Skip to main content
SpringerLink
Log in

External Beam Radiation Therapy for Liver Tumors: Simulation, Treatment Planning, and Advanced Delivery Techniques

  • Chapter
  • First Online:
Radiation Therapy for Liver Tumors

  • 1119 Accesses

Abstract

The advent of modern radiation therapy techniques has allowed for improved planning and delivery of radiation therapy for primary and metastatic liver disease. In particular, the use of stereotactic body radiation therapy (SBRT) offers the potential for enhanced local control of intrahepatic malignancies. The hypofractionated nature of SBRT requires special care to be taken during all stages of planning and treatment delivery to ensure accurate delivery of dose distributions which are necessarily conformal in order to achieve adequate sparing of healthy liver and surrounding normal tissues. Details involved in the planning and delivery of SBRT for liver cancer are the subject of this work. In particular, the authors describe the use of various imaging techniques, such as PET, contrast-enhanced CT, and 4DCT to aid in the accurate delineation of liver tumors. They also describe the use of fiducial markers for target localization. Conformal planning techniques such as 3D conformal radiation therapy (3DCRT) and volumetric-modulated arc therapy (VMAT) are discussed, as are dose-limiting toxicities and dose constraints for the healthy liver, gastrointestinal tract, and chest wall. Special attention is given to the use of motion management techniques in combination with daily image guidance to ensure accurate delivery of SBRT. The authors conclude with a discussion of practical issues that pertain to the development of a liver SBRT program including equipment commissioning and quality assurance.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 89.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Dawson LA, McGinn CJ, Normolle D, Ten Haken RK, Walker S, Ensminger W, Lawrence TS. Escalated focal liver radiation and concurrent hepatic artery fluorodeoxyuridine for unresectable intrahepatic malignancies. J Clin Oncol. 2000;18:2210–8.

    Article  CAS  PubMed  Google Scholar 

  2. Mohiuddin M, Chen E, Ahmad N. Combined liver radiation and chemotherapy for palliation of hepatic metastases from colorectal cancer. J Clin Oncol. 1996;14:722–8.

    Article  CAS  PubMed  Google Scholar 

  3. Robertson JM, Lawrence TS, Andrews JC, Walker S, Kessler ML, Ensminger WD. Long-term results of hepatic artery fluorodeoxyuridine and conformal radiation therapy for primary hepatobiliary cancers. Int J Radiat Oncol Biol Phys. 1997;37:325–30.

    Article  CAS  PubMed  Google Scholar 

  4. Kothary N, Heit JJ, Louie JD, Kuo WT, Loo BW Jr, Koong A, Chang DT, Hovsepian D, Sze DY, Hofmann LV. Safety and efficacy of percutaneous fiducial marker implantation for image-guided radiation therapy. J Vasc Interv Radiol. 2009;20:235–9. doi:10.1016/j.jvir.2008.09.026.

    Article  PubMed  Google Scholar 

  5. Fuss M, Salter BJ, Rassiah P, Cheek D, Cavanaugh SX, Herman TS. Repositioning accuracy of a commercially available double-vacuum whole body immobilization system for stereotactic body radiation therapy. Technol Cancer Res Treat. 2004;3:59–67. doi:10.1177/153303460400300107.

    Article  PubMed  Google Scholar 

  6. Hara R, Itami J, Aruga T, Kozuka T, Yamashita H, Abe Y, Fuse M, Kondo T, Shinohara D, Nagaoka T, Kobiki T. Development of stereotactic irradiation system of body tumors under respiratory gating. Nihon Igaku Hoshasen Gakkai Zasshi. 2002;62:156–60.

    PubMed  Google Scholar 

  7. Kini VR, Vedam SS, Keall PJ, Patil S, Chen C, Mohan R. Patient training in respiratory-gated radiotherapy. Med Dosim. 2003;28:7–11. doi:10.1016/S0958-3947(02)00136-X.

    Article  PubMed  Google Scholar 

  8. Vedam SS, Keall PJ, Kini VR, Mohan R. Determining parameters for respiration-gated radiotherapy. Med Phys. 2001;28:2139–46. doi:10.1118/1.1406524.

