The 3D image-guided Brachytherapy Suite at the St John’s Cancer Centre, in Lublin, Poland, is equipped with a large bore SOMATOM CT Sliding Gantry and GammaMedplus iX afterloader (Varian Medical Systems).
While the Polish healthcare system has not caught up with the speed of the rising economy, the Ministry of Health has invested in prevention and treatment of cancer in the last few decades. This has positively impacted especially the less prosperous east of the country. Today, a hospital like the St John’s Cancer Centre in Lublin, close to the Ukrainian border, can offer a wider range of high-quality brachytherapy treatments to its patients.
Photos: Filip Ćwik
“It started with the permission for a new building for our hospital,“ explains Dariusz Kieszko, MD, Deputy Director of Brachytherapy at St John’s Cancer Centre in Lublin. Knowing of the advantages of a CT with sliding gantry that enables imaging and treatment to be combined in one room, he asked to build a theater of 50 square meters, an unusually large suite for a Polish hospital. Today, the staff of the brachytherapy department is highly satisfied with its decision and the purchase made in 2011 – for many reasons.
While brachytherapy treatments were very limited in Lublin before, being used primarily for gynecological cases and sometimes for lung cancer, the department can now additionally treat breast cancer, advanced skin cancer, and liver cancer.
Issues of time …
Since the existing CT at St John’s Cancer Centre was permanently occupied by the demands of external beam radiation therapy, the brachytherapy department used an analog X-ray C-arm apparatus to visualize patient anatomy and implants – a time-intensive procedure.
As the need for 3D images became quite apparent, a further key time-related issue was the transport of the patient from the brachytherapy suite, where implants were set up, to the imaging room, where CT images were acquired. “Today, with the Siemens SOMATOM CT scanner with Sliding Gantry directly located in our theater, we save an hour with each patient,“ Kieszko says.
… and of precise use of HDR dose
Today, a 54-year-old woman is here for treatment, which is led by assistant radiation oncologist Pawel Cisek. The patient has breast cancer and metastases in the stump of the vagina have to be treated. The uterus has been removed previously, and the metastasis probably came from the ovary. Since her cancer has metastasized, she also receives chemotherapy as part of her treatment regimen.
A few days earlier, a CT scan of the vagina was made. On the day of the treatment, four titanium applicators were inserted by the physician and a new CT image was made with the implants in place. The patient lost some blood during the insertion, but the specially designed rails of the CT are sealed against fluids, ideal for a surgical environment.
In the computer room next to the brachytherapy suite, Pawel Cisek uses the images to analyze the position of the needles in the tumor relative to the anatomy. He marks critical structures to be spared during treatment in yellow – in this case, urinary bladder, large intestine, and rectum – for the physicist and sends him the images.
Dariusz Kieszko, MD, PhD (right) and Paweł Cisek, MD (left) are radiation oncologists specialized in imageguided brachytherapy. In addition to treating many diseases such as breast cancer and skin cancer, they continuously develop their techniques and recently started treating liver cancer patients.
The radiation oncologist discusses the dose and the duration of irradiation with the physicist and shows him the visualized critical structures. “There is not much tolerance of variation for the dose,“ says Cisek.
After the plan is finished, treatment is performed. Later applicators are removed and the patient can recover in a special post-surgery room, freeing up the operating theater for another patient. After a rest, the patient can go home the same day.
“We have been using high dose rate brachytherapy (HDR) since 2006,” explains Dariusz Kieszko. The more traditional low dose rate brachytherapy (LDR) treatment, which uses seeds implanted for a longer time in the body of the patient, typically necessitates hospitalization, thereby requiring more staff and typically incurring higher costs. Now, HDR is supported by the 3D accuracy and image quality of the in-room CT.
The 54-year-old woman would not have been treated with brachytherapy previously. „Too risky,“ Kieszko says, „because we wouldn’t have known exactly where the needles are.“ Also, the delicate organs in the surrounding area could not have been seen with a 2D conventional X-ray image. Nowadays, treatment like hers is routine.
The cost factor
The faster procedure allows the staff in Lublin to accept more outpatients, which is significant because these make up 80 percent of all cases in brachytherapy.
Further, the Narodowy Fundusz Zdrowia (NFZ), the national Polish health fund, is well aware of the possible cost savings and regards the use of a CT to be 50 percent cheaper than conventional 2D radiography. In general, the NFZ invests 250 million Zloty (approximately 59,5 million Euros or 77 million US-Dollars) in the purchase of radiology equipment per year. „Because of that solid financial background, the fund has financed 85 percent of the cost for the SOMATOM system, with the rest being contributed by the hospital,“ explains Krzysztof Paprota, Director of the Radiation Oncology Department.
With the possibilities of the CT located directly in the operating theater, brachytherapy treatments in Lublin have increased by about 50 percent. Currently, two new patients are treated each day, and about six patients come for repetitive treatment. Since spring of this year and using their image-guided suite, St John’s Cancer Centre also started offering a new kind of very demanding treatment for liver cancer and 16 patients have been already treated to date.
