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Wu Q, Wang Y, Wei Y, Yang Z, Chen K, Li J, Li L, Su T, Liang S. Development and validation of a nomogram for radiation-induced hepatic toxicity after intensity modulated radiotherapy for hepatocellular carcinoma: a retrospective study. Jpn J Clin Oncol 2024; 54:699-707. [PMID: 38376811 PMCID: PMC11144290 DOI: 10.1093/jjco/hyae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVE This study aimed to construct a nomogram to predict radiation-induced hepatic toxicity in patients with hepatocellular carcinoma treated with intensity-modulated radiotherapy. METHODS This study reviewed the clinical characteristics and dose-volume parameters of 196 patients with hepatocellular carcinoma. Radiation-induced hepatic toxicity was defined as progression of the Child-Pugh score caused by intensity-modulated radiotherapy. Factors relevant to radiation-induced hepatic toxicity were selected using receiver operating characteristic and univariate logistic analysis. A risk assessment model was developed, and its discrimination was validated. RESULTS Eighty-eight (44.90%) and 28 (14.29%) patients had radiation-induced hepatic toxicity ≥ 1 (Child-Pugh ≥ 1) and radiation-induced hepatic toxicity ≥ 2 (Child-Pugh ≥ 2). Pre-treatment Child-Pugh, body mass index and dose-volume parameters were correlated with radiation-induced hepatic toxicity ≥ 1 using univariate logistic analysis. V15 had the best predictive effectiveness among the dose-volume parameters in both the training (area under the curve: 0.763, 95% confidence interval: 0.683-0.842, P < 0.001) and validation cohorts (area under the curve: 0.759, 95% confidence interval: 0.635-0.883, P < 0.001). The area under the curve values of the model that was constructed by pre-treatment Child-Pugh, body mass index and V15 for radiation-induced hepatic toxicity ≥1 were 0.799 (95% confidence interval: 0.719-0.878, P < 0.001) and 0.775 (95% confidence interval: 0.657-0.894, P < 0.001) in the training and validation cohorts, respectively. Patients with a body mass index ≤ 20.425, Barcelona clinic liver cancer = C, Hepatitis B Virus-positive, Eastern Cooperative Oncology Group = 1-2 and hepatic fibrosis require lower V15 dose limits. CONCLUSIONS Risk assessment model constructed from Pre-treatment Child-Pugh, V15 and body mass index can guide individualized patient selection of toxicity minimization strategies.
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Affiliation(s)
- Qiaoyuan Wu
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Yudan Wang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Yuxin Wei
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Zhengqiang Yang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Chen
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA, and Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianxu Li
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Liqing Li
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Tingshi Su
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Shixiong Liang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
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Hall JT, Moon AM, Young M, Tan X, Darawsheh R, Danquah F, Tepper JE, Yanagihara TK. Biochemical Safety of SBRT to Multiple Intrahepatic Lesions for Hepatocellular Carcinoma. J Hepatocell Carcinoma 2024; 11:443-454. [PMID: 38476559 PMCID: PMC10928924 DOI: 10.2147/jhc.s447025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 02/06/2024] [Indexed: 03/14/2024] Open
Abstract
Background We aim to better characterize stereotactic body radiation therapy (SBRT)-related hepatic biochemical toxicity in patients with multiple intrahepatic lesions from hepatocellular carcinoma (HCC). Methods We conducted a retrospective analysis of patients with HCC who underwent SBRT for 2 or more synchronous or metachronous liver lesions. We collected patient characteristics and dosimetric data (mean liver dose [MLD], cumulative effective volume [Veff], cumulative volume of liver receiving 15 Gy [V15Gy], and cumulative planning target volume [PTV]) along with liver-related toxicity (measured by albumin-bilirubin [ALBI] and Child-Pugh [CP] scores). A linear mixed-effects model was used to assess the effect of multi-target SBRT on changes in ALBI. Results There were 25 patients and 56 lesions with median follow-up of 29 months. Eleven patients had synchronous lesions, and 14 had recurrent lesions treated with separate SBRT courses. Among those receiving multiple SBRT courses, there were 7 lesions with overlap of V15Gy (median V15Gy overlap: 35 mL, range: 0.5-388 mL). There was no association between cumulative MLD, Veff, V15Gy, or PTV and change in ALBI. Four of 25 patients experienced non-classic radiation-induced liver disease (RILD), due to an increase of CP score by ≥2 points 3 to 6 months after SBRT. Sixteen of 25 patients experienced an increase in ALBI grade by 1 or more points 3 to 6 months after SBRT. Comparing the groups that received SBRT in a single course versus multiple courses revealed no statistically significant differences in liver toxicity. Conclusion Liver SBRT for multiple lesions in a single or in separate courses is feasible and with acceptable risk of hepatotoxicity. Prospective studies with a larger cohort are needed to better characterize safety in this population.
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Affiliation(s)
- Jacob T Hall
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Michael Young
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Xianming Tan
- Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC, USA
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Rami Darawsheh
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Flora Danquah
- Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Joel E Tepper
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Ted K Yanagihara
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina Hospitals, Chapel Hill, NC, USA
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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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Bae SH, Chun SJ, Chung JH, Kim E, Kang JK, Jang WI, Moon JE, Roquette I, Mirabel X, Kimura T, Ueno M, Su TS, Tree AC, Guckenberger M, Lo SS, Scorsetti M, Slotman BJ, Kotecha R, Sahgal A, Louie AV, Kim MS. Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma: Meta-Analysis and International Stereotactic Radiosurgery Society Practice Guidelines. Int J Radiat Oncol Biol Phys 2024; 118:337-351. [PMID: 37597757 DOI: 10.1016/j.ijrobp.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/26/2023] [Accepted: 08/05/2023] [Indexed: 08/21/2023]
Abstract
This systematic review and meta-analysis reports on outcomes and hepatic toxicity rates after stereotactic body radiation therapy (SBRT) for liver-confined hepatocellular carcinoma (HCC) and presents consensus guidelines regarding appropriate patient management. Using the Preferred Reporting Items for Systemic Review and Meta-Analyses guidelines, a systematic review was performed from articles reporting outcomes at ≥5 years published before October 2022 from the Embase, MEDLINE, Cochrane, and Scopus databases with the following search terms: ("stereotactic body radiotherapy" OR "SBRT" OR "SABR" OR "stereotactic ablative radiotherapy") AND ("hepatocellular carcinoma" OR "HCC"). An aggregated data meta-analysis was conducted to assess overall survival (OS) and local control (LC) using weighted random effects models. In addition, individual patient data analyses incorporating data from 6 institutions were conducted as their own subgroup analyses. Seventeen observational studies, comprising 1889 patients with HCC treated with ≤9 SBRT fractions, between 2003 and 2019, were included in the aggregated data meta-analysis. The 3- and 5-year OS rates after SBRT were 57% (95% confidence interval [CI], 47%-66%) and 40% (95% CI, 29%-51%), respectively. The 3- and 5-year LC rates after SBRT were 84% (95% CI, 77%-90%) and 82% (95% CI, 74%-88%), respectively. Tumor size was the only prognostic factor for LC. Tumor size and region were significantly associated with OS. Five-year LC and OS rates of 79% (95% CI, 0.74-0.84) and 25% (95% CI, 0.20-0.30), respectively, were observed in the individual patient data analyses. Factors prognostic for improved OS were tumor size <3 cm, Eastern region, Child-Pugh score ≤B7, and the Barcelona Clinic Liver Cancer stage of 0 and A. The incidence of severe hepatic toxicity varied according to the criteria applied. SBRT is an effective treatment modality for patients with HCC with mature follow-up. Clinical practice guidelines were developed on behalf of the International Stereotactic Radiosurgery Society (ISRS).
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Affiliation(s)
- Sun Hyun Bae
- Department of Radiation Oncology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Seok-Joo Chun
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Joo-Hyun Chung
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Korea
| | - Eunji Kim
- Department of Radiation Oncology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jin-Kyu Kang
- Department of Radiation Oncology, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Won Il Jang
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea
| | - Ji Eun Moon
- Department of Biostatistics, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Isaure Roquette
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | - Xavier Mirabel
- Academic Department of Radiation Oncology, Centre Oscar Lambret, Lille, France
| | - Tomoki Kimura
- Department of Radiation Oncology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Masayuki Ueno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Okayama, Japan; Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ting-Shi Su
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Alison C Tree
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Matthias Guckenberger
- Department of Radiation Oncology, University Hospital Zürich, University of Zürich, Zürich, Switzerland
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ben J Slotman
- Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida; Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Alexander V Louie
- Department of Radiation Oncology, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mi-Sook Kim
- Department of Radiation Oncology, Korea Institute of Radiological and Medical Sciences, Seoul, Korea.
