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Kyrochristou I, Giannakodimos I, Tolia M, Georgakopoulos I, Pararas N, Mulita F, Machairas N, Schizas D. Robotic Stereotactic Body Radiation Therapy for Oligometastatic Liver Metastases: A Systematic Review of the Literature and Evidence Quality Assessment. Diagnostics (Basel) 2024; 14:1055. [PMID: 38786353 DOI: 10.3390/diagnostics14101055] [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: 04/22/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION The role of stereotactic body radiation therapy (SBRT) as a locally effective therapeutic approach for liver oligometastases from tumors of various origin is well established. We investigated the role of robotic SBRT (rSBRT) treatment on oligometastatic patients with liver lesions. MATERIAL AND METHODS This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The PubMed and Scopus databases were accessed by two independent investigators concerning robotic rSBRT for liver metastases, up to 3 October 2023. RESULTS In total, 15 studies, including 646 patients with 847 lesions that underwent rSBRT, were included in our systematic review. Complete response (CR) after rSBRT was achieved in 40.5% (95% CI, 36.66-44.46%), partial response (PR) in 19.01% (95% CI, 16.07-22.33%), whereas stable disease (SD) was recorded in 14.38% (95% CI, 11.8-17.41%) and progressive disease (PD) in 13.22% (95% CI, 10.74-16.17%) of patients. Progression-free survival (PFS) rates at 12 and 24 months were estimated at 61.49% (95% CI, 57.01-65.78%) and 32.55% (95% CI, 28.47-36.92%), respectively, while the overall survival (OS) rates at 12 and 24 months were estimated at 58.59% (95% CI, 53.67-63.33%) and 44.19% (95% CI, 39.38-49.12%), respectively. Grade 1 toxicity was reported in 13.81% (95% CI, 11.01-17.18%), Grade 2 toxicity in 5.57% (95% CI, 3.82-8.01%), and Grade 3 toxicity in 2.27% (955 CI, 1.22-4.07%) of included patients. CONCLUSIONS rSBRT represents a promising method achieving local control with minimal toxicity in a significant proportion of patients. Further studies are needed to evaluate the role of rSBRT in the management of metastatic liver lesions.
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Affiliation(s)
| | - Ilias Giannakodimos
- Second Department of Surgery, General Hospital of Nikaia, 18454 Athens, Greece
| | - Maria Tolia
- Department of Radiation Oncology, School of Medicine, University of Crete, 71300 Heraklion, Greece
| | - Ioannis Georgakopoulos
- Radiation Oncology Unit, First Department of Radiology, Medical School, Aretaieion Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Pararas
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Francesk Mulita
- Department of General Surgery, University General Hospital of Patras, 26504 Patras, Greece
| | - Nikolaos Machairas
- Second Department of Propaedeutic Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Klement RJ, Sweeney RA. Metabolic factors associated with the prognosis of oligometastatic patients treated with stereotactic body radiotherapy. Cancer Metastasis Rev 2023; 42:927-940. [PMID: 37261610 DOI: 10.1007/s10555-023-10110-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
Over the past two decades, it has been established that cancer patients with oligometastases, i.e., only a few detectable metastases confined to one or a few organs, may benefit from an aggressive local treatment approach such as the application of high-precision stereotactic body radiotherapy (SBRT). Specifically, some studies have indicated that achieving long-term local tumor control of oligometastases is associated with prolonged overall survival. This motivates investigations into which factors may modify the dose-response relationship of SBRT by making metastases more or less radioresistant. One such factor relates to the uptake of the positron emission tomography tracer 2-deoxy-2-[18F]fluoro-D-glucose (FDG) which reflects the extent of tumor cell glycolysis or the Warburg effect, respectively. Here we review the biological mechanisms how the Warburg effect drives tumor cell radioresistance and metastasis and draw connections to clinical studies reporting associations between high FDG uptake and worse clinical outcomes after SBRT for oligometastases. We further review the evidence for distinct metabolic phenotypes of metastases preferentially seeding to specific organs and their possible translation into distinct radioresistance. Finally, evidence that obesity and hyperglycemia also affect outcomes after SBRT will be presented. While delivered dose is the main determinant of a high local tumor control probability, there might be clinical scenarios when metabolic targeting could make the difference between achieving local control or not, for example when doses have to be compromised in order to spare neighboring high-risk organs, or when tumors are expected to be highly therapy-resistant due to heavy pretreatment such as chemotherapy and/or radiotherapy.
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Affiliation(s)
- Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Robert-Koch-Straße 10, 97422, Schweinfurt, Germany.
| | - Reinhart A Sweeney
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital Schweinfurt, Robert-Koch-Straße 10, 97422, Schweinfurt, Germany
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Moustakis C, Eich HT, Blanck O, Chan MKH, Boda-Heggemann J, Andratschke N, Schmitt D. In Reply to Oskan. Int J Radiat Oncol Biol Phys 2022; 114:374-375. [PMID: 36055320 DOI: 10.1016/j.ijrobp.2022.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/05/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Christos Moustakis
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig Holstein, Kiel, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, University Medical Center Schleswig Holstein, Kiel, Germany; Department of Radiation Oncology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medicine Mannheim, Medical Faculty Mannheim, University Heidelberg, Mannheim, Germany
| | - Nicolaus Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Daniela Schmitt
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany; Department of Radiation Oncology, University Medical Center Göttingen, Göttingen, Germany
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Nierer L, Eze C, da Silva Mendes V, Braun J, Thum P, von Bestenbostel R, Kurz C, Landry G, Reiner M, Niyazi M, Belka C, Corradini S. Dosimetric benefit of MR-guided online adaptive radiotherapy in different tumor entities: liver, lung, abdominal lymph nodes, pancreas and prostate. Radiat Oncol 2022; 17:53. [PMID: 35279185 PMCID: PMC8917666 DOI: 10.1186/s13014-022-02021-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/27/2022] [Indexed: 01/18/2023] Open
Abstract
Background Hybrid magnetic resonance (MR)-Linac systems have recently been introduced into clinical practice. The systems allow online adaption of the treatment plan with the aim of compensating for interfractional anatomical changes. The aim of this study was to evaluate the dose volume histogram (DVH)-based dosimetric benefits of online adaptive MR-guided radiotherapy (oMRgRT) across different tumor entities and to investigate which subgroup of plans improved the most from adaption. Methods Fifty patients treated with oMRgRT for five different tumor entities (liver, lung, multiple abdominal lymph nodes, pancreas, and prostate) were included in this retrospective analysis. Various target volume (gross tumor volume GTV, clinical target volume CTV, and planning target volume PTV) and organs at risk (OAR) related DVH parameters were compared between the dose distributions before and after plan adaption. Results All subgroups clearly benefited from online plan adaption in terms of improved PTV coverage. For the liver, lung and abdominal lymph nodes cases, a consistent improvement in GTV coverage was found, while many fractions of the prostate subgroup showed acceptable CTV coverage even before plan adaption. The largest median improvements in GTV near-minimum dose (D98%) were found for the liver (6.3%, p < 0.001), lung (3.9%, p < 0.001), and abdominal lymph nodes (6.8%, p < 0.001) subgroups. Regarding OAR sparing, the largest median OAR dose reduction during plan adaption was found for the pancreas subgroup (-87.0%). However, in the pancreas subgroup an optimal GTV coverage was not always achieved because sparing of OARs was prioritized. Conclusion With online plan adaptation, it was possible to achieve significant improvements in target volume coverage and OAR sparing for various tumor entities and account for interfractional anatomical changes.
