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STEREOTACTIC RADIOSURGERY IN THE MANAGEMENT OF LIVER AND
PANCREATIC TUMORS
C. RONALD KERSH, MD, FACR
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LIVER AND PANCREAS CANCER STEREOTACTIC
RADIOSURGERY
DEFINE WHAT IS STEREOTACTIC RADIOSURGERY
REVIEW METASTATIC LIVER TUMORS
REVIEW OUR PUBLISHED LITERATURE
REVIEW PRIMARY LIVER TUMORS
REVIEW ROLE OF RADIATION IN PANCREAS
OBJECTIVES
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WHAT IS RADIATION ONCOLOGY??
• ONE OF THE THREE SPECIALTIESSURGERYMEDICAL ONCOLOGY
LINEAR ACCELERATOR GAMMA KNIFE
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WHAT IS RADIATION ONCOLOGY??
• USED AS A PRIMARY TREATMENTPROSTATE, LUNG, HEAD AND NECK, HODGKINS DISEASE
• USED AS AN ADJUVANT TO SURGERYCHEMOTHERAPY AND IMMUNOTHERAPY
COLO-RECTAL , LUNG, HEAD AND NECK, BREAST, GYNPANCREAS, STOMACH, SARCOMAS
• USED TO IMPROVE SYMPTOMSBRAIN, SPINE, LIVER, ADRENAL, BONE
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ISN’T RADIATION BAD ??
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WHAT IS A RADIATION ONCOLOGIST?
• 4 YEARS OF COLLEGE
• PHYSICS AND MATH
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WHAT IS A RADIATION ONCOLOGIST?
• 4 YEARS OF MEDICAL SCHOOL
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WHAT IS A RADIATION ONCOLOGIST?
• INTERNSHIP ONE YEAR• RESIDENCY FOUR YEARS +/- FELLOWSHIP
• HELPED TRAIN > 100 RESIDENTS IN 37 YEARS
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WHAT IS A RADIATION ONCOLOGIST?
• TOP 10% OF MEDICAL STUDENTS
• 4,400 RADIATION ONCOLOGISTS IN USA400 DEDICATED RADIOSURGEONS
• TREAT 300 – 400 NEW PATIENTS PER YEAR
• ODDS OF CANCER IN LIFETIMEMALES = 39.66%FEMALES = 37.65%
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WHAT IS A RADIATION ONCOLOGIST?
INVOLVED IN THE TRAINING AND INSTILLATION OF 4 RUSSIAN CENTERS
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WHAT IS A RADIATION ONCOLOGIST?
• USE OF EXTERNAL BEAM RADIATIONWILLLIAMSBURG RADIATION – DR. CHISAM
• USE OF INTERNAL OR IMPLANTABLE RADIATIONBRACHYTHERAPY
• STEREOTACTIC RADIOSURGERY
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Lars Leksell, MD, PhD
1951 – STEREOTACTIC RADIOSURGERY
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DR. LADISLAU STEINER - SWEDEN
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Stereotactic Radiosurgery
GreekStereo = solid;
3 – dimensional (stere’os)
LatinTactic = to touch
(tactus)
Radio = beam (radius)
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Modern Stereotactic Systems
• Incorporate all advanced neuroimaging (e.g. SPECT, PET, functional MRI)
• MR compatible• Accurate and precise• User friendly• Concept of “minimally invasive surgery”
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Types of Stereotactic Radiosurgery
• Gamma Knife• Modified LINAC’s• Proton Beam• Cyberknife• X-Knife• Synergy-S• Tomotherapy• Novalis• Edge
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Chesapeake Regional, Riverside & UVA Radiosurgery Center Background
• Joint venture• Riverside Health System – Newport News• University of Virginia Gamma Knife Center• Chesapeake General Hospital (recent)
• June 2006 – Gamma Knife• SEPT 2019 - over 1200 SRS cases treated
• May 2007 – Synergy S• June 2018- over 2250 SBRT cases treated• Varian Edge – 350 9/30/19
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Chesapeake Regional, Riverside & UVA Radiosurgery Center
• Intra-cranial SRS (Gamma Knife)• Intra-cranial SRS/SRT (Varian Edge)
• Mets, Clivus, Sinus, Parotid, Pituitary
• Extra-cranial SBRT (Varian Edge)• Lung (incl. lymph nodes) and Spine –
majority of cases• Other – liver, pancreas, adrenal, kidney,
bladder, lymph nodes and other soft tissue masses, etc.
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• Non-invasive form of cancer treatment
• Small, highly focused accurate radiation beams
• Delivery in 1–5 fractions• Represents a major paradigm
shift in radiation biology• Advancement in tumor motion
quantification and image guidance was key
What is Stereotactic Radiation?
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• High ablative dose– SRS=Single Fx, SBRT=1-5 Fx– Overwhelms repair/repopulation mechanisms– Results in a high Biological Equivalent Dose
(BED)• Short Treatment (1-5 treatments)• Tight target and rapid dose fall off
– Damages tumor in high dose area– Limits toxicity to surrounding normal tissue
Why is SBRT useful?
