SBRT liver?

[CUBuffsgrad98]

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case of ocular melanoma treated years ago with brachy only in 2011 at outside institution (dont have all the details). further optho follow up declined. shows up a couple years later at our cancer center door with <4 cm liver met biopsy proven melanoma. Anyone treat SBRT as first line, or systemic meds first? Dose?

 

[Gfunk6]

I assume the patient has a solitary liver met only? Also, what is the precise size and location?

 

[CUBuffsgrad98]

I measured it out at about 3.5x4.0 cm or so on CT (MRI not done). Peripheral lesion well away from stomach, duodenum, etc. PET negative everywhere else.

 

[OTN]

You could treat stereotactically (40 Gy in 5 fractions would be reasonable, given HCC data), but if the patient could tolerate it surgical resection would be my first choice.

 

[medgator]

You could treat stereotactically (40 Gy in 5 fractions would be reasonable, given HCC data), but if the patient could tolerate it surgical resection would be my first choice.

agreed.

 

[CUBuffsgrad98]

If no sx, then what? systemics vs RFA (not sure size criteria for this) vs embolism vs SBRT? thoughts?

 

[Gfunk6]

If one met and no other sites of disease, I don't see a solid rationale for chemo. I would resect and observe. Second choice would be RFA or SBRT (personally, I use 60 Gy in 3 fx per U Colorado protocol).

If there is one 'smallish' met which is amenable to resection, RFA, or SBRT I don't see why you would need TARE or TACE.

 

[irwarrior]

Would consider additional advanced imaging with multiphase MRI (sometimes more tumor than seen on CT alone). Consider treatment with TACE (BCNU) or GM CSF immunoembolization (Jefferson protocol) followed by ablative therapy. May consider ablative therapy with cryoablation or microwave (more aggressive ablative zones). The synergistic effects may be of benefit based on some data for hepatocellular carcinoma of combo TACE/ablation. Some interesting approaches to this tumor with Delcath (isolated liver perfusion). http://www.delcath.com/. Unsure of role of drug eluting bead therapy or Y90 in this specific difficult patient population.

Curious of any tough spots for SBRT in the liver (ie dome near diaphragm or bowel (stomach/colon) or central lesions (near common bile duct). These are tougher spots for ablations due to collateral damage and in these cases may consider PEI or transcatheter treatment approaches. When should SBRT be considered in liver directed therapy (size criteria?/tumor types/locations/numbers etc). Any restrictions based on MELD score, ascites, thrombocytopenia etc for SBRT in the liver?

 

[Tanner]

Would consider additional advanced imaging with multiphase MRI (sometimes more tumor than seen on CT alone). Consider treatment with TACE (BCNU) or GM CSF immunoembolization (Jefferson protocol) followed by ablative therapy.

Agree, would get multiphase imaging first. I also agree that you should consider TACE --> SABR (60Gy in 3 - 5 fx) combination. TACE artifact may allow you to see the target better.

 

[oncology2020]

sorry to digress but can rad oncs use theraspheres or is this only IR? On the website it says nuclear medicine develops the plan and then IR performs the procedure even though it's under the rad onc website. Any way rad oncs can learn and get credentials to do this procedure?

http://my.clevelandclinic.org/cancer/treatments-procedures/radiation-therapy/therasphere.aspx

 

[medgator]

sorry to digress but can rad oncs use theraspheres or is this only IR? On the website it says nuclear medicine develops the plan and then IR performs the procedure even though it's under the rad onc website. Any way rad oncs can learn and get credentials to do this procedure?

http://my.clevelandclinic.org/cancer/treatments-procedures/radiation-therapy/therasphere.aspx

Like anything else nuc med, it's location and market specific. Where I trained, nuc med did the unsealed sources. In my practice, we do things like iodine, samarium, xofigo etc. Don't do theraspheres, but one of the iRs at my local hospital said they can actually get an authorized user certification to do it on their own?

 

[CUBuffsgrad98]

Agree, would get multiphase imaging first. I also agree that you should consider TACE --> SABR (60Gy in 3 - 5 fx) combination. TACE artifact may allow you to see the target better.

Apparently uveal melanoma doesnt really have much response to chemo (per the med onc), so they may try some targeted agents. They say there is an open trial for a MEK inhibitor for metastatic uveal melanoma, but I think TACE is off the table. It is near the dome of the diaphragm, which could be tough, but it is a solitary peripheral lesion. Will get multiphase imaging if we go down the SBRT pathway. Recent review IJROBP 2012 of RT and liver mets suggests at least 48 Gy in 3 fx.

 

[Palex80]

"Surgery first" is a reasonable approach here, but is the patient going to get any other treatment? If Ipilimumab is considered, one could advocate for radiation therapy as first choice.

