Prospective evaluation of fiducial marker placement quality and toxicity in liver CyberKnife stereotactic body radiotherapy

Dutta, Debnarayan; Kataki, K.; George, Shibu; Reddy, Sruthi K; Sashidharan, Ajay; Kannan, R.; Madhavan, Radha; Nair, Harikumar; Tatineni, Tushar; Holla, Raghavendra

doi:10.3857/roj.2020.00472

Cited by 9 publications

(8 citation statements)

References 26 publications

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“…Major complications after fiducial marker placement include pain, migration of fiducial markers, implantation of metastases, bleeding, and infection. Although the rate of complications is 12%-14%, complications other than pain are rare[ 25 , 26 ]. However, the fiducial marker is a relatively new method for HCC, and the accumulation of data is still limited.…”

Section: Discussionmentioning

confidence: 99%

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Hepatocellular carcinoma effective stereotactic body radiotherapy using Gold Anchor and the Synchrony system: Two case reports and review of literature

Masuda¹,

Tsukiyama²,

Minagawa³

et al. 2022

WJCC

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BACKGROUND Radiotherapy for hepatocellular carcinoma (HCC) is considered to have limited efficacy because of treatment intensity considering that the irradiated area includes the liver, which is highly radiosensitive. In this report, we present two cases in which tumor control by surgical resection, radiofrequency ablation, transcatheter arterial chemoembolization (TACE), and lenvatinib administration was difficult, but stereotactic body radiotherapy (SBRT) using the Synchrony system by Radixact™ and Gold Anchor ® (GA) was effective. CASE SUMMARY A 60-year-old man had a single 10-cm HCC in the right lobe. Viable lesions remained after TACE, and levels of alpha-fetoprotein and protein induced by vitamin K antagonists II (PIVKA-II) decreased and quickly re-elevated. We performed SBRT with GA. Three weeks after implantation, localized radiotherapy (SBRT; 40 Gy/5 fractions) was performed using the Synchrony system by Radixact™. Four weeks later, the viable lesion had disappeared, and the PIVKA-II levels decreased. A 77-year-old man had a single 12-cm HCC in the right lobe. The patient experienced recurrence after hepatectomy. Further recurrence occurred after TACE, and we performed SBRT with GA. Because of the proximity of the HCC to the gastrointestinal tract, localized radiotherapy (SBRT; 39 Gy/13 fractions) to the HCC was performed 3 wk after implantation using the Synchrony system by Radixact™. Four weeks later, the viable lesion had disappeared on computed tomography, and the PIVKA-Ⅱ levels decreased. CONCLUSION SBRT using the Synchrony system and GA can deliver a large dose accurately and safely, and could have a high therapeutic effect.

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Section: Discussionmentioning

confidence: 99%

“…Ultrasound-guided placement, CT-guided placement, and endoscopic ultrasound-guided placement have been performed, and each method has the same success and complication rates[ 25 , 28 , 29 ]. Because of the risk of fiducial marker migration, multiple implantations are recommended.…”

Section: Discussionmentioning

confidence: 99%

Hepatocellular carcinoma effective stereotactic body radiotherapy using Gold Anchor and the Synchrony system: Two case reports and review of literature

Masuda¹,

Tsukiyama²,

Minagawa³

et al. 2022

WJCC

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“…Apart from the acute complications, there can be migration of fiducials within the liver, rarely extra-hepatic sites also. Hence radiation planning and delivery is recommended to be scheduled after an interval of 48-72 hours post fiducial insertion [37,39] (n = 77) evaluated the safety and technical success rate of an USG guided fiducial marker implantation. 21% had minor complications.…”

