Gastrointestinal Cancer

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SU_14_2139 - Higher Risk Liver Stereotactic Body Radiation Therapy (SBRT): Treatment of Child-Pugh Class B and C Patients

Sunday, October 21
1:15 PM - 2:45 PM
Location: Innovation Hub, Exhibit Hall 3

Higher Risk Liver Stereotactic Body Radiation Therapy (SBRT): Treatment of Child-Pugh Class B and C Patients
R. Levin-Epstein, P. Lee, M. Cao, J. M. Lamb, D. Ruan, and A. Raldow; Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA

Purpose/Objective(s): Options are limited for patients with impaired hepatic function who require liver-directed therapy. Radiation induced liver disease (RILD) has been reported for stereotactic body radiation therapy (SBRT), with rates from 8-33%. However, most studies are comprised of mainly Child-Pugh (CP) A patients; local treatments are often considered too high-risk in CP B and C, and there is little data for SBRT in this population. At our institution, for patients who can undergo magnetic resonance (MR) guided radiotherapy (MRgRT), we have the benefit of MR guided inter- and intra-fraction monitoring, allowing on-target treatment while minimizing dose to surrounding liver by reducing internal and planning target volume margins. We retrospectively examined the safety and tolerability of liver SBRT in CP B and C patients.

Materials/Methods: From 2013-2017, 15 CP B and C patients with imaging stigmata of chronic liver disease who received SBRT were included. Volume of the liver receiving <15 Gy (V15) and mean liver dose (MLD) were examined. At treatment and at 1, 3, and 6 months, CP score, alkaline phosphatase (AP), and transaminases were recorded. We assessed development of RILD using classical and non-classical criteria (2-fold increase in AP and 5-fold increase in transaminase, respectively), and increase in CP score of ≥2 after SBRT.

Results: 13 patients were CP B (range 7-9 points) and 2 were CP C (10 and 13 points). Median age was 66 years (range 15-86), and median Karnofsky Performance Score was 80 (range 60-100). Histologies included 7 cholangiocarcinoma, 5 hepatocellular carcinoma, and 3 metastases. Mean prescribed dose was 37.4 Gy (range 25-54, median 40 Gy) in a mean 4.3 fractions (range 2-5, median 5). MLD was 9.4 Gy (range 2.7-15.2 Gy), with mean V15 of 1508.6cc (range 444.8-3954.8cc). 4/15 (26.7%) patients met criteria for development of RILD (all classical), and a rise in CP score ≥2 was seen in 3/15 (20%) patients; all of these instances were correlated with infection or progression of disease (PD). 5/15 (33.3%) patients showed a sustained decrease in CP score, 4/15 (26.7%) remained stable, and 6/15 (40%) increased. 5/6 patients with any CP score increase had concomitant infection or PD. No CP C patients experienced RILD or CP increase ≥2. 10/15 patients were treated with MRgRT; of these patients, none developed RILD or increased CP score in the absence of infection or PD.

Conclusion: Liver SBRT for CP B and C patients may be a safe option in select patients. Over half of the patients in our analysis demonstrated an improved or stable CP score after SBRT, and there were no instances of RILD independent of PD or infection. Notably, no patients developed non-classical RILD, which is the more common form in underlying liver disease. MRgRT, with its inter- and intra-fraction monitoring, may be a beneficial modality in treating these high risk patients.

Author Disclosure: R. Levin-Epstein: None. P. Lee: Honoraria; Viewray. Commitee Co-Chair; Committee Co-Chair. M. Cao: None. J.M. Lamb: None. D. Ruan: Independent Contractor; Omega BioSystems. Research Grant; Varian Medical Systems.

Rebecca Levin-Epstein, MD, BS

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