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Yang KL, Chi MS, Ko HL, Huang YY, Huang SC, Lin YM, Chi KH. Axitinib in combination with radiotherapy for advanced hepatocellular carcinoma: a phase I clinical trial. Radiat Oncol 2021; 16:18. [PMID: 33472666 PMCID: PMC7819176 DOI: 10.1186/s13014-020-01742-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND To investigate maximum tolerated dose (MTD) of axitinib, a selective vascular endothelial growth factor receptor 1-3 inhibitor, in combination with radiotherapy (RT) for advanced hepatocellular carcinoma (HCC). METHODS This phase I study followed the rule of traditional 3 + 3 design. Major eligibility included: (1) patients with advanced HCC unsuitable for surgery, radiofrequency ablation or transarterial chemoembolization, or who failed after prior local-regional treatment; (2) failure on sorafenib or no grant for sorafenib from health insurance system. Eligible patients with advanced HCC received axitinib for total 8 weeks during and after RT. Three cohorts with axitinib dose escalation were planned: 1 mg twice daily (level I), 2 mg twice daily (level II) and 3 mg twice daily (level III). The prescribed doses of RT ranged from 37.5 to 67.5 Gy in 15 fractions to liver tumor(s) and were determined based on an upper limit of mean liver dose of 18 Gy (intended isotoxic RT for normal liver). The primary endpoint was MTD of axitinib in combination with RT. The secondary endpoints included overall response rate (ORR), RT in-field response rate, acute and late toxicities, overall survival (OS) and progression free survival (PFS). RESULTS Total nine eligible patients received axitinib dose levels of 1 mg twice daily (n = 3), 2 mg twice daily (n = 3) and 3 mg twice daily (n = 3). Dose-limiting toxicity (DLT) did not occur in the 3 cohorts; the MTD was defined as 3 mg twice daily in this study. ORR was 66.7%, including 3 complete responses and 3 partial responses, at 3 months after treatment initiation. With a median follow-up of 16.6 months, median OS was not reached, 1-year OS was 66.7%, and median PFS was 7.4 months. CONCLUSIONS Axitinib in combination with RT for advanced HCC was well tolerated with an axitinib MTD of 3 mg twice daily in this study. The outcome analysis should be interpreted with caution due to the small total cohort. Trial registration ClinicalTrials.gov (Identifier: NCT02814461), Registered June 27, 2016-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02814461.
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Affiliation(s)
- Kai-Lin Yang
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Shih-Lin District, No. 95, Wen-Chang Road, Taipei City, 111, Taiwan
- School of Medicine, Fu Jen Catholic University, No. 510, Chung-Cheng Road, Hsin-Chuang, New Taipei City, Taiwan
| | - Mau-Shin Chi
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Shih-Lin District, No. 95, Wen-Chang Road, Taipei City, 111, Taiwan
| | - Hui-Ling Ko
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Shih-Lin District, No. 95, Wen-Chang Road, Taipei City, 111, Taiwan
| | - Yi-Ying Huang
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Shih-Lin District, No. 95, Wen-Chang Road, Taipei City, 111, Taiwan
| | - Su-Chen Huang
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Shih-Lin District, No. 95, Wen-Chang Road, Taipei City, 111, Taiwan
| | - Yu-Min Lin
- School of Medicine, Fu Jen Catholic University, No. 510, Chung-Cheng Road, Hsin-Chuang, New Taipei City, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei City, Taiwan
| | - Kwan-Hwa Chi
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Shih-Lin District, No. 95, Wen-Chang Road, Taipei City, 111, Taiwan.
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, No. 155, Sec. 2, Linong Street, Beitou District, Taipei City, Taiwan.
