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Stereotactic body radiotherapy for liver tumors

Principles and practical guidelines of the DEGRO Working Group on Stereotactic Radiotherapy

Stereotaktische Strahlentherapie von Lebertumorenn

Grundlegende und praktische Leitlinien der DEGRO Arbeitsgruppe Stereotaxie

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Abstract

Purpose

This report of the Working Group on Stereotactic Radiotherapy of the German Society of Radiation Oncology (DEGRO) aims to provide a practical guideline for safe and effective stereotactic body radiotherapy (SBRT) of liver tumors.

Methods

The literature on the clinical evidence of SBRT for both primary liver tumors and liver metastases was reviewed and analyzed focusing on both physical requirements and special biological characteristics.

Results

Recommendations were developed for patient selection, imaging, planning, treatment delivery, motion management, dose reporting, and follow-up. Radiation dose constraints to critical organs at risk are provided.

Conclusion

SBRT is a well-established treatment option for primary and secondary liver tumors associated with low morbidity.

Zusammenfassung

Ziel

Die Arbeitsgruppe Stereotaxie der Deutschen Gesellschaft für Radioonkologie (DEGRO) legt hier eine Empfehlung zur sicheren und effektiven Durchführung der SBRT von Lebertumoren vor.

Methoden

Eine Literaturrecherche zur Untersuchung der Evidenz der SBRT sowohl für primäre Lebertumore als auch für Lebermetastasen wurde durchgeführt. Auf dieser Basis werden Empfehlungen für technisch-physikalische Voraussetzungen wie auch für die tägliche Praxis der Leber-SBRT gegeben. Weiterhin werden radiobiologische Besonderheiten dieses Verfahrens dargestellt.

Ergebnisse

Praktische Vorgaben werden für Patientenselektion, Bildgebung, Planung, Applikation, Bewegungsmanagement, Dosisdokumentation und Follow-up gegeben. Dosisempfehlungen für die kritischen Risikoorgane werden dargestellt.

Schlussfolgerung

Die SBRT stellt eine etablierte Behandlungsmethode für primäre und sekundäre Lebertumore dar und ist mit niedriger Morbidität assoziiert.

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References

  1. Adam R, Chiche L, Aloia T et al (2006) Hepatic resection for noncolorectal nonendocrine liver metastases: analysis of 1,452 patients and development of a prognostic model. Ann Surg 244:524–535

    Article  PubMed  PubMed Central  Google Scholar 

  2. Almaghrabi MY, Supiot S, Paris F et al (2012) Stereotactic body radiation therapy for abdominal oligometastases: a biological and clinical review. Radiat Oncol 7:126

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ambrosino G, Polistina F, Costantin G et al (2009) Image-guided robotic stereotactic radiosurgery for unresectable liver metastases: preliminary results. Anticancer Res 29:3381–3384

    PubMed  Google Scholar 

  4. Andolino DL, Johnson CS, Maluccio M et al (2011) Stereotactic body radiotherapy for primary hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 81:e447–e453

    Article  PubMed  Google Scholar 

  5. Bae SH, Kim MS, Cho CK et al (2012) Predictor of severe gastroduodenal toxicity after stereotactic body radiotherapy for abdominopelvic malignancies. Int J Radiat Oncol Biol Phys 84:e469–e474

    Article  PubMed  Google Scholar 

  6. Barney BM, Olivier KR, Miller RC et al (2012) Clinical outcomes and toxicity using stereotactic body radiotherapy (SBRT) for advanced cholangiocarcinoma. Radiat Oncol 7:67

    Article  PubMed  PubMed Central  Google Scholar 

  7. Benedict SH, Yenice KM, Followill D et al (2010) Stereotactic body radiation therapy: the report of AAPM Task Group 101. Med Phys 37:4078–4101

    Article  PubMed  Google Scholar 

  8. Bloemen-Van Gurp E, Van Der Meer S, Hendry J et al (2013) Active breathing control in combination with ultrasound imaging: a feasibility study of image guidance in stereotactic body radiation therapy of liver lesions. Int J Radiat Oncol Biol Phys 85:1096–1102

    Article  PubMed  Google Scholar 

  9. Boda-Heggemann J, Dinter D, Weiss C et al (2012) Hypofractionated image-guided breath-hold SABR (stereotactic ablative body radiotherapy) of liver metastases-clinical results. Radiat Oncol 7:92

    Article  PubMed  PubMed Central  Google Scholar 

  10. Brown JM, Koong AC (2008) High-dose single-fraction radiotherapy: exploiting a new biology? Int J Radiat Oncol Biol Phys 71:324–325

