This research was supported by Taipei Medical University Hospital (106TMUH-NE-02).

Taipei Medical University Joint Institutional Review Board approval was obtained for this study.
1. SBRT Consultation
<ol>
	<li>Assess patient eligibility for SBRT for the treatment of liver metastases by consulting a multidisciplinary tumor board. 
	NOTE: The need for local ablation as well as operation and other treatment options must be evaluated by the tumor board. Our selection criteria were as follows: 1) adult patients with a good performance status (Eastern Cooperative Oncology ...

<ol>
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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=SIRFLOX:+Randomized+Phase+III+Trial+Comparing+First-Line+mFOLFOX6+(Plus+or+Minus+Bevacizumab)+Versus+mFOLFOX6+(Plus+or+Minus+Bevacizumab)+Plus+Selective+Internal+Radiation+Therapy+in+Patients+With+Metastatic+Colorectal+Cancer.">SIRFLOX: Randomized Phase III Trial Comparing First-Line mFOLFOX6 (Plus or Minus Bevacizumab) Versus mFOLFOX6 (Plus or Minus Bevacizumab) Plus Selective Internal Radiation Therapy in Patients With Metastatic Colorectal Cancer.</a> J Clin Oncol. 34 (15), 1723-1731 (2016).</li><li>Salama, J. K., Milano, M. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radical+irradiation+of+extracranial+oligometastases.">Radical irradiation of extracranial oligometastases.</a> J Clin Oncol. 32 (26), 2902-2912 (2014).</li><li>Rusthoven, K. 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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+and+inter-observer+variability+of+3D+versus+4D+cone-beam+CT+based+image-guidance+in+SBRT+for+lung+tumors.">Accuracy and inter-observer variability of 3D versus 4D cone-beam CT based image-guidance in SBRT for lung tumors.</a> Radiat Oncol. 7, 81 (2012).</li><li>Takahashi, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Verification+of+Planning+Target+Volume+Settings+in+Volumetric+Modulated+Arc+Therapy+for+Stereotactic+Body+Radiation+Therapy+by+Using+In-Treatment+4-Dimensional+Cone+Beam+Computed+Tomography.">Verification of Planning Target Volume Settings in Volumetric Modulated Arc Therapy for Stereotactic Body Radiation Therapy by Using In-Treatment 4-Dimensional Cone Beam Computed Tomography.</a> Int J Radiat Oncol Biol Phys. 86 (3), 426-431 (2013).</li><li>Yeo, U. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+dosimetric+misrepresentations+from+3D+conventional+planning+of+liver+SBRT+using+4D+deformable+dose+integration.">Evaluation of dosimetric misrepresentations from 3D conventional planning of liver SBRT using 4D deformable dose integration.</a> J Appl Clin Med Phys. 15 (6), 4978 (2014).</li><li>Shinmohigashi, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Tumor+motion+changes+in+stereotactic+body+radiotherapy+for+liver+tumors:+an+evaluation+based+on+four-dimensional+cone-beam+computed+tomography+and+fiducial+markers.">Tumor motion changes in stereotactic body radiotherapy for liver tumors: an evaluation based on four-dimensional cone-beam computed tomography and fiducial markers.</a> Radiat Oncol. 12, 61 (2017).</li><li>Goodman, B. 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The authors have no disclosures.

Respiration-induced liver deformity and organ motion contribute to the difficulties associated with radiation delivery, as well as contouring (target delineation) problems. Improvements in the techniques used for organ motion management have led to improvements in treatment accuracy and precision, which is fundamental to SBRT. Several image-guided techniques and respiratory motion management systems are currently available. Fiducial marker implantation is a common technique for target localization. A fiducial marker is u...

