Stereotactic Body Radiation Therapy: Principles and Practices [2 ed.] 9819939771, 9789819939770

The second edition of the well-received book updates the knowledge of clinical treatment, radiobiology, physics, and ins

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Table of contents :
Preface
Contents
Part I: Introduction
Chapter 1: Introduction and History of Stereotactic Body Radiation Therapy (SBRT)
1.1 Introduction
1.2 Intracranial Radiosurgery
1.3 Principles and Methods
1.4 Dose Fractionation and Normal Tissue Dose Constraints
1.5 Terminology
1.6 Survey of SBRT in Japan and Its Current Status
References
Part II: Basic Principles
Chapter 2: Radiobiology of Stereotactic Ablative Radiation Therapy
2.1 Introduction
2.2 More Than DNA Damage Is Involved in The Cell Death by High-Dose Hypofractionated Radiotherapy
2.3 Effect of High-Dose Hypofractionated Irradiation on Tumor Vasculatures and TME
2.4 Vascular Damages by High-Dose Hyperfractionated Irradiation
2.5 Indirect Cell Death Due to Vascular Damages
2.6 Immunologic Effects of SABR
2.7 The 5Rs and Fractionation in SABR
2.7.1 Reoxygenation of Hypoxic Cells
2.7.2 Repair of Sublethal Radiation Damage in Tumor Cells
2.7.3 Redistribution of Cells in Cell Cycle Phase
2.7.4 Repopulation of Tumor Cells
2.7.5 Radiosensitivity of Tumor Cells
2.8 The Linear Quadratic Model in SABR
2.9 Summary
References
Chapter 3: Physics of SBRT
3.1 Electromagnetic Wave: X-Rays, Gamma Rays
3.2 Interactions of Photons with Matter
3.2.1 Photoelectric Effect
3.2.2 Compton Scattering
3.2.3 Pair Production
3.3 Photon Flux in Matter
3.4 Energy Deposition by Incident Photons to Matter
3.5 Energy Spectrum and Dose Distribution of Therapeutic X-Rays from a Linear Accelerator (Linac)
References
Chapter 4: Quality Assurance in SBRT
4.1 Introduction
4.2 Physics QA in SBRT
4.2.1 Staffing and Equipment
4.2.2 Facility-Based Physics QA
4.2.2.1 Commissioning
4.2.2.2 Simulation
4.2.2.3 Planning
4.2.2.4 RMM
4.2.2.5 IGRT
4.2.2.6 Third Parity Evaluation
4.2.3 Multifacility-Based Physics QA
4.2.3.1 Physical QA in Clinical Trials
4.2.3.1.1 Credentialing
4.2.3.1.2 Individual Case Review
4.2.3.2 Secondary Analysis
4.3 Perspective of Physics QA for SBRT
4.4 Conclusion
References
Chapter 5: Patient Immobilization, IGRT, Respiratory Motion Management
5.1 Image-Guided Radiation Therapy (IGRT)
5.1.1 Objective of IGRT
5.1.2 Uncertainties in IGRT
5.1.3 IGRT Devices and Methods
5.2 Patient Immobilization
5.2.1 Objective of Patient Immobilization
5.2.2 Immobilization Devices
5.2.3 Setup Accuracy Using Immobilization Devices
5.2.4 Influence on Dose Distribution
5.3 Respiratory Motion Management
5.3.1 Objective of Respiratory Motion Management
5.3.2 RPM Methods
5.3.3 Evaluation of RPM
References
Chapter 6: Dose Calculation Algorithm
6.1 Basics of Dose Calculation Algorithm
6.1.1 Model-Based Algorithm
6.1.1.1 Convolution-Superposition Algorithm
6.1.1.2 Analytical Anisotropic Dose Calculation Algorithm
6.1.2 MC and GBBS
6.1.3 Medium of Dose Deposition and Radiation Transport
6.2 Comparison of Dose Calculation Algorithms for SBRT
6.2.1 Issues in Clinical Cases with Low-Density Material
6.2.2 Issues in Clinical Cases with High-Density Material
6.2.3 Impact of Dose Prescription
6.2.4 Impact of Dose Grid Size
6.3 Recommendations
References
Chapter 7: Treatment Planning
7.1 Respiratory Motion
7.2 Patient Fixation
7.3 Computed Tomography and Determination of Internal Target Volume
7.3.1 Computed Tomography Slice Thickness
7.3.2 Respiratory Motion Management
7.3.2.1 Inhibition of Respiratory Motion by Abdominal Compression
7.3.2.1.1 Inhale/Exhale Breath-Hold Computed Tomography
