SBRT Upper Abdomen

Stereotactic Body Radiation
Therapy (SBRT) for tumors of the

upper abdomen
Treatment Delivery & Setup Correction Strategies

SBRT for tumors of the upper abdomen
Bullet points
• Motion of tumors in the upper abdomen

• Imaging studies for motion measurement and evaluation
• Impact of respiration-induced target motion during radiation treatment
delivery
• Solutions for the Management of Respiration-induced Target Motion
• Planning margins
• Imaging for position verification and localization
[Enter DCID # here on master slide.]

Treatment Delivery & Setup Correction Strategies in SBRT for tumors of the upper abdomen
Motion of tumors in the upper abdomen
- Day-to-day differences in bowel position and shape

i.e.
• the left lobe of the liver is susceptible to deformation caused by stomach filling
• The amount of solid, liquid, and gas in the ascending, transverse, and descending colon can vary from day to day
→we instruct our patients to ingest nothing for at least 3 hours before radiation
→We use simethicone
- Respiration
Motion of tumors in the upper abdomen
Respiration-induced target motion (mean) in abdomen and pelvis
Yoganathan SA, et al. J Med Phys. 2017

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delivery

Imaging studies for motion measurement and evaluation
Brandner ED, et al. NRG Oncology Med Phys. 2017

Imaging studies for motion measurement and evaluation
AIM: To compare the extent of tumor motion between 4DCT and cine-
MRI in patients with hepatic tumors treated with radiation therapy.
Results: 16 patients were reviewed.
→The beam-on time is approximately 4 minutes for SBRT. Therefore, a 5-minute cine-MRI motion may offer better insight into actual
tumor motion during treatment compared with a 4DCT scan acquired over only 2 to 3 breathing cycles.
→ Inclusion of additional margins (3 mm, 2 mm, and 1 mm in the S/I, A/P, and L/R directions, respectively) to the ITV defined by 4DCT
may be needed to account for tumor motion detected by cine-MRI, particularly for patients with irregular breathing.
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delivery

Impact of respiration-induced target motion during radiation treatment delivery
in a static radiotherapy beam →dose blurring at field edge

in a dynamic intensity-modulated radiotherapy (IMRT) delivery→ interplay effect
The extent of the dosimetric effect of interplay depends on

• Breathing pattern : generally increased for larger breathing amplitudes and longer period times
• Plan complexity: generally increased for higher number of MU/Gy
• Delivery time: increased for FFF (shorter delivery times, higher dose rate, higher MLC speed) and lower dose levels (shorter
delivery times)
• CTV size: for smaller CTV sizes, however, the initial breathing phase has a larger impact on the interplay effects
• Collimator angles: slightly larger interplay effects were observed for 30° and 45° compared to 0° and 90°
Edvardsson A et al. Phys Med Biol 2018

Impact of respiration-induced target motion during radiation treatment delivery
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delivery

Solutions for the Management of Respiration-induced Target Motion
• Motion-encompassing method
• Motion mitigating strategies:

_Abdominal compression
_Breath hold methods
_Respiratory gating
• Real-time tumor tracking