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Kirichenko A, Uemura T, Liang Y, Hasan S, Abel S, Renz P, Shamsesfandabadi P, Carpenter J, Yin Y, Thai N. Stereotactic Body Radiation Therapy (SBRT) for Hepatocellular Carcinoma (HCC) With Single Photon Emission Computed Tomography (SPECT) Functional Treatment Planning in Patients With Advanced Hepatic Cirrhosis. Adv Radiat Oncol 2024; 9:101367. [PMID: 38405302 PMCID: PMC10885583 DOI: 10.1016/j.adro.2023.101367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/19/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose We report on the feasibility and outcomes of liver stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) with single-photon emission computed tomography (SPECT) functional treatment planning in patients with Child-Pugh (CP) B/C cirrhosis. Methods and Materials Liver SPECT with 99mTc-sulfur colloid was coregistered to treatment planning computed tomography (CT) for the guided avoidance of functional hepatic parenchyma during SBRT. Functional liver volumes (FLVs) obtained from SPECT were compared with anatomic liver volumes defined on the planning CT. Radiation dose constraints were adapted exclusively to FLV. Local control, toxicity, and survival were reported with at least 6 months of radiographic follow-up. Pre- and posttransplant outcomes were analyzed in a subset of patients who completed SBRT as a bridge to liver transplant. Model of End-Stage Liver Disease was used to score hepatic function before and after SBRT completion. Results With a median follow-up of 32 months, 45 patients (58 lesions) with HCC and CP-B/C cirrhosis received SBRT to a median dose of 45 Gy (3-5 fractions). FLV loss (34%, P < .001) was observed in all patients, and the functional and anatomic liver volumes matched well in a control group of noncirrhotic/non-HCC patients. Despite marked functional parenchyma retraction, the amount of FLV on SPECT exposed to the threshold irradiation was significantly less than the CT liver volumes (P < .001) because of the optimized beam placement during dosimetry planning. Twenty-three patients (51%) successfully completed orthotopic liver transplant, with a median time to transplant of 9.2 months. With 91% in-field local control, the overall 2-year survival was 65% (90% after the orthotopic liver transplant), with no incidence of radiation-induced liver disease observed within 3 to 4 months or accelerated CP class migration from B to C within the first 6 months post-SBRT. Mean Model of End-Stage Liver Disease-Na score was not significantly elevated at 3-month intervals after SBRT completion. Conclusions Functional treatment planning with 99mTc sulfur colloid SPECT/CT allows identification and avoidance of functional hepatic parenchyma in patients with CP-B/C cirrhosis, leading to low toxicity and satisfactory transplant outcomes.
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Affiliation(s)
- Alexander Kirichenko
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Tadahiro Uemura
- Division of Abdominal Transplantation and Hepato-Biliary Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Yun Liang
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | | | - Steven Abel
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Paul Renz
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Parisa Shamsesfandabadi
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Jennifer Carpenter
- Division of Abdominal Transplantation and Hepato-Biliary Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Yue Yin
- Allegheny-Singer Research Institute, Biostatistics, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ngoc Thai
- Division of Abdominal Transplantation and Hepato-Biliary Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Gutman MJ, Serra LM, Koshy M, Katipally RR. SBRT for Liver Tumors: What the Interventional Radiologist Needs to Know. Semin Intervent Radiol 2024; 41:1-10. [PMID: 38495259 PMCID: PMC10940045 DOI: 10.1055/s-0043-1778657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
This review summarizes the clinical evidence supporting the utilization of stereotactic body radiotherapy (SBRT) for liver tumors, including hepatocellular carcinoma, liver metastases, and cholangiocarcinoma. Emerging prospective evidence has demonstrated the benefit and low rates of toxicity across a broad range of clinical contexts. We provide an introduction for the interventional radiologist, with a discussion of underlying themes such as tumor dose-response, mitigation of liver toxicity, and the technical considerations relevant to performing liver SBRT. Ultimately, we recommend that SBRT should be routinely included in the armamentarium of locoregional therapies for liver malignancies, alongside those liver-directed therapies offered by interventional radiology.
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Affiliation(s)
- Michael J. Gutman
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
| | - Lucas M. Serra
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
| | - Matthew Koshy
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
| | - Rohan R. Katipally
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
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7
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Giudicelli H, Andraud M, Wagner M, Bourdais R, Goumard C, Scatton O, Thabut D, Simon JM, Allaire M. Portal-hypertension features are associated with ascites occurrence and survival in patients with hepatocellular carcinoma treated by external radiotherapy. United European Gastroenterol J 2023; 11:985-997. [PMID: 38018771 PMCID: PMC10720686 DOI: 10.1002/ueg2.12488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/19/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND AIMS We studied the impact of Portal hypertension (PHT) on ascites occurrence and on radiotherapy outcome in cirrhotic patients with hepatocellular carcinoma (HCC). METHOD All cirrhotic patients that received radiotherapy for HCC between 2012 and 2022 were included. Portal hypertension-Score was built using univariate analysis with the presence of esophageal varices (EV), platelet count, history of acute variceal bleeding (AVB) and spleen size. Time-to-events data were estimated using Kaplan-Meier method with log-rank and Cox-models. RESULTS 60 patients were included (female 27%, age 67 years-old, Child-Pugh A 82%, alcoholic/non-alcoholic steatohepatitis/hepatitis C virus 55/40/32%). 38% and 15% presented history of ascites and AVB respectively, 25% had large EV, 53.5% presented PHT score ≥ 5. 92% were BCLC-0/A, median tumor size was 30 mm. At 6 months, ascites incidence was 19% and precluded access to further HCC treatment for all patients with HCC recurrence. All PHT parameters included in the score and PHT score ≥ 5 (hazard ratio (HR) = 14.07, p = 0.01) were associated with ascites occurrence. Transplantation free survival and recurrence free survival at 1 year were 56% and 47% respectively. Albi grade 3 (HR = 3.01; p = 0.04) was independently associated with Transplantation free survival. CONCLUSION Radiotherapy should be cautiously performed in patients with PHT score ≥ 5 because of ascites occurrence risk precluding access to further HCC treatments.
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Affiliation(s)
- Héloïse Giudicelli
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
| | - Mickaël Andraud
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service de radiothérapie, Paris, France
| | - Mathilde Wagner
- AP-HP, Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'imagerie, Paris, France
- Sorbonne Université, Laboratoire d'Imagerie biomédicale, UMR 7371 - U1146, Paris, France
| | - Rémi Bourdais
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service de radiothérapie, Paris, France
| | - Claire Goumard
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service de chirurgie digestive, Paris, France
- Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Olivier Scatton
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service de chirurgie digestive, Paris, France
- Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
- Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
| | - Jean-Marc Simon
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service de radiothérapie, Paris, France
| | - Manon Allaire
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
- INSERM UMR 1138, Centre de recherche des Cordeliers, Paris, France
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Herr DJ, Wang C, Mendiratta-Lala M, Matuszak M, Mayo CS, Cao Y, Parikh ND, Haken RT, Owen D, Evans JR, Stanescu T, Yan M, Dawson LA, Schipper M, Lawrence TS, Cuneo KC. A Phase II Study of Optimized Individualized Adaptive Radiotherapy for Hepatocellular Carcinoma. Clin Cancer Res 2023; 29:3852-3858. [PMID: 37471457 PMCID: PMC10592290 DOI: 10.1158/1078-0432.ccr-23-1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE We hypothesized that optimizing the utility of stereotactic body radiotherapy (SBRT) based on the individual patient's probability for tumor control and risk of liver injury would decrease toxicity without sacrificing local control in patients with impaired liver function or tumors not amenable to thermal ablation. PATIENTS AND METHODS Patients with Child-Pugh (CP) A to B7 liver function with aggregate tumor size >3.5 cm, or CP ≥ B8 with any size tumor were prospectively enrolled on an Institutional Review Board-approved phase II clinical trial to undergo SBRT with baseline and midtreatment dose optimization using a quantitative, individualized utility-based analysis. Primary endpoints were change in CP score of ≥2 points within 6 months and local control. Protocol-treated patients were compared with patients receiving conventional SBRT at another cancer center using overlap weighting. RESULTS A total of 56 patients with 80 treated tumors were analyzed with a median follow-up of 11.2 months. Two-year cumulative incidence of local progression was 6.4% [95% confidence interval (CI, 2.4-13.4)]. Twenty-one percent of patients experienced treatment-related toxicity within 6 months, which is similar to the rate for SBRT in patients with CP A liver function. An analysis using overlap weighting revealed similar local control [HR, 0.69; 95% CI (0.25-1.91); P = 0.48] and decreased toxicity [OR, 0.26; 95% CI (0.07-0.99); P = 0.048] compared with conventional SBRT. CONCLUSIONS Treatment of individuals with impaired liver function or tumors not amenable to thermal ablation with a treatment paradigm designed to optimize utility may decrease treatment-related toxicity while maintaining tumor control.
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Affiliation(s)
- Daniel J. Herr
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Chang Wang
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Martha Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Charles S. Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Yue Cao
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Randy Ten Haken
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
- Current Address: Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Joseph R. Evans
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Teodor Stanescu
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Michael Yan
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Laura A. Dawson
- Department of Radiation Oncology, University of Toronto, Ontario, Canada
| | - Matthew Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | | | - Kyle C. Cuneo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Elaimy AL, Cao Y, Lawrence TS. Evolution of Response-Based Radiotherapy for Hepatocellular Cancer. Cancer J 2023; 29:266-271. [PMID: 37796644 PMCID: PMC10558084 DOI: 10.1097/ppo.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
ABSTRACT Stereotactic body radiation therapy has emerged as a safe and effective treatment modality for properly selected hepatocellular cancer (HCC) patients with normal liver function. However, many HCC patients have reduced baseline liver function due to underlying cirrhosis or prior liver-directed therapies. Therefore, because of the increased risk of hepatotoxicity, the use of stereotactic body radiation therapy for patients with reduced liver function has been approached with caution. Individualized, response-based radiotherapy incorporates models, imaging tools, and biomarkers that determine the dose-response relationship of the liver before, during, and after treatment and has been useful in reducing the likelihood of liver damage without sacrificing tumor control. This review discusses the evolution of response-based radiotherapy for HCC and highlights areas for further investigation.
