SBRT Liver

[Mandelin Rain]

What dose regimen and constraints is everyone currently using for liver SBRT for HCC and/or mets?

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[OTN]

50 in 5 for most mets, but obviously have to respect the bowel.

70 In 20 for HCC and cholangioca as per Chris Crane’s data. I’ve been very, very happy with outcomes with this.

5mm “PRV” (again, Crane, see his data) expansion around bowel as avoidance structure in both cases.

 

[Mandelin Rain]

Using the crane regimen freely in central tumors near CBD and vessels? I like that idea. This is a small recurrence on edge of previous ablation.

 

[Neuronix]

What dose regimen and constraints is everyone currently using for liver SBRT for HCC and/or mets?

Prefer Y-90 in appropriate cases.

SBRT 5 fractions, generally following RTOG 1112 protocol for HCC or mets. Will try to escalate mets to 60 Gy / 5 fractions if possible.

I require fiducials or MRI guidance for IGRT.

 

[w00tz]

I use 700cc of normal liver should receive less than 15 Gy (have also seen 17Gy threshold). Usually not a problem, unless the tumor is huge.

 

[BobbyHeenan]

I use 700cc of normal liver should receive less than 15 Gy (have also seen 17Gy threshold). Usually not a problem, unless the tumor is huge.

I've used this as well for a three fraction regimen for HCC.

I sometimes do TACE plus SBRT > 3cm HCC's. Has a beautiful "fiducial" with lipoiodal contrast in the liver. Some retrospective data supporting this with 15 Gy X 3.

Adjuvant stereotactic body radiotherapy following transarterial chemoembolization in patients with non-resectable hepatocellular carcinoma tumours of ≥ 3 cm - PubMed

This retrospective study suggests that in patients with HCC tumours of ≥ 3 cm, treatment with TACE + SBRT provides a survival advantage over treatment with only TACE. Confirmation of this observation requires that the concept be tested in a prospective, randomized clinical trial.

www.ncbi.nlm.nih.gov

For central tumors I've used Chris Crane's cholangio regimens (off the top of my head I think around 60-70 Gy in 15).

For mets 15-18 Gy X 3 or 10 Gy X 5.

If large solitary tumor in setting of HCC I think possible proton benefit, so I send there if feasible.

 

[evilbooyaa]

18 x 3 for smaller central (away from dose limiting organs) lesions (Colorado data), with 700cc spared getting < 15 Gy.

10 x 5 for larger lesions or closer to dose limiting structures, with turning down dose as necessary if abutting duodenum, stomach, esophagus, etc. Liver 700cc spared getting < 21 Gy in 5 fraction regimen.

This is for mets or HCC. Mets lower threshold to reduce dose or dose paint to respect critical structure OARs.

Fiducials if possible, but routinely line up to liver edge or vasculature as necessary.

 

[anonymuncule]

50 in 5 for most mets, but obviously have to respect the bowel.

70 In 20 for HCC and cholangioca as per Chris Crane’s data. I’ve been very, very happy with outcomes with this.

5mm “PRV” (again, Crane, see his data) expansion around bowel as avoidance structure in both cases.

what are you doing for verification on treat?

standard online cone beam ?

fiduicials ?

 

[OTN]

what are you doing for verification on treat?

standard online cone beam ?

fiduicials ?

Abdominal compression with the belt with the body pro lok, 4d ct sim, cone beam CT for verification, marker match for fiducials if they’re there. I no longer have GI or IR place fiducials unless they’re already going in for some reason.

 

[Mandelin Rain]

The one I'm struggling with is a multiply recurrent, but non-metastatic HCC. Partial hepatectomy 15 years ago with multiple ablative procedures since, most recently a cryo in April. Now with a small (1cm) recurrence sitting on the IVC and nearly abutting celiac trunk. Esophagus is close but really nothing else all too close. There's a bunch of clips in the area and anatomy is pretty crazy at this point so bile duct is a bit of a mystery.

I was thinking the 50Gy in 5fx vs the 67.5Gy in 15 fraction thing that Crane does.

 

[evilbooyaa]

If you're far enough away from bile duct and esophagus and can get 50/5 in safely, that is an ablative dose. Chris Crane does 67.5/15 or 75/25 instead of doing 33Gy in 5 fractions, which he is correct in saying is 'palliative' SBRT.

With the clips you have excellent localization. If it's close to IVC it's likely far from bile duct. Just double check esophagus/stomach given patient's anatomy can be an issue sometimes with the described location.

 

[Mandelin Rain]

Thanks much

 

[RadOncMegatron]

Abdominal compression with the belt with the body pro lok, 4d ct sim, cone beam CT for verification, marker match for fiducials if they’re there. I no longer have GI or IR place fiducials unless they’re already going in for some reason.

I haven't had the resolve to do liver SBRT without fiducials, though I've thought to myself many times that it would be ok. Any papers on this? Are there places (dome?) where you insist on fiducials? I'm too chicken to do it w/o fiducials