Conventionally, metastasis is considered the terminal stage of cancer and is associated with poor prognosis and survival. However, Mountain et al. in 1984 reported that according to their 20-year experience, complete surgical removal of pulmonary metastasis results in a relatively higher survival rate if the primary tumor site is under systemic control at the time of surgery1. Hellman and Weichselbaum in 1995 first proposed oligometastases, an intermediate stage between localized lesions and systemic disease with polymetastases, which can be cured using additional local treatment2,3. Over the past decades, early detection of metastasis, novel surgical methods for treating oligometastases (metastasectomy), and effective chemotherapy have improved the prognosis in patients with metastasis. The liver is one of the most common metastatic organs for solid tumors, and surgical resection of hepatic oligometastases can improve survival. Local ablation methods, including radiofrequency ablation, radioembolization, and radiotherapy, for treating liver metastases have been recommended for some inoperable patients to achieve the necessary local tumor control3,4,5,6,7. In past years, several prospective and retrospective studies have reported effective local tumor control of hepatic metastases through stereotactic body radiotherapy (SBRT), also known as stereotactic ablative radiotherapy, with tolerable toxicity4,5,8,9.
Improvements have been made in patient positioning and immobilization methods; image acquisition, integration, and transfer to radiotherapy systems; respiratory motion management; high-dose output and fast radiation delivery; and steep dose gradients from target lesions to surrounding normal tissues. Because of these advances, SBRT achieves highly precise and accurate radiotherapy with minimal serious toxicity10,11. Respiratory motion management is fundamental to SBRT, particularly for hepatic and pulmonary lesions. A respiratory management technique that is noninvasive and clinically convenient would substantially increase the popularity of SBRT as a treatment option. This article details an SBRT protocol for liver metastases that uses four-dimensional computed tomography (4D-CT) with an abdominal compressor (AC) for image-guided assistance and liver motion management.

<table border="0" cellpadding="0" cellspacing="0" width="875">
	<tbody>
		<tr height="51">
			<td height="51" style="height:51px;width:195px;">CT scan</td>
			<td style="width:188px;">Philips</td>
			<td style="width:265px;">Brilliance&#160;Big Bore&#160;16 Slice&#160;CT, 7387</td>
			<td style="width:228px;">Acquire CT images for contouring and planning</td>
		</tr>
		<tr height="51">
			<td height="51" style="height:51px;width:195px;">CT contrast</td>
			<td style="width:188px;">GE Healthcare</td>
			<td style="width:265px;">Omnipaque 350 mg L/mL</td>
			<td style="width:228px;">Enhence lesion in CT images</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Linear accelerator</td>
			<td>Elekta</td>
			<td>Synergy</td>
			<td>Deliver radiotherapy</td>
		</tr>
		<tr height="40">
			<td height="40" style="height:40px;">Palnning system</td>
			<td>Pinnacle</td>
			<td>Pinnacle 9.8</td>
			<td>Implement radiotherapy planning</td>
		</tr>
		<tr height="65">
			<td height="65" style="height:65px;width:195px;">Immobilization: BlueBag BodyFix</td>
			<td>Elekta</td>
			<td>900 mm x 2325 mm, P10104840</td>
			<td>Immobilize the patient</td>
		</tr>
		<tr height="66">
			<td height="66" style="height:66px;width:195px;">Immobilization: BodyFix Cover sheet</td>
			<td>Elekta</td>
			<td>2700 mm x 1400 mm, P10102-304</td>
			<td>Immobilize the patient</td>
		</tr>
		<tr height="73">
			<td height="73" style="height:73px;width:195px;">Immobilization: BodyFix abdominal compressor</td>
			<td>Elekta</td>
			<td>diaphragm control, P10102-149</td>
			<td style="width:228px;">Restrict breath motion and organ/lesion motion</td>
		</tr>
		<tr height="57">
			<td height="57" style="height:57px;width:195px;">Immobilization: vacuum pump</td>
			<td>Elekta</td>
			<td>vacuum pump, p2 120V, P10102-110</td>
			<td style="width:228px;">Shape body bag and cover sheet according to the patient</td>
		</tr>
	</tbody>
</table>

treatment of liver metastases using an internal target volume method for stereotactic body radiotherapy