    Article  PubMed  Google Scholar 

  11. Brunner TB, Eccles CL (2010) Radiotherapy and chemotherapy as therapeutic strategies in extrahepatic biliary duct carcinoma. Strahlenther Onkol 186:672–680

    Article  PubMed  Google Scholar 

  12. Bujold A, Massey CA, Kim JJ et al (2013) Sequential phase I and II trials of stereotactic body radiotherapy for locally advanced hepatocellular carcinoma. J Clin Oncol 31:1631–1639

    Article  PubMed  Google Scholar 

  13. Buther F, Ernst I, Dawood M et al (2010) Detection of respiratory tumour motion using intrinsic list mode-driven gating in positron emission tomography. Eur J Nucl Med Mol Imaging 37:2315–2327

    Article  PubMed  Google Scholar 

  14. Case RB, Moseley DJ, Sonke JJ et al (2010) Interfraction and intrafraction changes in amplitude of breathing motion in stereotactic liver radiotherapy. Int J Radiat Oncol Biol Phys 77:918–925

    Article  PubMed  Google Scholar 

  15. Case RB, Sonke JJ, Moseley DJ et al (2009) Inter- and intrafraction variability in liver position in non-breath-hold stereotactic body radiotherapy. Int J Radiat Oncol Biol Phys 75:302–308

    Article  PubMed  Google Scholar 

  16. Chang DT, Swaminath A, Kozak M et al (2011) Stereotactic body radiotherapy for colorectal liver metastases: a pooled analysis. Cancer 117:4060–4069

    Article  PubMed  Google Scholar 

  17. Dhanasekaran R, Hemming AW, Zendejas I et al (2013) Treatment outcomes and prognostic factors of intrahepatic cholangiocarcinoma. Oncol Rep 29:1259–1267

    PubMed  CAS  PubMed Central  Google Scholar 

  18. Dieterich S, Cavedon C, Chuang CF et al (2011) Report of AAPM TG 135: quality assurance for robotic radiosurgery. Med Phys 38:2914–2936

    Article  PubMed  Google Scholar 

  19. Fong Y, Salo J (1999) Surgical therapy of hepatic colorectal metastasis. Semin Oncol 26:514–523

    PubMed  CAS  Google Scholar 

  20. Garcea G, Lloyd TD, Aylott C et al (2003) The emergent role of focal liver ablation techniques in the treatment of primary and secondary liver tumours. Eur J Cancer 39:2150–2164

    Article  PubMed  CAS  Google Scholar 

  21. Ge J, Santanam L, Noel C et al (2013) Planning 4-dimensional computed tomography (4DCT) cannot adequately represent daily intrafractional motion of abdominal tumors. Int J Radiat Oncol Biol Phys 85:999–1005

    Article  PubMed  Google Scholar 

  22. Goodman KA, Wiegner EA, Maturen KE et al (2010) Dose-escalation study of single-fraction stereotactic body radiotherapy for liver malignancies. Int J Radiat Oncol Biol Phys 78:486–493

    Article  PubMed  Google Scholar 

  23. Guckenberger M, Andratschke N, Alheit H et al (2014) Definition of stereotactic body radiotherapy: principles and practice for the treatment of stage I non-small cell lung cancer. Strahlenther Onkol 190:26–33

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  24. Guckenberger M, Richter A, Boda-Heggemann J et al (2012) Motion compensation in radiotherapy. Crit Rev Biomed Eng 40:187–197

    Article  PubMed  Google Scholar 

  25. Habermehl D, Herfarth KK, Bermejo JL et al (2013) Single-dose radiosurgical treatment for hepatic metastases—therapeutic outcome of 138 treated lesions from a single institution. Radiat Oncol 8:175

    Article  PubMed  PubMed Central  Google Scholar 

  26. Hellman S, Weichselbaum RR (1995) Oligometastases. J Clin Oncol 13:8–10

    PubMed  CAS  Google Scholar 

  27. Herfarth KK, Debus J, Lohr F et al (2001) Stereotactic single-dose radiation therapy of liver tumors: results of a phase I/II trial. J Clin Oncol 19:164–170

    PubMed  CAS  Google Scholar 

  28. Herfarth KK, Debus J, Lohr F et al (2001) Stereotactic irradiation of liver metastases. Radiologe 41:64–68

    Article  PubMed  CAS  Google Scholar 

  29. Herfarth KK, Hof H, Bahner ML et al (2003) Assessment of focal liver reaction by multiphasic CT after stereotactic single-dose radiotherapy of liver tumors. Int J Radiat Oncol Biol Phys 57:444–451

