Skip to main content
SpringerLink
Log in

3D-CT-geplante interstitielle HDR-Brachytherapie + perkutane Bestrahlung und Chemotherapie bei inoperablen Pankreaskarzinomen

Interstitial HDR-brachytherapy of unresectable pancreatic carcinoma by 3D-CT-planning in combination with external beam radiation and chemotherapy. Methodology and clinical results

Methodik und klinische ergebnisse

  • Originalarbeit
  • Published:
Strahlentherapie und Onkologie Aims and scope Submit manuscript

Zusammenfassung

Ziel

Untersuchung der Praktikabilität, Verträglichkeit und Nebenwirkungen der interstitiellen 192-Iridium-HDR-Brachytherapie im Afterloadingverfahren in der Behandlung des nichtresektablen Pankreaskarzinoms. Die Brachytherapie wurde dabei als Boostbehandlung im Rahmen eines multimodalen therapiekonzepts, bestehend aus interstiteller Brachytherapie, perkutaner Radiatio und simultaner Chemotherapie, eingesetzt.

Patienten und Methoden

19 Patienten (neun Frauen, zehn Männer) mit einem inoperablen Adenokarzinom des Pankreas (UICC-Stadium IV n=5, Stadium III n=10, Stadium II n=4) im Alter von median 67 Jahren wurden mit einer interstitiellen Brachytherapie mit 192-Iridium HDR im Afterloadingverfahren behandelt. Die auf die Referenzisodose eingestrahlten Dosen lagen zwischen 10 und 34 Gy, bei Einzeldosen von 1,88 bis 5 Gy (median 2,0 Gy). Der interstitiellen Therapie schloß sich eine perkutane Radiatio mit Gesamtdosen zwischen 40 und 58 Gy an. Bei neun Patienten wurde zusätzlich eine Chemotherapie mit 5-Fluorouracil und Leucovorin appliziert. Für die interstitielle Brachytherapie wurde ein CT-gestütztes Planungsverfahren angewandt, das eine räumliche Zuordnung der Isodosenverteilung zur Patientenanatomie gestattet.

Ergebnis

Im Patientenkollektiv wurde eine mediane Überlebenszeit von sechs Monaten beobachtet, wobei sich ein Trend zur Abhängigkeit der Überlebenszeit vom Stadium der Tumorerkrankung zeigt (mediane Überlebenszeit Stadium IV vier Monate, Stadium II und III 6,5 Monate). Die lokale Tumorkontrollrate lag bei etwa 70%. Die Therapie zeichnete sich durch eine gute Verträglichkeit aus. Schwerwiegende akute Nebenwirkungen wurden nicht beobachtet. Eine Pankreasfistelung wurde vier Monate und ein unkompliziertes Magenulkus sieben Monate nach Therapiebeginn beobachtet. Bei allen Patienten konnte eine rasche und anhaltende Schmerzlinderung erreicht werden.

Schlußfolgerung

Die 3D-CT-geplante interstitielle HDR-Brachytherapie zeichnet sich beim nichtresektablen Pankreaskarzinom durch die geringe Nebenwirkungsrate im Vergleich zu konkurrierenden Verfahren wie der IORT und der interstitiellen Seedimplantation aus. Trotz der hohen lokalen Kontrollrate kann durch die frühzeitig einsetzende Fernmetastasierung keine Steigerung der medianen Überlebenszeit im Vergleich mit konkurrierenden Therapieverfahren erreicht werden.

Abstract

Purpose

Clinical experiences in interstitial 192-iridium HDR brachytherapy for the treatment of unresectable pancreatic carcinoma are presented. Brachytherapy has been used as boost irradiation in a multimodality treatment concept together with external radiotherapy and simultaneous chemotherapy. Practicability during clinical routine, tolerability and toxicity of treatment are investigated.

Patients and Methods

Nineteen patients (9 female, 10 male, median age 67 years) with unresectable carcinoma of the pancreas have been treated with interstitial brachytherapy. Distribution according to UICC stages showed 4, 10 and 5 patients in stage II to IV respectively. In all cases afterloading technique with 192-iridium in HDR-modus was used. A total dose of 10 to 34 Gy to the reference isodose was delivered (single dose 1.88 to 5 Gy, median 2.5 Gy). Brachytherapy was followed by external radiotherapy, delivering an additional dose of 40 to 58 Gy. Nine patients received simulatenous chemotherapy (5-fluorouracil, leucovorin). Treatment planning was performed based on CT scans, allowing spatial correlation of isodose curves to the patient’s anatomy.