    Article  CAS  PubMed  Google Scholar 

  9. Heinzerling JH, Anderson JF, Papiez L, Boike T, Chien S, Zhang G, Abdulrahman R, Timmerman R. Four-Dimensional computed tomography scan analysis of tumor and organ motion at varying levels of abdominal compression during stereotactic treatment of lung and liver. Int J Radiat Oncol Biol Phy 2008;70:1571–1578. doi:10.1016/j.ijrobp.2007.12.023.

  10. Dawson LA, Eccles C, Bissonnette JP, Brock KK. Accuracy of daily image guidance for hypofractionated liver radiotherapy with active breathing control. Int J Radiat Oncol Biol Phys. 2005;62:1247–52. doi:10.1016/j.ijrobp.2005.03.072.

    Article  PubMed  Google Scholar 

  11. Depuydt T, Verellen D, Haas O, Gevaert T, Linthout N, Duchateau M, Tournel K, Reynders T, Leysen K, Hoogeman M, Storme G, Ridder MD. Geometric accuracy of a novel gimbals based radiation therapy tumor tracking system. Radiother Oncol. 2011;98:365–72. doi:10.1016/j.radonc.2011.01.015.

    Article  PubMed  Google Scholar 

  12. Ozhasoglu C, Saw CB, Chen H, Burton S, Komanduri K, Yue, NJ, Huq SM, Heron DE. Synchrony—Cyberknife respiratory compensation technology. Med Dosim, Image-Guided Radiation Therapy:Part 4–Focal Irradiation and Image Fusion Techniques 2008;33:117–123. doi:10.1016/j.meddos.2008.02.004.

  13. Herfarth KK, Debus J, Lohr F, Bahner ML, Fritz P, Höss A, Schlegel W, Wannenmacher MF. Extracranial stereotactic radiation therapy: set-up accuracy of patients treated for liver metastases. Int J Radiat Oncol Biol Phys. 2000;46(2):329–35.

    Article  CAS  PubMed  Google Scholar 

  14. Lax I, Blomgren H, Näslund I, Svanström R. Stereotactic radiotherapy of malignancies in the abdomen. Methodol Aspects Acta Oncol. 1994;33(6):677–83.

    Article  CAS  Google Scholar 

  15. Lovelock DM, Zatcky J, Goodman K, Yamada Y. The effectiveness of a pneumatic compression belt in reducing respiratory motion of abdominal tumors in patients undergoing stereotactic body radiotherapy. Technol Cancer Res Treat. 2014;13(3):259–67.

    PubMed  Google Scholar 

  16. Wulf J, Hädinger U, Oppitz U, Olshausen B, Flentje M. Stereotactic radiotherapy of extracranial targets: CT-simulation and accuracy of treatment in the stereotactic body frame. Radiother Oncol. 2000;57(2):225–36.

    Article  CAS  PubMed  Google Scholar 

  17. de Pooter JA, Wunderink W, Méndez Romero A, Storchi PRM, Heijmen BJM. PTV dose prescription strategies for SBRT of metastatic liver tumours. Radiother Oncol. 2007;85:260–6. doi:10.1016/j.radonc.2007.08.004.

    Article  PubMed  Google Scholar 

  18. Kavanagh BD, Schefter TE, Cardenes HR, Stieber VW, Raben D, Timmerman RD, McCarter MD, Burri S, Nedzi LA, Sawyer TE, Gaspar LE. Interim analysis of a prospective phase I/II trial of SBRT for liver metastases. Acta Oncol. 2006;2006(45):848–55. doi:10.1080/02841860600904870.

    Article  Google Scholar 

  19. Rusthoven KE, Kavanagh BD, Cardenes H, Stieber VW, Burri SH, Feigenberg SJ, Chidel MA, Pugh TJ, Franklin W, Kane M, Gaspar LE, Schefter TE. Multi-Institutional phase I/II trial of stereotactic body radiation therapy for liver metastases. JCO. 2009;27:1572–8. doi:10.1200/JCO.2008.19.6329.

    Article  Google Scholar 

  20. van der Pool AEM, Méndez Romero A, Wunderink W, Heijmen BJ, Levendag PC, Verhoef C, IJzermans JNM. Stereotactic body radiation therapy for colorectal liver metastases. Br J Surg 2010;97:377–382. doi:10.1002/bjs.6895.

  21. Wambersie A, Landberg T. International commission on radiation units and measurements; Supplement to ICRU Report 50; 1999.

