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Abualnil AY, Kumar R, George MA, Lalos A, Shah MM, Deek MP, Jabbour SK. Role of Stereotactic Body Radiation Therapy in Hepatocellular Carcinoma. Surg Oncol Clin N Am 2024; 33:173-195. [PMID: 37945142 DOI: 10.1016/j.soc.2023.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Hepatocellular carcinoma (HCC)is a common type of liver cancer with a poor prognosis, especially in patients with advanced stages or underlying liver disease. While surgical resection, liver transplantation, and ablation therapies have traditionally been the mainstay of treatment for HCC, radiation therapy has become increasingly recognized as an effective alternative, particularly for those who are not surgical candidates. Stereotactic Body Radiation Therapy (SBRT) is a highly precise form of radiation therapy that delivers very high doses of radiation to the tumor while sparing surrounding healthy tissue. Several studies have reported favorable outcomes with SBRT in HCC treatment. Moreover, SBRT can be used to treat recurrent HCC after prior treatment, offering a potentially curative approach in select cases. While SBRT has demonstrated its efficacy and safety in treating HCC, future studies are needed to further investigate the potential role of SBRT in combination with other treatments for HCC.
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Affiliation(s)
- Aseel Y Abualnil
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Ritesh Kumar
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Mridula A George
- Department of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Alexander Lalos
- Division of Gasteroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30342, USA
| | - Matthew P Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Salma K Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA.
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2
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Herr DJ, Wang C, Mendiratta-Lala M, Matuszak M, Mayo CS, Cao Y, Parikh ND, Haken RT, Owen D, Evans JR, Stanescu T, Yan M, Dawson LA, Schipper M, Lawrence TS, Cuneo KC. A Phase II Study of Optimized Individualized Adaptive Radiotherapy for Hepatocellular Carcinoma. Clin Cancer Res 2023; 29:3852-3858. [PMID: 37471457 PMCID: PMC10592290 DOI: 10.1158/1078-0432.ccr-23-1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE We hypothesized that optimizing the utility of stereotactic body radiotherapy (SBRT) based on the individual patient's probability for tumor control and risk of liver injury would decrease toxicity without sacrificing local control in patients with impaired liver function or tumors not amenable to thermal ablation. PATIENTS AND METHODS Patients with Child-Pugh (CP) A to B7 liver function with aggregate tumor size >3.5 cm, or CP ≥ B8 with any size tumor were prospectively enrolled on an Institutional Review Board-approved phase II clinical trial to undergo SBRT with baseline and midtreatment dose optimization using a quantitative, individualized utility-based analysis. Primary endpoints were change in CP score of ≥2 points within 6 months and local control. Protocol-treated patients were compared with patients receiving conventional SBRT at another cancer center using overlap weighting. RESULTS A total of 56 patients with 80 treated tumors were analyzed with a median follow-up of 11.2 months. Two-year cumulative incidence of local progression was 6.4% [95% confidence interval (CI, 2.4-13.4)]. Twenty-one percent of patients experienced treatment-related toxicity within 6 months, which is similar to the rate for SBRT in patients with CP A liver function. An analysis using overlap weighting revealed similar local control [HR, 0.69; 95% CI (0.25-1.91); P = 0.48] and decreased toxicity [OR, 0.26; 95% CI (0.07-0.99); P = 0.048] compared with conventional SBRT. CONCLUSIONS Treatment of individuals with impaired liver function or tumors not amenable to thermal ablation with a treatment paradigm designed to optimize utility may decrease treatment-related toxicity while maintaining tumor control.
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Affiliation(s)
- Daniel J. Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Chang Wang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Martha Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Charles S. Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Randy Ten Haken
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
- Current Address: Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Joseph R. Evans
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Teodor Stanescu
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Michael Yan
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Laura A. Dawson
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Kyle C. Cuneo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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3
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Liu H, Schaal D, Curry H, Clark R, Magliari A, Kupelian P, Khuntia D, Beriwal S. Review of cone beam computed tomography based online adaptive radiotherapy: current trend and future direction. Radiat Oncol 2023; 18:144. [PMID: 37660057 PMCID: PMC10475190 DOI: 10.1186/s13014-023-02340-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023] Open
Abstract
Adaptive radiotherapy (ART) was introduced in the late 1990s to improve the accuracy and efficiency of therapy and minimize radiation-induced toxicities. ART combines multiple tools for imaging, assessing the need for adaptation, treatment planning, quality assurance, and has been utilized to monitor inter- or intra-fraction anatomical variations of the target and organs-at-risk (OARs). Ethos™ (Varian Medical Systems, Palo Alto, CA), a cone beam computed tomography (CBCT) based radiotherapy treatment system that uses artificial intelligence (AI) and machine learning to perform ART, was introduced in 2020. Since then, numerous studies have been done to examine the potential benefits of Ethos™ CBCT-guided ART compared to non-adaptive radiotherapy. This review will explore the current trends of Ethos™, including improved CBCT image quality, a feasible clinical workflow, daily automated contouring and treatment planning, and motion management. Nevertheless, evidence of clinical improvements with the use of Ethos™ are limited and is currently under investigation via clinical trials.
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Affiliation(s)
- Hefei Liu
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, USA
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | - Ryan Clark
- Varian Medical Systems Inc, Palo Alto, CA, USA
| | | | | | | | - Sushil Beriwal
- Varian Medical Systems Inc, Palo Alto, CA, USA.
- Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
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4
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Elaimy AL, Cao Y, Lawrence TS. Evolution of Response-Based Radiotherapy for Hepatocellular Cancer. Cancer J 2023; 29:266-271. [PMID: 37796644 PMCID: PMC10558084 DOI: 10.1097/ppo.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
ABSTRACT Stereotactic body radiation therapy has emerged as a safe and effective treatment modality for properly selected hepatocellular cancer (HCC) patients with normal liver function. However, many HCC patients have reduced baseline liver function due to underlying cirrhosis or prior liver-directed therapies. Therefore, because of the increased risk of hepatotoxicity, the use of stereotactic body radiation therapy for patients with reduced liver function has been approached with caution. Individualized, response-based radiotherapy incorporates models, imaging tools, and biomarkers that determine the dose-response relationship of the liver before, during, and after treatment and has been useful in reducing the likelihood of liver damage without sacrificing tumor control. This review discusses the evolution of response-based radiotherapy for HCC and highlights areas for further investigation.
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Affiliation(s)
- Ameer L Elaimy
- From the Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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5
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Mushonga M, Helou J, Weiss J, Dawson LA, Wong RKS, Hosni A, Kim J, Brierley J, Koch CA, Alrabiah K, Lindsay P, Stanescu T, Barry A. Clinical Outcomes of Patients with Metastatic Breast Cancer Treated with Hypo-Fractionated Liver Radiotherapy. Cancers (Basel) 2023; 15:2839. [PMID: 37345175 DOI: 10.3390/cancers15102839] [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: 04/13/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE To retrospectively review the clinical outcomes of patients with metastatic breast cancer (MBCa) following liver directed ablative intent radiotherapy (RT). METHODS Demographics, disease and treatment characteristics of patients with MBCa who received liver metastasis (LM) directed ablative RT between 2004-2020 were analysed. The primary outcome was local control (LC), secondary outcomes included overall survival (OS) and progression-free survival (PFS) analyzed by univariate (UVA) and multi-variable analysis (MVA). RESULTS Thirty MBCa patients with 50 LM treated with 5-10 fraction RT were identified. Median follow-up was 14.6 (range 0.9-156.2) months. Class of metastatic disease was described as induced (12 patients, 40%), repeat (15 patients, 50%) and de novo (three patients, 10%). Median size of treated LM was 3.1 cm (range 1-8.8 cm) and median biologically effective dose delivered was 122 (Q1-Q3; 98-174) Gy3. One-year LC rate was 100%. One year and two-year survival was 89% and 63%, respectively, with size of treated LM predictive of OS (HR 1.35, p = 0.023) on UVA. Patients with induced OMD had a significantly higher rate of progression (HR 4.77, p = 0.01) on UVA, trending to significance on MVA (HR 3.23, p = 0.051). CONCLUSIONS Hypo-fractionated ablative liver RT in patients with MBCa provides safe, tolerable treatment with excellent LC.
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Affiliation(s)
- Melinda Mushonga
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Joelle Helou
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
- Department of Oncology, Division of Radiation Oncology, Western University, London, ON N6A 5W9, Canada
| | - Jessica Weiss
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Rebecca K S Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - C Anne Koch
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Khalid Alrabiah
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Patricia Lindsay
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Teo Stanescu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON M5G 1L7, Canada
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON M5G 2M9, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5T 1P5, Canada
- Cancer Research @UCC, University College Cork, T12 R229 Cork, Ireland
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6
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MRI-based delta-radiomic features for prediction of local control in liver lesions treated with stereotactic body radiation therapy. Sci Rep 2022; 12:18631. [PMID: 36329116 PMCID: PMC9633752 DOI: 10.1038/s41598-022-22826-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022] Open
Abstract
Real-time magnetic resonance image guided stereotactic ablative radiotherapy (MRgSBRT) is used to treat abdominal tumors. Longitudinal data is generated from daily setup images. Our study aimed to identify delta radiomic texture features extracted from these images to predict for local control in patients with liver tumors treated with MRgSBRT. Retrospective analysis of an IRB-approved database identified patients treated with MRgSBRT for primary liver and secondary metastasis histologies. Daily low field strength (0.35 T) images were retrieved, and the gross tumor volume was identified on each image. Next, images' gray levels were equalized, and 39 s-order texture features were extracted. Delta-radiomics were calculated as the difference between feature values on the initial scan and after delivered biological effective doses (BED, α/β = 10) of 20 Gy and 40 Gy. Then, features were ranked by the Gini Index during training of a random forest model. Finally, the area under the receiver operating characteristic curve (AUC) was estimated using a bootstrapped logistic regression with the top two features. We identified 22 patients for analysis. The median dose delivered was 50 Gy in 5 fractions. The top two features identified after delivery of BED 20 Gy were gray level co-occurrence matrix features energy and gray level size zone matrix based large zone emphasis. The model generated an AUC = 0.9011 (0.752-1.0) during bootstrapped logistic regression. The same two features were selected after delivery of a BED 40 Gy, with an AUC = 0.716 (0.600-0.786). Delta-radiomic features after a single fraction of SBRT predicted local control in this exploratory cohort. If confirmed in larger studies, these features may identify patients with radioresistant disease and provide an opportunity for physicians to alter management much sooner than standard restaging after 3 months. Expansion of the patient database is warranted for further analysis of delta-radiomic features.
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7
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McComas KN, Yock A, Darrow K, Shinohara ET. Online Adaptive Radiation Therapy and Opportunity Cost. Adv Radiat Oncol 2022. [DOI: 10.1016/j.adro.2022.101034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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8
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Keall PJ, Brighi C, Glide-Hurst C, Liney G, Liu PZY, Lydiard S, Paganelli C, Pham T, Shan S, Tree AC, van der Heide UA, Waddington DEJ, Whelan B. Integrated MRI-guided radiotherapy - opportunities and challenges. Nat Rev Clin Oncol 2022; 19:458-470. [PMID: 35440773 DOI: 10.1038/s41571-022-00631-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2022] [Indexed: 12/25/2022]
Abstract
MRI can help to categorize tissues as malignant or non-malignant both anatomically and functionally, with a high level of spatial and temporal resolution. This non-invasive imaging modality has been integrated with radiotherapy in devices that can differentially target the most aggressive and resistant regions of tumours. The past decade has seen the clinical deployment of treatment devices that combine imaging with targeted irradiation, making the aspiration of integrated MRI-guided radiotherapy (MRIgRT) a reality. The two main clinical drivers for the adoption of MRIgRT are the ability to image anatomical changes that occur before and during treatment in order to adapt the treatment approach, and to image and target the biological features of each tumour. Using motion management and biological targeting, the radiation dose delivered to the tumour can be adjusted during treatment to improve the probability of tumour control, while simultaneously reducing the radiation delivered to non-malignant tissues, thereby reducing the risk of treatment-related toxicities. The benefits of this approach are expected to increase survival and quality of life. In this Review, we describe the current state of MRIgRT, and the opportunities and challenges of this new radiotherapy approach.