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Affiliation(s)
- Ameer L Elaimy
- From the Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Shannon AH, Manne A, Diaz Pardo DA, Pawlik TM. Combined radiotherapy and immune checkpoint inhibition for the treatment of advanced hepatocellular carcinoma. Front Oncol 2023; 13:1193762. [PMID: 37554167 PMCID: PMC10405730 DOI: 10.3389/fonc.2023.1193762] [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: 03/25/2023] [Accepted: 07/03/2023] [Indexed: 08/10/2023] Open
Abstract
Hepatocellular Carcinoma (HCC) is one of the most common cancers and a leading cause of cancer related death worldwide. Until recently, systemic therapy for advanced HCC, defined as Barcelona Clinic Liver Cancer (BCLC) stage B or C, was limited and ineffective in terms of long-term survival. However, over the past decade, immune check point inhibitors (ICI) combinations have emerged as a potential therapeutic option for patients with nonresectable disease. ICI modulate the tumor microenvironment to prevent progression of the tumor. Radiotherapy is a crucial tool in treating unresectable HCC and may enhance the efficacy of ICI by manipulating the tumor microenvironment and decreasing tumor resistance to certain therapies. We herein review developments in the field of ICI combined with radiotherapy for the treatment of HCC, as well as look at challenges associated with these treatment modalities, and review future directions of combination therapy.
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Affiliation(s)
- Alexander H. Shannon
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ashish Manne
- Department of Internal Medicine, Division of Medical Oncology at the Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, The Ohio State University Comprehensive Cancer Center, Columbus, OH, United States
| | - Dayssy A. Diaz Pardo
- Department of Radiation Oncology, The Ohio State University, Comprehensive Cancer Center-James Hospital and Solove Research Institute, Columbus, OH, United States
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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11
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Allignet B, Merle P, Rode A, Mabrut JY, Mohkam K, Mornex F. Transarterial chemoembolization followed by moderately hypofractionated radiotherapy in hepatocellular carcinoma: Long-term results of RTF3 regimen. Cancer Radiother 2023:S1278-3218(23)00064-1. [PMID: 37150729 DOI: 10.1016/j.canrad.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/04/2023] [Accepted: 01/12/2023] [Indexed: 05/09/2023]
Abstract
PURPOSE In early-stage hepatocellular carcinoma (HCC) patients merely fit for surgery, transarterial chemoembolization (TACE) achieve low long-term disease control. We evaluated the efficacy and safety of its combination with moderately hypofractionated radiotherapy (hRT) using RTF3 regimen. MATERIAL AND METHODS Between 2006 and 2016, 61 consecutive patients treated in our single expert center for a Barcelona Clinic Liver Cancer (BCLC) A HCC by TACE followed by hRT 3Gy/fraction were retrospectively included. RESULTS Sixty of the 61 included presented Child-Pugh A cirrhosis (A5, n=41, 67.2%; A6: n=19, 31.1%). Fourteen patients (22.9%) were already treated for a HCC, mainly by radiofrequency (n=12). All patient received a TACE followed by 3Gy per fraction hRT. Mean radiation dose was 54Gy (range: 48-60). After a median follow-up of 118 months, median time-to-progression, progression-free survival (PFS) and overall survival (OS) was 21.3, 18.1, and 31.5 months, respectively. In univariate analysis, PFS was related to dose > 54Gy (HR: 2, P=0.036), and OS was correlated to Child-Pugh A6 or B7 (HR: 1.93, P=0.03) and overall hRT time (HR: 1.06, P=0.015). At progression, orthotopic liver transplantation was performed in 8 patients (13.1%). Severe symptomatic adverse events occurred in 12 patients (19.7%), mainly ascites (n=7). CONCLUSION In BCLC-A Child-Pugh A HCC patients ineligible to surgery or thermoablation, TACE-hRT is a safe and effective treatment. Prospective studies are needed to compare this association with radioembolization, TACE-stereotactic radiotherapy, and systemic treatments combinations.
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Affiliation(s)
- B Allignet
- Department of Radiotherapy, centre hospitalier Lyon Sud, hospices civils de Lyon, université Claude-Bernard Lyon 1, Pierre-Bénite, France; Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1294 Lyon, France.
| | - P Merle
- Hepatology Unit, hôpital de La Croix-Rousse, hospices civils de Lyon, université Claude-Bernard Lyon 1, Lyon, France; Inserm 1052/CNRS 5286 Unit, Cancer Research Center of Lyon (CRCL), université Claude-Bernard Lyon 1, Lyon, France
| | - A Rode
- Department of Radiology, hôpital de La Croix-Rousse, hospices civils de Lyon, université-Claude Bernard Lyon 1, Lyon, France
| | - J Y Mabrut
- Inserm 1052/CNRS 5286 Unit, Cancer Research Center of Lyon (CRCL), université Claude-Bernard Lyon 1, Lyon, France; Department of General Surgery and Liver Transplantation, hôpital de La Croix-Rousse, hospices civils de Lyon, université Claude-Bernard Lyon 1, Lyon, France
| | - K Mohkam
- Inserm 1052/CNRS 5286 Unit, Cancer Research Center of Lyon (CRCL), université Claude-Bernard Lyon 1, Lyon, France; Department of General Surgery and Liver Transplantation, hôpital de La Croix-Rousse, hospices civils de Lyon, université Claude-Bernard Lyon 1, Lyon, France
| | - F Mornex
- Department of Radiotherapy, centre hospitalier Lyon Sud, hospices civils de Lyon, université Claude-Bernard Lyon 1, Pierre-Bénite, France
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Cuneo KC, Herr DJ. Advances in Radiation Therapy for Primary Liver Cancer. Surg Oncol Clin N Am 2023; 32:415-432. [PMID: 37182985 DOI: 10.1016/j.soc.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
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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13
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Li JX, Zhang RJ, Qiu MQ, Yan LY, He ML, Long MY, Zhong JH, Lu HY, Zhou HM, Xiang BD, Liang SX. Non-classic radiation-induced liver disease after intensity-modulated radiotherapy for Child-Pugh grade B patients with locally advanced hepatocellular carcinoma. Radiat Oncol 2023; 18:48. [PMID: 36890592 PMCID: PMC9993633 DOI: 10.1186/s13014-023-02232-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 02/16/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND The incidence of classic radiation-induced liver disease (cRILD) has been significantly reduced. However, non-classic radiation-induced liver disease (ncRILD) remains a major concern following radiotherapy in patients with hepatocellular carcinoma (HCC). This study evaluated the incidence of ncRILD following intensity-modulated radiotherapy (IMRT) for Child-Pugh grade B (CP-B) patients with locally advanced HCC and established a nomogram for predicting ncRILD probability. METHODS Seventy-five CP-B patients with locally advanced HCC treated with IMRT between September 2014 and July 2021 were included. The max tumor size was 8.39 cm ± 5.06, and the median prescribed dose was 53.24 Gy ± 7.26. Treatment-related hepatotoxicity was evaluated within three months of completing IMRT. A nomogram model was formulated to predict the probability of ncRILD, using univariate and multivariate analysis. RESULTS Among CP-B patients with locally advanced HCC, ncRILD occurred in 17 (22.7%) patients. Two patients (2.7%) exhibited a transaminase elevation of ≥ G3, fourteen (18.7%) exhibited a Child-Pugh score increase of ≥ 2, and one (1.3%) demonstrated both a transaminase elevation of ≥ G3 and a Child-Pugh score increase of ≥ 2. No cRILD cases were observed. A mean dose to the normal liver of ≥ 15.1 Gy was used as the cutoff for ncRILD. Multivariate analysis revealed that the prothrombin time before IMRT, tumour number, and mean dose to the normal liver were independent risk factors for ncRILD. The nomogram established on the basis of these risk factors displayed exceptional predictive performance (AUC = 0.800, 95% CI 0.674-0.926). CONCLUSIONS The incidence of ncRILD following IMRT for CP-B patients with locally advanced HCC was acceptable. A nomogram based on prothrombin time before IMRT, tumour number, and mean dose to the normal liver accurately predicted the probability of ncRILD in these patients.
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Affiliation(s)
- Jian-Xu Li
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Rui-Jun Zhang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Mo-Qin Qiu
- Department of Respiratory Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Liu-Ying Yan
- Department of General Affairs, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Mei-Ling He
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Mei-Ying Long
- School of Public Health, Guangxi Medical University, Nanning, 530021, China
| | - Jian-Hong Zhong
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Hai-Yan Lu
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Hong-Mei Zhou
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, 530021, China
| | - Bang-De Xiang
- Department of Hepatobiliary Surgery, Guangxi Medical University Cancer Hospital, Nanning, 530021, China.
| | - Shi-Xiong Liang
- Department of Radiation Oncology, Guangxi Medical University Cancer Hospital, Nanning, 530021, China.
