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Mizumoto M, Ogino H, Okumura T, Terashima K, Murakami M, Ogino T, Tamamura H, Akimoto T, Waki T, Katoh N, Araya M, Onoe T, Takagi M, Iwata H, Numajiri H, Okimoto T, Uchinami Y, Maruo K, Shibuya K, Sakurai H. Proton Beam Therapy for Hepatocellular Carcinoma: Multicenter Prospective Registry Study in Japan. Int J Radiat Oncol Biol Phys 2024; 118:725-733. [PMID: 37778422 DOI: 10.1016/j.ijrobp.2023.09.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 09/13/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
PURPOSE A prospective multicenter registry study was started May 2016 in Japan to evaluate the efficacy and safety of proton beam therapy (PBT) for hepatocellular carcinoma (HCC). METHODS AND MATERIALS Patients who received PBT for HCC from May 2016 to June 2018 were registered in the database of the Particle Beam Therapy Committee and Subcommittee of the Japanese Society for Radiation Oncology. Overall survival (OS), progression-free survival (PFS), and local recurrence were evaluated. RESULTS Of the 755 registered patients, 576 with initial PBT and no duplicate cancer were evaluated. At final follow-up, 322 patients were alive and 254 had died. The median follow-up period for survivors was 39 months (0-58 months). The median OS time of the 576 patients was 48.8 months (95% CI, 42.0-55.6 months) and the 1-, 2-, 3-, and 4-year OS rates were 83.8% (95% CI, 80.5%-86.6%), 68.5% (64.5%-72.2%), 58.2% (53.9%-62.2%), and 50.1% (44.9%-55.0%), respectively. Recurrence was observed in 332 patients, including local recurrence in 45 patients. The median PFS time was 14.7 months (95% CI, 12.4-17.0 months) and the 1-, 2-, 3-, and 4-year PFS rates were 55.2% (95% CI, 51.0%-59.2%), 37.5% (33.5%-41.5%), 30.2% (26.3%-34.2%), and 22.8% (18.5%-27.4%), respectively. The 1-, 2-, 3-, and 4-year OS rates were significantly higher for tumor size <5 versus 5 to 10 cm (P < .001) and <5 versus ≥10 cm (P < .001); Child-Pugh score A/B versus C (P < .001); and distance of the tumor from the gastrointestinal tract <1 versus 1 to 2 cm (P < .008) and <1 versus >2 cm (P < .001). At final follow-up, 27 patients (4.7%) had late adverse events of grade 3 or higher, with liver failure (n = 7), and dermatitis (n = 7) being most common. CONCLUSIONS This multicenter prospective data registry indicated that PBT for HCC gives good therapeutic effects (3-year local control rate of 90%) with a low risk of severe late adverse events.
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Affiliation(s)
- Masashi Mizumoto
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, 305-8576, Japan.
| | - Hiroyuki Ogino
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, 462-8508, Japan
| | - Toshiyuki Okumura
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, 305-8576, Japan
| | - Kazuki Terashima
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, 679-5165, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern Tohoku Proton Therapy Center, Koriyama, Fukushima, 963-8052, Japan
| | - Takashi Ogino
- Medipolis Proton Therapy and Research Center, 4423 Higashikata, Ibusuki, Kagoshima, 891-0304, Japan
| | - Hiroyasu Tamamura
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui, Fukui, 910-8526, Japan
| | - Tetsuo Akimoto
- Department of Radiation Oncology, National Cancer Center Hospital East, Chiba, 277-8577, Japan
| | - Takahiro Waki
- Department of Radiology, Tsuyama Chuo Hospital, Tsuyama, Okayama, 708-0841, Japan
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Institute of Medicine, Hokkaido, 060-8648, Japan
| | - Masayuki Araya
- Proton Therapy Center, Aizawa Hospital, Matsumoto, Nagano, 390-8510, Japan
| | - Tsuyoshi Onoe
- Radiation and Proton Therapy Center, Shizuoka Cancer Center, Nagaizumi, Suntou-gun, Shizuoka, 411-8777, Japan
| | - Masaru Takagi
- Department of Radiation Oncology, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, 065-0033, Japan
| | - Hiromitsu Iwata
- Department of Radiation Oncology, Nagoya Proton Therapy Center, Nagoya City University West Medical Center, Nagoya, 462-8508, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, 305-8576, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, 679-5165, Japan
| | - Yusuke Uchinami
- Department of Radiation Oncology, Hokkaido University Institute of Medicine, Hokkaido, 060-8648, Japan
| | - Kazushi Maruo
- Department of Biostatistics, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, 305-8575, Japan
| | - Kei Shibuya
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, Maebashi, 371-8511, Japan
| | - Hideyuki Sakurai
- Department of Radiation Oncology, University of Tsukuba, Tsukuba, Ibaraki, 305-8576, Japan
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2
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Bush DA, Volk M, Smith JC, Reeves ME, Sanghvi S, Slater JD, deVera M. Proton beam radiotherapy versus transarterial chemoembolization for hepatocellular carcinoma: Results of a randomized clinical trial. Cancer 2023; 129:3554-3563. [PMID: 37503907 DOI: 10.1002/cncr.34965] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND This study compares survival rates, recurrence patterns, toxicity, and treatment cost in patients with hepatocellular carcinoma (HCC) treated with either transarterial chemoembolization (TACE) or proton beam radiotherapy (PBT). METHODS Subjects with untreated HCC meeting Milan or San Francisco transplant criteria were recruited. Subjects were randomized to receive PBT (n = 36) or TACE (n = 40). Proton therapy was administered in 15 fractions over 3 weeks to a total dose of 70.2 Gy. TACE was repeated until complete or maximal response. The primary outcome measure was overall survival (OS). Secondary end points were progression-free survival (PFS), local control (LC), toxicity, and cost. RESULTS Of the 76 randomized patients, 74 were assessed for outcome measures. The 2-year OS for PBT versus TACE was similar at 68%, 95% confidence interval (CI), 0.54-0.86, and 65%, 95% CI, 0.52-0.83 (p = .80), however, median PFS was improved for PBT versus TACE (not reached vs. 12 months, p = .002). LC was improved with PBT versus TACE (hazard ratio, 5.64; 95% CI, 1.78-17.9, p = .003). Days of posttreatment hospitalization were 24 for PBT and 166 for TACE (p < .001). Total mean cost per patient for treatment and posttreatment care revealed a 28% cost savings for PBT. CONCLUSIONS PBT and TACE yielded similar OS for treatment of HCC, but PFS and LC were improved with PBT compared to TACE. Patients treated with PBT required fewer courses of treatment, fewer posttreatment hospitalization days, and reduced cost of treatment compared to TACE. These data support the use of PBT as a viable treatment alternative to TACE for patients with HCC within transplant criteria.
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Affiliation(s)
- David A Bush
- Loma Linda University Medical Center, Radiation Medicine, Loma Linda, California, USA
| | - Michael Volk
- Loma Linda University Medical Center, Transplant Institute and Liver Center, Loma Linda, California, USA
| | - Jason C Smith
- Loma Linda University Medical Center, Interventional Radiology, Loma Linda, California, USA
| | - Mark E Reeves
- Jerry L. Pettis Memorial Veterans Hospital, Loma Linda, California, USA
| | - Samrat Sanghvi
- Loma Linda University Medical Center, Radiation Medicine, Loma Linda, California, USA
| | - Jerry D Slater
- Loma Linda University Medical Center, Radiation Medicine, Loma Linda, California, USA
| | - Michael deVera
- Loma Linda University Medical Center, Transplant Institute and Liver Center, Loma Linda, California, USA
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Abstract
During the past 30 years, several advances have been made allowing for safer and more effective treatment of patients with liver cancer. This report reviews recent advances in radiation therapy for primary liver cancers including hepatocellular carcinoma and intrahepatic cholangiocarcinoma. First, studies focusing on liver stereotactic body radiation therapy (SBRT) are reviewed focusing on lessons learned and knowledge gained from early pioneering trials. Then, new technologies to enhance SBRT treatments are explored including adaptive therapy and MRI-guided and biology-guided radiation therapy. Finally, treatment with Y-90 transarterial radioembolization is reviewed with a focus on novel approaches focused on personalized therapy.
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Nosaka T, Matsuda H, Sugata R, Akazawa Y, Takahashi K, Naito T, Ohtani M, Kinoshita K, Tsujikawa T, Sato Y, Maeda Y, Tamamura H, Nakamoto Y. Longer Survival and Preserved Liver Function after Proton Beam Therapy for Patients with Unresectable Hepatocellular Carcinoma. Curr Oncol 2023; 30:3915-3926. [PMID: 37185409 PMCID: PMC10136995 DOI: 10.3390/curroncol30040296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Proton beam therapy (PBT) has been recently reported to achieve excellent tumor control with minimal toxicity in patients with unresectable hepatocellular carcinoma (HCC). Radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) was investigated for larger HCC. This study was designed to evaluate the therapeutic effect of PBT on unresectable HCC in comparison with TACE combined with RFA. Methods: We retrospectively analyzed 70 patients with HCC which was difficult to control by surgical resection or RFA monotherapy, 24 patients treated with PBT and 46 patients with TACE plus RFA. The therapeutic effects were assessed as local progression-free survival (PFS) and overall survival (OS). Results: The local PFS was more than 65% in 60 months for PBT and TACE plus RFA. The patients treated with PBT showed 82% OS at 60 months post-treatment. In contrast, those treated with TACE plus RFA showed 28% OS. When comparing the changes of ALBI scores in patients with different severities of chronic liver disease, the scores of PBT-treated patients were maintained at the baseline; however, those of TACE plus RFA-treated patients worsened after the treatments. Conclusions: The results indicated that PBT may show better benefits than TACE plus RFA therapy in terms of OS in patients with unresectable HCC by sparing the non-tumor liver tissues.
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2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma. JOURNAL OF LIVER CANCER 2023; 23:1-120. [PMID: 37384024 PMCID: PMC10202234 DOI: 10.17998/jlc.2022.11.07] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 06/30/2023]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.
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Affiliation(s)
- Korean Liver Cancer Association (KLCA) and National Cancer Center (NCC) Korea
- Corresponding author: KLCA-NCC Korea Practice Guideline Revision Committee (KPGRC) (Committee Chair: Joong-Won Park) Center for Liver and Pancreatobiliary Cancer, Division of Gastroenterology, Department of Internal Medicine, National Cancer Center, 323 Ilsan-ro, Ilsandong-gu, Goyang 10408, Korea Tel. +82-31-920-1605, Fax: +82-31-920-1520, E-mail:
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Zaki P, Chuong MD, Schaub SK, Lo SS, Ibrahim M, Apisarnthanarax S. Proton Beam Therapy and Photon-Based Magnetic Resonance Image-Guided Radiation Therapy: The Next Frontiers of Radiation Therapy for Hepatocellular Carcinoma. Technol Cancer Res Treat 2023; 22:15330338231206335. [PMID: 37908130 PMCID: PMC10621304 DOI: 10.1177/15330338231206335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 08/21/2023] [Accepted: 09/21/2023] [Indexed: 11/02/2023] Open
Abstract
External beam radiation therapy (EBRT) has increasingly been utilized in the treatment of hepatocellular carcinoma (HCC) due to technological advances with positive clinical outcomes. Innovations in EBRT include improved image guidance, motion management, treatment planning, and highly conformal techniques such as intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT). Moreover, proton beam therapy (PBT) and magnetic resonance image-guided radiation therapy (MRgRT) have expanded the capabilities of EBRT. PBT offers the advantage of minimizing low- and moderate-dose radiation to the surrounding normal tissue, thereby preserving uninvolved liver and allowing for dose escalation. MRgRT provides the advantage of improved soft tissue delineation compared to computerized tomography (CT) guidance. Additionally, MRgRT with online adaptive therapy is particularly useful for addressing motion not otherwise managed and reducing high-dose radiation to the normal tissue such as the stomach and bowel. PBT and online adaptive MRgRT are emerging technological advancements in EBRT that may provide a significant clinical benefit for patients with HCC.
