Univariate analysis of factors correlated with tumor control probability of three-dimensional conformal hypofractionated high-dose radiotherapy for small pulmonary or hepatic tumors

[Prognosis factors after lung stereotactic body radiotherapy for non-small cell lung carcinoma]

Lung cancer is the fourth most common cancer in France with a prevalence of 30,000 new cases per year. Lobectomy surgery with dissection is the gold standard treatment for T1-T2 localized non-small cell lung carcinoma. A segmentectomy may be proposed to operable patients but fragile from a respiratory point of view. For inoperable patients or patients with unsatisfactory pulmonary function tests, local treatment with stereotactic radiotherapy may be proposed to achieve local control rates ranging from 85 to 95% at 3-5 years. Several studies have examined prognostic factors after stereotaxic pulmonary radiotherapy. We conducted a general review of the literature to identify factors affecting local control.

Pan-Asian adapted ESMO consensus guidelines for the management of patients with metastatic colorectal cancer: a JSMO-ESMO initiative endorsed by CSCO, KACO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) consensus guidelines for the treatment of patients with metastatic colorectal cancer (mCRC) was published in 2016, identifying both a more strategic approach to the administration of the available systemic therapy choices, and a greater emphasis on the use of ablative techniques, including surgery. At the 2016 ESMO Asia Meeting, in December 2016, it was decided by both ESMO and the Japanese Society of Medical Oncology (JSMO) to convene a special guidelines meeting, endorsed by both ESMO and JSMO, immediately after the JSMO 2017 Annual Meeting. The aim was to adapt the ESMO consensus guidelines to take into account the ethnic differences relating to the toxicity as well as other aspects of certain systemic treatments in patients of Asian ethnicity. These guidelines represent the consensus opinions reached by experts in the treatment of patients with mCRC identified by the Presidents of the oncological societies of Japan (JSMO), China (Chinese Society of Clinical Oncology), Korea (Korean Association for Clinical Oncology), Malaysia (Malaysian Oncological Society), Singapore (Singapore Society of Oncology) and Taiwan (Taiwan Oncology Society). The voting was based on scientific evidence and was independent of both the current treatment practices and the drug availability and reimbursement situations in the individual participating Asian countries.

Three-Fraction Stereotactic Body Radiation Therapy for Isolated Liver Recurrence from Colorectal Cancer

Aims

To determine the feasibility and efficacy of 3-fraction stereotactic body radiation therapy for isolated colorectal cancer liver metastases.

Materials and methods

Ten patients with isolated inoperable liver metastasis from colorectal cancer with progression after salvage chemotherapy underwent stereotactic body radiation therapy. Follow-up was 7–49 months (median, 12). Six patients had a solitary lesion and 4 patients had 2 lesions. Internal target volumes of metastatic liver tumors ranged from 3.4 to 271 ml. Stereotactic body radiation therapy doses ranged from 36 to 51 Gy and were administered in three fractions. All patients demonstrated disease progression despite chemotherapy prior to stereotactic body radiation therapy.

Results

Three-year overall survival and local control rates were 40% and 60%, respectively. Tumors with an internal target volume <100 ml showed better local control rate than larger tumors. No severe complication was attributed to the therapy.

Conclusion

Our study suggests the potential feasibility of stereotactic body radiation therapy for selected patients with colorectal cancer liver metastasis and no treatment option. The study showed that excellent local control was achieved in patients with a total tumor volume of <100 ml but failed to clarify the role of stereotactic body radiation therapy for larger tumors. Further large scale studies are needed to define the indications of such therapy.

Analysis of the factors affecting the safety of robotic stereotactic body radiation therapy for hepatocellular carcinoma patients

Objective

The objective of this study was to investigate the safety of robotic stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) patients and its related factors.

Methods

A total of 74 HCC patients with Child-Turcotte-Pugh (CTP) Class A were included in a multi-institutional, single-arm Phase II trial (NCT 02363218) between February 2013 and August 2016. All patients received SBRT treatment at a dose of 45 Gy/3f. The liver function was compared before and after SBRT treatment by the analysis of adverse hepatic reactions and changes in CTP classification.

Results

After SBRT treatment, eight patients presented with decreases in CTP classification and 13 patients presented with ≥ grade 2 hepatic adverse reactions. For patients presenting with ≥ grade 2 hepatic adverse reactions, the total liver volume of ≤1,162 mL and a normal liver volume (total liver volume - gross tumor volume [GTV]) of ≤1,148 mL were found to be independent risk factors and statistically significant (P<0.05).

Conclusion

The total liver volume and normal liver volume are associated with the occurrence of ≥ grade 2 hepatic adverse reactions after SBRT treatment on HCC patients. Therefore, if the fractionated scheme of 45 Gy/3f is applied in SBRT for HCC patients, a total liver volume >1,162 mL and a normal liver volume >1,148 mL should be ensured to improve therapeutic safety.

Stereotactic Body Radiotherapy for Inoperable Liver Tumors: Results of a Single Institutional Experience

OBJECTIVES

Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumors unsuitable for ablation or surgery. We report our experience with SBRT in the treatment of liver tumors.

MATERIALS AND METHODS

Patients with primary or secondary liver cancer were identified in our local SBRT database. Patients were included irrespective of prior liver-directed therapies. The primary endpoint of our review was in-field local control (LC). Secondary endpoints were progression-free survival (PFS), overall survival (OS), and toxicity.