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Hui C, Baclay R, Lau B, von Eyben R, Vitzthum L, Pollom E, Chang DT. Outcomes and Imaging Analysis in Hepatocellular Carcinoma Treated With Stereotactic Body Radiation Therapy. Pract Radiat Oncol 2023; 13:e139-e148. [PMID: 36868725 DOI: 10.1016/j.prro.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Although arterial phase enhancement is commonly used to evaluate treatment response for hepatocellular carcinoma, it may not accurately describe response for lesions treated with stereotactic body radiation therapy (SBRT). We aimed to describe the post-SBRT imaging findings to better inform the optimal timing of salvage therapy after SBRT. METHODS AND MATERIALS We retrospectively reviewed patients with hepatocellular carcinoma treated with SBRT from 2006 to 2021 at a single institution with available imaging showing lesions with characteristic arterial enhancement and portal venous washout. Patients were then stratified into 3 groups based on treatment: (1) concurrent SBRT and transarterial chemoembolization, (2) SBRT only, and (3) SBRT followed by early salvage therapy due to persistent enhancement. Overall survival was analyzed with the Kaplan-Meier method, and cumulative incidences were calculated with competing risk analysis. RESULTS We included 82 lesions in 73 patients. The median follow-up time was 22.3 months (range, 2.2-88.1 months). The median time to overall survival was 43.7 months (95% confidence interval, 28.1-57.6 months) and median progression-free survival was 10.5 months (95% confidence interval, 7.2-14.0 months). There were 10 (12.2%) lesions that experienced local progression and there was no difference in rates of local progression between the 3 groups (P = .32). In the SBRT-only group, the median time to resolution of arterial enhancement and washout was 5.3 months (range, 1.6-23.7 months). At 3, 6, 9, and 12 months, 82%, 41%, 13%, and 8% of lesions, respectively, continued to show arterial hyperenhancement. CONCLUSIONS Tumors treated with SBRT may continue to exhibit persistence of arterial hyperenhancement. Without an increase in size of enhancement, continued surveillance may be appropriate for these patients.
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Affiliation(s)
- Caressa Hui
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Richel Baclay
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Brianna Lau
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Rie von Eyben
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Lucas Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Erqi Pollom
- Department of Radiation Oncology, Stanford University, Stanford, California
| | - Daniel T Chang
- Department of Radiation Oncology, Stanford University, Stanford, California.
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15
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Surgical resection versus transarterial chemoembolization followed by moderately hypofractionated radiotherapy in hepatocellular carcinoma. Strahlenther Onkol 2023; 199:293-303. [PMID: 36441171 DOI: 10.1007/s00066-022-02022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Transarterial chemoembolization (TACE) is the gold standard treatment in intermediate hepatocellular carcinoma (HCC), but long-term disease control rates remain low. Herein, we compared results of TACE followed by hypofractionated radiotherapy (TACE-hRT) to surgical resection (SR) in early single or paucinodular intrahepatic HCC. METHODS Between June 2004 and November 2016, data on 160 consecutive patients with Barcelona Clinic Liver Cancer (BCLC) stage A Child-Pugh A HCC treated with SR or TACE-hRT in our expert center were retrospectively reviewed. Time to progression (TTP), progression-free survival (PFS), and overall survival (OS) were evaluated. Clinical outcomes were compared using the stabilized-weights inverse probability of treatment weighting propensity score. RESULTS Ninety-eight patients underwent SR and 62 were treated by TACE-hRT. Median total dose of RT was 54 Gy (interquartile range [IQR] 54-54) in 3‑Gy fractions. Median OS follow-up was 93 months. TTP did not significantly differ between patients following SR and TACE-hRT, with 1‑year rates of 68.2% and 82.6% (p = 0.17), respectively. In contrast, PFS and OS were lower in the TACE-hRT group (p = 0.015 and p = 0.006), with a median OS of 37 vs. 63 months for patients with surgery and TACE-hRT, respectively. In multivariate analysis, a significant negative impact on PFS and OS was seen for age at diagnosis, on TTP for alcohol-related liver disease, and on OS for total number of HCC nodules. Symptomatic grade ≥ 3 adverse events were presented by 42 (42.9%) SR and 19 (30.6%) TACE-hRT patients (p = 0.17). CONCLUSION In patients presenting Child-Pugh A BCLC‑A HCC with high risk for surgical complications, TACE-hRT can be an effective and safe treatment. However, surgical management remains the standard of care whenever possible.
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Matsuo Y. Stereotactic Body Radiotherapy for Hepatocellular Carcinoma: A Brief Overview. Curr Oncol 2023; 30:2493-2500. [PMID: 36826151 PMCID: PMC9956001 DOI: 10.3390/curroncol30020190] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
Stereotactic body radiotherapy (SBRT), a type of external beam radiotherapy, yields local control of hepatocellular carcinoma (HCC) at rates as high as 90%. SBRT has been recognized as an alternative therapy for patients for whom standard modalities such as surgery (resection or transplantation) or ablation are deemed unsuitable. SBRT has the potential to improve the prognosis of HCC, as it can be used as an adjunct to other treatment modalities. The assessment of post-SBRT images of the treated tumor and surrounding normal liver tissue requires special attention. Future research is warranted to determine how best to use SBRT versus other therapies and how to combine them.
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Affiliation(s)
- Yukinori Matsuo
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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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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Tadimalla S, Wang W, Haworth A. Role of Functional MRI in Liver SBRT: Current Use and Future Directions. Cancers (Basel) 2022; 14:cancers14235860. [PMID: 36497342 PMCID: PMC9739660 DOI: 10.3390/cancers14235860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is an emerging treatment for liver cancers whereby large doses of radiation can be delivered precisely to target lesions in 3-5 fractions. The target dose is limited by the dose that can be safely delivered to the non-tumour liver, which depends on the baseline liver functional reserve. Current liver SBRT guidelines assume uniform liver function in the non-tumour liver. However, the assumption of uniform liver function is false in liver disease due to the presence of cirrhosis, damage due to previous chemo- or ablative therapies or irradiation, and fatty liver disease. Anatomical information from magnetic resonance imaging (MRI) is increasingly being used for SBRT planning. While its current use is limited to the identification of target location and size, functional MRI techniques also offer the ability to quantify and spatially map liver tissue microstructure and function. This review summarises and discusses the advantages offered by functional MRI methods for SBRT treatment planning and the potential for adaptive SBRT workflows.
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Affiliation(s)
- Sirisha Tadimalla
- Institute of Medical Physics, School of Physics, Faculty of Science, The University of Sydney, Camperdown, NSW 2006, Australia
- Correspondence:
| | - Wei Wang
- Crown Princess Mary Cancer Centre, Sydney West Radiation Oncology Network, Western Sydney Local Health District, Sydney, NSW 2145, Australia
| | - Annette Haworth
- Institute of Medical Physics, School of Physics, Faculty of Science, The University of Sydney, Camperdown, NSW 2006, Australia
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Sun X, Dai Z, Xu M, Guo X, Su H, Li Y. Quantifying 6D tumor motion and calculating PTV margins during liver stereotactic radiotherapy with fiducial tracking. Front Oncol 2022; 12:1021119. [DOI: 10.3389/fonc.2022.1021119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/18/2022] [Indexed: 11/18/2022] Open
Abstract
ObjectiveOur study aims to estimate intra-fraction six-dimensional (6D) tumor motion with rotational correction and the related correlations between motions of different degrees of freedom (DoF), as well as quantify sufficient anisotropic clinical target volume (CTV) to planning target volume (PTV) margins during stereotactic body radiotherapy (SBRT) of liver cancer with fiducial tracking technique.MethodsA cohort of 12 patients who were implanted with 3 or 4 golden markers were included in this study, and 495 orthogonal kilovoltage (kV) pairs of images acquired during the first fraction were used to extract the spacial position of each golden marker. Translational and rotational motions of tumor were calculated based on the marker coordinates by using an iterative closest point (ICP) algorithm. Moreover, the Pearson product-moment correlation coefficients (r) were applied to quantify the correlations between motions with different degrees of freedom (DoFs). The population mean displacement (MP¯), systematic error (Σ) and random error (σ) were obtained to calculate PTV margins based on published recipes.ResultsThe mean translational variability of tumors were 0.56, 1.24 and 3.38 mm in the left-right (LR, X), anterior-posterior (AP, Y), and superior-inferior (SI, Z) directions, respectively. The average rotational angles θX , θY and θZ around the three coordinate axes were 0.88, 1.24 and 1.12, respectively. (|r|>0.4) was obtainted between Y -Z , Y - θZ , Z -θZ and θX - θY . The PTV margins calculated based on 13 published recipes in X, Y, and Z directions were 1.08, 2.26 and 5.42 mm, and the 95% confidence interval (CI) of them were (0.88,1.28), (1.99,2.53) and (4.78,6.05), respectively.ConclusionsThe maximum translational motion was in SI direction, and the largest correlation coefficient of Y-Z was obtained. We recommend margins of 2, 3 and 7 mm in LR, AP and SI directions, respectively.
