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Dutta et al. Hepatoma Res 2019;5:23 I http://dx.doi.org/10.20517/2394-5079.2019.09 Page 7 of 8

There was no clinical sign of “RILD” after re-CK. Radiological evaluation, clinical examination and liver
function test done to exclude RILD at all post-CK follow up evaluation. In both the cases, liver volumes
were maintained after post-CK long-term follow up (> 2 years). There was regeneration of the treated
portion of liver. In the present series, patient was treated three times with CK for liver metastasis. There
are few small series of liver metastasis patients treated with SBRT for twice in two different lobes. There is
limited or no published literature on SBRT for three times in liver metastasis. In present study is novel in
terms of thrice CK treatment for liver metastasis and had complete response to treatment. Modern systemic
[9]
therapy improves the probability of control of distant metastasis as well as survival . Hence, the probability
of repeating focal treatment with RT has increased significantly with usage of modern systemic therapy.
Focused RT with Robotic Radiosurgery (CK) has minimal internal target volume and spares maximum
liver volume, hence enables to re-treat w ith radiosurgery in small volume recurrent or new lesions in liver.
[8]
Toxicity was assessed by liver function test parameters, ascitis and clinical symptoms . There was no gross
derangement of secretory or excretory functions (serum bilirubin, alkaline phosphatase, SGOT, SGPT) of
the liver. There was no ascitis after treatment or at follow up evaluation. Patients were asymptomatic with
liver metastasis and were on routine close follow up Usually, after liver metastasis survival outcome is poor,
mean overall survival is six to eight months after diagnosis. In this case series, both the patients survived
more than 2 years and after CK there is acceptable survival outcome in these patient cohort.

In recent years, with advent of modern more potent systemic therapies as second and third line treatment,
possibility of re-radiation of liver metastasis has increased [9,10] . RT for liver metastasis at diagnosis and at
follow up evaluation is more common and needs to be addressed. Long-term survival (> 2 years) is seen
in breast cancer patients with liver metastasis and also in known patients with liver metastasis on routine
follow up evaluation.

In summary, re-radiation for liver lesions is feasible but uncommon in clinical practice. In the present
series, two patients with liver metastasis were treated three times with radiosurgery for metastasis at
different segments of liver without any clinical signs of liver decompensation. There were are signs of
early regeneration in the irradiated regions of the liver in USG scan. High regeneration capacity and
hypertrophy of the irradiated region of liver suggest potential for Re-RT. Re-radiation of liver with CK will
be an exciting option in the era of highly potent systemic therapies.

DECLARATIONS
Authors’ contributions
Concept and design: Dutta D, Krishnamoorthy S
Data analysis and interpretation: Dutta D, Krishnamoorthy S, Nair H
Manuscript preparation: Dutta D, Das R, Madhavan R, Holla R
Critical review and finalization of the manuscript: Dutta D

Availability of data and materials
Not applicable.

Financial support and sponsorship
Not applicable.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.