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Dutta et al. Hepatoma Res 2019;5:23 I http://dx.doi.org/10.20517/2394-5079.2019.09 Page 5 of 8

Table 2. Case report of breast cancer with liver metastasis at follow up evaluation and re-treated with radiosurgery
Date Event Treatment Investigations
Nov 2010 Right breast carcinoma Right BCS (pT1N1M0) – Lumpectomy + SNLB and axillary dissection.
ER/PR +ve, Her2neu -ve 4 × CEF + 4 × Docetaxel – RT- 50 Gy/25 fr + 10 Gy, then Tamoxifen
Feb 2014 Metastatic disease USG Abdomen – Multiple lesions in Liver.
detected PET CT – Multiple metastatic deposits in both lobes of liver, largest 7.6 cm × 9 cm –Seg VI,
VII.
No other focus of distant metastases.
Needle biopsy Liver lesion – Metastatic high grade ductal carcinoma (ER/PR +ve, Her2neu
negative); CA 15.3: 1291
Started on Abraxane × 4 Cycle
June 2014 Restaging Partial response
PETCT – Significant reduction in no of lesions, metabolic activity and size. CA 15.3 = 60.
Started on LHRHA + Anastrozole
Oct 2014 Chemotherapy Abraxane × 3 cycles, Rising CA 15.3 = 39 à 66
then Gem/Carbo × 4 Cycle PET CT - Disease progression - Increase in size
and metabolic activity of liver lesion Segment VII
( 4.5 cm × 4 cm; SUVmax 6.1 ) . New metabolic
active liver lesion segment VI (1.4 cm × 1.4 cm;
SUVmax 5.4 )
March 2015 Restaging Complete metabolic response PETCT - Complete resolution of metabolic activity
and reduction in size of lesions in segment VI, VII.
On Tamoxifen
Aug 2015 Progression Inj Goserlin monthly + Exemestane + CA 15.3 = 25
Everolimus PETCT - Disease progression – New small liver
Then on Capecitabine lesions in segment V, VI, VII . No other site of
distant metastases.
Feb 2016 Restaging PETCT – Significant reduction in size of all lesions. 2 lesions appear metabolically active –
Segment VI – 1.8 cm × 1.5 cm , SUVmax 4.7 ; Seg VI/VII – 2.2 cm × 2.2 cm , SUVmax 7.6
March 2016 1st CK Liver SBRT - 45 Gy in 3 fractions (prescribed to 86% isodose line) delivered to the two FDG avid
liver lesions
Then on Ipilimumab + Nivolumab × 7 cycles
July 2016 Restaging CECT scan – resolution of all lesions , except lesion in Seg VI/VII which has substantially
reduced in size.(2 cm × 1.2 cm)
Nov 2016 3rd CK Liver MRI Brain –2.3 cm × 2.8 cm × 3.2 cm in left premotor region . CK 27 Gy/3 fr
CK – Brain PET-CT - Disease Progression - New FDG avid lesion in left lobe of liver - Segment II (2.3 cm
× 2.5 cm × 2 cm, SUVmax 8.0)
SBRT to Segment II liver lesion – 45 Gy in 3 fractions, (prescribed to 87% isodose line).
March 2017 Restaging PET-CT - Disease Progression – Segment II lesion - CR. Three new FDG avid poorly enhancing
ill defined lesions appeared Seg IVa (1.1 cm × 1.3 cm , SUVmax 4.2), Seg III/IV (1.8 cm × 1.3 cm,
SUVmax 8.0), Seg VI (1.2 cm × 1.2 cm, SUVmax 5.8)
FDG avid small lesion on left side of sacrum near neural foramina.
April 2017 4th CK Dose of 25 Gy in 5 fractions to sacral lesion
June 2018 Expired due to disease progression
FDG: fluorodeoxyglucose; SNLB: sentinel lymph node biopsy; BCS: breast conservative surgery; SUV: ; CECT: ; CEF:

previous dose distribution was evaluated. No “hot spot” (more than prescribed dose) outside the target
volume was seen. Follow-up PET scan (Oct 2017) showed extensive metastasis in other organs. She was on
metronomic chemotherapy and expired with progressive disease on June 2018.

DISCUSSION
Re-radiation in liver tumours are not common in clinical practice. There are only few published literatures
[6-8]
in this aspect and no standard consensus regarding dosage schedule . In most of the subsites, such as
in head and neck cancer or cervical cancer, in re-irridiation setting there is usually reduction of total
[9]
dose (BED) . Treatment volume is limited and fractionation schedule modified depending upon “time
to re-treat”. Irridiated volume is also important in selection of fractionation schedule . Usually, in head
[8]
and neck cancer “seven” year time is considered “safe” to re-challenge with full dose of RT. In case of re-
radiation before that period, there is a reduction of dose depending upon the “time to re-treat”. Usually
15% dose “decay” considered in 1st year after RT and then every year 10% “decay” in dose. As the time
gap between primary RT and re-irridiation is increasing, it’s safer to deliver higher (adequate) dose of RT