Zhi-Yong Yuan, MD, PhD Chun-Lei Liu, MD Ma0-Bin Meng, MD, PhD CyberKnife Center, Department of Radiation Oncology, Tianjin Medical University Cancer Institute & Hospital

1. Tianjin Medical University Cancer Institute & Hospital
HuanhuXi Road, TiYuanBei, He Xi District, Tianjin 300060, PRC
Tel: +86-22-23340123 Fax: + 86-22-23341405 Web site: www.tmucih.org
STEREOTACTIC BODY RADIATION THERAPY
USING CYBERKNIFE®
FOR LIVER METASTASES:
A REPORT FROM TIANJIN CANCER INSTITUTE &
HOSPITAL
Zhi-Yong Yuan, MD, PhD
Chun-Lei Liu, MD
Ma0-Bin Meng, MD, PhD
CyberKnife Center, Department of Radiation Oncology,
Tianjin Medical University Cancer Institute & Hospital

2. 2
Background
 The liver is the second
most common site for
metastatic spread of
cancer.
 Surgical resection is
currently considered as
the first line measure for
the treatment of liver
metastatises (LM).
Hess KR, et al. Cancer 2006; 106: 1624-1633.Timmerman RD, et al. CA Cancer J Clin 2009; 59: 145-170.

3. 3
Liver metastasis SBRT report

4. 4Hoyer M, et al. Int J Radiation Oncology Biol Phys 2012; 82: 1047-1057

5. 5
Questions and Aims
 The optimal dose and fractionation scheme
has not yet been determined.
 It is still unclear whether it is scientifically
rigorous enough to recommend its routine
use for curative treatment of LM.

6. 6
CyberKnife Treatment System
 The present study is aimed at assessing the efficacy and
safety of SBRT using CyberKnife on the treatment of LM,
It is anticipated that this study will provide additional
evidence for clinical practice.

7. 7
Inclusion Criteria
 The inclusion criteria were defined as follows:
 Patients of any age;
 LM Disease confirmed cytologically, pathologically, or diagnosed
through imaging;
 Patients with KPS ≥ 70;
 Patients within ≤ 4 LMs and individual tumor diameter < 6 cm;
 Patient’s life expectancy >3 months;
 Patient unsuitable for or refractory to surgery and received
CyberKnife treatment;
 Bilirubin less than 3 mg/dl, albumin greater than 2.5 g/dl, and
serum liver enzymes less than twice the upper limit of normal range.

8. 8
The dose constraints of SBRT

9. 9
Follow-up and endpoints
 The patients were observed at 1 month after completion
of treatment, then every 3 months for the first year, and
every 6 months thereafter until July 2012.
 The primary endpoint was local control (LC)
 OS, PFS, distant PFS (DPFS), and adverse events.
 Local control of LM was assessed at a minimum of 6
months of follow-up after CyberKnife treatment in order
to avoid uncertainty associated with early transient
radiographic changes within the high-dose region.

10. 10
Patient characteristics

11. 11
Summary of SBRT parameters

12. 12
Treatment characteristics

13. 13
Follow-up patients
Prior to RT 5 Weeks 3 Months 6 Months 13 Months 18 Months 25 Months

14. 14
LC rate, PFS, and DPFS
1 year LC: 94.4%
2 years LC: 89.7%
Median PFS: 12 months
Median DPFS: 37 months

15. 15
LC rate by subgroups

16. 16
Overall survival
Median OS: 37.5 months
1 year OS: 68.6 months
2 years OS: 55.9 months
Median OS for favorable patients : Not reached
Median OS for non-favorable patients: 8.7 months
Note: The favorable patients were defined as primaries originating from
colorectal, breast, and stomach cancers, and sarcomas.

17. 17
OS rate by subgroups

18. 18
Factors associated with OS

19. 19
Patterns of failure

20. 20
Toxicities
 The treatment was well tolerated by all patients; the
most common toxicities were grade 1 or 2 fatigue,
nausea, vomiting, and changes in liver function tests,
which were corrected by routine treatment.
 None of the patients developed grade 3 or higher toxicity.
In addition, no clinically significant changes were noted
in liver function evaluations or physical examinations of
LM patients.

21. 21
Discussion
The RT strategies:
The type of RT should be determined according to the Barcelona
Clinic Liver Cancer (BCLC) stage and liver function.

22. 22
Discussion
The dose and fractionation scheme :
The prescribed dose and fractionation were specified
according to lesion Location and Volume in this
study.

23. 23
Discussion
The optimal dose and fractionation scheme :
29 patients: 40 Gy/4f
13 patients: 45 Gy/3f
LC: 45Gy/3f > 40Gy/4f
Vautravers DC, et al. Int J Radiation Oncology Biol Phys 2011; 81: e39-47
LC: 60Gy/5f > 50Gy/5f >30Gy/3f
Rule WR, et al. Ann Surg Oncol 2011; 18: 1081-1087

24. 24
Discussion
The BED correlative with LC:
Chang DT, et al. Cancer 2011; 117: 4060-4069
Median prescription dose: 41.7Gy (22-60)
Median fractions: 6 fractions (1-6)
Lanciano R, et al. Fron Oncol 2012; 2: 1-8
Median prescription dose/fraction: 12Gy
Median fractions: 3 fractions (3-5)

25. 25
Discussion
The LC correlative with tumor volume:
13 patients: < 60 Gy/3f
36 patients: = 60 Gy/3f
Rusthoven KE, et al. JCO 2009; 27: 1572-1578
Median prescription dose/fraction: 12Gy
Median fractions: 3 fractions (3-5)
Lanciano R, et al. Fron Oncol 2012; 2: 1-8
≠

26. 26
Limitations
 This is a retrospective study. As record keeping and bias
may influence results, prospective studies of LM must be
performed to confirm the efficacy and safety of SBRT
with CyberKnife.
 LC appears to be excellent with CyberKnife, however, our
follow-up is short and the study included a
heterogeneous group of patients with various primary
tumors, previous treatments, and liver disease statuses,
etc.
 The optimal dose and fractionation scheme has not yet
been determined. Despite these limitations, the study
showed that SBRT using CyberKnife can improve LC as
well as OS in patients with LM.

27. 27
Conclusions
 SBRT with CyberKnife is an effective modality with good
local control and acceptable toxicity for unresectable or
medically inoperable LM.
 Such studies will hopefully also help identify the subset
of patients most likely to benefit from this therapy.
 Further study: Guideline for the SBRT Dose-Fraction for
Different Volume and Sites LM lesions (Large number
cases and Muticenter needed)

28. THANKS
Tianjin Medical University Cancer Institute & Hospital

29. Radiation Oncologist ：
Wang Ping, Song Yongchun,
Zhuang Hongqing, Meng Maobing
Nerosurgeon ：
Wang Xiaoguang, Liuqun
Thoracic Surgeon
Wang Changli, Zhang Zhenfa
Belly Surgeon:
Hao Jihui, Song Tianqiang
Physicist ：
Li Fengtong, Dong Yong
Therapist
Wang Jingsheng, Chen
Huaming
The TUMC Cyberknife Team
Acknowledgements
 F0unndations: NFSC (No. 81201754) and the
Cyberknife Foundation (No. 4-1-3).