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Hu Y, Zhao C, Ji R, Chen W, Shen Q, Chiang CL, Chan J, Ma L, Yang H, Wong T, Ellsworth S, Lo CM, Dawson LA, Kong FM. The role of stereotactic body radiotherapy in hepatocellular carcinoma: guidelines and evidences. JOURNAL OF THE NATIONAL CANCER CENTER 2022. [DOI: 10.1016/j.jncc.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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21
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Park Y, Chang AR. Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio in Hepatocellular Carcinoma Treated with Stereotactic Body Radiotherapy. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2022; 79:252-259. [PMID: 35746839 DOI: 10.4166/kjg.2022.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To investigate the prognostic value of the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) in patients with hepatocellular carcinoma (HCC) treated with stereotactic body radiotherapy (SBRT). METHODS The medical records of HCC patients treated with SBRT between 2008 and 2019 were reviewed retrospectively. The NLR and PLR were calculated from the serum complete blood count before and after SBRT, and the prognostic values of the NLR and PLR for the treatment outcomes were evaluated. RESULTS Thirty-nine patients with 49 HCC lesions were included. After a median follow-up of 26.8 months (range, 8.4-80.0 months), three-year local control, overall survival (OS), and progression-free survival (PFS) rate were 97.4%, 78.3%, and 35.2%, respectively. Both NLR and PLR increased significantly after SBRT and decreased slowly to the pre-SBRT value at 6 months. Univariable analysis showed that gross tumor volume (GTV) >14 cc, post-SBRT PLR >90, and PLR change >30 were associated with a poorer OS (p=0.002, p=0.011, and p=0.001, respectively), and the PLR change was significant in multivariable analysis (hazard ratio [HR], 10.09; 95% CI, 1.15-88.40; p=0.037). For PFS, GTV >14 cc, post-SBRT NLR >2.5 and post-SBRT PLR >90 were predictive of a poorer PFS in univariable analysis (p=0.011, p=0.004 and p=0.041, respectively) and only post-SBRT NLR >2.5 remained significant in multivariable analysis (HR, 2.44; 95% CI, 1.03-5.76; p=0.042, respectively). CONCLUSIONS The NLR and PLR increased transiently after SBRT, and the post-SBRT NLR and PLR were associated with the clinical outcomes of HCC patients.
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Affiliation(s)
- Younghee Park
- Department of Radiation Oncology, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Ah Ram Chang
- Department of Radiation Oncology, Soonchunhyang University Seoul Hospital, Seoul, Korea
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22
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Lewis S, Barry A, Hawkins MA. Hypofractionation in Hepatocellular Carcinoma - The Effect of Fractionation Size. Clin Oncol (R Coll Radiol) 2022; 34:e195-e209. [PMID: 35314091 DOI: 10.1016/j.clon.2022.02.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 02/11/2022] [Accepted: 02/24/2022] [Indexed: 12/26/2022]
Abstract
The use of stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC) has increased over the years. Several prospective studies have demonstrated its safety and efficacy, and randomised trials are underway. The advancement in technology has enabled the transition from three-dimensional conformal radiotherapy to highly focused SBRT. Liver damage is the primary limiting toxicity with radiation, with the incidence of grade 3 varying from 0 to 30%. The reported radiotherapy fractionation schedule for HCC, and in practice use, ranges from one to 10 fractions, based on clinician preference and technology available, tumour location and tumour size. This review summarises the safety and efficacy of various SBRT fractionation schedules for HCC.
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Affiliation(s)
- S Lewis
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - A Barry
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - M A Hawkins
- Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
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23
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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: 16] [Impact Index Per Article: 8.0] [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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24
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Srivastava A, Parambath HK, Ramdulari AV, Saxena H, Kumar R, Pandey S, Shalimar, Gupta S, Jee B. Is hepatocellular carcinoma complicated with portal vein tumor thrombosis potentially curable by radiotherapy in the form of stereotactic body radiation therapy? Int J Radiat Biol 2022; 98:1495-1509. [PMID: 35311612 DOI: 10.1080/09553002.2022.2055800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE The prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal. Despite best treatment and care, the patients with this malignancy only showed 2.7-4 months of overall survival. It is debatable whether liver transplantation helps PVTT sufferers. The effectiveness of radiation therapy in treating HCC patients with PVTT should not be undervalued. By limiting the high dosage region to a small planning target volume, stereotactic radiation delivery has shifted toward hypofractionation, limiting the radiation exposure to healthy organs and tissues. Stereotactic body radiotherapy (SBRT) has a local control rate of 75-100%, depending on the treatment. The major limitation in SBRT for hepatocellular carcinoma with PVTT is the paucity of prospective evidence for longer periods beyond the first two years after treatment. More prospective studies/randomized clinical trials with a longer follow-up, larger sample size, and adequate statistical power are the dire need of the present situation to ascertain the curative effect of SBRT as primary therapy for advanced HCC with PVTT. CONCLUSION SBRT can improve survival, particularly for patients receiving multidisciplinary treatment. This review sums up our most current understanding of how radiation therapy, notably SBRT, can be used to treat hepatocellular carcinoma when combined with PVTT. Recent research has led us to believe that irradiation in the form of SBRT may cure hepatocellular carcinoma complicated by PVTT.
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Affiliation(s)
- Astha Srivastava
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Haresh Kunhi Parambath
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Anjali V Ramdulari
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Harsh Saxena
- Department of Medicine Trauma, All India Institute of Medical Sciences, New Delhi, India
| | - Rishabh Kumar
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Suyash Pandey
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Subhash Gupta
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Babban Jee
- Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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25
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Cho IJ, Jeong JU, Nam TK, Joo YE, Cho SB, Kim YH, Song JY, Yoon MS, Ahn SJ, Chung WK. PIVKA-II as a surrogate marker for prognosis in patients with localized hepatocellular carcinoma receiving stereotactic body radiotherapy. Radiat Oncol J 2022; 40:20-28. [PMID: 35368197 PMCID: PMC8984128 DOI: 10.3857/roj.2021.00934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose This study aimed to determine the correlation between protein induced by vitamin K absence or antagonist-II (PIVKA-II) and stereotactic body radiotherapy (SBRT) in patients with hepatocellular carcinoma (HCC). Materials and Methods Sixty-one patients received SBRT between 2015 and 2020 with a median dose of 48 Gy (range, 39 to 60 Gy) with a median of 4 fractions. Changes in tumor markers before and after SBRT were analyzed. Results The median follow-up period was 31 months (range, 12 to 64 months). The estimated 2-year in-field failure-free survival, progression-free survival (PFS), and overall survival rates were 82.0%, 39.3%, and 96.7%, respectively. Patients with decreased PIVKA-II levels through SBRT had significantly few in-field failures (p = 0.005). Patients with PIVKA-II levels of ≤25 mAU/mL after SBRT had significantly long PFS (p = 0.004). Conclusion PIVKA-II could be a useful surrogate marker for response or survival outcomes in patients with localized HCC receiving SBRT.
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Affiliation(s)
- Ick Joon Cho
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae-Uk Jeong
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
- Correspondence: Taek-Keun Nam Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, 322 Seoyangro, Hwasun-eup, Hwasun-gun, Jeollanam-do 58128, Korea. Tel: +82-61-379-7200 Fax: +82-61-379-7249 E-mail:
| | - Young-Eun Joo
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sung-Bum Cho
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yong-Hyub Kim
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Ju-Young Song
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Mee Sun Yoon
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sung-Ja Ahn
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Woong-Ki Chung
- Department of Radiation Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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26
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Masuda S, Tsukiyama T, Minagawa Y, Koizumi K, Kako M, Kinbara T, Haruki U. Hepatocellular carcinoma effective stereotactic body radiotherapy using Gold Anchor and the Synchrony system: Two case reports and review of literature. World J Clin Cases 2022; 10:2591-2603. [PMID: 35434047 PMCID: PMC8968590 DOI: 10.12998/wjcc.v10.i8.2591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/12/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Radiotherapy for hepatocellular carcinoma (HCC) is considered to have limited efficacy because of treatment intensity considering that the irradiated area includes the liver, which is highly radiosensitive. In this report, we present two cases in which tumor control by surgical resection, radiofrequency ablation, transcatheter arterial chemoembolization (TACE), and lenvatinib administration was difficult, but stereotactic body radiotherapy (SBRT) using the Synchrony system by Radixact™ and Gold Anchor® (GA) was effective.
CASE SUMMARY A 60-year-old man had a single 10-cm HCC in the right lobe. Viable lesions remained after TACE, and levels of alpha-fetoprotein and protein induced by vitamin K antagonists II (PIVKA-II) decreased and quickly re-elevated. We performed SBRT with GA. Three weeks after implantation, localized radiotherapy (SBRT; 40 Gy/5 fractions) was performed using the Synchrony system by Radixact™. Four weeks later, the viable lesion had disappeared, and the PIVKA-II levels decreased. A 77-year-old man had a single 12-cm HCC in the right lobe. The patient experienced recurrence after hepatectomy. Further recurrence occurred after TACE, and we performed SBRT with GA. Because of the proximity of the HCC to the gastrointestinal tract, localized radiotherapy (SBRT; 39 Gy/13 fractions) to the HCC was performed 3 wk after implantation using the Synchrony system by Radixact™. Four weeks later, the viable lesion had disappeared on computed tomography, and the PIVKA-Ⅱ levels decreased.
