SBRT Upper Abdomen
SBRT Upper Abdomen
SBRT Upper Abdomen
→we instruct our patients to ingest nothing for at least 3 hours before radiation
→We use simethicone
- Respiration
Treatment Delivery & Setup Correction Strategies in SBRT for tumors of the upper abdomen
Motion of tumors in the upper abdomen
AIM: To compare the extent of tumor motion between 4DCT and cine-
MRI in patients with hepatic tumors treated with radiation therapy.
→The beam-on time is approximately 4 minutes for SBRT. Therefore, a 5-minute cine-MRI motion may offer better insight into actual
tumor motion during treatment compared with a 4DCT scan acquired over only 2 to 3 breathing cycles.
→ Inclusion of additional margins (3 mm, 2 mm, and 1 mm in the S/I, A/P, and L/R directions, respectively) to the ITV defined by 4DCT
may be needed to account for tumor motion detected by cine-MRI, particularly for patients with irregular breathing.
SBRT for tumors of the upper abdomen
Treatment Delivery & Setup Correction Strategies
Bullet points
• Motion-encompassing method
Overview of the main published studies of Linac-based SBRT for liver mets and the corresponding techniques used motion
management and planning imaging.
Author Year n of patients RT technique Total dose (Gy) N of fractions PTV definition RT planning technique Fiducials Motion management
Llacer Novalis TrueBeam CT scan with
Moscardo 2016 41 STX VMAT 40-50 5-10 ITV+5mm contrast+MRI+4DCT+4DPET-CT Yes Adaptive gating
Abdominal compression/4D PET-
Andratschke 2015 74 3D-CRT 30-35 3-5 ITV+5mm 4D-CT No CT/4D CT
GTV+4-6mm(7-10 mm
Scorsetti 2013 61 VMAT 75 3 cc) CT scan with contrast,4DCT No Abdominal compression,4DCT
Lee 2009 68 3D-CRT 27.7-60 6 GTV+8mm(CTV)+5mm CT scan with contrast+MRI No Abdominal compression or BH
3D-CRT or conformal Abdominal compression or FB or
Rusthoven 2009 47 arcs 36-60 3 GTV+7-15mm CT scan with contrast No external fiducial markers
Katz 2007 69 Novalis ExacTrac 30-55 10 GTV+7mm (10mm cc) CT scan with contrast No External body fiducial markers
Dawson 2006 34 3D-CRT 24-57 6 GTV+8mm(CTV)+5mm MRI simulation No BH
Hoyer 2006 44 3D-CRT 45 3 GTV+5mm (10mm cc) CT scan with contrast No FB
Kavanagh 2006 36 3D-CRT 60 3 GTV+5-10mm CT scan with contrast No Abdominal compression or BH
Mendez
Romero 2006 17 3D-CRT 30-37.5 3 GTV+5-10mm CT scan with contrast Yes Abdominal compression
Wulf 2006 39 3D-CRT 26-37.5 1-4 GTV+3mm(CTV)+5mm CT scan with contrast,4DCT No Abdominal compression
3D-CRT or conformal Abdominal compression or BH or
Schefter 2005 18 arcs 36-60 3 GTV+5mm (10mm cc) CT scan with contrast No external fiducial markers
Van de
Voorde 2005 33 VMAT or IMRT 3-10 GTV+10mm CT scan with contrast,4DCT No 4D PETCT
Herfarth 2001 37 3D-CRT 14-26 1 GTV+6mm(10mm cc) CT scan with contrast No FB
Treatment Delivery & Setup Correction Strategies in SBRT for tumors of the upper abdomen
Solutions for the Management of Respiration-induced Target Motion
• Motion-encompassing methods
In patients when the lesions have homogenous low CT density, located intrahepatic, not adjacent to perihepatic organs, using
Minimum Intensity Projection (MinIP) image can bean an appropriate tool
Most liver metastases and cholangiocarcinomas can be imaged in the portal venous phase, while hepatocellular carcinomas are
most visible in the delayed phase.
At simulation, IV contrast is considered standard particularly for hepatocellular carcinoma
4D-CT procedure
The respiration of the patient is tracked using the RPM System
Acquisition of
1) normal helical scouts for patient positioning and isocenter localization
2) a helical free-breathing scan from the carina to the iliac crest for treatment planning (free
from contrast agents so as not to interfere with heterogeneity dose calculations)
3) a 4D-CT scan (from 2 to 3 cm above the diaphragm to 2–3 cm below the liver edge noted on
the scout) performed in cine mode with a voltage of 120 kV and a tube current of 175 mA.
The tube current is increased for larger patients.
Intravenous contrast
Prior to the initiation of the free-breathing scan, the patient’s IV line is
connected to a contrast injector.
Standard protocol of 150 mL of contrast with a concentration of 320-mg I/mL.
injected at a flow rate of 5 mL/s.
A time delay can be programmed within the 4D-CT image acquisition protocol
so that the start of the contrast injection is initiated simultaneously with the
start of the scanner’s timer countdown.
.
