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任益民 Yee-Min Jen, MD, PhD
Department of Radiation Oncology,
Tri-Service General Hospital
國防醫學院三軍總醫院
放射腫瘤部
2013.5.31
Stereot...
國防醫學中心
National Defense Medical Center
5
民國56年改制成立三軍總醫院
內湖國醫中心占地面積 43公頃
員工總數 3,239人
主治醫師 254人
護理人員 1,325人
專科數 26科
病床數 1,895床(含加護病房107床及特殊病床)
附設護理之家 228床
101年平均醫療...
Stereotactic Body RT
versus ---
Blomgren H, Lax I, Naslund I, Svanstrom R.
Stereotactic high dose fraction radiation
ther...
SABR vs. SBRT
 Discov Med. 2010 May;9(48):411-7.
 Stereotactic body radiation therapy (stereotactic
ablative radiotherap...
0
100
200
300
400
500
600
700
腦部 脊椎 鼻咽部 肝 肺 胰 腎臟 攝護腺 其他
CaseNumber
個案數
治療部位
Cyberknife Case Distribution, Tri-Service Gene...
EXPERIENCES USING SABR
AT TRI-SERVICE GENERAL
HOSPITAL, TAIPEI
肝癌
LIVER CANCER
SABR OF LIVER CANCER
Fiducial CT sim SABR
GTV + 1-3 mm = PTV
10 Gy x 5 fractions
V15 of normal liver  700 ml
V20 of ...
SABR IN RECURRENT LIVER CANCER
Before SABR After SABR
Before SABR 3 months after SABR
68 y/o male
a 2.3-cm recurrent tumor
Complete response after SBRT
Newly diagnosed HCC
2 years after subsequent hepatectomy with NED
Recurrent HCC
 2008.1 - 2009.12
 Study Group: 36 patients with 42 lesions
 Control Group: 138 patients with
recurrent H...
Eligibility criteria
 Recurrence after prior treatment with
curative intent
 Unresectable or medically inoperable
 ECOG...
放療劑量
 Median does: 37 Gy (25-48 Gy)
 4-5 fractions in 4-5 consecutive working
days.
Tumor response
 41/42 lesions evaluable (One patient
died of brain metastasis before follow-up
study)
CR, 22%
PR, 37%
SD,...
Local Control and Failure
 Local failure pattern
- in-field: 15%
- out-field: 56%
1-year in-field failure-free rate: 87.6...
Acute Toxicities
 No grade 4-5 toxicity
 Most common sequelae - fatigue, anorexia
(56%)
 No SBRT interruption due to in...
三軍總醫院治療門靜脈栓塞經驗
TSGH Experience Treating
HCC with Portal Vein Thrombosis
PVT Result
 16 SBRT patients
 All patients completed planned
radiotherapy.
 No ≧Gr. 3 toxicity
 1 CR, 7 PR, 3 SD, 2 PD...
立體定位放射治療用於原發肝癌
SABR for Primary Liver Cancer
PATIENTS
53 from June 2008 to June 2011 with 68
lesions
Unresectable or medically inoperable HCC,
patients
ECOG ≦2, Chi...
LOCAL CONTROL
The median follow-up period for all
patients was 13.1 months (range, 1-41
months) and for living patients 1...
SURVIVAL
The 1- and 2- year OS was 70.1% and
45.4% respectively.
Acute toxicities in patients undergoing SABR (n = 53)
Toxicity
N0. of patients (%)
Grade 1 Grade 2 Total
Fatigue/Malaise 1...
Cyberknife Stereotactic
Radiosurgery for Other Cancers
2012.11.16
Before SABR
2013.4.5
after SABR
Pancreas Cancer
HYPOXIA IN SABR
The presence of tumor hypoxia is a
major negative factor in limiting the
curability of tumors by SABR at
...
HYPOXIA IN SABR
However, this could be overcome by
the addition of clinically tolerable
doses of the hypoxic cell
radiose...
CONCLUSIONS
9-12 Gy x 5 fractions over 5 consecutive
days.
Cyberknife SABR is effective and very safe
for liver cancer.
