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STEREOTACTIC BODY RADIATION THERAPY USING CYBERKNIFE® FOR LIVER METASTASES: A REPORT FROM TIANJIN CANCER INSTITUTE & HOSPITAL
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STEREOTACTIC BODY RADIATION THERAPY USING CYBERKNIFE® FOR LIVER METASTASES: A REPORT FROM TIANJIN CANCER INSTITUTE & HOSPITAL

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Zhi-Yong Yuan, MD, PhD …

Zhi-Yong Yuan, MD, PhD
Chun-Lei Liu, MD Ma0-Bin Meng, MD, PhD
CyberKnife Center, Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital

Published in: Health & Medicine

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  • 1. Tianjin Medical University Cancer Institute & Hospital HuanhuXi Road, TiYuanBei, He Xi District, Tianjin 300060, PRC Tel: +86-22-23340123 Fax: + 86-22-23341405 Web site: www.tmucih.org STEREOTACTIC BODY RADIATION THERAPY USING CYBERKNIFE® FOR LIVER METASTASES: A REPORT FROM TIANJIN CANCER INSTITUTE & HOSPITAL Zhi-Yong Yuan, MD, PhD Chun-Lei Liu, MD Ma0-Bin Meng, MD, PhD CyberKnife Center, Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital
  • 2. 2 Background  The liver is the second most common site for metastatic spread of cancer.  Surgical resection is currently considered as the first line measure for the treatment of liver metastatises (LM). Hess KR, et al. Cancer 2006; 106: 1624-1633.Timmerman RD, et al. CA Cancer J Clin 2009; 59: 145-170.
  • 3. 3 Liver metastasis SBRT report
  • 4. 4Hoyer M, et al. Int J Radiation Oncology Biol Phys 2012; 82: 1047-1057
  • 5. 5 Questions and Aims  The optimal dose and fractionation scheme has not yet been determined.  It is still unclear whether it is scientifically rigorous enough to recommend its routine use for curative treatment of LM.
  • 6. 6 CyberKnife Treatment System  The present study is aimed at assessing the efficacy and safety of SBRT using CyberKnife on the treatment of LM, It is anticipated that this study will provide additional evidence for clinical practice.
  • 7. 7 Inclusion Criteria  The inclusion criteria were defined as follows:  Patients of any age;  LM Disease confirmed cytologically, pathologically, or diagnosed through imaging;  Patients with KPS ≥ 70;  Patients within ≤ 4 LMs and individual tumor diameter < 6 cm;  Patient’s life expectancy >3 months;  Patient unsuitable for or refractory to surgery and received CyberKnife treatment;  Bilirubin less than 3 mg/dl, albumin greater than 2.5 g/dl, and serum liver enzymes less than twice the upper limit of normal range.
  • 8. 8 The dose constraints of SBRT
  • 9. 9 Follow-up and endpoints  The patients were observed at 1 month after completion of treatment, then every 3 months for the first year, and every 6 months thereafter until July 2012.  The primary endpoint was local control (LC)  OS, PFS, distant PFS (DPFS), and adverse events.  Local control of LM was assessed at a minimum of 6 months of follow-up after CyberKnife treatment in order to avoid uncertainty associated with early transient radiographic changes within the high-dose region.
  • 10. 10 Patient characteristics
  • 11. 11 Summary of SBRT parameters
  • 12. 12 Treatment characteristics
  • 13. 13 Follow-up patients Prior to RT 5 Weeks 3 Months 6 Months 13 Months 18 Months 25 Months
  • 14. 14 LC rate, PFS, and DPFS 1 year LC: 94.4% 2 years LC: 89.7% Median PFS: 12 months Median DPFS: 37 months
  • 15. 15 LC rate by subgroups
  • 16. 16 Overall survival Median OS: 37.5 months 1 year OS: 68.6 months 2 years OS: 55.9 months Median OS for favorable patients : Not reached Median OS for non-favorable patients: 8.7 months Note: The favorable patients were defined as primaries originating from colorectal, breast, and stomach cancers, and sarcomas.
  • 17. 17 OS rate by subgroups
  • 18. 18 Factors associated with OS
  • 19. 19 Patterns of failure
  • 20. 20 Toxicities  The treatment was well tolerated by all patients; the most common toxicities were grade 1 or 2 fatigue, nausea, vomiting, and changes in liver function tests, which were corrected by routine treatment.  None of the patients developed grade 3 or higher toxicity. In addition, no clinically significant changes were noted in liver function evaluations or physical examinations of LM patients.
  • 21. 21 Discussion The RT strategies: The type of RT should be determined according to the Barcelona Clinic Liver Cancer (BCLC) stage and liver function.
  • 22. 22 Discussion The dose and fractionation scheme : The prescribed dose and fractionation were specified according to lesion Location and Volume in this study.
  • 23. 23 Discussion The optimal dose and fractionation scheme : 29 patients: 40 Gy/4f 13 patients: 45 Gy/3f LC: 45Gy/3f > 40Gy/4f Vautravers DC, et al. Int J Radiation Oncology Biol Phys 2011; 81: e39-47 LC: 60Gy/5f > 50Gy/5f >30Gy/3f Rule WR, et al. Ann Surg Oncol 2011; 18: 1081-1087
  • 24. 24 Discussion The BED correlative with LC: Chang DT, et al. Cancer 2011; 117: 4060-4069 Median prescription dose: 41.7Gy (22-60) Median fractions: 6 fractions (1-6) Lanciano R, et al. Fron Oncol 2012; 2: 1-8 Median prescription dose/fraction: 12Gy Median fractions: 3 fractions (3-5)
  • 25. 25 Discussion The LC correlative with tumor volume: 13 patients: < 60 Gy/3f 36 patients: = 60 Gy/3f Rusthoven KE, et al. JCO 2009; 27: 1572-1578 Median prescription dose/fraction: 12Gy Median fractions: 3 fractions (3-5) Lanciano R, et al. Fron Oncol 2012; 2: 1-8 ≠
  • 26. 26 Limitations  This is a retrospective study. As record keeping and bias may influence results, prospective studies of LM must be performed to confirm the efficacy and safety of SBRT with CyberKnife.  LC appears to be excellent with CyberKnife, however, our follow-up is short and the study included a heterogeneous group of patients with various primary tumors, previous treatments, and liver disease statuses, etc.  The optimal dose and fractionation scheme has not yet been determined. Despite these limitations, the study showed that SBRT using CyberKnife can improve LC as well as OS in patients with LM.
  • 27. 27 Conclusions  SBRT with CyberKnife is an effective modality with good local control and acceptable toxicity for unresectable or medically inoperable LM.  Such studies will hopefully also help identify the subset of patients most likely to benefit from this therapy.  Further study: Guideline for the SBRT Dose-Fraction for Different Volume and Sites LM lesions (Large number cases and Muticenter needed)
  • 28. THANKS Tianjin Medical University Cancer Institute & Hospital
  • 29. Radiation Oncologist : Wang Ping, Song Yongchun, Zhuang Hongqing, Meng Maobing Nerosurgeon : Wang Xiaoguang, Liuqun Thoracic Surgeon Wang Changli, Zhang Zhenfa Belly Surgeon: Hao Jihui, Song Tianqiang Physicist : Li Fengtong, Dong Yong Therapist Wang Jingsheng, Chen Huaming The TUMC Cyberknife Team Acknowledgements  F0unndations: NFSC (No. 81201754) and the Cyberknife Foundation (No. 4-1-3).