Impact of inadequate respiratory motion management in SBRT for oligometastatic colorectal cancer

doi:10.1016/j.radonc.2014.11.005

Radiotherapy and Oncology

Volume 113, Issue 2, November 2014, Pages 235-239

https://doi.org/10.1016/j.radonc.2014.11.005 Get rights and content

Abstract

Purpose

Stereotactic body radiotherapy (SBRT) in oligometastatic colorectal cancer (CRC) resulted in a disappointing 1-year local control rate of 54% in our experience. We aimed to determine the root cause(s).

Methods

47 oligometastatic CRC patients were treated with SBRT by helical tomotherapy to a dose of 40 or 50 Gy in 10 fractions, without specific respiratory motion management and PTV-margins of 10–10–12 mm in all patients. The local recurrences (LRs) were delineated on diagnostic PET–CT scans and co-registered with initial planning CTs. LRs were classified as in-field or marginal with respect to the initial dose distribution, and predictors for LR were determined.

Results

Out of 105 irradiated metastases, LR modeling yielded 15 in-field and 15 marginal failures. Metastases in moving organs (liver and lung) exhibited a local control of 53% at 1-year (95% confidence interval (CI): 38–67%), compared to 79% for lymph nodes (95% CI: 32–95%). The first group exhibited a sixfold increased risk compared to the latter on multivariate analysis (p = 0.01).

Conclusions

The nature and locations of LR indicated that dose prescription and methodology were both inadequate for liver and lung metastases. This study demonstrates the need for individual respiratory motion management and a biological effective dose of >75 Gy.

Section snippets

Patient population

47 CRC patients with a radically resected primary tumor and five or less metastases were enrolled consecutively in 2 phase II trials between July 2008 and July 2011 (NCT00807313). Patients had to be considered inoperable by the localization, number or dimension of the metastases, medically unfit to undergo resection or refusing surgery. Patients who did not receive previous chemotherapy for metastatic disease had to be medically unfit to undergo systemic treatment or refusing chemotherapy. [9],

Results

After a median follow-up of 10.6 months for a total of 105 irradiated metastases, a local failure occurred in 30 lesions (29%), of which 17 and 13 were in the group of 10 × 4 Gy and 10 × 5 Gy, respectively. The median time to local progression was 3.2 months for 10 × 4 Gy, as compared to 8 months for 10 × 5 Gy. We report a 1-year actuarial lesion-based LC of 59% (95% C.I. 41–73%) and 53% (95% C.I. 30–71%) for the metastases who received 10 × 4 Gy and 10 × 5 Gy, respectively (Fig. 2A) (p = 0.3).

Modeling of the LRs

Discussion

The main asset of helical tomotherapy in SBRT of oligometastases is the possibility to treat multiple metastases in one treatment plan (a single helical delivery), which is especially convenient when multiple targets are located in the same plane. At that time, Tomotherapy provided also the most reliable dose calculation in lung tissue and the best on-board soft tissue imaging available in our department. On the other hand, we did not have access to 4D planning CT in order to define an internal

Conflict of interest statement

This study was funded by grants from Foundation Against Cancer (foundation of public interest, 219.2008) and the Belgian Government (Nationaal Kankerplan). The authors declare no conflict of interest.

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This work reports on the results of a survey performed on the use of computed tomography (CT) imaging for motion management, surface guidance devices, and their quality assurance (QA). Additionally, it details the collected user insights regarding professional needs in CT for radiotherapy. The purpose of the survey is to understand current practice, professional needs and future directions in the field of fan-beam CT in radiation therapy (RT).
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The definition of OMD had gradually evolved [4,5,7,20–24] (Table 1). Although there were increasingly evaluations in various solid tumors, including colon, lung, prostate, breast, renal and other cancers, the definition of OMD was not consistent in number and location of metastasis (with number from less than three to less than five and location from 1 to 2 organs) [6,8,25,26]. Interest in identifying and managing gastric cancer patients with OMD has been increasing.
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Since prescription could therefore not be separated from patient characteristics and confound the analysis of these baseline factors, RT dose was not included in the multivariate analysis. Local control (LC) was investigated in detail in previous articles, showing a LC of 53–59% for 40–50 Gy in 10 fractions without motion management, compared to 89% for 10 × 5Gy prescribed at the 80% isodose with motion management [18,20]. Exact survival data were obtained from the Belgian National Cancer Registry, updated in May 2017, and was calculated from the first day of SRT.
Stereotactic radiotherapy (SRT, SBRT) is widely used in oligometastatic cancer, but the heterogeneity of the population complicates estimation of the prognosis. We investigated the role of different clinical and inflammatory parameters.
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403 patients received SRT for 760 metastases. Treated sites were mainly lung, liver, nodal areas, and brain. Most common primaries were colorectal and lung cancer. Median follow-up for living patients reached 42 months and median overall survival (MS) was 26.6 months (95% CI 23.8–29.3). Five independent adverse factors were discriminated: male sex, synchronous timing of oligometastases, brain metastasis, non-adenocarcinoma histology, KPS <80. A risk score is formed by summation of the points of each factor (M:4, T:2, B:7, N:7, K:8). Four risk groups were defined: (1) 0–2 points: MS 41.2 months (95% CI 30.2–52.3); (2) 3–8 points: 29.3 months (24.6–34.0); (3) 9–13 points: 17.4 months (10.1–24.7), and (4) 14–28 points: 7.9 months (5.5–10.3).
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Motion management in SBRTImpact of inadequate respiratory motion management in SBRT for oligometastatic colorectal cancer

Abstract

Purpose

Methods

Results

Conclusions

Section snippets

Patient population

Results

Discussion

Conflict of interest statement

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Motion management in SBRT
Impact of inadequate respiratory motion management in SBRT for oligometastatic colorectal cancer