RESULTS

From 2009 to 2015, a total of 71 liver lesions in 68 patients were treated with SBRT (three patients had two liver lesions treated). The median age was 71 years (27-89 years). Hepatocellular carcinoma (HCC) was the diagnosis in 23 patients (34%), with the grade of Child-Pugh A (52%), B (39%), or C (nine percent) cirrhosis. Six patients (nine percent) had intrahepatic cholangiocarcinoma (IHC). The remaining 39 patients (57%) had metastatic liver lesions. Colorectal adenocarcinoma was the most common primary tumor type (81%). The median size for HCC, IHC, and metastatic lesions was 5 cm (2-9 cm), 3.6 cm (2-4.9 cm), and 4 cm (1-8 cm), respectively. The median prescribed dose was 45 Gy (16-50 Gy). Median follow-up was 11.5 months (1-45 months). Actuarial one-year in-field LC for HCC and metastatic lesions was 85% and 64% respectively (p= 0.66). At one year, the actuarial rate of new liver lesions was 40% and 26%, respectively, (p=0.58) for HCC and metastases. Only six patients with IHC were treated with SBRT in this study - in these patients, one-year LC was 78% with new liver lesions in 53%. The SBRT treatments were well tolerated. The side effects included common criteria for adverse events (CTCAE) v4 grade 1 acute gastrointestinal toxicity in three patients, grade 3 nausea in one patient, and grade 3 acute dermatitis in another patient. Two patients had grade 5 toxicity. Radiation pneumonitis was observed in one patient two months post-SBRT treatment, and another patient was suspected to have had radio-induced liver disease (RILD) two months after SBRT. No late toxicity was seen.

CONCLUSION

SBRT is a well-tolerated and effective alternative treatment option for selected patients with primary and metastatic liver tumors.

ESMO consensus guidelines for the management of patients with metastatic colorectal cancer

Colorectal cancer (CRC) is one of the most common malignancies in Western countries. Over the last 20 years, and the last decade in particular, the clinical outcome for patients with metastatic CRC (mCRC) has improved greatly due not only to an increase in the number of patients being referred for and undergoing surgical resection of their localised metastatic disease but also to a more strategic approach to the delivery of systemic therapy and an expansion in the use of ablative techniques. This reflects the increase in the number of patients that are being managed within a multidisciplinary team environment and specialist cancer centres, and the emergence over the same time period not only of improved imaging techniques but also prognostic and predictive molecular markers. Treatment decisions for patients with mCRC must be evidence-based. Thus, these ESMO consensus guidelines have been developed based on the current available evidence to provide a series of evidence-based recommendations to assist in the treatment and management of patients with mCRC in this rapidly evolving treatment setting.

Liver metastases and SBRT: A new paradigm?

BACKGROUND

The outstanding innovations made by early diagnosis, novel surgical techniques, effective chemotherapy regimens and conformal radiotherapy, have significantly improved patients overall survival and quality of life. Multidisciplinary approach to cancer has also led to an increased prevalence of patients with few, organ-confined metastases, who can experience long-term survival even if their disease is no longer localized. Liver is one of the most common site for metastatic disease from several cancers, and when metastatic disease is confined to liver, given the ability of this organ to regenerate almost to its optimal volume, surgical resection represents the standard of care because is associated with a better prognosis. Approximately 70-90% of liver metastases, however, are unresectable and a safe, effective alternative therapeutic option is necessary for these patients.

MATERIALS AND METHODS

A review of the current literature was performed to analyze the role of SBRT in treating liver metastases from different cancers. A literature search using the terms "SBRT" and "liver metastases" was carried out in PUBMED.

RESULTS

Stereotactic body radiation therapy has shown to provide promising results in the treatment of liver metastases, thanks to the ability of this procedure to deliver a conformal high dose of radiation to the target lesion and a minimal dose to surrounding critical tissues.

CONCLUSION

Stereotactic body radiation therapy is a non-invasive, well-tolerated and effective treatment for patients with liver metastases not suitable for surgical resection.

Stereotactic body radiotherapy for liver metastases

The role for local ablative therapies in the management paradigm of oligometastatic liver disease is increasing. The evidence base supporting the use of stereotactic body radiotherapy for liver metastases has expanded rapidly over the past decade, showing high rates of local control with low associated toxicity. This review summarises the evidence base to date, discussing optimal patient selection, challenges involved with treatment delivery and optimal dose and fractionation. The reported toxicity associated with liver stereotactic body radiotherapy is presented, together with possible pitfalls in interpreting the response to treatment using standard imaging modalities. Finally, potential avenues for future research in this area are highlighted.

Image-guided radiation therapy for liver tumors: gastrointestinal histology matters

OBJECTIVES

To describe the safety and efficacy of single-fraction and hypofractionated image-guided radiotherapy techniques for the treatment of large liver tumors.

METHODS

Forty-six patients, with 50 tumors (10 primary liver tumors, 40 liver metastases) from March 2004 to March 2011 were reviewed. The maximal tumor diameter ranged from 1.2 to 11.3 cm (median, 4.2 cm). Eighty-seven percent of patients received prior systemic chemotherapy. Fifty-nine percent had prior invasive local therapy including surgery, ablation, or embolization. Twenty-five lesions were treated with hypofractionated therapy (24 to 30 Gy in 3 to 5 fractions), whereas 19 received a single fraction (18 or 24 Gy). Local control (LC) was calculated using competing risk analysis. Overall survival was calculated by the Kaplan-Meier method.

RESULTS

Median follow-up for all patients was 29.8 months (range, 3 to 46 mo). The median survival was 15.4 months. The 1- and 2-year LC rates were 78% and 75%, respectively. Dose and tumor size had no significant effect on tumor progression. The local progression at 1 and 2 years was 29% and 32% for gastrointestinal (GI) histologies versus 0% for non-GI histologies (P=0.02). Tumor volumes larger than 112 cm correlated with decreased survival (P=0.05). Three patients developed late grade 3 GI stricture or ulceration.