7.3.2.1.2 Slow Computed Tomography
7.3.2.1.3 Four-Dimensional Computed Tomography
7.3.2.2 Breath-Holding
7.3.2.3 Respiratory-Gating and Real-Time Tumor Tracking
7.4 Targeting
7.4.1 Gross Tumor Volume and Clinical Target Volume
7.4.2 ITV or iGTV
7.4.3 PTV
7.5 Beam Arrangement
7.6 Beam Energy
7.7 Dose Calculation
7.8 Normal Tissue Dose Tolerance
7.9 Treatment Plan Reporting
References
Part III: Clinical Applications
Chapter 8: Lung: Peripheral
8.1 Introduction
8.2 Japanese Experience
8.3 Western Countries Studies
8.4 Phase III Study
8.5 Conclusion
References
Chapter 9: Lung: Central
9.1 Centrally and Ultra-Centrally Located Lung Tumors
9.2 Fatal Toxicity
9.3 Treatment Outcomes
9.4 Treatment Planning
References
Chapter 10: Lung: Toxicities
10.1 Introduction
10.2 Toxicities by Sites
10.2.1 Lung
10.2.1.1 Clinical Manifestations
10.2.1.2 Dose Constraints
10.2.2 Heart
10.2.2.1 Clinical Manifestations
10.2.2.2 Dose Constraints
10.2.3 Brachial Plexus
10.2.3.1 Clinical Manifestations
10.2.3.2 Dose Constraints
10.2.4 Central Airways
10.2.4.1 Clinical Manifestations
10.2.4.2 Dose Constraints
10.2.5 Esophagus
10.2.5.1 Clinical Manifestations
10.2.5.2 Dose Constraints
10.2.6 Great Vessels
10.2.6.1 Dose Constraints
10.2.7 Chest Wall and Ribs
10.2.7.1 Clinical Manifestations
10.2.7.2 Dose Constraints
10.2.8 Skin
10.2.8.1 Clinical Manifestations
10.2.8.2 Dose Constraints
10.3 Considerations on Re-irradiation
10.4 Summary
References
Chapter 11: Liver
11.1 Etiology and Epidemiology
11.2 External-Beam Radiation Therapy (EBRT)
11.3 Dose Prescription
11.4 Number and Size
11.5 Dose Constraints: Liver
11.6 Dose Constraints: GI Tract
11.7 Clinical Results of Stereotactic Body Radiation Therapy (SBRT)
11.8 Comparison of Outcomes by Treatment Modalities
11.9 Application of SBRT/EBRT to Advanced Lesions
11.10 CT Appearance of Tumor Response After SBRT
11.11 Summary—Eligibility of SBRT for HCC
References
Chapter 12: Kidney
12.1 Reasons Why SBRT Is Receiving Attention for Renal Cancer Therapy
12.1.1 Renal Cancer Shows Lower α/β Compared to Other Cancers
12.1.2 RCC Has Traditionally Been Considered to be Radio-Resistant
12.1.3 After Removal of the Affected Kidney, Recurrence of Cancer Frequently Occurs in the Remaining Kidney, and the Patient Is Forced to Undergo Dialysis After the Second Nephrectomy.
12.1.4 An Increase of Abscopal Effect Can Be Expected After a Single Irradiation with a High Dose, and the Effect May Be Further Enhanced by Combined Use of Immune Checkpoint Inhibitors.
12.2 Techniques of SBRT for RCC
12.3 Problems in Planning SBRT for Renal Cancer
12.4 Examples of SBRT for RCC
12.5 Results of SBRT for RCC
12.6 Comparison with Other Therapeutic Modalities
12.7 Summary and Future Outlook
References
Chapter 13: Spine
13.1 Overview of Spine Stereotactic Body Radiotherapy (SBRT)
13.2 Patient Selection
13.3 Methodology
13.3.1 Planning Images
13.3.1.1 Treatment Planning Computed Tomography (CT)
13.3.1.2 MRI
13.3.2 Contouring
13.3.2.1 Target Volume Definition
13.3.2.2 Defining Organs-at-Risk
13.3.3 Optimal Dose Fractionation Schedule
13.3.4 Optimizing the Target Dose Distribution
13.3.5 Dose Constraints
13.3.5.1 Spinal Cord and Cauda Equina
13.3.5.2 Esophagus
13.3.6 MESCC
13.3.6.1 Treatment Strategy
13.3.6.2 Separation Surgery
13.3.7 Follow-Up
13.3.7.1 Evaluation of LC
13.3.7.2 Evaluation of Pain Response
13.3.8 Adverse Effects
13.3.8.1 Pain Flare
13.3.8.2 Pharyngeal and Esophageal Toxicity
13.3.8.3 VCF
13.3.8.4 Radiation Myelopathy
References
Chapter 14: Oligomets
14.1 Definition of Oligometastatic Disease
14.1.1 Classification of OMD