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Walter F, Nierer L, Rottler M, Duque AS, Weingandt H, Well J, Shpani R, Landry G, Seidensticker M, Streitparth F, Ricke J, Belka C, Corradini S. Comparison of liver exposure in CT-guided high-dose rate (HDR) interstitial brachytherapy versus SBRT in hepatocellular carcinoma. Radiat Oncol 2021; 16:86. [PMID: 33957941 PMCID: PMC8103624 DOI: 10.1186/s13014-021-01812-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/26/2021] [Indexed: 12/14/2022] Open
Abstract
Background In unresectable hepatocellular carcinoma several local ablative treatments are available. Among others, radiation based treatments such as stereotactic body radiotherapy (SBRT) and high-dose rate interstitial brachytherapy (HDR BT) have shown good local control rates. Methods We conducted a dose comparison between actually performed HDR BT versus virtually planned SBRT to evaluate the respective clinically relevant radiation exposure to uninvolved liver tissue. Moreover, dose coverage and conformity indices were assessed. Results Overall, 46 treatment sessions (71 lesions, 38 patients) were evaluated. HDR BT was applied in a single fraction with a dose prescription of 1 × 15 Gy. D98 was 17.9 ± 1.3 Gy, D50 was 41.8 ± 8.1 Gy. The SBRT was planned with a prescribed dose of 3 × 12.5 Gy (65%-Isodose), D98 was 50.7 ± 3.1 Gy, D2 was 57.0 ± 2.3 Gy, and D50 was 55.2 ± 2.3 Gy. Regarding liver exposure Vliver10GyBT was compared to Vliver15.9GySBRT, Vliver16.2GySBRT (EQD2 equivalent doses), and Vliver20GySBRT (clinically relevant dose), all results showed significant differences (p < .001). In a case by case analysis Vliver10GyBT was smaller than Vliver20GySBRT in 38/46 cases (83%). Dmean of the liver was significantly smaller in BT compared to SBRT (p < .001). GTV volume was correlated to the liver exposure and showed an advantage of HDR BT over SBRT in comparison of clinically relevant doses, and for EQD2 equivalent doses. The advantage was more pronounced for greater liver lesions The Conformity Index (CI) was significantly better for BT, while Healthy Tissue Conformity Index (HTCI) and Conformation Number (CN) showed an advantage for SBRT (p < .001). Conclusion HDR BT can be advantageous in respect of sparing of normal liver tissue as compared to SBRT, while providing excellent target conformity.
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Affiliation(s)
- Franziska Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany.
| | - Lukas Nierer
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Maya Rottler
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Anna Sophie Duque
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Helmut Weingandt
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Justus Well
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Roel Shpani
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
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Stera S, Miebach G, Buergy D, Dreher C, Lohr F, Wurster S, Rödel C, Marcella S, Krug D, Frank A G, Ehmann M, Fleckenstein J, Blanck O, Boda-Heggemann J. Liver SBRT with active motion-compensation results in excellent local control for liver oligometastases: An outcome analysis of a pooled multi-platform patient cohort. Radiother Oncol 2021; 158:230-236. [PMID: 33667585 DOI: 10.1016/j.radonc.2021.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 02/10/2021] [Accepted: 02/24/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Local treatment of metastases in combination with systemic therapy can prolong survival of oligo-metastasized patients. To fully exploit this potential, safe and effective treatments are needed to ensure long-term metastases control. Stereotactic body radiotherapy (SBRT) is one means, however, for moving liver tumors correct delivery of high doses is challenging. After validating equal in-vivo treatment accuracy, we analyzed a pooled multi-platform liver-SBRT-database for clinical outcome. METHODS Local control (LC), progression-free interval (PFI), overall survival (OS), predictive factors and toxicity was evaluated in 135 patients with 227 metastases treated by gantry-based SBRT (deep-inspiratory breath-hold-gating; n = 71) and robotic-based SBRT (fiducial-tracking, n = 156) with mean gross tumor volume biological effective dose (GTV-BEDα/β=10Gy) of 146.6 Gy10. RESULTS One-, and five-year LC was 90% and 68.7%, respectively. On multivariate analysis, LC was significantly predicted by colorectal histology (p = 0.006). Median OS was 20 months with one- and two-year OS of 67% and 37%. On multivariate analysis, ECOG-status (p = 0.003), simultaneous chemotherapy (p = 0.003), time from metastasis detection to SBRT-treatment (≥2months; p = 0.021) and LC of the treated metastases (≥12 months, p < 0.009) were significant predictors for OS. One- and two-year PFI were 30.5% and 14%. Acute toxicity was mild and rare (14.4% grade I, 2.3% grade II, 0.6% grade III). Chronic °III/IV toxicities occurred in 1.1%. CONCLUSIONS Patient selection, time to treatment and sufficient doses are essential to achieve optimal outcome for SBRT with active motion compensation. Local control appears favorable compared to historical control. Long-term LC of the treated lesions was associated with longer overall survival.
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Affiliation(s)
- Susanne Stera
- University Hospital Frankfurt, Department of Radiation Oncology, Frankfurt am Main, Germany.
| | - Georgia Miebach
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Daniel Buergy
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Constantin Dreher
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Frank Lohr
- UO di Radioterapia, Dipartimento di Oncologia, Azienda Ospedaliero-Universitaria di Modena, Italy
| | - Stefan Wurster
- Saphir Radiosurgery Center, Güstrow, Germany; University Medicine Greifswald, Department of Radiation Oncology, Germany
| | - Claus Rödel
- University Hospital Frankfurt, Department of Radiation Oncology, Frankfurt am Main, Germany
| | - Szücs Marcella
- University Medicine Rostock, Department of Radiation Oncology, Germany
| | - David Krug
- Saphir Radiosurgery Center, Güstrow, Germany; University Medical Center Schleswig-Holstein, Department of Radiation Oncology, Kiel, Germany
| | - Giordano Frank A
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Michael Ehmann
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Jens Fleckenstein
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Güstrow, Germany; University Medical Center Schleswig-Holstein, Department of Radiation Oncology, Kiel, Germany
| | - Judit Boda-Heggemann
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Department of Radiation Oncology, Germany
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Wilhelm ML, Chan MKH, Abel B, Cremers F, Siebert FA, Wurster S, Krug D, Wolff R, Dunst J, Hildebrandt G, Schweikard A, Rades D, Ernst F, Blanck O. Tumor-dose-rate variations during robotic radiosurgery of oligo and multiple brain metastases. Strahlenther Onkol 2020; 197:581-591. [PMID: 32588102 PMCID: PMC8219559 DOI: 10.1007/s00066-020-01652-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 06/02/2020] [Indexed: 12/31/2022]
Abstract
Purpose For step-and-shoot robotic stereotactic radiosurgery (SRS) the dose delivered over time, called local tumor-dose-rate (TDR), may strongly vary during treatment of multiple lesions. The authors sought to evaluate technical parameters influencing TDR and correlate TDR to clinical outcome. Material and methods A total of 23 patients with 162 oligo (1–3) and multiple (>3) brain metastases (OBM/MBM) treated in 33 SRS sessions were retrospectively analyzed. Median PTV were 0.11 cc (0.01–6.36 cc) and 0.50 cc (0.12–3.68 cc) for OBM and MBM, respectively. Prescription dose ranged from 16 to 20 Gy prescribed to the median 70% isodose line. The maximum dose-rate for planning target volume (PTV) percentage p in time span s during treatment (TDRs,p) was calculated for various p and s based on treatment log files and in-house software. Results TDR60min,98% was 0.30 Gy/min (0.23–0.87 Gy/min) for OBM and 0.22 Gy/min (0.12–0.63 Gy/min) for MBM, respectively, and increased by 0.03 Gy/min per prescribed Gy. TDR60min,98% strongly correlated with treatment time (ρ = −0.717, p < 0.001), monitor units (MU) (ρ = −0.767, p < 0.001), number of beams (ρ = −0.755, p < 0.001) and beam directions (ρ = −0.685, p < 0.001) as well as lesions treated per collimator (ρ = −0.708, P < 0.001). Median overall survival (OS) was 20 months and 1‑ and 2‑year local control (LC) was 98.8% and 90.3%, respectively. LC did not correlate with any TDR, but tumor response (partial response [PR] or complete response [CR]) correlated with all TDR in univariate analysis (e.g., TDR60min,98%: hazard ration [HR] = 0.974, confidence interval [CI] = 0.952–0.996, p = 0.019). In multivariate analysis only concomitant targeted therapy or immunotherapy and breast cancer tumor histology remained a significant factor for tumor response. Local grade ≥2 radiation-induced tissue reactions were noted in 26.3% (OBM) and 5.2% (MBM), respectively, mainly influenced by tumor volume (p < 0.001). Conclusions Large TDR variations are noted during MBM-SRS which mainly arise from prolonged treatment times. Clinically, low TDR corresponded with decreased local tumor responses, although the main influencing factor was concomitant medication.