CONCLUSIONS

Image-guided radiotherapy for liver tumors achieves good rates of LC with minimal toxicity at 1 and 2 years even in patients with large or recurrent disease that has been heavily pretreated. GI histology demonstrated decreased LC rates. Further management strategies should be considered in these patients.

Oligometastasis and oligo-recurrence: more than a mirage

The standard treatment choice for cancer metastasis has been systemic management, including cytotoxic chemotherapy, hormonal manipulation, and targeted therapy. Emerging evidence has shown an oligometastatic state, an intermediate state between limited primary cancer and polymetastatic cancer, in which local therapy for metastatic lesions results in satisfactory survival comparable to non-metastatic disease. We provide a comprehensive introduction of evidence from experimental and clinical studies in favor of the oligometastatic phenotype, we review the efficacy and safety of surgery and stereotactic body radiotherapy in the treatment of oligometastases, and finally, we discuss the way to differentiate the oligometastatic state from polymetastasis.

Robotic stereotactic body radiation therapy for liver-limited malignant tumors

Introduction

Stereotactic body radiotherapy (SBRT) is rapidly gaining favor as a new treatment modality for malignant liver tumors. Most of the studies have recruited patients with disseminated disease originating from the liver. This study focuses on disease limited to the liver.

Aim

To perform a retrospective analysis of all patients with liver tumors treated by robotic stereotactic body radiation therapy in a single center.

Material and methods

The study included 13 patients with 22 lesions. The inclusion criteria were: patients with 1–4 inoperable liver lesions and absence of any extrahepatic disease. All but 3 patients received 3 fractions delivered by the Cyberknife system of a total of 45 grey (Gy). The other 3 patients received 30 Gy.

Results

The median follow-up time was 10.8 months (range: 7–16). The median dose was 41.5 Gy (range: 30–45). One lesion regressed (8%). In 5 patients, the disease was locally stabilized (38%), and in 7 other patients progression occurred (54%). Twelve patients (92%) are still alive, and 1 patient (8%) died. In 1 patient a new cancer (leukemia) was diagnosed.

Conclusions

The SBRT is well tolerated and effective for local control of most liver malignant tumors. It appears that SBRT is best suited for those patients in whom systemic recurrence can be controlled by chemotherapy. Further studies are mandatory to elucidate these effects on tumors of varying histology and to elaborate upon criteria used to select patients who can benefit most from this treatment.

Stereotactic body radiation therapy for liver metastases

Over the years, early diagnosis of metastatic disease has improved and the prevalence of oligometastatic patients is increasing. Liver is a most common site of progression from gastrointestinal, lung and breast cancer and in the setting of oligometastatic patients, surgical resection is associated with increased survival. Approximately 70-90% of liver metastases, however, are unresectable and an effective and safe alternative therapeutic option is necessary for these patients. The role of stereotactic body radiation therapy (SBRT) was investigated in the treatment of oligometastatic patients with promising results, thanks to the ability of this procedure to deliver a conformal high dose of radiation to the target lesion and a minimal dose to surrounding critical tissues. This paper was performed to review the current literature and to provide the practice guidelines on the use of stereotactic body radiotherapy in the treatment of liver metastases. We performed a literature search using Medical Subject Heading terms "SBRT" and "liver metastases", considering a period of ten years.

Local effect of stereotactic body radiotherapy for primary and metastatic liver tumors in 130 Japanese patients

BACKGROUND AND AIMS

Stereotactic body radiotherapy (SBRT) is a relatively new treatment for liver tumor. The outcomes of SBRT for liver tumor unfit for ablation and surgical resection were evaluated.

METHODS

Liver tumor patients treated with SBRT in seven Japanese institutions were studied retrospectively. Patients given SBRT for liver tumor between 2004 and 2012 were collected. Patients treated with SBRT preceded by trans-arterial chemoembolization (TACE) were eligible. Seventy-nine patients with hepatocellular carcinoma (HCC) and 51 patients with metastatic liver tumor were collected. The median biologically effective dose (BED) (α/β = 10 Gy) was 96.3 Gy for patients with HCC and 105.6 Gy with metastatic liver tumor.

RESULTS

The median follow-up time was 475.5 days in patients with HCC and 212.5 days with metastatic liver tumor. The 2-year local control rate (LCR) for HCC and metastatic liver tumor was 74.8% ± 6.3% and 64.2 ± 9.5% (p = 0.44). The LCR was not different between BED10 ≥ 100 Gy and < 100 Gy (p = 0.61). The LCR was significantly different between maximum tumor diameter > 30 mm vs. ≤ 30 mm (64% vs. 85%, p = 0.040) in all 130 patients. No grade 3 laboratory toxicities in the acute, sub-acute and chronic phases were observed.

CONCLUSIONS

There was no difference in local control after SBRT in the range of median BED10 around 100 Gy for between HCC and metastatic liver tumor. SBRT is safe and might be an alternative method to resection and ablation.

SUMMARY

There was no difference in local control after SBRT in the range of median BED10 around 100 Gy for between HCC and metastatic liver tumor and SBRT is safe and might be an alternative method to resection and ablation.

Examining tumor control and toxicity after stereotactic body radiotherapy in locally recurrent previously irradiated head and neck cancers: implications of treatment duration and tumor volume

BACKGROUND

Stereotactic body radiotherapy (SBRT) has been studied in locally recurrent previously-irradiated head and neck cancers; however, the optimum fractionation and patient selection continues to be defined.

