Image-guided interstitial high-dose-rate brachytherapy in hepatocellular carcinoma

New interventional options especially for patients with HCC and BCLC scores B and C give rise to disputes about the optimal therapeutic management. CT-guided brachytherapy complements established interventional techniques like RFA and TACE since it may also be used successfully in tumors much greater than 5 cm in diameter. In addition, unlike thermal ablation, the brachytherapy technique may be applied in tumors located nearby risk structures such as liver hilum or gallbladder and it is independent of cooling effects such as through large blood vessels or strong tumor perfusion. Depending on tumor size, geometry and visibility, MRI or CT guidance may be used. 15 Gy minimal target dose can be applied safely in a single or--in case of very large tumors--a sequential approach targeting different tumor portions. Local recurrence rates will be very low, and the rate of complications is moderate despite the fact that most patients present with underlying cirrhosis and related comorbidities. Preliminary data suggest a positive impact on overall survival. Randomized controlled trials are on their way to assess combination schemes with systemic treatments such as sorafenib.