    Article  PubMed  Google Scholar 

  30. House MG, Ito H, Gonen M et al (2010) Survival after hepatic resection for metastatic colorectal cancer: trends in outcomes for 1,600 patients during two decades at a single institution. J Am Coll Surg 210:744–752, 752–745

    Article  PubMed  Google Scholar 

  31. Hoyer M, Roed H, Traberg Hansen A et al (2006) Phase II study on stereotactic body radiotherapy of colorectal metastases. Acta Oncol 45:823–830

    Article  PubMed  Google Scholar 

  32. Huang WY, Jen YM, Lee MS et al (2012) Stereotactic body radiation therapy in recurrent hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 84:355–361

    Article  PubMed  Google Scholar 

  33. Ibarra RA, Rojas D, Snyder L et al (2012) Multicenter results of stereotactic body radiotherapy (SBRT) for non-resectable primary liver tumors. Acta Oncol 51:575–583

    Article  PubMed  Google Scholar 

  34. Iwata H, Shibamoto Y, Hashizume C et al (2010) Hypofractionated stereotactic body radiotherapy for primary and metastatic liver tumors using the novalis image-guided system: preliminary results regarding efficacy and toxicity. Technol Cancer Res Treat 9:619–627

    PubMed  Google Scholar 

  35. Jung J, Yoon SM, Kim SY et al (2013) Radiation-induced liver disease after stereotactic body radiotherapy for small hepatocellular carcinoma: clinical and dose-volumetric parameters. Radiat Oncol 8:249

    Article  PubMed  PubMed Central  Google Scholar 

  36. Kavanagh BD, Mcgarry RC, Timmerman RD (2006) Extracranial radiosurgery (stereotactic body radiation therapy) for oligometastases. Semin Radiat Oncol 16:77–84

    Article  PubMed  Google Scholar 

  37. Kavanagh BD, Schefter TE, Cardenes HR et al (2006) Interim analysis of a prospective phase I/II trial of SBRT for liver metastases. Acta Oncol 45:848–855

    Article  PubMed  Google Scholar 

  38. Kawahara D, Ozawa S, Nakashima T et al (2014) Availability of using diaphragm matching in stereotactic body radiotherapy (SBRT) at the time in breath-holding SBRT for liver cancer. Nihon Hoshasen Gijutsu Gakkai Zasshi 70:51–56

    Article  PubMed  Google Scholar 

  39. Keall PJ, Mageras GS, Balter JM et al (2006) The management of respiratory motion in radiation oncology report of AAPM Task Group 76. Med Phys 33:3874–3900

    Article  PubMed  Google Scholar 

  40. Klein J, Dawson LA (2013) Hepatocellular carcinoma radiation therapy: review of evidence and future opportunities. Int J Radiat Oncol Biol Phys 87:22–32

    Article  PubMed  Google Scholar 

  41. Kopek N, Holt MI, Hansen AT et al (2010) Stereotactic body radiotherapy for unresectable cholangiocarcinoma. Radiother Oncol 94:47–52

    Article  PubMed  Google Scholar 

  42. Kruis MF, Van De Kamer JB, Sonke JJ et al (2013) Registration accuracy and image quality of time averaged mid-position CT scans for liver SBRT. Radiother Oncol 109:404–408

    Article  PubMed  Google Scholar 

  43. Kwon JH, Bae SH, Kim JY et al (2010) 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. BMC Cancer 10:475

    Article  PubMed  PubMed Central  Google Scholar 

  44. Lee MT, Kim JJ, Dinniwell R et al (2009) Phase I study of individualized stereotactic body radiotherapy of liver metastases. J Clin Oncol 27:1585–1591

    Article  PubMed  Google Scholar 

  45. Louis C, Dewas S, Mirabel X et al (2010) Stereotactic radiotherapy of hepatocellular carcinoma: preliminary results. Technol Cancer Res Treat 9:479–487

    PubMed  CAS  Google Scholar 

  46. Mancosu P, Castiglioni S, Reggiori G et al (2012) Stereotactic body radiation therapy for liver tumours using flattening filter free beam: dosimetric and technical considerations. Radiat Oncol 7:16

    Article  PubMed  PubMed Central  Google Scholar 

  47. Mccammon R, Schefter TE, Gaspar LE et al (2009) Observation of a dose-control relationship for lung and liver tumors after stereotactic body radiation therapy. Int J Radiat Oncol Biol Phys 73:112–118