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Affiliation(s)
- Peter Zaki
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Michael D. Chuong
- Department of Radiation Oncology, Miami Cancer Institute, Miami, FL, USA
| | - Stephanie K. Schaub
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Simon S. Lo
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA
| | - Mariam Ibrahim
- School of Medicine, St. George's University, St. George's, Grenada
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2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma. Korean J Radiol 2022; 23:1126-1240. [PMID: 36447411 PMCID: PMC9747269 DOI: 10.3348/kjr.2022.0822] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.
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8
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Bou S, Takamatsu S, Matsumoto S, Asahi S, Tatebe H, Sato Y, Kawamura M, Shibata S, Kondou T, Tameshige Y, Maeda Y, Sasaki M, Yamamoto K, Sunagozaka H, Aoyagi H, Tamamura H, Kobayashi S, Gabata T. Long-Term Results of Proton Therapy for Hepatocellular Carcinoma Using Four-Dimensional Computed Tomography Planning without Fiducial Markers. Cancers (Basel) 2022; 14:5842. [PMID: 36497323 PMCID: PMC9735597 DOI: 10.3390/cancers14235842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
We report here the long-term results of marker-less respiratory-gated proton therapy (PT), without fiducial markers for hepatocellular carcinoma (HCC), which was planned using a four-dimensional computed tomography technique. Local tumor control (LTC) and overall survival (OS) were estimated using the Kaplan-Meier method. Toxicity was graded per CTCAE v5.0. Patients (n = 105; median age 73 years, range 38-90 years) with 128 lesions were treated. The median radiation dose was 66 gray relative biological effectiveness (GyRBE) (range, 52.8-82.5 GyRBE) delivered in 2.0 to 6.6 GyRBE fractions, depending on lesion volume, the involved liver, and the patient's condition. The median follow-up of surviving patients was 63 months (range, 1-126 months), and the 5-year LTC and OS rates were 93.2% and 40.4%, respectively. Univariate and multivariate analyses identified tumors near the gastrointestinal tract as an independent risk factor for local recurrence and revealed that hepatic reserve, tumor stage, performance status, operability, sex, and portal vein thrombosis were independent risk factors for OS. Acute and late treatment-related grade 3 toxicities were experienced by eight patients (7.6%). Adverse events ≥ grade 4 were not evident. Marker-less respiratory-gated PT for HCC is a safe and effective treatment without severe complications.
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Affiliation(s)
- Sayuri Bou
- Department of Radiology, Kanazawa University, Kanazawa 920-8641, Japan
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Shigeyuki Takamatsu
- Department of Radiology, Kanazawa University, Kanazawa 920-8641, Japan
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Sae Matsumoto
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Satoko Asahi
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Hitoshi Tatebe
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Yoshitaka Sato
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Mariko Kawamura
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Satoshi Shibata
- Department of Radiology, Kanazawa University, Kanazawa 920-8641, Japan
| | - Tamaki Kondou
- Department of Diagnostic and Therapeutic Radiology, Kanazawa Medical University, Kahoku 920-0293, Japan
| | - Yuji Tameshige
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Yoshikazu Maeda
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Makoto Sasaki
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Kazutaka Yamamoto
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Hajime Sunagozaka
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Hiroyuki Aoyagi
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Hiroyasu Tamamura
- Proton Therapy Center, Fukui Prefectural Hospital, Fukui 910-8526, Japan
| | - Satoshi Kobayashi
- Department of Radiology, Kanazawa University, Kanazawa 920-8641, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, Kanazawa 920-8641, Japan
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Kim K, Yu JI, Park HC, Yoo GS, Lim DH, Noh JM, Jeong WK. A phase II trial of hypofractionated high-dose proton beam therapy for unresectable liver metastases. Radiother Oncol 2022; 176:9-16. [PMID: 36113779 DOI: 10.1016/j.radonc.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Proton beam therapy (PBT) is an effective treatment option for primary malignant liver disease. However, evidence regarding liver metastasis is insufficient. We aimed to investigate the efficacy and safety of hypofractionated high-dose PBT in the treatment of metastatic liver disease. MATERIALS AND METHODS From January 2019 to January 2021, patients with unresectable liver metastases were enrolled. For PBT, the dose schemes of 60 Gy relative biological effectiveness (GyRBE) in 5 fractions (fx) (biologically effective dose [BED] 132 GyE) or 70 GyRBE in 10 fx (BED 119 GyE) were used. Either a passive scattered beam or pencil beam scanning (PBS)-based intensity-modulated proton therapy (IMPT) was performed with proper respiratory management. The primary endpoint of the study was 6-month freedom from local progression (FFLP) rate; and the Kaplan-Meier method was used to calculate the FFLP and survival rates. RESULTS Of the 49 liver metastases in 46 patients, the colorectum accounted for 60% of the primary cancer sites, followed by the gastrointestinal organs and pancreas/biliary tract. Forty patients presented only 1 liver metastasis, while the other 6 patients had 2 to 4 metastases. The Six-month FFLP rate was 95.2%. The 1-year FFLP rate in patients with <3 cm liver metastasis was 87.4%, while that was 74.1% in patients with > 3 cm group (p = 0.087). With regard to systemic treatment, the 1-year FFLP rate after PBT was better (94.1%) than that without systemic treatment (75.8%; p = 0.051). Regarding PBT-related toxicity, one patient developed a grade 2 gastric ulcer, while none of the patients developed grade ≥3 toxicities. CONCLUSIONS Hypofractionated PBT with a BED > 100 GyRBE for liver metastasis is safe and effective, given the high rate of 6-month FFLP without grade ≥3 treatment-related toxicities. However, further improvements are required for larger tumors and/or those without prior systemic therapy.
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Affiliation(s)
- Kangpyo Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Sciences, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma. Clin Mol Hepatol 2022; 28:583-705. [PMID: 36263666 PMCID: PMC9597235 DOI: 10.3350/cmh.2022.0294] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/27/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.
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11
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Kim TH, Kim BH, Park JW, Cho YR, Koh YH, Chun JW, Oh ES, Lee DY, Lee SU, Suh YG, Woo SM, Moon SH, Kim SS, Lee WJ. Proton Beam Therapy for Treatment-Naïve Hepatocellular Carcinoma and Prognostic Significance of Albumin-Bilirubin (ALBI) Grade. Cancers (Basel) 2022; 14:cancers14184445. [PMID: 36139604 PMCID: PMC9497120 DOI: 10.3390/cancers14184445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/16/2022] Open
Abstract
To evaluate the efficacy of proton beam therapy (PBT) as an initial treatment in treatment-naïve hepatocellular carcinoma (HCC) patients and to assess the prognostic significance of albumin-bilirubin (ALBI) grade, 46 treatment-naïve HCC patients treated with PBT were analyzed. The ALBI grade distribution was grade 1 in 11 (23.9%) patients, grade 2 in 34 (73.9%) patients, and grade 3 in 1 (2.2%) patient. The median duration of follow-up was 56.5 months (95% confidence interval [CI], 48.2−64.7). Among the 46 patients, disease progression was observed in 23 (50%) patients: local progression in 3 (6.5%) patients; intrahepatic progression in 22 (47.8%); and extrahepatic progression in 5 (10.9%). The 5-year freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) rates were 92.7% (95% CI, 84.7−100.7), 43.3% (95% CI, 28.2−58.4), and 69.2% (95% CI, 54.9−83.5), respectively. In multivariate analysis, there were no independent factors for FFLP (p > 0.05 each), but tumor stage and ALBI grade were independent factors for PFS and OS (p < 0.05 each). PBT could result in comparable OS in treatment-naïve HCC patients to other recommended first-line treatments, and ALBI grade, in addition to tumor stage, could be useful for predicting OS.
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Affiliation(s)
- Tae Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
- Correspondence: ; Tel.: +82-31-920-1725; Fax: +82-31-920-0149
| | - Bo Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
| | - Joong-Won Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
| | - Yu Ri Cho
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
| | - Young-Hwan Koh
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
| | - Jung Won Chun
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
| | - Eun Sang Oh
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
| | - Do Yeul Lee
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
| | - Sung Uk Lee
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
| | - Yang-Gun Suh
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
| | - Sang Myung Woo
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
| | - Sung Ho Moon
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
| | - Sang Soo Kim
- Center for Proton Therapy, National Cancer Center, Goyang 10408, Korea
| | - Woo Jin Lee
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang 10408, Korea
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12
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Dionisi F, Scartoni D, Fracchiolla F, Giacomelli I, Siniscalchi B, Goanta L, Cianchetti M, Sanguineti G, Brolese A. Proton therapy in the treatment of hepatocellular carcinoma. Front Oncol 2022; 12:959552. [PMID: 36003769 PMCID: PMC9393743 DOI: 10.3389/fonc.2022.959552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/13/2022] [Indexed: 12/24/2022] Open
Abstract
Liver cancer represents one of the most common causes of death from cancer worldwide. Hepatocellular carcinoma (HCC) accounts for 90% of all primary liver cancers. Among local therapies, evidence regarding the use of radiation therapy is growing. Proton therapy currently represents the most advanced radiation therapy technique with unique physical properties which fit well with liver irradiation. Here, in this review, we aim to 1) illustrate the rationale for the use of proton therapy (PT) in the treatment of HCC, 2) discuss the technical challenges of advanced PT in this disease, 3) review the major clinical studies regarding the use of PT for HCC, and 4) analyze the potential developments and future directions of PT in this setting.
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Affiliation(s)
- Francesco Dionisi
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
- *Correspondence: Francesco Dionisi,
| | - Daniele Scartoni
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | | | - Irene Giacomelli
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | | | - Lucia Goanta
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, Napoli, Italy
| | - Marco Cianchetti
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Giuseppe Sanguineti
- Department of Radiation Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Alberto Brolese
- General Surgery & Hepato-Pancreato-Biliary Unit, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
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13
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Kobeissi JM, Hilal L, Simone CB, Lin H, Crane CH, Hajj C. Proton Therapy in the Management of Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:2900. [PMID: 35740567 PMCID: PMC9220794 DOI: 10.3390/cancers14122900] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/29/2022] [Accepted: 06/07/2022] [Indexed: 12/04/2022] Open
Abstract
Proton radiation therapy plays a central role in the treatment of hepatocellular carcinoma (HCC). Because of the near-zero exit dose and improved sparing of normal liver parenchyma, protons are being used even in challenging scenarios, including larger or multifocal liver tumors, and those associated with vascular tumor thrombus. There is a mounting level of evidence that suggests that protons are superior to photons in terms of survival and toxicity outcomes, specifically the progression to liver failure. A randomized controlled trial comparing protons to photons is currently underway to verify this hypothesis.
