Stereotactic Body Radiation Therapy for Patients with Heavily Pretreated Liver Metastases and Liver Tumors

We present our initial experience with CyberKnife stereotactic body radiation therapy (SBRT) in a heavily pretreated group of patients with liver metastases and primary liver tumors. From October 2007 to June 2009, 48 patients were treated at the Philadelphia CyberKnife Center for liver metastases or primary liver tumors. We report on 30 patients with 41 discrete lesions (1–4 tumors per patient) who received an ablative radiation dose (BED ≥ 79.2 Gy10 = 66 Gy EQD2). The treatment goal was to achieve a high SBRT dose to the liver tumor while sparing at least 700 cc of liver from radiation doses above 15 Gy. Twenty-three patients were treated with SBRT for metastatic cancer to the liver; the remainder (n = 7) were primary liver tumors. Eighty-seven percent of patients had prior systemic chemotherapy with a median 24 months from diagnosis to SBRT; 37% had prior liver directed therapy. Local control was assessed for 28 patients (39 tumors) with 4 months or more follow-up. At a median follow-up of 22 months (range, 10–40 months), 14/39 (36%) tumors had documented local failure. A decrease in local failure was found with higher doses of SBRT (p = 0.0237); 55% of tumors receiving a BED ≤ 100 Gy10 (10/18) had local failure compared with 19% receiving a BED > 100 Gy10 (4/21). The 2-year actuarial rate of local control for tumors treated with BED > 100 Gy10 was 75% compared to 38% for those patients treated with BED ≤ 100 Gy10 (p = 0.04). At last follow-up, 22/30 patients (73%) had distant progression of disease. Overall, seven patients remain alive with a median survival of 20 months from treatment and 57 months from diagnosis. To date, no patient experienced persistent or severe adverse effects. Despite the heavy pretreatment of these patients, SBRT was well tolerated with excellent local control rates when adequate doses (BED > 100 Gy10) were used. Median survival was limited secondary to development of further metastatic disease in the majority of patients

SBRT: An opportunity to improve quality of life for oligometastatic prostate cancer?

Objective: Oligometastatic prostate cancer is a limited metastatic disease state in which potential long-term control is still possible with the use of targeted therapies such as surgery or stereotactic body radiation therapy (SBRT). SBRT may as well potentially prolong the time before the initiation of androgen deprivation therapy (ADT) and docetaxel chemotherapy for oligometastatic prostate cancer. The goal of this study is to outline prognostic factors associated with improved outcome with SBRT for metastatic prostate cancer and to quantify the effect of prior systemic treatments such as ADT and docetaxel on survival after SBRT.Methods: Twenty-four prostate cancer patients were treated with SBRT at the Philadelphia CyberKnife Center between August 2007 and April 2014. Retrospective data collection and analysis were performed for these patients on this IRB approved study. Kaplan–Meier methodology was utilized to estimate and visually assess overall survival at the patient level, with comparisons accomplished using the log-rank test. Unadjusted hazard ratios were estimated using Cox proportional hazards regression modeling. Results: An improved median survival was noted for patients with oligometastatic disease defined as 4 or fewer lesions with median survival of greater than 3 years compared with 11 months for polymetastases (p=0.02). The use of docetaxel at some time in follow up either before or after SBRT was associated with decreased survival with median survival of 9 months vs. greater than 3 years (p=0.01). Conclusion: Prognosis was better for men with recurrent prostate cancer treated with SBRT if they had 4 or less metastases (oligometastases) or if docetaxel was not necessary for salvage treatment. The prolonged median overall survival for men with oligometastases in this population of heavily pretreated prostate cancer patients following SBRT may allow for improved quality of life due to a delay of more toxic salvage therapies

Definitive Treatment of Early-Stage Non-Small Cell Lung Cancer with Stereotactic Ablative Body Radiotherapy in a Community Cancer Center Setting

IntroductionSABR provides a superior NSCLC treatment option when compared to conventional radiotherapy for patients deemed inoperable or refusing surgery. This study retrospectively analyzed the rates of tumor control and toxicity following SABR treatment (Cyberknife system) of primary early-stage NSCLC in a community setting.MethodsOne hundred patients were treated between 2007 and 2011. Patients with T3-4 or N1-3 disease, metastasis, recurrent local disease, or a non-lung primary were excluded from analysis. All patients had biopsy proven disease. Staging included CT or FDGPET scan. Median dose was 54Gy (45-60); 18Gy (10-20) per fraction. Median PTV expansion was 8mm (2-10). Median BED was 151.2. Tumors were tracked via Synchrony, X-Sight Lung, or X-Sight Spine. Patients were evaluated for local control, overall survival, and toxicity. All local failures were determined by evaluating post treatment PET/CT.ResultsWith a median follow up of 27.5 months, the 1-, 2-, and 3-year local control rates were 100%, 93.55%, and 84.33%, respectively. Median survival was 2.29 years; actuarial 3- year survival was 37.20%. Grade-3 toxicity was observed in 2% of patients (pneumonia within two months of treatment, n=1; chronic pneumonitis requiring hospital admission, n=1). No patients demonstrated toxicity above Grade-3. Multivariate analysis did not show T-stage as an independent predictor of OS, though it did trend toward significance.ConclusionIn a community-center setting, definitive treatment of NSCLC with SABR for nonsurgical candidates and those who choose to forego surgery result in excellent and comparable rates of local control and toxicity compared to published series from large academic centers

Salvage fractionated Stereotactic Radiotherapy (fSRT) with or without chemotherapy and immunotherapy for recurrent Glioblastoma Multiforme: A single institution experience

Background: The current standard of care for salvage treatment of Glioblastoma Multiforme (GBM) is gross total resection and adjuvant chemoradiation for operable patients. Limited evidence exists to suggest that any particular treatment modality improves survival for recurrent GBM, especially if inoperable. We report our experience with fractionated stereotactic radiotherapy (fSRT) with and without chemo/immunotherapy, identifying prognostic factors associated with prolonged survival. Methods: From 2007 to 2014, 19 patients between 29 and 78 years old (median 55) with recurrent GBM following resection and chemoradiation for their initial tumor, received 18 – 35 Gy (median 25) in 3 – 5 fractions via Cyberknife fSRT. Clinical target volume (CTV) ranged from 0.9 to 152 cc. Sixteen patients received adjuvant systemic therapy with bevacizumab (BEV), temozolomide (TMZ), anti-epidermal growth factor receptor (125)I-mAb 425, or some combination thereof. Results: The median overall survival (OS) from date of recurrence was 8 months (2.5 – 61) and 5.3 months (0.6 – 58) from the end of fSRT. The OS at 6 and 12 months was 47% and 32%, respectively. Three of 19 patients were alive at the time of this review at 20, 49 and 58 months from completion of fSRT. Hazard ratios for survival indicated that patients with a frontal lobe tumor, adjuvant treatment with either BEV or TMZ, time to first recurrence >16 months, CTV < 36 cc, Recursive Partitioning Analysis (RPA) < 5, and ECOG (Eastern Cooperative Oncology Group) performance status < 2 were all associated with improved survival (P <0.05). There was no evidence of radionecrosis for any patient.Conclusions: Radiation Therapy Oncology Group (RTOG) 1205 will establish the role of reirradiation for recurrent GBM, however our study suggests that cyberknife with chemotherapy can be safely delivered, and is most effective in patients with smaller frontal lobe tumors, good performance status or long interval from diagnosis