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Affiliation(s)
- Maria-Lisa Wilhelm
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany.,Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.,Strahlenklinik, University Hospital Essen, Hufelandstr. 55, Essen, Germany
| | - Benedikt Abel
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Florian Cremers
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Frank-Andre Siebert
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | - David Krug
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Robert Wolff
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany.,Department of Neurosurgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, University of Luebeck, Luebeck, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center Frankfurt and Northern Germany, Guestrow, Germany. .,Department of Radiation Oncology, Karl-Lennert-Krebscentrum Nord, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, Haus 50, 24105, Kiel, Germany.
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Hass P, Mohnike K, Kropf S, Brunner TB, Walke M, Albers D, Petersen C, Damm R, Walter F, Ricke J, Powerski M, Corradini S. Comparative analysis between interstitial brachytherapy and stereotactic body irradiation for local ablation in liver malignancies. Brachytherapy 2019; 18:823-828. [PMID: 31522972 DOI: 10.1016/j.brachy.2019.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE Interstitial high-dose-rate brachytherapy (BT) is an alternative treatment option to stereotactic body radiotherapy (SBRT) for the ablative treatment of liver malignancies. The aim of the present comparative planning study was to reveal the possibilities and limitations of both techniques with regard to dosimetric properties. METHODS AND MATERIALS Eighty-five consecutive patients with liver malignancy diagnosis were treated with interstitial BT between 12/2008 and 09/2009. The prescription dose of BT varied between 15 and 20 Gy, depending on histology. For dosimetric comparison, virtual SBRT treatment plans were generated using the original BT planning CTs. Additional margins reflecting the respiratory tumor motion were added to the target volumes for SBRT planning. RESULTS The mean PTVBT was 34.7 cm3 (0.5-410.0 cm3) vs. a mean PTVSBRT of 73.2 cm3 (6.1-593.4 cm3). Regarding the minimum peripheral dose (D99.9), BT achieved the targeted prescription dose of 15 Gy/20 Gy better without violating organ at risk constraints. The dose exposure of the liver was significantly influenced by treatment modality. The liver exposure to 5 Gy was statistically lower with 611 ± 43 cm3 for BT as compared with 694 ± 37 cm3 for SBRT plans (20-Gy group, p = 0.001), corresponding to 41.8% vs. 45.9% liver volume, respectively. CONCLUSIONS To the best of our knowledge, this is the first report on the comparison of clinically treated liver BT treatments with virtually planned SBRT treatments. The planning study showed a superior outcome of BT regarding dose coverage of the target volume and exposed liver volume. Nevertheless, further studies are needed to determine ideal applicability for each treatment approach.
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Affiliation(s)
- Peter Hass
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Konrad Mohnike
- Diagnostisch Therapeutisches Zentrum (DTZ), Berlin, Germany
| | - Siegfried Kropf
- Institute of Biometry and Medical Informatics, University Hospital Magdeburg, Magdeburg, Germany
| | - Thomas B Brunner
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Mathias Walke
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - Dirk Albers
- Department of Radiation Oncology, University Hamburg-Eppendorf, Hamburg, Germany
| | - Cordula Petersen
- Department of Radiation Oncology, University Hamburg-Eppendorf, Hamburg, Germany
| | - Robert Damm
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Maciej Powerski
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany.
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Liu M, Cygler JE, Vandervoort E. Geometrical tracking accuracy and appropriate PTV margins for robotic radiosurgery of liver lesions by SBRT. Acta Oncol 2019; 58:906-915. [PMID: 30799669 DOI: 10.1080/0284186x.2019.1578896] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: To assess the geometrical accuracy and estimate adequate PTV margins for liver treatments using the Synchrony respiratory tracking system. Material and methods: Treatment log files are analyzed for 72 liver patients to assess tracking accuracy. The tracking error is calculated as the quadratic sum of the correlation, the predictor and the beam positioning errors. Treatment target rotations and rigid body errors reported by the system are also evaluated. The impact of uncorrected rotations is assessed by rotating the planned dose distribution and reassessing target coverage. Total PTV margins are estimated by summing in quadrature tracking errors and rigid body errors. Relationships are explored between tracking errors, model linearity and motion amplitudes of internal and external markers. Results: Margins of 3, 2, 2 mm in SUP-INF, LT-RT and ANT-POST directions, respectively, are sufficient to account for tracking and beam positioning errors for 95% of patients. If rigid body error is also considered, margins increase to 4 mm isotropic. Rotations could not be corrected for 92% of patients due to imperfect fiducial implantation and limitations in the magnitude of corrections that the system can apply. Uncorrected rotations would lead to average estimated dose reductions of 2.7% ± 5.8% of the prescribed dose for D99 of GTVs (5 mm PTV expansion) in which the target was well covered in the original plan (28 of 31 GTVs). 80% of tracking models exhibit near linear correlation between internal and external marker motions with small tracking errors (<2.2 mm). Conclusions: Isotropic PTV margins considering tracking errors and target rigid body errors could be used for liver SBRT treatments if rotational corrections can be calculated accurately so that systematic rotational offsets can be avoided. The linearity of the internal and external breathing motions might be useful for other types of treatment modalities for liver cancer.
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Affiliation(s)
- Ming Liu
- Department of Physics, Carleton University, Ottawa, Canada
| | - Joanna E. Cygler
- Department of Physics, Carleton University, Ottawa, Canada
- Department of Medical Physics, The Ottawa Hospital Cancer Centre, Ottawa, Canada
- Department of Radiology, University of Ottawa, Ottawa, Canada
| | - Eric Vandervoort
- Department of Physics, Carleton University, Ottawa, Canada
- Department of Medical Physics, The Ottawa Hospital Cancer Centre, Ottawa, Canada
- Department of Radiology, University of Ottawa, Ottawa, Canada
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10
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Klement RJ, Abbasi-Senger N, Adebahr S, Alheid H, Allgaeuer M, Becker G, Blanck O, Boda-Heggemann J, Brunner T, Duma M, Eble MJ, Ernst I, Gerum S, Habermehl D, Hass P, Henkenberens C, Hildebrandt G, Imhoff D, Kahl H, Klass ND, Krempien R, Lewitzki V, Lohaus F, Ostheimer C, Papachristofilou A, Petersen C, Rieber J, Schneider T, Schrade E, Semrau R, Wachter S, Wittig A, Guckenberger M, Andratschke N. The impact of local control on overall survival after stereotactic body radiotherapy for liver and lung metastases from colorectal cancer: a combined analysis of 388 patients with 500 metastases. BMC Cancer 2019; 19:173. [PMID: 30808323 PMCID: PMC6390357 DOI: 10.1186/s12885-019-5362-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 02/11/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The aim of this analysis was to model the effect of local control (LC) on overall survival (OS) in patients treated with stereotactic body radiotherapy (SBRT) for liver or lung metastases from colorectal cancer. METHODS The analysis is based on pooled data from two retrospective SBRT databases for pulmonary and hepatic metastases from 27 centers from Germany and Switzerland. Only patients with metastases from colorectal cancer were considered to avoid histology as a confounding factor. An illness-death model was employed to model the relationship between LC and OS. RESULTS Three hundred eighty-eight patients with 500 metastatic lesions (lung n = 209, liver n = 291) were included and analyzed. Median follow-up time for local recurrence assessment was 12.1 months. Ninety-nine patients with 112 lesions experienced local failure. Seventy-one of these patients died after local failure. Median survival time was 27.9 months in all patients and 25.4 months versus 30.6 months in patients with and without local failure after SBRT. The baseline risk of death after local failure exceeds the baseline risk of death without local failure at 10 months indicating better survival with LC. CONCLUSION In CRC patients with lung or liver metastases, our findings suggest improved long-term OS by achieving metastatic disease control using SBRT in patients with a projected OS estimate of > 12 months.