Section: Fiducial Related Toxicitymentioning

confidence: 99%

Radiation Induced Liver Toxicity

Dutta¹,

Sreenija²

2022

Hepatotoxicity

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Liver was always considered to be ‘highly sensitive’ to radiation therapy (RT) and was not considered ‘safe’ for radiation therapy treatment. The most significant radiation induced liver toxicity was described by Ingold et al. as “Radiation hepatitis.” Historically, radiation to liver lesions with curative intent or incidental exposure during adjacent organ treatment or total body irradiation implied whole organ irradiation due to lack of high precision technology. Whole organ irradiation led to classic clinical picture termed as “Radiation Induced Liver Disease (RILD).” In conventional fractionation, the whole liver could be treated only to the doses of 30–35Gy safely, which mostly serves as palliation rather than cure. With the advent of technological advancements like IMRT, especially stereotactic radiation therapy (SBRT), the notion of highly precise and accurate treatment has been made practically possible. The toxicity profile for this kind of focused radiation was certainly different from that of whole organ irradiation. There have been attempts made to characterize the effects caused by the high precision radiation. Thus, the QUANTEC liver paper distinguished RILD to ‘classic’ and ‘non-classic’ types. Classic RILD is defined as ‘anicteric hepatomegaly and ascites’, and also can also have elevated alkaline phosphatase (more than twice the upper limit of normal or baseline value). This is the type of clinical picture encountered following irradiation of whole or greater part of the organ. Non-classic RILD is defined by elevated liver transaminases more than five times the upper limit of normal or a decline in liver function (measured by a worsening of Child-Pugh score by 2 or more), in the absence of classic RILD. In patients with baseline values more than five times the upper limit of normal, CTCAE Grade 4 levels are within 3 months after completion of RT. This is the type of RILD that is encountered typically after high-dose radiation to a smaller part of liver. It is commonly associated with infective etiology. Emami et al. reported the liver tolerance doses or TD 5/5 (5% complication rate in 5 years) as 50 Gy for one-third (33%) of the liver, 35 Gy for two-thirds (67%) of the liver, and 30 Gy for the whole liver (100%). Liver function (Child Pugh Score), infective etiology, performance status and co-morbidities influence the radiation induced toxicity. Lyman–Kutcher–Burman (LKB)-NTCP model was used to assess dose-volume risk of RILD. Lausch et al. at London Regional Cancer Program (LRCP), developed a logistic TCP model. Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) reported recommendations that mean normal liver dose should be <18 Gy for baseline CP-A patients and < 6 Gy for those with CP-B, for a 6-fraction SBRT regimen. The University of Colorado phase 1 clinical trial of SBRT for liver metastases described the importance of the liver volume spared, that is, ‘critical volume model.’ It is estimated that a typical normal liver volume is approximately 2000 mL and specified that a minimum volume of 700 mL or 35% of normal liver should remain uninjured by SBRT i.e. at least 700 mL of normal liver (entire liver minus cumulative GTV) had to receive at total dose less than 15 Gy. In treatment regimen of 48 Gy in 3 fractions, CP-A patients were required to either limit the dose to 33% of the uninvolved liver (D33%) < 10 Gy and maintain the liver volume receiving <7 Gy to <500 cc. In more conservative treatment regimen, such as in 40 Gy in 5 fractions schedule, CP-B7 patients had to meet constraints of D33% < 18 Gy and/or > 500 cc receiving <12 Gy. The concept of body surface area (BSA) and Basal Metabolic Index (BMI) guided estimation of optimal liver volume is required to estimate the liver volume need to be spared during SBRT treatment. Radiation induced liver injury is potentially hazardous complication. There is no definitive treatment and a proportion of patient may land up in gross decompensation. Usually supportive care, diuretics, albumin supplement, and vitamin K replacement may be useful. Better case selection will avert incidence of RILD. Precise imaging, contouring, planning and respecting normal tissue constraints are critical. Radiation delivery with motion management and image guidance will allow delivery of higher dose and spare normal liver and hence will improve response to treatment and reduce RILD.

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“…[3][4][5] Surrogate markers for tumor positioning during treatment such as invasive internal fiducial and radioopacities either has inherent risks or are not readily available. [6][7][8] The liver dome, however, is always present, and has been shown to correlate with actual tumor position. 9 Clinical outcomes on liver-directed SBRTs without implant fiducial or radio-opaque markers at index lesions are lacking.…”

Section: Introductionmentioning

confidence: 99%

“…3-5 Surrogate markers for tumor positioning during treatment such as invasive internal fiducial and radio-opacities either has inherent risks or are not readily available. 6-8 The liver dome, however, is always present, and has been shown to correlate with actual tumor position. 9…”

Section: Introductionmentioning

confidence: 99%

Liver directed stereotactic body radiotherapy can be reliably delivered to selected patients without internal fiducial markers- a case series

Chen

Yang

et al. 2022

Journal of the Chinese Medical Association

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Tumor motion and the lack of tissue-tumor contrast have been challenging parts of liver-directed stereotactic body radiotherapy (SBRT). In this study, we investigated the possibility of liver-directed SBRT without internal fiducials using breath hold technique and diaphragm matching technique. One hundred thirty-four volumetric images of 13 consecutive patients with either primary or metastatic liver tumors who underwent expiratory breath hold SBRT were compared and analyzed. Reproducibility of diaphragm position between fractions relative to bone was evaluated on image registration software. At median follow-up time of 13 months, 1-year and 2-year local control rates of index lesions were 90% and 72%, respectively. In comparison to diaphragm matching, a greater margin is required for bone matching technique for that 19 of 67 (28%) of all interfractional SI offsets were more than 6 mm, whereas 6 of 67 (9%) intrafractional SI exceeded 6 mm. Despite the small study size, our study showed that breath hold SBRT without internal hepatic fiducial is a valid approach for selected patients.

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Prospective evaluation of fiducial marker placement quality and toxicity in liver CyberKnife stereotactic body radiotherapy

Cited by 9 publications

References 26 publications

Hepatocellular carcinoma effective stereotactic body radiotherapy using Gold Anchor and the Synchrony system: Two case reports and review of literature

Hepatocellular carcinoma effective stereotactic body radiotherapy using Gold Anchor and the Synchrony system: Two case reports and review of literature

Radiation Induced Liver Toxicity

Liver directed stereotactic body radiotherapy can be reliably delivered to selected patients without internal fiducial markers- a case series

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