In recent years, modern advances in treatment technology for imaging and delivery have renewed enthusiasm for radiation as a potentially curative treatment modality for liver malignancies. In the joint session of the ESR and the European Society for Radiotherapy and Oncology (ESTRO), international experts focus on this hot topic and provide insights into how much radiation treatment has to offer in the management of liver malignancies.
Liver cancer frequently occurs in the setting of chronic liver disease and cirrhosis. Due to the aggressive nature of the tumour, the associated underlying liver disease, a limited range of therapeutic options, and other factors, so far, liver malignancies have been associated with a poor prognosis. Surgical resection is the standard therapy for both primary and metastatic liver tumours. Along with liver transplantation, it is traditionally regarded as the most effective form of therapy. However, as the majority of patients with liver cancer present with locally advanced or unresectable disease, in recent years, many efforts have focused on non-operative treatment approaches, including different radiotherapy (RT) techniques like stereotactic body radiation therapy (SBRT) and selective internal radiation therapy (SIRT).
“Developments that have become available within our field in recent years, including continuous MRI-guidance and daily plan adaptation, have helped us to take big steps forward. They enable us to deliver radiotherapy without the need to implant fiducial markers and give us the opportunity to easily adapt the treatment plan from day to day,” said ESTRO President, Prof. Ben J. Slotman, from the Department of Radiation Oncology, University Medical Center Amsterdam, the Netherlands, who chairs the session together with ESR 1st Vice-President, Prof. Regina G.H. Beets-Tan, from the Department of Radiology at the Netherlands Cancer Institute in Amsterdam. “Out of the range of radiation treatment options, for patients with liver metastases, SBRT seems to be an especially good one,” Slotman added.
SBRT is a relatively new radiotherapy technique, whose development has generated further promise for liver-directed RT. SBRT includes techniques to deliver ablative radiation and hit the target accurately; it delivers high doses of RT in a small number of fractions or in a single treatment with high precision, thereby minimising RT doses to adjacent normal tissues, which is the major feature that distinguishes SBRT from conventionally fractionated radiation treatment. Meanwhile, SBRT is widely accepted as a treatment option for patients with liver tumours characterised by small size and limited numbers.
However, some challenges regarding the use of SBRT for liver cancer remain and need to be addressed, including SBRT-related toxicity, as Dr. Maria Hawkins, from University College London, UK, will discuss. During her talk on SBRT, she will specifically address indications for using the technique in liver tumours and help ECR delegates to understand outcomes after SBRT, as well as potential toxicities of SBRT in this setting.
Also in the joint ESR/ESTRO session, Dr. Luca Boldrini from Gemelli Advanced Radiation Therapy Center, Gemelli University Hospital, Rome, Italy, plans to discuss MRI-guided RT in liver tumours, while Prof. José Ignacio Bilbao, from the University of Navarra, Pamplona, Spain, will focus on SIRT.
SIRT, a multidisciplinary treatment involving nuclear medicine, interventional radiology and oncology, is characterised by high doses of localised internal radiation, selectively delivered to liver tumour tissues, with relative sparing of adjacent normal liver parenchyma. Generally, the therapy involves a delivery of yttrium-90 (90Y) microspheres into the tumour vascular supply (the common hepatic artery, the left or right hepatic arteries, or in smaller branches, depending on the tumour site) via an intra-arterial catheter, which is placed under radiological guidance. Meanwhile, there is established clinical evidence of the efficacy of SIRT in patients with liver cancer refractory to chemotherapy. In order to help ECR attendees to understand the complex multiprofessional pathway, Bilbao plans to discuss the most common indications of SIRT and to point out the main anatomical and haemodynamic aspects that will lead to a successful technique.
Bilbao is not the only person providing guidance on this topic. Dr. Naama Lev-Cohain, from the Department of Radiology and Medical Imaging at the Hadassah Medical Center, Jerusalem, Israel, will also share her suggestions on SIRT when discussing evaluation of post-selective intra-arterial radiation therapy response, specifically addressing tumour response assessment after SIRT, benign post-SIRT imaging findings and possible complications radiologists should be familiar with.
Please note that for pre-recorded sessions published during the ECR Highlight Weeks, there will be no chairpersons. However, we still wanted to keep Professor Slotman’s statement for the article as he initially gave it.
Joint Session of the ESR and ESTRO
Radiology and radiotherapy in liver tumours
- Stereotactic body radiation therapy (SBRT) in liver tumours
Maria Hawkins; London/UK - MRI-guided RT in liver tumours
Luca Boldrini; Rome/IT - Selective internal radiation therapy (SIRT) for liver tumours
José Ignacio Bilbao; Pamplona/ES - Post-selective intra-arterial radiation therapy (SIRT) response evaluation: what a radiologist should know
Naama Lev-Cohain; Jerusalem/IL
FURTHER READING
Castagnoli F, Bertuletti M, Nicoli I et al (2019) Stereotactic body radiotherapy (SBRT) for primary and secondary liver tumors: efficacy and dosimetric correlation with focal liver reaction (FLR). ECR 2019 / C-2019: myESR.org/192019
Galdieri C, Mancosu P, Comito T, Franzese C, Scorsetti M (2019) SBRT as alternative to liver-directed therapies in the treatment of hepatic metastasis. ECR 2019 / C-3082: myESR.org/193082
Fendler WP, Ilhan H, Paprottka PM (2015) Nomogram including pretherapeutic parameters for prediction of survival after SIRT of hepatic metastases from colorectal cancer. Eur Radiol. 25(9):2693-700: european-radiology.org/3658
Leclair N, Petersen TO, Fuchs J, Kahn T, Moche M, Purz S (2014) Selective Internal Radiation Therapy (SIRT): requirements, technique and procedure. ECR 2014 / C-2125: myESR.org/142125