    Article  PubMed  Google Scholar 

  48. Mendez Romero A, Hoyer M (2012) Radiation therapy for liver metastases. Curr Opin Support Palliat Care 6:97–102

    Article  PubMed  Google Scholar 

  49. Mendez Romero A, Wunderink W, Hussain SM et al (2006) Stereotactic body radiation therapy for primary and metastatic liver tumors: a single institution phase I-II study. Acta Oncol 45:831–837

    Article  PubMed  Google Scholar 

  50. Milano MT, Katz AW, Zhang H et al (2012) Oligometastases treated with stereotactic body radiotherapy: long-term follow-up of prospective study. Int J Radiat Oncol Biol Phys 83:878–886

    Article  PubMed  Google Scholar 

  51. Mohnike K, Wieners G, Schwartz F et al (2010) Computed tomography-guided high-dose-rate brachytherapy in hepatocellular carcinoma: safety, efficacy, and effect on survival. Int J Radiat Oncol Biol Phys 78:172–179

    Article  PubMed  Google Scholar 

  52. Momm F, Schubert E, Henne K et al (2010) Stereotactic fractionated radiotherapy for Klatskin tumours. Radiother Oncol 95:99–102

    Article  PubMed  Google Scholar 

  53. Nahum AE, Uzan J (2012) (Radio)biological optimization of external-beam radiotherapy. Comput Math Methods Med 2012:329214

    Article  PubMed  PubMed Central  Google Scholar 

  54. Nordlinger B, Guiguet M, Vaillant JC et al (1996) Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Francaise de Chirurgie. Cancer 77:1254–1262

    Article  PubMed  CAS  Google Scholar 

  55. Park JC, Park SH, Kim JH et al (2012) Liver motion during cone beam computed tomography guided stereotactic body radiation therapy. Med Phys 39:6431–6442

    Article  PubMed  Google Scholar 

  56. Parkin DM, Bray F, Ferlay J et al (2005) Global cancer statistics, 2002. CA Cancer J Clin 55:74–108

    Article  PubMed  Google Scholar 

  57. Polistina FA, Guglielmi R, Baiocchi C et al (2011) Chemoradiation treatment with gemcitabine plus stereotactic body radiotherapy for unresectable, non-metastatic, locally advanced hilar cholangiocarcinoma. Results of a five year experience. Radiother Oncol 99:120–123

    Article  PubMed  CAS  Google Scholar 

  58. Reddy SK, Barbas AS, Marroquin CE et al (2007) Resection of noncolorectal nonneuroendocrine liver metastases: a comparative analysis. J Am Coll Surg 204:372–382

    Article  PubMed  Google Scholar 

  59. Ricke J, Mohnike K, Pech M et al (2010) Local response and impact on survival after local ablation of liver metastases from colorectal carcinoma by computed tomography-guided high-dose-rate brachytherapy. Int J Radiat Oncol Biol Phys 78:479–485

    Article  PubMed  Google Scholar 

  60. Robertson DJ, Stukel TA, Gottlieb DJ et al (2009) Survival after hepatic resection of colorectal cancer metastases: a national experience. Cancer 115:752–759

    Article  PubMed  PubMed Central  Google Scholar 

  61. Ruers T, Punt C, Van Coevorden F et al (2012) Radiofrequency ablation combined with systemic treatment versus systemic treatment alone in patients with non-resectable colorectal liver metastases: a randomized EORTC Intergroup phase II study (EORTC 40004). Ann Oncol 23:2619–2626

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  62. Rule W, Timmerman R, Tong L et al (2011) Phase I dose-escalation study of stereotactic body radiotherapy in patients with hepatic metastases. Ann Sur Oncol 18:1081–1087

    Article  Google Scholar 

  63. Rusthoven KE, Kavanagh BD, Cardenes H et al (2009) Multi-institutional phase I/II trial of stereotactic body radiation therapy for liver metastases. J Clin Oncol 27:1572–1578

    Article  PubMed  Google Scholar 

  64. Schefter TE, Kavanagh BD, Timmerman RD et al (2005) A phase I trial of stereotactic body radiation therapy (SBRT) for liver metastases. Int J Radiat Oncol Biol Phys 62:1371–1378

    Article  PubMed  Google Scholar 

  65. Scorsetti M, Arcangeli S, Tozzi A et al (2013) Is stereotactic body radiation therapy an attractive option for unresectable liver metastases? A preliminary report from a phase 2 trial. Int J Radiat Oncol Biol Phys 86:336–342

    Article  PubMed  Google Scholar 

  66. Seo YS, Kim MS, Yoo SY et al (2010) Preliminary result of stereotactic body radiotherapy as a local salvage treatment for inoperable hepatocellular carcinoma. J Surg Oncol 102:209–214