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Pérez-Romasanta LA, González-Del Portillo E, Rodríguez-Gutiérrez A, Matías-Pérez Á. Stereotactic Radiotherapy for Hepatocellular Carcinoma, Radiosensitization Strategies and Radiation-Immunotherapy Combination. Cancers (Basel) 2021; 13:cancers13020192. [PMID: 33430362 PMCID: PMC7825787 DOI: 10.3390/cancers13020192] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary Radiotherapy is rapidly turning into a crucial component of multidisciplinary treatment for liver cancer because many patients are not surgical treatment candidates. Thanks to technical developments, radiotherapy have achieved high precision treatments, making it possible to eliminate tumor cells without severe damage to the liver and other organs. Stereotactic Body Radiation Therapy is an advanced radiotherapy technique able to eradicate malignant tumors wherever they are located in properly selected patients. The best use of radiotherapy, the most fruitful radiotherapy strategy, and the best way to combine it with other treatments for liver cancer are largely unknown. Radiosensitizers, agents that can potentiate radiotherapy, could broaden the radiotherapeutic landscape. Radiotherapy potentiation can be achieved with diverse treatments, not only drugs but also nanoparticles. In order to clear up the performance of radiotherapy in liver cancer management in the future and the best ways to potentiate its effects, considerable medical research is needed. Abstract Stereotactic body radiotherapy (SBRT) is an emerging ablative modality for hepatocellular carcinoma (HCC). Most patients with HCC have advanced disease at the time of diagnosis, and therefore, are not candidates for definitive-intent therapies such as resection or transplantation. For this reason, various alternative local and regional therapies have been used to prevent disease progression, palliate symptoms, and delay liver failure. Stereotactic body radiation therapy is a non-invasive technique of delivering ablative doses of radiation to tumors while sparing normal or non-tumor hepatic tissue. Incorporation of SBRT in multidisciplinary HCC management is gradual, initially applied when other liver-directed therapies have failed or are contraindicated, and tried in combination with other locoregional or systemic therapies for more unfavorable conditions by more experienced teams. In order to improve SBRT therapeutic ratio, there has been much interest in augmenting the effect of radiation on tumors by combining it with chemotherapy, molecularly targeted therapeutics, nanoparticles, and immunotherapy. This review aims to synthesize available evidence to evaluate the clinical feasibility and efficacy of SBRT for HCC, and to explore novel radio-potentiation concepts by combining SBRT with novel therapeutics. It is expected that those approaches would result in improved therapeutic outcomes, even though many questions remain with regard to the optimal way to assemble treatments. Further trials are needed to evaluate and consolidate these promising therapies for HCC.
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Hamming LC, Slotman BJ, Verheul HMW, Thijssen VL. The clinical application of angiostatic therapy in combination with radiotherapy: past, present, future. Angiogenesis 2017; 20:217-232. [PMID: 28364160 PMCID: PMC5437175 DOI: 10.1007/s10456-017-9546-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 03/14/2017] [Indexed: 12/14/2022]
Abstract
Although monotherapy with angiostatic drugs is still far from effective, there is abundant evidence that angiostatic therapy can improve the efficacy of conventional treatments like radiotherapy. This has instigated numerous efforts to optimize and clinically implement the combination of angiostatic drugs with radiation treatment. The results from past and present clinical trials that explored this combination therapy indeed show encouraging results. However, current findings also show that the combination has variable efficacy and is associated with increased toxicity. This indicates that combining radiotherapy with angiostatic drugs not only holds opportunities but also provides several challenges. In the current review, we provide an update of the most recent insights from clinical trials that evaluated the combination of angiostatic drugs with radiation treatment. In addition, we discuss the outstanding questions for future studies in order to improve the clinical benefit of combining angiostatic therapy with radiation therapy.
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Affiliation(s)
- Lisanne C Hamming
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Victor L Thijssen
- Department of Radiation Oncology, VU University Medical Centre, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
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4