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Affiliation(s)
- Paul J Keall
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia.
| | - Caterina Brighi
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin, Madison, WI, USA
| | - Gary Liney
- Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
| | - Paul Z Y Liu
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Suzanne Lydiard
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Chiara Paganelli
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Trang Pham
- Faculty of Medicine and Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shanshan Shan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Alison C Tree
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Uulke A van der Heide
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, Netherlands
| | - David E J Waddington
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Brendan Whelan
- ACRF Image X Institute, The University of Sydney, Sydney, New South Wales, Australia
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9
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Mohamad I, Barry A, Dawson L, Hosni A. Stereotactic body radiation therapy for colorectal liver metastases. Int J Hyperthermia 2022; 39:611-619. [DOI: 10.1080/02656736.2021.1923836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Issa Mohamad
- Department of Radiation Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Aisling Barry
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Laura Dawson
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Ali Hosni
- The Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
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10
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Cheung MLM, Kan MWK, Yeung VTY, Poon DMC, Kam MKM, Lee LKY, Chan ATC. The radiobiological effect of using Acuros XB vs anisotropic analytical algorithm on hepatocellular carcinoma stereotactic body radiation therapy. Med Dosim 2022; 47:161-165. [PMID: 35241348 DOI: 10.1016/j.meddos.2022.01.004] [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: 10/22/2021] [Revised: 01/23/2022] [Accepted: 01/31/2022] [Indexed: 11/26/2022]
Abstract
The purpose of this work was to study the radiobiological effect of using Acuros XB (AXB) vs Analytic Anisotropic Algorithm (AAA) on hepatocellular carcinoma (HCC) stereotactic body radiation therapy (SBRT). Seventy SBRT volumetric modulated arc therapy (VMAT) plans for HCC were calculated using AAA and AXB respectively with the same treatment parameters. Published tumor control probability (TCP) and normal tissue complication probability (NTCP) models were used to quantify the effect of dosimetric difference between AAA and AXB on TCP, NTCP and uncomplicated tumor control probability (UTCP). There was an average decrease of 2.5% in 6-month TCP. Normal liver has the largest average decrease in NTCP which was 59.7%. Bowels followed with 26.6% average decrease in NTCP. Duodenum, stomach and esophagus had 10.2%, 5.1%, and 4.3% average decrease in NTCP. There was an average decrease of 1.8% and up to 7.2% in 6-month UTCP. There was an overall decrease in TCP, NTCP, and UTCP for HCC SBRT plans calculated using AXB compared to AAA which could be clinically significant.
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Affiliation(s)
- Michael L M Cheung
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China; State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Monica W K Kan
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China; State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vanessa T Y Yeung
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China; State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Darren M C Poon
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michael K M Kam
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Louis K Y Lee
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anthony T C Chan
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China; State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
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11
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Thaper D, Yadav HP, Sharma D, Kamal R, Singh G, Oinam AS, Kumar V. Degree of reduction in normal liver complication probability from free-breathing to breath-hold liver SBRT: a dose-escalation strategy using radiation dose-volume effect. Biomed Phys Eng Express 2021; 8. [PMID: 34874286 DOI: 10.1088/2057-1976/ac3fe5] [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: 11/16/2021] [Accepted: 12/03/2021] [Indexed: 11/12/2022]
Abstract
Introduction. This study aimed to analyze the degree of reduction in normal liver complication probability (NTCP) from free-breathing (FB) to breath-hold (BH) liver SBRT. The effect of the radiation dose-volume on the mean liver dose (MLD) was also analyzed due to dose prescription, normal liver volume (NLV), and PTV.Materials and Methods. Thirty-three stereotactic body radiation therapy (SBRT) cases of hepatocellular carcinoma were selected, retrospectively. For FB, the treatments were planned on average intensity projection scan (CTavg), and patient-specific internal target volume (ITV) margins were applied. To simulate the BH treatment, computed tomography (CT) scan correspond to the 40%-50% of the respiratory cycle (CT40%-50%) was chosen, and an appropriate intrafraction margin of 2 mm, 1.5 mm, and 1.5 mm were given in craniocaudal (CC), superior-inferior (SI), and lateral direction to generate the final iGTV. As per RTOG 1112, all organs at risk (OAR's) were considered during the optimization of treatment plans. NTCP was calculated using LKB fractionated model. Multivariate regression analysis was performed to see the effect of EQD2Gy, NLV, and PTV on MLD2Gy.Results.A significant dosimetric difference was observed in the normal liver (liver-ITV/iGTV). A reduction of 1.7% in NTCP was observed from FB to BH technique. The leverage of dose escalation is more in BH because MLD2Gycorresponds to 5%, 10%, 20%, and 50% NTCP was 0.099 Gy, 0.41 Gy, 1.21 Gy, and 3.432 Gy more in BH as compared to FB technique. In MVRA, the major factor which was attributed to a change in MLD2Gyis EQD2Gy. Conclusion. From FB to BH technique, a significant reduction in NTCP was observed. The dose prescription is a major factor attributed to the change in MLD2Gy. Advances in knowledge: If feasible, prefer BH treatment either for tumor dose escalation or for the reduction in NTCP.
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Affiliation(s)
- Deepak Thaper
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Radiation Oncology Department, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Hanuman P Yadav
- Radiation Oncology Department, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Deepti Sharma
- Radiation Oncology Department, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rose Kamal
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Radiation Oncology Department, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gaganpreet Singh
- Centre for Medical Physics, Panjab University, Chandigarh, India.,Radiotherapy Department, PGIMER, Regional Cancer Centre, Chandigarh, India
| | - Arun S Oinam
- Radiotherapy Department, PGIMER, Regional Cancer Centre, Chandigarh, India
| | - Vivek Kumar
- Centre for Medical Physics, Panjab University, Chandigarh, India
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12
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Wong TC, Lee VH, Law AL, Pang HH, Lam K, Lau V, Cui TY, Fong AS, Lee SW, Wong EC, Dai JW, Chan AC, Cheung T, Fung JY, Yeung RM, Luk M, Leung T, Lo C. Prospective Study of Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma on Waitlist for Liver Transplant. Hepatology 2021; 74:2580-2594. [PMID: 34091914 PMCID: PMC9291538 DOI: 10.1002/hep.31992] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 05/26/2021] [Accepted: 05/30/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS There are no prospective data on stereotactic body radiation therapy (SBRT) as a bridge to liver transplantation for HCC. This study aimed to evaluate the efficacy and safety of SBRT as bridging therapy, with comparison with transarterial chemoembolization (TACE) and high-intensity focused ultrasound (HIFU). APPROACH AND RESULTS Patients were prospectively enrolled for SBRT under a standardized protocol from July 2015 and compared with a retrospective cohort of patients who underwent TACE or HIFU from 2010. The primary endpoint was tumor control rate at 1 year after bridging therapy. Secondary endpoints included cumulative incidence of dropout, toxicity, and posttransplant survival. During the study period, 150 patients were evaluated (SBRT, n = 40; TACE, n = 59; HIFU, n = 51). The tumor control rate at 1 year was significantly higher after SBRT compared with TACE and HIFU (92.3%, 43.5%, and 33.3%, respectively; P = 0.02). With competing risk analysis, the cumulative incidence of dropout at 1 and 3 years after listing was lower after SBRT (15.1% and 23.3%) compared with TACE (28.9% and 45.8%; P = 0.034) and HIFU (33.3% and 45.1%; P = 0.032). Time-to-progression at 1 and 3 years was also superior after SBRT (10.8%, 18.5% in SBRT, 45%, 54.9% in TACE, and 47.6%, 62.8% in HIFU; P < 0.001). The periprocedural toxicity was similar, without any difference in perioperative complications and patient and recurrence-free survival rates after transplant. Pathological complete response was more frequent after SBRT compared with TACE and HIFU (48.1% vs. 25% vs. 17.9%, respectively; P = 0.037). In multivariable analysis, tumor size <3 cm, listing alpha-fetoprotein <200 ng/mL, Child A, and SBRT significantly reduced the risk of dropout. CONCLUSIONS SBRT was safe, with a significantly higher tumor control rate, reduced the risk of waitlist dropout, and should be used as an alternative to conventional bridging therapies.
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Affiliation(s)
- Tiffany Cho‐Lam Wong
- Department of SurgeryThe University of Hong KongHong Kong S.A.R.,Department of SurgeryQueen Mary HospitalHong Kong S.A.R.
| | - Victor Ho‐Fun Lee
- Department of Clinical OncologyThe University of Hong KongHong Kong S.A.R.,Department of Clinical OncologyQueen Mary HospitalHong Kong S.A.R.
| | - Ada Lai‐Yau Law
- Department of Clinical OncologyPamela Youde Nethersole Eastern HospitalHong Kong S.A.R.
| | - Herbert H. Pang
- School of Public HealthThe University of Hong KongHong Kong S.A.R.
| | - Ka‐On Lam
- Department of Clinical OncologyThe University of Hong KongHong Kong S.A.R.,Department of Clinical OncologyQueen Mary HospitalHong Kong S.A.R.
| | - Vince Lau
- Department of RadiologyQueen Mary HospitalHong Kong S.A.R.
| | | | | | - Sarah Wai‐Man Lee
- Department of Clinical OncologyPamela Youde Nethersole Eastern HospitalHong Kong S.A.R.
| | - Edwin Chun‐Yin Wong
- Department of Clinical OncologyPamela Youde Nethersole Eastern HospitalHong Kong S.A.R.
| | - Jeff Wing‐Chiu Dai
- Department of SurgeryThe University of Hong KongHong Kong S.A.R.,Department of SurgeryQueen Mary HospitalHong Kong S.A.R.
| | - Albert Chi‐Yan Chan
- Department of SurgeryThe University of Hong KongHong Kong S.A.R.,Department of SurgeryQueen Mary HospitalHong Kong S.A.R.
| | - Tan‐To Cheung
- Department of SurgeryThe University of Hong KongHong Kong S.A.R.,Department of SurgeryQueen Mary HospitalHong Kong S.A.R.
| | - James Yan‐Yue Fung
- Department of MedicineThe University of Hong KongHong Kong S.A.R.,Department of MedicineQueen Mary HospitalHong Kong S.A.R.
| | - Rebecca Mei‐Wan Yeung
- Department of Clinical OncologyPamela Youde Nethersole Eastern HospitalHong Kong S.A.R.
| | - Mai‐Yee Luk
- Department of Clinical OncologyThe University of Hong KongHong Kong S.A.R.,Department of Clinical OncologyQueen Mary HospitalHong Kong S.A.R.
| | - To‐Wai Leung
- Department of Clinical OncologyThe University of Hong KongHong Kong S.A.R.,Department of Clinical OncologyQueen Mary HospitalHong Kong S.A.R.
| | - Chung‐Mau Lo
- Department of SurgeryThe University of Hong KongHong Kong S.A.R.,Department of SurgeryQueen Mary HospitalHong Kong S.A.R.
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13
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Worm ES, Hansen R, Høyer M, Weber B, Mortensen H, Poulsen PR. Uniform versus non-uniform dose prescription for proton stereotactic body radiotherapy of liver tumors investigated by extensive motion-including treatment simulations. Phys Med Biol 2021; 66. [PMID: 34544071 DOI: 10.1088/1361-6560/ac2880] [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: 04/08/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
Compared to x-ray-based stereotactic body radiotherapy (SBRT) of liver cancer, proton SBRT may reduce the normal liver tissue dose. For an optimal trade-off between target and liver dose, a non-uniform dose prescription is often applied in x-ray SBRT, but lacks investigation for proton SBRT. Also, proton SBRT is prone to breathing-induced motion-uncertainties causing target mishit or dose alterations by interplay with the proton delivery. This study investigated non-uniform and uniform dose prescription in proton-based liver SBRT, including effects of rigid target motion observed during planning-4DCT and treatment. The study was based on 42 x-ray SBRT fractions delivered to 14 patients under electromagnetic motion-monitoring. For each patient, a non-uniform and uniform proton plan were made. The uniform plan was renormalized to be iso-toxic with the non-uniform plan using a NTCP model for radiation-induced liver disease. The motion data were used in treatment simulations to estimate the delivered target dose with rigid motion. Treatment simulations were performed with and without a repainting scheme designed to mitigate interplay effects. Including rigid motion, the achieved CTV mean dose after three fractions delivered without repainting was on average (±SD) 24.8 ± 8.4% higher and the D98%was 16.2 ± 11.3% higher for non-uniform plans than for uniform plans. The interplay-induced increase in D2%relative to the static plans was reduced from 3.2 ± 4.1% without repainting to -0.5 ± 1.7% with repainting for non-uniform plans and from 1.5 ± 2.0% to 0.1 ± 1.3% for uniform plans. Considerable differences were observed between estimated CTV doses based on 4DCT motion and intra-treatment motion. In conclusion, non-uniform dose prescription in proton SBRT may provide considerably higher tumor doses than uniform prescription for the same complication risk. Due to motion variability, target doses estimated from 4DCT motion may not accurately reflect the delivered dose. Future studies including modelling of deformations and associated range uncertainties are warranted to confirm the findings.
