Stereotactic radiotherapy of targets in the lung and liver

Stereotactic irradiation of extracranial targets offers a non-invasive treatment modality for patients with localized tumors, which are not amenable for surgery or other invasive approaches because of age or impaired medical condition. The purpose of the study was the evaluation of the method to achieve local control of irradiated targets in relation to treatment toxicity.

Irradiation was performed as hypofractionated treatment in three fractions of 10 Gy each, normalized to the PTV enclosing 65% isodose with patient fixation in a stereotactic body frame. The isocenter was localized by stereotactic coordinates. Targets were circumscribed tumors in the lung (n = 27) and liver (n = 24) not amenable for other treatment modalities: primary lung cancer (n = 12), local recurrences of lung cancer (n = 4), lung metastases (n = 11), liver metastases (n = 23) and one cholangiocellular carcinoma. Median CTV/PTV for targets in the lung was 57/113 cm3 (min/max 5-277 cm3/17-343 cm3) and for targets in the liver 50/102 cm3 (min/max 9-516 cm3/42-772 cm3). Median follow-up for targets in the lung was 8 months (2-33) and 9 months (2-28) for liver targets. Local control was defined as complete or partial remission and stable disease, measured by repeated CT scans after 6 weeks and in 3 months intervals. Treatment toxicity was evaluated according to the WHO score.

Crude local control was 85% for pulmonary targets and 83% for hepatic targets. Actuarial local control after 1 and 2 years was 76% and 76% for lung tumors and 76% and 61% for liver tumors. Actuarial overall patient survival was 48% after 1 year and 21% after 2 years for targets in the lung and 71% and 43% for targets in the liver. No acute grade 3-5 side effects were observed. Serious late toxicity occurred in two patients: a chronic ulceration of the esophagus at a target close to the mediastinum after 3 months (grade 3) and fatal bleeding from the pulmonary artery after 9 months (grade 5) in a previously irradiated patient. It remained unclear, whether the bleeding was a side effect of irradiation or due to tumor infiltration.

Hypofractionated stereotactic irradiation of targets in the lung and liver is a locally effective treatment with actuarial local control rates of 76% after 1 year and 61-76% after 2 years without relevant acute toxicity. Severe late toxicity did not occur, if targets close to the mediastinum were avoided.