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Que J, Kuo HT, Lin LC, Lin KL, Lin CH, Lin YW, Yang CC. Clinical outcomes and prognostic factors of cyberknife stereotactic body radiation therapy for unresectable hepatocellular carcinoma. BMC Cancer 2016; 16:451. [PMID: 27405814 PMCID: PMC4941022 DOI: 10.1186/s12885-016-2512-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/05/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Stereotactic body radiation therapy (SBRT) has been an emerging non-invasive treatment modality for patients with hepatocellular carcinoma (HCC) when curative treatments cannot be applied. In this study, we report our clinical experience with Cyberknife SBRT for unresectable HCC and evaluate the efficacy and clinical outcomes of this highly sophisticated treatment technology. METHODS Between 2008 and 2012, 115 patients with unresectable HCC treated with Cyberknife SBRT were retrospectively analyzed. Doses ranged from 26 Gy to 40 Gy were given in 3 to 5 fractions for 3 to 5 consecutive days. The cumulative probability of survival was calculated according to the Kaplan-Meier method and compared using log-rank test. Univariate and multivariate analysis were performed using Cox proportional hazard models. RESULTS The median follow-up was 15.5 months (range, 2-60 months). Based on Response Evaluation and Criteria in Solid Tumors (RECIST). We found that 48.7 % of patients achieved a complete response and 40 % achieved a partial response. Median survival was 15 months (4-25 months). Overall survival (OS) at 1- and 2-years was 63.5 %(54-71.5 %) and 41.3 % (31.6-50.6 %), respectively, while 1- and 2- years Progression-free Survival (PFS) rates were 42.8 %(33.0-52.2 %) and 38.8 % (29.0-48.4 %). Median progression was 6 months (3-16 months). In-field recurrence free survival at 1 and 2 years was 85.3 % (76.2-91.1 %) and 81.6 % (72.2-88.6 %), respectively, while the 1- and 2-years out-field recurrence free survival were 52.5 % (41.2-60.8 %) and 49.5 %(38.9-59.2 %), respectively. Multivariate analysis revealed that Child-Pugh score (A vs. B), Portal vein tumor thrombosis (positive vs. negative), Tumor size (≤4 cm vs >4-9 cm /≥10 cm), and tumor response after SBRT (CR vs. PR/stable) were independent predictors of OS. Acute toxicity was mostly transient and tolerable. CONCLUSIONS Cyberknife SBRT appears to be an effective non-invasive treatment for local unresectable HCC with low risk of severe toxicity. These results suggested that Cyberknife SBRT can be a good alternative treatment for unresectable HCC unsuitable for standard treatment.
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Affiliation(s)
- Jenny Que
- />Department of Radiation Oncology, Chi Mei Medical Center, No.901, Zhonghua Road, Yongkang district Tainan, 710 Taiwan
| | - Hsing-Tao Kuo
- />Department of Internal Medicine, Division of Hepatogastroenterology, Chi Mei Medical Center, Tainan, Taiwan
| | - Li-Ching Lin
- />Department of Radiation Oncology, Chi Mei Medical Center, No.901, Zhonghua Road, Yongkang district Tainan, 710 Taiwan
| | - Kuei-Li Lin
- />Department of Radiation Oncology, Chi Mei Medical Center, No.901, Zhonghua Road, Yongkang district Tainan, 710 Taiwan
| | - Chia-Hui Lin
- />Department of Radiation Oncology, Chi Mei Medical Center, No.901, Zhonghua Road, Yongkang district Tainan, 710 Taiwan
| | - Yu-Wei Lin
- />Department of Radiation Oncology, Chi Mei Medical Center, No.901, Zhonghua Road, Yongkang district Tainan, 710 Taiwan
| | - Ching-Chieh Yang
- />Department of Radiation Oncology, Chi Mei Medical Center, No.901, Zhonghua Road, Yongkang district Tainan, 710 Taiwan
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Kim R, Prithviraj GK, Shridhar R, Hoffe SE, Jiang K, Zhao X, Chen DT, Almhanna K, Strosberg J, Campos T, Shibata D. Phase I study of pre-operative continuous 5-FU and sorafenib with external radiation therapy in locally advanced rectal adenocarcinoma. Radiother Oncol 2016; 118:382-6. [PMID: 26861740 DOI: 10.1016/j.radonc.2016.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 01/07/2016] [Accepted: 01/15/2016] [Indexed: 01/05/2023]
Abstract
PURPOSE The standard of care in locally advanced rectal cancer is preoperative treatment with fluoropyrimidine-based chemoradiotherapy. Sorafenib works synergistically with radiation and inhibits Ras/Raf, PDFGR, and VEGFR. This phase I study evaluated the safety and efficacy of sorafenib with infusional 5-fluorouracil (5-FU) and radiation in patients with locally advanced rectal cancer. METHODS AND MATERIALS Patients with confirmed stage II or III rectal cancer were recruited in 4 cohorts of 3 patients per dose level, with an expansion cohort at the maximum tolerated dose. A 3+3 dose escalation design was used. Radiation was given in 28 fractions at 1.8 Gy (50.4 Gy) day 1-5 at all dose levels. Initial dose of sorafenib was 200mg qd and titrated up to 400mg BID to determine the MTD. Standard dose of infusional 5-FU was used (225 mg/m(2)/24h). Patients underwent surgery 6-10 weeks after neoadjuvant therapy. RESULTS Between August 2011 and August 2014, 17 patients (median age of 54 years) were enrolled. After toxicities requiring dose interruptions were observed in cohort 1 (2 patients with grade 2 (G2) and grade 3 (G3) hand foot skin reaction and 1 patient with G2 mucositis), the protocol was amended, changing administration of chemotherapy and sorafenib from daily to days 1-5 only. With the amended protocol, the primary G3 toxicity was hypertension in 2 patients at the 200-mg adjusted dose level (day1-5) and 1 patient at the 400-mg twice daily dose level. One patient had G3 ALT elevation at 400mg, and no grade IV toxicities were observed. G1 and G2 toxicities included hand-foot skin reaction, diarrhea, mucositis, nausea, fatigue, and proctitis. No perioperative complications were seen. Two patients refused to undergo surgery. The pathological complete remission (pCR) rate was 33%, and downstaging was observed in 85.7% of patients. Median neoadjuvant rectal cancer score was 8.7. CONCLUSIONS With the changed dosing schedule, this regimen was very well tolerated. The tumor pCR and downstaging rates are encouraging and support further clinical investigation of this regimen.