Overview of the main published studies of Linac-based SBRT for liver mets and the corresponding techniques used motion
management and planning imaging.
Author Year n of patients RT technique Total dose (Gy) N of fractions PTV definition RT planning technique Fiducials Motion management
Llacer Novalis TrueBeam CT scan with
Moscardo 2016 41 STX VMAT 40-50 5-10 ITV+5mm contrast+MRI+4DCT+4DPET-CT Yes Adaptive gating
Abdominal compression/4D PET-
Andratschke 2015 74 3D-CRT 30-35 3-5 ITV+5mm 4D-CT No CT/4D CT
GTV+4-6mm(7-10 mm
Scorsetti 2013 61 VMAT 75 3 cc) CT scan with contrast,4DCT No Abdominal compression,4DCT
Lee 2009 68 3D-CRT 27.7-60 6 GTV+8mm(CTV)+5mm CT scan with contrast+MRI No Abdominal compression or BH
3D-CRT or conformal Abdominal compression or FB or
Rusthoven 2009 47 arcs 36-60 3 GTV+7-15mm CT scan with contrast No external fiducial markers
Katz 2007 69 Novalis ExacTrac 30-55 10 GTV+7mm (10mm cc) CT scan with contrast No External body fiducial markers
Dawson 2006 34 3D-CRT 24-57 6 GTV+8mm(CTV)+5mm MRI simulation No BH
Hoyer 2006 44 3D-CRT 45 3 GTV+5mm (10mm cc) CT scan with contrast No FB
Kavanagh 2006 36 3D-CRT 60 3 GTV+5-10mm CT scan with contrast No Abdominal compression or BH
Mendez
Romero 2006 17 3D-CRT 30-37.5 3 GTV+5-10mm CT scan with contrast Yes Abdominal compression
Wulf 2006 39 3D-CRT 26-37.5 1-4 GTV+3mm(CTV)+5mm CT scan with contrast,4DCT No Abdominal compression
3D-CRT or conformal Abdominal compression or BH or
Schefter 2005 18 arcs 36-60 3 GTV+5mm (10mm cc) CT scan with contrast No external fiducial markers
Van de
Voorde 2005 33 VMAT or IMRT 3-10 GTV+10mm CT scan with contrast,4DCT No 4D PETCT
Herfarth 2001 37 3D-CRT 14-26 1 GTV+6mm(10mm cc) CT scan with contrast No FB
• Motion-encompassing methods
To obtain the ITV:

The GTV can be delineated on each image of the 4D image set.
The individual contours can then be combined on one of the images in the set corresponding to the phase nearest the
midpoint of the breathing cycle (CT50) for free breathing treatments
Maximum Intensity Projection (MIP) image

MIP image cannot be used for tumors located near normal tissues with equal or greater density (e.g. those near the
diaphragm or in the upper abdomen)
Tian Y, et al. Med Phys. 2012
In patients when the lesions have homogenous low CT density, located intrahepatic, not adjacent to perihepatic organs, using
Minimum Intensity Projection (MinIP) image can bean an appropriate tool
Liu J, et al. Radiat Oncol. 2012

• Motion-encompassing methods
Most liver metastases and cholangiocarcinomas can be imaged in the portal venous phase, while hepatocellular carcinomas are
most visible in the delayed phase.
At simulation, IV contrast is considered standard particularly for hepatocellular carcinoma
4D-CT procedure
The respiration of the patient is tracked using the RPM System
Acquisition of
1) normal helical scouts for patient positioning and isocenter localization
2) a helical free-breathing scan from the carina to the iliac crest for treatment planning (free
from contrast agents so as not to interfere with heterogeneity dose calculations)
3) a 4D-CT scan (from 2 to 3 cm above the diaphragm to 2–3 cm below the liver edge noted on
the scout) performed in cine mode with a voltage of 120 kV and a tube current of 175 mA.
The tube current is increased for larger patients.
Intravenous contrast
Prior to the initiation of the free-breathing scan, the patient’s IV line is
connected to a contrast injector.
Standard protocol of 150 mL of contrast with a concentration of 320-mg I/mL.
injected at a flow rate of 5 mL/s.
A time delay can be programmed within the 4D-CT image acquisition protocol
so that the start of the contrast injection is initiated simultaneously with the
start of the scanner’s timer countdown.
.
• Motion-mitigating strategies: abdominal compression
Abdominal compression effectively reduced liver tumor motion, yielding small and
reproducible excursions in three dimensions. The compression level established at
planning could have been safely used on the treatment days
Wunderink W, et al. Int J Radiat Oncol Biol Phys. 2008
…Residual excursions became substantially <5 mm in all directions by applying abdominal compression, except for
in 2 patients in whom a slightly larger motion toward the CC direction was observed…
Significant liver motion control via abdominal compression of the subxiphoid area;
however, this control of liver motion was not observed with compression of the caudal
umbilicus Hu Y, et al. Med Phys. 2016
The magnitude of respiration-induced liver motion of patients with intrahepatic carcinoma undergoing abdominal
compression is affected by gender and BMI, with abdominal compression being less effective in men and overweight
patients.
Hu Y, et al. Radiat Oncol. 2017
• Motion-mitigating strategies: breath hold and gating strategies
AIM: To implement a reliable, practical and reproducible treatment procedure,

