SRS Liver at GI Tumor board

[xrt123]

Anyone have any insight into how and when to make recommendations for SRS liver at tumor board. Somewhat frequently a patient is presented with HCC or 1-3 oligometastasis to liver and is unresectable or needs a bridge to transplant. I often think I could easily meet dose constraints and provide local control but these people invariably get sent to IR for TACE. I have done some literature review and have brought up the following articles when appropriate with little enthusiasm from anyone at the tumor board.

https://www.ncbi.nlm.nih.gov/pubmed/23216217
http://www.advancesradonc.org/article/S2452-1094(15)00009-3/abstract?cc=y=

I was wondering if anyone has insight or evidence that could help me make a better argument for SRS liver or at least refine the patient population that a radiation oncologist should push hard for treating.

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[RadOncDoc21]

Anyone have any insight into how and when to make recommendations for SRS liver at tumor board. Somewhat frequently a patient is presented with HCC or 1-3 oligometastasis to liver and is unresectable or needs a bridge to transplant. I often think I could easily meet dose constraints and provide local control but these people invariably get sent to IR for TACE. I have done some literature review and have brought up the following articles when appropriate with little enthusiasm from anyone at the tumor board.

https://www.ncbi.nlm.nih.gov/pubmed/23216217
http://www.advancesradonc.org/article/S2452-1094(15)00009-3/abstract?cc=y=

I was wondering if anyone has insight or evidence that could help me make a better argument for SRS liver or at least refine the patient population that a radiation oncologist should push hard for treating.

Most data is phase I/II and there are a lot of retrospective reviews from multiple institutions.

I am in a similar position but not just with liver but SBRT in general. I see them, but not the numbers I really should be seeing. You could also just wait for the current generation of providers to retire.

 

[Neuronix]

I'm not convinced that TACE does anything more than bland embolization alone: http://ascopubs.org/doi/full/10.1200/jco.2015.64.0821

Randomized data for TARE is still pending. Several retrospective series exist to show its efficacy and safety, especially compared to TACE (Riad Salem has been champion of this).

Similar for SBRT. Several retrospective series show safety and efficacy compared to other modalities. Again because surgery controls the patients, the best we can do for randomization is the RTOG 1112 trial vs sorafenib which is basically for advanced HCC only.

Unfortunately surg onc and med onc tend to have more pull at tumor boards than rad onc. So it seems like no matter what papers I pull to argue for radiation therapy for liver mets or HCC, I often get ignored. Just too many competing modalities here--resection, RFA, microwave, nanoknife, chemoembo, radembo, SBRT, probably something I'm forgetting... Many of them are controlled by the surgeons, IRs, and/or med oncs who control the patients. For HCC, this figure gets thrown around a lot. No radiation in the whole figure.

 

[medgator]

Most data is phase I/II and there are a lot of retrospective reviews from multiple institutions.

I am in a similar position but not just with liver but SBRT in general. I see them, but not the numbers I really should be seeing. You could also just wait for the current generation of providers to retire.

Or cut things off at the source. Talk to the pulmonologist directly, or the med onc diagnosing those liver mets, before they have a chance to send to IR/thoracic surgery/surg onc

 

[Palex80]

It's the same problem where I work at. No randomized trials, thus quite difficult to get in there.

I've heard that super-selective ablation of entire liver segments with SIRT nanospheres is a new approach, showing impressive results.

 

[xrt123]

Thanks for the responses. Looking forward to RTOG1112 results, positive or negative.

 

[Ray D. Ayshun]

Obviously not an RCT but good nonetheless.
https://www.ncbi.nlm.nih.gov/pubmed/26628466

 

[BobbyHeenan]

Obviously not an RCT but good nonetheless.
https://www.ncbi.nlm.nih.gov/pubmed/26628466

I use this article above (RFA vs. SBRT for HCC) and the UAB experience with TACE plus SBRT when I try to push for SBRT as well in HCC (see hyperlink below). I've treated a couple of patients this way (some had only bland embolization then SBRT) with so far so good outcomes.

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

I too have fought the uphill battle at tumor board for SBRT for both HCC and liver mets. All you can do is show them the data, try to get patients, and then follow up after treatment is over with a re-presentation at tumor board especially if there is a good outcome so that they can see the results.

 

[Reaganite]

Point it out as an option when they put up NCCN guidelines. It's listed there now. Don't go in guns blazing saying it should replace TACE, but give a little spiel about when it might be considered. I'm always deferential to TACE as "first-line", but I also point out encouraging local control on early follow up and tell them if they want a rad onc opinion I'm happy to provide it. I usually say "as you can see, NCCN now lists SBRT as an options. This is because..." They'll still go for TACE, but present it in a thoughtful way, and you'll you get the reasonable guys thinking. I've had a few referrals come out of these discussions.

 

[thecarbonionangle]

This is very institutional. It is virtually impossible to penetrate the "IR firewall" in many tumor boards. To make things worst, some of the old school liver transplant surgeons you will encounter in large academic centres will hate radiation. Radiation oncologists depend on referrals and it is really quite hard to go into a tumor board "guns blazing" and take on the med onc or the liver surgeon who may run it. Easy way to get pushed out.

 

[seper]

Good news on SBRT for HCC from last week's ASCO GI meeting: a randomized trial

http://abstracts.asco.org/195/AbstView_195_175620.html

 

[xrt123]

Very promising. Anyone know if in the talk they mentioned max size of tumors treated or would be eligible?

 

[seper]

I don't remember, but since patients were transplant eligible, that would be within Milan criteria by size.