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Advantage of SBRT
Outpatient 30-45 MinutesPer Treatment
Entire course ofRx in 3-5 weeks
No Sedation orAnesthesia(painless)
1 Treatmentweekly
Immediate ReturnTo Activities
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Proposed Biological Basis of SBRT
Balagamwala et al.
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Multidisciplinary Approach to Stereotactic Radiosurgery Liver
Radiology RadiotherapyRadiation Technicians
andRadiation Oncologists
MedicalPhysics
Medical Oncology
Pathology
Gastrointestinal Physicians
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Role of SBRT in Liver Cancer
METASTATIC LIVER TUMORS
HEPATOCELLULAR CARCINOMA
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WHAT IS A METASTASIS?
CANCER THAT HAS SPREAD FROM PRIMARY SITE TO OVER SITES IN THE BODY
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WHERE DO CANCERS SPREAD?
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WHERE DO CANCERS SPREAD?
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WHY DO CANCERS SPREAD TO THE LIVER
BLOOD FLOW PER MINUTE LIVER IS SECOND TO ONLY THE LUNG
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WHY DO CANCERS SPREAD TO THE LIVER??
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INCIDENCE OF LIVER METASTASESWHEN CANCERS SPREAD
COLON CANCER = 65%
PANCREAS = 63%
BREAST = 61%
OVARY = 52%
RECTUM AND STOMACH = 47%
LUNG = 36%
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METASTATIC LIVER TUMORS -
CURRENT TREATMENTS
SURGICAL RESECTION = 20-40% SURVIVAL (ONLY 10-20% RESECTABLE)
CHEMOTHERAPY = 20% RESPONSE RATE RADIOFRQEUNCY ABLATION = RECURRENCE
RATE OF 40% - NEW METS = 50% CHEMOEMBOLIZATION = RESPONSE RATES
15 – 40 %HEPATIC ARTERY CHEMOINFUSION = 20-30% RESPONSE RATE
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LIVER METASTASES RADIOSURGERY
3 OR FEWER TUMORS
< 4.0 CM = 1.57 INCHES
MUST HAVE DEDICATEDRADIOSURGERY PROGRAM
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9/2013 TREATED WITH 8Gy X 3 10 / 2019
47 NURSE, BREAST CANCER, TOLD SHE HAD 6 MONTHS TO LIVE
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David Asher, MD 1; David Bergman, MD 1 Akanksha Rajeurs, MD 1; Zaker Rana, MD 1 Kelly Spencer, MS, DABMP 1; Martin K.
Richardson, MS, DABR 1; Ronald Kersh, MD 1,2
1 Chesapeake Regional, Riverside and University of Virginia Radiosurgery Center, Newport News, VA, 2 University of Virginia, Charlottesville, VA
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50,000
25%
• SBRT
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UVA-RIVERSIDE RADIOSURGERY
• July 2007 – August 2015
• Local Control
• Toxicity
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UVA-RIVERSIDE RADIOSURGERY
Total PatientsTotal Number of Lesions
80128
Females 46
Males 34
# that received chemotherapy within 6 months
64
Median/Mean Age (years) 67.3 / 64.5
Age Range 32 - 91
• No patients were considered candidates for surgical resection at time of radiation
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• 4D image guidance
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Median / Mean Prescription Dose (Gy)
30.0 / 28.8 Gy
Dose (Gy) Range 18 – 40 Gy
Median / Mean # of Fractions
3 / 3
Median / Mean # of Lesions Treated
1.0 / 1.6
Range of # of Lesions Treated
1 – 4
Mean Interval BetweenFractions (days)
5 days
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• 86.2% Local control rate
• At 1 year: 41.3%
• <5% complication rate (Grade 2+ toxicity
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Tumor ResponseNumber of
Lesions% of Lesions
Complete or Partial Response
41 37.6%
Stable 53 48.6%
Increase 15 13.8%
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• 6 months: 89.3%• 12 months: 81.8%• 24 months: 79.5%
Local Control After Treatment
0 12 24 36 48 600
20
40
60
80
100
Months
Perc
ent w
ith L
ocal
Con
trol
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0 1 2 2 4 3 60
2 5
5 0
7 5
1 0 0
L o c a l C o n tr o l a n d P re s c r ip t io n D o s e
M o n ths
Pe
rce
nt
Lo
cal
Co
ntr
ol < 3 0 G y
> = 3 0 G y
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Category Log-Rank P-valueStatistically Significant?
Primary Tumor 0.0073 Yes
Prescription Dose 0.0163 Yes
Tumor Size (GTV) 0.0991 No
Number of Lesions 0.3538 No
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• Median Overall Survival: 21.0 months
Gynecologic Lesions
Ovarian (16)
Uterine (3)Vulvar (1)
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ToxicityNumber of
PatientsCTCAE 4.0
GradeResolved?
Pain 5Grade 1 (4)Grade 2 (1)
Yes
Nausea / Vomiting
4 Grade 1 Yes
Diarrhea 3 Grade 1 Yes
Cholangitis 1 Grade 2 Yes
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• No Radiation Induced Liver Disease
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