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Affiliation(s)
- Rainer J Klement
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, Schweinfurt, Germany
| | - N Abbasi-Senger
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany
| | - S Adebahr
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - H Alheid
- Strahlentherapie Bautzen, Bautzen, Germany
| | - M Allgaeuer
- Department of Radiation Oncology, Hospital Barmherzige Brueder, Regensburg, Germany
| | - G Becker
- RadioChirurgicum CyberKnife Suedwest, Goeppingen, Germany
| | - O Blanck
- Department of Radiation Oncology Universitaetsklinikum Schleswig-Holstein, Luebeck, Germany
| | - J Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - T Brunner
- Department of Radiation Oncology, University Hospital Freiburg, Freiburg, Germany
| | - M Duma
- Department of Radiation Oncology, Klinikum rechts der Isar- Technische Universitaet Muenchen, Munich, Germany
| | - M J Eble
- Department of Radiation Oncology, University Hospital Aachen, Aachen, Germany
| | - I Ernst
- Department of Radiation Oncology, University Hospital Muenster, Muenster, Germany
| | - S Gerum
- Department of Radiation Oncology, Ludwig Maximilians University Munich, Munich, Germany
| | - D Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar- Technische Universitaet Muenchen, Munich, Germany.,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - P Hass
- Department of Radiation Oncology, University Hospital Magdeburg, Magdeburg, Germany
| | - C Henkenberens
- Department of Radiotherapy and Special Oncology, Medical School Hannover, Hanover, Germany
| | - G Hildebrandt
- Department of Radiation Oncology, University of Rostock, Rostock, Germany
| | - D Imhoff
- Department of Radiation Oncology, University Hospital Frankfurt, Frankfurt, Germany
| | - H Kahl
- Department of Radiation Oncology, Hospital Augsburg, Augsburg, Germany
| | - N D Klass
- Department of Radiation Oncology, University Hospital Bern, Bern, Switzerland
| | - R Krempien
- Department of Radiation Oncology, Helios Klinikum Berlin Buch, Berlin, Germany
| | - V Lewitzki
- Department of Radiation Oncology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - F Lohaus
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - C Ostheimer
- Department of Radiation Oncology, University Hospital Halle, Halle, Germany
| | - A Papachristofilou
- Department of Radiation Oncology, University Hospital Hamburg, Hamburg, Germany
| | - C Petersen
- Department of Radiation Oncology, University Hospital Basel, Basel, Switzerland
| | - J Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - E Schrade
- Department of Radiation Oncology, Hospital Heidenheim, Heidenheim, Germany
| | - R Semrau
- Department of Radiation Oncology, University Hospital of Cologne, Cologne, Germany
| | - S Wachter
- Department of Radiation Oncology, Klinikum Passau, Passau, Germany
| | - A Wittig
- Department of Radiation Oncology, University Hospital Jena, Jena, Germany.,Department of Radiotherapy and Radiation Oncology, Philipps-University Marburg, University Hospital Giessen and Marburg, Marburg, Germany
| | - M Guckenberger
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - N Andratschke
- Department of Radiation Oncology, University Hospital Zurich, University of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
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11
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In-vivo treatment accuracy analysis of active motion-compensated liver SBRT through registration of plan dose to post-therapeutic MRI-morphologic alterations. Radiother Oncol 2019; 134:158-165. [PMID: 31005210 DOI: 10.1016/j.radonc.2019.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND/PURPOSE In-vivo-accuracy analysis (IVA) of dose-delivery with active motion-management (gating/tracking) was performed based on registration of post-radiotherapeutic MRI-morphologic-alterations (MMA) to the corresponding dose-distributions of gantry-based/robotic SBRT-plans. METHODS Forty targets in two patient cohorts were evaluated: (1) gantry-based SBRT (deep-inspiratory breath-hold-gating; GS) and (2) robotic SBRT (online fiducial-tracking; RS). The planning-CT was deformably registered to the first post-treatment contrast-enhanced T1-weighted MRI. An isodose-structure cropped to the liver (ISL) and corresponding to the contoured MMA was created. Structure and statistical analysis regarding volumes, surface-distance, conformity metrics and center-of-mass-differences (CoMD) was performed. RESULTS Liver volume-reduction was -43.1 ± 148.2 cc post-RS and -55.8 ± 174.3 cc post-GS. The mean surface-distance between MMA and ISL was 2.3 ± 0.8 mm (RS) and 2.8 ± 1.1 mm (GS). ISL and MMA volumes diverged by 5.1 ± 23.3 cc (RS) and 16.5 ± 34.1 cc (GS); the median conformity index of both structures was 0.83 (RS) and 0.80 (GS). The average relative directional errors were ≤0.7 mm (RS) and ≤0.3 mm (GS); the median absolute 3D-CoMD was 3.8 mm (RS) and 4.2 mm (GS) without statistically significant differences between the two techniques. Factors influencing the IVA included GTV and PTV (p = 0.041 and p = 0.020). Four local relapses occurred without correlation to IVA. CONCLUSIONS For the first time a method for IVA was presented, which can serve as a benchmarking-tool for other treatment techniques. Both techniques have shown median deviations <5 mm of planned dose and MMA. However, IVA also revealed treatments with errors ≥5 mm, suggesting a necessity for patient-specific safety-margins. Nevertheless, the treatment accuracy of well-performed active motion-compensated liver SBRT seems not to be a driving factor for local treatment failure.
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12
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ICRU report 91 on prescribing, recording, and reporting of stereotactic treatments with small photon beams : Statement from the DEGRO/DGMP working group stereotactic radiotherapy and radiosurgery. Strahlenther Onkol 2019; 195:193-198. [PMID: 30649567 DOI: 10.1007/s00066-018-1416-x] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 12/13/2018] [Indexed: 12/14/2022]
Abstract
The International Commission on Radiation Units and Measurements (ICRU) report 91 with the title "prescribing, recording, and reporting of stereotactic treatments with small photon beams" was published in 2017. This extensive publication covers different relevant aspects of stereotactic radiotherapy such as small field dosimetry, accuracy requirements for volume definition and planning algorithms, and the precise application of treatment by means of image guidance. Finally, recommendations for prescribing, recording and reporting are given.
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13
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Vogel L, Sihono DSK, Weiss C, Lohr F, Stieler F, Wertz H, von Swietochowski S, Simeonova-Chergou A, Wenz F, Blessing M, Boda-Heggemann J. Intra-breath-hold residual motion of image-guided DIBH liver-SBRT: An estimation by ultrasound-based monitoring correlated with diaphragm position in CBCT. Radiother Oncol 2018; 129:441-448. [DOI: 10.1016/j.radonc.2018.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 10/28/2022]
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14
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Baumann R, Chan MKH, Pyschny F, Stera S, Malzkuhn B, Wurster S, Huttenlocher S, Szücs M, Imhoff D, Keller C, Balermpas P, Rades D, Rödel C, Dunst J, Hildebrandt G, Blanck O. Clinical Results of Mean GTV Dose Optimized Robotic-Guided Stereotactic Body Radiation Therapy for Lung Tumors. Front Oncol 2018; 8:171. [PMID: 29868486 PMCID: PMC5966546 DOI: 10.3389/fonc.2018.00171] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 05/01/2018] [Indexed: 12/24/2022] Open
Abstract
Introduction We retrospectively evaluated the efficacy and toxicity of gross tumor volume (GTV) mean dose optimized stereotactic body radiation therapy (SBRT) for primary and secondary lung tumors with and without robotic real-time motion compensation. Materials and methods Between 2011 and 2017, 208 patients were treated with SBRT for 111 primary lung tumors and 163 lung metastases with a median GTV of 8.2 cc (0.3–174.0 cc). Monte Carlo dose optimization was performed prioritizing GTV mean dose at the potential cost of planning target volume (PTV) coverage reduction while adhering to safe normal tissue constraints. The median GTV mean biological effective dose (BED)10 was 162.0 Gy10 (34.2–253.6 Gy10) and the prescribed PTV BED10 ranged 23.6–151.2 Gy10 (median, 100.8 Gy10). Motion compensation was realized through direct tracking (44.9%), fiducial tracking (4.4%), and internal target volume (ITV) concepts with small (≤5 mm, 33.2%) or large (>5 mm, 17.5%) motion. The local control (LC), progression-free survival (PFS), overall survival (OS), and toxicity were analyzed. Results Median follow-up was 14.5 months (1–72 months). The 2-year actuarial LC, PFS, and OS rates were 93.1, 43.2, and 62.4%, and the median PFS and OS were 18.0 and 39.8 months, respectively. In univariate analysis, prior local irradiation (hazard ratio (HR) 0.18, confidence interval (CI) 0.05–0.63, p = 0.01), GTV/PTV (HR 1.01–1.02, CI 1.01–1.04, p < 0.02), and PTV prescription, mean GTV, and maximum plan BED10 (HR 0.97–0.99, CI 0.96–0.99, p < 0.01) were predictive for LC while the tracking method was not (p = 0.97). For PFS and OS, multivariate analysis showed Karnofsky Index (p < 0.01) and tumor stage (p ≤ 0.02) to be significant factors for outcome prediction. Late radiation pneumonitis or chronic rip fractures grade 1–2 were observed in 5.3% of the patients. Grade ≥3 side effects did not occur. Conclusion Robotic SBRT is a safe and effective treatment for lung tumors. Reducing the PTV prescription and keeping high GTV mean doses allowed the reduction of toxicity while maintaining high local tumor control. The use of real-time motion compensation is strongly advised, however, well-performed ITV motion compensation may be used alternatively when direct tracking is not feasible.
