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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 195-197

Oligometastasis liver in carcinoma breast treated with stereotactic body radiotherapy


Department of Radiation Oncology, Government Medical College, Rajindra Hospital, Patiala, Punjab, India

Date of Submission06-Feb-2020
Date of Decision20-Feb-2020
Date of Acceptance02-Mar-2020
Date of Web Publication9-Apr-2020

Correspondence Address:
Anshuma Bansal
Department of Radiation Oncology, Government Medical College, Rajindra Hospital, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_18_20

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  Abstract 


This case report highlights the management of single metastasis in the liver with stereotactic body radiotherapy in a previously treated case of carcinoma breast.

Keywords: Liver metastasis, oligometastasis, stereotactic body radiotherapy


How to cite this article:
Bansal A, Bedi N, Kaur R, Kaur J, Singh G, Bagga H, Dangwal V. Oligometastasis liver in carcinoma breast treated with stereotactic body radiotherapy. Int J Health Allied Sci 2020;9:195-7

How to cite this URL:
Bansal A, Bedi N, Kaur R, Kaur J, Singh G, Bagga H, Dangwal V. Oligometastasis liver in carcinoma breast treated with stereotactic body radiotherapy. Int J Health Allied Sci [serial online] 2020 [cited 2020 Nov 28];9:195-7. Available from: https://www.ijhas.in/text.asp?2020/9/2/195/282134




  Introduction Top


Oligometastasis refers to limited number of metastasis in a single site when the primary cancer of origin is free from disease. Colorectal carcinoma and carcinoma breast are two such primary sites, which can later present with oligometastasis. The liver is the most common site of metastasis in these cases. Stereotactic body radiotherapy (SBRT) is an advanced highly precise radiation technique for treating patients with oligometastasis. This case report highlights the results of managing oligometastasis in the liver in a previously treated case of carcinoma breast with SBRT.


  Case Report Top


A 40-year-old diabetic patient previously diagnosed case of carcinoma left breast pT3N0Mo (ER+, PR +, Her2 −) managed with modified radical mastectomy, eight cycles of adjuvant chemotherapy (four cycles of adriamycin and cyclophosphamide; and four cycles of docetaxel) and locoregional radiotherapy (50.4 Gy in 28# in 5 weeks) last on June 17, 2017, was on tablet letrozole 2.5 mg once daily for the past 2 years.

She was asymptomatic and had an incidental finding of liver space-occupying lesions (SOL) on follow-up ultrasound done on July 14, 2019. Positron emission tomography (PET) Computed tomography (CT) scan done on July 17, 2019 showed fluorodeoxyglucose avid (standardized uptake value [SUV] max 8.8) isodense SOL in segment V of the right lobe of the liver measuring 2.1 cm × 2 cm [Figure 1]. The rest of the body had no hypermetabolic lesion. Ultrasonography-guided fine-needle aspiration cytology done on July 25, 2019 was suggestive of metastatic adenocarcinoma.
Figure 1: Baseline positron emission tomography scan showing liver metastasis

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The patient was treated by SBRT with the dose of 36 Gy in 4 fractions at 9 Gy per fraction prescribed to the 80% isodose line covering the PTV, treated on alternate days last on July 12, 2019. Planning was done with volumetric modulated arc radiotherapy (technique) with two semi arcs (181° clockwise 15° and 15° counterclockwise 181°) with 6 MV beams [Figure 2]. Normal tissue dose constraints were achieved, with at least 700 ml liver receiving <15 Gy, dose to the stomach and small bowel not exceeding 30 Gy/4 fractions or 7 Gy/fraction, dose to the spinal cord within 18 Gy/4 fractions or 4 Gy/fraction, and dose to two-third of the right kidney being <15 Gy/4 fractions or 4 Gy/fraction. Cone beam CT was done every day before treatment for image guidance and precise treatment delivery to the target lesion.
Figure 2: Stereotactic body radiotherapy treatment plan for metastatic liver lesion

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Contrast-enhanced CT of the abdomen done on September 24, 2019 showed 1.5 cm × 1.4 cm hypodense lesion in segment VI of the liver with no obvious enhancement [Figure 3].
Figure 3: Contrast-enhanced computed tomography of the abdomen 2 months poststereotactic body radiotherapy

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In view of young age, instead of putting on hormonal therapy only, the patient was planned with chemotherapy with injection paclitaxel 300 mg day 1 and injection gemcitabine 1.4 g day 1 and day 8, three weekly for six cycles last on November 21, 2019.

PET scan done on January 6, 2020 shows focus in liver measuring 3 cm × 2 cm × 1 cm (SUV 3) suggestive of postradiotherapy/inflammatory changes. Size increase could be due to radiotherapy-induced tumor edema [Figure 4].
Figure 4: Positron emission tomography scan posttreatment completion

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The patient is now on regular follow-up and started on tablet anastrozole 1 mg once a day planned for 5 years.


