Yonsei Med J.  2016 Jan;57(1):41-49. 10.3349/ymj.2016.57.1.41.

Re-Irradiation of Hepatocellular Carcinoma: Clinical Applicability of Deformable Image Registration

• Lee DS
• Woo JY
• Kim JW
• Seong J

• KMID: 2466350
• DOI: http://doi.org/10.3349/ymj.2016.57.1.41

Abstract

PURPOSE
This study aimed to evaluate whether the deformable image registration (DIR) method is clinically applicable to the safe delivery of re-irradiation in hepatocellular carcinoma (HCC).
MATERIALS AND METHODS
Between August 2010 and March 2012, 12 eligible HCC patients received re-irradiation using helical tomotherapy. The median total prescribed radiation doses at first irradiation and re-irradiation were 50 Gy (range, 36-60 Gy) and 50 Gy (range, 36-58.42 Gy), respectively. Most re-irradiation therapies (11 of 12) were administered to previously irradiated or marginal areas. Dose summation results were reproduced using DIR by rigid and deformable registration methods, and doses of organs-at-risk (OARs) were evaluated. Treatment outcomes were also assessed.
RESULTS
Thirty-six dose summation indices were obtained for three OARs (bowel, duodenum, and stomach doses in each patient). There was no statistical difference between the two different types of DIR methods (rigid and deformable) in terms of calculated summation operatorD (0.1 cc, 1 cc, 2 cc, and max) in each OAR. The median total mean remaining liver doses (M(RLD)) in rigid- and deformable-type registration were not statistically different for all cohorts (p=0.248), although a large difference in M(RLD) was observed when there was a significant difference in spatial liver volume change between radiation intervals. One duodenal ulcer perforation developed 20 months after re-irradiation.
CONCLUSION
Although current dose summation algorithms and uncertainties do not warrant accurate dosimetric results, OARs-based DIR dose summation can be usefully utilized in the re-irradiation of HCC. Appropriate cohort selection, watchful interpretation, and selective use of DIR methods are crucial to enhance the radio-therapeutic ratio.

Keyword

Deformable image registration; hepatocellular carcinoma; radiotherapy; re-irradiation

MeSH Terms

Adult
Aged
Algorithms
Carcinoma, Hepatocellular/*radiotherapy
Female
Humans
Liver Neoplasms/*radiotherapy
Male
Middle Aged
Organs at Risk/*radiation effects
*Radiation Dosage
Radiometry/*methods
Radiotherapy/methods
Radiotherapy Dosage
Radiotherapy Planning, Computer-Assisted
Radiotherapy, Intensity-Modulated
*Re-Irradiation
Tomography, X-Ray Computed/methods
Treatment Outcome

Figure

• 

  Fig. 1 Illustrative case (patient 4). Contrast-enhanced axial computed tomography before the first course of radiation (A) and at re-irradiation (B). Reconstructed isodose lines using deformable image registration (DIR) at the first (A-1) and second course of irradiation (B-1) are shown, as well as the axial (C) and coronal (C-1) dose summation results using DIR. Narrow arrows in (A) and (B) indicate the tumor extent and wide arrows in (C) indicate potential high-risk regions (bowels) at re-irradiation.

Reference

1. Feng M, Ben-Josef E. Radiation therapy for hepatocellular carcinoma. Semin Radiat Oncol. 2011; 21:271–277.

2. Wang PM, Hsu WC, Chung NN, Chang FL, Fogliata A, Cozzi L. Radiation treatment with volumetric modulated arc therapy of hepatocellular carcinoma patients. Early clinical outcome and toxicity profile from a retrospective analysis of 138 patients. Radiat Oncol. 2012; 7:207.

3. Lee DS, Seong J. Radiotherapeutic options for hepatocellular carcinoma with portal vein tumor thrombosis. Liver Cancer. 2014; 3:18–30.

4. Abusaris H, Hoogeman M, Nuyttens JJ. Re-irradiation: outcome, cumulative dose and toxicity in patients retreated with stereotactic radiotherapy in the abdominal or pelvic region. Technol Cancer Res Treat. 2012; 11:591–597.

5. Koom WS, Choi Y, Shim SJ, Cha J, Seong J, Kim NK, et al. Reirradiation to the pelvis for recurrent rectal cancer. J Surg Oncol. 2012; 105:637–642.

6. Castadot P, Lee JA, Parraga A, Geets X, Macq B, Grégoire V. Comparison of 12 deformable registration strategies in adaptive radiation therapy for the treatment of head and neck tumors. Radiother Oncol. 2008; 89:1–12.

7. Kovalchuk N, Jalisi S, Subramaniam RM, Truong MT. Deformable registration of preoperative PET/CT with postoperative radiation therapy planning CT in head and neck cancer. Radiographics. 2012; 32:1329–1341.

8. Olteanu LA, Madani I, De Neve W, Vercauteren T, De Gersem W. Evaluation of deformable image coregistration in adaptive dose painting by numbers for head-and-neck cancer. Int J Radiat Oncol Biol Phys. 2012; 83:696–703.

9. Edeline J, Boucher E, Rolland Y, Vauléon E, Pracht M, Perrin C, et al. Comparison of tumor response by Response Evaluation Criteria in Solid Tumors (RECIST) and modified RECIST in patients treated with sorafenib for hepatocellular carcinoma. Cancer. 2012; 118:147–156.

10. Senthi S, Griffioen GH, van Sörnsen de Koste JR, Slotman BJ, Senan S. Comparing rigid and deformable dose registration for high dose thoracic re-irradiation. Radiother Oncol. 2013; 106:323–326.

11. Brock KK. Deformable Registration Accuracy Consortium. Results of a multi-institution deformable registration accuracy study (MIDRAS). Int J Radiat Oncol Biol Phys. 2010; 76:583–596.

12. Juang T, Das S, Adamovics J, Benning R, Oldham M. On the need for comprehensive validation of deformable image registration, investigated with a novel 3-dimensional deformable dosimeter. Int J Radiat Oncol Biol Phys. 2013; 87:414–421.

13. Pan CC, Kavanagh BD, Dawson LA, Li XA, Das SK, Miften M, et al. Radiation-associated liver injury. Int J Radiat Oncol Biol Phys. 2010; 76:3 Suppl. S94–S100.

14. Bae SH, Kim MS, Cho CK, Kang JK, Lee SY, Lee KN, et al. Predictor of severe gastroduodenal toxicity after stereotactic body radiotherapy for abdominopelvic malignancies. Int J Radiat Oncol Biol Phys. 2012; 84:e469–e474.

15. Chon YE, Seong J, Kim BK, Cha J, Kim SU, Park JY, et al. Gastroduodenal complications after concurrent chemoradiation therapy in patients with hepatocellular carcinoma: endoscopic findings and risk factors. Int J Radiat Oncol Biol Phys. 2011; 81:1343–1351.

16. Lee IJ, Kim JW, Han KH, Kim JK, Kim KS, Choi JS, et al. Concurrent chemoradiotherapy shows long-term survival after conversion from locally advanced to resectable hepatocellular carcinoma. Yonsei Med J. 2014; 55:1489–1497.