August 24, 2017. Killing hepatic tumor burden without killing teetering liver functions can be a hard line to toe. While reported local control with stereotactic body radiotherapy (SBRT) is promising, most trials exclude patients with underlying liver disease--arguably one of the most relevant real-world cohorts. Enter adaptive liver stereotactic body radiation (SBRT) tailored to each individual’s mid-treatment liver function as determined via plasma retention fraction of indocyanine green (ICG). A Phase 2 trial published this month in JAMA Onc explores the safety and effectiveness of adaptive SBRT to previously-treated intrahepatic cancers. Based on ICG assessment after 3 of 5 planned SBRT treatments of 12 Gy, dose was de-escalated in 45% of tumors...leaving over half getting the full planned 60 Gy (well above commonly-used conservative doses for previously treated livers). Safety and local control (95%) at 2 years were excellent, though there was overall survival (36%) left to be desired. Bottom line: this shows that with a little extra tailoring, maximal tumor control and maximal patient safety need not be mutually exclusive.


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