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Affiliation(s)
| | - Rune Hansen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Britta Weber
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.,Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Hanna Mortensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Per Rugaard Poulsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.,Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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14
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Baak R, Willemssen FEJA, van Norden Y, Eskens FALM, Milder MTW, Heijmen BJM, Koerkamp BG, Sprengers D, van Driel LMJW, Klümpen HJ, den Toom W, Koedijk MS, IJzermans JNM, Méndez Romero A. Stereotactic Body Radiation Therapy after Chemotherapy for Unresectable Perihilar Cholangiocarcinoma: The STRONG Trial, a Phase I Safety and Feasibility Study. Cancers (Basel) 2021; 13:cancers13163991. [PMID: 34439146 PMCID: PMC8394718 DOI: 10.3390/cancers13163991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 12/25/2022] Open
Abstract
Simple Summary The role of radiotherapy in the treatment of perihilar cholangiocarcinoma has not yet been properly defined. In this prospective study, we therefore explored the addition to first-line chemotherapy of stereotactic body radiation therapy (SBRT) delivered in 15 fractions. Patients eligible for the study had been diagnosed with unresectable perihilar cholangiocarcinoma, and then had no progressive disease after completing treatment with 6–8 cycles of cisplatin-gemcitabine. Primary endpoints were feasibility and safety. Secondary endpoints were local control, progression-free survival, overall survival, and quality of life. As each patient completed the SBRT successfully and no dose-limiting toxicity was found, we consider this treatment to be both feasible and safe. The local control rate and overall survival were promising. However, due to the small sample size of this study, we urge the analysis of this treatment in a larger series of patients. Abstract Background: In unresectable pCCA, the standard of care is palliative chemotherapy. We investigated the feasibility and safety of adding stereotactic body radiation therapy (SBRT) after chemotherapy. Methods: Patients with unresectable pCCA, stage T1-T4N0-N1M0, ECOG 0-1, having finished 6–8 cycles of cisplatin and gemcitabine without disease progression were eligible. SBRT was planned in 15 fractions of 3.0–4.5 Gy. The primary endpoints were feasibility (defined as completing SBRT as planned) and toxicity, evaluated within 3 months after SBRT (CTCAE v4.03). A conventional “3 + 3” design was used, corresponding to a sample size of 6 patients. Dose-limiting toxicity (DLT) was defined as grade ≥ 4 hepatobiliary or grade ≥ 3 gastrointestinal toxicity. The secondary endpoints, measured from the start of radiotherapy, were local control, progression-free survival, overall survival, and quality of life (QoL). ClinicalTrials.gov identifier: NCT03307538. Results: Six patients were enrolled between November 2017 and March 2020. SBRT was delivered as planned. All patients were treated with 60Gy (15 × 4.0Gy). No SBRT-related DLT was observed. The most common grade ≥ 3 toxicity was cholangitis (n = 5). The median follow-up was 14 months. The 12-month local control rate was 80%. We observed no substantial changes in QoL. Conclusion: In patients with unresectable pCCA with stable disease after palliative chemotherapy, adding SBRT is feasible and safe. The observed local control merits an additional evaluation of effectiveness.
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Affiliation(s)
- Rogier Baak
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands; (Y.v.N.); (M.T.W.M.); (B.J.M.H.); (W.d.T.); (A.M.R.)
- Correspondence:
| | - François E. J. A. Willemssen
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, 3015 CN Rotterdam, The Netherlands;
| | - Yvette van Norden
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands; (Y.v.N.); (M.T.W.M.); (B.J.M.H.); (W.d.T.); (A.M.R.)
| | - Ferry A. L. M. Eskens
- Department of Medical Oncology, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands;
| | - Maaike T. W. Milder
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands; (Y.v.N.); (M.T.W.M.); (B.J.M.H.); (W.d.T.); (A.M.R.)
| | - Ben J. M. Heijmen
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands; (Y.v.N.); (M.T.W.M.); (B.J.M.H.); (W.d.T.); (A.M.R.)
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, 3015 CN Rotterdam, The Netherlands; (B.G.K.); (J.N.M.I.)
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 3015 CN Rotterdam, The Netherlands; (D.S.); (L.M.J.W.v.D.)
| | - Lydi M. J. W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, 3015 CN Rotterdam, The Netherlands; (D.S.); (L.M.J.W.v.D.)
| | - Heinz-Josef Klümpen
- Department of Medical Oncology, Amsterdam University Medical Centers, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
| | - Wilhelm den Toom
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands; (Y.v.N.); (M.T.W.M.); (B.J.M.H.); (W.d.T.); (A.M.R.)
| | - Merel S. Koedijk
- Radiotherapeutisch Instituut Friesland, 8934 AD Leeuwarden, The Netherlands;
| | - Jan N. M. IJzermans
- Department of Surgery, Erasmus MC University Medical Center, 3015 CN Rotterdam, The Netherlands; (B.G.K.); (J.N.M.I.)
| | - Alejandra Méndez Romero
- Department of Radiotherapy, Erasmus MC Cancer Institute, 3015 CN Rotterdam, The Netherlands; (Y.v.N.); (M.T.W.M.); (B.J.M.H.); (W.d.T.); (A.M.R.)
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15
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Li X, Ye Z, Lin S, Pang H. Predictive factors for survival following stereotactic body radiotherapy for hepatocellular carcinoma with portal vein tumour thrombosis and construction of a nomogram. BMC Cancer 2021; 21:701. [PMID: 34126955 PMCID: PMC8204556 DOI: 10.1186/s12885-021-08469-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 06/08/2021] [Indexed: 02/06/2023] Open
Abstract
Background We evaluated the treatment response and predictive factors for overall survival (OS) in patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis (PVTT), who underwent stereotactic body radiotherapy (SBRT). Additionally, we developed and validated a personalised prediction model for patient survival. Methods Clinical information was retrospectively collected for 80 patients with HCC and PVTT, who were treated with SBRT at the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) between December 2015 and June 2019. A multivariate Cox proportional hazard regression model was used to identify the independent predictive factors for survival. Clinical factors were subsequently presented in a nomogram. The area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA) were used to evaluate the accuracy of the model and the net clinical benefit. Results All patients completed the planned radiotherapy treatment, and the median follow-up duration was 10 months (range, 1–35.3 months). The median survival duration was 11.5 months, with 3-, 6-, and 12-month survival rates of 92.5, 74.5, and 47.5%, respectively. The multivariable Cox regression model indicated that the following were significant independent predictors of OS: clinical T stage (p = 0.001, hazard ratio [HR] = 3.085, 95% confidence interval [CI]: 1.514–6.286), cirrhosis (p = 0.014, HR = 2.988, 95% CI: 1.246–7.168), age (p = 0.005, HR = 1.043, 95% CI: 1.013–1.075), alpha-fetoprotein level (p = 0.022, HR = 1.000, 95% CI: 1.000–1.000), and haemoglobin level (p = 0.008, HR = 0.979, 95% CI: 0.963–0.994). A nomogram based on five independent risk factors and DCA demonstrated a favourable predictive accuracy of patient survival (AUC = 0.74, 95% CI: 0.63–0.85) and the clinical usefulness of the model. Conclusions SBRT is an effective treatment for patients with HCC with PVTT. Notably, clinical T stage, presence of cirrhosis, age, alpha-fetoprotein levels, and haemoglobin levels are independent prognostic factors for survival. The presented nomogram can be used to predict the survival of patients with HCC and PVTT, who underwent SBRT.
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Affiliation(s)
- Xiaojie Li
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China
| | - Zhimin Ye
- Department of Radiation Oncology, Cancer Hospital of The University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, 310022, China
| | - Sheng Lin
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China.
| | - Haowen Pang
- Department of Oncology, The Affiliated Hospital of Southwest Medical University, Luzhou, 646000, Sichuan, China.
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16
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Mathew AS, Dawson LA. Current Understanding of Ablative Radiation Therapy in Hepatocellular Carcinoma. J Hepatocell Carcinoma 2021; 8:575-586. [PMID: 34164350 PMCID: PMC8214025 DOI: 10.2147/jhc.s284403] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/06/2021] [Indexed: 12/11/2022] Open
Abstract
The role of ablative stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC) has been evolving over the last few decades. SBRT has mostly been used in early stages of HCC, including few (≤ 3 in number) tumors, small tumours (< 3 cm in size), as well as larger tumours which are ineligible for other ablative modalities, mostly without vascular invasion. In early stage HCC, SBRT is used as a definitive treatment with curative intent or with intent to bridge to liver transplant. Retrospective and prospective institutional series document a high rate of local control (68–95% at 3 years) following SBRT. This coupled with a low risk of toxicity makes this non-invasive ablative treatment an attractive option for patients who are ineligible for other ablative treatments. Small randomized studies of ablative radiation have also shown non-inferiority of radiation as compared to radiofrequency ablation (RFA). Currently, SBRT is widely available as a safe and effective liver directed therapy, although there is a need for more studies providing higher level evidence. This review gives a brief overview of SBRT and the evidence for its use in HCC patients with ablative intent.
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Affiliation(s)
- Ashwathy S Mathew
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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17
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Cheung MLM, Kan MWK, Yeung VTY, Poon DMC, Kam MKM, Lee LKY, Chan ATC. Analysis of Hepatocellular Carcinoma Stereotactic Body Radiation Therapy Dose Prescription Method Using Uncomplicated Tumor Control Probability Model. Adv Radiat Oncol 2021; 6:100739. [PMID: 34355107 PMCID: PMC8321929 DOI: 10.1016/j.adro.2021.100739] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/12/2021] [Accepted: 06/08/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose This work was to establish an uncomplicated tumor control probability (UTCP) model using hepatocellular carcinoma (HCC) stereotactic body radiation therapy (SBRT) clinical data in our institution. The model was then used to analyze the current dose prescription method and to seek the opportunity for improvement. Methods and Materials A tumor control probability (TCP) model was generated based on local clinical data using the maximum likelihood method. A UTCP model was then formed by combining the established TCP model with the normal tissue complication probability model based on the study by Dawson et al. The authors investigated the dependence of maximum achievable UTCP on planning target volume equivalent uniform dose (EUD) at various ratio between planning target volume EUD and normal liver EUD (T/N EUD ratios). A new term uncomplicated tumor control efficiency (UTCE) was also introduced to analyze the outcome. A UTCE value of 1 implied that the theoretical maximum UTCP for the corresponding T/N EUD ratio was achieved. Results The UTCE of the HCC SBRT patients based on the current dose prescription method was found to be 0.93 ± 0.05. It was found that the UTCE could be increased to 0.99 ± 0.03 by using a new dose prescription scheme, for which the UTCP could be maximized while keeping the normal tissue complication probability value smaller than 5%. Conclusions The dose prescription method of the current HCC SBRT in our institution was analyzed using a UTCP model established based on local clinical data. It was shown that there could be a potential to increase the prescription dose of HCC SBRT. A new dose prescription scheme was proposed to achieve better UTCP. Additional clinical trials would be required to validate the proposed dose prescription scheme in the future.
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Affiliation(s)
- Michael L M Cheung
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China.,State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Monica W K Kan
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China.,State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vanessa T Y Yeung
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China.,State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Darren M C Poon
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michael K M Kam
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Louis K Y Lee
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anthony T C Chan
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong SAR, China.,State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
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18
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Mastrocostas K, Fischer S, Munoz-Schuffenegger P, Jang HJ, Dawson LA, Liu ZA, Sapisochin G, Kim TK. Radiological tumor response and histopathological correlation of hepatocellular carcinoma treated with stereotactic body radiation therapy as a bridge to liver transplantation. Abdom Radiol (NY) 2021; 46:1572-1585. [PMID: 33074426 DOI: 10.1007/s00261-020-02821-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the imaging findings of hepatocellular carcinoma (HCC) treated with stereotactic body radiation therapy (SBRT) as a bridging therapy prior to liver transplantation (LT), with histopathological correlation at liver explant. METHODS Our institutional review board approved this retrospective study. The study subjects included 25 HCC lesions in 23 patients (20 males; median age, 60 years; range 41-68 years) who underwent LT after SBRT for HCC as a bridge to LT in a single tertiary referral institution over a 12-year period. Target HCC lesions were assessed for imaging biomarkers on contrast-enhanced CT or MRI including change in HCC diameter and assessment of percentage necrosis. The radiologic response at pre-LT imaging was compared to explant pathology. RESULTS There was a positive correlation between the tumor size (Spearman's ρ = 0.86; p < 0.001) and percentage necrosis (p < 0.001) on Pre-LT imaging and those on pathology. Partial response (PR), stable disease (SD), and progressive disease (PD) according to RECIST 1.1 were seen in 8 (32%), 15 (60%), and 2 (8%) lesions on pre-LT imaging, respectively. Of the 15 lesions with radiologic SD, 5/15 (33%) showed necrosis of more than 50% on post-SBRT imaging, while 9/15 (60%) showed necrosis of more than 50% at explant pathologic analysis, showing a tendency to underestimate the degree of tumor necrosis compared to pathology. CONCLUSION RECIST 1.1 radiologic response criteria may underestimate the response to treatment with SBRT, and radiologic estimation of percent tumor necrosis was more closely correlated with pathologic percent tumor necrosis.
