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• W148020853 abstract "The concept and technique of stereotactic body radiation therapy (SBRT) is presented. This focally tumor-ablative radiation approach is delivered in a few fractions of high radiation doses to a limited volume of metastatic disease to the liver. Indications include one to five metastatic lesions with maximum diameters up to 5 cm. While clinical experience is limited with few larger case series, preliminary outcomes with respect to tumor control and normal liver sparing are encouraging. This new treatment modality offers patients an alternate noninvasive treatment modality promising high local tumor control rates. Concept of Stereotactic Body Radiation Therapy (SBRT) Stereotactic body radiation therapy (SBRT) is a relatively novel concept in which high doses of radiation are directed focally onto malignant lesions in organ sites other than the brain, including lung, liver, and spine tumors. The concept of SBRT is derived from the experience in treating metastatic lesions in the brain by stereotactic radiosurgery (SRS). In SRS, very high radiation doses are delivered to small brain lesions in a single session, with the intent to ablate all malignant tumor cells in one setting. The success rates of this treatment approach, with local tumor control rates as high as 93.3 %, have made SRS a standard of care for limited metastatic disease to the brain [1–3]. Similar antitumor efficacy should be achievable for metastatic lesions in organs other than the brain, when high radiation doses are comparably confined to a small tumor. In this chapter, an attempt is made to summarize the clinical experience with SBRT for metastases to the liver. The indications, technical considerations, as well as outcomes of SBRT for liver metastases are discussed, including available data of prospectively designed clinical trials. SBRT as discussed here will largely adhere to the accepted definition in the United States as the M. Fuss (*) Department of Radiation Medicine, Oregon Health and Science University, Portland, OR, USA e-mail: fussm@ohsu.edu A. Simeonova Department of Radiation Oncology, University Medical Center Mannheim, Mannheim, Germany e-mail: anna.simeonova@umm.de S. Ryu Department of Radiation Oncology and Neurosurgery, Henry Ford Hospital, Detroit, MI, USA e-mail: sryu1@hfhs.org D.E. Dupuy et al. (eds.), Image-Guided Cancer Therapy, DOI 10.1007/978-1-4419-0751-6_32, # Springer Science+Business Media New York 2013 455 delivery of high-dose focused radiation in 1–5 fractions onto small malignant lesions. The high-dose aspect of delivery, as well as what constitutes a small lesion, is less clearly defined. High-dose delivery is most often understood as single-fraction doses exceeding 5 Gray (Gy). Small lesions are most often defined as being less than 5 cm in maximum diameter. Focal radiation delivery refers to the ability to deliver tumoricidal radiation doses in a highly conformal manner, so that a target volume delineated in CT, MRI, or PET imaging is exposed to high, tumorablative doses of radiation, while steep dose gradients toward normal tissues afford sparing the organ harboring the disease from radiation injury. However, highly precise dose planning also requires similarly accurate dose delivery. Unique to the concept of SBRT is the stipulation of image-guidance in the context of dose delivery. As such, SBRT is currently the only radiation therapy concept for which a target has to be directly or indirectly localized before the radiation dose is delivered. Liver Metastases: Incidence and Established Treatment Options The liver is second only to regional lymph nodes as a site for metastatic disease for a variety of primary malignancies [4]. For colorectal cancer, the liver is often the first site of metastatic disease manifestation, with 15–25 % of patients harboring liver metastases at the time of diagnosis [5]. At autopsy, liver metastases are found in 25–50 % of patients who have died from cancer [6]. For patients diagnosed with liver metastases, the life expectancy without treatment is poor at about 5 months [7]. Surgical resection is the standard therapy for solitary or few lesions confined to the liver with favorable survival rates at 5 years of 25–35 % [5]. Unfortunately, 80–90 % of patients diagnosed with metastatic disease to the liver are not resection candidates, either due to the extent of metastatic disease, multiorgan metastatic disease, insufficient functional liver reserve, or general medical condition [4, 5]. Alternate liver-directed treatment options for patients with limited but unresectable liver metastases include radiofrequency ablation (RFA) [8], transarterial embolization (TAE) with or without transarterial chemotherapy administration (TACE), and radioembolization [6, 7, 9, 10] (Fig. 30.1). Local tumor control rates for RFA are comparable with surgery for lesions less than 3 cm, but lesions in close proximity to large vessels and the diaphragm, as well as subcapsular location, can be relative contraindications for this technique. Cryotherapy has been largely used in the past for palliation of unresectable liver tumors, but high local recurrence rates and peculiar systemic complications have determined its progressive abandonment. Despite long-term clinical use, the optimum number of freeze-thaw cycles, the role of inflow occlusion, and the potential corrupting effects of intralesional or proximal blood vessels on ablation morphology are still controversial [11]. For patients with multifocal liver metastases that are not candidates for liver-directed therapy, chemotherapy represents the only viable treatment option. Advances in chemotherapy treatment have been impressive for a variety of tumors. For patients with metastatic colorectal cancer, for example, the median survival has been improved from 10 to 20 months after the introduction of new chemotherapeutic agents and targeted therapies [10]. Unfortunately, these results are not seen for most other malignancies. Radiation Therapy for Liver Metastases: From Conventional Radiation to SBRT For decades, radiation therapy has had a limited role in the treatment of hepatic metastases because of the limited tolerance of the liver. The entire liver will not tolerate more than 30–35 Gy of conventionally fractionated radiation. At higher doses, radiation-induced liver disease (RILD) occurs frequently. RILD describes a clinical syndrome of anicteric hepatomegaly, ascites, and elevated liver enzymes (particularly serum alkaline phosphatase) occurring from 456 M. Fuss et al." @default.
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• W148020853 title "Stereotactic Body Radiation Therapy for Liver Metastases" @default.
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