Feasibility of split-course stereotactic ablative radiotherapy for oligometastases

Eun Kyung Paik, Mi-Sook Kim, Young-Seok Seo, Won Il Jang, Jin-Kyu Kang, Chul-Koo Cho, Hyung Jun Yoo, Eun Kyung Paik, Mi-Sook Kim, Young-Seok Seo, Won Il Jang, Jin-Kyu Kang, Chul-Koo Cho, Hyung Jun Yoo

Abstract

Background: There is growing interest in the use of stereotactic ablative radiotherapy (SABR) for oligometastases. However, extreme caution should be exercised in treating tumors closely located to organs at risk (OARs) with SABR. To reduce complications, we have applied split-course SABR to oligometastases closely located to OARs or to those being retreated with radiotherapy.

Methods: We retrospectively reviewed the records of patients with oligometastases who were treated with planned split-course SABR between January 2012 and December 2016.

Results: A total of 23 patients with 29 oligometastatic lesions were enrolled. The primary diagnoses were bone and soft tissue cancers in 13 lesions, liver cancers in 12 lesions, and colorectal cancers in four lesions. The median tumor volume was 78 cm3 (range, 4-1781 cm3). The lesions were treated with 1-3 fractions in the first stage of SABR (first SABR), and one or two fractions in the second stage of SABR (second SABR). The time interval between the two stages was about 4 weeks. A partial response was noted in 16 lesions (55%) after the first SABR, and practical reductions in the doses to OARs were observed in the second SABR compared with the first SABR. The 1-, 2- and 3-year local control rates were 92%, 65% and 43%, respectively. No Grade 4 or 5 toxicities were observed during or after treatment.

Conclusion: Split-course SABR appeared to be feasible for the treatment of oligometastases closely located to OARs.

Figures

Figure 1.
Figure 1.
Clinical decision-making flow chart for treating oligometastasis with SABR. The standard split-course SABR of our center consists of two treatment courses. One to three fractions were delivered in the first SABR. Patients underwent a computed tomography (CT) scan ~4 weeks after the completion of the first SABR for the planning of the second SABR. One or two fractions were additionally delivered for the second SABR. SABR, stereotactic ablative radiotherapy.
Figure 2.
Figure 2.
Waterfall plot demonstrating the proportional volume change of GTVs and OARs. Volumetric/dosimetric changes in target volumes and OARs between two courses of SABR were assessed. Lesions were ranked by proportional volume change in the GTV. (A) Sixteen lesions (55%) were in the responder group, showing more than a 10% change in the GTV after the first SABR treatment, and 13 lesions (45%) were in the non-responder group. (B) Dosimetric changes of OARs in 16 lesions that showed a response after the first SABR were analyzed. Practical radiation dose reductions of OARs were observed in the second SABR compared with the first SABR in lesions that responded after the first SABR. GTV, gross tumor volume; OAR, organ at risk; SABR, stereotactic ablative radiotherapy; Vx%, volume of OARs that received x% of prescribed dose; GI, gastrointestinal tract; SC, spinal cord.
Figure 3.
Figure 3.
Illustrated examples of tumors that showed an excellent response after the first SABR. (A) The first patient was a 66-year-old male with a history of hepatocellular carcinoma who was previously treated with radiofrequency ablation and transcatheter arterial chemoembolization and presented with recurrent disease in the liver. Pre-treatment CT imaging revealed a 6.5-cm mass abutting the stomach. The patient was subsequently treated with split-course SABR (39 Gy/3fx + 11 Gy/1fx boost) separated by a 4-week break. (B) After the first SABR, CT imaging demonstrated a dramatically reduced tumor size, and a safety margin of about 1 cm could be secured from the stomach in the second SABR. (C) The second patient was a 46-year-old male with a history of multiple recurrent liposarcoma, previously treated with several resections, who presented with recurrent disease in the mesentery. Pre-treatment CT imaging revealed an 8.5-cm mass abutting the small bowel. The patient was subsequently treated with split-course SABR (10 Gy/1fx + 10 Gy/1fx boost) separated by a 3-week break. (D) After the first SABR, CT imaging demonstrated a dramatically reduced tumor size, making it possible to reduce the irradiated volume of the small bowel in the second SABR. SABR, stereotactic ablative radiotherapy; CT, computed tomography.
Figure 4.
Figure 4.
Local control probability of oligometastatases treated with split-course SABR. SABR, stereotactic ablative radiotherapy.

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