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19
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Thaper D, Singh G, Kamal R, Oinam AS, Yadav HP, Kumar R, Kumar V. Impact of dose heterogeneity in target on TCP and NTCP for various radiobiological models in liver SBRT: different isodose prescription strategy. Biomed Phys Eng Express 2021; 7:015020. [PMID: 33522499 DOI: 10.1088/2057-1976/abd3f0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The impact of dose heterogeneity within the tumor on TCP and NTCP was studied using various radiobiological models. The effect of the degree of heterogeneity index (HI) on TCP was also analyzed. MATERIALS AND METHODS Thirty-seven pre-treated liver SBRT cases were included in this study. Two different kinds of treatment techniques were employed. In both arms, the prescribed dose was received by 95% of the PTV. Initially, the inhomogeneous treatment plans (IHTP) were made in which the spatial change of dose within the PTV was high and the maximum dose within the PTV can go up to 160%. Subsequently, in another arm, homogeneous treatment plans (HTP) were generated in which PTV was covered with the same prescription isodose and the maximum dose can go up to 120%. As per RTOG 1112, all organs at risk (OAR's) were considered while optimization of the treatment plans. TCP was calculated using the Niemierko and Poisson model. NTCP was calculated using the Niemierko and LKB fractionated model. RESULTS For the IHTP, TCP was decreasing as 'a' value decreased in the Niemierko model whereas, for HTP, TCP was found to be the same. NTCP of the normal liver was less in IHTP as compared to HTP, and the Niemierko model overestimates the NTCP as compared to LKB fractionated model. NTCP for all other OAR's was <1% in both kinds of treatment plans. CONCLUSION IHTP is found to be clinically better than HTP because NTCP of the normal liver was significantly less and TCP was more for certain 'a' values of the Niemierko model and the Poisson model. There is not any effect of HI on TCP was observed. Advances in knowledge: IHTP could be used clinically because of the dose-escalation and subsequently, leads to an increase in the TCP.
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Affiliation(s)
- Deepak Thaper
- Centre for Medical Physics, Panjab University, Chandigarh, India. Department of Radiation Oncology, Institute of Liver and Biliary Sciences, New Delhi, India
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20
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Oliver PAK, Yewondwossen M, Summers C, Shaw C, Cwajna S, Syme A. Influence of intra- and interfraction motion on planning target volume margin in liver stereotactic body radiation therapy using breath hold. Adv Radiat Oncol 2021; 6:100610. [PMID: 33490733 PMCID: PMC7809510 DOI: 10.1016/j.adro.2020.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/13/2020] [Accepted: 10/29/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose This study aimed to investigate intra- and interfraction motion during liver stereotactic body radiation therapy for the purpose of planning target volume (PTV) margin estimation, comparing deep inspiration breath hold (DIBH) and deep expiration breath hold (DEBH). Methods and materials Pre- and posttreatment kV cone beam computed tomography (CT) images were acquired for patients with liver cancer who were treated using stereotactic body radiation therapy with DIBH or DEBH. A total of 188 images were analyzed from 18 patients. Positioning errors were determined based on a comparison with planning CT images and matching to the liver. Treatment did not proceed until errors were ≤3 mm. Standard deviations of random and systematic errors resulting from this image matching process were used to calculate PTV margin estimates. Results DIBH errors are generally larger than DEBH errors, especially in the anterior-posterior and superior-inferior directions. Posttreatment errors tend to be larger than pretreatment errors, especially for DIBH. Standard deviations of random errors are larger than those of systematic errors. Considering both pre- and posttreatment cone beam CT images, PTV margins for DIBH and DEBH are estimated as anterior-posterior, superior-inferior, right-left = (5.7, 6.3, 3.0) mm and (3.1, 3.4, 2.8) mm, respectively. Conclusions This study suggests that DEBH results in more reproducible target positioning, which could in turn justify the use of smaller PTV margins.
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Affiliation(s)
- Patricia A K Oliver
- Department of Medical Physics, Nova Scotia Health Authority, Halifax, Canada
| | - Mammo Yewondwossen
- Department of Medical Physics, Nova Scotia Health Authority, Halifax, Canada.,Department of Radiation Oncology, Dalhousie University, Halifax, Canada.,Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Canada
| | - Clare Summers
- Department of Radiation Oncology, Dalhousie University, Halifax, Canada
| | - Conor Shaw
- Department of Medical Physics, Nova Scotia Health Authority, Halifax, Canada
| | - Slawa Cwajna
- Department of Radiation Oncology, Dalhousie University, Halifax, Canada
| | - Alasdair Syme
- Department of Medical Physics, Nova Scotia Health Authority, Halifax, Canada.,Department of Radiation Oncology, Dalhousie University, Halifax, Canada.,Department of Physics and Atmospheric Science, Dalhousie University, Halifax, Canada
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21
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Munoz-Schuffenegger P, Barry A, Atenafu EG, Kim J, Brierley J, Ringash J, Brade A, Dinniwell R, Wong RKS, Cho C, Kim TK, Sapisochin G, Dawson LA. Stereotactic body radiation therapy for hepatocellular carcinoma with Macrovascular invasion. Radiother Oncol 2020; 156:120-126. [PMID: 33285195 DOI: 10.1016/j.radonc.2020.11.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/26/2020] [Accepted: 11/29/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND In patients with hepatocellular carcinoma (HCC), macrovascular invasion (MVI) is associated with a poor prognosis. The purpose of this study is to describe long-term outcomes of patients with HCC and MVI treated with stereotactic body radiation therapy (SBRT). METHODS Patients with HCC and MVI who were treated with SBRT from January 2003 to December 2016 were analyzed. Patients who had extrahepatic disease or previous liver transplant were excluded. Demographical, clinical, and treatment variables were analyzed. RESULTS 128 eligible patients with HCC and MVI were treated with SBRT. Median age was 60.5 years (39 to 90 years). Baseline Child-Pugh (CP) score was A5 in 67%, A6 in 20%. Median SBRT dose was 33.3 Gy (range: 27 to 54 Gy) in 5 fractions. Local control at 1 year was 87.4% (95% CI 78.6 to 96.1%). Median overall survival (OS) was 18.3 months (95% CI 11.2 to 21.4 months); ECOG performance status > 1 (HR:1.85, p = 0.0138) and earlier treatment era (HR: 2.20, p = 0.0015) were associated with worsening OS. In 43 patients who received sorafenib following SBRT, median OS was 37.9 months (95% CI 19.5 to 54.4 months). Four patients developed GI bleeding possibly related to SBRT at 2 to 8 months, and 27% (31/112 evaluable patients) had worsening of CP class at three months after SBRT. CONCLUSIONS SBRT was associated with encouraging outcomes for patients with HCC and MVI, especially in those patients who received sorafenib after SBRT. Randomized phase III trials of SBRT with systemic and/or regional therapy are warranted and ongoing.
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Affiliation(s)
- Pablo Munoz-Schuffenegger
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Jolie Ringash
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Anthony Brade
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Robert Dinniwell
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Rebecca K S Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Charles Cho
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada
| | - Tae Kyoung Kim
- Joint Department of Medical Imaging, University of Toronto, Canada
| | - Gonzalo Sapisochin
- Multi-Organ Transplant and HPB Surgical Oncology, Division of General Surgery, Department of Surgery, University of Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada; Department of Radiation Oncology, University of Toronto, Canada.
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22
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Glide-Hurst CK, Lee P, Yock AD, Olsen JR, Cao M, Siddiqui F, Parker W, Doemer A, Rong Y, Kishan AU, Benedict SH, Li XA, Erickson BA, Sohn JW, Xiao Y, Wuthrick E. Adaptive Radiation Therapy (ART) Strategies and Technical Considerations: A State of the ART Review From NRG Oncology. Int J Radiat Oncol Biol Phys 2020; 109:1054-1075. [PMID: 33470210 DOI: 10.1016/j.ijrobp.2020.10.021] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 12/21/2022]
Abstract
The integration of adaptive radiation therapy (ART), or modifying the treatment plan during the treatment course, is becoming more widely available in clinical practice. ART offers strong potential for minimizing treatment-related toxicity while escalating or de-escalating target doses based on the dose to organs at risk. Yet, ART workflows add complexity into the radiation therapy planning and delivery process that may introduce additional uncertainties. This work sought to review presently available ART workflows and technological considerations such as image quality, deformable image registration, and dose accumulation. Quality assurance considerations for ART components and minimum recommendations are described. Personnel and workflow efficiency recommendations are provided, as is a summary of currently available clinical evidence supporting the implementation of ART. Finally, to guide future clinical trial protocols, an example ART physician directive and a physics template following standard NRG Oncology protocol is provided.
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Affiliation(s)
- Carri K Glide-Hurst
- Department of Human Oncology, University of Wisconsin-Madison, Madison, Wisconsin.
| | - Percy Lee
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Adam D Yock
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Olsen
- Department of Radiation Oncology, University of Colorado- Denver, Denver, Colorado
| | - Minsong Cao
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Farzan Siddiqui
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - William Parker
- Department of Radiation Oncology, McGill University, Montreal, Quebec, Canada
| | - Anthony Doemer
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Yi Rong
- Department of Radiation Oncology, University of California-Davis, Sacramento, California
| | - Amar U Kishan
- Department of Radiation Oncology, University of California-Los Angeles, Los Angeles, California
| | - Stanley H Benedict
- Department of Radiation Oncology, University of California-Davis, Sacramento, California
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Beth A Erickson
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jason W Sohn
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ying Xiao
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Evan Wuthrick
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida
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23
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Tchelebi LT, Haustermans K, Scorsetti M, Hosni A, Huguet F, Hawkins MA, Dawson LA, Goodman KA. Recommendations for the use of radiation therapy in managing patients with gastrointestinal malignancies in the era of COVID-19. Radiother Oncol 2020; 148:194-200. [PMID: 32342878 PMCID: PMC7194719 DOI: 10.1016/j.radonc.2020.04.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 12/30/2022]
Abstract
As of April 6, 2020, there are over 1,200,000 reported cases and 70,000 deaths worldwide due to COVID-19, the disease caused by the SARS-CoV-2 virus, and these numbers rise exponentially by the day [1]. According to the Centers for Disease Control (CDC), the most effective means of minimizing the spread of the virus is through reducing interactions between individuals [2]. We performed a review of the literature, as well as national and international treatment guidelines, seeking data in support of the RADS principle (Remote visits, Avoid radiation, Defer radiation, Shorten radiation) [3] as it applies to gastrointestinal cancers. The purpose of the present work is to guide radiation oncologists managing patients with gastrointestinal cancers during the COVID-19 crisis in order to maintain the safety of our patients, while minimizing the impact of the pandemic on cancer outcomes.
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Affiliation(s)
- Leila T Tchelebi
- Department of Radiation Oncology, Penn State College of Medicine, Hershey, USA.
| | - Karin Haustermans
- Department of Radiation Oncology, Particle Therapy Interuniversity Center Leuven, Belgium
| | - Marta Scorsetti
- Humanitas Clinical and Research Center - IRCCS, Department of Radiotherapy and Radiosurgery, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Ali Hosni
- Department of Radiation Oncology, University of Toronto, Radiation Medicine Program, Princess Margaret Cancer Center, Toronto, Canada
| | - Florence Huguet
- Department of Radiation Oncology, Hôpital Tenon, AP-HP.Sorbonne Université, Paris, France
| | - Maria A Hawkins
- Medical Physics and Biomedical Engineering, University College London, University College London Hospitals NHS Foundation Trust, London, UK
| | - Laura A Dawson
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Karyn A Goodman
- Department of Radiation Oncology, The Mount Sinai Hospital, New York, USA
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24
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Hansen AT, Poulsen PR, Høyer M, Worm ES. Isotoxic dose prescription level strategies for stereotactic liver radiotherapy: the price of dose uniformity. Acta Oncol 2020; 59:558-564. [PMID: 31833432 DOI: 10.1080/0284186x.2019.1701200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: To find the optimal dose prescription strategy for liver SBRT, this study investigated the tradeoffs between achievable target dose and healthy liver dose for a range of isotoxic uniform and non-uniform prescription level strategies.Material and methods: Nine patients received ten liver SBRT courses with intrafraction motion monitoring during treatment. After treatment, five VMAT treatment plans were made for each treatment course. The PTV margin was 5 mm (left-right, anterior-posterior) and 10 mm (cranio-caudal). All plans had a mean CTV dose of 56.25 Gy in three fractions, while the PTV was covered by 50%, 67%, 67 s% (steep dose gradient outside CTV), 80%, and 95% of this dose, respectively. The 50%, 67 s%, 80%, and 95% plans were then renormalized to be isotoxic with the standard 67% plan according to a Lyman-Kutcher-Burman normal tissue complication probability model for radiation induced liver disease. The CTV D98 and mean dose of the iso-toxic plans were calculated both without and with the observed intrafraction motion, using a validated method for motion-including dose reconstruction.Results: Under isotoxic conditions, the average [range] mean CTV dose per fraction decreased gradually from 21.2 [20.5-22.7] Gy to 15.5 [15.0-16.6] Gy and the D98 dose per fraction decreased from 20.4 [19.7-21.7] Gy to 15.0 [14.5-15.5] Gy, as the prescription level to the PTV rim was increased from 50% to 95%. With inclusion of target motion the mean CTV dose was 20.5 [16.5-22.5] Gy (50% PTV rim dose) and 15.4 [13.9-16.7] Gy (95% rim dose) while D98 was 17.8 [7.4-20.6] Gy (50% rim dose) and 14.6 [8.8-15.7] Gy (95% rim dose).Conclusion: Requirements of a uniform PTV dose come at the price of excess normal tissue dose. A non-uniform PTV dose allows increased CTV mean dose at the cost of robustness toward intrafraction motion. The increase in planned CTV dose by non-uniform prescription outbalanced the dose deterioration caused by motion.