Results

Median survival time was 6 months. A trend of lower survival rates with advanced stage of disease (median survival stage IV 4 months, stage II and III 6.5 months) was seen. Local control rate was 70%. Brachytherapy treatment was well tolerated, severe acute side effects were not observed. One patient developed pancreatic fistulae 4 months and 1 patient a gastric ulcer 7 months after treatment. Pain release was achieved in all patients.

Conclusions

192-iridium HDR-brachytherapy is an effective tool in the treatment of unresectable pancreatic carcinoma with a high rate of local control and a low rate of side effects and is comparable IORT or seed implantation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Abe M, Takahashi M. Intraoperative radiotherapy: the Japanese experience. Int J Radiat Oncol Biol Phys 1981;7:863–8.

    PubMed  CAS  Google Scholar 

  2. Ahlgren JD. Chemotherapy for pankreatic carcinoma. Cancer 1996;78: 654–63.

    PubMed  CAS  Google Scholar 

  3. Bukowski RM, Schacter LP, Groppe CW, Hewlett JS, Weick JK, Livingston RB. Phase II trial of 5-fluorouracil, adriamycin, mitomycin C, and strepozotocin (FAM-S) in pancreatic carcinoma. Cancer 1982;50: 197–200.

    Article  PubMed  CAS  Google Scholar 

  4. Connolly MM, Dawson PJ, Path FRC, Michelassi F, Moossa AR, Lowenstein F. Survival in 1001 patients with carcinoma of the pancreas. Ann Surg 1987;206:366–70.

    Article  PubMed  CAS  Google Scholar 

  5. Copping J, Willix R, Kraft R. Palliative chemical splanchniectomy. Arch Surg 1978;13:509–11.

    Google Scholar 

  6. Dobelbower RR Jr, Howard J, Bagne J, Eltaki F, Merrick III H. Treatment of cancer of the pancreas by precision high dose (PHD) external photon beam and intraoperative electron beam therapy (IOEBT). Int J Radiat Oncol Biol Phys 1989;16:205–9.

    PubMed  Google Scholar 

  7. Dobelbower RR Jr, Konski AA, Merrick III HW, Bronn DG, Schifeling D, Kamen C. Intraoperative electron beam radiation therapy (IOEBRT) for carcinoma of the exocrine pancreas. Int J Radiat Oncol Biol Phys 1991;20:113–9.

    PubMed  Google Scholar 

  8. Dobelbower RR Jr, Merrick III HW, Ahuja RK, Skeel RT. 125 I interstitial implant, precision high-dose external beam therapy, and 5 FU for unresectable adenocarcinoma of pancreas and extrahepatic biliary tree. Cancer 1986;58:2185–95.

    Article  PubMed  Google Scholar 

  9. Dutreix A, Marinello G. The Paris system. In: Pierquin B, Wilson J-F, Chassagne D. Modern brachytherapy. New York-Paris: Masson, 1987: 25–42.

    Google Scholar 

  10. Evans DB, Termuhlen PM, Byrd DR, Ames FC, Dehran TG, Rich TA. Intraoperative radiation therapy following pancreaticoduodenectomy. Ann Surg 1993;218:54–60.

    Article  PubMed  CAS  Google Scholar 

  11. Foo ML, Gunderson LL, Nargorney DM et al. Patterns of failure in grossly resected pancreatic ductal adenocarcinoma treated with adjuvant irradiation ± 5 fluorouracil. Int J Radiat Oncol Biol Phys 1993;26:483–9.

    PubMed  CAS  Google Scholar 

  12. Fortner JG, D’Angio GJ, Hilaris BS, Arthur K, Murphy JM, Fischer HJ. Iodine-125 implantation for unresectable cancer of the pancreas. Postgrad Med 1970;47:226–30.

    Google Scholar 

  13. Gastrointestinal Tumor Study Group. Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Cancer 1987;59:2006–10.

    Article  Google Scholar 

  14. Goertz SR, Ali MM, Parker GA. Local management of pancreatic carcinoma: iodine-125 implantation. Clin Oncol 1990;2:22–6.

    Article  CAS  Google Scholar 

  15. Goldson A. Preliminary clinical experence with intraoperative radiotherapy. J Natl Med Assoc 1978;70:493–5.

    PubMed  CAS  Google Scholar 

  16. Gunderson LL, Martin JK, Kvols LT. Intraoperative and external beam irradiation +5-FU for locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys 1987;13:319–25.