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Affiliation(s)
- Rene Baumann
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Florian Pyschny
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Susanne Stera
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Bettina Malzkuhn
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Stefan Huttenlocher
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
| | - Marcella Szücs
- Department of Radiation Oncology, Universitätsmedizin Rostock, Rostock, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Christian Keller
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Panagiotis Balermpas
- Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany.,Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Dirk Rades
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Claus Rödel
- Department of Radiation Oncology, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Guido Hildebrandt
- Department of Radiation Oncology, Universitätsmedizin Rostock, Rostock, Germany
| | - Oliver Blanck
- Department of Radiation Oncology, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Saphir Radiochirurgie Zentrum Frankfurt und Norddeutschland, Güstrow, Germany
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15
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Nakamura M, Hashimoto N, Mayahara H, Uezono H, Harada A, Nishikawa R, Matsuo Y, Kawaguchi H, Nishimura H. Additional chemotherapy improved local control and overall survival after stereotactic body radiation therapy for patients with oligo-recurrence. Radiat Oncol 2018; 13:75. [PMID: 29688858 PMCID: PMC5914071 DOI: 10.1186/s13014-018-1031-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 04/16/2018] [Indexed: 12/16/2022] Open
Abstract
Background Oligo-recurrence has been considered to confer improved prognosis than other oligometastatic conditions, and stereotactic body radiation therapy (SBRT) is considered as an option of local therapy for lung or liver metastases. The purpose of this study was to investigate the efficacy and safety of SBRT for lung and liver oligo-recurrent lesions and evaluate predictive factors for local control and prognosis. Methods This retrospective study included patients who presented with 1–3 matachronous lung or liver metastases, and treated with SBRT between May 2013 and March 2016 at a single institution. All patients harbored a controlled primary lesion. Patients with < 6 months of follow-up were excluded. Local control, progression free survival, and overall survival rates were analyzed according to the Kaplan–Meier product limit method. Univariable log-rank and multivariable Cox regression analyses were performed to clarify predictive factors for local control and prognosis. Toxicity was graded according to the Common Terminology Criteria for Adverse Events, version 4.0. Results Seventy-six patients with a total of 70 and 44 lung and liver lesions were included. The median follow-up period was 21 (range, 7–43) months. The 1-year local control, progression-free survival and overall survival rates were 89, 38 and 96%, respectively. Smaller gross tumor volume and additional chemotherapy after SBRT were significant predictive factors for better local control (p = 0.005 and p = 0.047), and the presence of a single metastatic lesion was a significant factor of good progression free survival (p = 0.008). Additional chemotherapy after SBRT was not a significant predictive factor but conferred to better overall survival (p = 0.078). Among colorectal cancer patients, post SBRT chemotherapy was significantly associated with better OS (p = 0.025). Over grade 3 adverse event was seen in only one patient. Conclusion SBRT is a safe and effective treatment for patients with lung and liver oligo-recurrence. Additional chemotherapy after SBRT improved local control, and single metastatic lesion was a significant predictive factor of better PFS in this study. Among colorectal cancer patients, additional chemotherapy after SBRT significantly associated better OS.
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Affiliation(s)
- Masaki Nakamura
- Department of Radiation Oncology, Kobe Minimally invasive Cancer Center, 8-5-1, Minatojima Nakamachi, Chuo-ku, Kobe, Hyogo, 650-0046, Japan. .,Division of Radiation Oncology and Particle Therapy, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Naoki Hashimoto
- Department of Radiation Oncology, Kobe Minimally invasive Cancer Center, 8-5-1, Minatojima Nakamachi, Chuo-ku, Kobe, Hyogo, 650-0046, Japan
| | - Hiroshi Mayahara
- Department of Radiation Oncology, Kobe Minimally invasive Cancer Center, 8-5-1, Minatojima Nakamachi, Chuo-ku, Kobe, Hyogo, 650-0046, Japan
| | - Haruka Uezono
- Department of Radiation Oncology, University of Florida Proton Therapy Institute, 2015 N Jefferson St, Jacksonville, FL, 32206, USA
| | - Aya Harada
- Department of Radiation Oncology, Kobe Minimally invasive Cancer Center, 8-5-1, Minatojima Nakamachi, Chuo-ku, Kobe, Hyogo, 650-0046, Japan
| | - Ryo Nishikawa
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-Cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoshiro Matsuo
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1, Koto, Shingu-cho, Tatsuno, Hyogo, 679-5165, Japan
| | - Hiroki Kawaguchi
- Department of Radiation Oncology, Kobe Minimally invasive Cancer Center, 8-5-1, Minatojima Nakamachi, Chuo-ku, Kobe, Hyogo, 650-0046, Japan
| | - Hideki Nishimura
- Department of Radiation Oncology, Kobe Minimally invasive Cancer Center, 8-5-1, Minatojima Nakamachi, Chuo-ku, Kobe, Hyogo, 650-0046, Japan
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16
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Under-reported dosimetry errors due to interplay effects during VMAT dose delivery in extreme hypofractionated stereotactic radiotherapy. Strahlenther Onkol 2018; 194:570-579. [PMID: 29450592 DOI: 10.1007/s00066-018-1264-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 01/05/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Radiotherapy of extracranial metastases changed from normofractioned 3D CRT to extreme hypofractionated stereotactic treatment using VMAT beam techniques. Random interaction between tumour motion and dynamically changing beam parameters might result in underdosage of the CTV even for an appropriately dimensioned ITV (interplay effect). This study presents a clinical scenario of extreme hypofractionated stereotactic treatment and analyses the impact of interplay effects on CTV dose coverage. METHODS For a thoracic/abdominal phantom with an integrated high-resolution detector array placed on a 4D motion platform, dual-arc treatment plans with homogenous target coverage were created using a common VMAT technique and delivered in a single fraction. CTV underdosage through interplay effects was investigated by comparing dose measurements with and without tumour motion during plan delivery. RESULTS Our study agrees with previous works that pointed out insignificant interplay effects on target coverage for very regular tumour motion patterns like simple sinusoidal motion. However, we identified and illustrated scenarios that are likely to result in a clinically relevant CTV underdosage. For tumour motion with abnormal variability, target coverage quantified by the CTV area receiving more than 98% of the prescribed dose decreased to 78% compared to 100% at static dose measurement. CONCLUSION This study is further proof of considerable influence of interplay effects on VMAT dose delivery in stereotactic radiotherapy. For selected conditions of an exemplary scenario, interplay effects and related motion-induced target underdosage primarily occurred in tumour motion pattern with increased motion variability and VMAT plan delivery using complex MLC dose modulation.
