Multi-institutional comparison of treatment planning using stereotactic ablative body radiotherapy for hepatocellular carcinoma - benchmark for a prospective multi-institutional study

Introduction: Several single institution phase I and phase II trials of stereotactic ablative body radiotherapy (SABR) for liver tumors have reported promising results and high local control rates of over 90%. However, there are wide variations in dose and fractionation due to different prescription policies and treatment methods across SABR series that have been published to date. This study aims to assess and minimize inter-institutional variations in treatment planning using SABR for hepatocellular carcinoma (HCC) in preparation for a prospective multi-institutional study. Methods: Four institutions (A-D) participated in this study. Each institution was provided with data from four cases, including planning and diagnostic CT images and clinical information, and asked to implement three plans (a practice plan and protocol plans 1 and 2). Practice plans were established based on the current treatment protocols at each institution. In protocol plan 1, each institution was instructed to prescribe 40 Gy in five fractions within 95% of the planning target volume (PTV). After protocol plan 1 was evaluated, we made protocol plan 2, The additional regulation to protocol plan 1 was that 40 Gy in five fractions was prescribed to a 70% isodose line of the global maximum dose within the PTV. Planning methods and dose volume histograms (DVHs) including the median PTV D50 (D(m)50) and the median normal liver volume that received 20 Gy or higher (V(m)20) were compared. Results: In the practice plan, D(m)50 was 48.4 Gy (range, 43.6-51.2 Gy). V(m)20 was 15.9% (range, 12.2-18.9%). In protocol plan 1, the D(m)50 at institution A was higher (51.2 Gy) than the other institutions (42.0-42.2 Gy) due to differences in dose specifications. In protocol plan 2, variations in DVHs were reduced. The D(m)50 was 51.9 Gy (range, 51.0-53.1 Gy), and the V(m)20 was 12.3% (range, 10.4-13.2%). The homogeneity index was nearly equivalent at all institutions. Conclusions: There were notable inter-institutional differences in practice planning using SABR to treat HCC. The range of PTV and normal liver DVH values was reduced when the dose was prescribed to an isodose line within the PTV. In multi-institutional studies, detailed dose specifications based on collaboration are necessary.