Strategies to tackle the challenges of external beam radiotherapy for liver tumors

Michael I. Lock, Jonathan H. Klein, Hans T. Chung, Joseph M. Herman, Edward Y. Kim, William Small, Nina A. Mayr, Simon S. Lo

Research output: Contribution to journalReview article

4 Citations (Scopus)

Abstract

Primary and metastatic liver cancer is an increasingly common and difficult to control disease entity. Radiation offers a non-invasive treatment alternative for these patients who often have few options and a poor prognosis. However, the anatomy and aggressiveness of liver cancer poses significant challenges such as accurate localization at simulation and treatment, management of motion and appropriate selection of dose regimen. This article aims to review the options available and provide information for the practical implementation and/or improvement of liver cancer radiation programs within the context of stereotactic body radiotherapy and image-guided radiotherapy guidelines. Specific patient inclusion and exclusion criteria are presented given the significant toxicity found in certain sub-populations treated with radiation. Indeed, certain sub-populations, such as those with tumor thrombosis or those with larger lesions treated with transarterial chemoembolization, have been shown to have significant improvements in outcome with the addition of radiation and merit special consideration. Implementing a liver radiation program requires three primary challenges to be addressed: (1) immobilization and motion management; (2) localization; and (3) dose regimen and constraint selection. Strategies to deal with motion include simple internal target volume (ITV) expansions, non-gated ITV reduction strategies, breath hold methods, and surrogate marker methods to enable gating or tracking. Localization of the tumor and organs-at-risk are addressed using contrast infusion techniques to take advantage of different normal liver and cancer vascular anatomy, imaging modalities, and margin management. Finally, a dose response has been demonstrated and dose regimens appear to be converging. A more uniform approach to treatment in terms of technique, dose selection and patient selection will allow us to study liver radiation in larger and, hopefully, multicenter randomized studies.

Original languageEnglish (US)
Pages (from-to)645-656
Number of pages12
JournalWorld Journal of Hepatology
Volume9
Issue number14
DOIs
StatePublished - May 18 2017
Externally publishedYes

Fingerprint

Radiotherapy
Radiation
Liver Neoplasms
Liver
Neoplasms
Anatomy
Organs at Risk
Body Image
Immobilization
Patient Selection
Population
Multicenter Studies
Blood Vessels
Thrombosis
Therapeutics
Biomarkers
Guidelines

Keywords

  • 4DCT
  • Hepatocellular carcinoma
  • Image-guided radiotherapy
  • Liver metastases
  • Stereotactic body radiation therapy

ASJC Scopus subject areas

  • Hepatology

Cite this

Strategies to tackle the challenges of external beam radiotherapy for liver tumors. / Lock, Michael I.; Klein, Jonathan H.; Chung, Hans T.; Herman, Joseph M.; Kim, Edward Y.; Small, William; Mayr, Nina A.; Lo, Simon S.

In: World Journal of Hepatology, Vol. 9, No. 14, 18.05.2017, p. 645-656.

Research output: Contribution to journalReview article

Lock, MI, Klein, JH, Chung, HT, Herman, JM, Kim, EY, Small, W, Mayr, NA & Lo, SS 2017, 'Strategies to tackle the challenges of external beam radiotherapy for liver tumors', World Journal of Hepatology, vol. 9, no. 14, pp. 645-656. https://doi.org/10.4254/wjh.v9.i14.645
Lock, Michael I. ; Klein, Jonathan H. ; Chung, Hans T. ; Herman, Joseph M. ; Kim, Edward Y. ; Small, William ; Mayr, Nina A. ; Lo, Simon S. / Strategies to tackle the challenges of external beam radiotherapy for liver tumors. In: World Journal of Hepatology. 2017 ; Vol. 9, No. 14. pp. 645-656.
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AB - Primary and metastatic liver cancer is an increasingly common and difficult to control disease entity. Radiation offers a non-invasive treatment alternative for these patients who often have few options and a poor prognosis. However, the anatomy and aggressiveness of liver cancer poses significant challenges such as accurate localization at simulation and treatment, management of motion and appropriate selection of dose regimen. This article aims to review the options available and provide information for the practical implementation and/or improvement of liver cancer radiation programs within the context of stereotactic body radiotherapy and image-guided radiotherapy guidelines. Specific patient inclusion and exclusion criteria are presented given the significant toxicity found in certain sub-populations treated with radiation. Indeed, certain sub-populations, such as those with tumor thrombosis or those with larger lesions treated with transarterial chemoembolization, have been shown to have significant improvements in outcome with the addition of radiation and merit special consideration. Implementing a liver radiation program requires three primary challenges to be addressed: (1) immobilization and motion management; (2) localization; and (3) dose regimen and constraint selection. Strategies to deal with motion include simple internal target volume (ITV) expansions, non-gated ITV reduction strategies, breath hold methods, and surrogate marker methods to enable gating or tracking. Localization of the tumor and organs-at-risk are addressed using contrast infusion techniques to take advantage of different normal liver and cancer vascular anatomy, imaging modalities, and margin management. Finally, a dose response has been demonstrated and dose regimens appear to be converging. A more uniform approach to treatment in terms of technique, dose selection and patient selection will allow us to study liver radiation in larger and, hopefully, multicenter randomized studies.

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