14.1.2 Non-small Cell Lung Cancer
14.1.3 Clinical Trials for De Novo OMD (Synchronous OMD, Metachronous OMD) with Non-Small Cell Lung Cancer
14.1.4 Clinical Trials for Induced OMD and Repeat OMD with Non-Small Cell Lung Cancer
14.1.5 Ongoing Trials for OMD with Non-small Cell Lung Cancer
14.2 Breast Cancer
14.2.1 Clinical Trials for OMD with Breast Cancer
14.2.2 Ongoing Trials for OMD with Breast Cancer
14.3 Prostate Cancer
14.3.1 Clinical Trials for OMD with Prostate Cancer
14.3.2 Ongoing Trials for OMD with Prostate Cancer
14.4 OMD with Other Primary Cancers
14.4.1 Clinical Trials for OMD with Other Primary Cancers
14.5 OMD in Mixed Primaries
14.5.1 Clinical Trials for OMD with Mixed Primaries
14.5.2 Ongoing Trials for OMD with Mixed Primaries
14.6 Conclusions
References
Chapter 15: Other Indications
15.1 Stereotactic Body Radiation Therapy (SBRT) for Prostate Cancer
15.1.1 Treatment Strategy
15.1.2 Treatment Techniques
15.1.3 Clinical Outcomes
15.1.4 Future Directions
15.2 SBRT for Pancreatic Cancer
15.2.1 Treatment Strategy
15.2.2 Treatment Techniques
15.2.3 Clinical Outcomes
15.3 SBRT for Adrenal Gland Tumor
15.3.1 Treatment Strategy
15.3.2 Clinical Outcomes
15.4 SBRT for Head and Neck Cancer
15.4.1 Treatment Strategy
15.4.2 Clinical Outcomes
15.5 SBRT for Locally Advanced Non-Small Cell Lung Cancer
References
Part IV: Development of Machines
Chapter 16: Vero4DRT System and Dynamic Tumor Tracking SBRT
16.1 Introduction
16.2 Specification of the Vero4DRT
16.3 History of the Development
16.4 Physics Evaluation and Clinical Application
16.4.1 Physics Evaluation
16.4.2 Initial Clinical Application
16.4.3 Dynamic Tumor Tracking SBRT
16.5 Summary
References
Chapter 17: Real-Time Tumor-Tracking Radiotherapy (RTRT), SyncTraX
17.1 Introduction
17.2 Physical Aspects and Clinical Application of the RTRT System
17.3 Method of Gold Marker Insertion
17.3.1 Non-small Cell Lung Cancer
17.3.2 Liver and Prostate
17.4 CT Acquisition and Treatment Planning
17.5 Clinical Results
17.5.1 Non-small Cell Lung Cancer
17.5.2 Hepatocellular Carcinomas
17.5.3 Other Tumors
17.6 Marker Movement Analysis
17.7 Future Directions
17.8 Summary
References
Chapter 18: CyberKnife®
18.1 Introduction
18.2 Xsight® Spine Tracking
18.3 Fiducial Marker Tracking
18.4 Synchrony Respiratory Motion Tracking System
18.5 Xsight® Lung Tracking
18.6 Summary
References
Chapter 19: Tomotherapy
19.1 General
19.2 Beam Model
19.2.1 Common Model
19.2.2 Machine-Specific Model
19.3 Treatment Planning
19.4 Quality Assurance
19.5 Synchrony®
19.6 Practicality of SBRT
References
Chapter 20: MR-LINAC: Elekta Unity
20.1 Introduction
20.2 History of Unity
20.3 Characteristics of Unity
References
Chapter 21: ViewRay MR-Linac
21.1 Machine Specification
21.2 Patient Positioning
21.3 Gated Radiotherapy
21.4 Online Adaptive Radiotherapy
21.5 Offline Adaptive Radiotherapy
21.6 Commissioning
21.7 Stereotactic Body Radiation Therapy (SBRT) in Lung Cancer
21.8 Safety Control and Quality Management
21.9 Machine Installation
References
Part V: Future Perspectives
Chapter 22: Future of SBRT with AI (Artificial Intelligence)
22.1 Introduction
22.2 Application of AI for SBRT
22.2.1 Auto-segmentation
22.2.2 Auto-Planning and Synthetic Image
22.2.3 Automated QA
22.2.4 Outcome Prediction
References
Chapter 23: Future of SBRT with Photon and Charged Particles
23.1 FLASH Radiotherapy (FLASH-RT)
23.2 Combination with Systemic Therapy
23.3 Assessment of Recurrence Risk
23.4 New Indications for SBRT
23.5 Charged Particle: Proton and Carbon
23.6 Future Perspectives on Charged Particle Therapy Technology
References
Index
Recommend Papers