based on in-room kV-image guidance and respiratory control, for liver cancer
patients treated with high dose conformal radiotherapy using a commercially
available treatment system
M&M CT stimulation was conducted under voluntary breath hold or gating
(expiratory phase, 30-50% of duty cycle) using the Varian Real-time Position
Management™ (RPM) System. 3D conformal treatments (55 Gy/5 fr.) were
delivered daily under kV image guidance to verify the diaphragmatic or lipiodol-
defined tumor position.
Results: Thirty-three patients with liver confined hepatocellular carcinoma were

treated between May 2006 and Dec 2009
Conclusions: Excellent treatment results with minimal toxicities

could be achieved in a clinical environment with a
commercially available highly sophisticated radiotherapy
system
• Motion-mitigating strategies: abdominal compression vs gating strategies
AIM: To compare FB treatments with two

competing methods of motion mitigation—
abdominal compression and respiratory gating in
pancreatic cancer
Daily rates of target coverage with reduced internal margins (2 mm for LR and AP, 3
mm for SI) plotted with respect to daily ranges of unmitigated motion SI directions
and three scenarios
respiratory gating
M&M: Daily target motion without mitigation was compared
against motion with compression and with simulated abdominal compression
respiratory gating in 19 pancreatic cancer patients receiving
no mitigation
SBRT
→Compared to no motion mitigation, abdominal compression
significantly reduced motion in AP and SI directions. However,
respiratory gating was significantly better. Hence, respiratory
gating was shown to be the most effective strategy for
reducing target motion in pancreatic SBRT.
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delivery

Planning margins
Margins added to the ITV to create the PTV must be designed with an understanding of the random and systematic setup
uncertainties associated with patient setup to account for residual tumor motion and setup uncertainty
Van Herk M, et al. Int J Radiat Oncol Biol Phys. 2000
For SBRT, motion management and daily IGRT are the recommended standard-of care
Benedict SH, et al. Med Phys. 2010
Without gating, PTV margins can range from 3–10 mm

Slotman BJ, et al. Acta Oncol. 2006
Bissonnette JP, et al. Radiother Oncol. 2005
Shah C, et al. Int J Radiat Oncol Biol Phys. 2012
Margins tend to be larger in the superior-inferior direction where respiration-induced motion is more dominant relative
to motion in the axial plane (usually 5 mm LL and AP; and 10 mm CC)
Nagata Y, et al. Int J Radiat Oncol. 2011
When gating is used for treatment, margins can generally be reduced. Some groups have defined the PTV as ITV + 5 mm
Zhao B, et al. Med Phys. 2012
Shirato H, et al. Int J Clin Oncol. 2007
Zhao B, et al. Phys Med Biol. 2011
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delivery

Imaging for position verification and localization
At treatment, localization of the tumor in the liver is sometimes not possible in contrast to other sites such as lung cancer
where the tumor location is often very clear
InternaI and/or external surrogate markers or structures may be used
At treatment the consistency of correlation with respiratory motion or breath hold ability at time of simulation must be
verified.
The diaphragm is a good surrogate of target position→a superior-inferior CTV-PTV margin of 0.8 cm provided sufficient
coverage.
Vedam SS, et al. Med Phys. 2003
The Calypso system (Varian Medical Systems, Palo Alto, CA) provides an option for internal motion monitoring for respiratory
gated treatment at a conventional linac.
With sub-mm accuracy, the system wirelessly and without ionizing radiation monitors the motion of electromagnetic
transponders implanted near the target
“A prospective cohort study on gated stereotactic liver radiotherapy based on continuous internal electromagnetic motion
monitoring» Esben S. et al. (Aarhus University Hospital, Denmark) IJROBP 2018
15 patients with primary liver cancer (n=4) or metastases (n=11)

