dose constraints for the OARs
 Liver:
 V5< 30-60% [Ricke 2016]
 V10<30% [Colletini 2014]
 Stomach
 D1ml<12 Gray [Colletini 2014]
 D1ml<15.5 Gy [Ricke 2006]
 Hilar Structures
 D1ml<12 Gray [Colletini 2014]
 Duodenum, Small Bowel,
Lung, Kidneys

29. Response Evaluation
 Criteria: RECIST/PERCIST
 Time of evaluation
 Imaging modality:
CECT
MRI
PET-CT

31. Take home message
 Hepato-biliary brachytherapy is a safe, effective and
applicable technique
 The indications have expanded over the period of time
 Volume delineation, dose constraints need to be better
defined
 In difficult to treat situations, HDR-IBT could be useful
competitive modality
 Prospective and multi-institutional studies are
warranted
 Teaching workshops would propagate knowledge and
promote its use

32. Thank you!!