Joined: 5/1/2009
Posts: 1
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My father is considering CyberKnife for a second liver metastasis of colon cancer (the first was surgically removed). His current tumor is surgically resectable but they would need to take a good
portion of his right lobe. Volume study shows he'll have enough left
but the surgeon seems a bit hesitant because of some renal impairment
(creatinine 1.6-1.9). My father is also hesitant to do surgery. Given
this situation- which, in your opinion, would provide a better outcome
in terms of survival benefit - CyberKnife or surgery?
Also, can you all provide citations for studies involving CyberKnife and its use with the liver? I haven't been able find much so far. Additionally, if you can provide any data regarding its use for liver in your practices, that would be wonderful.
Thanks,
JT
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Joined: 10/10/2008
Posts: 2346
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It is not possible to say which will provide a better outcome in his case. A surgical resection that removed the tumor and some surrounding tissue would be the thing most likely to get rid of this tumor. But there are surgical risks and always the chance of more tumor appearing later. Treatment with CK probably has about a 90% chance of controlling the tumor. Most of the data quoted is from less capable systems than the CK, but is still relevant. We do not have any formally analyzed institutional data, but control most of the tumors we treat.
J Clin Oncol. 2009 Apr 1;27(10):1572-8. Epub 2009 Mar 2. Links
Comment in:
J Clin Oncol. 2009 Apr 1;27(10):1537-9.
Multi-institutional phase I/II trial of stereotactic body radiation therapy for liver metastases.
Rusthoven KE, Kavanagh BD, Cardenes H, Stieber VW, Burri SH, Feigenberg SJ, Chidel MA, Pugh TJ, Franklin W, Kane M, Gaspar LE, Schefter TE.
University of Colorado Denver, Department of Radiation Oncology, Pathology, and Medical Oncology, Aurora, CO 80045, USA.
PURPOSE: To evaluate the efficacy and tolerability of high-dose stereotactic body radiation therapy (SBRT) for the treatment of patients with one to three hepatic metastases. PATIENTS AND METHODS: Patients with one to three hepatic lesions and maximum individual tumor diameters less than 6 cm were enrolled and treated on a multi-institutional, phase I/II clinical trial in which they received SBRT delivered in three fractions. During phase I, the total dose was safely escalated from 36 Gy to 60 Gy. The phase II dose was 60 Gy. The primary end point was local control. Lesions with at least 6 months of radiographic follow-up were considered assessable for local control. Secondary end points were toxicity and survival. RESULTS: Forty-seven patients with 63 lesions were treated with SBRT. Among them, 69% had received at least one prior systemic therapy regimen for metastatic disease (range, 0 to 5 regimens), and 45% had extrahepatic disease at study entry. Only one patient experienced grade 3 or higher toxicity (2%). Forty-nine discrete lesions were assessable for local control. Median follow-up for assessable lesions was 16 months (range, 6 to 54 months). The median maximal tumor diameter was 2.7 cm (range, 0.4 to 5.8 cm). Local progression occurred in only three lesions at a median of 7.5 months (range, 7 to 13 months) after SBRT. Actuarial in-field local control rates at one and two years after SBRT were 95% and 92%, respectively. Among lesions with maximal diameter of 3 cm or less, 2-year local control was 100%. Median survival was 20.5 months. CONCLUSION: This multi-institutional, phase I/II trial demonstrates that high-dose liver SBRT is safe and effective for the treatment of patients with one to three hepatic metastases
J Clin Oncol. 2009 Apr 1;27(10):1585-91. Epub 2009 Mar 2. Links
Comment in:
J Clin Oncol. 2009 Apr 1;27(10):1537-9.
Phase I study of individualized stereotactic body radiotherapy of liver metastases.
Lee MT, Kim JJ, Dinniwell R, Brierley J, Lockwood G, Wong R, Cummings B, Ringash J, Tse RV, Knox JJ, Dawson LA.