SBRT, 45-48 Gy in 3 fractions (IMRT or 3DCRT) in FB with a TrueBeam
linac (Varian) equipped with a Calypso 3.0 system
Treatment gated to the end-exhale phase of the respiratory cycle
guided by 3 implanted electromagnetic transponders.
PTV: CTV+ 5mm axial and 7mm (n=12) or 10mm (n=3) CC
Beam-on when the target deviated less than 3mm (LR/AP) and 4mm
(CC) from the planned position, according to the monitored
transponder centroid position.
The Calypso system (Varian Medical Systems, Palo Alto, CA) provides an option for internal motion monitoring for respiratory
gated treatment at a conventional linac.
With sub-mm accuracy, the system wirelessly and without ionizing radiation monitors the motion of electromagnetic
transponders implanted near the target
“A prospective cohort study on gated stereotactic liver radiotherapy based on continuous internal electromagnetic motion
monitoring» Esben S. et al. (Aarhus University Hospital, Denmark) IJROBP 2018
CONCLUSION
• Calypso-guidance provides continuous internal motion monitoring
without ionizing radiation for motion adaptive liver SBRT.
• Compared to simulated non-gated standard treatments, Calypso-based
gating and couch adjustments to correct for baseline shifts markedly
improved the geometric and dosimetric accuracy of the treatments.
• With a relatively high duty cycle (mean 62.5%) during gated treatment
and swift remote couch shifts, the prolongation in treatment time
introduced by the Calypso usage was acceptable and tolerated by all
patients.
Take home messages
Day-to-day differences in bowel position and shape should be considered
A motion study should be performed for all SBRT of tumors of the upper abdomen at the time of simulation
The full range of motion of the treatment phases for the target (ITV) must be incorporated into planning contours
At simulation, IV contrast is considered standard particularly for hepatocellular carcinoma
MIP images cannot be used for ITV, MinIP images can bean an appropriate tool on patients when the lesions have
homogenous low CT density, located intrahepatic, not adjacent to perihepatic organs
Planning image data sets can be derived from end expiration, CT50, or free breathing CT images
PTV margins are typically 5 mm radially and 10 mm CC
Consider motion limiting technique if normal tissue tolerances, based on Quantec guidelines, relevant NRG/ RTOG
protocols, or institutional criteria are exceeded, or if the interplay effect is of concern
We use a motion limit of 1 cm
Abdominal compression, gating at end expiration, breath hold are all valid strategies
Daily image guidance is required, with planar images or volumetric imaging using the diaphagram as target positon
surrogate or internal fiducials

SBRT Upper Abdomen

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SBRT Upper Abdomen

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Stereotactic Body Radiation

Therapy (SBRT) for tumors of the

Treatment Delivery & Setup Correction Strategies

• Motion of tumors in the upper abdomen

[Enter DCID # here on master slide.]

- Day-to-day differences in bowel position and shape

Respiration-induced target motion (mean) in abdomen and pelvis

Yoganathan SA, et al. J Med Phys. 2017

• Motion of tumors in the upper abdomen

[Enter DCID # here on master slide.]

Brandner ED, et al. NRG Oncology Med Phys. 2017

Results: 16 patients were reviewed.

• Motion of tumors in the upper abdomen

[Enter DCID # here on master slide.]

in a static radiotherapy beam →dose blurring at field edge

The extent of the dosimetric effect of interplay depends on

Edvardsson A et al. Phys Med Biol 2018

• Motion of tumors in the upper abdomen

[Enter DCID # here on master slide.]

• Motion mitigating strategies:

• Real-time tumor tracking

To obtain the ITV:

Maximum Intensity Projection (MIP) image

Liu J, et al. Radiat Oncol. 2012

AIM: To implement a reliable, practical and reproducible treatment procedure,

Results: Thirty-three patients with liver confined hepatocellular carcinoma were

Conclusions: Excellent treatment results with minimal toxicities

AIM: To compare FB treatments with two

• Motion of tumors in the upper abdomen

[Enter DCID # here on master slide.]

Without gating, PTV margins can range from 3–10 mm

• Motion of tumors in the upper abdomen

[Enter DCID # here on master slide.]

InternaI and/or external surrogate markers or structures may be used

15 patients with primary liver cancer (n=4) or metastases (n=11)

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