Hypofractionated Image-Guided Radiation Therapy With Simultaneous-Integrated Boost Technique for Limited Metastases: A Multi-Institutional Analysis.


Purpose: To perform a multi-institutional analysis following treatment of limited osseous and/or nodal metastases in patients using a novel hypofractionated image-guided radiotherapy with simultaneous-integrated boost (HIGRT-SIB) technique. Methods: Consecutive patients treated with HIGRT-SIB for ≤5 active metastases at Duke University Medical Center or Durham Veterans' Affairs Medical Center between 2013 and 2018 were analyzed to determine toxicities and recurrence patterns following treatment. Most patients received 50 Gy to the PTVboost and 30 Gy to the PTVelect simultaneously in 10 fractions. High-dose treatment volume recurrence (HDTVR) and low-dose treatment volume recurrence (LDTVR) were defined as recurrences within PTVboost and PTVelect, respectively. Marginal recurrence (MR) was defined as recurrence outside PTVelect, but within the adjacent bone or nodal chain. Distant recurrence (DR) was defined as recurrences not meeting HDTVR, LDTVR, or MR criteria. Freedom from pain recurrence (FFPR) was calculated in patients with painful osseous metastases prior to HIGRT-SIB. Outcome rates were estimated at 12 months using the Kaplan-Meier method. Results: Forty-two patients met inclusion criteria with 59 sites treated with HIGRT-SIB (53% nodal and 47% osseous). Median time from diagnosis to first metastasis was 31 months and the median age at HIGRT-SIB was 69 years. The most common primary tumors were prostate (36%), gastrointestinal (24%), and lung (24%). Median follow-up was 11 months. One acute grade ≥3 toxicity (febrile neutropenia) occurred after docetaxel administration immediately following HIGRT-SIB. Four patients developed late grade ≥3 toxicities: two ipsilateral vocal cord paralyzes and two vertebral compression fractures. The overall pain response rate was 94% and the estimated FFPR at 12 months was 72%. The estimated 12 month rate of HDTVR, LDTVR, MR, and DR was 3.6, 6.2, 7.6, and 55.8%, respectively. DR preceded MR, HDTVR, or LDTVR in each instance. The estimated 12 month probability of in-field and marginal control was 90.0%. Conclusion: Targeting areas at high-risk for occult disease with a lower radiation dose, while simultaneously boosting gross disease with HIGRT in patients with limited osseous and/or nodal metastases, has a high rate of treated metastasis control, a low rate of MR, acceptable toxicity, and high rate of pain palliation. Further investigation with prospective trials is warranted.





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Publication Info

Jacobs, Corbin D, Manisha Palta, Hannah Williamson, Jeremy G Price, Brian G Czito, Joseph K Salama and Michael J Moravan (2019). Hypofractionated Image-Guided Radiation Therapy With Simultaneous-Integrated Boost Technique for Limited Metastases: A Multi-Institutional Analysis. Frontiers in Oncology, 9. p. 469. 10.3389/fonc.2019.00469 Retrieved from https://hdl.handle.net/10161/19054.

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Manisha Palta

Associate Professor of Radiation Oncology

Clinical research in gastrointestinal malignancies, lymphomas and breast malignancies.


Brian Gary Czito

Professor of Radiation Oncology

Listed in Best Doctors in America. Listed in Top Doctors in North Carolina. His research interests include gastrointestinal malignancies, including treatment and integration of novel systemic agents with radiation therapy in the treatment of esophageal, gastric, hepatobiliary, pancreatic, colorectal and anal malignancies; phase I/II clinical trials evaluating novel systemic/targeted agents in conjunction with radiation therapy; investigation and optimization of the treatment of gastrointestinal malignancies, with focus on the above tumor sites.


Joseph Kamel Salama

Professor of Radiation Oncology

I have the privilege to be the Chief of the Durham VA Radiation Oncology Service, where I care for veterans who have served our country. I am a dedicated educator, serving as the Residency Program Director for the Duke Radiation Oncology Residency Program.  I am also a cancer researcher developing novel treatment techniques for patients with head and neck cancer, lung cancer, prostate cancer, and those limited metastatic disease, and integration of these treatments with drug therapies. 

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