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17
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Direct dose correlation of MRI morphologic alterations of healthy liver tissue after robotic liver SBRT. Strahlenther Onkol 2018; 194:414-424. [PMID: 29404626 DOI: 10.1007/s00066-018-1271-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/16/2018] [Indexed: 12/23/2022]
Abstract
PURPOSE For assessing healthy liver reactions after robotic SBRT (stereotactic body radiotherapy), we investigated early morphologic alterations on MRI (magnetic resonance imaging) with respect to patient and treatment plan parameters. PATIENTS AND METHODS MRI data at 6-17 weeks post-treatment from 22 patients with 42 liver metastases were analyzed retrospectively. Median prescription dose was 40 Gy delivered in 3-5 fractions. T2- and T1-weighted MRI were registered to the treatment plan. Absolute doses were converted to EQD2 (Equivalent dose in 2Gy fractions) with α/β-ratios of 2 and 3 Gy for healthy, and 8 Gy for modelling pre-damaged liver tissue. RESULTS Sharply defined, centroid-shaped morphologic alterations were observed outside the high-dose volume surrounding the GTV. On T2-w MRI, hyperintensity at EQD2 isodoses of 113.3 ± 66.1 Gy2, 97.5 ± 54.7 Gy3, and 66.5 ± 32.0 Gy8 significantly depended on PTV dimension (p = 0.02) and healthy liver EQD2 (p = 0.05). On T1-w non-contrast MRI, hypointensity at EQD2 isodoses of 113.3 ± 49.3 Gy2, 97.4 ± 41.0 Gy3, and 65.7 ± 24.2 Gy8 significantly depended on prior chemotherapy (p = 0.01) and total liver volume (p = 0.05). On T1-w gadolinium-contrast delayed MRI, hypointensity at EQD2 isodoses of 90.6 ± 42.5 Gy2, 79.3 ± 35.3 Gy3, and 56.6 ± 20.9 Gy8 significantly depended on total (p = 0.04) and healthy (p = 0.01) liver EQD2. CONCLUSIONS Early post-treatment changes in healthy liver tissue after robotic SBRT could spatially be correlated to respective isodoses. Median nominal doses of 10.1-11.3 Gy per fraction (EQD2 79-97 Gy3) induce characteristic morphologic alterations surrounding the lesions, potentially allowing for dosimetric in-vivo accuracy assessments. Comparison to other techniques and investigations of the short- and long-term clinical impact require further research.
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18
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Dreher C, Oechsner M, Mayinger M, Beierl S, Duma MN, Combs SE, Habermehl D. Evaluation of the tumor movement and the reproducibility of two different immobilization setups for image-guided stereotactic body radiotherapy of liver tumors. Radiat Oncol 2018; 13:15. [PMID: 29378624 PMCID: PMC5789593 DOI: 10.1186/s13014-018-0962-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/22/2018] [Indexed: 01/24/2023] Open
Abstract
Background The purpose of this study is to evaluate the tumor movement and accuracy of patient immobilization in stereotactic body radiotherapy of liver tumors with low pressure foil or abdominal compression. Methods Fifty-four liver tumors treated with stereotactic body radiotherapy were included in this study. Forty patients were immobilized by a vacuum couch with low pressure foil, 14 patients by abdominal compression. We evaluated the ratio of gross tumor volume/internal target volume, the tumor movement in 4D-computed tomography scans and daily online adjustments after cone beam computed tomography scans. Results The ratio of gross tumor volume/internal target volume was smaller with low pressure foil. The tumor movement in 4D-computed tomography scans was smaller with abdominal compression, the cranial movement even significantly different (p = 0.02). The mean online adjustments and their mean absolute values in the vertical, lateral and longitudinal axis were smaller with abdominal compression. The online adjustments were significantly different (p < 0.013), their absolute values in case of the longitudinal axis (p = 0.043). There was no significant difference of the adjustments’ 3D vectors. Conclusions In comparison to low pressure foil, abdominal compression leads to a reduction of the tumor movement. Online adjustments decreased significantly, thus leading to higher accuracy in patient positioning.
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Affiliation(s)
- Constantin Dreher
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Michael Mayinger
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Stefanie Beierl
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Marciana-Nona Duma
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy, Helmholtzzentrum München, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, University Hospital Rechts der Isar, Technical University München, Ismaningerstr. 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy, Helmholtzzentrum München, Munich, Germany.
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19
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Unkelbach J, Papp D, Gaddy MR, Andratschke N, Hong T, Guckenberger M. Spatiotemporal fractionation schemes for liver stereotactic body radiotherapy. Radiother Oncol 2017; 125:357-364. [PMID: 28951010 PMCID: PMC5705331 DOI: 10.1016/j.radonc.2017.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/01/2017] [Accepted: 09/03/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Dose prescription in stereotactic body radiotherapy (SBRT) for liver tumors is often limited by the mean liver dose. We explore the concept of spatiotemporal fractionation as an approach to facilitate further dose escalation in liver SBRT. MATERIALS AND METHODS Spatiotemporal fractionation schemes aim at partial hypofractionation in the tumor along with near-uniform fractionation in normal tissues. This is achieved by delivering distinct dose distributions in different fractions, which are designed such that each fraction delivers a high single fraction dose to complementary parts of the tumor while creating a similar dose bath in the surrounding noninvolved liver. Thereby, higher biologically effective doses (BED) can be delivered to the tumor without increasing the mean BED in the liver. Planning of such treatments is performed by simultaneously optimizing multiple dose distributions based on their cumulative BED. We study this concept for five liver cancer patients with different tumor geometries. RESULTS Spatiotemporal fractionation presents a method of increasing the ratio of prescribed tumor BED to mean BED in the noninvolved liver by approximately 10-20%, compared to conventional SBRT using identical fractions. CONCLUSIONS Spatiotemporal fractionation may reduce the risk of liver toxicity or facilitate dose escalation in liver SBRT in circumstances where the mean dose to the non-involved liver is the prescription-limiting factor.
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Affiliation(s)
- Jan Unkelbach
- Department of Radiation Oncology, University Hospital Zürich, Switzerland.
| | - Dávid Papp
- Department of Mathematics, North Carolina State University, Raleigh, USA
| | - Melissa R Gaddy
- Department of Mathematics, North Carolina State University, Raleigh, USA
| | | | - Theodore Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
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20
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Stera S, Balermpas P, Chan MKH, Huttenlocher S, Wurster S, Keller C, Imhoff D, Rades D, Dunst J, Rödel C, Hildebrandt G, Blanck O. Breathing-motion-compensated robotic guided stereotactic body radiation therapy : Patterns of failure analysis. Strahlenther Onkol 2017; 194:143-155. [PMID: 28875297 DOI: 10.1007/s00066-017-1204-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/16/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE We retrospectively evaluated the patterns of failure for robotic guided real-time breathing-motion-compensated (BMC) stereotactic body radiation therapy (SBRT) in the treatment of tumors in moving organs. PATIENTS AND METHODS Between 2011 and 2016, a total of 198 patients with 280 lung, liver, and abdominal tumors were treated with BMC-SBRT. The median gross tumor volume (GTV) was 12.3 cc (0.1-372.0 cc). Medians of mean GTV BEDα/β =10 Gy (BED = biological effective dose) was 148.5 Gy10 (31.5-233.3 Gy10) and prescribed planning target volume (PTV) BEDα/β =10 Gy was 89.7 Gy10 (28.8-151.2 Gy10), respectively. We analyzed overall survival (OS) and local control (LC) based on various factors, including BEDs with α/β ratios of 15 Gy (lung metastases), 21 Gy (primary lung tumors), and 27 Gy (liver metastases). RESULTS Median follow-up was 10.4 months (2.0-59.0 months). The 2‑year actuarial LC was 100 and 86.4% for primary early and advanced stage lung tumors, respectively, 100% for lung metastases, 82.2% for liver metastases, and 90% for extrapulmonary extrahepatic metastases. The 2‑year OS rate was 47.9% for all patients. In uni- and multivariate analysis, comparatively lower PTV prescription dose (equivalence of 3 × 12-13 Gy) and higher average GTV dose (equivalence of 3 × 18 Gy) to current practice were significantly associated with LC. For OS, Karnofsky performance score (100%), gender (female), and SBRT without simultaneous chemotherapy were significant prognostic factors. Grade 3 side effects were rare (0.5%). CONCLUSIONS Robotic guided BMC-SBRT can be considered a safe and effective treatment for solid tumors in moving organs. To reach sufficient local control rates, high average GTV doses are necessary. Further prospective studies are warranted to evaluate these points.