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Affiliation(s)
- Richard Kim
- Departments of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA.
| | - Gopi Kesaria Prithviraj
- Departments of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Ravi Shridhar
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Sarah E Hoffe
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Kun Jiang
- Department of Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Xiuhua Zhao
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Khaldoun Almhanna
- Departments of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Jonathan Strosberg
- Departments of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - Tiffany Campos
- Departments of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
| | - David Shibata
- Departments of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, USA
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Swaminath A, Knox JJ, Brierley JD, Dinniwell R, Wong R, Kassam Z, Kim J, Coolens C, Brock KK, Dawson LA. Changes in Liver Volume Observed Following Sorafenib and Liver Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 94:729-37. [PMID: 26972645 DOI: 10.1016/j.ijrobp.2015.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 11/03/2015] [Accepted: 12/02/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to quantify unexpected liver volume reductions in patients treated with sorafenib prior to and during liver radiation therapy (RT). METHODS AND MATERIALS Fifteen patients were treated in a phase 1 study of sorafenib for 1 week, followed by concurrent sorafenib-RT (in 6 fractions). Patients had either focal cancer (treated with stereotactic body RT [SBRT]) or diffuse disease (treated with whole-liver RT). Liver volumes were contoured and recorded at planning (day 0) from the exhale CT. After 1 week of sorafenib (day 8), RT image guidance at each fraction was performed using cone beam CT (CBCT). Planning liver contours were propagated and modified on the reconstructed exhale CBCT. This was repeated in 12 patients treated with SBRT alone without sorafenib. Three subsequent patients (2 sorafenib-RT and 1 non-sorafenib) were also assessed with multiphasic helical breath-hold CTs. RESULTS Liver volume reductions on CBCT were observed in the 15 sorafenib-RT patients (median decrease of 68 cc, P=.02) between day 0 and 8; greater in the focal (P=.025) versus diffuse (P=.52) cancer stratum. Seven patients (47%) had reductions larger than the 95% intraobserver contouring error. Liver reductions were also observed from multiphasic CTs in the 2 additional sorafenib-RT patients between days 0 and 8 (decreases of 232.5 cc and 331.7 cc, respectively) and not in the non-sorafenib patient (increase of 92 cc). There were no significant changes in liver volume between planning and first RT in 12 patients with focal cancer treated with SBRT alone (median increase, 4.8 cc, P=.86). CONCLUSIONS Liver volume reductions were observed after 7 days of sorafenib, prior to RT, most marked in patients with focal liver tumors, suggesting an effect of sorafenib on normal liver. Careful assessment of potential liver volume changes immediately prior to SBRT may be necessary in patients in sorafenib or other targeted therapies.
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Affiliation(s)
- Anand Swaminath
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Jennifer J Knox
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - James D Brierley
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Rob Dinniwell
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Rebecca Wong
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Zahra Kassam
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - John Kim
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Catherine Coolens
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Kristy K Brock
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada.
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Pollom EL, Deng L, Pai RK, Brown JM, Giaccia A, Loo BW, Shultz DB, Le QT, Koong AC, Chang DT. Gastrointestinal Toxicities With Combined Antiangiogenic and Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 92:568-76. [PMID: 26068491 DOI: 10.1016/j.ijrobp.2015.02.016] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/03/2015] [Accepted: 02/09/2015] [Indexed: 12/14/2022]
Abstract
Combining the latest targeted biologic agents with the most advanced radiation technologies has been an exciting development in the treatment of cancer patients. Stereotactic body radiation therapy (SBRT) is an ablative radiation approach that has become established for the treatment of a variety of malignancies, and it has been increasingly used in combination with biologic agents, including those targeting angiogenesis-specific pathways. Multiple reports have emerged describing unanticipated toxicities arising from the combination of SBRT and angiogenesis-targeting agents, particularly of late luminal gastrointestinal toxicities. In this review, we summarize the literature describing these toxicities, explore the biological mechanism of action of toxicity with the combined use of antiangiogenic therapies, and discuss areas of future research, so that this combination of treatment modalities can continue to be used in broader clinical contexts.