Treatment Delivery & Setup Correction Strategies in SBRT for tumors of the upper abdomen
Solutions for the Management of Respiration-induced Target Motion
• Motion-mitigating strategies: abdominal compression
Abdominal compression effectively reduced liver tumor motion, yielding small and
reproducible excursions in three dimensions. The compression level established at
planning could have been safely used on the treatment days
Wunderink W, et al. Int J Radiat Oncol Biol Phys. 2008
…Residual excursions became substantially <5 mm in all directions by applying abdominal compression, except for
in 2 patients in whom a slightly larger motion toward the CC direction was observed…
Significant liver motion control via abdominal compression of the subxiphoid area;
however, this control of liver motion was not observed with compression of the caudal
umbilicus Hu Y, et al. Med Phys. 2016
The magnitude of respiration-induced liver motion of patients with intrahepatic carcinoma undergoing abdominal
compression is affected by gender and BMI, with abdominal compression being less effective in men and overweight
patients.
Hu Y, et al. Radiat Oncol. 2017
Treatment Delivery & Setup Correction Strategies in SBRT for tumors of the upper abdomen
Solutions for the Management of Respiration-induced Target Motion
• Motion-mitigating strategies: breath hold and gating strategies
respiratory gating
M&M: Daily target motion without mitigation was compared
against motion with compression and with simulated abdominal compression
respiratory gating in 19 pancreatic cancer patients receiving
no mitigation
SBRT
→Compared to no motion mitigation, abdominal compression
significantly reduced motion in AP and SI directions. However,
respiratory gating was significantly better. Hence, respiratory
gating was shown to be the most effective strategy for
reducing target motion in pancreatic SBRT.
SBRT for tumors of the upper abdomen
Treatment Delivery & Setup Correction Strategies
Bullet points
For SBRT, motion management and daily IGRT are the recommended standard-of care
Benedict SH, et al. Med Phys. 2010
Margins tend to be larger in the superior-inferior direction where respiration-induced motion is more dominant relative
to motion in the axial plane (usually 5 mm LL and AP; and 10 mm CC)
Nagata Y, et al. Int J Radiat Oncol. 2011
When gating is used for treatment, margins can generally be reduced. Some groups have defined the PTV as ITV + 5 mm
Zhao B, et al. Med Phys. 2012
Shirato H, et al. Int J Clin Oncol. 2007
Zhao B, et al. Phys Med Biol. 2011
SBRT for tumors of the upper abdomen
Treatment Delivery & Setup Correction Strategies
Bullet points
At treatment, localization of the tumor in the liver is sometimes not possible in contrast to other sites such as lung cancer
where the tumor location is often very clear
At treatment the consistency of correlation with respiratory motion or breath hold ability at time of simulation must be
verified.
The diaphragm is a good surrogate of target position→a superior-inferior CTV-PTV margin of 0.8 cm provided sufficient
coverage.
Vedam SS, et al. Med Phys. 2003
Treatment Delivery & Setup Correction Strategies in SBRT for tumors of the upper abdomen
Imaging for position verification and localization
The Calypso system (Varian Medical Systems, Palo Alto, CA) provides an option for internal motion monitoring for respiratory
gated treatment at a conventional linac.
With sub-mm accuracy, the system wirelessly and without ionizing radiation monitors the motion of electromagnetic
transponders implanted near the target
“A prospective cohort study on gated stereotactic liver radiotherapy based on continuous internal electromagnetic motion
monitoring» Esben S. et al. (Aarhus University Hospital, Denmark) IJROBP 2018
The Calypso system (Varian Medical Systems, Palo Alto, CA) provides an option for internal motion monitoring for respiratory
gated treatment at a conventional linac.
With sub-mm accuracy, the system wirelessly and without ionizing radiation monitors the motion of electromagnetic
transponders implanted near the target
“A prospective cohort study on gated stereotactic liver radiotherapy based on continuous internal electromagnetic motion
monitoring» Esben S. et al. (Aarhus University Hospital, Denmark) IJROBP 2018
CONCLUSION
• Calypso-guidance provides continuous internal motion monitoring
without ionizing radiation for motion adaptive liver SBRT.
• Compared to simulated non-gated standard treatments, Calypso-based
gating and couch adjustments to correct for baseline shifts markedly
improved the geometric and dosimetric accuracy of the treatments.
• With a relatively high duty cycle (mean 62.5%) during gated treatment
and swift remote couch shifts, the prolongation in treatment time
introduced by the Calypso usage was acceptable and tolerated by all
patients.
SBRT for tumors of the upper abdomen
Treatment Delivery & Setup Correction Strategies
Take home messages
Day-to-day differences in bowel position and shape should be considered
A motion study should be performed for all SBRT of tumors of the upper abdomen at the time of simulation
The full range of motion of the treatment phases for the target (ITV) must be incorporated into planning contours
At simulation, IV contrast is considered standard particularly for hepatocellular carcinoma
MIP images cannot be used for ITV, MinIP images can bean an appropriate tool on patients when the lesions have
homogenous low CT density, located intrahepatic, not adjacent to perihepatic organs
Planning image data sets can be derived from end expiration, CT50, or free breathing CT images
PTV margins are typically 5 mm radially and 10 mm CC
Consider motion limiting technique if normal tissue tolerances, based on Quantec guidelines, relevant NRG/ RTOG
protocols, or institutional criteria are exceeded, or if the interplay effect is of concern
We use a motion limit of 1 cm
Abdominal compression, gating at end expiration, breath hold are all valid strategies
Daily image guidance is required, with planar images or volumetric imaging using the diaphagram as target positon
surrogate or internal fiducials
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