CONCLUSION SBRT using the Synchrony system and GA can deliver a large dose accurately and safely, and could have a high therapeutic effect.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology, Shonankamakura General Hospital, Kanagawa 247-8533, Japan
| | - Toshitaka Tsukiyama
- Department of Interventional Radiology Center, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Yumiko Minagawa
- Department of Radiation Oncology, Shonan Kamakura General Hospital, Kanagawa 247-8533, Japan
| | - Kazuya Koizumi
- Department of Gastroenterology, Shonankamakura General Hospital, Kanagawa 247-8533, Japan
| | - Makoto Kako
- Department of Gastroenterology, Shonankamakura General Hospital, Kanagawa 247-8533, Japan
| | - Takeshi Kinbara
- Department of Gastroenterology, Shonankamakura General Hospital, Kanagawa 247-8533, Japan
| | - Uojima Haruki
- Department of Gastroenterology, Shonankamakura General Hospital, Kanagawa 247-8533, Japan
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27
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Aquina CT, Eskander MF, Pawlik TM. Liver-Directed Treatment Options Following Liver Tumor Recurrence: A Review of the Literature. Front Oncol 2022; 12:832405. [PMID: 35174097 PMCID: PMC8841620 DOI: 10.3389/fonc.2022.832405] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/11/2022] [Indexed: 01/27/2023] Open
Abstract
Recurrence following curative-intent hepatectomy for colorectal cancer liver metastasis, hepatocellular carcinoma, or cholangiocarcinoma is unfortunately common with a reported incidence as high as 75%. Various treatment modalities can improve survival following disease recurrence. A review of the literature was performed using PubMed. In addition to systemic therapy, liver-directed treatment options for recurrent liver disease include repeat hepatectomy, salvage liver transplantation, radiofrequency or microwave ablation, intra-arterial therapy, and stereotactic body radiation therapy. Repeat resection can be consider for patients with limited recurrent disease that meets resection criteria, as this therapeutic approach can provide a survival benefit and is potentially curative in a subset of patients. Salvage liver transplantation for recurrent hepatocellular carcinoma is another option, which has been associated with a 5-year survival of 50%. Salvage transplantation may be an option in particular for patients who are not candidates for resection due to underlying liver dysfunction but meet criteria for transplantation. Ablation is another modality to treat patients who recur with smaller tumors and are not surgical candidates due to comorbidity, liver dysfunction, or tumor location. For patients with inoperable disease, transarterial chemoembolization, or radioembolization with Yttrium-90 are liver-directed intra-arterial therapy modalities with relatively low risks that can be utilized. Stereotactic body radiation therapy is another palliative treatment option that can provide a response and local tumor control for smaller tumors.
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Affiliation(s)
- Christopher T. Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Digestive Health and Surgery Institute, AdventHealth Orlando, Orlando, FL, United States
| | - Mariam F. Eskander
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Division of Surgical Oncology, Department of Surgery, Robert Wood Johnson Medical School and Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Timothy M. Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- *Correspondence: Timothy M. Pawlik,
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28
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Jia J, Sun J, Duan X, Li W. Clinical Values and Markers of Radiation-Induced Liver Disease for Hepatocellular Carcinoma With Portal Vein Tumor Thrombus Treated With Stereotactic Body Radiotherapy. Front Oncol 2022; 11:760090. [PMID: 34970485 PMCID: PMC8712705 DOI: 10.3389/fonc.2021.760090] [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: 08/17/2021] [Accepted: 11/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background Information about radiation-induced liver disease (RILD) in hepatocellular carcinoma (HCC) patients preexisting hepatitis B cirrhosis with portal vein tumor thrombus (PVTT) extended to the main portal vein treated with stereotactic body radiotherapy (SBRT) is still inadequate and the predictive markers for RILD have not been cleared in these patients. The aim of the study is to identify factors that can be used to predict RILD and to evaluate the influence of RILD in these patients. Methods In our study, 59 patients were analyzed and evaluated from December 2015 to June 2019, according to the entry criteria. After treatment, 59 patients were followed up within the first month and then every 3 months. Hematology test, tumor markers, three-phasic CT scan of the lungs, and CT or MRI scan of the liver were performed at each follow up. Results Median overall survival time was 10.7 months (range, 5.8 to 14.9). RILD appeared in 17 of the 59 patients (28.8%) at the 3rd month after SBRT. In the univariate analysis, not only the CP score class (A or B) but also each different pretreatment CP score (p < 0.05) was a significant predictive factor of RILD. More RILD cases were detected with the increase of CP score. The recovery rate decreased as the baseline CP score increased (p < 0.05). It was found that the overall survival time was affected by only baseline CP score and RILD (p < 0.05). Conclusions The development of RILD has a dependency on the CP score in these patients. CP scores before treatment and RILD are significantly associated with overall survival. SBRT is an effective and safe method for patients with CP ≤ B7. For patients with CP-B8, liver function should be monitored more frequently. It is not safe enough for the SBRT treatment in CP-B9 patients.
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Affiliation(s)
- Jun Jia
- Radiation Oncology Department, The Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Jing Sun
- Radiation Oncology Department, The Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xuezhang Duan
- Radiation Oncology Department, The Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Wengang Li
- Radiation Oncology Department, The Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
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29
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Approach to Stereotactic Body Radiotherapy for the Treatment of Advanced Hepatocellular Carcinoma in Patients with Child-Pugh B-7 Cirrhosis. Curr Treat Options Oncol 2022; 23:1761-1774. [PMID: 36333623 PMCID: PMC9768006 DOI: 10.1007/s11864-022-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2022] [Indexed: 11/08/2022]
Abstract
OPINION STATEMENT Patients with hepatocellular carcinoma (HCC) with underlying Child-Pugh B-7 cirrhosis benefit from management from an experienced, multidisciplinary team. In patients with localized disease who meet criteria for liver transplant, establishing care at a liver transplant center is crucial. For those awaiting transplant, local bridge therapies have emerged as a strategy to maintain priority status and eligibility. Multiple liver-directed therapies exist to provide locoregional tumor control. The careful selection of locoregional therapy is a multidisciplinary endeavor that takes into account patient factors including tumor resectability, underlying liver function, performance status, previous treatment, tumor location/size, and vascular anatomy to determine the optimal management strategy. Technological advances in external beam radiation therapy have allowed stereotactic body radiation therapy (SBRT) to emerge in recent years as a versatile and highly effective bridge therapy consisting of typically between 3 and 5 high dose, highly focused, and non-invasive radiation treatments. When treating cirrhotic patients with HCC, preserving liver function is of utmost importance to prevent clinical decline and decompensation. SBRT has been shown to be both safe and effective in carefully selected patients with Child-Pugh B cirrhosis; however, care must be taken to prevent radiation-induced liver disease. This review summarizes the evolving role of SBRT in the treatment of HCC in patients with Child-Pugh B-7 cirrhosis.
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30
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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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31
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Patel A, Subbanna I, Bhargavi V, Swamy S, Kallur KG, Patil S. Transarterial Radioembolization (TARE) with 131 Iodine-Lipiodol for Unresectable Primary Hepatocellular Carcinoma: Experience from a Tertiary Care Center in India. South Asian J Cancer 2021; 10:81-86. [PMID: 34568220 PMCID: PMC8460342 DOI: 10.1055/s-0041-1731600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose
This article presents our experience regarding survival benefits in inoperable intermediate stage hepatocellular carcinoma (HCC) and advanced stage HCC treated with
131
I-lipiodol.
Materials and Methods
This is a retrospective study of intermediate stage HCC (Barcelona Clinic Liver Cancer [BCLC] stage B) not responding to prior treatment and/or advanced stage HCC (BCLC stage C) treated with
131
I-lipiodol.
131
I-lipiodol was injected into the hepatic artery through transfemoral route. Postprocedure, the patient was isolated for 5 to 7 days. All patients underwent tumor response evaluation after 4 weeks. Survival of patients was calculated up to either death or conclusion of the study.
Results
A total of 55 patients (52 males [94.5%], 3 females [5.4%]) were given intra-arterial
131
I-lipiodol therapy. The median overall survival after transarterial radioembolization (TARE) was 172 ± 47 days (95% confidence limit, 79–264 days). The overall survival at 3, 6, 9, and 12 months was 69, 47, 32, and 29%, respectively. A multivariate Cox regression analysis showed the presence of treatment prior to TARE to most significantly influence survival (
B
= 2.161,
p
≤ 0.001). This was followed by size of the lesion which was second in line (
B
= 0.536,
p
= 0.034). Among 45 patients, 14 patients (31.1%) showed a partial response, 11 patients (24.4%) showed stable disease, and 20 patients (44.4%) showed progressive diseases.
Conclusion
TARE with
131
I-lipiodol can be a safe and effective palliative treatment in advanced stage HCC and in patients with poor response to prior treatments like transarterial chemoembolization.
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Affiliation(s)
- Aakash Patel
- Department of Interventional Radiology, HCG Hospital, Bangalore, Karnataka, India
| | - Indusekhara Subbanna
- Department of Interventional Radiology, HCG Hospital, Bangalore, Karnataka, India
| | - Vidya Bhargavi
- Department of Interventional Radiology, HCG Hospital, Bangalore, Karnataka, India
| | - Shivakumar Swamy
- Department of Interventional Radiology, HCG Hospital, Bangalore, Karnataka, India
| | | | - Shekhar Patil
- Department of Medical Oncology, HCG Hospital, Bangalore, Karnataka, India
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32
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Tsang SH, Ma KW, She WH, Chu F, Lau V, Lam SW, Cheung TT, Lo CM. High-intensity focused ultrasound ablation of liver tumors in difficult locations. Int J Hyperthermia 2021; 38:56-64. [PMID: 34420450 DOI: 10.1080/02656736.2021.1933217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
High-intensity focused ultrasound (HIFU) has been shown to be a valuable tool in the management of small liver tumors such as hepatocellular carcinoma (HCC). It has been shown to be a safe and effective means to ablate small HCC even in the presence of advanced cirrhosis. This review examines the challenges faced during HIFU ablation when the target tumors are located in difficult locations such as the liver dome, close to the rib cage, near large blood vessels or the heart, or adjacent to hollow viscera; and the special maneuvers employed to tackle such lesions.