METHODS

Patients (n = 132) with locally recurrent head and neck cancer salvaged via SBRT ± cetuximab (median, 44 Gy/5 fractions) from November 2004 to May 2011 were retrospectively reviewed. Disease outcomes and toxicity were analyzed by predictive factors including treatment duration and tumor volume.

RESULTS

At a median 6-month follow-up (range, 0-55 months), treatment duration <14 days was associated with significantly improved recurrence-free survival (RFS) at the expense of increased late toxicity (p = .029). Tumor volume >25 cc remained a significant predictor of inferior survival and tumor control, and was associated with significantly more acute toxicity (p = .017) but no difference in late toxicity.

CONCLUSION

SBRT ± cetuximab achieves promising tumor control and survival with low rates of acute/late toxicity even for recurrences >25 cc. Prolongations in treatment time may decrease late toxicity at the expense of disease control.

Stereotactic body radiotherapy: a critical review for nonradiation oncologists

Stereotactic body radiotherapy (SBRT) involves the treatment of extracranial primary tumors or metastases with a few, high doses of ionizing radiation. In SBRT, tumor kill is maximized and dose to surrounding tissue is minimized, by precise and accurate delivery of multiple radiation beams to the target. This is particularly challenging, because extracranial lesions often move with respiration and are irregular in shape, requiring careful treatment planning and continual management of this motion and patient position during irradiation. This review presents the rationale, process workflow, and technology for the safe and effective administration of SBRT, as well as the indications, outcome, and limitations for this technique in the treatment of lung cancer, liver cancer, and metastatic disease.

Phase II trial of palliative radiotherapy for hepatocellular carcinoma and liver metastases

PURPOSE

To evaluate the feasibility and response of liver radiotherapy (RT) in improving symptoms and quality of life in patients with hepatocellular carcinoma (HCC) or liver metastases (LM).

PATIENTS AND METHODS

Eligible patients had HCC or LM, unsuitable for or refractory to standard therapies, with an index symptom of pain, abdominal discomfort, nausea, or fatigue. The Brief Pain Inventory (BPI), Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep), and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) were completed by patients at baseline and each follow-up. The primary outcome was the percentage of patients with a clinically significant change at 1 month in the BPI subscale of symptom on average in the past 24 hours. Secondary outcomes were improvement in other BPI subscales and at other time points, FACT-Hep and EORTC QLQ-C30 at each follow-up, and toxicity at 1 week.

RESULTS

Forty-one patients (30 men and 11 women) with HCC (n = 21) or LM (n = 20) were accrued. At 1 month, 48% had an improvement in symptom on average in the past 24 hours. Fifty-two percent of patients had improvement in symptom at its worst, 37% at its least, and 33% now. Improvements in the FACT-G and hepatobiliary subscale were seen in 23% and 29% of patients, respectively, at 1 month. There were also improvements in EORTC QLQ-C30 functional (range, 11% to 21%) and symptom (range, 11% to 50%) domains. One patient developed grade 3 nausea at 1 week.

CONCLUSION

Improvements in symptoms were observed at 1 month in a substantial proportion of patients. A phase III study of palliative liver RT is planned. [Corrected]

Prognostic factors affecting local control of hepatic tumors treated by Stereotactic Body Radiation Therapy

Purpose

Robotic Stereotactic Body Radiation Therapy with real-time tumor tracking has shown encouraging results for hepatic tumors with good efficacy and low toxicity. We studied the factors associated with local control of primary or secondary hepatic lesions post-SBRT.

Methods and materials

Since 2007, 153 stereotactic liver treatments were administered to 120 patients using the CyberKnife® System. Ninety-nine liver metastases (72 patients), 48 hepatocellular carcinomas (42 patients), and six cholangiocarcinomas were treated. On average, three to four sessions were delivered over 12 days. Twenty-seven to 45 Gy was prescribed to the 80% isodose line. Margins consisted of 5 to 10 mm for clinical target volume (CTV) and 3 mm for planning target volume (PTV).

Results

Median size was 33 mm (range, 5–112 mm). Median gross tumor volume (GTV) was 32.38 cm³ (range, 0.2–499.5 cm³). Median total dose was 45 Gy in three fractions. Median minimum dose was 27 Gy in three fractions. With a median follow-up of 15.0 months, local control rates at one and two years were 84% and 74.6%, respectively. The factors associated with better local control were lesion size < 50 mm (p = 0.019), GTV volume (p < 0.05), PTV volume (p < 0.01) and two treatment factors: a total dose of 45 Gy and a dose–per-fraction of 15 Gy (p = 0.019).

Conclusions

Dose, tumor diameter and volume are prognostic factors for local control when a stereotactic radiation therapy for hepatic lesions is considered. These results should be considered in order to obtain a maximum therapeutic efficacy.

Scoring system predictive of survival for patients undergoing stereotactic body radiation therapy for liver tumors

Background

Stereotactic body radiation therapy (SBRT) is an emerging treatment option for liver tumors. This study evaluated outcomes after SBRT to identify prognostic variables and to develop a novel scoring system predictive of survival.

Methods

The medical records of 52 patients with a total of 85 liver lesions treated with SBRT from 2003 to 2010 were retrospectively reviewed. Twenty-four patients had 1 lesion; 27 had 2 or more. Thirteen lesions were primary tumors; 72 were metastases. Fiducials were placed in all patients prior to SBRT. The median prescribed dose was 30 Gy (range, 16 – 50 Gy) in a median of 3 fractions (range, 1–5).