Radiation Medicine Program, Department of Biostatistics and Medical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
PURPOSE: To report on the outcomes of a phase I study of stereotactic body radiotherapy (SBRT) for treatment of liver metastases. PATIENTS AND METHODS: Patients with liver metastases that were inoperable or medically unsuitable for resection, and who were not candidates for standard therapies, were eligible for this phase I study of individualized SBRT. Individualized radiation doses were chosen to maintain the same nominal risk of radiation-induced liver disease (RILD) for three estimated risk levels (5%, 10%, and 20%). Additional patients were treated at the maximal study dose (MSD) in an expanded cohort. Median SBRT dose was 41.8 Gy (range, 27.7 to 60 Gy) in six fractions over 2 weeks. RESULTS: Sixty-eight patients with inoperable colorectal (n = 40), breast (n = 12), or other (n = 16) liver metastases were treated. Median tumor volume was 75.2 mL (range, 1.19 to 3,090 mL). The highest RILD risk level investigated was safe, with no dose-limiting toxicity. Two grade 3 liver enzyme changes occurred, but no RILD or other grade 3 to 5 liver toxicity was seen, for a low estimated risk of serious liver toxicity (95% CI, 0 to 5.3%). Six (9%) acute grade 3 toxicities (two gastritis, two nausea, lethargy, and thrombocytopenia) and one (1%) grade 4 toxicity (thrombocytopenia) were seen. The 1-year local control rate was 71% (95 CI, 58% to 85%). The median overall survival was 17.6 months (95% CI, 10.4 to 38.1 months). CONCLUSION: Individualized six-fraction liver metastases SBRT is safe, with sustained local control observed in the majority of patients.
Acta Oncol. 2006;45(7):838-47. Links
Stereotactic radiotherapy of primary liver cancer and hepatic metastases.
Wulf J, Guckenberger M, Haedinger U, Oppitz U, Mueller G, Baier K, Flentje M.
Department of Radiotherapy, University of Wuerzburg, Josef-Schneider-Strasse 11, D-97080, Wuerzburg, Germany. wulf@lindenhof.netline.ch
The purpose was to evaluate the clinical results of stereotactic radiotherapy in primary liver tumors and hepatic metastases. Five patients with primary liver cancer and 39 patients with 51 hepatic metastases were treated by stereotactic radiotherapy since 1997. Twenty-eight targets were treated in a "low-dose"-group with 3 x 10 Gy (n = 27) or 4 x 7 Gy (n = 1) prescribed to the PTV-encl. 65%-isodose. In a "high-dose"-group patients were treated with 3 x 12 - 12.5 Gy (n = 19; same dose prescription) or 1 x 26 Gy/PTV-enclosing 80%-isodose (n = 9). Median follow-up was 15 months (2-48 months) for primary liver cancer and 15 months (2-85 months) for hepatic metastases. While all primary liver cancers were controlled, nine local failures (3-19 months) of 51 metastases were observed resulting in an actuarial local control rate of 92% after 12 months and 66% after 24 months and later. A borderline significant correlation between dose and local control was observed (p = 0.077): the actuarial local control rate after 12 and 24 months was 86% and 58% in the low-dose-group versus 100% and 82% in the high-dose-group. In multivariate analysis high versus low-dose was the only significant factor predicting local control (p = 0.0089). Overall survival after 1 and 2 years was 72% and 32% for all patients and was impaired due to systemic progression of disease. No severe acute or late toxicity exceeding RTOG/EORTC-score 2 were observed. Stereotactic irradiation of primary liver cancer and hepatic metastases offers a locally effective treatment without significant complications in patients, who are not amenable for surgery. Patient selection is important, because those with low risk for systemic progression are more likely to benefit from this approach.
Clinton A. Medbery, III, M.D.
St. Anthony Hospital Cyberknife Center
(405) 272-7311
buddy@swrads.org
Mail to:
Clinton A. Medbery, III, M.D.
Southwest Radiation Oncology
1011 N. Dewey Ave. #101
Oklahoma City, OK 73102
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