...
QUESTIONS
Patient selection
When should SABR be given to patients after
TACE?
What exactly is the optimal dose-fraction...
THOUGHTS FOR THE FUTURE
Add thalidomide or nexavar after SABR
Nimorazole trial
Randomized clinical trial
三總放腫與電腦刀團隊
Department of Radiation
Oncology & SRS Center
祝
健康愉快
Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
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Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan

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任益民 Yee-Min Jen, MD, PhD
Department of Radiation Oncology,
Tri-Service General Hospital
國防醫學院三軍總醫院 放射腫瘤部
2013.5.31

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Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan

  1. 1. 任益民 Yee-Min Jen, MD, PhD Department of Radiation Oncology, Tri-Service General Hospital 國防醫學院三軍總醫院 放射腫瘤部 2013.5.31 Stereotactic Ablative Radiotherapy for Liver Cancer: Report from Tri-Service General Hospital, Taiwan
  2. 2. 國防醫學中心 National Defense Medical Center
  3. 3. 5 民國56年改制成立三軍總醫院 內湖國醫中心占地面積 43公頃 員工總數 3,239人 主治醫師 254人 護理人員 1,325人 專科數 26科 病床數 1,895床(含加護病房107床及特殊病床) 附設護理之家 228床 101年平均醫療服務量: 營業額 6.9億元/月 住院 4,015 人次/月 門診 6,092 人次/日 急診 304 人次/日
  4. 4. Stereotactic Body RT versus --- Blomgren H, Lax I, Naslund I, Svanstrom R. Stereotactic high dose fraction radiation therapy of extracranial tumors using an accelerator: clinical experience of the first thirty-one patients. Acta Oncol 1995
  5. 5. SABR vs. SBRT  Discov Med. 2010 May;9(48):411-7.  Stereotactic body radiation therapy (stereotactic ablative radiotherapy) for stage I non-small cell lung cancer--updates of radiobiology, techniques, and clinical outcomes.  Hadziahmetovic M, Loo BW, Timmerman RD, Mayr NA, Wang JZ, Huang Z, Grecula JC, Lo SS.  Department of Radiation Oncology, Arthur G. James Cancer Hospital, Ohio State University, Columbus, OH 43210, USA.
  6. 6. 0 100 200 300 400 500 600 700 腦部 脊椎 鼻咽部 肝 肺 胰 腎臟 攝護腺 其他 CaseNumber 個案數 治療部位 Cyberknife Case Distribution, Tri-Service General Hospital (2007/8-2013/4) Brain Spinal cord NP Liver Lung Pancreas Kidney Prostate Others Total: 1362, cranial= 696, body=666 248 209
  7. 7. EXPERIENCES USING SABR AT TRI-SERVICE GENERAL HOSPITAL, TAIPEI
  8. 8. 肝癌 LIVER CANCER
  9. 9. SABR OF LIVER CANCER Fiducial CT sim SABR GTV + 1-3 mm = PTV 10 Gy x 5 fractions V15 of normal liver  700 ml V20 of normal liver  30% The dose was prescribed to the isodose curve that encloses 100% of the GTV and more than 95% of the PTV. 7 days 7-10 days
  10. 10. SABR IN RECURRENT LIVER CANCER
  11. 11. Before SABR After SABR
  12. 12. Before SABR 3 months after SABR 68 y/o male a 2.3-cm recurrent tumor Complete response after SBRT
  13. 13. Newly diagnosed HCC 2 years after subsequent hepatectomy with NED
  14. 14. Recurrent HCC  2008.1 - 2009.12  Study Group: 36 patients with 42 lesions  Control Group: 138 patients with recurrent HCC in Tri-Service General Hospital with other or no treatments
  15. 15. Eligibility criteria  Recurrence after prior treatment with curative intent  Unresectable or medically inoperable  ECOG performance status of 0-2
  16. 16. 放療劑量  Median does: 37 Gy (25-48 Gy)  4-5 fractions in 4-5 consecutive working days.