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Affiliation(s)
- Jana M. Kobeissi
- Department of Radiation Oncology, School of Medicine, American University of Beirut Medical Center, Beirut 1107, Lebanon; (J.M.K.); (L.H.)
| | - Lara Hilal
- Department of Radiation Oncology, School of Medicine, American University of Beirut Medical Center, Beirut 1107, Lebanon; (J.M.K.); (L.H.)
| | - Charles B. Simone
- New York Proton Center, Department of Radiation Oncology, New York, NY 10035, USA; (C.B.S.2nd); (H.L.)
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10027, USA;
| | - Haibo Lin
- New York Proton Center, Department of Radiation Oncology, New York, NY 10035, USA; (C.B.S.2nd); (H.L.)
| | - Christopher H. Crane
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10027, USA;
| | - Carla Hajj
- New York Proton Center, Department of Radiation Oncology, New York, NY 10035, USA; (C.B.S.2nd); (H.L.)
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10027, USA;
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14
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The Role of Hypofractionation in Proton Therapy. Cancers (Basel) 2022; 14:cancers14092271. [PMID: 35565400 PMCID: PMC9104796 DOI: 10.3390/cancers14092271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 12/07/2022] Open
Abstract
Hypofractionated radiotherapy is an attractive approach for minimizing patient burden and treatment cost. Technological advancements in external beam radiotherapy (EBRT) delivery and image guidance have resulted in improved targeting and conformality of the absorbed dose to the disease and a reduction in dose to healthy tissue. These advances in EBRT have led to an increasing adoption and interest in hypofractionation. Furthermore, for many treatment sites, proton beam therapy (PBT) provides an improved absorbed dose distribution compared to X-ray (photon) EBRT. In the past 10 years there has been a notable increase in reported clinical data involving hypofractionation with PBT, reflecting the interest in this treatment approach. This review will discuss the reported clinical data and radiobiology of hypofractionated PBT. Over 50 published manuscripts reporting clinical results involving hypofractionation and PBT were included in this review, ~90% of which were published since 2010. The most common treatment regions reported were prostate, lung and liver, making over 70% of the reported results. Many of the reported clinical data indicate that hypofractionated PBT can be well tolerated, however future clinical trials are still needed to determine the optimal fractionation regime.
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15
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Lewis S, Dawson L, Barry A, Stanescu T, Mohamad I, Hosni A. Stereotactic body radiation therapy for hepatocellular carcinoma: from infancy to ongoing maturity. JHEP Rep 2022; 4:100498. [PMID: 35860434 PMCID: PMC9289870 DOI: 10.1016/j.jhepr.2022.100498] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 12/16/2022] Open
Affiliation(s)
- Shirley Lewis
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Laura Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Aisling Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Teodor Stanescu
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
| | - Issa Mohamad
- Department of Radiation Oncology, King Hussein Cancer Centre, Jordan
| | - Ali Hosni
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Canada
- Corresponding author. Address: Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Canada.
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16
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Pham TT, Whelan B, Oborn BM, Delaney GP, Vinod S, Brighi C, Barton M, Keall P. Magnetic resonance imaging (MRI) guided proton therapy: A review of the clinical challenges, potential benefits and pathway to implementation. Radiother Oncol 2022; 170:37-47. [DOI: 10.1016/j.radonc.2022.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 02/09/2022] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
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17
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Apisarnthanarax S, Barry A, Cao M, Czito B, DeMatteo R, Drinane M, Hallemeier CL, Koay EJ, Lasley F, Meyer J, Owen D, Pursley J, Schaub SK, Smith G, Venepalli NK, Zibari G, Cardenes H. External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12:28-51. [PMID: 34688956 DOI: 10.1016/j.prro.2021.09.004] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE This guideline provides evidence-based recommendations for the indications and technique-dose of external beam radiation therapy (EBRT) in hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC). METHODS The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the indications, techniques, and outcomes of EBRT in HCC and IHC. This guideline is intended to cover the definitive, consolidative, salvage, preoperative (including bridge to transplant), and adjuvant settings as well as palliative EBRT for symptomatic primary lesions. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS Strong recommendations are made for using EBRT as a potential first-line treatment in patients with liver-confined HCC who are not candidates for curative therapy, as consolidative therapy after incomplete response to liver-directed therapies, and as a salvage option for local recurrences. The guideline conditionally recommends EBRT for patients with liver-confined multifocal or unresectable HCC or those with macrovascular invasion, sequenced with systemic or catheter-based therapies. Palliative EBRT is conditionally recommended for symptomatic primary HCC and/or macrovascular tumor thrombi. EBRT is conditionally recommended as a bridge to transplant or before surgery in carefully selected patients. For patients with unresectable IHC, consolidative EBRT with or without chemotherapy should be considered, typically after systemic therapy. Adjuvant EBRT is conditionally recommended for resected IHC with high-risk features. Selection of dose-fractionation regimen and technique should be based on disease extent, disease location, underlying liver function, and available technologies. CONCLUSIONS The task force has proposed recommendations to inform best clinical practices on the use of EBRT for HCC and IHC with strong emphasis on multidisciplinary care. Future studies should focus on further defining the role of EBRT in the context of liver-directed and systemic therapies and refining optimal regimens and techniques.
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Affiliation(s)
| | - Aisling Barry
- Department of Radiation Oncology, Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Minsong Cao
- Department of Radiation Oncology, University of California, Los Angeles, California
| | - Brian Czito
- Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Ronald DeMatteo
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Drinane
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Eugene J Koay
- Department of Radiation Oncology, UT-MD Anderson Cancer Center, Houston, Texas
| | - Foster Lasley
- Department of Radiation Oncology, GenesisCare, Rogers, Arkansas
| | - Jeffrey Meyer
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland
| | - Dawn Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jennifer Pursley
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Stephanie K Schaub
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Grace Smith
- Department of Radiation Oncology, UT-MD Anderson Cancer Center, Houston, Texas
| | - Neeta K Venepalli
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Gazi Zibari
- Department of Transplantation Services, Willis-Knighton Medical Center, Shreveport, Louisiana
| | - Higinia Cardenes
- Department of Radiation Oncology, Weill Cornell, New York, New York
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18
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Tong VJW, Shelat VG, Chao YK. Clinical application of advances and innovation in radiation treatment of hepatocellular carcinoma. J Clin Transl Res 2021; 7:811-833. [PMID: 34988334 PMCID: PMC8715712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 09/22/2021] [Accepted: 09/29/2021] [Indexed: 02/08/2023] Open
Abstract
Background Hepatocellular carcinoma (HCC) management has evolved over the past two decades, with the development of newer treatment modalities. While various options are available, unmet needs are reflected through the mixed treatment outcome for intermediate-stage HCC. As HCC is radiosensitive, radiation therapies have a significant role in management. Radiation therapies offer local control for unresectable lesions and for patients who are not surgical candidates. Radiotherapy also provides palliation in metastatic disease, and acts as a bridge to resection and transplantation in selected patients. Advancements in radiotherapy modalities offer improved dose planning and targeted delivery, allowing for better tumor response and safer dose escalations while minimizing the risks of radiation-induced liver damage. Radiotherapy modalities are broadly classified into external beam radiation therapy and selective internal radiation therapy. With emerging modalities, radiotherapy plays a complementary role in the multidisciplinary care of HCC patients. Aim We aim to provide an overview of the role and clinical application of radiation therapies in HCC management. Relevance for Patients The continuous evolution of radiotherapy techniques allows for improved therapeutic outcomes while mitigating unwanted adverse effects, making it an attractive modality in HCC management. Rigorous clinical studies, quality research and comprehensive datasets will further its application in the present era of evidence-based practice in Medicine.
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Affiliation(s)
- Valerie J. W. Tong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vishal G. Shelat
- Department of General Surgery, Tan Tock Seng Hospital, 308433, Singapore
| | - Yew Kuo Chao
- Department of Gastroenterology and Hepatology, Tan Tock Seng Hospital, 308433, Singapore
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19
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The Role of Ablative Radiotherapy to Liver Oligometastases from Colorectal Cancer. CURRENT COLORECTAL CANCER REPORTS 2021. [DOI: 10.1007/s11888-021-00472-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Abstract
Purpose of Review
This review describes recent data supporting locoregional ablative radiation in the treatment of oligometastatic colorectal cancer liver metastases.
Recent Findings
Stereotactic body radiotherapy (SBRT) demonstrates high rates of local control in colorectal cancer liver metastases when a biologically equivalent dose of > 100 Gy is delivered. Future innovations to improve the efficacy of SBRT include MRI-guided radiotherapy (MRgRT) to enhance target accuracy, systemic immune activation to treat extrahepatic disease, and genomic customization. Selective internal radiotherapy (SIRT) with y-90 is an intra-arterial therapy that delivers high doses to liver metastases internally which has shown to increase liver disease control in phase 3 trials. Advancements in transarterial radioembolization (TARE) dosimetry could improve local control and decrease toxicity.
Summary
SBRT and SIRT are both promising options in treating unresectable metastatic colorectal cancer liver metastases. Identification of oligometastatic patients who receive long-term disease control from either therapy is essential. Future advancements focusing on improving radiation design and customization could further improve efficacy and toxicity.
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20
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Yoo GS, Yu JI, Park HC. Current role of proton beam therapy in patients with hepatocellular carcinoma. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Affiliation(s)
- Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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21
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Hilal L, Reyngold M, Wu AJ, Araji A, Abou-Alfa GK, Jarnagin W, Harding JJ, Gambarin M, El Dika I, Brady P, Navilio J, Berry SL, Flynn J, Zhang Z, Tuli R, Zinovoy M, Romesser PB, Cuaron JJ, Crane CH, Hajj C. Ablative radiation therapy for hepatocellular carcinoma is associated with reduced treatment- and tumor-related liver failure and improved survival. J Gastrointest Oncol 2021; 12:1743-1752. [PMID: 34532124 DOI: 10.21037/jgo-21-116] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/08/2021] [Indexed: 11/06/2022] Open
Abstract
Background More than 70% of patients with hepatocellular carcinoma (HCC) are not candidates for curative therapy or recur after curative-intent therapy. There is growing evidence on the use of ablative radiation therapy (RT) for liver tumors. We aimed to analyze outcomes of HCC patients treated with conventional versus ablative RT. Methods We retrospectively analyzed medical records of HCC patients treated with liver RT from 2001 to 2019. We defined ablative RT as biologically effective dose (BED) ≥80 Gy. RECIST 1.1 was used to define early responses at 3-6 months after RT, and local control (LC) at last follow-up (FU). Data was analyzed using Fisher exact test, Kaplan-Meier, cumulative incidence rates, Cox proportional hazards model and Fine-Gray competing risks. Results Forty-five patients were identified, of whom 14 (31.1%) received ablative RT using a stereotactic technique. With median FU of survivors of 10.1 months, 1-year cumulative incidence of LC was 91.7% for ablative and 75.2% for BED <80 Gy. At early FU, patients treated with ablative RT had better responses compared to BED <80 Gy, with 7% progressing versus 19%, and 21.4% with complete response versus none (P=0.038). On univariate analysis (UVA), Child-Pugh (CP) score [hazard ratio (HR): 3 for CP-B, HR: 16 for CP-C] and BED (HR: 7.69 for BED <80 Gy) correlated with deterioration of liver function, leading to liver failure. Most liver failure cases were due to disease progression. No RT-related liver failure occurred in the ablative RT group. On UVA, only BED ≥80 Gy was associated with improved overall survival (OS) (HR: 0.4; P=0.044). Median OS (mOS) and 1-year OS were 7 months and 35% respectively for BED <80 Gy compared to 28 months and 66% for BED ≥80 Gy. No grade 3+ bowel toxicity was reported in either group. Conclusions Greater than 90% LC was achieved after stereotactic ablative RT, which was associated with minimized tumor- and treatment-related liver failure and improved survival for highly selected inoperable HCC patients.
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Affiliation(s)
- Lara Hilal
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marsha Reyngold
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Abdallah Araji
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ghassan K Abou-Alfa
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - William Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James J Harding
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Maya Gambarin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Imane El Dika
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Paul Brady
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John Navilio
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean L Berry
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica Flynn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Richard Tuli
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Zinovoy
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Paul B Romesser
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John J Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christopher H Crane
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carla Hajj
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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22
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Coffman AR, Sufficool DC, Kang JI, Hsueh CT, Swenson S, McGee PQ, Nagaraj G, Patyal B, Reeves ME, Slater JD, Yang GY. Proton stereotactic body radiation therapy for liver metastases-results of 5-year experience for 81 hepatic lesions. J Gastrointest Oncol 2021; 12:1753-1760. [PMID: 34532125 DOI: 10.21037/jgo-20-424] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
Background To report on our institutional experience using Proton stereotactic body radiation therapy (SBRT) for patients with liver metastases. Methods All patients with liver metastases treated with Proton SBRT between September 2012 and December 2017 were retrospectively analyzed. Local control (LC) and overall survival (OS) were estimated using the Kaplan-Meier method calculated from the time of completion of Proton SBRT. LC was defined according to Response Evaluation Criteria in Solid Tumors (RECIST) guidelines (version 1.1). Toxicity was graded according to Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Results Forty-six patients with 81 lesions were treated with Proton SBRT. The median age was 65.5 years old (range, 33-86 years) and the median follow up was 15 months (range, 1-54 months). The median size of the gross tumor volume (GTV) was 2.5 cm (range, 0.7-8.9 cm). Two or more lesions were treated in 56.5% of patients, with one patient receiving treatment to a total of five lesions. There were 37 lesions treated with a biologically effective dose (BED) ≤60, 9 lesions with a BED of 61-80, 22 lesions with a BED of 81-100, and 13 lesions with a BED >100. The 1-year and 2-year LC for all lesions was 92.5% (95% CI, 82.7% to 96.8%). The grade 1 and grade 2 toxicity rates were 37% and 6.5%, respectively. There were no grade 3 or higher toxicities and no cases of radiation-induced liver disease (RILD). Conclusions Proton SBRT for the treatment of liver metastases has promising LC rates with the ability to safely treat multiple liver metastases. Accrual continues for our phase II trial treating liver metastases with Proton SBRT to 60 GyE (Gray equivalent) in 3 fractions.
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Affiliation(s)
- Alex R Coffman
- Department of Radiation Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Daniel C Sufficool
- Department of Radiation Oncology, Kettering Health Network, Kettering, OH, USA
| | - Joseph I Kang
- Department of Radiation Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Chung-Tsen Hsueh
- Department of Medical Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sasha Swenson
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Patrick Q McGee
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Gayathri Nagaraj
- Department of Medical Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Baldev Patyal
- Department of Radiation Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Mark E Reeves
- Department of Surgical Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Jerry D Slater
- Department of Radiation Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Gary Y Yang
- Department of Radiation Oncology, Loma Linda University Medical Center, Loma Linda, CA, USA
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23
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Bhangoo RS, Mullikin TC, Ashman JB, Cheng TW, Golafshar MA, DeWees TA, Johnson JE, Shiraishi S, Liu W, Hu Y, Merrell KW, Haddock MG, Krishnan S, Rule WG, Sio TT, Hallemeier CL. Intensity Modulated Proton Therapy for Hepatocellular Carcinoma: Initial Clinical Experience. Adv Radiat Oncol 2021; 6:100675. [PMID: 34409199 PMCID: PMC8361033 DOI: 10.1016/j.adro.2021.100675] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/14/2021] [Accepted: 02/10/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose Our purpose was to assess the safety and efficacy of intensity modulated proton therapy (IMPT) for the treatment of hepatocellular carcinoma (HCC). Methods and Materials A retrospective review was conducted on all patients who were treated with IMPT for HCC with curative intent from June 2015 to December 2018. All patients had fiducials placed before treatment. Inverse treatment planning used robust optimization with 2 to 3 beams. The majority of patients were treated in 15 fractions (n = 30, 81%, 52.5-67.5 Gy, relative biological effectiveness), whereas the remainder were treated in 5 fractions (n = 7, 19%, 37.5-50 Gy, relative biological effectiveness). Daily image guidance consisted of orthogonal kilovoltage x-rays and use of a 6° of freedom robotic couch. Outcomes (local control, progression free survival, and overall survival) were determined using Kaplan-Meier methods. Results Thirty-seven patients were included. The median follow-up for living patients was 21 months (Q1-Q3, 17-30 months). Pretreatment Child-Pugh score was A5-6 in 70% of patients and B7-9 in 30% of patients. Nineteen patients had prior liver directed therapy for HCC before IMPT. Eight patients (22%) required a replan during treatment, most commonly due to inadequate clinical target volume coverage. One patient (3%) experienced a grade 3 acute toxicity (pain) with no recorded grade 4 or 5 toxicities. An increase in Child-Pugh score by ≥ 2 within 3 months of treatment was observed in 6 patients (16%). At 1 year, local control was 94%, intrahepatic control was 54%, progression free survival was 35%, and overall survival was 78%. Conclusions IMPT is safe and feasible for treatment of HCC.
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Affiliation(s)
- Ronik S Bhangoo
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Trey C Mullikin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Tiffany W Cheng
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Todd A DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona.,Department of Health Sciences Research, Mayo Clinic, Scottsdale, Arizona
| | | | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | | | - Sunil Krishnan
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - William G Rule
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Mathew AS, Dawson LA. Current Understanding of Ablative Radiation Therapy in Hepatocellular Carcinoma. J Hepatocell Carcinoma 2021; 8:575-586. [PMID: 34164350 PMCID: PMC8214025 DOI: 10.2147/jhc.s284403] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/06/2021] [Indexed: 12/11/2022] Open
Abstract
The role of ablative stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC) has been evolving over the last few decades. SBRT has mostly been used in early stages of HCC, including few (≤ 3 in number) tumors, small tumours (< 3 cm in size), as well as larger tumours which are ineligible for other ablative modalities, mostly without vascular invasion. In early stage HCC, SBRT is used as a definitive treatment with curative intent or with intent to bridge to liver transplant. Retrospective and prospective institutional series document a high rate of local control (68–95% at 3 years) following SBRT. This coupled with a low risk of toxicity makes this non-invasive ablative treatment an attractive option for patients who are ineligible for other ablative treatments. Small randomized studies of ablative radiation have also shown non-inferiority of radiation as compared to radiofrequency ablation (RFA). Currently, SBRT is widely available as a safe and effective liver directed therapy, although there is a need for more studies providing higher level evidence. This review gives a brief overview of SBRT and the evidence for its use in HCC patients with ablative intent.
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Affiliation(s)
- Ashwathy S Mathew
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Lee SU, Yang K, Moon SH, Suh YG, Yoo GS. Patterns of Proton Beam Therapy Use in Clinical Practice Between 2007 and 2019 in Korea. Cancer Res Treat 2021; 53:935-943. [PMID: 34015892 PMCID: PMC8524026 DOI: 10.4143/crt.2021.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/14/2021] [Indexed: 11/21/2022] Open
Abstract
Purpose Proton beam therapy (PBT) is a state-of-the-art technology employed in radiotherapy (RT) for cancer patients. This study characterized how PBT has been used in clinical practice in Korea. Materials and Methods Patients who received any type of RT between 2007 and 2019 were identified from the radiation oncology registry of the two PBT facilities operating in Korea (National Cancer Center and Samsung Medical Center). The χ2 test was used to identify patient- and treatment-related characteristics associated with the receipt of PBT. Results A total of 54,035 patients had been treated with some form of RT in the two institutions, of whom 5,398 received PBT (10.0%). The number of patients who receive PBT has gradually increased since PBT first started, from 162 patients in 2007 to 1304 patients in 2019. Among all types of cancer, PBT use in liver cancer has been steadily increasing from 20% in 2008-2009 to 32% in 2018-2019. In contrast, that in prostate cancer has been continuously decreasing from 20% in 2008-2009 to <10% in 2018-2019. Male sex, very young or old age, stage I-II disease, residency in non-capital areas, a definitive setting, a curative treatment aim, enrollment in a clinical trial, re-irradiation and insurance coverage were significantly associated with the receipt of PBT (all p < 0.05). Conclusion Since PBT started in Korea, the number of patients receiving PBT has increased to more than 1,000 per year and treatment indications have expanded. Liver cancer is the most common primary tumor among all PBT cases in Korea.
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Affiliation(s)
- Sung Uk Lee
- Center for Proton Therapy, National Cancer Center, Goyang, Korea
| | - Kyungmi Yang
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Ho Moon
- Center for Proton Therapy, National Cancer Center, Goyang, Korea
| | - Yang-Gun Suh
- Center for Proton Therapy, National Cancer Center, Goyang, Korea
| | - Gyu Sang Yoo
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kim TH, Koh YH, Kim BH, Kim MJ, Lee JH, Park B, Park JW. Proton beam radiotherapy vs. radiofrequency ablation for recurrent hepatocellular carcinoma: A randomized phase III trial. J Hepatol 2021; 74:603-612. [PMID: 33031846 DOI: 10.1016/j.jhep.2020.09.026] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Proton beam radiotherapy (PBT) has recently been applied to treat hepatocellular carcinoma (HCC); however, there is no randomized controlled trial-based evidence on its safety and efficacy. We compared the outcomes of PBT and radiofrequency ablation (RFA) in patients with recurrent/residual HCC (rHCC) in a phase III non-inferiority trial. METHODS Patients with rHCC (size <3 cm, number ≤2) were randomly assigned to receive PBT or RFA according to Child-Pugh score and tumor stage. After randomization, if the assigned treatment was technically infeasible, crossover was allowed. The primary endpoint was 2-year local progression-free survival (LPFS), with a non-inferiority margin of 15% in the per-protocol (PP) population; a complementary analysis was performed in the intention-to-treat (ITT) population (NCT01963429). RESULTS The ITT population comprised 144 patients receiving either PBT (n = 72) or RFA (n = 72). Six patients switched from the PBT arm to the RFA arm and 19 patients switched from the RFA arm to the PBT arm. In the PP population, the 2-year LPFS rate with PBT (n = 80) vs. RFA (n = 56) was 94.8% vs. 83.9%, a difference of 10.9 percentage points (90% CI 1.8-20.0; p <0.001); in the ITT population, the 2-year LPFS rate with PBT vs. RFA was 92.8% vs. 83.2%, a difference of 9.6 percentage points (90% CI 0.7-18.4; p <0.001), meeting the criteria for non-inferiority. The 3- and 4-year LPFS rates for PBT were also non-inferior to those for RFA. The most common adverse events were radiation pneumonitis (32.5%) and decreased leukocyte counts (23.8%) for PBT and increased alanine aminotransferase levels (96.4%) and abdominal pain (30.4%) for RFA. No Grade 4 adverse events or mortality were noted. CONCLUSIONS PBT showed LPFS values that were non-inferior to those for RFA; in addition, PBT was tolerable and safe. CLINICAL TRIAL NUMBER: #NCT01963429 (ClinicalTrials.gov). LAY SUMMARY Radiofrequency ablation is the standard of care for patients with small hepatocellular carcinoma in whom surgery is not feasible. This study is the first phase III randomized controlled trial to evaluate the clinical outcomes of proton beam radiotherapy vs. radiofrequency ablation in patients with recurrent small HCC. Our findings show that this new technique is not inferior and can be applied safely in patients with small recurrent hepatocellular carcinoma.
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Affiliation(s)
- Tae Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea; Center for Proton Therapy, National Cancer Center, Goyang, Republic of Korea
| | - Young Hwan Koh
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea; Department of Radiology, National Cancer Center, Goyang, Republic of Korea
| | - Bo Hyun Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea
| | - Min Ju Kim
- Department of Radiology, National Cancer Center, Goyang, Republic of Korea
| | - Ju Hee Lee
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea; Department of Radiology, National Cancer Center, Goyang, Republic of Korea
| | - Boram Park
- Biostatistics Collaboration Team, Research Core Center, National Cancer Center, Goyang, Republic of Korea
| | - Joong-Won Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Republic of Korea.
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Sota Y, Einama T, Kobayashibayashi K, Fujinuma I, Tsunenari T, Takihata Y, Iwasaki T, Miyata Y, Okamoto K, Kajiwara Y, Shinto E, Tsujimoto H, Yasuda S, Isozaki Y, Yamada S, Yamamoto J, Ueno H, Kishi Y. Recurrent cholangiocarcinoma with long-term survival by multimodal treatment: A case report. Mol Clin Oncol 2021; 14:72. [PMID: 33732458 PMCID: PMC7907798 DOI: 10.3892/mco.2021.2234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022] Open
Abstract
Long-term outcomes after surgical resection of bile duct cancer remain unsatisfactory, and survival, particularly after tumor recurrence, is poor. Gemcitabine and cisplatin combination (GC) therapy is the standard first-line treatment; however, second-line approaches are yet to be established. Radiotherapy may prolong the survival of patients with advanced biliary tract cancer, and particle radiotherapy delivers a more concentrated dose than conventional radiotherapy to deeper tumors. The present report describes the long-term survival of a 65-year-old man with distal bile duct cancer of pathological stage IIA (T2N0M0; depth of invasion, 5.5 mm) following multimodal treatment. Following subtotal stomach-preserving pancreatoduodenectomy, multiple hepatic recurrences were identified 9 months later, and GC therapy was initiated. The tumors were no longer evident 18 months later, and GC therapy was discontinued at the patient's request. A computed tomography (CT) scan performed 30 months after surgery identified a new solitary hepatic recurrence and duke pancreatic monoclonal antigen type-2 (DUPAN-2) levels were increased. Further GC therapy was declined. Carbon ion radiotherapy (CIRT) at a dose of 60 Gy [relative biological effectiveness (RBE)-weighted absorbed dose] was then delivered in four fractions over 4 days [15 Gy (RBE)/day]. Tumor size decreased on CT, and fluorodeoxyglucose-positron emission tomography/CT revealed a decline in the standardized uptake value of the tumor after 2 months, with decreased DUPAN-2 levels. Following regrowth of the hepatic recurrence, CIRT was repeated at a dose of 66 Gy (RBE) in four fractions over 4 days [16.5 Gy (RBE)/day] and stable disease was maintained for 19 months. After 19 months, CT revealed tumor regrowth and another new metastatic lesion was identified in the left kidney. The patient received systematic chemotherapy again and died of the disease 81 months after the initial surgery. In conclusion, CIRT is a potential treatment option to control solitary recurrence of biliary tract cancer.
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Affiliation(s)
- Yuki Sota
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Kazuki Kobayashibayashi
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Ibuki Fujinuma
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Takazumi Tsunenari
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Yasuhiro Takihata
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Toshimitsu Iwasaki
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Yoichi Miyata
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Koichi Okamoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Yoshiki Kajiwara
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Eiji Shinto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Shigeo Yasuda
- Department of Gastrointestinal Oncology, QST Hospital International Therapy Research Center, Chiba 263-8555, Japan
| | - Yuka Isozaki
- Department of Gastrointestinal Oncology, QST Hospital International Therapy Research Center, Chiba 263-8555, Japan
| | - Shigeru Yamada
- Department of Gastrointestinal Oncology, QST Hospital International Therapy Research Center, Chiba 263-8555, Japan
| | - Junji Yamamoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama 359-8513, Japan
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Tsai YL, Takei H, Iizumi T, Okumura T, Sekino Y, Numajiri H, Ishikawa H, Sakae T, Sakurai H. Capacity of proton beams in preserving normal liver tissue during proton beam therapy for hepatocellular carcinoma. JOURNAL OF RADIATION RESEARCH 2021; 62:133-141. [PMID: 33392617 PMCID: PMC7779355 DOI: 10.1093/jrr/rraa098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/26/2020] [Accepted: 09/29/2020] [Indexed: 06/12/2023]
Abstract
Unirradiated liver volume (ULV) preservation rate is an important factor associated with radiation-induced liver disease (RILD) in patients with hepatocellular carcinoma (HCC) undergoing proton beam therapy (PBT). The purpose of this study is to identify the predictors for ULV preservation and quantify the capacity of proton beams in normal liver sparing during PBT. We reviewed planning data of 92 patients with single intrahepatic HCC tumors undergoing PBT. The potential clinical and planning factors that may affect ULV preservation were involved in multiple linear regression for ULV preservation rate. The significant factors were determined to be predictors and their influences were quantified. The median ULV preservation rate was 62.08%. All the assessed clinical factors showed significant effects on ULV preservation rate: clinical target volume (CTV), P < 0.001; portal vein tumor thrombosis (PVTT), P = 0.010; left lobe tumor, P = 0.010. In contrast, none of the planning factors demonstrated significance. The coefficients of significant factors in multiple linear regression were 60.85 for intercept, -0.02 for CTV, -9.01 for PVTT and 8.31 for left lobe tumors. The capacity of proton beams to spare normal liver tissue during PBT for HCC is mainly affected by clinical factors. The baseline of the ULV preservation rate is 60.85%, decreasing 0.02% with each milliliter of CTV increase and 9.01% for tumors with PVTT, and increasing 8.31% for tumors limited to the left lobe. Further clinical studies should be carried out to correlate our dosimetric findings with clinical outcomes.
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Affiliation(s)
- Yu-Lun Tsai
- Corresponding author. Department of Radiation Oncology, Cathay General Hospital, 280 Renai Rd. Sec.4, Taipei, Taiwan. Tel: +886227082121#3711; E-mail:
| | - Hideyuki Takei
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takashi Iizumi
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Toshiyuki Okumura
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Yuta Sekino
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Haruko Numajiri
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hitoshi Ishikawa
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takeji Sakae
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hideyuki Sakurai
- Proton Medical Research Center, University of Tsukuba, Tsukuba, Ibaraki, Japan
- Department of Radiation Oncology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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Parzen JS, Hartsell W, Chang J, Apisarnthanarax S, Molitoris J, Durci M, Tsai H, Urbanic J, Ashman J, Vargas C, Stevens C, Kabolizadeh P. Hypofractionated proton beam radiotherapy in patients with unresectable liver tumors: multi-institutional prospective results from the Proton Collaborative Group. Radiat Oncol 2020; 15:255. [PMID: 33148296 PMCID: PMC7643436 DOI: 10.1186/s13014-020-01703-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 10/29/2020] [Indexed: 01/07/2023] Open
Abstract
Background Recent advances in radiotherapy techniques have allowed ablative doses to be safely delivered to inoperable liver tumors. In this setting, proton beam radiotherapy (PBT) provides the means to escalate radiation dose to the target volume while sparing the uninvolved liver. This study evaluated the safety and efficacy of hypofractionated PBT for liver tumors, predominantly hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Methods We evaluated the prospective registry of the Proton Collaborative Group for patients undergoing definitive PBT for liver tumors. Demographic, clinicopathologic, toxicity, and dosimetry information were compiled. Results To date, 63 patients have been treated at 9 institutions between 2013 and 2019. Thirty (48%) had HCC and 25 (40%) had ICC. The median dose and biological equivalent dose (BED) delivered was 58.05 GyE (range 32.5–75) and 80.5 GyE (range 53.6–100), respectively. The median mean liver BED was 13.9 GyE. Three (4.8%) patients experienced at least one grade ≥ 3 toxicity. With median follow-up of 5.1 months (range 0.1–40.8), the local control (LC) rate at 1 year was 91.2% for HCC and 90.9% for ICC. The 1-year LC was significantly higher (95.7%) for patients receiving BED greater than 75.2 GyE than for patients receiving BED of 75.2 GyE or lower (84.6%, p = 0.029). The overall survival rate at 1 year was 65.6% for HCC and 81.8% for ICC. Conclusions Hypofractionated PBT results in excellent LC, sparing of the uninvolved liver, and low toxicity, even in the setting of dose-escalation. Higher dose correlates with improved LC, highlighting the importance of PBT especially in patients with recurrent or bulky disease.
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Affiliation(s)
| | - William Hartsell
- Northwestern Medicine Chicago Proton Center, Warrenville, IL, USA
| | - John Chang
- Oklahoma Proton Center, Oklahoma City, OK, USA
| | | | | | | | - Henry Tsai
- Princeton ProCure Proton Therapy Center, Kendall Park, NJ, USA
| | - James Urbanic
- California Protons Therapy Center, San Diego, CA, USA
| | | | | | | | - Peyman Kabolizadeh
- Beaumont Proton Therapy Center, Royal Oak, MI, USA. .,Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, 3601 W Thirteen Mile Rd, Royal Oak, MI, 48073, USA.