Results

With median follow-up of 11.3 months, median overall survival (OS) was 12.5 months, and 1 year OS was 50.8%. In 42 patients with radiographic follow up, 1 year local control was 74.8%. On univariate analysis, number of lesions (p = 0.0243) and active extralesional disease (p < 0.0001) were predictive of OS; Karnofsky Performance Status (KPS) approached statistical significance (p = 0.0606). A scoring system for predicting survival was developed by allocating 1 point for each of the three following factors: active extralesional disease, 2 or more lesions, and KPS ≤ 80%. Score was associated with OS (p < 0.0001). For scores of 0, 1, 2 and 3, median survival intervals were 34, 12.5, 7.6, and 2.8 months, respectively.

Conclusions

SBRT offers a safe and feasible treatment option for liver tumors. A prognostic scoring system based on the number of liver lesions, activity of extralesional disease, and KPS predicts survival following SBRT and can be used as a guide for prospective validation and ultimately for treatment decision-making.

Review and uses of stereotactic body radiation therapy for oligometastases

In patients with proven distant metastases from solid tumors, it has been a notion that the condition is incurable, warranting palliative care only. The term "oligometastases" was coined to refer to isolated sites of metastasis, whereby the entire burden of disease can be recognized as a finite number of discrete lesions that can be potentially cured with local therapies. Stereotactic body radiation therapy (SBRT) is a novel treatment modality in radiation oncology that delivers a very high dose of radiation to the tumor target with high precision using single or a small number of fractions. SBRT is the result of technological advances in patient and tumor immobilization, image guidance, and treatment planning and delivery. A number of studies, both retrospective and prospective, showed promising results in terms of local tumor control and, in a limited subset of patients, of survival. This article reviews the radiobiologic, technical, and clinical aspects of SBRT for various anatomical sites.

Multicenter results of stereotactic body radiotherapy (SBRT) for non-resectable primary liver tumors

BACKGROUND

An excess of 100 000 individuals are diagnosed with primary liver tumors every year in USA but less than 20% of those patients are amenable to definitive surgical management due to advanced local disease or comorbidities. Local therapies to arrest tumor growth have limited response and have shown no improvement on patient survival. Stereotactic body radiotherapy (SBRT) has emerged as an alternative local ablative therapy. The purpose of this study was to evaluate the tumor response to SBRT in a combined multicenter database.

STUDY DESIGN

Patients with advanced hepatocellular carcinoma (HCC, n = 21) or intrahepatic cholangiocarcinoma (ICC, n = 11) treated with SBRT from four Academic Medical Centers were entered into a common database. Statistical analyses were performed for freedom from local progression (FFLP) and patient survival.

RESULTS

The overall FFLP for advanced HCC was 63% at a median follow-up of 12.9 months. Median tumor volume decreased from 334.2 to 135 cm(3) (p < 0.004). The median time to local progression was 6.3 months. The 1- and 2-years overall survival rates were 87% and 55%, respectively. Patients with ICC had an overall FFLP of 55.5% at a median follow-up of 7.8 months. The median time to local progression was 4.2 months and the six-month and one-year overall survival rates were 75% and 45%, respectively. The incidence of grade 1-2 toxicities, mostly nausea and fatigue, was 39.5%. Grade 3 and 4 toxicities were present in two and one patients, respectively.

CONCLUSION

Higher rates of FFLP were achieved by SBRT in the treatment of primary liver malignancies with low toxicity.

Radiotherapy for liver metastases: a review of evidence

Over the past decade, there has been an increasing use of radiotherapy (RT) for the treatment of liver metastases. Most often, ablative doses are delivered to focal liver metastases with the goal of local control and ultimately improving survival. In contrast, low-dose whole-liver RT may be used for the palliation of symptomatic diffuse metastases. This review examines the available clinical data for both approaches. The review found that RT is effective both for local ablation of focal liver metastases and for palliation of patients with symptomatic liver metastases. However, there is a lack of a high level of evidence from randomized clinical trials.

[Stereotactic body radiation therapy for liver primary and metastases: the Lille experience]

PURPOSE

The CyberKnife(®) system is a recent radiation therapy technique that allows treatment of liver lesions with real-time tracking. Because of its high precision, the dose administered to the tumor can be increased. We report Oscar-Lambret Cancer Centre experience in the treatment of primary and secondary liver lesions.

PATIENTS AND METHODS

It is a retrospective study analyzing all the patients who have been treated for their liver lesions since July 2007. A hundred and twenty patients have been treated: 42 for hepatocellular carcinoma, 72 for liver metastases and six for cholangiocarcinoma. Gold seeds need to be implanted before the treatment and are used as markers to follow the movement of the lesion due to respiration. On average, the treatment is administered in three to four sessions over 12 days. A total dose of 40 to 45 Gy at the 80% isodose is delivered. Local control and overall survival analysis with Log-rank is performed for each type of lesion.

RESULTS

Treatment tolerance is good. The most common toxicities are of digestive type, pain and asthenia. Six gastro-duodenal ulcers and two radiation-induced liver disease (RILD) were observed. At a median follow-up of 15 months, the local control rate is respectively of 80.4% and 72.5% at 1 and 2 years. Overall survival is 84.6 and 58.3% at 1 and 2 years. The local control is significantly better for the hepatocellular carcinoma and overall survival is significantly better for liver metastases (P<0.05). The local control rate and overall survival at 1 year for cholangiocarcinoma is 100%.

CONCLUSION

CyberKnife(®) is a promising technique, well tolerated, with tumoral local control rates comparable to other techniques. Its advantage is that it is very minimally invasive delivered as an outpatient procedure in a frail population of patient (disease, age).

Image-guided robotic stereotactic body radiation therapy for liver metastases: is there a dose response relationship?

PURPOSE

To evaluate the outcome, tolerance, and toxicity of stereotactic body radiotherapy, using image-guided robotic radiation delivery, for the treatment of patients with unresectable liver metastases.