The prognosis of patients with metastatic cancers has improved in the past decades due to effective chemotherapy and oligometastatic surgery. For inoperable patients, local ablation therapies, such as stereotactic body radiotherapy (SBRT), can provide effective local tumor control with minimal toxicity. Because of its high precision and accuracy, SBRT delivers a higher radiation dose per fraction, is more effective, and targets smaller irradiation volumes than does conventional radiotherapy. In addition, steep dose gradients from target lesions to surrounding normal tissues are achieved using SBRT; thus, SBRT provides more effective tumor control and exhibits fewer side effects than conventional radiotherapy. The use of SBRT is prevalent for treating intracranial lesions (known as stereotactic radiosurgery); however, it is now also used for treating spinal and adrenal metastases. Because of advancements in image-guided assistance and respiratory motion management, several studies have investigated the use of SBRT for treating lung or liver tumors, which move as a patient breathes. The results of these studies have suggested that SBRT favorably controls tumors in the case of moving lesions.
Four-dimensional computed tomography (4D-CT) with an abdominal compressor (AC) is clinically convenient for effective respiratory motion management. Because this method is noninvasive and allows free breathing, its use reduces complications. Furthermore, patients consider this method convenient. Moreover, it is considered more efficient than other methods of respiratory motion management by physicians and therapists. The use of 4D-CT with an AC for treating pulmonary lesions has also been widely investigated, and the technique is gaining acceptance for treating hepatic lesions. However, the protocols for using 4D-CT with an AC for treating hepatic lesions are different from those used for treating pulmonary lesions. In this article, we describe a new protocol for SBRT with 4D-CT and an AC for treating liver metastases.

SBRT can be implemented by intense-modulated radiotherapy (IMRT) (with <img alt="image" src="/files/ftp_upload/57050/57050imgv2.jpg" /> 6 radiation beams) or volumetric arc radiotherapy (VMAT) (with continuous dose delivery and gantry rotation) to cover all targets in a single treatment because a single surgery may not achieve removal of all the tumors. A representative SBRT treatment plan demonstrated successful radiotherapy planning for two hepatic metastatic tumors when surgery was inf...

Watch this Scientific Journal Video about Treatment of Liver Metastases Using an Internal Target Volume Method for Stereotactic Body Radiotherapy at JoVE.com

Treatment of Liver Metastases Using an Internal Target Volume Method for Stereotactic Body Radiotherapy

Stereotactic body radiotherapy (SBRT) requires rigorous accuracy and precision for delivering high radiation doses per fraction to small treatment volumes to improve tumor control and simultaneously reduce toxicity. Herein, we present a noninvasive and clinically convenient respiratory motion management protocol for SBRT for liver metastases.

The prognosis of patients with metastatic cancers has improved in the past decades due to effective chemotherapy and oligometastatic surgery. For ...