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Affiliation(s)
- Anders T. Hansen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Per R. Poulsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- The Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- The Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Esben S. Worm
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
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25
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Pursley J, El Naqa I, Sanford NN, Noe B, Wo JY, Eyler CE, Hwang M, Brock KK, Yeap BY, Wolfgang JA, Hong TS, Grassberger C. Dosimetric Analysis and Normal-Tissue Complication Probability Modeling of Child-Pugh Score and Albumin-Bilirubin Grade Increase After Hepatic Irradiation. Int J Radiat Oncol Biol Phys 2020; 107:986-995. [PMID: 32353390 DOI: 10.1016/j.ijrobp.2020.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 04/08/2020] [Accepted: 04/19/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This study aimed to develop robust normal-tissue complication probability (NTCP) models for patients with hepatocellular carcinoma treated with radiation therapy (RT) using Child-Pugh (CP) score and albumin-bilirubin (ALBI) grade increase as endpoints for hepatic toxicity. METHODS AND MATERIALS Data from 108 patients with hepatocellular carcinoma treated with RT between 2008 and 2017 were evaluated, of which 47 patients (44%) were treated with proton RT. Of these patients, 29 received stereotactic body RT and 79 moderately hypofractionated RT to median physical tumor doses of 43 Gy in 5 fractions and 59 Gy in 15 fractions, respectively. A generalized Lyman-Kutcher-Berman (LKB) model was used to model the NTCP using 2 clinical endpoints, both evaluated at 3 months after RT: CP score increase of ≥2 and ALBI grade increase of ≥1 from the pre-RT baseline. Confidence intervals on LKB fit parameters were determined using bootstrap resampling. RESULTS Compared with previous NTCP models, this study found a stronger correlation between normal liver volume receiving low doses of radiation (5-10 Gy) and a CP score or ALBI grade increase. A CP score increase exhibited a stronger correlation to normal liver volumes irradiated than an ALBI grade increase. LKB models for CP increase found values for the volume-effect parameter of a = 0.06 for all patients, and a = 0.02/0.09 when fit to photon/proton patients separately. Subset analyses for patients with superior initial liver functions showed consistent dose-volume effects (a = 0.1) and consistent dose-response relationships. CONCLUSIONS This study presents an update of liver NTCP models in the era of modern RT techniques using relevant endpoints of hepatic toxicity, CP score and ALBI grade increase. The results show a stronger influence of low-dose bath on hepatic toxicity than those found in previous studies, indicating that RT techniques that minimize the low-dose bath may be beneficial for patients.
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Affiliation(s)
- Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Nina N Sanford
- Department of Radiation Oncology, University of Texas Southwestern, Dallas, Texas
| | - Bridget Noe
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christine E Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Kristy K Brock
- Department of Imaging Physics, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - John A Wolfgang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
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26
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Rusu I, Thomas TO, Roeske JC, Mescioglu I, Melian E, Surucu M. Failure mode and effects analysis of linac-based liver stereotactic body radiotherapy. Med Phys 2020; 47:937-947. [PMID: 31837024 DOI: 10.1002/mp.13965] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 12/05/2019] [Accepted: 12/05/2019] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Although stereotactic body radiation therapy (SBRT) is an attractive noninvasive approach for liver irradiation, it presents specific challenges associated with respiration-induced liver motion, daily tumor localization due to liver deformation, and poor visualization of target with respect to adjacent normal liver in computed tomography (CT). We aim to identify potential hazards and develop a set of mitigation strategies to improve the safety of our liver SBRT program, using failure mode and effect analysis (FMEA). MATERIALS AND METHODS A multidisciplinary group consisting of two physicians, three physicists, two dosimetrists, and two therapists was formed. A process map covering ten major stages of the liver SBRT program from the initial diagnosis to posttreatment follow-up was generated. A total of 102 failure modes (FM), together with their causes and effects, were identified. The occurrence (O), severity (S), and lack of detectability (D) were independently scored using a scale from 1 (lowest risk) to 10 (largest risk). The ranking was done using the risk probability number (RPN) defined as the product of average O, S, and D numbers for each mode. Two fault tree analyses were performed. The failure modes with the highest RPN values as well as highest severity score were considered for investigation and a set of mitigation strategies was developed to address these. RESULTS The median RPN (RPNmed ) values for all modes ranged from of 9 to 105 and the highest median S score (Smed ) was 8. Fourteen FMs were identified to be significant by both RPNmed and Smed (top ten RPNmed ranked and highest Smed FMs) and 12 of them were considered for risk mitigation efforts. The remaining two were omitted due to either sufficient checks already in place, or lack of practical mitigation strategies. Implemented measures consisted of five physics tasks, two physician tasks, and three workflow changes. CONCLUSIONS The application of FMEA to our liver SBRT program led to the identification of potential FMs and allowed improvement measures to enhance the safety of our clinical practice.
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Affiliation(s)
- Iris Rusu
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Tarita O Thomas
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - John C Roeske
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Ibrahim Mescioglu
- Department of Business Analytics, Lewis University, Romeoville, IL, 60446, USA
| | - Edward Melian
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Murat Surucu
- Department of Radiation Oncology, Loyola University Medical Center, Maywood, IL, 60153, USA
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27
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Lee HL, Tsai JT, Chen CY, Lin YC, Ho CB, Ting LL, Kuo CC, Lai IC, Lin CY, Tang JH, Huang YM, Kao WY, Cheng SW, Shen CN, Chen SW, Chiou JF. Effectiveness of stereotactic ablative radiotherapy in patients with advanced hepatocellular carcinoma unsuitable for transarterial chemoembolization. Ther Adv Med Oncol 2019; 11:1758835919889002. [PMID: 31839809 PMCID: PMC6893933 DOI: 10.1177/1758835919889002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Stereotactic ablative radiotherapy (SABR) can deliver tumoricidal doses and achieve long-term control in early hepatocellular carcinoma (HCC). However, limited studies have investigated the safety and effectiveness of SABR in patients with advanced diseases that is unsuitable for transarterial chemoembolization (TACE). Methods: In this observational study, we reviewed the medical records of patients with Barcelona Clinic Liver Cancer (BCLC) stage C disease treated with linear accelerator-based SABR between 2008 and 2016. Their tumors were either refractory to TACE or TACE was contraindicated. Overall survival (OS), in-field progression-free survival (IFPFS), and out-field progression-free survival were calculated using Kaplan–Meier analysis. The Cox regression model was used to examine the effects of variables. Treatment-related toxicities were scored according to the Common Terminology Criteria for Adverse Events (version 4.03) and whether patients developed radiation-induced liver disease (RILD) after SABR. Results: This study included 32 patients. The mean maximal tumor diameter and tumor volumes were 4.7 cm and 135.9 ml, respectively. Patients received linear accelerator-based SABR with a median prescribed dose of 48 Gy (30–60 Gy) in three to six fractions. Based on the assessment of treatment response by using the Response Evaluation Criteria in Solid Tumors (version 1.1), 19% of patients achieved a complete response and 53% achieved a partial response. After a median follow-up of 18.1 months (4.0–65.9 months), 10, 19, and 9 patients experienced in-field failure, out-field hepatic recurrence, and extrahepatic metastases, respectively. The estimated 2-year OS and IFPFS rates were 54.4% and 62.7%, respectively. In a multivariate analysis, a pretreatment Cancer of the Liver Italian Program (CLIP) score of ⩾2 (p = 0.01) was a prognostic factor for shorter OS, and a biologically effective dose (BED) of < 85 Gy10 (p = 0.011) and a Child–Pugh score of ⩾6 (p = 0.014) were prognostic factors for inferior IFPFS. In this study five and eight patients developed classic and nonclassic RILD, respectively. Conclusions: SABR can serve as a salvage treatment for patients with HCC with BCLC stage C disease unsuitable for TACE, in particular, in those with a baseline CLIP score of ⩽1. A BED10 of ⩾85 Gy is an appropriate prescribed dose for tumor control. Because out-field relapse is the major cause of treatment failure, SABR in combination with novel systemic modalities should be investigated in future studies.
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Affiliation(s)
- Hsin-Lun Lee
- The PhD Program for Translational Medicine, College of Medical Science and Technology, Taipei
| | - Jo-Ting Tsai
- Department of Radiation Oncology, Shuang Ho Hospital, Taipei Medical University, New Taipei City
| | - Chun-You Chen
- Taipei Cancer Center, Taipei Medical University, Taipei
| | - Ying-Chun Lin
- Department of Radiation Oncology, China Medical University Hospital, Taichung
| | - Chin-Beng Ho
- Cancer Center, Camillians Saint Mary's Hospital Luodong, Yilan
| | - Lai-Lei Ting
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei Medical University, Taipei
| | - Chia-Chun Kuo
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei Medical University, Taipei
| | - I-Chun Lai
- The PhD Program for Translational Medicine, College of Medical Science and Technology, Taipei
| | - Chun-Yu Lin
- Department of Medical Imaging, Taipei Medical University Hospital, Taipei Medical University, Taipei
| | - Jui-Hsiang Tang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei
| | - Yu-Min Huang
- Department of Surgery, College of Medicine, Taipei Medical University, Taipei
| | - Wei-Yu Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei
| | - Sheng-Wei Cheng
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Chia-Ning Shen
- Genomics Research Center, Academia Sinica, No. 128, Academia Road, Section 2, Nankang District, 11529, Taipei City
| | - Shang-Wen Chen
- Department of Radiation Oncology, China Medical University Hospital, No. 2, Yude Road, North District, 40447, Taichung City
| | - Jeng-Fong Chiou
- Taipei Cancer Center, Taipei Medical University, No.250, Wu Hsing Street, Xinyi District, 110, Taipei City
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28
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Kuznetsova S, Grendarova P, Roy S, Sinha R, Thind K, Ploquin N. Structure guided deformable image registration for treatment planning CT and post stereotactic body radiation therapy (SBRT) Primovist ® (Gd-EOB-DTPA) enhanced MRI. J Appl Clin Med Phys 2019; 20:109-118. [PMID: 31755658 PMCID: PMC6909124 DOI: 10.1002/acm2.12773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/12/2019] [Accepted: 10/23/2019] [Indexed: 01/01/2023] Open
Abstract
The purpose of this study was to assess the performance of structure‐guided deformable image registration (SG‐DIR) relative to rigid registration and DIR using TG‐132 recommendations. This assessment was performed for image registration of treatment planning computed tomography (CT) and magnetic resonance imaging (MRI) scans with Primovist® contrast agent acquired post stereotactic body radiation therapy (SBRT). SBRT treatment planning CT scans and posttreatment Primovist® MRI scans were obtained for 14 patients. The liver was delineated on both sets of images and matching anatomical landmarks were chosen by a radiation oncologist. Rigid registration, DIR, and two types of SG‐DIR (using liver contours only; and using liver structures along with anatomical landmarks) were performed for each set of scans. TG‐132 recommended metrics were estimated which included Dice Similarity Coefficient (DSC), Mean Distance to Agreement (MDA), Target Registration Error (TRE), and Jacobian determinant. Statistical analysis was performed using Wilcoxon Signed Rank test. The median (range) DSC for rigid registration was 0.88 (0.77–0.89), 0.89 (0.81–0.93) for DIR, and 0.90 (0.86–0.94) for both types of SG‐DIR tested in this study. The median MDA was 4.8 mm (3.7–6.8 mm) for rigid registration, 3.4 mm (2.4–8.7 mm) for DIR, 3.2 mm (2.0–5.2 mm) for SG‐DIR where liver structures were used to guide the registration, and 2.8 mm (2.1–4.2 mm) for the SG‐DIR where liver structures and anatomical landmarks were used to guide the registration. The median TRE for rigid registration was 7.2 mm (0.5–23 mm), 6.8 mm (0.7–30.7 mm) for DIR, 6.1 mm (1.1–20.5 mm) for the SG‐DIR guided by only the liver structures, and 4.1 mm (0.8–19.7 mm) for SG‐DIR guided by liver contours and anatomical landmarks. The SG‐DIR shows higher liver conformality as per TG‐132 metrics and lowest TRE compared to rigid registration and DIR in Velocity AI software for the purpose of registering treatment planning CT and post‐SBRT MRI for the liver region. It was found that TRE decreases when liver contours and corresponding anatomical landmarks guide SG‐DIR.
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Affiliation(s)
- Svetlana Kuznetsova
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada
| | - Petra Grendarova
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Soumyajit Roy
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Radiation Oncology, The Ottawa Hospital Cancer Program, University of Ottawa, Ottawa, Ontario, Canada
| | - Rishi Sinha
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Kundan Thind
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Nicolas Ploquin
- Department of Physics and Astronomy, University of Calgary, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Medical Physics, Tom Baker Cancer Centre, Calgary, Alberta, Canada
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29
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Barry A, Wong R, Dawson LA. The Management of Colorectal Cancer Liver Metastases: The Radiation Oncology Viewpoint. Int J Radiat Oncol Biol Phys 2019; 103:540-541. [PMID: 30722966 DOI: 10.1016/j.ijrobp.2018.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada.