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Stereotactic Body Radiation Therapy Principles and Practices Yasushi Nagata Editor Second Edition

123

Stereotactic Body Radiation Therapy

Yasushi Nagata Editor

Stereotactic Body Radiation Therapy Principles and Practices Second Edition

Editor Yasushi Nagata Department of Radiation Oncology Hiroshima University Hiroshima, Japan

ISBN 978-981-99-3977-0    ISBN 978-981-99-3978-7 (eBook) https://doi.org/10.1007/978-981-99-3978-7 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Paper in this product is recyclable.

Preface

The first edition of this book was published in 2015. At that time, stereotactic body radiation therapy (SBRT) for lung cancer was just going to expand in the world. New technologies and new indications were on the verge of development. This book covered basic and clinical information of SBRT. Eight years after that, various new techniques and new indications were developed. Intensity-modulated radiotherapy (IMRT) technique became more widely available for SBRT. Various clinical trials were reported and are now ongoing. The indications of various organs and oligo-metastases have become more popular than before. I am very happy that we can publish the second edition of this book today. This article represents the most updated basic and clinical information of SBRT. I hope that this book will be helpful in facilitating clinical and research activities on SBRT. Finally, I would like to thank all of the authors for their contributions as well as Springer Japan for their efforts in publishing this book. Hiroshima, Japan May 2023

Yasushi Nagata

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Contents

Part I Introduction 1

I ntroduction and History of Stereotactic Body Radiation Therapy (SBRT)��������������������������������������������������������������������������������������    3 Yasushi Nagata

Part II Basic Principles 2

 adiobiology of Stereotactic Ablative Radiation Therapy������������������   13 R Chang W. Song, Sun Ha Paek, Mi-Sook Kim, Stephanie Terezakis, Yoichi Watanabe, and L. Chinsoo Cho

3

 hysics of SBRT ��������������������������������������������������������������������������������������   35 P Teiji Nishio

4

 uality Assurance in SBRT��������������������������������������������������������������������   55 Q Shuichi Ozawa

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 atient Immobilization, IGRT, Respiratory Motion Management ����   69 P Yu Kumazaki and Igari Mitsunobu

6

Dose Calculation Algorithm��������������������������������������������������������������������   83 Satoru Sugimoto, Tatsuya Inoue, and Jun Takatsu

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Treatment Planning ��������������������������������������������������������������������������������   97 Mitsuhiro Nakamura

Part III Clinical Applications 8

Lung: Peripheral��������������������������������������������������������������������������������������  113 Masaki Kokubo

9

Lung: Central ������������������������������������������������������������������������������������������  125 Takafumi Komiyama