    Google Scholar 

  22. Goodman KA, Wiegner EA, Maturen KE, Zhang Z, Mo Q, Yang G, Gibbs IC, Fisher GA, Koong AC. Dose-escalation study of single-fraction stereotactic body radiotherapy for liver malignancies. Int J Radiat Oncol Biol Phys. 2010;78(2):486–9.

    Article  PubMed  Google Scholar 

  23. Liu R, Buatti JM, Howes TL, Dill J, Modrick JM, Meeks SL, Optimal number of beams for stereotactic body radiotherapy of lung and liver lesions. Int J Radiat Oncol Biol Phys 2006;66:906–912. doi:10.1016/j.ijrobp.2006.05.014.

  24. Tanyi JA, Summers PA, McCracken CL, Chen Y, Ku L-C, Fuss M. Implications of a high-definition multileaf collimator (HD-MLC) on treatment planning techniques for stereotactic body radiation therapy (SBRT): a planning study. Radiat Oncol. 2009;4:22. doi:10.1186/1748-717X-4-22.

    Article  PubMed  PubMed Central  Google Scholar 

  25. de Pooter JA, Romero AM, Wunderink W, Storchi PRM, Heijmen BJM. Automated non-coplanar beam direction optimization improves IMRT in SBRT of liver metastasis. Radiother Oncol. 2008;88:376–81. doi:10.1016/j.radonc.2008.06.001.

    Article  PubMed  Google Scholar 

  26. Webb S. Intensity-Modulated Radiation Therapy. CRC Press; 2001

    Google Scholar 

  27. Bortfeld T. IMRT: a review and preview. Phys Med Biol. 2006;51:R363. doi:10.1088/0031-9155/51/13/R21.

    Article  PubMed  Google Scholar 

  28. Bortfeld T, Jokivarsi K, Goitein M, Kung J, Jiang SB. Effects of intra-fraction motion on IMRT dose delivery: statistical analysis and simulation. Phys Med Biol. 2002;47:2203. doi:10.1088/0031-9155/47/13/302.

    Article  PubMed  Google Scholar 

  29. Yu CX, Jaffray DA, Wong JW. The effects of intra-fraction organ motion on the delivery of dynamic intensity modulation. Phys Med Biol. 1998;43:91–104.

    Article  CAS  PubMed  Google Scholar 

  30. Ecclestone G, Pierce G. The role of VMAT interplay effects for liver stereotactic body radiation therapy. In: Jaffray AD, editor. World Congress on Medical Physics and Biomedical Engineering, June 7-12, 2015, Toronto, Canada. Cham: Springer International Publishing; 2015. p. 409–12.

    Chapter  Google Scholar 

  31. Stambaugh C, Nelms BE, Dilling T, Stevens C, Latifi K, Zhang G, Moros E, Feygelman V. Experimentally studied dynamic dose interplay does not meaningfully affect target dose in VMAT SBRT lung treatments. Med Phys. 2013;40:91710. doi:10.1118/1.4818255.

    Article  Google Scholar 

  32. Otto K. Volumetric modulated arc therapy: IMRT in a single gantry arc. Med Phys. 2008;35:310–7. doi:10.1118/1.2818738.

    Article  PubMed  Google Scholar 

  33. Solberg TD, Boedeker KL, Fogg R, Selch MT, DeSalles AAF. Dynamic arc radiosurgery field shaping: a comparison with static field conformal and noncoplanar circular arcs. Int J Radiat Oncol Biol Phys 2001;49:1481–1491. doi:10.1016/S0360-3016(00)01537-6.

  34. Yu CX. Intensity-modulated arc therapy with dynamic multileaf collimation: an alternative to tomotherapy. Phys Med Biol. 1995;40:1435. doi:10.1088/0031-9155/40/9/004.

    Article  CAS  PubMed  Google Scholar 

  35. Mackie TR, Holmes T, Swerdloff S, Reckwerdt P, Deasy JO, Yang J, Paliwal B, Kinsella T. Tomotherapy: a new concept for the delivery of dynamic conformal radiotherapy. Med Phys. 1993;20:1709–19. doi:10.1118/1.596958.

    Article  CAS  PubMed  Google Scholar 

  36. Mackie TR, Balog J, Ruchala K, Shepard D, Aldridge S, Fitchard E, Reckwerdt P, Olivera G, McNutt T, Mehta M. Radiation therapy treatment optimization tomotherapy. Semin Radiat Oncol. 1999;9:108–17. doi:10.1016/S1053-4296(99)80058-7.