Treating liver cancer
Dariusz Kieszko learned about liver brachytherapy, quite an advanced procedure, at the University Clinic for Hematology and Oncology in Magdeburg, Germany. “We use it when chemotherapy yields no results and the location of the tumor does not allow an operation,“ says Kieszko. Most of the cases are secondary malignancies, which are less than 8 centimeters. The treatment has a mainly palliative character – a real cure happens seldom.
The major therapeutic challenge is based on the fact that the liver does not tolerate high radiation and that it is well supplied with blood. For this reason, the radiation oncologist works together with an interventional radiologist, who can assist in the case of serious bleeding. Furthermore, the team consists of an anesthetist, who performs local anesthesia between the lower ribs, where the catheter is implanted, plus two nurses and a technician.
The images provided by CT aid the physicians in the precise positioning of the needles and elastic applicator. This is of paramount importance in this form of image-guided radiation therapy (IGRT), during which the patient is lying and imaged on the operating table. However, even IGRT needs the help of additional imaging. Therefore, following anesthesia, contrast medium is injected in order to locate the liver tumor. Here, too, precision is fundamental. After this, a standard biopsy needle is placed in the tumor, before an angiographic device with a hemostatic valve is inserted. Through the device, which is wider than the needle, elastic catheters can enter the body and reach the tumor: These will be used to deliver the treatment. In order to irradiate the entire tumor volume, clinicians plan carefully dwell positions throughout the targeted area, typically spacing them 2 centimeters apart from each other. Radiation treatment itself takes about 30 to 40 minutes, which is long for brachytherapy.
To establish the clinical target volume (CTV) two CT datasets are combined – one pre-surgery and the other acquired for planning. The high-definition 3D CT images are necessary to identify the parenchyma of the liver, the stomach, the large intestine, duodenum, the spinal cord, and bile ducts. These are critical structures, that have to be protected, while the dose delivered to the target ranging from 15 to 25 Gray by D90% depending on the tolerance of the neighboring organs.
After the treatment, the patient receives hemostatic agent to stop any possible bleeding, before another CT with contrast medium is performed to check that indeed no bleeding has occurred.
There are two worst-case scenarios that need to be considered with such treatment: Bleeding caused by a rupture of the liver vessels and bleeding caused by the removal of the applicators. But Kieszko ensures: “We are prepared for bleeding, which is hard to control, during and after the treatment.“ After a night at the hospital, the patient’s pulse, blood pressure, and heart activity are checked again on the second day and a final CT with contrast medium is made to check once more that there is no bleeding. If everything is all right, the patient can go home.
More IGRT in the future
For Kieszko, it is too early to talk about the success of such treatments. But by monitoring the 16 patients over several months via CT or MRI, the radiation oncologists in Lublin have seen a stabilization or even a reduction of the alteration activity of metastases in several patients – an encouraging result.
Up to now, five of the 16 patients were referred from other hospitals, even from the far-away capital of Warsaw. Kieszko believes the number will increase – with the same happening for other cancer types, such as breast cancer. In this case, the Polish Ministry of Health has invested 30 million zloty (approximately 7 million euros or 9 million US dollars) in educating women about the disease, leading to more patients being treated earlier.
One established treatment approach, recommended by renowned American medical societies consists in irradiating the breast externally after breast-conserving surgery, during which the tumor has been removed.
In addition to external beam radiation therapy, where the whole breast is irradiated, brachytherapy treatment as a boost (increasing radiation levels to the tumor bed) can hit the target precisely with a high dose, thereby shortening the treatment time in comparison with external irradiation.
With this technique, the neighboring tissue that has been partially infiltrated by cancer cells, receives a weaker but necessary dose of radiation. The high-definition 3D CT images help to visualize clearly and thereby protect the neighboring tissue and organs from unnecessary radiation.
"There is not much tolerance for variation in the treatment dose."
Another method in use is accelerated partial breast irradiation (APBI), also performed after breastconserving surgery, and used for smaller tumors. In this procedure, elastic applicators are inserted through the breast to lead the radiation to the area of the former tumor twice a day, and this for a week. This procedure also requires precise planning using CT-based 3D imaging for every application, in order to preserve sensitive structures. Today, 20 percent of breast cancer cases in Lublin are treated with brachytherapy.
Skin cancer is also an issue in the agricultural population of southeast Poland, because workers are intensively exposed to the sun during summer-time field work. With advanced skin cancer on the scalp, planning using CT is indispensable, too, in order to avoid radiation to the eyes and brain. As applicators need to be positioned on the surface of the head of the patient, the team in Lublin has developed an approach, using a meshed mask that keep the elastic applicators in place, during imaging and treatment.
According to Dariusz Kieszko, the brachytherapy department will use more IGRT in the future, and he and his team are already planning to broaden their treatment spectrum to prostate cancer and metastases on the lung. “We are in a state of permanent development,“ Kieszko says, his gaze shifting to the cranes swinging over a construction site outside the window: The second enlargement of the St John’s Cancer Centre has already started.
About the Author
Jens Mattern born in Freiburg im Breisgau, Germany, works as a freelance journalist in Poland. He has contributed to countless German-language publications, among them Berliner Zeitung, Tages-Anzeiger, Profil, Spiegel online, ZEIT online, and Welt.de.