METHODS AND MATERIAL

Patients were treated with real-time respiratory tracking between July 2007 and April 2009. Their records were retrospectively reviewed. Metastases from colorectal carcinoma and other primaries were not necessarily confined to liver. Toxicity was evaluated using National Cancer Institute Common Criteria for Adverse Events version 3.0.

RESULTS

Forty-two patients with 62 metastases were treated with two dose levels of 40 Gy in four Dose per Fraction (23) and 45 Gy in three Dose per Fraction (13). Median follow-up was 14.3 months (range, 3-23 months). Actuarial local control for 1 and 2 years was 90% and 86%, respectively. At last follow-up, 41 (66%) complete responses and eight (13%) partial responses were observed. Five lesions were stable. Nine lesions (13%) were locally progressed. Overall survival was 94% at 1 year and 48% at 2 years. The most common toxicity was Grade 1 or 2 nausea. One patient experienced Grade 3 epidermitis. The dose level did not significantly contribute to the outcome, toxicity, or survival.

CONCLUSION

Image-guided robotic stereotactic body radiation therapy is feasible, safe, and effective, with encouraging local control. It provides a strong alternative for patients who cannot undergo surgery.

[Radiotherapy of hepatic metastases]

Non-invasive treatment of hepatic metastases has become a focal point of interdisciplinary oncology especially since the advent of stereotactic radiation techniques. Worldwide several centers have shown that this treatment is a curative and well tolerated regimen with excellent rates of local control. Modern devices which combine radiation therapy with imaging techniques (image-guided radiotherapy) in particular allow precise dose application, especially for hypofractionated treatment concepts requiring daily repositioning.

Long-term effect of stereotactic body radiation therapy for primary hepatocellular carcinoma ineligible for local ablation therapy or surgical resection. Stereotactic radiotherapy for liver cancer

BACKGROUND

We evaluated the long-term effect of stereotactic body radiation therapy (SBRT) for primary small hepatocellular carcinoma (HCC) ineligible for local therapy or surgery.

METHODS

Forty-two HCC patients with tumors ≤ 100 cc and ineligible for local ablation therapy or surgical resection were treated with SBRT: 30-39 Gy with a prescription isodose range of 70-85% (median 80%) was delivered daily in three fractions. Median tumor volume was 15.4 cc (3.0-81.8) and median follow-up duration 28.7 months (8.4-49.1).

RESULTS

Complete response (CR) for the in-field lesion was initially achieved in 59.6% and partial response (PR) in 26.2% of patients. Hepatic out-of-field progression occurred in 18 patients (42.9%) and distant metastasis developed in 12 (28.6%) patients. Overall in-field CR and overall CR were achieved in 59.6% and 33.3%, respectively. Overall 1-year and 3-year survival rates were 92.9% and 58.6%, respectively. In-field progression-free survival at 1 and 3 years was 72.0% and 67.5%, respectively. Patients with smaller tumor had better in-field progression-free survival and overall survival rates (<32 cc vs. ≥32 cc, P < 0.05). No major toxicity was encountered but one patient died with extrahepatic metastasis and radiation-induced hepatic failure.

CONCLUSIONS

SBRT is a promising noninvasive-treatment for small HCC that is ineligible for local treatment or surgical resection.

Emerging role of radiotherapy in the management of liver metastases

Improvements with systemic therapy in controlling occult metastatic disease in patients with colorectal cancer and other solid malignancies have raised renewed interest in local therapies that can treat isolated or "oligo" sites of metastatic disease within the liver. Radiotherapy (RT) is a treatment option that can be offered to patients unsuitable for surgery or other ablative therapies. Technological advances in RT planning and delivery have made it possible to administer high doses conformally around focal liver metastases effectively. Methods to facilitate safe delivery of high-dose RT include conformal RT planning, stereotactic body RT, breathing motion management, and image-guided RT. The clinical experience in conformal RT and stereotactic body RT for liver metastases is emerging, with phase I and II trials demonstrating excellent local control and occasional long-term survivors. With appropriate patient selection and sparing of the uninvolved liver, serious toxicity can be avoided. Out-of-field recurrences are common, providing rationale for combining systemic or regional therapies with RT for these patients. Finally, randomized trials of RT for liver metastases are needed to better define the benefits of RT for these patients.

Stereotactic body radiation therapy: a novel treatment modality

Stereotactic body radiation therapy (SBRT) involves the delivery of a small number of ultra-high doses of radiation to a target volume using very advanced technology and has emerged as a novel treatment modality for cancer. The role of SBRT is most important at two cancer stages-in early primary cancer and in oligometastatic disease. This modality has been used in the treatment of early-stage non-small-cell lung cancer, prostate cancer, renal-cell carcinoma, and liver cancer, and in the treatment of oligometastases in the lung, liver, and spine. A large body of evidence on the use of SBRT for the treatment of primary and metastatic tumors in various sites has accumulated over the past 10-15 years, and efficacy and safety have been demonstrated. Several prospective clinical trials of SBRT for various sites have been conducted, and several other trials are currently being planned. The results of these clinical trials will better define the role of SBRT in cancer management. This article will review the radiobiologic, technical, and clinical aspects of SBRT.

