Magnetic Resonance-Guided Stereotactic Body Radiation Therapy With Daily Online Plan Adaptation for Reirradiation in the Abdomen.

Abstract

Reirradiation in the abdomen poses a challenge due to both interfraction and intrafraction motion of the target and nearby organs at risk. We hypothesized that magnetic resonance-guided stereotactic body radiation therapy (MRgSBRT) with daily online adaptation allows for safe and effective dose-escalated treatment by minimizing grade 3+ gastrointestinal toxicities. We performed a single-institution retrospective review of 38 patients who received a total of 44 courses of MRgSBRT reirradiation within the abdomen. Clinical outcomes included local control, overall survival, and gastrointestinal toxicities assessed using Common Terminology Criteria for Adverse Events v5. Organs at risk (OAR) metrics of original and adapted plans were compared to assess the added value of daily adaptation. Fourteen different primary histologies were treated, with the most common including pancreatic (18.2%), renal (18.2%), and prostate (15.9%) cancers. The most common site for reirradiation was abdominal lymph nodes (61.3%). A majority (70.4%) of MRgSBRT courses were preceded by prior stereotactic body radiation therapy. The median and modal prescribed dose of MRgSBRT reirradiation was 40 Gy in 5 fractions (biologically effective dose for α/β = BED₁₀ = 72); 87% of courses were treated to a biologically effective dose for α/β = 10 of at least 59.5. Across 218 total fractions, daily adaptation improved planning target volume coverage by a mean of 4.1% (95% CI, 3.1%-5.1%, P < .0001) and met 100% of hard luminal gastrointestinal organs at risk 0.03 cc constraints that would have been exceeded without adaptation in 53.2% of fractions. The median follow-up after MRgSBRT reirradiation was 15.8 months. One-year local control and overall survival were 89.5% and 74.9%, respectively. Grade 3+ toxicity possibly related to MRgSBRT reirradiation was observed after 2 (4.5%) courses. MRgSBRT allows for dose escalation and good local control in cases of abdominal reirradiation with acceptable toxicity. Daily adaptation provided substantial benefits in meeting safety goals and improving coverage. This retrospective study supports the development of a prospective clinical trial of MRgSBRT reirradiation in the abdomen.