There are several anecdotal reports of patients having received ipilimumab with little response initially and then showing abscopal responses in non irradiated tumors immediately after radiation was delivered at some other metastatic site. Radiation therapy can act as a booster for ipilimumab mediated effects on the immune system. This probably comes from the inflammation reaction within irradiated tumors, attracting immune cells, which then go on to attack other melanoma sites.

 

[CUBuffsgrad98]

"Surgery first" is a reasonable approach here, but is the patient going to get any other treatment?

There are several anecdotal reports of patients having received ipilimumab with little response initially and then showing abscopal responses in non irradiated tumors immediately after radiation was delivered at some other metastatic site.

Yeah, the abscopal effect has been an interesting thing that has been thrown out there in a few case reports where people did well, but who know the real reason until more data is in on that.

She is a little beat up for surgery, not sure if they are considering ipi or not. Generally speaking, though, uveal melanoma is a different animal than typical skin melanoma (eg no BRAF pathway), so extrapolating from skin may not be beneficial, but ipi does seem to have some effect in this type of melanoma.

I generally hate liver cases, though. I think they are difficult to target well unless you have an MRI sim. We cant even give contrast at our sim, so makes it even more complicated, do have 4D technology though.

 

[Palex80]

You can use PET-CT fusion. And still, liver is an organ, that can very well heal itself. If the location of the lesion in the liver is not too problematic (close to bowel or gall bladder), then just make your CTV bigger and hit it. I haven't seen any patient with a normal liver developing chronic toxicity because of SBRT originating from the liver itself.

On a side note: Is it just me or do more of you have the impression that SBRT-liver patients tend to:
A) develop lots of fatigue after treatment
A) sometimes experience cold shivers or fever after the first (couple of) fraction(s).

I have witnessed A several times and the magnitude of fatigue is in my opinion lots more than in SBRT-lung patients with lesions of the same size. B is something I've seen in large lung-SBRT volumes as well but more often in liver. I guess B is some kind of cytokine rush and A the liver repairing itself after treatment?

 

[HepatoSite]

You can use PET-CT fusion. And still, liver is an organ, that can very well heal itself. If the location of the lesion in the liver is not too problematic (close to bowel or gall bladder), then just make your CTV bigger and hit it. I haven't seen any patient with a normal liver developing chronic toxicity because of SBRT originating from the liver itself.

On a side note: Is it just me or do more of you have the impression that SBRT-liver patients tend to:
A) develop lots of fatigue after treatment
A) sometimes experience cold shivers or fever after the first (couple of) fraction(s).

I have witnessed A several times and the magnitude of fatigue is in my opinion lots more than in SBRT-lung patients with lesions of the same size. B is something I've seen in large lung-SBRT volumes as well but more often in liver. I guess B is some kind of cytokine rush and A the liver repairing itself after treatment?

Agree. Use all of the tools at your disposal to contour a reasonably accurate target (MRI or multiphase CT or PET/CT fusion, 4DCT with minip reconstruction, etc.). In patients with otherwise normal hepatic function, would deliver 60Gy/3 or 60Gy/5 if you're a tad nervous. Both regimens should give you very good odds of local control. Follow the published normal tissue constraints closely and it is unlikely that you will have issues with significant toxicity. Liver SBRT folks can certainly develop more constitutional symptoms than lung patients (who hardly ever develop any acute issues). This can typically be mitigated with pre-SBRT dex (~4mg prior to each fraction).

 

[Haybrant]

Is there any issue giving Radioembo after a patient had liver EBRT? Med Onc was asking about a guy that got palliative EBRT over a year ago to liver (non-SBRT partial liver). Had prior TACE and RFA apparently too. Wasnt certain about this, I know there are rare cases of venoocclusive liver failure after radioembo which I assume is from RILD. Thank you

 

[seper]

traditionally, Y-90 and EBRT for liver are mutually exclusive. If you know any data on safety of combined use, please share

 

[evilbooyaa]

traditionally, Y-90 and EBRT for liver are mutually exclusive. If you know any data on safety of combined use, please share

Just did a quick pubmed search and couldn't find anything.

Did find this: https://www.ncbi.nlm.nih.gov/pubmed/27284477
It's comparing SBRT to SIRT (Y-90). Seems comparable, and I wonder why (at least at my institution) SBRT liver is not performed more frequently, as all patients with any liver mets immediately get shuffled off to IR or to (overly) aggressive surgeons.

 

[seper]

drug insert for Theraspheres says prior XRT is exlcuded.


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[mavrik13]

Solitary liver met -> further imaging to confirm solitary -> Surgery. Generally only see SBRT liver in non-operable candidates (either tumour related or patient related).