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Affiliation(s)
- Susanne Stera
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Panagiotis Balermpas
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Mark K H Chan
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | - Stefan Wurster
- Saphir Radiosurgery Center, Güstrow, Germany.,Department of Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | - Christian Keller
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.,Saphir Radiosurgery Center, Frankfurt, Germany
| | - Detlef Imhoff
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Dirk Rades
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Jürgen Dunst
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Department of Radiation Oncology, University Hospital Copenhagen, Copenhagen, Denmark
| | - Claus Rödel
- Department of Radiation Oncology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Oliver Blanck
- Saphir Radiosurgery Center, Frankfurt, Germany.,Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany.,Saphir Radiosurgery Center, Güstrow, Germany
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21
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Lacornerie T, Rio E, Mahé MA. [Stereotactic body radiation therapy for hepatic malignancies: Organs at risk, uncertainties margins, doses]. Cancer Radiother 2017; 21:574-579. [PMID: 28844506 DOI: 10.1016/j.canrad.2017.07.028] [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: 07/07/2017] [Revised: 07/20/2017] [Accepted: 07/22/2017] [Indexed: 11/30/2022]
Abstract
Stereotactic body radiation therapy for primary and metastatic hepatic malignancies can be performed in association and/or as an alternative to surgery and radiofrequency. The consequences of the great number of techniques available are heterogeneity in contouring, dose prescription and in determination of dose constraints for organs at risk. The objective of this paper is to improve the quality and safety and to help the diffusion of this technique for a majority of patients. In 2016, the French Society of Radiation Oncology (SFRO) published guidelines for external radiotherapy and brachytherapy ("Recorad"). This paper is an update of these recommendations considering recent publications.
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Affiliation(s)
- T Lacornerie
- Service de physique médicale, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59020 Lille, France.
| | - E Rio
- Service de radiothérapie, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Professeur-Jacques-Monod, 44805 Saint-Herblain, France
| | - M-A Mahé
- Service de radiothérapie, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Professeur-Jacques-Monod, 44805 Saint-Herblain, France
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22
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Moustakis C, Blanck O, Ebrahimi Tazehmahalleh F, Ka Heng Chan M, Ernst I, Krieger T, Duma MN, Oechsner M, Ganswindt U, Heinz C, Alheit H, Blank H, Nestle U, Wiehle R, Kornhuber C, Ostheimer C, Petersen C, Pollul G, Baus W, Altenstein G, Beckers E, Jurianz K, Sterzing F, Kretschmer M, Seegenschmiedt H, Maass T, Droege S, Wolf U, Schoeffler J, Haverkamp U, Eich HT, Guckenberger M. Planning benchmark study for SBRT of early stage NSCLC : Results of the DEGRO Working Group Stereotactic Radiotherapy. Strahlenther Onkol 2017; 193:780-790. [PMID: 28567503 DOI: 10.1007/s00066-017-1151-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 05/10/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The aim was to evaluate stereotactic body radiation therapy (SBRT) treatment planning variability for early stage nonsmall cell lung cancer (NSCLC) with respect to the published guidelines of the Stereotactic Radiotherapy Working Group of the German Society for Radiation Oncology (DEGRO). MATERIALS AND METHODS Planning computed tomography (CT) scan and the structure sets (planning target volume, PTV; organs at risk, OARs) of 3 patients with early stage NSCLC were sent to 22 radiotherapy departments with SBRT experience: each department was asked to prepare a treatment plan according to the DEGRO guidelines. The prescription dose was 3 fractions of 15 Gy to the 65% isodose. RESULTS In all, 87 plans were generated: 36 used intensity-modulated arc therapy (IMAT), 21 used three-dimensional conformal radiation therapy (3DCRT), 6 used static field intensity-modulated radiation therapy (SF-IMRT), 9 used helical radiotherapy and 15 used robotic radiosurgery. PTV dose coverage and simultaneously kept OARs doses were within the clinical limits published in the DEGRO guidelines. However, mean PTV dose (mean 58.0 Gy, range 52.8-66.4 Gy) and dose conformity indices (mean 0.75, range 0.60-1.00) varied between institutions and techniques (p ≤ 0.02). OARs doses varied substantially between institutions, but appeared to be technique independent (p = 0.21). CONCLUSION All studied treatment techniques are well suited for SBRT of early stage NSCLC according to the DEGRO guidelines. Homogenization of SBRT practice in Germany is possible through the guidelines; however, detailed treatment plan characteristics varied between techniques and institutions and further homogenization is warranted in future studies and recommendations. Optimized treatment planning should always follow the ALARA (as low as reasonably achievable) principle.
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Affiliation(s)
- Christos Moustakis
- Department of Radiation Oncology, University Muenster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
- German CyberKnife Center, Soest, Germany.
| | - Oliver Blanck
- Department of Radiation Oncology, UKSH Universitätsklinikum Schleswig Holstein, Kiel, Germany
- Güstrow and Frankfurt, Saphir Radiosurgery Center, Frankfurt, Germany
| | - Fatemeh Ebrahimi Tazehmahalleh
- Department of Radiation Oncology, University Muenster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
- City Hospital Dessau, Dessau, Germany
| | - Mark Ka Heng Chan
- Department of Radiation Oncology, UKSH Universitätsklinikum Schleswig Holstein, Kiel, Germany
| | - Iris Ernst
- Department of Radiation Oncology, University Muenster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
- German CyberKnife Center, Soest, Germany
| | - Thomas Krieger
- Department of Radiation Oncology, University of Wuerzburg, Wuerzburg, Germany
| | - Marciana-Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, Ludwig-Maximilians-University, Munich, Germany
| | - Christian Heinz
- Department of Radiation Oncology, Ludwig-Maximilians-University, Munich, Germany
| | | | | | - Ursula Nestle
- Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - Rolf Wiehle
- Department of Radiation Oncology, University Medical Center Freiburg, Freiburg, Germany
| | | | | | | | - Gerhard Pollul
- Department of Radiation Oncology, University Mainz, Mainz, Germany
| | | | | | | | | | | | | | | | - Torsten Maass
- Radiationtherapy and Cyberknife Center Hamburg, Hamburg, Germany
| | | | - Ulrich Wolf
- Department of Radiation Oncology, University Leipzig, Leipzig, Germany
| | | | - Uwe Haverkamp
- Department of Radiation Oncology, University Muenster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
- German CyberKnife Center, Soest, Germany
| | - Hans Theodor Eich
- Department of Radiation Oncology, University Muenster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
- German CyberKnife Center, Soest, Germany
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23
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Klement RJ. Radiobiological parameters of liver and lung metastases derived from tumor control data of 3719 metastases. Radiother Oncol 2017; 123:218-226. [PMID: 28363484 DOI: 10.1016/j.radonc.2017.03.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/13/2017] [Accepted: 03/13/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE The radiobiological parameters for liver and lung metastases treated with stereotactic body radiation therapy (SBRT) are poorly defined. This project aimed at estimating these parameters from published tumor control probability (TCP) data, and separately for metastases with colorectal cancer (CRC) and non-CRC histology. MATERIALS AND METHODS A total of 62 studies with 89 different treatment prescriptions for a total of 3719 metastases were analyzed in a Bayesian framework using four different radiobiological models: The LQ, mLQ, LQ-L and the regrowth model which accounts for tumor regrowth after SBRT. RESULTS Depending on the particular model, α/β ratios in the range 13-23Gy for pulmonary metastases and 16-28Gy for hepatic metastases were estimated. For CRC metastases the estimated α/β ratio was 43.1±4.7Gy compared to 21.6±7.8Gy for non-CRC metastases. Typical isocenter dose prescriptions of 3×12Gy, 3×14.5Gy and 3×17Gy applied within 5days were predicted sufficient to control 90% of lung, liver and CRC metastases after 1yr, respectively. CONCLUSIONS α/β ratios for liver and lung metastases are higher than the usually assumed 10Gy. Differences between CRC and non-CRC histology were found. Future studies confirming these findings in individual patient data are needed.
