Opportunities with Stereotactic Radiotherapy in Upper GI Cancers (#60)
Stereotactic body radiotherapy allows the delivery of high doses, potentially ablative doses of radiotherapy to tumors, typically using a few (<10) fractions, while limiting toxicity by using stereotactic and treatment guidance techniques to minimize dose to normal tissues. The technical expertise required to implement stereotactic radiotherapy, and the biological factors necessary to the safe delivery of these high doses is maturing in recent years. The ability to deliver locally ablative radiotherapy safely has created therapeutic opportunities in upper gastrointestinal malignancies that were not previously possible.
In the case of hepatocellular carcinoma, the use of SBRT offers a therapeutic modality for patients not suitable for conventional therapies, either due to local extent or co-morbidities. Outcomes such as local control of 80% can be expected with appropriate dose intensity. For pancreas and other hilar tumors, promising results have been described with locally advanced tumors in terms of safety and symptom relief, while the possibility to enhance outcomes for surgical candidates is being tested in prospective studies. Oligometastases represent a clinical state where the possibility of cure persists despite the presence of systemic disease. Liver metastases can now be treated successfully with favorable local control. Adrenal metastases, traditionally expected to have a poor prognosis have also shown promise. Solitary nodal metastases from esophagogastric primaries represent a subgroup that could be considered for aggressive therapy. Careful reporting of critical biological and treatment factors is likely the cornerstone towards defining when SBRT could provide the greatest therapeutic advantage in upper gastrointestinal cancers.