Stereotactic body radiation therapy for liver metastases

Although resection is the standard of care for liver metastasis, 80-90% of patients are not resectable at diagnosis. Advances in combination chemotherapy, particularly with targeted agents, have increased tumour response and survival in patients with unresectable metastatic colorectal cancer, but these techniques have limitations and may be associated with high recurrence rates. Some autopsy series have shown that as many as 40% of patients with metastatic colorectal cancer have disease confined to the liver; aggressive local therapy may improve overall survival in such patients. Local control of liver metastases can also ease hepatic capsular pain to improve quality of life. Stereotactic body radiation therapy (SBRT) offers an alternative, non-invasive approach to the treatment of liver metastasis through precisely targeted delivery of radiation to the tumours while minimising normal tissue toxicity. Early applications of SBRT to liver metastases have been promising with the reports of 2-year local control rates of 71-86% and other studies reporting 18-month local control rates of 71-93%. While these data establish the safety of SBRT for liver metastases, more rigorous phase II clinical studies are needed to fully evaluate long-term efficacy and toxicity results. In the interim, this review stresses that SBRT of liver must be performed cautiously given the challenges of organ motion and the low toxicity tolerance of the surrounding hepatic parenchyma.

[CyberKnife robotic stereotactic radiotherapy: technical aspects and medical indications]

In 2006, 3 sites have been selected by the Institut national of cancer (Lille, Nancy et Nice) to evaluate a radiotherapy robot, the CyberKnife. This machine, able to track mobile tumours in real time, gives new possibilities in the field of extra cranial stereotactic radiotherapy. Functionalities and medico economical issues of the machine will be evaluated during 2 years on the 3 sites.

A phase II study on stereotactic body radiotherapy for stage I non-small cell lung cancer

BACKGROUND AND PURPOSE

The outcome of stage I non-small cell lung cancer (NSCLC) patients treated with conventional radiotherapy is inferior to that of patients treated surgically. We aimed to evaluate the clinical outcome of stereotactic body radiotherapy (SBRT) in the treatment of stage I NSCLC.

MATERIALS AND METHODS

We performed SBRT for 31 stage I NSCLC patients. Of these, 20 were medically inoperable, and 11 refused surgery. Nineteen tumours were T1-stage masses, and 12 tumours were T2. Median tumour size was 25 mm. SBRT was administered as 45 Gy/3 fractions; however, when the tumour was close to an organ at risk, 60 Gy/8 fractions were used. These doses were prescribed at the centre of the tumours.

RESULTS

The median duration of observation for all patients was 32 months (range, 4-87 months). In 9 of the 31 cases, local recurrence was observed. The 3-year local control rates of T1 and T2 tumours were 77.9% and 40.0%, respectively. The 3-year overall and cause-specific survival rates were 71.7% and 83.5%, respectively. Although the symptoms improved with medical treatment, 5 patients developed acute pulmonary toxicity > or =grade 2.

CONCLUSIONS

SBRT is safe and effective for stage I NSCLC patients. However, a more intensive treatment regimen should be considered for T2 tumours.

Stereotactic body radiation therapy for primary and metastatic liver tumors: A single institution phase i-ii study

The feasibility, toxicity and tumor response of stereotactic body radiation therapy (SBRT) for treatment of primary and metastastic liver tumors was investigated. From October 2002 until June 2006, 25 patients not suitable for other local treatments were entered in the study. In total 45 lesions were treated, 34 metastases and 11 hepatocellular carcinoma (HCC). Median follow-up was 12.9 months (range 0.5-31). Median lesion size was 3.2 cm (range 0.5-7.2) and median volume 22.2 cm3 (range 1.1-322). Patients with metastases, HCC without cirrhosis, and HCC < 4 cm with cirrhosis were mostly treated with 3 x 12.5 Gy. Patients with HCC > or =4 cm and cirrhosis received 5 x 5 Gy or 3 x 10 Gy. The prescription isodose was 65%. Acute toxicity was scored following the Common Toxicity Criteria and late toxicity with the SOMA/LENT classification. Local failures were observed in two HCC and two metastases. Local control rates at 1 and 2 years for the whole group were 94% and 82%. Acute toxicity grade > or =3 was seen in four patients; one HCC patient with Child B developed a liver failure together with an infection and died (grade 5), two metastases patients presented elevation of gamma glutamyl transferase (grade 3) and another asthenia (grade 3). Late toxicity was observed in one metastases patient who developed a portal hypertension syndrome with melena (grade 3). SBRT was feasible, with acceptable toxicity and encouraging local control. Optimal dose-fractionation schemes for HCC with cirrhosis have to be found. Extreme caution should be used for patients with Child B because of a high toxicity risk.

Hypofractionated stereotactic body radiation therapy (SBRT) for limited hepatic metastases

PURPOSE

To evaluate the feasibility and efficacy of hypofractionated stereotactic body radiation therapy (SBRT) for the treatment of liver metastases.

METHODS AND MATERIALS

The records of 69 patients with 174 metastatic liver lesions treated with SBRT between April 2001 and October 2004 were reviewed. The most common primary tumors were colorectal (n = 20), breast (n = 16), pancreas (n = 9), and lung (n = 5). The mean number of lesions treated per patient was 2.5 (range, 1-6). The longest diameter of the lesions ranged in size from 0.6 to 12.2 cm (median, 2.7 cm). Dose per fraction ranged from 2 Gy to 6 Gy, with a median total dose of 48 Gy (range, 30-55 Gy). Dose was prescribed to the 100% isodose line (IDL), with the 80% IDL covering the gross tumor volume with a minimum margin of 7 mm.

RESULTS

The median follow up was 14.5 months. Sixty patients were evaluable for response based on an abdominal computed tomography scan obtained at a minimum of 3 months after completion of SBRT. The actuarial overall infield local control rate of the irradiated lesions was 76% and 57% at 10 and 20 months, respectively. The median overall survival time was 14.5 months. The progression-free survival rate was 46% and 24% at 6 and 12 months, respectively. None of the patients developed Grade 3 or higher toxicity.

CONCLUSION

Hypofractionated SBRT provides excellent local control with minimal side effects in selected patients with limited hepatic metastases.