    Article  CAS  PubMed  Google Scholar 

  37. Westerly DC, Schefter TE, Kavanagh BD, Chao E, Lucas D, Flynn RT, Miften M. High-dose MVCT image guidance for stereotactic body radiation therapy. Med Phys. 2012;39:4812–9. doi:10.1118/1.4736416.

    Article  PubMed  Google Scholar 

  38. Sterzing F, Uhl M, Hauswald H, Schubert K, Sroka-Perez G, Chen Y, Lu W, Mackie R, Debus J, Herfarth K, Oliveira G. Dynamic jaws and dynamic couch in helical tomotherapy. Int J Radiat Oncol Biol Phys 2010;76:1266–1273. doi:10.1016/j.ijrobp.2009.07.1686.

  39. Bortfeld T, Webb S. Single-Arc IMRT? Phys Med Biol. 2009;54:N9. doi:10.1088/0031-9155/54/1/N02.

    Article  PubMed  Google Scholar 

  40. Reed GB Jr, Cox AJ Jr. The human liver after radiation injury. A form of veno-occlusive disease. Am J Pathol. 1966;48(4):597–611.

    Google Scholar 

  41. Seong J, Kim SH, Chung EJ, Lee WJ, Suh CO. Early alteration in TGF-beta mRNA expression in irradiated rat liver. Int J Radiat Oncol Biol Phys. 2000;46:639–43.

    Article  CAS  PubMed  Google Scholar 

  42. Christiansen H, Saile B, Neubauer-Saile K, Tippelt S, Rave-Frank M, Hermann RM, Dudas J, Hess CF, Schmidberger H, Ramadori G. Irradiation leads to susceptibility of hepatocytes to TNF-alpha mediated apoptosis. Radiother Oncol. 2004;72:291–6.

    Article  CAS  PubMed  Google Scholar 

  43. Dawson LA, Ten Haken RK. Partial volume tolerance of the liver to radiation. Semin Radiat Oncol. 2005;15:279–83.

    Article  PubMed  Google Scholar 

  44. Lawrence TS, Robertson JM, Anscher MS, Jirtle RL, Ensminger WD, Fajardo LF. Hepatic toxicity resulting from cancer treatment. Int J Radiat Oncol Biol Phys. 1995;31:1237–48.

    Article  CAS  PubMed  Google Scholar 

  45. Pan CC, Kavanagh BD, Dawson LA, et al. Radiation-associated liver injury. Int J Radiat Oncol Biol Phys. 2010;76:S94–100.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Dawson LA, Normolle D, Balter JM, McGinn CJ, Lawrence TS, Ten Haken RK. Analysis of radiation-induced liver disease using the Lyman NTCP model. Int J Radiat Oncol Biol Phys. 2002;53:810–21.

    Article  PubMed  Google Scholar 

  47. Wulf J, Guckenberger M, Haedinger U, Oppitz U, Mueller G, Baier K, Flentje M. Stereotactic radiotherapy of primary liver cancer and hepatic metastases. Acta Oncol. 2006;45(7):838–47.

    Article  PubMed  Google Scholar 

  48. Cheng JC, Liu HS, Wu JK, Chung HW, Jan GJ. Inclusion of biological factors in parallel-architecture normal-tissue complication probability model for radiation-induced liver disease. Int J Radiat Oncol Biol Phys. 2005;62:1150–6.

    Article  PubMed  Google Scholar 

  49. Hoyer M, Roed H, Traberg Hansen A, et al. Phase II study on stereotactic body radiotherapy of colorectal metastases. Acta Oncol. 2006;45:823–30.

    Article  PubMed  Google Scholar 

  50. Schefter TE, Kavanagh BD, Timmerman RD, et al. A phase I trial of stereotactic body radiation therapy (SBRT) for liver metastases. Int J Radiat Oncol Biol Phys. 2005;62:1371–8.

    Article  PubMed  Google Scholar 

  51. Cox BW, Jackson A, Hunt M, et al. Esophageal toxicity from high-dose, single-fraction paraspinal stereotactic radiosurgery. Int J Radiat Oncol Biol Phys. 2012;83:e661–7.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Rule W, Timmerman R, Tong L, Abdulrahman R, Meyer J, Boike T, Schwarz RE, Weatherall P, Chinsoo CL. Phase I dose-escalation study of stereotactic body radiotherapy in patients with hepatic metastases. Ann Surg Oncol. 2011;18(4):1081–7.