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
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[Liver stereotactic body radiotherapy: Clinical features and technical consequences, results. Which treatment machine in which situation?]. Cancer Radiother 2019; 23:636-650. [PMID: 31444078 DOI: 10.1016/j.canrad.2019.07.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 12/31/2022]
Abstract
Liver stereotactic body radiotherapy is a developing technique for the treatment of primary tumours and metastases. Its implementation is complex because of the particularities of the treated organ and the comorbidities of the patients. However, this technique is a treatment opportunity for patients otherwise in therapeutic impasse. The scientific evidence of liver stereotactic body radiotherapy has been considered by the French health authority as insufficient for its widespread use outside specialized and experienced centers, despite a growing and important number of retrospective and prospective studies, but few comparative data. This article focuses on the specific features of stereotactic body radiotherapy for liver treatments and the results of published studies of liver stereotactic body radiotherapy performed with classic linear accelerators and dedicated radiosurgery units.
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Mastrocostas K, Jang HJ, Fischer S, Dawson LA, Munoz-Schuffenegger P, Sapisochin G, Kim TK. Imaging post-stereotactic body radiation therapy responses for hepatocellular carcinoma: typical imaging patterns and pitfalls. Abdom Radiol (NY) 2019; 44:1795-1807. [PMID: 30710166 DOI: 10.1007/s00261-019-01901-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Stereotactic body radiation therapy (SBRT) has increased utility in the management of hepatocellular carcinoma (HCC) ranging from local therapy in early-stage HCC not suitable for other focal therapies to end-stage HCC. As the indications for the use of SBRT in HCC expand, diagnostic imaging is being increasingly used to assess response to treatment. The imaging features of tumor response do not parallel those of other focal therapies such as radiofrequency ablation or trans-arterial chemoembolization that immediately devascularize the tumor. The tumor response to SBRT on imaging takes much longer and often shows gradual changes including the reduction of enhancement and size over several months. It is essential to recognize the typical imaging patterns of response, as well as the appearance of focal liver reaction in the non-target liver that can confound image interpretation. The timing of treatment response assessment imaging is fundamental to minimize the potential for false negative response. The purpose of this article is to review the variable post-SBRT imaging features of HCC and adjacent liver parenchyma and discuss the potential pitfalls of imaging evaluation after SBRT for HCC.
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Byun HK, Kim N, Park S, Seong J. Acute severe lymphopenia by radiotherapy is associated with reduced overall survival in hepatocellular carcinoma. Strahlenther Onkol 2019; 195:1007-1017. [DOI: 10.1007/s00066-019-01462-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 03/25/2019] [Indexed: 01/27/2023]
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Schaub SK, Hartvigson PE, Lock MI, Høyer M, Brunner TB, Cardenes HR, Dawson LA, Kim EY, Mayr NA, Lo SS, Apisarnthanarax S. Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Current Trends and Controversies. Technol Cancer Res Treat 2018; 17:1533033818790217. [PMID: 30068240 PMCID: PMC6071169 DOI: 10.1177/1533033818790217] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hepatocellular carcinoma is the fourth leading cause of cancer-related death worldwide.
Depending on the extent of disease and competing comorbidities for mortality, multiple
liver-directed therapy options exist for the treatment of hepatocellular carcinoma.
Advancements in radiation oncology have led to the emergence of stereotactic body
radiation therapy as a promising liver-directed therapy, which delivers high doses of
radiation with a steep dose gradient to maximize local tumor control and minimize
radiation-induced treatment toxicity. In this study, we review the current clinical data
as well as the unresolved issues and controversies regarding stereotactic body radiation
therapy for hepatocellular carcinoma: (1) Is there a radiation dose–response relationship
with hepatocellular carcinoma? (2) What are the optimal dosimetric predictors of
radiation-induced liver disease, and do they differ for patients with varying liver
function? (3) How do we assess treatment response on imaging? (4) How does stereotactic
body radiation therapy compare to other liver-directed therapy modalities, including
proton beam therapy? Based on the current literature discussed, this review highlights
future possible research and clinical directions.
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Affiliation(s)
- Stephanie K Schaub
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Pehr E Hartvigson
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Michael I Lock
- 2 Department of Radiation Oncology, University of Western Ontario, London, Canada
| | - Morten Høyer
- 3 Aarhus University Hospital, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Thomas B Brunner
- 4 Klinik für Strahlentherapie, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | | | - Laura A Dawson
- 6 Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Edward Y Kim
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Nina A Mayr
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Simon S Lo
- 1 Department of Radiation Oncology, University of Washington, Seattle, WA, USA
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Abstract
Modern radiotherapy techniques have enabled high focal doses of radiation to be delivered to patients with primary and secondary malignancies of the liver. The current clinical practice of radiation oncology has benefitted from decades of research that have informed how to achieve excellent local control and survival outcomes with minimal toxicities. Still, one of the most devastating consequences of radiation to the liver remains a challenge: radiation-induced liver disease (RILD). Here, we will review the current understanding of classic and nonclassic RILD from a clinical perspective, the evaluation and management of patients who are at risk of developing RILD, methods to reduce the likelihood of RILD using modern radiation techniques, and the diagnosis and treatment of radiation-related liver toxicities.
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Apisarnthanarax S, Bowen SR, Combs SE. Proton Beam Therapy and Carbon Ion Radiotherapy for Hepatocellular Carcinoma. Semin Radiat Oncol 2018; 28:309-320. [PMID: 30309641 DOI: 10.1016/j.semradonc.2018.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Charged particle therapy with proton beam therapy (PBT) and carbon ion radiotherapy (CIRT) has emerged as a promising radiation modality to minimize radiation hepatotoxicity while maintaining high rates of tumor local control. Both PBT and CIRT deposit the majority of their dose at the Bragg peak with little to no exit dose, resulting in superior sparing of normal liver tissue. CIRT has an additional biological advantage of increased relative biological effectiveness, which may allow for increased hypofractionation regimens. Retrospective and prospective studies have demonstrated encouragingly high rates of local control and overall survival and low rates of hepatotoxicity with PBT and CIRT. Ongoing randomized trials will evaluate the value of PBT over photons and other standard liver-directed therapies and future randomized trials are needed to assess the value of CIRT over PBT.
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Affiliation(s)
| | - Stephen R Bowen
- Departments of Radiation Oncology and Radiology, University of Washington, Seattle, WA
| | - Stephanie E Combs
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Munich, Germany; Institute of Innovative Radiotherapy, Helmholtzzentrum München, Munich, Germany
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Gkika E, Strouthos I, Kirste S, Adebahr S, Schultheiss M, Bettinger D, Fritsch R, Brass V, Maruschke L, Neeff HP, Lang SA, Nestle U, Grosu AL, Brunner TB. Repeated SBRT for in- and out-of-field recurrences in the liver. Strahlenther Onkol 2018; 195:246-253. [DOI: 10.1007/s00066-018-1385-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 10/09/2018] [Indexed: 12/21/2022]
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Koedijk MS, Heijmen BJM, Groot Koerkamp B, Eskens FALM, Sprengers D, Poley JW, van Gent DC, van der Laan LJW, van der Holt B, Willemssen FEJA, Méndez Romero A. Protocol for the STRONG trial: stereotactic body radiation therapy following chemotherapy for unresectable perihilar cholangiocarcinoma, a phase I feasibility study. BMJ Open 2018; 8:e020731. [PMID: 30327398 PMCID: PMC6196820 DOI: 10.1136/bmjopen-2017-020731] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION For patients with perihilar cholangiocarcinoma (CCA), surgery is the only treatment modality that can result in cure. Unfortunately, in the majority of these patients, the tumours are found to be unresectable at presentation due to either local invasive tumour growth or the presence of distant metastases. For patients with unresectable CCA, palliative chemotherapy is the standard treatment yielding an estimated median overall survival (OS) of 12-15.2 months. There is no evidence from randomised trials to support the use of stereotactic body radiation therapy (SBRT) for CCA. However, small and most often retrospective studies combining chemotherapy with SBRT have shown promising results with OS reaching up to 33-35 months. METHODS AND ANALYSIS This study has been designed as a single-centre phase I feasibility trial and will investigate the addition of SBRT after standard chemotherapy in patients with unresectable perihilar CCA (T1-4 N0-1 M0). A total of six patients will be included. SBRT will be delivered in 15 fractions of 3-4.5 Gy (risk adapted). The primary objective of this study is to determine feasibility and toxicity. Secondary outcomes include local tumour control, progression-free survival (PFS), OS and quality of life. Length of follow-up will be 2 years. As an ancillary study, the personalised effects of radiotherapy will be measured in vitro, in patient-derived tumour and bile duct organoid cultures. ETHICS AND DISSEMINATION Ethics approval for the STRONG trial has been granted by the Medical Ethics Committee of Erasmus MC Rotterdam, the Netherlands. It is estimated that all patients will be included between October 2017 and October 2018. The results of this study will be published in a peer-reviewed journal, and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT03307538; Pre-results.
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Affiliation(s)
- Merel S Koedijk
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Ben J M Heijmen
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ferry A L M Eskens
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Dave Sprengers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Dik C van Gent
- Department of Molecular Genetics, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Luc J W van der Laan
- Department of Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bronno van der Holt
- Department of Haematology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - François E J A Willemssen
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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A Spatiotemporal-Constrained Sorting Method for Motion-Robust 4D-MRI: A Feasibility Study. Int J Radiat Oncol Biol Phys 2018; 103:758-766. [PMID: 30321690 DOI: 10.1016/j.ijrobp.2018.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 09/18/2018] [Accepted: 10/05/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE To develop a spatiotemporal-constrained sorting technique for motion-robust 4 dimensional-magnetic resonance imaging. METHODS AND MATERIALS This sorting method implemented 2 new approaches for 4-dimensional imaging: (1) an optimized sparse k-space acquisition trajectory with self-gating signal derivation, and (2) a retrospective k-space sorting for reconstruction using a novel spatiotemporal-constrained strategy to minimize breathing variation-induced motion artifacts. Such sorting was regularized by a spatiotemporal index. Volumetric reconstruction was implemented iteratively with a secnd-order total generalized variation penalty. The proposed method was evaluated and compared with the conventional phase-sorting and amplitude-sorting methods in 2 studies. In a computer simulation study, 6 abdominal motion scenarios, including 2 cosine and 4 patient breathing motion patterns, were studied. Reconstruction accuracy was evaluated quantitatively in reference to the ground truth by average image relative error (IRE) in 10 phases and target Dice similarity coefficients (DSCs) in end-of-exhalation/inhalation phases. In addition, the proposed method was evaluated using a custom-made motion phantom. Reconstruction accuracy was evaluated by motion range measurement and image quality comparison in both fast and slow breathing motions. RESULTS In the simulation study, stitching motion artifacts in restricted images were lessened using the proposed method compared with those using the conventional methods. The average IRE and target DSC (end-of-exhalation/inhalation) were 0.031 and 0.95/0.94, respectively, suggesting better motion reconstruction accuracy than the phase-sorted method (IRE, 0.057; DSC, 0.89/0.89) and the amplitude-sorted method (IRE, 0.048; DSC, 0.91/0.88). In the phantom study, the moving target reconstructed by the proposed method demonstrated better rendering with less edge blurring. With fast breathing motion, the range measured using the proposed method was more accurate than that of the phase-sorted method and was comparable to the result of amplitude-sorted method and ground truths. CONCLUSIONS Preliminary results suggested that the proposed sorting technique could reconstruct high-quality images and accurate motion estimation with reduced artifacts in 4 dimensional-magnetic resonance imaging.
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Chen Y, Grassberger C, Li J, Hong TS, Paganetti H. Impact of potentially variable RBE in liver proton therapy. Phys Med Biol 2018; 63:195001. [PMID: 30183674 PMCID: PMC6207451 DOI: 10.1088/1361-6560/aadf24] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Currently, the relative biological effectiveness (RBE) is assumed to be constant with a value of 1.1 in proton therapy. Although trends of RBE variations are well known, absolute values in patients are associated with considerable uncertainties. This study aims to evaluate the impact of a variable proton RBE in proton therapy liver trials using different fractionation schemes. Sixteen liver cancer cases were evaluated assuming two clinical schedules of 40 Gy/5 fractions and 58.05 Gy/15 fractions. The linear energy transfer (LET) and physical dose distribution in patients were simulated using Monte Carlo. The variable RBE distribution was calculated using a phenomenological model, considering the influence of the LET, fraction size and α/β value. Further, models to predict normal tissue complication probability (NTCP) and tumor control probability (TCP) were used to investigate potential RBE effects on outcome predictions. Applying the variable RBE model to the 5 and 15 fractions schedules results in an increase in mean fraction-size equivalent dose (FED) to the normal liver of 5.0% and 9.6% respectively. For patients with a mean FED to the normal liver larger than 29.8 Gy, this results in a non-negligible increase in the predicted NTCP of the normal liver averaging 11.6%, ranging from 2.7% to 25.6%. On the other hand, decrease in TCP was less than 5% for both fractionation regimens for all patients when assuming a variable RBE instead of constant. Consequently, the difference in TCP between the two fractionation schedules did not change significantly assuming a variable RBE while the impact on the NTCP difference was highly case specific. In addition, both the NTCP and TCP decrease with increasing α/β value for both fractionation schemes, with the decreases being more pronounced when using a variable RBE compared to using RBE = 1.1. Assuming a constant RBE of 1.1 most likely overestimates the therapeutic ratio in proton therapy for liver cancer, predominantly due to underestimation of the RBE-weighted dose to the normal liver. The impact of applying a variable RBE (as compared to RBE = 1.1) on the NTCP difference of the two fractionation regimens is case dependent. A variable RBE results in a slight increase in TCP difference. Variations in patient radiosensitivity increase when using a variable RBE.