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Affiliation(s)
- Erqi L Pollom
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Lei Deng
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Reetesh K Pai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - J Martin Brown
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Amato Giaccia
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Billy W Loo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - David B Shultz
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Quynh Thu Le
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Albert C Koong
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California.
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Kitajima T, Hatano E, Mitsunori Y, Taura K, Fujimoto Y, Mizumoto M, Okajima H, Kaido T, Minamiguchi S, Uemoto S. Complete pathological response induced by sorafenib for advanced hepatocellular carcinoma with multiple lung metastases and venous tumor thrombosis allowing for curative resection. Clin J Gastroenterol 2015; 8:300-5. [PMID: 26249525 DOI: 10.1007/s12328-015-0594-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 07/18/2015] [Indexed: 12/16/2022]
Abstract
We report the first case of initially unresectable advanced hepatocellular carcinoma (HCC) with portal vein and hepatic venous tumor thrombosis and multiple lung metastases that allowed for curative hepatectomy after multidisciplinary treatment including sorafenib. A 54-year-old male presented with a large HCC in the right liver with tumor thrombosis of the left portal vein and middle hepatic vein (MHV) as well as multiple lung metastases. His serum alpha-fetoprotein level was elevated at 52,347 ng/mL and palliative treatment with sorafenib was initiated. One month later, a significant reduction in the serum AFP level, decrease in the tumor size with recanalization of the portal vein and the absence of lung metastases were noted. Three months after the start of sorafenib treatment, external-beam radiotherapy was performed to treat enlargement of the area of MHV thrombosis, and the thrombosis regressed. Five months after the initiation of sorafenib treatment, central bisegmentectomy associated with removal of the tumor thrombus in the inferior vena cava was performed. A microscopic examination revealed complete necrosis of the tumor. Sorafenib treatment may be a bridge to curative resection in selected patients with initially unresectable advanced HCC, even in cases involving multiple extrahepatic metastases.
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Affiliation(s)
- Toshihiro Kitajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Etsuro Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yusuke Mitsunori
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kojiro Taura
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yasuhiro Fujimoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Masaki Mizumoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideaki Okajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Toshimi Kaido
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
| | | | - Shinji Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawaharacho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
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Knox JJ, Cleary SP, Dawson LA. Localized and Systemic Approaches to Treating Hepatocellular Carcinoma. J Clin Oncol 2015; 33:1835-44. [DOI: 10.1200/jco.2014.60.1153] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Jennifer J. Knox
- All authors: University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Sean P. Cleary
- All authors: University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Laura A. Dawson
- All authors: University of Toronto, Princess Margaret Cancer Centre, Toronto, ON, Canada
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10
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Jacob J, Nguyen F, Deutsch E, Mornex F. [Stereotactic body radiation therapy in the management of liver tumours]. Cancer Radiother 2014; 18:486-94. [PMID: 25195113 DOI: 10.1016/j.canrad.2014.07.145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 12/22/2022]
Abstract
Stereotactic radiotherapy is a high-precision technique based on the administration of high doses to a limited target volume. This treatment constitutes a therapeutic progress in the management of many tumours, especially hepatic ones. If surgery remains the standard local therapy, stereotactic radiotherapy is first dedicated to inoperable patients or unresectable tumours. Patients with moderately altered general status, preserved liver function and tumour lesions limited in number as in size are eligible to this technique. Results in terms of local control are satisfying, regarding primary tumours (notably hepatocellular carcinomas) as metastases stemming from various origins. If treatment protocols and follow-up modalities are not standardized to this day, iconographic acquisition using four-dimensional computed tomography, target volumes delineation based on morphological and/or metabolic data, and image-guided radiotherapy contribute to an oncologic efficacy and an improved sparing of the functional liver. The purpose of this literature review is to report the results of the main works having assessed stereotactic radiotherapy in the management of primary and secondary liver tumours. Technical particularities of this radiation modality will also be described.