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Contents

10 Lung: Toxicities����������������������������������������������������������������������������������������  137 Yukinori Matsuo, Noriko Kishi, Kazuhito Ueki, and Masahiro Yoneyama 11 L  iver����������������������������������������������������������������������������������������������������������  153 Yoshiko Doi 12 Kidney ������������������������������������������������������������������������������������������������������  171 Hiroshi Onishi 13 Spine����������������������������������������������������������������������������������������������������������  183 Kei Ito and Yujiro Nakajima 14 Oligomets��������������������������������������������������������������������������������������������������  199 Nobuki Imano 15 Other Indications ������������������������������������������������������������������������������������  215 Tomoki Kimura Part IV Development of Machines 16 V  ero4DRT System and Dynamic Tumor Tracking SBRT��������������������  233 Takashi Mizowaki, Yukinori Matsuo, and Masahiro Hiraoka 17 R  eal-Time Tumor-Tracking Radiotherapy (RTRT), SyncTraX����������  243 Naoki Miyamoto, Norio Katoh, Hiroshi Taguchi, Kentaro Nishioka, and Hidefumi Aoyama 18 CyberKnife®���������������������������������������������������������������������������������������������  255 Satoshi Kito 19 Tomotherapy��������������������������������������������������������������������������������������������  263 Hidetoshi Shimizu 20 M  R-LINAC: Elekta Unity ����������������������������������������������������������������������  277 Noriyuki Kadoya, Shohei Tanaka, Yoshiyuki Katsuta, Kiyokazu Sato, Noriyoshi Takahashi, and Keiichi Jingu 21 ViewRay MR-Linac ��������������������������������������������������������������������������������  285 Hiroyuki Okamoto, Takahito Chiba, Junichi Kuwahara, and Hiroshi Igaki Part V Future Perspectives 22 F  uture of SBRT with AI (Artificial Intelligence)����������������������������������  299 Daisuke Kawahara 23 F  uture of SBRT with Photon and Charged Particles ��������������������������  311 Tadamasa Yoshitake, Akira Matsunobu, and Yoshiyuki Shioyama Index������������������������������������������������������������������������������������������������������������������  323

Part I

Introduction

Chapter 1

Introduction and History of Stereotactic Body Radiation Therapy (SBRT) Yasushi Nagata

1.1 Introduction Intracranial Stereotactic Radiosurgery (SRS) was a new treatment method for brain tumor introduced in the twentieth century to deliver tight spatial/temporal distribution using a high precision technique. The clinical experience from intracranial SRS, together with the technical developments in conventional RT, initiated the development of Stereotactic Body Radiation Therapy (SBRT) for extracranial tumors characterized by a very high dose per fraction, delivered in a short time. This was started at the Swedish Karolinska University hospital in 1991 with tumors in the liver and lungs by Bromgren and Lax [1–3]. In parallel, this method was developed in Japan and clinically introduced in 1994 for lung tumors [4–6]. During the last 5 years of the 1990s, SBRT was introduced in several centers in Europe, Japan, and the USA. Wulf and Herfarth in Germany reported their clinical results on lung cancer in 2001, followed by Timmerman in the USA in 2003. In Japan, Japanese study group of stereotactic body radiation therapy was formed in 1999, and it expands annually. It then transformed into the Japan 3-D Conformal External Beam Radiotherapy Group (J-CERG) in 2002 and the Japan High-Precision External-­ beam Radiotherapy Group in 2016. The SBRT procedure was approved by the Japanese government to be covered by the health insurance in 2004. The early reports had already shown very promising results with regard to local control and toxicity for the hypofractionation schedules which were adopted with 10–15 Gy/ fraction given in 3–5 fractions during a short time . However, due to the new aspects introduced in SBRT, clinical experience was initially accumulated at a very slow rate, and it was only during the last decade that outcome data from several centers Y. Nagata (*) Department of Radiation Oncology, Graduate School of Biomedical & Health Sciences, Hiroshima University, Hiroshima, Japan e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 Y. Nagata (ed.), Stereotactic Body Radiation Therapy, https://doi.org/10.1007/978-981-99-3978-7_1

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Y. Nagata

was available to confirm the initial promising results. In this session, the historical development of SBRT was reviewed.

1.2 Intracranial Radiosurgery The field of intracranial radiosurgery was mainly developed between 1950 and 1970. The treatment was named as radiosurgery by Leksell as an alternative to neurosurgery [7, 8]. Thereafter, the terminology of stereotactic radiosurgery meant single high dose with accurate spatial precision. The system named the Gamma Knife is a system with a metal helmet and multiple holes attached to a capsule of 201 multiple gamma sources. The Gamma Knife system developed from the original system up to a modern new system. The new system has an automatic beam shaped modification with multi-leaf collimators. Metallic ring attached to a patient is currently replaced with noninvasive plastic mask with the development of cone-beam CT. The radiosurgery technique was also possible using a conventional linear accelerator with a threedimensional radiosurgery systems. This system included metallic ring to be attached to a patient and fixation system attached to a couch. The three-­dimensional coordinates were essential for SRS. The accuracy of linear accelerator was essential.