    Article  PubMed  Google Scholar 

  53. Dunlap NE, Cai J, Biedermann GB, et al. Chest wall volume receiving >30 Gy predicts risk of severe pain and/or rib fracture after lung stereotactic body radiotherapy. Int J Radiat Oncol Biol Phys. 2010;76:796–801.

    Article  PubMed  Google Scholar 

  54. Mutter RW, Liu F, Abreu A, et al. Dose–volume parameters predict for the development of chest wall pain after stereotactic body radiation for lung cancer. Int J Radiat Oncol Biol Phys. 2012;82:1783–90.

    Article  PubMed  Google Scholar 

  55. Solberg TD, Balter JM, Benedict SH, Fraass BA, Kavanagh B, Miyamoto C, Pawlicki T, Potters L, Yamada Y. Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy: executive summary. Pract Radiat Oncol. 2012;2:2–9. doi:10.1016/j.prro.2011.06.014.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Benedict SH, Yenice KM, Followill D, Galvin JM, Hinson W, Kavanagh B, Keall P, Lovelock M, Meeks S, Papiez L, Purdie T, Sadagopan R, Schell MC, Salter B, Schlesinger DJ, Shiu AS, Solberg T, Song DY, Stieber V, Timmerman R, Tomé WA, Verellen D, Wang L, Yin F-F. Stereotactic body radiation therapy: The report of AAPM Task Group 101. Med Phys. 2010;37:4078–101. doi:10.1118/1.3438081.

    Article  PubMed  Google Scholar 

  57. Lutz W, Winston KR, Maleki N, A system for stereotactic radiosurgery with a linear accelerator. Int J Radiat Oncol Biol Phys 1988;14:373–381. doi:10.1016/0360-3016(88)90446-4.

  58. Klein EE, Hanley J, Bayouth J, Yin F-F, Simon W, Dresser S, Serago C, Aguirre F, Ma L, Arjomandy B, Liu C, Sandin C, Holmes T. Task Group 142 report: Quality assurance of medical acceleratorsa). Med Phys. 2009;36:4197–212. doi:10.1118/1.3190392.

    Article  PubMed  Google Scholar 

  59. Prendergast BM, Fiveash JB, Popple RA, Clark GM, Thomas EM, Minnich DJ, Jacob R, Spencer SA, Bonner JA, Dobelbower MC. Flattening filter-free linac improves treatment delivery efficiency in stereotactic body radiation therapy. J Appl Clin Med Phys. 2013;14(3):4126.

    Article  PubMed  Google Scholar 

  60. RTOG 1112: Randomized Phase III Study of Sorafenib versus Stereotactic Body Radiation Therapy followed by Sorafenib in Hepatocellular Carcinoma. 2016. Website: https://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=1112.

Download references

Author information

Authors and Affiliations

  1. Department of Radiation Oncology, University of Colorado School of Medicine, 1665 Aurora Court, Suite 1032, Aurora, CO, 80045, USA

    David C. Westerly PhD

  2. Radiation Oncology, University of Colorado Cancer Center, 1665 Aurora Court, Suite 1032, Aurora, CO, 80045, USA

    Karyn A. Goodman MD, MS

Authors
  1. David C. Westerly PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Karyn A. Goodman MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David C. Westerly PhD .

Editor information

Editors and Affiliations

  1. Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA

    Jeffrey Meyer

  2. Department of Radiation Oncology, University of Colorado Comprehensive Cancer Center, Aurora, Colorado, USA

    Tracey Schefter

Rights and permissions

Reprints and permissions

Copyright information

© 2017 Springer International Publishing AG

About this chapter

Cite this chapter

Westerly, D.C., Goodman, K.A. (2017). External Beam Radiation Therapy for Liver Tumors: Simulation, Treatment Planning, and Advanced Delivery Techniques. In: Meyer, J., Schefter, T. (eds) Radiation Therapy for Liver Tumors. Springer, Cham. https://doi.org/10.1007/978-3-319-54531-8_9

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-54531-8_9

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-54530-1

  • Online ISBN: 978-3-319-54531-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation