Robotic radiosurgery and the “fingers of death”

Abstract

Background: Stereotactic body radiotherapy is emerging as an effective and efficient method for treating liver tumors, including hepatocellular carcinoma. With the widespread application of this complex treatment modality, new toxicities are encountered. Case Presentation: We present the case of a patient treated with stereotactic body radiotherapy for a hepatocellular carcinoma who developed unexpected Grade 3 dermatitis in the contralateral axilla. Discussion: In this paper we examine some of the intricacies of robotic stereotactic body radiotherapy, noting potential sources of unexpected toxicity. We assess the treatment plan and delivery method in our patient to determine potential causes of the dermatitis. We found that the contralateral axilla was not included in the calculation grid, and therefore, the high dose region was not reported. Conclusions: We present simple practice methods to prevent unexpected “fingers of death” from affecting other patients: calculating the dose to the entire CT volume and limiting the monitor units per node treated.