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Affiliation(s)
- Yizheng Chen
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States of America. Department of Engineering Physics, Tsinghua University, Beijing 100084, People's Republic of China. Key Laboratory of Particle & Radiation Imaging, Tsinghua University, Ministry of Education, Beijing 100084, People's Republic of China
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Murray LJ, Sykes J, Brierley J, Kim JJ, Wong RKS, Ringash J, Craig T, Velec M, Lindsay P, Knox JJ, Dawson LA. Baseline Albumin-Bilirubin (ALBI) Score in Western Patients With Hepatocellular Carcinoma Treated With Stereotactic Body Radiation Therapy (SBRT). Int J Radiat Oncol Biol Phys 2018; 101:900-909. [PMID: 29976502 DOI: 10.1016/j.ijrobp.2018.04.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 03/18/2018] [Accepted: 04/04/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE To assess the baseline albumin-bilirubin (ALBI) score as a predictor of toxicity and survival in a prospective cohort of Western patients with hepatocellular carcinoma (HCC) treated with stereotactic body radiation therapy (SBRT) in 2 prospective trials. METHODS AND MATERIALS The study included 102 patients with Child-Pugh class A liver disease who received 6-fraction SBRT for HCC. Univariate and multivariable logistic regression investigated factors associated with toxicity, defined as an increase in Child-Pugh score ≥ 2 within 3 months of SBRT. Univariate and multivariable Cox regression analyses investigated factors predictive of overall survival (OS). The ALBI score was analyzed as a continuous and binary variable in separate analyses. RESULTS On multivariable analysis of toxicity, including the ALBI score as a continuous variable, the ALBI score (odds ratio [OR] per 0.1-unit increase, 1.51; 95% confidence interval [CI] 1.23-1.85; P = .00074), mean liver dose (OR, 1.31; 95% CI 1.02-1.68; P = .036), and dose received by 800 cm3 of normal liver (OR, 1.10; 95% CI 1.01-1.20; P = .028) were significant. When the ALBI score was included as a dichotomous variable, the ALBI grade remained a significant predictor of toxicity (OR, 7.44; 95% CI 2.34-23.70; P = .00069). On multivariable analysis of OS, including the ALBI score as a continuous variable, the ALBI score (hazard ratio [HR] per 0.1-unit increase, 1.09; 95% CI 1.03-1.17; P = .004), tumor thrombus (HR, 1.94; 95% CI 1.23-3.07; P = .004), and treatment in trial 1 versus trial 2 (HR, 1.92; 95% CI 1.23-3.03; P = .004) were significant. Similarly, when the ALBI score was included as a binary variable, the ALBI grade, tumor thrombus, and trial were significant predictors of OS. When the ALBI score was considered, the Child-Pugh score (A6 vs A5) was not significant in multivariable models analyzing toxicity or survival. Concordance statistics indicated models containing the ALBI score were superior to those containing the Child-Pugh score. CONCLUSIONS The baseline ALBI score was more discriminating than the Child-Pugh score in predicting OS and toxicity in patients with Child-Pugh class A liver disease. The ALBI score should be used as a factor for stratification in future HCC SBRT trials.
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Affiliation(s)
- Louise J Murray
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jenna Sykes
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - James Brierley
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - John J Kim
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Rebecca K S Wong
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jolie Ringash
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Tim Craig
- Department of Medical Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Michael Velec
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Patricia Lindsay
- Department of Medical Physics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Jennifer J Knox
- Department of Medical Oncology, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
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McDuff SGR, Remillard KA, Zheng H, Raldow AC, Wo JY, Eyler CE, Drapek LC, Goyal L, Blaszkowsky LS, Clark JW, Allen JN, Parikh AR, Ryan DP, Ferrone CR, Tanabe KK, Wolfgang JA, Zhu AX, Hong TS. Liver reirradiation for patients with hepatocellular carcinoma and liver metastasis. Pract Radiat Oncol 2018; 8:414-421. [PMID: 29937235 DOI: 10.1016/j.prro.2018.04.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/27/2018] [Accepted: 04/18/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE This study aimed to assess the safety and efficacy of administering liver reirradiation to patients with primary liver tumors or liver metastasis. METHODS AND MATERIALS A total of 49 patients (with 64 individual tumors) who received liver reirradiation at our institution between June 2008 and December 2016 were identified for retrospective review. Patients were treated to the same, different, or a combination of previously treated liver tumors for recurrent primary (53%) or metastatic (47%) disease using photons or protons. Clinical and treatment-related factors were compiled and patients were monitored for toxicity and evidence of classic or nonclassic radiation-induced liver disease. Survival was estimated with the Kaplan-Meier method and cumulative incidence of local failure (LF) was used to estimate LF using the Response Evaluation Criteria in Solid Tumors version 1.1. RESULTS The median age at the time of reirradiation was 72 years and the median interval between radiation courses was 9 months. At a median follow-up of 10.5 months, 36 patients (73%) had died, 9 patients (18%) were alive, and 4 patients (8%) were lost to follow-up. The median survival for the cohort was 14 months. The overall 1-year estimate of LF was 46.4%. The 1-year estimates of LF for liver metastases and hepatocellular carcinoma were 61.0% and 32.5%, respectively. The average prescription dose was similar between the reirradiation and initial courses (equivalent dose in 2 Gy fractions EQD2: 65.0 vs 64.3 Gyα/β = 10, respectively) but the average dose to the untreated liver was lower at the time of reirradiation (EQD2: 10.5 vs 13.9 Gyα/β = 3, respectively, P = .01). Among patients with hepatocellular carcinoma, the average normal liver dose was significantly larger for patients who exhibited a worsening of Child-Pugh score after reirradiation compared with those who did not (1210 cGy vs 759 cGy, P = .04). With regard to toxicity, 85.7% of patients experienced grade 1 to 2 toxicity, 4.1% developed grade 3, and only 2 patients (4.1%) met the criteria for radiation-induced liver disease after reirradiation. CONCLUSIONS Liver reirradiation may be an effective and safe option for select patients; however, further prospective study is necessary to establish treatment guidelines and recommended dosing.
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Affiliation(s)
- Susan G R McDuff
- Harvard Radiation Oncology Program, Massachusetts General Hospital, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts.
| | - Kyla A Remillard
- Department of Radiation Oncology, Medical Physics and Dosimetry, Massachusetts General Hospital, Boston, Massachusetts
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Ann C Raldow
- Department of Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christine E Eyler
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorraine C Drapek
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lipika Goyal
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Lawrence S Blaszkowsky
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey W Clark
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jill N Allen
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Aparna R Parikh
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - David P Ryan
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Cristina R Ferrone
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth K Tanabe
- Department of General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John A Wolfgang
- Department of Radiation Oncology, Medical Physics and Dosimetry, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew X Zhu
- Department of Internal Medicine and Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Perkó Z, Bortfeld T, Hong T, Wolfgang J, Unkelbach J. Derivation of mean dose tolerances for new fractionation schemes and treatment modalities. Phys Med Biol 2018; 63:035038. [PMID: 29099720 DOI: 10.1088/1361-6560/aa9836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Avoiding toxicities in radiotherapy requires the knowledge of tolerable organ doses. For new, experimental fractionation schemes (e.g. hypofractionation) these are typically derived from traditional schedules using the biologically effective dose (BED) model. In this report we investigate the difficulties of establishing mean dose tolerances that arise since the mean BED depends on the entire spatial dose distribution, rather than on the dose level alone. A formula has been derived to establish mean physical dose constraints such that they are mean BED equivalent to a reference treatment scheme. This formula constitutes a modified BED equation where the influence of the spatial dose distribution is summarized in a single parameter, the dose shape factor. To quantify effects we analyzed 24 liver cancer patients for whom both proton and photon IMRT treatment plans were available. The results show that the standard BED equation-neglecting the spatial dose distribution-can overestimate mean dose tolerances for hypofractionated treatments by up to 20%. The shape difference between photon and proton dose distributions can cause 30-40% differences in mean physical dose for plans having identical mean BEDs. Converting hypofractionated, 5/15-fraction proton doses to mean BED equivalent photon doses in traditional 35-fraction regimens resulted in up to 10 Gy higher doses than applying the standard BED formula. The dose shape effect should be accounted for to avoid overestimation of mean dose tolerances, particularly when estimating constraints for hypofractionated regimens. Additionally, tolerances established for one treatment modality cannot necessarily be applied to other modalities with drastically different dose distributions, such as proton therapy. Last, protons may only allow marginal (5-10%) dose escalation if a fraction-size adjusted organ mean dose is constraining instead of a physical dose.
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Affiliation(s)
- Zoltán Perkó
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States of America. Delft University of Technology, Delft, Netherlands
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Huang P, Yu G, Kapp DS, Bian XF, Ma CS, Li HS, Chen JH, Liang YQ, Zhang Y, Qin SH, Xie YQ, Yang Y, Yin Y, Xing L, Li DW. Cumulative dose of radiation therapy of hepatocellular carcinoma patients and its deterministic relation to radiation-induced liver disease. Med Dosim 2017; 43:258-266. [PMID: 29198389 DOI: 10.1016/j.meddos.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 09/24/2017] [Accepted: 10/09/2017] [Indexed: 12/25/2022]
Abstract
This study aimed to investigate the relationship between dose and radiation-induced liver disease (RILD) in patients with hepatocellular carcinoma (HCC) receiving 3-dimensional conformal radiotherapy (3DCRT). Twenty-three patients with HCC who received conventional fractionated 3DCRT, including 7 who were diagnosed with classic RILD, were enrolled in this retrospective investigation. Cone-beam computed tomography (CBCT) scans were acquired at the time of treatment for each patient. The beams from each patient's treatment plan were applied to each pretreatment CBCT (the modified CBCT or mCBCT) to construct the delivered dose distribution of the day considering inter-treatment anatomy changes. The daily doses were summed together with the help of deformable image registration (DIR) to obtain the adjusted cumulative dose (Dadjusted). The dose changes to the normal liver between the original planned dose (Dplan) and Dadjusted were evaluated by V20, V30, V40, and the mean dose to normal liver (MDTNL). Univariate analysis was performed to identify the significant dose changes. Among the 23 patients, the liver V20, V30, V40, and MDTNL showed significant differences between Dplan and Dadjusted, with average values of these parameters increased by 4.1%, 4.7%, 4.5%, and 3.9 Gy, respectively (p < 0.05). The adjusted liver dose in 21 patients (91%) was higher than the planned value. For patients without and with RILD,the MDTNL was increased on average by 3.5 Gy and 4.7 Gy, and normal tissue complication probability (NTCP) increased on average by 2.8% and 7.5%, respectively. Our study found that the adjusted cumulative dose based on calculations using pretreatment mCBCT differs significantly from planned dose; the use of the dosimetric results of the initial plan was found to be less predictive of RILD as compared with Dadjusted. Determination of a reconstructed Dadjusted using the mCBCT scans are more accurate in predicting RILD and has the potential to reduce the risk of RILD.
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Affiliation(s)
- Pu Huang
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, Jinan, Shandong, China
| | - Gang Yu
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, Jinan, Shandong, China
| | - Daniel S Kapp
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Xue-Feng Bian
- Jinan Municipal Center for Disease Control and Prevention of Shandong Province, Jinan, Shandong, China
| | - Chang-Sheng Ma
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Hong-Sheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Jin-Hu Chen
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Yue-Qiang Liang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Yang Zhang
- Department of Radiation Oncology, Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, China
| | - Shao-Hua Qin
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, Jinan, Shandong, China
| | - Yao-Qin Xie
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Yong Yang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Lei Xing
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Deng-Wang Li
- Shandong Province Key Laboratory of Medical Physics and Image Processing Technology, Institute of Biomedical Sciences, School of Physics and Electronics, Shandong Normal University, Jinan, Shandong, China.