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Mitigation of motion effects in pencil-beam scanning - Impact of repainting on 4D robustly optimized proton treatment plans for hepatocellular carcinoma. Z Med Phys 2020; 32:63-73. [PMID: 33131995 PMCID: PMC9948857 DOI: 10.1016/j.zemedi.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 07/29/2020] [Accepted: 08/14/2020] [Indexed: 12/27/2022]
Abstract
Proton fields delivered by the active scanning technique can be interfered with the intrafractional motion. This in-silico study seeks to mitigate the dosimetric impacts of motion artifacts, especially its interplay with the time-modulated dose delivery. Here four-dimensional (4d) robust optimization and dose repainting, which is the multiple application of the same field with reduced fluence, were combined. Two types of repainting were considered: layered and volumetric repainting. The time-resolved dose calculation, which is necessary to quantify the interplay effect, was integrated into the treatment planning system and validated. Nine clinical cases of hepatocellular carcinoma (HCC) showing motion in the range of 0.4-1.5cm were studied. It was found that the repainted delivery of 4D robustly optimized plans reduced the impact of interplay effect as quantified by the homogeneity index within the clinical target volume (CTV) to a tolerable level. Similarly, the fractional over- and underdosage was reduced sufficiently for some HCC cases to achieve the purpose of motion management. This holds true for both investigated types of repainting with small dosimetric advantages of volume repainting over layered repainting. Volume repainting, however, cannot be applied clinically in proton centers with slow energy changes. Thus, it served as a reference in the in-silico evaluation. It is recommended to perform the dynamic dose calculation for individual cases to judge if robust optimization in conjunction with repainting is sufficient to keep the interplay effect within bounds.
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Fracchiolla F, Dionisi F, Righetto R, Widesott L, Giacomelli I, Cartechini G, Farace P, Bertolini M, Amichetti M, Schwarz M. Clinical implementation of pencil beam scanning proton therapy for liver cancer with forced deep expiration breath hold. Radiother Oncol 2020; 154:137-144. [PMID: 32976870 DOI: 10.1016/j.radonc.2020.09.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE To present our technique for liver cancer treatments with proton therapy in pencil beam scanning mode and to evaluate the impact of uncertainties on plan quality. MATERIALS AND METHODS Seventeen patients affected by liver cancer were included in this study. Patients were imaged and treated in forced breath-hold using the Active Breathing Coordinator system and monitored with an optical tracking system. Three simulation CTs were acquired to estimate the anatomical variability between breath-holds and generate an internal target volume (ITV). The treatment plans were optimized with a Single Field Optimization technique aimed at minimizing the use of range shifter. Plan robustness was tested simulating systematic range and setup uncertainties, as well as the interplay effect between breath-holds. The appropriateness of margin was further verified based on the actual positioning data acquired during treatment. RESULTS The dose distributions of the nominal plans achieved a satisfactory target coverage in 11 out of 17 patients, while in the remaining 6 D95 to the PTV was affected by the constraint on mean liver dose. The constraints for all other organs at risk were always within tolerances. The interplay effect had a limited impact on the dose distributions: the worst case scenario showed a D95 reduction in the ITV < 3.9 GyRBE and no OAR with D1 > 105% of the prescription dose. The robustness analysis showed that for 13 out of 17 patients the ITV coverage in terms of D95 was better than D95 of the PTV in the nominal plan. For the remaining 4 patients, the maximum difference between ITV D95 and PTV D95 was ≤0.7% even for the largest simulated setup error and it was deemed clinically acceptable. Hot spots in the OARs were always lower than 105% of the prescription dose. Positioning images confirmed that the breath hold technique and the PTV margin were adequate to compensate for inter- and intra-breath-hold variations in liver position. CONCLUSION We designed and clinically applied a technique for the treatment of liver cancer with proton pencil beam scanning in forced deep expiration breath-hold. The initial data on plan robustness and patient positioning suggest that the choices in terms of planning technique and treatment margins are able to reach the desired balance between target coverage and organ at risk sparing.
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Affiliation(s)
- Francesco Fracchiolla
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy.
| | - Francesco Dionisi
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Roberto Righetto
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Lamberto Widesott
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Irene Giacomelli
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | | | - Paolo Farace
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Mattia Bertolini
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Maurizio Amichetti
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy
| | - Marco Schwarz
- Azienda Provinciale per i Servizi Sanitari (APSS) Protontherapy Department, Trento, Italy; TIFPA Trento Institute for Fundamental Physics and Applications, Italy
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Dionisi F, Brolese A, Siniscalchi B, Giacomelli I, Fracchiolla F, Righetto R, Morganti AG, Pravadelli C, Avancini I, Rozzanigo U, Mattiuzzi A, Frisinghelli M, Pertile R, Ciarleglio FA, Vitale A, Schwarz M, Amichetti M. Clinical results of active scanning proton therapy for primary liver tumors. TUMORI JOURNAL 2020; 107:71-79. [PMID: 32648818 DOI: 10.1177/0300891620937809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Evidence for the efficacy of radiation therapy for primary liver cancer is growing. In this context, proton therapy (PT) can potentially improve the therapeutic ratio, as demonstrated by recent clinical studies. Here we report the first European clinical experience on the use of PT for primary liver cancer. METHODS All patients treated for primary liver cancer in our center entered the analysis. Patients were simulated during deep expiration breath-hold. A 15-fraction treatment schedule was adopted using active scanning PT. Clinical outcome and toxicity were retrospectively analyzed. RESULTS Between January 2018 and December 2019, 18 patients were treated. Fourteen patients had hepatocellular carcinoma (HCC), three patients had intrahepatic cholangiocarcinoma (ICC), and one patient had synchronous ICC-HCC. The Child-Pugh score was A5 in the majority of patients with HCC (71.4%). Median prescription dose was 58.05 Gy (range, 50.31-67.5). Median follow-up was 10 months (range, 1-19). The majority of deaths occurred from liver tumor progression. One-year overall survival (OS) was 63%. A significant correlation between worse OS and patient performance status, vascular invasion, and tumor stage was recorded. One-year local control was 90%. Toxicity was low, with a decrease in Child-Pugh score ⩾2 points detected in one patient. No cases of classic radiation-induced liver disease occurred. CONCLUSIONS Our initial results of active scanning PT for primary liver cancer demonstrated the feasibility, safety, and effectiveness of this advanced technique in this setting. The potential of the combination of PT with other locoregional therapies is under evaluation.
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Affiliation(s)
- Francesco Dionisi
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | | | | | - Irene Giacomelli
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Francesco Fracchiolla
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Roberto Righetto
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | | | | | - Ivo Avancini
- Gastroenterology Department, APSS, Trento, Italy
| | | | | | | | | | | | - Alessandro Vitale
- Department of Surgical, Oncological & Gastroenterological Sciences, Padua University Hospital, Italy
| | - Marco Schwarz
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy.,Trento Insitute for Fundamental Physics and Applications, TIFPA, National Institute for Nuclaer Physics, INFN, Trento, Italy
| | - Maurizio Amichetti
- Proton Therapy Unit, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
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Transitions of Liver and Biliary Enzymes during Proton Beam Therapy for Hepatocellular Carcinoma. Cancers (Basel) 2020; 12:cancers12071840. [PMID: 32650519 PMCID: PMC7408831 DOI: 10.3390/cancers12071840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 02/07/2023] Open
Abstract
Proton beam therapy (PBT) is a curative treatment for hepatocellular carcinoma (HCC), because it can preserve liver function due to dose targeting via the Bragg peak. However, the degree of direct liver damage by PBT is unclear. In this study, we retrospectively analyzed liver/biliary enzymes and total bilirubin (T-Bil) as markers of direct liver damage during and early after PBT in 300 patients. The levels of these enzymes and bilirubin were almost stable throughout the treatment period. In patients with normal pretreatment levels, aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), and T-Bil were abnormally elevated in only 2 (1.2%), 1 (0.4%), 0, 2 (1.2%), and 8 (3.5%) patients, respectively, and in 8 of these 13 patients (61.5%) the elevations were temporary. In patients with abnormal pretreatment levels, the levels tended to decrease during PBT. GGT and T-Bil were elevated by 1.62 and 1.57 times in patients who received 66 Gy (RBE) in 10 fractions and 74 Gy (RBE) in 37 fractions, respectively, but again these changes were temporary. These results suggest that direct damage to normal liver caused by PBT is minimal, even if a patient has abnormal pretreatment enzyme levels.
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Kim TH, Park JW, Kim BH, Oh ES, Youn SH, Moon SH, Kim SS, Woo SM, Koh YH, Lee WJ, Kim DY. Phase II Study of Hypofractionated Proton Beam Therapy for Hepatocellular Carcinoma. Front Oncol 2020; 10:542. [PMID: 32411594 PMCID: PMC7198869 DOI: 10.3389/fonc.2020.00542] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/26/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Proton beam has an excellent depth dose distribution due to its unique physical properties, and thus proton beam therapy (PBT) has been tried and showed promising outcomes in hepatocellular carcinoma (HCC). The purpose of this phase II study is to evaluate the efficacy of hypofractionated PBT in HCC. Methods: The eligibility criteria for this study were as follows: patients with HCC lesion(s) who were failed after, were difficult to treat with, or refused to other local treatments; tumor size and number of ≤7 and ≤2 cm, respectively, and HCC lesion(s) of ≥2 cm from gastrointestinal organs; Child–Pugh score of ≤7; Eastern Cooperative Oncology Group performance status ≤1; and age ≥18 years. The prescribed dose of PBT was 70 Gy equivalent in 10 fractions. The primary endpoint was 3-year local progression-free survival (LPFS) rate. Results: Forty-five patients were prospectively enrolled, and there were 35 men and 10 women with a median age of 63 years (range, 46–78 years). Thirty-seven patients had recurrent and/or residual disease, and eight patients had treatment-naive disease. All patients received the planned treatments without treatment interruption, and grade ≥3 acute toxicity did not occur. The median follow-up duration was 35.1 months (range, 11.2–56.3 months) and local progression occurred in two patients (8.7%). The 3-year rates of LPFS and overall survival (OS) were 95.2% (95% confidence interval [CI], 89.1%−100%) and 86.4% (95% CI, 72.9–99.9%), respectively. Conclusion: Hypofractionated PBT showed promising LPFS and OS, and further studies are warranted to compare PBT with other local modalities.
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Affiliation(s)
- Tae Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea.,Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Joong-Won Park
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Bo Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Eun Sang Oh
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sang Hee Youn
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sung Ho Moon
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sang Soo Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Sang Myung Woo
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Young-Hwan Koh
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Woo Jin Lee
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
| | - Dae Yong Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang, South Korea
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Hwang EJ, Gorayski P, Le H, Hanna GG, Kenny L, Penniment M, Buck J, Thwaites D, Ahern V. Particle therapy tumour outcomes: An updated systematic review. J Med Imaging Radiat Oncol 2020; 64:711-724. [PMID: 32270626 DOI: 10.1111/1754-9485.13021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/20/2019] [Accepted: 02/13/2020] [Indexed: 12/25/2022]
Abstract
Particle therapy (PT) offers the potential for reduced normal tissue damage as well as escalation of target dose, thereby enhancing the therapeutic ratio in radiation therapy. Reflecting the building momentum of PT use worldwide, construction has recently commenced for The Australian Bragg Centre for Proton Therapy and Research in Adelaide - the first PT centre in Australia. This systematic review aims to update the clinical evidence base for PT, both proton beam and carbon ion therapy. The purpose is to inform clinical decision-making for referral of patients to PT centres in Australia as they become operational and overseas in the interim. Three major databases were searched by two independent researchers, and evidence quality was classified according to the National Health and Medical Research Council evidence hierarchy. One hundred and thirty-six studies were included, two-thirds related to proton beam therapy alone. PT at the very least provides equivalent tumour outcomes compared to photon controls with the possibility of improved control in the case of carbon ion therapy. There is suggestion of reduced morbidities in a range of tumour sites, supporting the predictions from dosimetric modelling and the wide international acceptance of PT for specific indications based on this. Though promising, this needs to be counterbalanced by the overall low quality of evidence found, with 90% of studies of level IV (case series) evidence. Prospective comparative clinical trials, supplemented by database-derived outcome information, preferably conducted within international and national networks, are strongly recommended as PT is introduced into Australasia.
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Affiliation(s)
- Eun Ji Hwang
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia.,Medicine, Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Peter Gorayski
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hien Le
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Gerard G Hanna
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Liz Kenny
- Department of Radiation Oncology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Michael Penniment
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jacqueline Buck
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia
| | - David Thwaites
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Sydney West Radiation Oncology Network, Crown Princess Mary Cancer Centre, Sydney, New South Wales, Australia
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Palliative External Beam Radiation Therapy for Hepatocellular Carcinoma With Right Atrial Tumor Thrombus. Pract Radiat Oncol 2020; 10:e183-e187. [PMID: 31931178 DOI: 10.1016/j.prro.2019.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/18/2019] [Indexed: 12/25/2022]
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37
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Novel Radiotherapy Technologies in the Treatment of Gastrointestinal Malignancies. Hematol Oncol Clin North Am 2019; 34:29-43. [PMID: 31739949 DOI: 10.1016/j.hoc.2019.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Over the past 2 decades, major technical advances in radiation therapy planning and delivery have made it possible to deliver higher doses to select high-risk volumes. This has helped to expand the role of radiation therapy in the treatment of gastrointestinal malignancies. Whereas dose escalation was previously limited by the radiosensitivity of normal tissues within and adjacent to the gastrointestinal tract, advances in target delineation, patient immobilization, treatment planning, and image-guided treatment delivery have greatly improved the therapeutic ratio. More conformal radiation modalities can offer further dose optimization to target volumes while sparing normal tissue from toxicity.
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A comparison of the outcomes between surgical resection and proton beam therapy for single primary hepatocellular carcinoma. Surg Today 2019; 50:369-378. [PMID: 31602531 DOI: 10.1007/s00595-019-01888-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 09/13/2019] [Indexed: 12/22/2022]
Abstract
PURPOSE There are many treatment choices for hepatocellular carcinoma (HCC), one of which is proton beam therapy (PBT). The purpose of this study was to compare surgical resection (SR) and PBT to clarify the prognostic factors for operable HCC based on a single institution's database. METHODS Patients with single primary nodular HCC ≤ 100 mm without vessel invasion on pretreatment imaging were divided into the SR group and PBT group. In the PBT group, the patients with unresectable HCC due to their liver function and/or performance status were excluded. RESULTS There were 314 and 31 patients who underwent SR and PBT, respectively. The median survival time in the SR group was significantly better than in the PBT group (104.1 vs. 64.6 months, p = 0.008). Regarding the relapse-free survival (RFS), there was no significant difference between the SR and PBT groups (33.8 vs. 14.0 months, p = 0.099). CONCLUSION The RFS was comparable between the PBT and SR groups. However, the PBT group had a significantly worse overall survival than the SR group. SR may therefore be favorable as an initial treatment for HCC compared to PBT.
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Hojo H, Raturi V, Nakamura N, Arahira S, Akita T, Mitsunaga S, Nakamura M, Motegi A, Kageyama SI, Zenda S, Okumura M, Ikeda M, Akimoto T. Impact of Proton Beam Irradiation of an Anatomic Subsegment of the Liver for Hepatocellular Carcinoma. Pract Radiat Oncol 2019; 10:e264-e271. [PMID: 31585204 DOI: 10.1016/j.prro.2019.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/12/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The objective of this research was to elucidate the impact on the prognosis, including the survival prognosis, resulting from proton beam irradiation of an anatomic subsegment of the liver (ASPT) for the treatment of hepatocellular carcinoma (HCC). METHODS AND MATERIALS A total of 110 patients who received a diagnosis of HCC were analyzed in this retrospective study. Definitive proton beam therapy was delivered at a dose of 76 Gy (relative biological effectiveness) in 20 fractions between January 2008 and December 2015. When the HCC widely abutted blood vessels or when multiple HCC tumors occurred within the same liver subsegment, the clinical target volume was outlined as an anatomic subsegment of the liver, according to the portal territory, containing the tumor. In the remaining cases, the clinical target volume was delineated by adding a 5-mm margin around the gross tumor volume. The overall survival (OS), progression-free survival (PFS), and local control rates and adverse events were assessed. A review of the medical charts assessed adverse events that occurred during and after the treatment and were classified according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS The median follow-up duration was 36.5 months (range, 1-90.6 months). The median age of the patients was 73 years (range, 48-90 years). ASPT was performed in 31 patients (28%). Three-year OS, PFS, and local control rates were 74.2%, 40.4%, and 91.7%, respectively. Multivariate analysis identified ASPT as a factor that significantly improved PFS (P = .049) but not OS (P = .79). No association was found between ASPT and the frequency of grade ≥3 acute/late adverse events. CONCLUSIONS ASPT was associated with a reduction in the rate of tumor progression and no significant toxicity but was not associated with OS.
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Affiliation(s)
- Hidehiro Hojo
- Division of Radiation Oncology and Particle Therapy.
| | - Vijay Raturi
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Chiba, Japan
| | | | | | | | - Shuichi Mitsunaga
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Chiba, Japan
| | | | | | | | | | | | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Chiba, Japan
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Hasan S, Abel S, Verma V, Webster P, Arscott WT, Wegner RE, Kirichenko A, Simone CB. Proton beam therapy versus stereotactic body radiotherapy for hepatocellular carcinoma: practice patterns, outcomes, and the effect of biologically effective dose escalation. J Gastrointest Oncol 2019; 10:999-1009. [PMID: 31602338 PMCID: PMC6776803 DOI: 10.21037/jgo.2019.08.03] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 06/24/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) and proton beam therapy (PBT) generally are safe and effective for non-operative hepatocellular carcinoma (HCC). To date, data comparing the two modalities are limited. We aimed to identify the practice patterns and outcomes of nonsurgical HCC cases treated definitively with either SBRT or PBT. METHODS We queried the National Cancer Database for T1-2N0 HCC patients receiving PBT or SBRT from 2004 to 2015. Patients were excluded for any treatment other than non-palliative external beam radiotherapy. A multivariable binomial regression model identified patterns of SBRT/PBT use, and propensity-matched multivariable Cox regression assessed correlates of survival. RESULTS A total of 71 patients received PBT and 918 patients received SBRT (median follow-up 45 months). SBRT was used in 1.8% of nonoperative early stage HCC cases in 2004 and 4.2% of cases in 2015, whereas PBT was used in 0.1-0.2% of cases every year. The median biologically effective dose (BED) for SBRT and PBT was 100 Gy10 and 98 Gy10, respectively (OR =0.70, P=0.17). Factors predictive of receiving PBT included: white race, higher comorbidity score, higher education, metropolitan residence, tumors >5 cm and recent treatment (all P<0.05). Both PBT (HR =0.48, 95% CI: 0.29-0.78) and BED ≥100 Gy10 (HR =0.61, 95% CI: 0.38-0.98) were independent predictors for longer survival. CONCLUSIONS Although not implying causation and requiring prospective corroboration, PBT was independently associated with longer survival than SBRT, despite being delivered to HCC patients with multiple poor prognostic factors. PBT may also allow for safer BED escalation, which also independently associated with outcomes.
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Affiliation(s)
- Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Stephen Abel
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Vivek Verma
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Patrick Webster
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - W. Tristam Arscott
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rodney E. Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Alexander Kirichenko
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Charles B. Simone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Raldow A, Lamb J, Hong T. Proton beam therapy for tumors of the upper abdomen. Br J Radiol 2019; 93:20190226. [PMID: 31430202 DOI: 10.1259/bjr.20190226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Proton radiotherapy has clear dosimetric advantages over photon radiotherapy. In contrast to photons, which are absorbed exponentially, protons have a finite range dependent on the initial proton energy. Protons therefore do not deposit dose beyond the tumor, resulting in great conformality, and offers the promise of dose escalation to increase tumor control while minimizing toxicity. In this review, we discuss the rationale for using proton radiotherapy in the treatment of upper abdominal tumors-hepatocellular carcinomas, cholangiocarcinomas and pancreatic cancers. We also review the clinical outcomes and technical challenges of using proton radiotherapy for the treatment of these malignancies. Finally, we discuss the ongoing clinical trials implementing proton radiotherapy for the treatment of primary liver and pancreatic tumors.
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Affiliation(s)
- Ann Raldow
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - James Lamb
- Department of Radiation Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Theodore Hong
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
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42
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Hsu CY, Wang CW, Cheng AL, Kuo SH. Hypofractionated particle beam therapy for hepatocellular carcinoma-a brief review of clinical effectiveness. World J Gastrointest Oncol 2019; 11:579-588. [PMID: 31435460 PMCID: PMC6700034 DOI: 10.4251/wjgo.v11.i8.579] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/22/2019] [Accepted: 07/16/2019] [Indexed: 02/05/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the second leading cause of cancer mortality worldwide. The cornerstone to improving the prognosis of HCC patients has been the control of loco-regional disease progression and the lesser toxicities of local treatment. Although radiotherapy has not been considered a preferred treatment modality for HCC, charged particle therapy (CPT), including proton beam therapy (PBT) and carbon ion radiotherapy (CIRT), possesses advantages (for example, it allows ablative radiation doses to be applied to tumors but simultaneously spares the normal liver parenchyma from radiation) and has emerged as an alternative treatment option for HCC. With the technological advancements in CPT, various radiation dosages of CPT have been used for HCC treatment via CPT. However, the efficacy and safety of the evolving dosages remain uncertain. To assess the association between locoregional control of HCC and the dose and regimen of CPT, we provide a brief overview of selected literature on dose regimens from conventional to hypofractionated short-course CPT in the treatment of HCC and the subsequent determinants of clinical outcomes. Overall, CPT provides a better local control rate compared with photon beam therapy, ranging from 80% to 96%, and a 3-year overall survival ranging from 50% to 75%, and it results in rare grade 3 toxicities of the late gastrointestinal tract (including radiation-induced liver disease). Regarding CPT for the treatment of locoregional HCC, conventional CPT is preferred to treat central tumors of HCC to avoid late toxicities of the biliary tract. In contrast, the hypo-fractionation regimen of CPT is suggested for treatment of larger-sized tumors of HCC to overcome potential radio-resistance.
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Affiliation(s)
- Che-Yu Hsu
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan
- National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
- Cancer Research Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
| | - Chun-Wei Wang
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan
- National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
- Cancer Research Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
| | - Ann-Lii Cheng
- National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
- Department of Internal Medicine and Department of Oncology, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Sung-Hsin Kuo
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 100, Taiwan
- National Taiwan University Cancer Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
- Cancer Research Center, National Taiwan University College of Medicine, Taipei 100, Taiwan
- Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei 100, Taiwan
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Precision Locoregional Therapies for Hepatocellular Carcinoma: Percutaneous Ablation and Radiotherapy. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/978-3-030-21540-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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44
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2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma. Korean J Radiol 2019; 20:1042-1113. [PMID: 31270974 PMCID: PMC6609431 DOI: 10.3348/kjr.2019.0140] [Citation(s) in RCA: 172] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 02/24/2019] [Indexed: 01/10/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.