  17. 17. Tumor response  41/42 lesions evaluable (One patient died of brain metastasis before follow-up study) CR, 22% PR, 37% SD, 39% PD, 2%
  18. 18. Local Control and Failure  Local failure pattern - in-field: 15% - out-field: 56% 1-year in-field failure-free rate: 87.6% 2-year in-field failure-free rate: 75.1%
  19. 19. Acute Toxicities  No grade 4-5 toxicity  Most common sequelae - fatigue, anorexia (56%)  No SBRT interruption due to intolerable side effects. SBRT is tolerable. Acute toxicities in patients undergoing SBRT (N = 36) Case No. Gr. 1 Gr. 2 Gr. 3 Nausea/Vomiting 2 3 0 Anorexia 5 4 0 Abdominal pain 1 1 0 Gastric ulcer 0 1 1 Fatigue 12 1 0 Musculoskeletal 1 0 0
  20. 20. 三軍總醫院治療門靜脈栓塞經驗 TSGH Experience Treating HCC with Portal Vein Thrombosis
  21. 21. PVT Result  16 SBRT patients  All patients completed planned radiotherapy.  No ≧Gr. 3 toxicity  1 CR, 7 PR, 3 SD, 2 PD (3 no FU image)  Median survival: 8.2 m
  22. 22. 立體定位放射治療用於原發肝癌 SABR for Primary Liver Cancer
  23. 23. PATIENTS 53 from June 2008 to June 2011 with 68 lesions Unresectable or medically inoperable HCC, patients ECOG ≦2, Child-Pugh class A or B Patients who had failed with TACE or 17 patients with main portal vein thrombosis which precluded TACE.
  24. 24. LOCAL CONTROL The median follow-up period for all patients was 13.1 months (range, 1-41 months) and for living patients 18.1 months ( range, 2-41 months ). 1- and 2-year in-field failure free rate of 73.3% and 66.8% respectively.  Out -field intra-hepatic recurrence was the main cause of treatment failure and occurred in 28/52 patients.
  25. 25. SURVIVAL The 1- and 2- year OS was 70.1% and 45.4% respectively.
  26. 26. Acute toxicities in patients undergoing SABR (n = 53) Toxicity N0. of patients (%) Grade 1 Grade 2 Total Fatigue/Malaise 12 ( 22.6) 3 (5.7) 15 (28.3) Nausea/vomiting 0 6 (11.3) 6(11.3) Abdominal distension 2 (3.8) 0 2 (3.8) Abdominal pain 2 (3.8) 1 (1.9) 3 (5.7) Anorexia 3 (5.7) 3 (5.7) 6 (11.3) Gastritis 0 1 (1.9) 1 (1.9) Gastric ulcer 0 1 (1.9) 1(1.9) Abbreviations: SABR, stereotactic ablative radiotherapy
  27. 27. Cyberknife Stereotactic Radiosurgery for Other Cancers
  28. 28. 2012.11.16 Before SABR 2013.4.5 after SABR Pancreas Cancer
  29. 29. HYPOXIA IN SABR The presence of tumor hypoxia is a major negative factor in limiting the curability of tumors by SABR at radiation doses that are tolerable to surrounding normal tissues. Brown M et al. Int J Radiat Oncol Biol Phys 78: 323-327, 2010
  30. 30. HYPOXIA IN SABR However, this could be overcome by the addition of clinically tolerable doses of the hypoxic cell radiosensitizer etanidazole. Brown M et al. Int J Radiat Oncol Biol Phys 78: 323-327, 2010
  31. 31. CONCLUSIONS 9-12 Gy x 5 fractions over 5 consecutive days. Cyberknife SABR is effective and very safe for liver cancer. Local recurrence is a problem. Is hypoxic cell radiosensitizer worth a trial?
  32. 32. QUESTIONS Patient selection When should SABR be given to patients after TACE? What exactly is the optimal dose-fractionation?
  33. 33. THOUGHTS FOR THE FUTURE Add thalidomide or nexavar after SABR Nimorazole trial Randomized clinical trial
  34. 34. 三總放腫與電腦刀團隊 Department of Radiation Oncology & SRS Center
  35. 35. 祝 健康愉快

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