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Affiliation(s)
- J Jacob
- Service d'oncologie-radiothérapie, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard de Port-Royal, 75230 Paris cedex 05, France.
| | - F Nguyen
- Département de radiothérapie, institut de cancérologie Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - E Deutsch
- Département de radiothérapie, institut de cancérologie Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - F Mornex
- Service de radiothérapie-oncologie, centre hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; EMR 3738, université Claude-Bernard Lyon 1, 69373 Lyon cedex 08, France
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Sharma H. Role of external beam radiation therapy in management of hepatocellular carcinoma. J Clin Exp Hepatol 2014; 4:S122-5. [PMID: 25755603 PMCID: PMC4284217 DOI: 10.1016/j.jceh.2014.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
Diagnosis at advanced disease stage and early vascular invasion are the bane of majority of patients with hepatocellular carcinoma (HCC) in India. The currently standardized curative and palliative treatment modalities [surgery, ablative techniques, trans-catheter chemotherapy, systemic chemotherapy] are suboptimal for a significant proportion of disease stages. Interest in radiotherapy for hepatocellular carcinoma has seen a resurgence with revolutionary improvements in targeting radiation doses safely. Encouraging results have been reported with a host of radiation techniques from conformal radiotherapy, stereotactic whole body radiation therapy to charged particle based therapies. The dissemination of this knowledge has been slow across other specialties involved in care of patients with HCC. However the increasing availability of radiotherapy services predicts a hopeful future for wider evaluation of radiotherapy in HCC.
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Affiliation(s)
- Hanish Sharma
- Address for correspondence: Hanish Sharma, Senior Research Associate, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
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Tanguturi SK, Wo JY, Zhu AX, Dawson LA, Hong TS. Radiation therapy for liver tumors: ready for inclusion in guidelines? Oncologist 2014; 19:868-79. [PMID: 25001265 DOI: 10.1634/theoncologist.2014-0097] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Despite the historically limited role of radiotherapy in the management of primary hepatic malignancies, modern advances in treatment design and delivery have renewed enthusiasm for radiation as a potentially curative treatment modality. Surgical resection and/or liver transplantation are traditionally regarded as the most effective forms of therapy, although the majority of patients with hepatocellular carcinoma and intrahepatic cholangiocarcinoma present with locally advanced or unresectable disease on the basis of local vascular invasion or inadequate baseline hepatobiliary function. In this context, many efforts have focused on nonoperative treatment approaches including novel systemic therapies, transarterial chemoembolization, ethanol ablation, radiofrequency ablation, and stereotactic body radiation therapy (SBRT). This review aims to summarize modern advances in radiotherapy, particularly SBRT, in the treatment of primary hepatic malignancies.
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Affiliation(s)
- Shyam K Tanguturi
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Y Wo
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew X Zhu
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Theodore S Hong
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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Chen SW, Lin LC, Kuo YC, Liang JA, Kuo CC, Chiou JF. Phase 2 study of combined sorafenib and radiation therapy in patients with advanced hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2014; 88:1041-7. [PMID: 24661657 DOI: 10.1016/j.ijrobp.2014.01.017] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 01/04/2014] [Accepted: 01/13/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE This phase 2 study evaluated the efficacy of radiation therapy (RT) with concurrent and sequential sorafenib therapy in patients with unresectable hepatocellular carcinoma (HCC). METHODS AND MATERIALS Forty patients with unresectable HCC unfit for transarterial chemoembolization were treated with RT with concurrent and sequential sorafenib. Sorafenib was administered from the commencement of RT at a dose of 400 mg twice daily and continued to clinical or radiologic progression, unacceptable adverse events, or death. All patients had underlying Child-Pugh A cirrhosis. The maximal tumor diameter ranged from 3.0 cm to 15.5 cm. Coexisting portal vein thrombosis was found in 24 patients and was irradiated simultaneously. The cumulative RT dose ranged from 40 Gy to 60 Gy (median, 50 Gy). Image studies were done 1 month after RT and then every 3 months thereafter. RESULTS Thirty-three (83%) completed the allocated RT. During RT, the incidence of hand-foot skin reactions ≥ grade 2 and diarrhea were 37.5% and 25%, respectively, and 35% of patients had hepatic toxicities grade ≥2. Twenty-two (55.0%) patients achieved complete or partial remission at the initial assessment, and 18 (45%) had stable or progressive disease. The 2-year overall survival and infield progression-free survival (IFPS) were 32% and 39%, respectively. A Cancer of the Liver Italian Program (CLIP) score ≥2 was associated with an inferior outcome in overall survival. Six patients (15%) developed treatment-related hepatic toxicity grade ≥3 during the sequential phase, and 3 of them were fatal. CONCLUSIONS When RT and sorafenib therapy were combined in patients with unresectable HCC, the initial complete or partial response rate was 55% with a 2-year IFPS of 39%. A CLIP score ≥2 was associated with an inferior outcome in overall survival. Hepatic toxicities are a major determinant of the safety; the combination should be used with caution and needs further investigation.