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Affiliation(s)
- Simon H Tsang
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Ka Wing Ma
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Wong Hoi She
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Ferdinand Chu
- Department of Radiology, Queen Mary Hospital, Hong Kong, China
| | - Vince Lau
- Department of Radiology, Queen Mary Hospital, Hong Kong, China
| | - Shuk Wan Lam
- Department of Anaesthesiology, The University of Hong Kong, Hong Kong, China
| | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Hong Kong, China
| | - Chung Mau Lo
- Department of Surgery, The University of Hong Kong, Hong Kong, China
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33
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Shanker MD, Moodaley P, Soon W, Liu HY, Lee YY, Pryor DI. Stereotactic ablative radiotherapy for hepatocellular carcinoma: A systematic review and meta-analysis of local control, survival and toxicity outcomes. J Med Imaging Radiat Oncol 2021; 65:956-968. [PMID: 34396706 DOI: 10.1111/1754-9485.13309] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022]
Abstract
There is a growing body of literature supporting the use of stereotactic ablative body radiotherapy (SABR) in the management of primary hepatocellular carcinoma (HCC). This systematic review and meta-analysis of the current published evidence for SABR for HCC assessed the impact of treatment dose, fractionation and tumour size on the outcomes of local control (LC), overall survival (OS) and toxicity. A systematic search was independently performed by two authors for articles published in peer-reviewed journals between January 2005 and December 2019. A DerSimonian and Laird random effects model was used to assess pooled results. A multivariate meta-regression analysis incorporated the effect of explanatory variables (radiation dose in EQD2[10], fractionation and tumour size) on outcomes of OS, LC and toxicity. Forty-nine cohorts involving 2846 HCC patients with 3088 lesions treated with SABR were included. Pooled 1-, 2- and 3-year LC rates were 91.1% (95% confidence interval [CI] 88.3-93.2), 86.7% (95% CI 82.7-89.8) and 84.2% (95% CI 77.9-88.9) respectively. Pooled 1-, 2- and 3-year OS rates were 78.4% (95% CI 73.4-82.6), 61.3% (55.2-66.9) and 48.3% (95% CI 39.0-57). Population-weighted median grade 3 toxicity rates were 6.5% (IQR 3.2-16) and mean grade 4/5 rates were 1.4% (IQR 0-2.1). Within EQD2[10] ranges of 40 to 83.33 Gy corresponding to common dose-fractionation regimens of 30-50 Gy in 5 fractions, there was a multivariate association between superior LC and OS with increasing EQD2[10] , with a proportionately smaller increase in grade 3 toxicity and no association with grade 4/5 toxicity. Stereotactic ablative body radiotherapy is a viable treatment option for HCC with high LC rates and low rates of reported grade 3/4 toxicity. Increasing EQD2[10] was associated with improvements in LC and OS with a comparatively smaller increase in toxicity. Prospective randomised trials are warranted to define optimal patient selection and dose-fractionation regimens.
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Affiliation(s)
- Mihir D Shanker
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Pereshin Moodaley
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Wei Soon
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Howard Y Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Yoo Young Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - David I Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Bauer U, Gerum S, Roeder F, Münch S, Combs SE, Philipp AB, De Toni EN, Kirstein MM, Vogel A, Mogler C, Haller B, Neumann J, Braren RF, Makowski MR, Paprottka P, Guba M, Geisler F, Schmid RM, Umgelter A, Ehmer U. High rate of complete histopathological response in hepatocellular carcinoma patients after combined transarterial chemoembolization and stereotactic body radiation therapy. World J Gastroenterol 2021; 27:3630-3642. [PMID: 34239274 PMCID: PMC8240047 DOI: 10.3748/wjg.v27.i24.3630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/20/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver transplantation (LT) presents a curative treatment option in patients with early stage hepatocellular carcinoma (HCC) who are not eligible for resection or ablation therapy. Due to a risk of up 30% for waitlist drop-out upon tumor progression, bridging therapies are used to halt tumor growth. Transarterial chemoembolization (TACE) and less commonly stereotactic body radiation therapy (SBRT) or a combination of TACE and SBRT, are used as bridging therapies in LT. However, it remains unclear if one of those treatment options is superior. The analysis of explant livers after transplantation provides the unique opportunity to investigate treatment response by histopathology.
AIM To analyze histopathological response to a combination of TACE and SBRT in HCC in comparison to TACE or SBRT alone.
METHODS In this multicenter retrospective study, 27 patients who received liver transplantation for HCC were analyzed. Patients received either TACE or SBRT alone, or a combination of TACE and SBRT as bridging therapy to liver transplantation. Liver explants of all patients who received at least one TACE and/or SBRT were analyzed for the presence of residual vital tumor tissue by histopathology to assess differences in treatment response to bridging therapies. Statistical analysis was performed using Fisher-Freeman-Halton exact test, Kruskal-Wallis and Mann-Whitney-U tests.
RESULTS Fourteen patients received TACE only, four patients SBRT only, and nine patients a combination therapy of TACE and SBRT. There were no significant differences between groups regarding age, sex, etiology of underlying liver disease or number and size of tumor lesions. Strikingly, analysis of liver explants revealed that almost all patients in the TACE and SBRT combination group (8/9, 89%) showed no residual vital tumor tissue by histopathology, whereas TACE or SBRT alone resulted in significantly lower rates of complete histopathological response (0/14, 0% and 1/4, 25%, respectively, P value < 0.001).
CONCLUSION Our data suggests that a combination of TACE and SBRT increases the rate of complete histopathological response compared to TACE or SBRT alone in bridging to liver transplantation.
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Affiliation(s)
- Ulrike Bauer
- Internal Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Sabine Gerum
- Department of Radiotherapy and Radiation Oncology, University of Salzburg, Salzburg 5020, Austria
- Department of Radiation Oncology, University Hospital of Munich, Campus Großhadern, LMU Munich, Munich 81377, Germany
| | - Falk Roeder
- Department of Radiotherapy and Radiation Oncology, University of Salzburg, Salzburg 5020, Austria
- Department of Radiation Oncology, University Hospital of Munich, Campus Großhadern, LMU Munich, Munich 81377, Germany
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Alexander B Philipp
- Department of Medicine II, Liver Centre, University Hospital, LMU Munich, Munich 81377, Germany
| | - Enrico N De Toni
- Department of Medicine II, Liver Centre, University Hospital, LMU Munich, Munich 81377, Germany
| | - Martha M Kirstein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover 30625, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover 30625, Germany
| | - Carolin Mogler
- Institute of Pathology, Technical University of Munich, Munich 81675, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Jens Neumann
- Institute of Pathology, Faculty of Medicine, University Hospital of Munich, Munich 81377, Germany
| | - Rickmer F Braren
- Institute of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Marcus R Makowski
- Institute of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Philipp Paprottka
- Institute of Diagnostic and Interventional Radiology, Section for Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Markus Guba
- Department of General-, Visceral-, Vascular- and Transplant-Surgery, University hospital of Munich, Campus Großhadern, LMU Munich, Munich 81377, Germany
| | - Fabian Geisler
- Internal Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Roland M Schmid
- Internal Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
| | - Andreas Umgelter
- Internal Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
- Emergency Department, Vivantes hospital group, Humboldt hospital, Berlin 13509, Germany
| | - Ursula Ehmer
- Internal Medicine II, Klinikum rechts der Isar, Technical University of Munich, Munich 81675, Germany
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Chen LC, Lin HY, Hung SK, Chiou WY, Lee MS. Role of modern radiotherapy in managing patients with hepatocellular carcinoma. World J Gastroenterol 2021; 27:2434-2457. [PMID: 34092968 PMCID: PMC8160620 DOI: 10.3748/wjg.v27.i20.2434] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/16/2021] [Accepted: 04/26/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer. Several treatment options are available for managing HCC patients, classified roughly as local, local-regional, and systemic therapies. The high post-monotherapy recurrence rate of HCC urges the need for the use of combined modalities to increase tumor control and patient survival. Different international guidelines offer treatment recommendations based on different points of view and classification systems. Radiotherapy (RT) is a well-known local-regional treatment modality for managing many types of cancers, including HCC. However, only some of these treatment guidelines include RT, and the role of combined modalities is rarely mentioned. Hence, the present study reviewed clinical evidence for the use of different combined modalities in managing HCC, focusing on modern RT's role. Modern RT has an increased utility in managing HCC patients, mainly due to two driving forces. First, technological advancement (e.g., stereotactic body radiotherapy and advanced proton-beam therapy) enables precise delivery of radiation to increase tumor control and reduce side effects in the surrounding normal tissue. Second, the boom in developing target therapies and checkpoint-blockade immunotherapy prolongs overall survival in HCC patients, re-emphasizing the importance of local tumor control. Remarkably, RT combines with systemic therapies to generate the systemic therapy augmented by radiotherapy effect, a benefit now being actively investigated.
