Stereotactic body radiation therapy for patients with heavily pretreated liver metastases and liver tumors

Rachelle Lanciano, John Lamond, Jun Yang, Jing Feng, Steve Arrigo, Michael Good, Luther Brady, Rachelle Lanciano, John Lamond, Jun Yang, Jing Feng, Steve Arrigo, Michael Good, Luther Brady

Abstract

We present our initial experience with CyberKnife stereotactic body radiation therapy (SBRT) in a heavily pretreated group of patients with liver metastases and primary liver tumors. From October 2007 to June 2009, 48 patients were treated at the Philadelphia CyberKnife Center for liver metastases or primary liver tumors. We report on 30 patients with 41 discrete lesions (1-4 tumors per patient) who received an ablative radiation dose (BED ≥ 79.2 Gy10 = 66 Gy EQD2). The treatment goal was to achieve a high SBRT dose to the liver tumor while sparing at least 700 cc of liver from radiation doses above 15 Gy. Twenty-three patients were treated with SBRT for metastatic cancer to the liver; the remainder (n = 7) were primary liver tumors. Eighty-seven percent of patients had prior systemic chemotherapy with a median 24 months from diagnosis to SBRT; 37% had prior liver directed therapy. Local control was assessed for 28 patients (39 tumors) with 4 months or more follow-up. At a median follow-up of 22 months (range, 10-40 months), 14/39 (36%) tumors had documented local failure. A decrease in local failure was found with higher doses of SBRT (p = 0.0237); 55% of tumors receiving a BED ≤ 100 Gy10 (10/18) had local failure compared with 19% receiving a BED > 100 Gy10 (4/21). The 2-year actuarial rate of local control for tumors treated with BED > 100 Gy10 was 75% compared to 38% for those patients treated with BED ≤ 100 Gy10 (p = 0.04). At last follow-up, 22/30 patients (73%) had distant progression of disease. Overall, seven patients remain alive with a median survival of 20 months from treatment and 57 months from diagnosis. To date, no patient experienced persistent or severe adverse effects. Despite the heavy pretreatment of these patients, SBRT was well tolerated with excellent local control rates when adequate doses (BED > 100 Gy10) were used. Median survival was limited secondary to development of further metastatic disease in the majority of patients.

Keywords: hepatocellular carcinoma and cholangiocarcinoma; liver metastases; stereotactic body radiation therapy.

Figures

Figure 1
Figure 1
Example of complete response to SBRT assessed by PET/CT. A 63-year-old African American male with two metachronous liver metastases 4 years after colon resection (T3N0 adenocarcinoma). He received 2 years of chemotherapy for the liver metastases with progression and was referred for SBRT. (A) Tumor 1 and (B) tumor 2. Shown in each panel are the (a) axial and (b) coronal views of the pretreatment PET/CT; the (c) axial and (d) coronal views of the post-treatment PET/CT and the (e) axial and coronal treatment planning CT denoting the SBRT dose distribution.
Figure 2
Figure 2
Local control analysis (A) from time of SBRT. (B) Comparison of local control for tumors with a CTV ≤25.3 cc to those with a CTV >25.3 cc. (C) Comparison of local control for those tumors receiving a BED10 of ≤100 Gy10 to those receiving a BED10 > 100 Gy10.
Figure 3
Figure 3
Survival analysis (A) from time of SBRT and (B) from time of diagnosis. (C) Comparison of overall survival for patients with a largest CTV ≤46.85 cc to those with a largest CTV >46.85 cc. (D) Comparison of overall survival for those patients receiving a BED10 of ≤100 Gy10 to those receiving a BED10 > 100 Gy10.

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