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Affiliation(s)
- Shang-Wen Chen
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan; School of Medicine, Taipei Medical University, Taipei, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan.
| | - Li-Ching Lin
- Department of Radiation Oncology, Chi-Mei Hospital, Tainan, Taiwan; School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yu-Cheng Kuo
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan; Department of Biomedical Imaging and Radiological Science, China Medical University, Taichung, Taiwan
| | - Ji-An Liang
- Department of Radiation Oncology, China Medical University Hospital, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Chun Kuo
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Jeng-Fong Chiou
- Department of Radiation Oncology, Taipei Medical University Hospital, Taipei, Taiwan; School of Medicine, Taipei Medical University, Taipei, Taiwan
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Barney BM, Markovic SN, Laack NN, Miller RC, Sarkaria JN, Macdonald OK, Bauer HJ, Olivier KR. Increased Bowel Toxicity in Patients Treated With a Vascular Endothelial Growth Factor Inhibitor (VEGFI) After Stereotactic Body Radiation Therapy (SBRT). Int J Radiat Oncol Biol Phys 2013; 87:73-80. [DOI: 10.1016/j.ijrobp.2013.05.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 05/03/2013] [Accepted: 05/05/2013] [Indexed: 12/18/2022]
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Bujold A, Massey CA, Kim JJ, Brierley J, Cho C, Wong RKS, Dinniwell RE, Kassam Z, Ringash J, Cummings B, Sykes J, Sherman M, Knox JJ, Dawson LA. Sequential phase I and II trials of stereotactic body radiotherapy for locally advanced hepatocellular carcinoma. J Clin Oncol 2013; 31:1631-9. [PMID: 23547075 DOI: 10.1200/jco.2012.44.1659] [Citation(s) in RCA: 552] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To describe outcomes of prospective trials of stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC). PATIENTS AND METHODS Two trials of SBRT for patients with active HCC unsuitable for standard locoregional therapies were conducted from 2004 to 2010. All patients had Child-Turcotte-Pugh class A disease, with at least 700 mL of non-HCC liver. The SBRT dose range was 24 to 54 Gy in six fractions. Primary end points were toxicity and local control at 1 year (LC1y), defined as no progressive disease (PD) of irradiated HCC by RECIST (Response Evaluation Criteria in Solid Tumors). RESULTS A total of 102 patients were evaluable (Trial 1, 2004 to 2007: n = 50; Trial 2, 2007 to 2010: n = 52). Underlying liver disease was hepatitis B in 38% of patients, hepatitis C in 38%, alcohol related in 25%, other in 14%, and none in 7%. Fifty-two percent received prior therapies (no prior sorafenib). TNM stage was III in 66%, and 61% had multiple lesions. Median gross tumor volume was 117.0 mL (range, 1.3 to 1,913.4 mL). Tumor vascular thrombosis (TVT) was present in 55%, and extrahepatic disease was present in 12%. LC1y was 87% (95% CI, 78% to 93%). SBRT dose (hazard ratio [HR] = 0.96; P = .02) and being in Trial 2 (HR = 0.38; P = .03) were associated with LC1y on univariate analysis. Toxicity ≥ grade 3 was seen in 30% of patients. In seven patients (two with TVT PD), death was possibly related to treatment (1.1 to 7.7 months after SBRT). Median overall survival was 17.0 months (95% CI, 10.4 to 21.3 months), for which only TVT (HR = 2.47; P = .01) and being in Trial 2 (HR = 0.49; P = .01) were significant on multivariate analysis. CONCLUSION These results provide strong rationale for studying SBRT for HCC in a randomized trial.
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Affiliation(s)
- Alexis Bujold
- Princess Margaret Hospital, University Health Network, University of Toronto, Canada.
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