    Article  PubMed  Google Scholar 

  67. Sherman M, Burak K, Maroun J et al (2011) Multidisciplinary Canadian consensus recommendations for the management and treatment of hepatocellular carcinoma. Curr Oncol 18:228–240

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  68. Small R, Lubezky N, Ben-Haim M (2007) Current controversies in the surgical management of colorectal cancer metastases to the liver. Isr Med Assoc J 9:742–747

    PubMed  Google Scholar 

  69. Smith MD, Mccall JL (2009) Systematic review of tumour number and outcome after radical treatment of colorectal liver metastases. Br J Sur 96:1101–1113

    Article  CAS  Google Scholar 

  70. Sterzing F, Munter MW, Schafer M et al (2005) Radiobiological investigation of dose-rate effects in intensity-modulated radiation therapy. Strahlenther Onkol 181:42–48

    Article  PubMed  Google Scholar 

  71. Sudan D, Deroover A, Chinnakotla S et al (2002) Radiochemotherapy and transplantation allow long-term survival for nonresectable hilar cholangiocarcinoma. Am J Transplant 2:774–779

    Article  PubMed  Google Scholar 

  72. Takeda A, Takahashi M, Kunieda E et al (2008) Hypofractionated stereotactic radiotherapy with and without transarterial chemoembolization for small hepatocellular carcinoma not eligible for other ablation therapies: preliminary results for efficacy and toxicity. Hepatol Res 38:60–69

    Article  PubMed  Google Scholar 

  73. Tse RV, Hawkins M, Lockwood G et al (2008) Phase I study of individualized stereotactic body radiotherapy for hepatocellular carcinoma and intrahepatic cholangiocarcinoma. J Clin Oncol 26:657–664

    Article  PubMed  Google Scholar 

  74. Wei AC, Greig PD, Grant D et al (2006) Survival after hepatic resection for colorectal metastases: a 10-year experience. Ann Surg Oncol 13:668–676

    Article  PubMed  Google Scholar 

  75. Wieners G, Mohnike K, Peters N et al (2011) Treatment of hepatic metastases of breast cancer with CT-guided interstitial brachytherapy—a phase II-study. Radiother Oncol 100:314–319

    Article  PubMed  Google Scholar 

  76. Wong SL, Mangu PB, Choti MA et al (2010) American Society of Clinical Oncology 2009 clinical evidence review on radiofrequency ablation of hepatic metastases from colorectal cancer. J Clin Oncol 28:493–508

    Article  PubMed  Google Scholar 

  77. Yang W, Fraass BA, Reznik R et al (2014) Adequacy of inhale/exhale breathhold CT based ITV margins and image-guided registration for free-breathing pancreas and liver SBRT. Radiat Oncol 9:11

    Article  PubMed  PubMed Central  Google Scholar 

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Conflict of interest

F. Sterzing, T. B. Brunner, I. Ernst, W. W. Baus, B. Greve, K. Herfarth, and M. Guckenberger state that there are no conflicts of interest.

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Authors and Affiliations

  1. Klinische Kooperationseinheit Strahlentherapie, Deutsches Krebsforschungszentrum (dkfz), INF 280, 69120, Heidelberg, Germany

    Florian Sterzing

  2. Abteilung für Radioonkologie und Strahlentherapie, Radiologische Universitätsklinik, Heidelberg, Germany

    Florian Sterzing & Klaus Herfarth

  3. Klinik für Strahlenheilkunde, Radiologische Klinik, Universitätsklinikum Freiburg, Freiburg, Germany

    Thomas B. Brunner

  4. Klinik für Strahlentherapie – Radioonkologie, Universitätsklinikum Münster, Münster, Germany

    Iris Ernst & Burkhard Greve

  5. Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Köln, Köln, Germany

    Wolfgang W. Baus

  6. Klinik für Radio-Onkologie, UniversitätsSpital Zürich, Zürich, Switzerland

    Matthias Guckenberger

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  1. Florian Sterzing
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  2. Thomas B. Brunner
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  3. Iris Ernst
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  4. Wolfgang W. Baus
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  5. Burkhard Greve
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  6. Klaus Herfarth
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  7. Matthias Guckenberger
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Correspondence to Florian Sterzing.

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Sterzing, F., Brunner, T., Ernst, I. et al. Stereotactic body radiotherapy for liver tumors. Strahlenther Onkol 190, 872–881 (2014). https://doi.org/10.1007/s00066-014-0714-1

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  • DOI: https://doi.org/10.1007/s00066-014-0714-1

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