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Stera S, Miebach G, Buergy D, Dreher C, Lohr F, Wurster S, Rödel C, Marcella S, Krug D, Frank A G, Ehmann M, Fleckenstein J, Blanck O, Boda-Heggemann J. Liver SBRT with active motion-compensation results in excellent local control for liver oligometastases: An outcome analysis of a pooled multi-platform patient cohort. Radiother Oncol 2021; 158:230-236. [PMID: 33667585 DOI: 10.1016/j.radonc.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 02/10/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Local treatment of metastases in combination with systemic therapy can prolong survival of oligo-metastasized patients. To fully exploit this potential, safe and effective treatments are needed to ensure long-term metastases control. Stereotactic body radiotherapy (SBRT) is one means, however, for moving liver tumors correct delivery of high doses is challenging. After validating equal in-vivo treatment accuracy, we analyzed a pooled multi-platform liver-SBRT-database for clinical outcome. METHODS Local control (LC), progression-free interval (PFI), overall survival (OS), predictive factors and toxicity was evaluated in 135 patients with 227 metastases treated by gantry-based SBRT (deep-inspiratory breath-hold-gating; n = 71) and robotic-based SBRT (fiducial-tracking, n = 156) with mean gross tumor volume biological effective dose (GTV-BEDα/β=10Gy) of 146.6 Gy10. RESULTS One-, and five-year LC was 90% and 68.7%, respectively. On multivariate analysis, LC was significantly predicted by colorectal histology (p = 0.006). Median OS was 20 months with one- and two-year OS of 67% and 37%. On multivariate analysis, ECOG-status (p = 0.003), simultaneous chemotherapy (p = 0.003), time from metastasis detection to SBRT-treatment (≥2months; p = 0.021) and LC of the treated metastases (≥12 months, p < 0.009) were significant predictors for OS. One- and two-year PFI were 30.5% and 14%. Acute toxicity was mild and rare (14.4% grade I, 2.3% grade II, 0.6% grade III). Chronic °III/IV toxicities occurred in 1.1%. CONCLUSIONS Patient selection, time to treatment and sufficient doses are essential to achieve optimal outcome for SBRT with active motion compensation. Local control appears favorable compared to historical control. Long-term LC of the treated lesions was associated with longer overall survival.
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Affiliation(s)
- Susanne Stera
- University Hospital Frankfurt, Department of Radiation Oncology, Frankfurt am Main, Germany.
| | - Georgia Miebach
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Daniel Buergy
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Constantin Dreher
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Frank Lohr
- UO di Radioterapia, Dipartimento di Oncologia, Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Stefan Wurster
- Saphir Radiosurgery Center, Güstrow, Germany; University Medicine Greifswald, Department of Radiation Oncology, Germany
| | - Claus Rödel
- University Hospital Frankfurt, Department of Radiation Oncology, Frankfurt am Main, Germany
| | - Szücs Marcella
- University Medicine Rostock, Department of Radiation Oncology, Germany
| | - David Krug
- Saphir Radiosurgery Center, Güstrow, Germany; University Medical Center Schleswig-Holstein, Department of Radiation Oncology, Kiel, Germany
| | - Giordano Frank A
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Michael Ehmann
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Jens Fleckenstein
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Güstrow, Germany; University Medical Center Schleswig-Holstein, Department of Radiation Oncology, Kiel, Germany
| | - Judit Boda-Heggemann
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
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Schmid RK, Tai A, Klawikowski S, Straza M, Ramahi K, Li XA, Robbins JR. The Dosimetric Impact of Interfractional Organ-at-Risk Movement During Liver Stereotactic Body Radiation Therapy. Pract Radiat Oncol 2019; 9:e549-e558. [PMID: 31176791 DOI: 10.1016/j.prro.2019.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 05/07/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Stereotactic body radiation therapy (SBRT) is an effective therapy for treating liver malignancies. However, little is known about interfractional dose variations to adjacent organs at risk (OARs). We examine the effects of interfractional organ movement and setup variation on dose delivered to OARs in patients receiving liver SBRT. METHODS AND MATERIALS Thirty patients treated with liver SBRT were analyzed. Daily image guidance with diagnostic quality computed tomography-on-rails imaging was performed before each fraction. In phase 1, these daily images were used to delineate all OARs including the liver, heart, right kidney, esophagus, stomach, duodenum, and large bowel in 10 patients. In phase 2, only OARS in close proximity to the target were contoured in 20 additional patients. Dose distribution on each daily computed tomography was generated, and daily doses to each OAR were recorded and compared with clinical thresholds to determine whether a daily dose excess (DDE) occurred. RESULTS In phase 1, significant interfractional dose differences between planned and delivered dose to OARs were observed, but differences were rarely clinically significant, with just 1 DDE. In phase 2, multiple DDEs were recorded for OARs close to the target, mainly involving the stomach, heart, and esophagus. Tumors in the hilum and liver segments I, IV, and VIII were the most common locations for DDEs. On root cause analysis, 3 etiologies of DDE emerged: craniocaudal shift (69.2%), anatomic changes (28.2%), and anteroposterior shifts (2.6%). CONCLUSIONS OARs close to liver lesions may receive higher doses than expected during SBRT owing to interfractional variations in OARs relative to the target. These differences in planned versus expected dose can lead to toxicity. Efforts to better evaluate OARs with daily image guidance may help reduce risks. Application of adaptive replanning and improved and real-time image guidance could mitigate risks of toxicity, and further study into their applications is warranted.
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Affiliation(s)
- Ryan K Schmid
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - An Tai
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Slade Klawikowski
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Straza
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Khalid Ramahi
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jared R Robbins
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Radiation Oncology, University of Arizona College of Medicine, Tucson, Arizona.
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