The overall goal of this motion management and image guided technique is to use stereotactic body radiotherapy or SBRT to treat liver metastases. This measure can help make SBRT a significantly more feasible and accessible option for treating liver metastases. The main advantages of this technique are that it is non-invasive, does not require extensive training, and has more manageable treatment and it work for us for both patients and the staff.We first had the idea when we compare fiducial marker, air breath control and full-dimensional computed tomography or CT with abdominal compressor use in the irradiation of hepatocellular carcinomas. Demonstrating the procedure will be Yang-Bin Lin, a technician from our department. To begin place the patient in the supine position, head first with the arms over the head, and secure the patient onto the couch.Make a personalized evacuated vacuum bag according to the patient's position and body shape, and cover the patient with the cover sheet. Apply an abdominal compressor, and mark the depth of the compressor. Then, place a breath tracking sensor on the chest wall, and monitor the respiratory wave form.To acquire CT images for radiotherapy treatment planning, first select the 4D-CT mode with a three millimeter slice thickness. Click go on both the screen and the control panel to conduct a SERV-U scan for obtaining both anterior, posterior, and lateral views of the patient. On the helical scan page, set the CT scanning coverage area to extend from the apex of both lungs to five centimeters from the caudal border of the liver.On the pulmonary gating scan page, set the 4D-CT scanning field to cover the liver, extending three to five centimeters from both the cranial and caudal liver borders. When the respiratory wave form has been stable for three minutes, inject 100 milliliters of an appropriate contrast agent through an 18 gauge IV catheter into the antecubital vein At a rate of four to five milliliters per second. 15 seconds after all of the agent has been injected, conduct a contrasted contiguous helical CT scan.Then, click next series to conduct a 4D-CT scan. For radiotherapy treatment planning, first import the images from the CT simulation and diagnostic scans into the planning system. To contour the metastatic tumors into gross tumor volume and adjacent organs at risk, first select an organ of interest, and a contour tool to select the organ in each slice of the CT slice.The gross tumor volume can be determined using the diagnostic images from the CT scan, MRI, and opaque scans. As well as the contrast images from the CT simulation. Next, contour the internal target volume of the tumors according to the organ motion observed on the dynamic tracking images adding a five millimeter margin to the internal target volume to obtain the planning target volume.Observe all of the dynamic images of the entire liver area to ascertain the tumor and liver movement during respiration. Then contour the internal target volume in all of the dynamic slices to encompass the entire tumor motion. On the day of the treatment, first identify the patient by name, birth date, and ID card.Position the patient in the vacuum bag. Place the cover sheet, and fix the abdominal compressor as just demonstrated. When the patient is ready, acquire a 4D cone beam CT image, and adjust the couch to corelate the target location obtained on the 4D cone beam CT image to that obtained on the simulation CT images.At the end of the scan, load the image into the image guided radiotherapy system. The upper left and lower right images are from the CT simulation for the contouring and treatment planning. The upper right and lower left images are from the 4D cone beam CT.Compare the difference of patient position according to images from CT simulation, and confirm treatment location daily.Then, manually adjust the couch position to eliminate set-up error of patient position. Record and print out the parameters for daily adjustment. Then, confirm the treatment plan and the system configuration, and click go to start the treatment, monitoring the patient during the entire treatment using real-time cameras to ensure patient safety.In this study, an SBRT treatment plan demonstrated successful radiotherapy planning for two hepatic metastatic tumors for which surgery or another local ablation therapy was not feasible. The two metastatic tumors were three centimeters and 4.3 centimeters in length with 13 cubic centimeter and 22 cubic centimeter volumes respectively. The prescribed dose was 50 grays in five fractions, and the four partial beam arcs were directed to avoid the organs at risk.These dose volume histograms illustrate the coverage over both of the tumors with 100%of the volume of the planning target volume covered by greater than 95%of the prescribed dose, and with the radiation doses to the organs at risk, within an appropriately restricted range. Once mastered, the CT simulation and image guidance before each fraction steps, can be completed in 10 minutes each if they are performed properly. While attempting this procedure, it's important to remember to monitor the patient's condition to confirm that they can tolerate and breathe normally under the abdominal compression.After its implementation, this technique has paved the way for radiation oncologists in the inspiration of exerting local control of all local metastases in the liver without invasive motion management or inconvenient image guidance techniques in SBRT. After watching this video, you should have a good understanding of how to adapt a 4D-CT scan with abdominal compressor in image guided radiotherapy and the internal target volume in SBRT for liver metastasis. As not every patient is eligible for or willing to have an invasive procedure, this technique provides a non-invasive convenient option that requires minimal training for local operation for a oligometastasis in the liver.

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14.0K visualizações.  Taipei Medical University Hospital. The overall goal of this motion management and image guided technique is to use stereotactic body radiotherapy or SBRT to treat liver metastases. This measure can help make SBRT a significantly more feasible and accessible option for treating liver metastases. The main advantages of this technique are that it is non-invasive, does not require extensive training, and has more manageable treatment and it work for us for both patients and the staff.We first had the idea when we compare fi...