  Discussion Top


The liver is one of the most common sites of metastasis from carcinoma breast. The prognosis of patients with untreated liver metastases, however, can be poor, with a 3-year survival of <5% and median survival of 5–8 months.[1] The term oligometastasis refers to the condition when distant relapse is limited to a single lesion/site and is amenable for local treatment. Treatment options include surgery, transarterial chemoembolization, radiofrequency ablation, and SBRT, all of which are found to have similar local control rates.[2],[3]

SBRT is the delivery of a large dose of radiation to an extracranial site in a limited number of high dose fractions (five or fewer fractions), resulting in a higher biological equivalent dose (BED).[4] Multiple external beams are utilized for precise, conformal dose distribution to the target, and relative sparing of the nearby normal tissues.

Indications of doing SBRT are tumor size ≤3 cm, number of lesions ≤3, organ at risk distance >8 mm (site of tumor can be periphery/central/even near to porto-hepatic structures), Child-Pugh A and Eastern Cooperative Oncology Group 0–1, free liver volume (>1000 cc), and absent extrahepatic disease. The age of the patient is not a contraindication.[4]

The optimal dose and fractionation scheme have yet to be determined and continues to be under investigation. Jang et al. estimated that 51.1 Gy in three fractions (BED10 = 138.1 Gy) were necessary for lesions <3 cm to achieve a 90% probability of 2-year local control.[5] Chang et al. estimated a >90% probability of 3-year local control with 40 Gy in five fractions (BED10 =72 Gy).[6] Dose escalation and modification of the treatment schedule are required for metastatic tumors ≥3 cm.[7]

In recent years, high tumor control rates post-SBRT have dramatically changed the role of radiotherapy from palliative care to radical intent. SBRT can provide 1-, and 2-year local control rates of 62%–100%, and 45%–100% for liver metastases, respectively, and is, therefore, a potential therapeutic candidate for the treatment of oligometastases.[5],[6],[7],[8] A study of 130 patients with metastatic liver tumors in Japan reported that SBRT was associated with a local control rate of 64.2% and an overall survival rate of 72% at 2 years, with no significant (over Grade 2) elevation of liver enzymes during treatment.[8] These outcomes confirm that SBRT has a beneficial effect in patients who are unsuitable for surgery.


  Conclusion Top


For a liver metastasis, SBRT is safe and effective, with excellent local control achieved. Liver SBRT can be considered a potential game changer in multimodality treatment of metastatic disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar S, Kapoor R, Oinam AS, Kalra N, Duseja A. Role of stereotactic body radiation therapy in liver metastasis: A pilot study from tertiary cancer institute in India. J Cancer Res Ther 2019;15:169-75.  Back to cited text no. 1
    
2.
Bruix J, Reig M, Sherman M. Evidence-based diagnosis, staging, and treatment of patients with hepatocellular carcinoma. Gastroenterology 2016;150:835-53.  Back to cited text no. 2
    
3.
de Baere T, Tselikas L, Yevich S, Boige V, Deschamps F, Ducreux M, et al. The role of image-guided therapy in the management of colorectal cancer metastatic disease. Eur J Cancer 2017;75:231-42.  Back to cited text no. 3
    
4.
Benedict SH, Yenice KM, Followill D, Galvin JM, Hinson W, Kavanagh B, et al. Stereotactic body radiation therapy: The report of AAPM task group 101. Med Phys 2010;37:4078-101.  Back to cited text no. 4
    
5.
Jang WI, Kim MS, Bae SH, Cho CK, Yoo HJ, Seo YS, et al. High-dose stereotactic body radiotherapy correlates increased local control and overall survival in patients with inoperable hepatocellular carcinoma. Radiat Oncol 2013;8:250.  Back to cited text no. 5
    
6.
Chang DT, Swaminath A, Kozak M, Weintraub J, Koong AC, Kim J, et al. Stereotactic body radiotherapy for colorectal liver metastases: A pooled analysis. Cancer 2011;117:4060-9.  Back to cited text no. 6
    
7.
Doi H, Uemoto K, Suzuki O, Yamada K, Masai N, Tatsumi D, et al. Effect of primary tumor location and tumor size on the response to radiotherapy for liver metastases from colorectal cancer. Oncol Lett 2017;14:453-60.  Back to cited text no. 7
    
8.
Yamashita H, Onishi H, Matsumoto Y, Murakami N, Matsuo Y, Nomiya T, et al. Local effect of stereotactic body radiotherapy for primary and metastatic liver tumors in 130 Japanese patients. Radiat Oncol 2014;9:112.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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