    PubMed  CAS  Google Scholar 

  17. Ishikawa O, Ohhigashi H, Imaoka S, Furikawa H, Sasaki Y, Fujita M. Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein. Ann Surg 1992;215:231–6.

    Article  PubMed  CAS  Google Scholar 

  18. Ishikawa O, Ohhigashi H, Sasaki Y, Kabuto T, Fukuda I, Furukawa H. Practical usefulness of lymphatic and connective tissue clearance for the carcinoma of the pancreas head. Ann Surg 1988;208:215–20.

    Article  PubMed  CAS  Google Scholar 

  19. Jessup JM, Steele G, Mayer RJ et al. Neoadjuvant therapy for unresectable pancreatic adenocarcinoma. Arch Surg 1993;128:559–64.

    PubMed  CAS  Google Scholar 

  20. Johnson CD, Schwail G, Flechtenmacher J, Trede M. Resection for adenocarcinoma of the body and tail of the pancreas. Br J Surg 1993; 80:1177–9.

    Article  PubMed  CAS  Google Scholar 

  21. Johnstone PA, Sindelar WF. Lymph node involvement and pancreatic resection: correlation with prognosis and local disease control in a clinical trial. Pancreas 1993;8:535–9.

    Article  PubMed  CAS  Google Scholar 

  22. Johnstone PA, Sindelar WF. Patterns of disease recurrence following definitive therapy of adenocarcinoma of the pancreas using surgery and adjuvant radiotherapy: correlations of a clinical trial. Int J Radiat Oncol Biol Phys 1993;27:831–4.

    PubMed  CAS  Google Scholar 

  23. Joyce F, Burcharth F, Holm H, Stroyer I. Ultrasonically guided percutaneous implantation of iodine-125 seeds in pancreatic carcinoma. Int J Radiat Oncol Biol Phys 1990;19:1049–52.

    PubMed  CAS  Google Scholar 

  24. Kawamura M, Kataoka M, Fujii T et al. Electron beam intraoperative radiation therapy (EBIORT) for localized pancreatic carcinoma. Int J Radiat Oncol Biol Phys 1992;23:751–7.

    PubMed  CAS  Google Scholar 

  25. Kinsella TJ, Sindelar WF. Intraoperative radiotherapy for pancreatic carcinoma — experimental and clinical studies. Cancer 1996;78:598–604.

    PubMed  CAS  Google Scholar 

  26. Levin DL, Connolly RR, Devesa SS. Demographic characteristics of cancer of the pancreas: mortality, incidence and survival. Cancer 1981;47: 1446–8.

    Google Scholar 

  27. Lillemoe KD, Pitt HA. Palliation — surgical and otherwise. Cancer 1996; 78:605–14.

    PubMed  CAS  Google Scholar 

  28. Mohiuddin M, Cantor RJ, Biermann W, Weiss SM, Barbot D, Rosato FE. Combined modality treatment of localized unresectable adenocarcinoma of the pancreas. Int J Radiat Oncol Biol Phys 1988;14:79–84.

    PubMed  CAS  Google Scholar 

  29. Muchmore JH, Preslan JE, George WJ. Regional Chemotherapy for inoperable pancreatic carcinoma. Cancer 1996;78:664–73.

    PubMed  CAS  Google Scholar 

  30. Nishimura A, Nakano M, Otsu H et al. Introaperative radiotherapy for advanced carcinoma of the pancreas. Cancer 1984;54:2375–84.

    Article  PubMed  CAS  Google Scholar 

  31. Nori D, Hilaris B, Halberg F, Peschel R. Pancreatic cancer. In: Interstitial Collaborative Working Group: Interstitial brachytherapy: physical, biological, and clinical considerations. New York: Raven Press, 1990: 157–64.

    Google Scholar 

  32. Peretz T, Nori D, Hilaris B et al. Treatment of primary unresectable carcinoma of the pancreas with I-125 implantation. Int J Radiat Oncol Biol Phys 1989;17:931–5.

    PubMed  CAS  Google Scholar 

  33. Raben A, Mychalczak B, Brennan M et al. Feasibility study of the treatment of primary unresectable carcinoma of the pancreas with 103 PD brachytherapy. Int J Radiat Oncol Biol Phys 1996;35:351–6.