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The TRENDY multi-center randomized trial on hepatocellular carcinoma – Trial QA including automated treatment planning and benchmark-case results. Radiother Oncol 2017; 125:507-513. [DOI: 10.1016/j.radonc.2017.09.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/07/2017] [Accepted: 09/09/2017] [Indexed: 11/20/2022]
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Riou O, Azria D, Mornex F. [Stereotactic body radiotherapy for liver tumors: State of the art]. Cancer Radiother 2017; 21:563-573. [PMID: 28888744 DOI: 10.1016/j.canrad.2017.07.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 07/18/2017] [Accepted: 07/19/2017] [Indexed: 01/04/2023]
Abstract
Thanks to the improvement in radiotherapy physics, biology, computing and imaging, patients presenting with liver tumors can be efficiently treated by radiation. Radiotherapy has been included in liver tumors treatment guidelines at all disease stages. Liver stereotactic radiotherapy has to be preferred to standard fractionated radiotherapy whenever possible, as potentially more efficient because of higher biological equivalent dose. Liver stereotactic radiotherapy planning and delivery require extensive experience and optimal treatment quality at every step, thus limiting its availability to specialized centres. Multicentre studies are difficult to develop due to a large technical heterogeneity. Respiratory management, image guidance and immobilization are considerations as important as machine type. The use of multimodal planning imaging is compulsory to achieve expected contouring quality. Treatment efficacy is difficult to assess following liver stereotactic radiotherapy, but local control is high and toxicity unusual. As a consequence, liver stereotactic radiotherapy is part of multimodal and multidisciplinary management of liver tumors.
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Affiliation(s)
- O Riou
- Département de cancérologie radiothérapie, ICM-Val d'Aurelle, rue de la Croix-Verte, 34298 Montpellier, France; Institut de recherche en cancérologie de Montpellier (IRCM), avenue des Apothicaires, 34298 Montpellier cedex 05, France; Inserm U1194, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Université de Montpellier 1, avenue des Apothicaires, 34298 Montpellier cedex 05, France.
| | - D Azria
- Département de cancérologie radiothérapie, ICM-Val d'Aurelle, rue de la Croix-Verte, 34298 Montpellier, France; Institut de recherche en cancérologie de Montpellier (IRCM), avenue des Apothicaires, 34298 Montpellier cedex 05, France; Inserm U1194, avenue des Apothicaires, 34298 Montpellier cedex 05, France; Université de Montpellier 1, avenue des Apothicaires, 34298 Montpellier cedex 05, France
| | - F Mornex
- Département de radiothérapie-oncologie, centre hospitalier Lyon sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; EMR 3738, université Claude-Bernard Lyon-1, domaine Rockefeller, 8, avenue Rockefeller, 69373 Lyon cedex 08, France
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Gallbladder toxicity and high-dose ablative-intent radiation for liver tumors: Should we constrain the dose? Pract Radiat Oncol 2017; 7:e323-e329. [DOI: 10.1016/j.prro.2017.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 01/26/2017] [Accepted: 02/02/2017] [Indexed: 12/21/2022]
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McPartlin A, Swaminath A, Wang R, Pintilie M, Brierley J, Kim J, Ringash J, Wong R, Dinniwell R, Craig T, Dawson LA. Long-Term Outcomes of Phase 1 and 2 Studies of SBRT for Hepatic Colorectal Metastases. Int J Radiat Oncol Biol Phys 2017; 99:388-395. [PMID: 28871989 DOI: 10.1016/j.ijrobp.2017.04.010] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 04/05/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE To report mature outcomes of prospective phase 1 and 2 studies of stereotactic body radiation therapy (SBRT) for the treatment of colorectal liver metastases (CLMs). METHODS AND MATERIALS Patients with histologically confirmed CLMs unsuitable for resection or standard therapies were eligible for sequential phase 1 and 2 studies conducted from 2003 to 2012. RESULTS Of 60 patients treated, 82% had received previous chemotherapy, 23% had undergone previous focal liver treatment, and 38% had extrahepatic disease at the time of SBRT. The median number of gross tumor volume (GTV) targets per patient was 1 (range, 1-6), with a median total target volume of 117.7 cm3 (range, 6.7-3115.4 cm3). The median minimum dose to the GTV was 37.6 Gy (range, 22.7-62.1 Gy) in 6 fractions over a period of 2 weeks. Other than 1 case of grade 3 nausea, there were no acute toxicities greater than grade 2. With a median follow-up period of 28.1 months for survivors, no gastrointestinal bleed or biliary or liver toxicity was seen. The local control rate per lesion at 1 and 4 years was 49.8% and 26.2%, respectively. Increasing minimum dose to the GTV was associated with improved local control (P=.003). Median overall survival was 16.0 months (95% confidence interval, 11.9-20.5 months). On multivariate analysis, improved survival was associated with smaller total GTV (P=.017), performance status of 0 or 1 (P=.007), no extrahepatic disease at the time of treatment (P=.005), and local control of targeted liver disease (P=.001). Two long-term survivors remain disease free at 49 and 125 months. CONCLUSIONS Six-fraction SBRT for CLM is safe and may be associated with long-term cure. Local control was significantly associated with delivered dose and was lower than seen in other studies using a higher SBRT dose. Survival was associated with smaller tumor volume, absence of extrahepatic disease, performance status of 0 or 1, and local control of treated liver lesions.
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Affiliation(s)
- Andrew McPartlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Anand Swaminath
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Ri Wang
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Melania Pintilie
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Jolie Ringash
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Rob Dinniwell
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Tim Craig
- Department of Medical Physics, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, and Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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Riou O, Llacer Moscardo C, Fenoglietto P, Deshayes E, Tetreau R, Molinier J, Lenglet A, Assenat E, Ychou M, Guiu B, Aillères N, Bedos L, Azria D. SBRT planning for liver metastases: A focus on immobilization, motion management and planning imaging techniques. Rep Pract Oncol Radiother 2017; 22:103-110. [PMID: 28490980 DOI: 10.1016/j.rpor.2017.02.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 01/05/2017] [Accepted: 02/25/2017] [Indexed: 02/08/2023] Open
Abstract
AIM To evaluate the different techniques used for liver metastases Stereotactic Body Radiation Therapy (SBRT) planning. We especially focused on immobilization devices, motion management and imaging used for contouring. BACKGROUND Although some guidelines exist, there is no consensus regarding the minimal requirements for liver SBRT treatments. MATERIALS AND METHODS We reviewed the main liver metastases SBRT publications and guidelines; and compared the techniques used for immobilization, motion management, margins and imaging. RESULTS There is a wide variety of techniques used for immobilization, motion management and planning imaging. CONCLUSIONS We provide a subjective critical analysis of minimal requirements and ideal technique for liver SBRT planning.
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Affiliation(s)
- Olivier Riou
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Carmen Llacer Moscardo
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Pascal Fenoglietto
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Emmanuel Deshayes
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Raphaël Tetreau
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Jessica Molinier
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Alexis Lenglet
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Eric Assenat
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France.,CHU Saint Eloi, 80 Avenue Augustin Fliche, 34090 Montpellier, France
| | - Marc Ychou
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France.,CHU Saint Eloi, 80 Avenue Augustin Fliche, 34090 Montpellier, France
| | - Boris Guiu
- CHU Saint Eloi, 80 Avenue Augustin Fliche, 34090 Montpellier, France
| | - Norbert Aillères
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - Ludovic Bedos
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
| | - David Azria
- Institut Régional du Cancer de Montpellier, ICM-Val d'Aurelle, Rue de la Croix Verte, Montpellier, France
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Chan M, Chiang CL, Lee V, Cheung S, Leung R, Wong M, Lee F, Blanck O. Target localization of 3D versus 4D cone beam computed tomography in lipiodol-guided stereotactic radiotherapy of hepatocellular carcinomas. PLoS One 2017; 12:e0174929. [PMID: 28384187 PMCID: PMC5383048 DOI: 10.1371/journal.pone.0174929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/18/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Aim of this study was to comparatively evaluate the accuracy of respiration-correlated (4D) and uncorrelated (3D) cone beam computed tomography (CBCT) in localizing lipiodolized hepatocellular carcinomas during stereotactic body radiotherapy (SBRT). METHODS 4D-CBCT scans of eighteen HCCs were acquired during free-breathing SBRT following trans-arterial chemo-embolization (TACE) with lipiodol. Approximately 1320 x-ray projections per 4D-CBCT were collected and phase-sorted into ten bins. A 4D registration workflow was followed to register the reconstructed time-weighted average CBCT with the planning mid-ventilation (MidV) CT by an initial bone registration of the vertebrae and then tissue registration of the lipiodol. For comparison, projections of each 4D-CBCT were combined to synthesize 3D-CBCT without phase-sorting. Using the lipiodolized tumor, uncertainties of the treatment setup estimated from the absolute and relative lipiodol position to bone were analyzed separately for 4D- and 3D-CBCT. RESULTS Qualitatively, 3D-CBCT showed better lipiodol contrast than 4D-CBCT primarily because of a tenfold increase of projections used for reconstruction. Motion artifact was observed to subside in 4D-CBCT compared to 3D-CBCT. Group mean, systematic and random errors estimated from 4D- and 3D-CBCT agreed to within 1 mm in the cranio-caudal (CC) and 0.5 mm in the anterior-posterior (AP) and left-right (LR) directions. Systematic and random errors are largest in the CC direction, amounting to 4.7 mm and 3.7 mm from 3D-CBCT and 5.6 mm and 3.8 mm from 4D-CBCT, respectively. Safety margin calculated from 3D-CBCT and 4D-CBCT differed by 2.1, 0.1 and 0.0 mm in the CC, AP, and LR directions. CONCLUSIONS 3D-CBCT is an adequate alternative to 4D-CBCT when lipoid is used for localizing HCC during free-breathing SBRT. Similar margins are anticipated with 3D- and 4D-CBCT.
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Affiliation(s)
- Mark Chan
- Department of Radiation Oncology, University Medical Center Schleswig–Holstein, Kiel, Germany
- * E-mail:
| | - Chi Leung Chiang
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong (S.A.R)
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong (S.A.R)
- Department of Clinical Oncology, University of Hong Kong-Shenzhen Hospital, China
| | - Venus Lee
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong (S.A.R)
- Department of Clinical Oncology, The University of Hong Kong, Hong Kong (S.A.R)
| | - Steven Cheung
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong (S.A.R)
| | - Ronnie Leung
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong (S.A.R)
| | - Matthew Wong
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong (S.A.R)
| | - Frankle Lee
- Department of Clinical Oncology, Tuen Mun Hospital, Hong Kong (S.A.R)
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig–Holstein, Kiel, Germany
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Barry A, McPartlin A, Lindsay P, Wang L, Brierley J, Kim J, Ringash J, Wong R, Dinniwell R, Craig T, Dawson LA. Dosimetric analysis of liver toxicity after liver metastasis stereotactic body radiation therapy. Pract Radiat Oncol 2017; 7:e331-e337. [PMID: 28442242 DOI: 10.1016/j.prro.2017.03.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 02/15/2017] [Accepted: 03/03/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE The aim of this study is to describe the incidence and type of liver toxicity seen following liver metastases stereotactic body radiation therapy (SBRT) and the corresponding clinical and dosimetric factors associated with toxicity. METHODS AND MATERIALS Between 2002 and 2009, 81 evaluable patients with liver metastases were treated on 2 prospective studies assessing SBRT, with prescription doses based on the effective liver volume irradiated evaluated. Toxicity was defined as grade ≥2 classic or nonclassic radiation induced liver disease (RILD). Specific toxicity endpoints evaluated were worsening transaminases and albumin levels within 3 months of SBRT. RESULTS Seventy percent of patients had colorectal carcinoma, 55% had extrahepatic disease, 1 patient had hepatitis B, and 54% had received prior chemotherapy. Baseline transaminases were elevated at Common Terminology Criteria for Adverse Effects, V4.0, grade 1, 2, and 3 levels in 33 (41%), 2 (2%), and 0 (0%) patients. The mean prescription dose was 43 Gy (27.7-60 Gy) in 6 fractions. The mean liver (minus gross tumor volume) dose (MLD) was 16 Gy (3-25.6 Gy) in 6 fractions. No classic or nonclassical ≥grade 2 RILD was observed. Within 3 months of SBRT, 49 (61%) patients had worsening of grade of transaminase and 23 (28%) patients had a reduction in albumin, all transient (majority grade ≤2 toxicity) without subsequent clinical toxicity. Seventeen patients exceeded Quantitative Analysis of Normal Tissue Effects in the Clinic MLD guidelines (≤20 Gy), 13 (76%) of whom had worsening of transaminase grade. On multivariate analysis, worsening of liver enzymes was more likely in patients with higher doses to the spared 700 mL of liver (P = .026), and reduction of albumin was more likely with higher effective liver volume (odds ratio, 1.53 [range, 1.08-2.16]) P = .016). CONCLUSIONS Liver metastases SBRT is safe with a low risk of transient biochemical liver toxicity, more likely in patients with a higher effective liver volume and higher doses to the spared uninvolved liver volume.
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Affiliation(s)
- Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Andrew McPartlin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Patricia Lindsay
- Department of Medical Physics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Lisa Wang
- Department of Biostatistics, Princess Margaret Cancer Centre, Toronto, Canada
| | - James Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - John Kim
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Jolie Ringash
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Rebecca Wong
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Rob Dinniwell
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Tim Craig
- Department of Medical Physics, Princess Margaret Cancer Centre, Toronto, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, Toronto, Canada.
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