1.3 Principles and Methods To extend the intracranial radiosurgery technology to extracranial tumors, two problems should be solved. First, most extracranial tumors move with or without respiratory motion. With tumor motions, wide ITV margins prevent delivering high dose to the tumor. The other difficulty is the unknown normal tissue toxicity using single high dose. Previous experiences with clinical radiotherapy are based on daily 2 Gy radiotherapy up to 60 or 70 Gy. Therefore, 48–60 Gy in 3–5 fractions are unknown areas. Therefore, initial SBRT was based on stereotactic coordinates using the Stereotactic Body Frame. Patients were stored within a plastic frame with three-­ dimensional coordinates. After the setup with these coordinates, single high dose was irradiated with non-coplanar beams. The other concern is the respiratory tumor movement. To regulate respiratory movement, various methods were used. Initially, abdominal press techniques or breath-hold techniques were most popular methods, thereafter, developed into respiratory gating and chasing methods. Geometric verification at each treatment is essential for SBRT, it is because single dose setup error will consequently make local tumor recurrence. Therefore, AP and lateral portal verifications using films were essential before each treatment, which now developed into EPID technology and cone-beam CT technology. The indications of SBRT expanded from lung cancer, liver cancer, renal cancer, prostate cancer, adrenal cancer, pancreatic cancer, vertebral bone tumor, lymph nodal tumors and other indications. The details of clinical application will be presented in this book [9–68].

1  Introduction and History of Stereotactic Body Radiation Therapy (SBRT)

5

1.4 Dose Fractionation and Normal Tissue Dose Constraints Even now, the best dose fractionation schedule for lung and liver tumors could not be determined. Various dose fractionation schedules are used at different countries and at different institutions by now. The dose constraints for normal tissue are still finalized, and different dose constraints are used in different clinical trials. Previously in Japan, 50 Gy in 10 fractions, 60 Gy in 8 fractions, 48Gy in 4 fractions were prescribed at the isocenter. In the USA and Europe, 60 Gy in 3 fractions, 54 Gy in 3, and 48–50 Gy in 4 were prescribed at D95. We must be careful that these doses were prescribed at different points. The normal tissue dose constraints were set by JCOG (Japan Clinical Oncology Group) first proposed by Dr. Shirato and modified by JCOG1408.

1.5 Terminology The name of SBRT was introduced by Timmerman in 2002. He originally used Stereotactic Ablative Radiosurgery for this treatment. However, there were several oppositions from radiation oncologists because this treatment is completely different from radiofrequency ablation (RFA). In 2005, SBRT was used as a code of radiation therapy in the USA.  Extracranial stereotactic radiation therapy (ESRT) was used in Europe in the late 1990s and pin-pointed radiation therapy was used in Japan in the late 1990s. In 2010, stereotactic ablative radiotherapy (SABR) was introduced by Loo et al. It was because the pronunciation of SBRT was difficult. Currently, the terminology of SBRT and SABR are both used and are confusing.

1.6 Survey of SBRT in Japan and Its Current Status The Japan 3-D conformal external beam radiotherapy group (J-CERG) developed into the Japan High-Precision External Beam Radiotherapy Group of the JASTRO in 2016. J-CERG and the JASTRO group continuously conducted a survey of the SBRT in Japan since 2006. Figure 1.1 is the accumulated number of cases for SBRT in Japan. The number of institutions where SBRT is performed increased from 58 in 2006 to 310 in 2020. The indications of SBRT were lung cancer (70%), followed by liver cancer (13%), prostate cancer (6%), head and neck cancer, vertebral bone tumor, oligo-mets, adrenal tumor, renal cancer, and others as shown in Fig. 1.2. Grade 5 sequela are listed in Table  1.1 by the same survey. Radiation pneumonitis was the most common Grade 5 toxicity followed by pulmonary bleeding, liver damage, radiation esophagitis, and GI bleeding. The frequency of Grade 5 toxicity is 0.2 % on average.

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NSCLC:T1N0M0

Fig. 1.1  Accumulated number of SBRT cases in Japan

Fig. 1.2 Accumulated number of major cases for SBRT as in 2021

ɼ

Table 1.1  Accumulated Grade 5 sequela of SBRT by 2020 (by 2018, 2016, 2014, 2010, 2008) 1. Radiation pneumonitis 2. Pulmonary bleeding 3. Liver damage 4. Radiation esophagitis 5. GI bleeding 6. Others 76 cases/36,557 total cases = 0.2% 0.2% (0.2%, 0.2%, 0.5%, 0.5%, 0.6%)

55 (43, 40, 41, 42, 28) 6 (5, 4, 3, 3, 3) 4 (7, 0, 2, 0, 0) 4 (1, 2, 1, 1, 1) 4 (3, 3, 0, 0, 0) 3 (4, 3, 6, 5, 4)

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