Clinicalprotocol,Workflow

Primary and metastatic liver tumors SBRTAmsterdam2017

Nodisclosures

Learning objective

• Specifics ofliver SBRTcompared toother sites(lung)

Basic principle:

StartSBRTprogramwith lung

Copy asmuch aspossible from experience inlung SBRT!

àLiver SBRTis“identical”but morecomplex

LiverSBRT:

Bothprimarytumorsandmets

NW-Europe:livermets!

Inmanyothercountries:primarylivercancer

SBRTLIVER

•DOESITWORK??

Publishedresultsbothmets andprimarylever:• Widevarietyoftechniquesanddoseschedules,>10yearsexperience

Author Nooflesions Dose Localcontrol Remarks

Blomgren1995 42 4x7.7Gy– 1x30Gy@50%

80%

Wulf 2006 56 Various:4x7Gy-1x26Gy@80%

Actuarial:HCC:100%Mets:1yr:92%

2yr:66%2yrOS:32%

Localcontrolincreasedathigherdoses(trend)

Tse2008 31HCC10IHC

6x4-9Gyisoc 1yr:65%

Chiba2005 192HCC Various,median16x4.5Gy

5yr87% Protons/gating/chemo-embolisation

Kavanagh2006

36 Max3x20Gy 93% Doseescalation,MTDnotreached

8

Consider when starting SBRTliver program

• Getting patients

• Imaging (planningandtreatment)

• Motionmanagement(Tumorand OAR!)

• Followup

Radiationtherapyinlivertumors:

• Historicalproblem:RILDà Radiationinducedliverdisease

• Wholeliverradiation:RILDafter>30Gy• 30Gynotenoughforlocalcontrol(mosttumors>60Gy)

àRadiationoncologists:-nohistory/notmuchinterest-notinvolvedinspecificlivertumorboards/liverguidelines-specificknowledgerequired!

Getting patients referred

BarcelonaCriteria(HCC)

SBRT SBRT SBRT SBRT/Conventional XRT

BarcelonaCriteria(HCC)

Gettingpatientsreferred:Manycompetinglocaltreatmentoptions:

• Surgery• RFA• TACE/Radioembolisation• Electroporation (“IRE/Nanoknife”)

• Alltreatmentshavedifferent:– (contra)indications(anesthesia/bleedingdisordersetc)– localcontrol(tumorsize)– “difficult”locations

ProSBRT(attumorboardmeetings):• Highlocalcontrol(especiallylargertumorscomparedtocompetingtechniques)

• Overlapwithlargevessels/hilar structuresnoproblem• Outpatientprocedure• Nogeneralanesthesia• Completelynon-invasive(ifwithoutfiducials)• Bleedingdisorders:noproblem

Patientselection:

• “Oligometastases”oroligoprogression– Nopatientswithactivewidespreaddisease– Reasonablelifeexpectancy

• Nomaximumsizeornumber– dependingonsparednormalliver– mostcommon:one(ortwo)mets

• Somemarginneededbetweentumorandbowel/stomach/esophagusà SBRT-likedoseshouldbepossible

Diagnostics• Mostcasesheavilypretreated:tissueproofofM1diseaseavailableformostpatients

• 4-phase CTscan(contrastenhancementpattern)– DifferentcontrasttimingHCCvs mets

• PET-CTscan– Ruleoutwidespreaddistantmets– LesionFDGpos??(usefulnessofmakingplanningPETCT)

• OftenMRIisavailable– RoleofPET-MRIstillunclear

Step by step CASE(pre-MRIdian)

• Mr X• Age 66• Excellent performance score

• Dec 2010 sigmoid carcinoma: resection• Widespread synchronous liver metastases: chemotherapy (capecitabine +

oxaliplatin + bevacizumab)• July 2011: RFA liver metastases segment I, II, III, VI, 2 x VII and 2 x in VIII. • December 2011: 6 liver metastases: 4 x RFA (segment II, III, IVa, IV) and 2 x

microwave ablation (segment III, VIII). • April 2012: Multifocal recurrence ablation cavity segment 8. No extrahepatic

disease: • Microwafe +TACE. • October 2012: recurrence same location• SABR???

Livermetastases:referralpatterns• WhoarereferredforSBRT:

– Colorectal liver metastases– (very)poorperformancescore– Afterresection– AftermultipleRFA/TACE– Centrallocation- overlaplargevessels– Contra-indicationorrefusalinvasivetreatment– Inmostcasesalloftheabove

-NonColorectallivermetastasespatients-lessheavilypretreated-lessaggressivelocaltreatmentànon-invasive

treatmentmoreimportant!

Typicalreferralcasenon-colorectal

Typicalcolorectalcase(dosereductionatOAR~local control)

Step by step CASE

• July:Diagnostic4-phaseCTscan

Step by step CASE

• October: Diagnostic 4-phase CT scan

Step by step CASE

• Diagnostic PET/CT scan

Patientfixation/respiration

– Standard:identicaltolungSBRT– Armsup– Noextrafixation(nobodyframe,vacuummattressetc)– Freebreathing

– Consider(notusedinVumc):Abdominal compression device

– Reduces motion– Interfraction reproducibility poor– Not patient friendly

àConsider when no gating/breathhold available

ImagingforliverSABR• ‘Large’area4DCTscanwithoutivcontrast

– Dosecalculation

• ‘Smallarea’4DCTscanofliverareawithivcontrast– Contrasttimingeasierwithsmallscanarea

ImagingforSABR• Insomecases:double4DCTwithivcontrast(differentdays)• Duringplanning4DCTand4DPETCT