    PubMed  CAS  Google Scholar 

  34. Sarr MG, Cameron JL. Surgical management cof unresectable carcinoma of the pancreas. Surgery 1983;91:123–33.

    Google Scholar 

  35. Shibamoto Y, Manabe T, Baba N et al. High dose, external beam and intraoperative radiotherapy in the treatment of resectable and unresectable pancreatic cancer. Int J Radiat Oncol Biol Phys 1990;19:605–11.

    PubMed  CAS  Google Scholar 

  36. Shipley WU, Wood WC, Tepper JE. Intraoperative electron beam irradiation for patients with unresectable pancreatic carcinoma. Ann Surg 1984;200:289–95.

    Article  PubMed  CAS  Google Scholar 

  37. Sindelar WF, Kinsella TJ, Mayer RJ. Cancer of the Pancreas. In: De Vita VT, Hellman S, Rosenberg SA (eds.): Principles and practice of oncology, 2nd edn. Philadelphia: Lippincott, 1985:722–6.

    Google Scholar 

  38. Staley CA, Lee JE, Cleary KR et al. Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma of the pancreatic head. Am J Surg 1996;171:118–24.

    Article  PubMed  CAS  Google Scholar 

  39. Tepper J, Noyes D, Krall J et al. Intraoperative radiation therapy of pancreatic carcinoma: a report of RTOG-8505. Int J Radiat Oncol Biol Phys 1991;21:1145–9.

    PubMed  CAS  Google Scholar 

  40. Tepper JE, Shipley WU, Warshaw AL. The role of misonidazole combined with intraoperative radiotherapy in the treatment of pancreatic carcinoma. J Clin Oncol 1987;5:579–84.

    PubMed  CAS  Google Scholar 

  41. Thomas PR. Radiotherapy for carcinoma of the pancreas. Semin Oncol 1996;23:213–9.

    PubMed  CAS  Google Scholar 

  42. Ulmer Forschergruppe Onkologie Gastrointestinaler Tumoren (U-FOGT). Palliative Radiochemotherapie beim primär inoperablen Pankreaskarzino: Intraarterielle Chemotherapie + Radiotherapie alternierend/kontinuierlich. Studienprotokoll.

  43. Watanapa P, Williamson RCN. Surgical pallation for pancreatic cancer: developments during the past two decades. Br J Surg 1992;79:8–20.

    Article  PubMed  CAS  Google Scholar 

  44. Whittington R, Solin L, Mohiuddin M et al. Multimodality therapy of localized unresectable pancreatic adenocarcinoma. Cancer 1984;54:1991–8.

    Article  PubMed  CAS  Google Scholar 

  45. Willich N, Teichmann R, Krimmel K et al. Intraoperative Elektronenbestrahlung (IORT) maligner Pankreastumoren — erste Großhaderner Erfahrungen. Strahlenther Onkol 1988;164:187–94.

    PubMed  CAS  Google Scholar 

  46. Yeung RS, Weese JL, Hoffman JP et al. Neoadjuvant chemoradiation in pancreatic and duodenal carcinoma. Cancer 1993;72:2124–33.

    Article  PubMed  CAS  Google Scholar 

  47. Zerbi A, Fossati V, Parolini D et al. Intraoperative radiation therapy adjuvant to resection in the treatment of pancreatic cancer. Cancer 1994; 73:2930–35.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Strahlentherapie der Julius-Maximilians-Universität, Würzburg

    L. Pfreundner, K. Baier, F. Schwab, J. Willner, K. Bratengeier & M. Flentje

  2. Chirurgische Abteilung der Missionsärztlichen Klinik, Würzburg

    H. Feustel

  3. Chirurgische Universitätsklinik, Würzburg

    K. H. Fuchs

  4. Klinik und Poliklinik für Strahlentherapie der Universität, Josef-Schneider-Straße 11, D-97080, Würzburg

    L. Pfreundner

Authors
  1. L. Pfreundner
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. K. Baier
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. F. Schwab
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. Willner
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. K. Bratengeier
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. M. Flentje
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. H. Feustel
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. K. H. Fuchs
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pfreundner, L., Baier, K., Schwab, F. et al. 3D-CT-geplante interstitielle HDR-Brachytherapie + perkutane Bestrahlung und Chemotherapie bei inoperablen Pankreaskarzinomen. Strahlenther Onkol 174, 133–141 (1998). https://doi.org/10.1007/BF03038496

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03038496

Schlüsselwörter

Key Words

Search

Navigation