Stereotactic body radiation therapy for extracranial oligometastases: does the sword have a double edge?

Understanding the acute and chronic toxicities of stereotactic body radiation therapy (SBRT) for extracranial oligometastases might reveal treatment parameters that can be modulated to enhance the therapeutic ratio. Therefore, we searched PubMed from 1995 to 2005 for reports on stereotactic body radiation therapy, with emphasis on treatment of metastatic lesions of the lung and/or liver. Reports of SBRT for primary tumors of these sites were included to increase the number of evaluable patients. The reports were categorized by organ system and evaluated based on number of patients, number of lesions treated, dose fractionation scheme, and local control. A total of 15 lung studies (including 683 patients) and 7 liver studies (including 156 patients) were identified. Overall grade 3 to 5 toxicity was seen in up to 15% of patients in the lung SBRT studies and up to 18% of patients in the liver SBRT studies. Only 3 deaths were reported after SBRT of the liver and 2 after SBRT of the lung for treatment related mortality rates of 2% and 0.3%, respectively. No definitive relationship was found between radiation dose and toxicity. Conversely, radiation treatment volume may be associated with the infrequent toxicities that occur. The literature supports SBRT as a safe and effective treatment for oligometastases of the liver and lung. Further studies are needed to define the optimal dose and fractionation schedule.

Fractionated stereotactic radiotherapy in patients with primary hepatocellular carcinoma

OBJECTIVE

The purpose of our study was to evaluate the feasibility and treatment outcomes of fractionated stereotactic radiotherapy (SRT) for primary hepatocellular carcinoma (HCC).

METHODS

We enrolled 20 patients who had been histologically diagnosed as HCC patients and treated by fractionated SRT. Tumor size was 2-6.5 cm (average: 3.8 cm). We prescribed 50 Gy in 5 or 10 fractions at the 85-90% isodose line of the planning target volume for 2 weeks. The follow-up period was 3-55 months (median: 23 months).

RESULTS

The overall response rate was 80%, with 4 patients showing complete response (20%), 14 patients showing partial response (60%) and 4 patients showing stable disease (20%). The 1-year and 2-year survival rates were 70.0 and 43.1%, respectively (median: 20 months). The 1-year and 2-year disease-free survival rates were 65.0 and 32.5%, respectively (median: 19 months). The fractionated SRT was well tolerated, because grade 3 or grade 4 toxicity was not observed.

CONCLUSION

These results suggest that fractionated SRT is a relatively safe and effective method for treating small primary HCC. Thus, fractionated SRT may be suggested as a local treatment of choice for small HCC when the patients are inoperable or when the patients refuse operation.

Nonsurgical Therapy for Stages I and II Non–Small Cell Lung Cancer

For patients who have stages I and II non-small cell lung cancer (NSCLC) and who are unable or unwilling to undergo surgical resection, nonsurgical treatment modalities have been used with curative intent. Conventionally fractionated radiotherapy has been the mainstay of nonsurgical therapy; however, advances in technology and the clinical application of radiobiologic principles have allowed more accurately targeted treatment that delivers higher effective doses to the tumor, while respecting the tolerance of surrounding normal tissues. This article discusses nonsurgical approaches to the treatment of early-stage NSCLC, including several promising techniques, such as radiation dose escalation, altered radiation fractionation, stereotactic radiotherapy, and radiofrequency ablation.

A challenge to traditional radiation oncology

PURPOSE

To investigate and compare the biologically effective doses, equivalent doses in 2-Gy fractions, log tumor cells killed, and late effects that can be estimated for the large fractions in short overall times that are now being delivered in various clinically used schedules in several countries for the treatment of cancer in human lungs, liver, and kidney.

METHODS AND MATERIALS

Linear quadratic (LQ) modeling is employed with only the standard assumptions that tumor alpha/beta ratio is 10 Gy, pneumonitis and late complication alpha/beta ratios are 3 Gy, that intrinsic radiosensitivity of tumor cells is 0.35 ln/Gy, that no tumor repopulation occurs within 2 weeks, and that LQ modeling is valid up to 23 Gy per fraction. As well as the planning target volume (PTV), we propose a practical term called the prescription isodose volume (PIV) to be used in this discussion. In the ideal case of 100% conformity, PIV equals PTV, but usually PIV is larger than the PTV. Biologically effective doses (BED) in Gy(10) for tumors or Gy(3) for normal lung are calculated and converted to equivalent doses in 2 Gy fractions (= normalized total doses [NTD]), and to estimated log cell kill. How such large biologic doses might be delivered to tissues is discussed.

RESULTS

Tumor cell kill varies between 16 and 27 logs to base 10 for schedules from 4F x 12 Gy to 3F x 23 Gy. The rationale for the high end of this scale is the possible presence of hypoxic or otherwise extraordinarily resistant cells, but how many tumors and which ones require such doses is not known. How can such large doses be tolerated? In "parallel type organs," it is shown to be theoretically possible, provided that suitably small volumes are irradiated, with rapid fall-off of dose outside the PTV, and a mean dose (excluding PTV and allowing for local fraction size) to both lungs of less than 19 Gy NTD. If suitably small PTVs were used, local late BEDs have been given which were as large as 600 Gy(3), equivalent to 2 Gy x 180F = 360 Gy in 2-Gy fractions, with remarkably few complications reported clinically. Questions of concurrent chemotherapy and microscopic extension of lung tumor cells are discussed briefly.

CONCLUSIONS

Such large doses can apparently be given, with suitable precautions and experience. Ongoing clinical trials from an increasing number of centers will be reporting the results of tumor control and complications from this new modality of biologically higher doses.