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45
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Sayan M, Yegya-Raman N, Greco SH, Gui B, Zhang A, Chundury A, Grandhi MS, Hochster HS, Kennedy TJ, Langan RC, Malhotra U, Rustgi VK, Shah MM, Spencer KR, Carpizo DR, Nosher JL, Jabbour SK. Rethinking the Role of Radiation Therapy in the Treatment of Unresectable Hepatocellular Carcinoma: A Data Driven Treatment Algorithm for Optimizing Outcomes. Front Oncol 2019; 9:345. [PMID: 31275846 PMCID: PMC6591511 DOI: 10.3389/fonc.2019.00345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/15/2019] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the second most common cause of cancer death worldwide, with a majority of HCC patients not suitable for curative therapies. Approximately 70% of initially diagnosed patients cannot undergo surgical resection or transplantation due to locally advanced disease, poor liver function/underlying cirrhosis, or additional comorbidities. Local therapeutic options for patients with unresectable HCC, who are not suitable for thermal ablation, include transarterial embolization (bland, chemoembolization, radioembolization) and/or external beam radiation therapy (EBRT). Regarding EBRT specifically, technological advancements provide a means for safe and effective radiotherapy delivery in a wide spectrum of HCC patients. In multiple prospective studies, EBRT delivery in a variety of different fractionation schemes or in combination with transcatheter arterial chemoembolization (TACE) demonstrate improved outcomes, particularly with combination therapy. The Barcelona Clinic Liver Cancer classification provides a framework for treatment selection; however, given the growing complexity of treatment strategies, this classification system tends to simplify decision-making. In this review, we discuss the current literature regarding unresectable HCC and propose a modified treatment algorithm that emphasizes the role of radiation therapy for Child-Pugh score A or B patients with ≤3 nodules measuring >3 cm, multinodular disease or portal venous thrombosis.
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Affiliation(s)
- Mutlay Sayan
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Nikhil Yegya-Raman
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Stephanie H. Greco
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Bin Gui
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Andrew Zhang
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Anupama Chundury
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Miral S. Grandhi
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Howard S. Hochster
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Timothy J. Kennedy
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Russell C. Langan
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Usha Malhotra
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Vinod K. Rustgi
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Mihir M. Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Kristen R. Spencer
- Division of Medical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, United States
| | - Darren R. Carpizo
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - John L. Nosher
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
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2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma. Gut Liver 2019; 13:227-299. [PMID: 31060120 PMCID: PMC6529163 DOI: 10.5009/gnl19024] [Citation(s) in RCA: 233] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 01/24/2019] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.
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47
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Komatsu S, Terashima K, Matsuo Y, Takahashi D, Suga M, Nishimura N, Lee D, Tai K, Kido M, Toyama H, Demizu Y, Tokumaru S, Okimoto T, Sasaki R, Fukumoto T. Validation of combination treatment with surgical spacer placement and subsequent particle radiotherapy for unresectable hepatocellular carcinoma. J Surg Oncol 2019; 120:214-222. [PMID: 31075183 DOI: 10.1002/jso.25495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/12/2019] [Accepted: 04/20/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Shohei Komatsu
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kazuki Terashima
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Yoshiro Matsuo
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Daiki Takahashi
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Masaki Suga
- Department of Radiation Physics, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Naoko Nishimura
- Department of Radiation Technology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Dongha Lee
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kentaro Tai
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Masahiro Kido
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hirochika Toyama
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan.,Department of Radiation Oncology, Hyogo Ion Beam Medical Center Kobe Proton Center, Kobe, Hyogo, Japan
| | - Sunao Tokumaru
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Tomoaki Okimoto
- Department of Radiology, Hyogo Ion Beam Medical Center, Tatsuno, Hyogo, Japan
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takumi Fukumoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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48
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Soni PD, Palta M. Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Current State and Future Opportunities. Dig Dis Sci 2019; 64:1008-1015. [PMID: 30868409 DOI: 10.1007/s10620-019-05539-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatocellular carcinoma is a rising cause of morbidity and mortality in the USA and around the world. Surgical resection and liver transplantation are the preferred management strategies; however, less than 30% of patients are eligible for surgery. Stereotactic body radiation therapy is a promising local treatment option for non-surgical candidates. Local control rates between 95 and 100% have been reported at 1-2 years post-treatment, and classical radiation-induced liver disease described with conventional radiation is an unlikely complication from stereotactic radiotherapy. Enrollment in randomized trials will be essential in establishing the role of stereotactic radiation in treatment paradigms for hepatocellular carcinoma.
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Affiliation(s)
- Payal D Soni
- Radiation Oncology Service, Hunter Holmes McGuire VA Medical Center, 1201 Broad Rock Blvd, Richmond, VA, 23249, USA.
| | - Manisha Palta
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
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49
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Hsieh CE, Venkatesulu BP, Lee CH, Hung SP, Wong PF, Aithala SP, Kim BK, Rao A, Tung-Chieh Chang J, Tsang NM, Wang CC, Lee CC, Lin CC, Tseng JH, Chou WC, Wang YC, Krishnan S, Hong JH. Predictors of Radiation-Induced Liver Disease in Eastern and Western Patients With Hepatocellular Carcinoma Undergoing Proton Beam Therapy. Int J Radiat Oncol Biol Phys 2019; 105:73-86. [PMID: 30797890 DOI: 10.1016/j.ijrobp.2019.02.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/03/2019] [Accepted: 02/11/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE To identify predictors of radiation-induced liver disease (RILD) in patients with hepatocellular carcinoma (HCC) treated with proton beam therapy (PBT). METHODS This multicenter study included 136 patients with HCC (eastern, n = 102; western, n = 34) without evidence of intrahepatic tumor progression after PBT. The RILD was defined as ascites with alkaline-phosphatase abnormality, grade ≥3 hepatic toxicity, or Child-Pugh score worsening by ≥2 within 4 months after PBT completion. The proton doses were converted to equivalent doses in 2-GyE fractions. The unirradiated liver volume (ULV) was defined as the absolute liver volume (LV) receiving <1 GyE; the standard liver volume (SLV) was calculated using body surface area. Possible correlations of clinicodosimetric parameters with RILD were examined. RESULTS The mean pretreatment LV was 85% of SLV, and patients with a history of hepatectomy (P < .001) or hepatitis B virus infection (P = .035) had significantly smaller LV/SLV. Nineteen (14%) patients developed RILD. Multivariate logistic regression analysis identified ULV/SLV (P = .001), gross tumor volume (P = .001), and Child-Pugh classification (P = .002) as independent RILD predictors, and mean liver dose and target-delivered dose were not associated with RILD occurrence. A "volume-response" relationship between ULV/SLV and RILD was consistently observed in both eastern and western cohorts. In Child-Pugh class-A patients whose ULV/SLV were ≥50%, 49.9%-40%, 39.9%-30% and <30%, the RILD incidences were 0%, 6%, 16%, and 39% (P < .001), respectively. For the Child-Pugh class-B group, the RILD incidences in patients with ≥60%, 59.9%-40%, and <40% of ULV/SLV were 0%, 14%, and 83% (P = .006), respectively. CONCLUSIONS The ULV/SLV, not mean liver dose, independently predicts RILD in patients with HCC undergoing PBT. The relative and absolute contraindications for Child-Pugh class-A patient's ULV/SLV are <50% and <30%, and <60% and <40% for Child-Pugh class-B patients, respectively. Our results indicate that the likelihood of hepatic complications for PBT is dictated by similar metrics as that for surgery.
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Affiliation(s)
- Cheng-En Hsieh
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China; Department of Experimental Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, Texas
| | - Bhanu Prasad Venkatesulu
- Department of Experimental Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ching-Hsin Lee
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Sheng-Ping Hung
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Pei-Fong Wong
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sathvik Panambur Aithala
- Department of Radiation Physics, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Byung Kyu Kim
- Department of Experimental Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, Texas
| | - Arvind Rao
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Joseph Tung-Chieh Chang
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Ngan-Ming Tsang
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China; School of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Chun-Chieh Wang
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China; Department of Medical Imaging and Radiological Science, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Chung-Chi Lee
- Department of Medical Imaging and Radiological Science, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Chen-Chun Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Jeng-Hwei Tseng
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Wen-Chi Chou
- Department of Medical Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Yu-Chao Wang
- Department of Surgery, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China
| | - Sunil Krishnan
- Department of Experimental Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; The University of Texas MD Anderson Cancer Center-UT Health Graduate School of Biomedical Sciences, Houston, Texas; Department of Radiation Oncology, Division of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ji-Hong Hong
- Department of Radiation Oncology, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China; Department of Institute for Radiological Research, Chang Gung Memorial Hospital, Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan, China.
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50
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Kim TH, Park JW, Kim BH, Kim H, Moon SH, Kim SS, Woo SM, Koh YH, Lee WJ, Kim DY, Kim CM. Does Risk-Adapted Proton Beam Therapy Have a Role as a Complementary or Alternative Therapeutic Option for Hepatocellular Carcinoma? Cancers (Basel) 2019; 11:cancers11020230. [PMID: 30781391 PMCID: PMC6406298 DOI: 10.3390/cancers11020230] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 02/08/2023] Open
Abstract
To evaluate the role of risk-adapted proton beam therapy (PBT) in hepatocellular carcinoma (HCC) patients, a total of 243 HCC patients receiving risk-adapted PBT with three dose-fractionation regimens (regimen A [n = 40], B [n = 60], and C [n = 143]) according to the proximity of their gastrointestinal organs (<1 cm, 1–1.9 cm, and ≥2 cm, respectively) were reviewed: The prescribed doses to planning target volume 1 (PTV1) were 50 gray equivalents (GyE) (EQD2 [equivalent dose in 2 Gy fractions], 62.5 GyE10), 60 GyE (EQD2, 80 GyE10), and 66 GyE (EQD2, 91.3 GyE10) in 10 fractions, respectively, and those of PTV2 were 30 GyE (EQD2, 32.5 GyE10) in 10 fractions. In all patients, the five-year local recurrence-free survival (LRFS) and overall survival (OS) rates were 87.5% and 48.1%, respectively, with grade ≥3 toxicity of 0.4%. In regimens A, B, and C, the five-year LRFS and OS rates were 54.6%, 94.7%, and 92.4% (p < 0.001), and 16.7%, 39.2%, and 67.9% (p < 0.001), respectively. The five-year OS rates of the patients with the Modified Union for International Cancer Control (mUICC) stages I, II, III, and IVA and Barcelona Clinic Liver Cancer (BCLC) stages A, B, and C were 69.2%, 65.4%, 43.8%, and 26.6% (p < 0.001), respectively, and 65.1%, 40%, and 32.2% (p < 0.001), respectively. PBT could achieve promising long-term tumor control and have a potential role as a complementary or alternative therapeutic option across all stages of HCC.
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Affiliation(s)
- Tae Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Joong-Won Park
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Bo Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Hyunjung Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Sung Ho Moon
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Sang Soo Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Sang Myung Woo
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Young-Hwan Koh
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Woo Jin Lee
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Dae Yong Kim
- Center for Proton Therapy, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
| | - Chang-Min Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang 410-769, Korea.
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