Solutions that enable ablative radiotherapy for large liver tumors: Fractionated dose painting, simultaneous integrated protection, motion management, and computed tomography image guidance - PubMed (original) (raw)

Review

. 2016 Jul 1;122(13):1974-86.

doi: 10.1002/cncr.29878. Epub 2016 Mar 7.

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Review

Solutions that enable ablative radiotherapy for large liver tumors: Fractionated dose painting, simultaneous integrated protection, motion management, and computed tomography image guidance

Christopher H Crane et al. Cancer. 2016.

Abstract

The emergence and success of stereotactic body radiation therapy (SBRT) for the treatment of lung cancer have led to its rapid adoption for liver cancers. SBRT can achieve excellent results for small liver tumors. However, the vast majority of physicians interpret SBRT as meaning doses of radiation (range, 4-20 Gray [Gy]) that may not be ablative but are delivered within about 1 week (ie, in 3-6 fractions). Adherence to this approach has limited the effectiveness of SBRT for large liver tumors (>7 cm) because of the need to reduce doses to meet organ constraints. The prognosis for patients who present with large liver tumors is poor, with a median survival ≤12 months, and most of these patients die from tumor-related liver failure. Herein, the authors present a comprehensive solution to achieve ablative SBRT doses for patients with large liver tumors by using a combination of classic, modern, and novel concepts of radiotherapy: fractionation, dose painting, motion management, image guidance, and simultaneous integrated protection. The authors discuss these concepts in the context of large, inoperable liver tumors and review how this approach can substantially prolong survival for patients, most of whom otherwise have a very poor prognosis and few effective treatment options. Cancer 2016;122:1974-86. © 2016 American Cancer Society.

Keywords: gating; hepatoma; image-guided radiation therapy (IGRT); intrahepatic cholangiocarcinoma; stereotactic ablative radiation therapy.

© 2016 American Cancer Society.

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Conflict of interest statement

The authors have no conflicts of interest

Figures

Figure 1

Figure 1

Radiation treatment plan and illustration of the Simultaneous Integrated Boost/Protection (SIB/SIP) technique. A dose of 100 Gy in 25 fractions is delivered to the center of the tumor while the planning target volume (PTV) receives 75 Gy in 25 fractions. This does not overlap with the planning risk volume (PRV) created by a 5 mm expansion of adjacent organs at risk for SIP.] A microscopic dose of 45 Gy that is within the tolerance of the gastric mucosa is delivered to the whole tumor with margin.

Figure 2

Figure 2

Ablative proton and IMRT plans for large liver tumors. Shown are axial (A) and sagittal (B) views of a proton plan for a right-sided HCC receiving 75 CGE in 15 fractions to the center of the tumor and 67.5 CGE in 15 fractions to the entire tumor. Another case of fractionated SABR is shown for a massive IHCC that received 75Gy in 25 fractions using IMRT (axial (C) and sagittal (D)) to the center of the tumor, 60Gy to the GTV, and a microscopic dose of 45Gy. Due to the small remnant of normal liver and location of this massive IHCC, the tumor the central SIB and GTV doses had to be reduced from initial goals of 100Gy and 75Gy, respectively.

Figure 3

Figure 3

Kaplan-Meier estimates by treatment with radiation doses greater than a Biologic Equivalent Dose (BED) of 80.5 Gy. The lower dose regimens were 58Gy in 15 fractions and 50.4 Gy in 28 fractions and the higher dose regimens were either 75 Gy in 25 fractions or 67.5 Gy in 15 fractions. Effect of radiation dose of local control (A) and overall survival (B).

Comment in

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