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Affiliation(s)
- Rainer J Klement
- Department of Radiotherapy and Radiation Oncology, Leopoldina Hospital, Schweinfurt, Germany.
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24
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Klement RJ, Guckenberger M, Alheid H, Allgäuer M, Becker G, Blanck O, Boda-Heggemann J, Brunner T, Duma M, Gerum S, Habermehl D, Hildebrandt G, Lewitzki V, Ostheimer C, Papachristofilou A, Petersen C, Schneider T, Semrau R, Wachter S, Andratschke N. Stereotactic body radiotherapy for oligo-metastatic liver disease - Influence of pre-treatment chemotherapy and histology on local tumor control. Radiother Oncol 2017; 123:227-233. [PMID: 28274491 DOI: 10.1016/j.radonc.2017.01.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/02/2017] [Accepted: 01/21/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Stereotactic body radiation therapy (SBRT) is applied in the oligometastatic setting to treat liver metastases. However, factors influencing tumor control probability (TCP) other than radiation dose have not been thoroughly investigated. Here we set out to investigate such factors with a focus on the influence of histology and chemotherapy prior to SBRT using a large multi-center database from the German Society of Radiation Oncology. METHODS 452 SBRT treatments in 363 patients were analyzed after collection of patient, tumor and treatment data in a multi-center database. Histology was considered through random effects in semi-parametric and parametric frailty models. Dose prescriptions were parametrized by conversion to the maximum biologically effective dose using alpha/beta of 10Gy (BEDmax). RESULTS After adjusting for histology, BEDmax was the strongest predictor of TCP. Larger PTV volumes, chemotherapy prior to SBRT and simple motion management techniques predicted significantly lower TCP. The model predicted a BED of 209±67Gy10 necessary for 90% TCP at 2years with no prior chemotherapy, but 286±78Gy10 when chemotherapy had been given. Breast cancer metastases were significantly more responsive to SBRT compared to other histologies with 90% TCP at 2years achievable with BEDmax of 157±80Gy10 or 80±62Gy10 with and without prior chemotherapy, respectively. CONCLUSIONS Besides dose, histology and pretreatment chemotherapy were important factors influencing local TCP in this large cohort of liver metastases. After adjusting for prior chemotherapy, our data add to the emerging evidence that breast cancer metastases do respond better to hypofractionated SBRT compared to other histologies.
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Affiliation(s)
- R J Klement
- Leopoldina Hospital Schweinfurt, Department of Radiation Oncology, Germany
| | - M Guckenberger
- University Hospital Zürich, Department of Radiation Oncology, University of Zurich, Switzerland
| | - H Alheid
- Strahlentherapie Bautzen, Radiation Oncology, Germany
| | - M Allgäuer
- Krankenhaus Barmherzige Brüder, Radiation Oncology, Regensburg, Germany
| | - G Becker
- RadioChirurgicum CyberKnife Südwest, Radiation Oncology, Göppingen, Germany
| | - O Blanck
- Universitätsklinikum Schleswig-Holstein, Radiation Oncology, Kiel/Lübeck, Germany
| | - J Boda-Heggemann
- University Hospital Mannheim, Radiation Oncology, University of Heidelberg, Germany
| | - T Brunner
- University Hospital Freiburg, Radiation Oncology, Germany
| | - M Duma
- Klinikum rechts der Isar- Technische Universität München, Radiation Oncology, Germany
| | - S Gerum
- Department of Radiation Oncology, University of Munich - LMU Munich, Germany
| | - D Habermehl
- University Hospital Heidelberg, Radiation Oncology, Germany
| | - G Hildebrandt
- University Hospital Rostock, Radiation Oncology, Germany
| | - V Lewitzki
- University Hospital Würzburg, Radiation Oncology, Germany
| | - C Ostheimer
- University Hospital Halle, Radiation Oncology, Germany
| | | | - C Petersen
- University Medical Center Hamburg-Eppendorf, Radiation Oncology, Germany
| | - T Schneider
- Strahlenzentrum Hamburg, Radiation Oncology, Germany
| | - R Semrau
- University Hospital of Cologne, Radiation Oncology, Germany
| | - S Wachter
- Klinikum Passau, Radiation Oncology, Germany
| | - N Andratschke
- University Hospital Zürich, Department of Radiation Oncology, University of Zurich, Switzerland.
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25
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Chan M, Grehn M, Cremers F, Siebert FA, Wurster S, Huttenlocher S, Dunst J, Hildebrandt G, Schweikard A, Rades D, Ernst F, Blanck O. Dosimetric Implications of Residual Tracking Errors During Robotic SBRT of Liver Metastases. Int J Radiat Oncol Biol Phys 2016; 97:839-848. [PMID: 28244421 DOI: 10.1016/j.ijrobp.2016.11.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/21/2016] [Accepted: 11/21/2016] [Indexed: 12/25/2022]
Abstract
PURPOSE Although the metric precision of robotic stereotactic body radiation therapy in the presence of breathing motion is widely known, we investigated the dosimetric implications of breathing phase-related residual tracking errors. METHODS AND MATERIALS In 24 patients (28 liver metastases) treated with the CyberKnife, we recorded the residual correlation, prediction, and rotational tracking errors from 90 fractions and binned them into 10 breathing phases. The average breathing phase errors were used to shift and rotate the clinical tumor volume (CTV) and planning target volume (PTV) for each phase to calculate a pseudo 4-dimensional error dose distribution for comparison with the original planned dose distribution. RESULTS The median systematic directional correlation, prediction, and absolute aggregate rotation errors were 0.3 mm (range, 0.1-1.3 mm), 0.01 mm (range, 0.00-0.05 mm), and 1.5° (range, 0.4°-2.7°), respectively. Dosimetrically, 44%, 81%, and 92% of all voxels differed by less than 1%, 3%, and 5% of the planned local dose, respectively. The median coverage reduction for the PTV was 1.1% (range in coverage difference, -7.8% to +0.8%), significantly depending on correlation (P=.026) and rotational (P=.005) error. With a 3-mm PTV margin, the median coverage change for the CTV was 0.0% (range, -1.0% to +5.4%), not significantly depending on any investigated parameter. In 42% of patients, the 3-mm margin did not fully compensate for the residual tracking errors, resulting in a CTV coverage reduction of 0.1% to 1.0%. CONCLUSIONS For liver tumors treated with robotic stereotactic body radiation therapy, a safety margin of 3 mm is not always sufficient to cover all residual tracking errors. Dosimetrically, this translates into only small CTV coverage reductions.
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Affiliation(s)
- Mark Chan
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany; Tuen Mun Hospital, Hong Kong, China
| | - Melanie Grehn
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany; Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Florian Cremers
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Frank-Andre Siebert
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stefan Wurster
- Saphir Radiosurgery Center Northern Germany, Güstrow, Germany; Department for Radiation Oncology, University Medicine Greifswald, Greifswald, Germany
| | | | - Jürgen Dunst
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany; Department for Radiation Oncology, University Clinic Copenhagen, Copenhagen, Denmark
| | - Guido Hildebrandt
- Department for Radiation Oncology, University Medicine Rostock, Rostock, Germany
| | - Achim Schweikard
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Dirk Rades
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Floris Ernst
- Institute for Robotics and Cognitive Systems, University of Lübeck, Lübeck, Germany
| | - Oliver Blanck
- Department for Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany; Saphir Radiosurgery Center Northern Germany, Güstrow, Germany.
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