– Influenceofrespiratorybeltonanatomyandbreathingpattern– RPMsystemonlyavailableon4DCT– Difficultimagingandivcontrasttiming:doubleismore…

• Noroutinelyimplantedfiducials– Logistical

– Time– Somerad oncs implantmarkersthemselves…

– KeeptreatmentNon-invasive!– Complications

• Manypatientshavecavities/clipsfromprevioustreatmentsthatcanbeused

• Thinktwiceaboutusinggoldmarkers…

Prostategoldmarkersimplanted inliver

àalso CTfollow-upproblem

4DCTwithoutivcontrast(AveIP)

4DCTwithivcontrast(AveIP)

4DCTwithoutivcontrast(Phase0%)

4DCTwithivcontrast(Phase0%)

ITVincludingallmotiononcontrastenhanced4DCT

Delineation

MatchofdiagnosticPETtocontrastenhanced4DCT

Mismatchbetween diagnostic PETCTandplanning4DCT-mismatchPETCTand4DCT?-mismatchPETenlowdoseCT?-deformation ofliver?-differentbreathing pattern?(à insome centersmax inspiration diagnostic CTduring PET)

àDonot rely on diagnostic PETCTonly,dedicated RTimaging neededàSame problem applies todiagnostic MRI

Target/OARdelineation

• Hypodense areaonivcontrast4DCT– ExcludeRFAcavity

• Minimumintensityprojection(MinIp)– OppositeofMIP

• ITVbasedonallmotiononallavailableimaging– Contrast4DCT,PET,MR

• LivervolumebasedonAverageCTbin.• Criticalorgans(esophagus/stomach/smallbowel)basedonallbins(includingallmovement)

ITV-PTVmargin5mm

Planning• DoseschedulesandplanningidenticaltolungSBRT

– Prescriptionisodose covers95%ofPTVvolume

– DosereductionofpartofPTVifnecessaryfororgansatrisk,andusemorefractionatedschedules(8-12x)

– RapidArc:2(partial)arcs

Constraints(Dutchnationalconsensusguideline):3x 5x 8x 12 Equivalent 2Gy

Liver (α/ß=3) >700ml max 3x5=15Gy

>700ml max 5x3.6=18Gy

>700ml max 8x2,7=21.6Gy

>700ml max 12x2=24Gy

24Gy

Myelum (α/ß=2)

3 x 6 =18Gy 5 x 4,5 =22,5Gy 8 x 3,5 =28Gy 12 x 2.7 = 32 36 Gy

Esophagus (α/ß=3)

3 x 9 =27Gy 5 x 6,5 =32,5Gy 8 x 5,0 =40Gy 12 x 4.0 = 48 66 Gy

Small bowel/ stomach (α/ß=3)

3 x 10 =30Gy 5 x 7,3 =36,5 8 x 5,5 =44Gy 12x4.4=53Gy 78Gy

Kidneys (α/ß=3)

67% volume r kidney max 3x5=15Gy

And:35% Total

volume kidneys (r +l) max 3x5=15Gy

67% volume r kidney max 5x3.6=18Gy

And:35% Total

volume kidneys (r +l) max 5x3.6=18Gy

67% volume r kidney max 8x2,7=21.6Gy

And:35% Total

volume kidneys (r +l) max 8x2,7=21.6Gy

67% volume r kidney max 12x2=24Gy

And:35% Total

volume kidneys (r +l) max 12x2=24Gy

24Gy

55Gy

LiverDVH

Planning/treatmentdelivery:

• Standard:freebreathing

• Onlyinexceptionalcases(overlapboweletc):– Gatingduringin- orexpirationphases(audiocoaching)– Breathhold(FFF)

– Newimaging(breathhold oraudiocoachedCT)neededL

Treatmentdelivery• Patientpositioning:

– Dayly onlineCBCTsetupduringfreebreathing– CBCTqualitypoor– PTVmatchoftennotsensible(ITV/PTV/liverallgrey…)– Matchonlivercontourand/orcriticalorganatrisk– MakeuseofoldclipsandRFAcavities

– Intra-fractionmonitoringbreathingandpatientmotion:– RPMsystem/ExacTrac

CBCTPTVmatchimpossibe

CBCT(partial)livermatch

PTVmargins

• Theoretically5mmshouldbeenough….

• Clinicalpractice:liversmuchmoredifficultthanlung– ITVàPTVmargin1cmiffeasible(liverandotherconstraints).

Followup

• IfinRad Onc department:– 3-modiagnosticCTwithivcontrast.

• Bothhyperandhypodens areas(halo’s)described inthe>30GySBRTarea after 3-6months!

• Heavilypretreatedpatients:– OftenFUonlybyreferringphysician

– FrequentCTorPET/CT

GeneralPatientinformation

• Promisingtreatmentwithhighlocalcontrol(~lung>80%)

• Possibleacutetox:Nausea/pain

• Chanceofhighgradetoxicity– Dependingontumorlocation

– Smallbowel/esophagus/stomachperforation– Fibrosis/stenosis biliary tract

• Mostpatients:notoxicity!

àMostpatientsheavilypretreated- noother/betteroptions..

Generalremarks

• Nostandard profylactic medication (no dexa,no anti-emetics)

• Noroutineblood tests(except creatinine for iv contrast)

Conclusions/Takehome- LiverSBRT:

• ExcellentresultsforhighdoseSBRT

• Keepitsimple(useexperienceinlungSBRT)!

• Bewareofoverlapwithesophagus/stomach/bowelandlargechangesbetweenfractions

• Additionalcomparedtolung:– 4DCTusingivcontrast(extraprotocols/equipment)– Consider larger PTVmargin

• Liver istheideal indication for MRguided SBRT!

Questions…