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Affiliation(s)
- Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chia-Yi 62247, Taiwan
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chia-Yi 62247, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien 970, Taiwan
- Institute of Molecular Biology, National Chung Cheng University, Min-Hsiung, Chia-Yi 62102, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chia-Yi 62247, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien 970, Taiwan
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chia-Yi 62247, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien 970, Taiwan
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin, Chia-Yi 62247, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien 970, Taiwan
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36
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Jackson WC, Hartman HE, Gharzai LA, Maurino C, Karnak DM, Mendiratta-Lala M, Parikh ND, Mayo CS, Haken RKT, Schipper MJ, Cuneo KC, Lawrence TS. The Potential for Midtreatment Albumin-Bilirubin (ALBI) Score to Individualize Liver Stereotactic Body Radiation Therapy. Int J Radiat Oncol Biol Phys 2021; 111:127-134. [PMID: 33878421 DOI: 10.1016/j.ijrobp.2021.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/29/2021] [Accepted: 04/11/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE Our individualized functional response adaptive approach to liver stereotactic body radiation therapy (SBRT) with assessment of indocyanine green (ICG) retention at baseline and midtreatment to detect subclinical changes in liver function, permitting dose adjustment, has decreased toxicity while preserving efficacy. We hypothesized that assessment of the albumin-bilirubin (ALBI) score at baseline and midtreatment would allow for more practical identification of patients at risk for treatment-related toxicity (TRT). METHODS AND MATERIALS Patients with hepatocellular carcinoma were treated on 3 prospective institutional review board-approved trials using baseline and midtreatment ICG to deliver individualized functional response adaptive liver SBRT. Patients received 3 or 5 fractions, with fraction 3 followed by a 1-month treatment break. TRT was a ≥2-point rise in Child-Pugh score within 6 months of SBRT. Logistic regression was used to estimate odds ratios (ORs) and confidence intervals (CIs) for assessment of TRT. Area under the receiver operating curve was used to compare predictive ability across models. RESULTS In total, 151 patients underwent 166 treatments. Baseline Child-Pugh class and ALBI grade were A (66.9%), B (31.3%), or C (1.8%) and 1 (25.9%), 2 (65.7%), or 3 (8.4%), respectively. Thirty-five patients (20.3%) experienced TRT. On univariate analysis, baseline ALBI (OR, 1.8; 95% CI, 1.24-2.62; P = .02), baseline ICG (OR, 1.66; 95% CI, 1.17-2.35; P = .04), and change in ALBI (OR, 3.07; 95% CI, 1.29-7.32; P = .003) were associated with increased odds of TRT. ALBI-centric models performed similarly to ICG-centric models on multivariate analyses predicting toxicity (area under the receiver operating curve of 0.79 for both). In a model incorporating baseline and midtreatment change in ALBI and ICG, both ALBI values were statistically significantly associated with toxicity, whereas ICG values were not. CONCLUSIONS Incorporation of midtreatment change in ALBI in addition to baseline ALBI improves the ability to predict TRT in patients with hepatocellular carcinoma receiving SBRT. Our findings suggest that functional response adaptive treatment could be implemented in a practical manner because the ALBI score is easily obtained from standard laboratory values.
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Affiliation(s)
| | | | | | | | | | | | - Neehar D Parikh
- Gastroenterology, University of Michigan Ann Arbor, Michigan
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37
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Mastrocostas K, Fischer S, Munoz-Schuffenegger P, Jang HJ, Dawson LA, Liu ZA, Sapisochin G, Kim TK. Radiological tumor response and histopathological correlation of hepatocellular carcinoma treated with stereotactic body radiation therapy as a bridge to liver transplantation. Abdom Radiol (NY) 2021; 46:1572-1585. [PMID: 33074426 DOI: 10.1007/s00261-020-02821-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the imaging findings of hepatocellular carcinoma (HCC) treated with stereotactic body radiation therapy (SBRT) as a bridging therapy prior to liver transplantation (LT), with histopathological correlation at liver explant. METHODS Our institutional review board approved this retrospective study. The study subjects included 25 HCC lesions in 23 patients (20 males; median age, 60 years; range 41-68 years) who underwent LT after SBRT for HCC as a bridge to LT in a single tertiary referral institution over a 12-year period. Target HCC lesions were assessed for imaging biomarkers on contrast-enhanced CT or MRI including change in HCC diameter and assessment of percentage necrosis. The radiologic response at pre-LT imaging was compared to explant pathology. RESULTS There was a positive correlation between the tumor size (Spearman's ρ = 0.86; p < 0.001) and percentage necrosis (p < 0.001) on Pre-LT imaging and those on pathology. Partial response (PR), stable disease (SD), and progressive disease (PD) according to RECIST 1.1 were seen in 8 (32%), 15 (60%), and 2 (8%) lesions on pre-LT imaging, respectively. Of the 15 lesions with radiologic SD, 5/15 (33%) showed necrosis of more than 50% on post-SBRT imaging, while 9/15 (60%) showed necrosis of more than 50% at explant pathologic analysis, showing a tendency to underestimate the degree of tumor necrosis compared to pathology. CONCLUSION RECIST 1.1 radiologic response criteria may underestimate the response to treatment with SBRT, and radiologic estimation of percent tumor necrosis was more closely correlated with pathologic percent tumor necrosis.
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38
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Shanker MD, Liu HY, Lee YY, Stuart KA, Powell EE, Wigg A, Pryor DI. Stereotactic radiotherapy for hepatocellular carcinoma: Expanding the multidisciplinary armamentarium. J Gastroenterol Hepatol 2021; 36:873-884. [PMID: 32632941 DOI: 10.1111/jgh.15175] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/23/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide and the third most common cause of cancer-related death. Long-term prognosis remains poor with treatment options frequently limited by advanced tumor stage, tumor location, or underlying liver dysfunction. Stereotactic ablative body radiotherapy (SABR) utilizes technological advances to deliver highly precise, tumoricidal doses of radiation. There is an emerging body of literature on SABR in HCC demonstrating high rates of local control in the order of 80-90% at 3 years. SABR is associated with a low risk of radiation-induced liver disease or decompensation in appropriately selected HCC patients with compensated liver function and is now being incorporated into guidelines as an additional treatment option. This review outlines the emerging role of SABR in the multidisciplinary management of HCC and summarizes the current evidence for its use as an alternative ablative option for early-stage disease, as a bridge to transplant, and as palliation for advanced-stage disease. We outline specific considerations regarding patient selection, toxicities, and response assessment. Finally, we compare current international guidelines and recommendations for the use of SABR and summarize ongoing studies.
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Affiliation(s)
- Mihir D Shanker
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Howard Y Liu
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Yoo Young Lee
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Katherine A Stuart
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Elizabeth E Powell
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Alan Wigg
- Hepatology and Liver Transplantation Medicine Unit, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David I Pryor
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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39
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Bai S, Wu Y, Yan Y, Li R, Kang H, Zhang J, Ma W, Gao Y, Hui B, Ma H, Zhang X, Ren J. Evaluation of the Efficacy and Toxicity of Radiotherapy for Type III-IV Portal Vein Tumor Thrombi. Technol Cancer Res Treat 2021; 20:1533033821995286. [PMID: 33590809 PMCID: PMC7894593 DOI: 10.1177/1533033821995286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Type Ⅲ and Ⅳ portal vein tumor thrombi (PVTT) cannot be removed through surgery, and no effective therapeutic procedure is available. Type Ⅲ/Ⅳ PVTT can be downstage to type I/II PVTT by using Radiotherapy, and can further be can be removed surgically. Thus, radiotherapy may be an effective treatment for type Ⅲ/Ⅳ PVTT. This study aims to evaluate the efficacy and toxicity of radiotherapy for type III-IV PVTT. Methods: This prospective study was conducted from August 1, 2017, to September 30, 2019, for patients with type Ⅲ and Ⅳ PVTT. Patients received radiotherapy with a target dose of 50Gy/25f or 59.5Gy/17 f. Advanced radiological technique such as image fusion technique for CT image and MRI image were utilized to produce more precise lesion localization, and limit the dose to organs at risk in order to get a better downstage rate and less adverse complications. Results: Nine (9) patients with type Ⅲ PVTT and 5 patients with type Ⅳ PVTT were included in this study. 12 patients received a radiotherapy dose of 50Gy/25f, 2 patients received 59.50Gy/17 f. After radiotherapy, 92.9% of patients with PVTT were successfully downstage to type II/I. In patients with primary hepatocellular carcinoma, 8 patients (accounting 88.9%) achieved down-stage. 5 patients with other types of tumors achieved downstage which accounts 100%. In addition, none of the 14 patients observed radiation hepatitis and radiation liver failure. And none of the patients developed gastrointestinal ulcers and thrombocytopenia. Conclusion: Radiotherapy is a suitable treatment measure for type Ⅲ and Ⅳ PVTT to get downstage and make the opportunity for surgery. Image fusion technology for precise lesion location such as CT-MRI image fusion, and strict dose limitation of organ at risk, contributed to the improvement of radiotherapy efficiency and the significant decrease in adverse complications.
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Affiliation(s)
- Shuheng Bai
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - YinYing Wu
- Department of Chemotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Yanli Yan
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Rong Li
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Haojing Kang
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Jiangzhou Zhang
- Medical School, Xi'an Jiaotong University Xi'an, Shaanxi Province, China
| | - Wen Ma
- Medical School, Xi'an Jiaotong University Xi'an, Shaanxi Province, China
| | - Ying Gao
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Beina Hui
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Hailin Ma
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Xiaozhi Zhang
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
| | - Juan Ren
- Department of Radiotherapy, Oncology Department, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province, China
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Fujimoto K, Shiinoki T, Yuasa Y, Tanaka H. Estimation of liver elasticity using the finite element method and four-dimensional computed tomography images as a biomarker of liver fibrosis. Med Phys 2021; 48:1286-1298. [PMID: 33449406 DOI: 10.1002/mp.14723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Current radiotherapy planning procedures are generally designed based on anatomical information only and use computed tomography (CT) images that do not incorporate organ-functional information. In this study, we developed a method for estimating liver elasticity using the finite element method (FEM) and four-dimensional CT (4DCT) images acquired during radiotherapy planning, and we subsequently evaluated its feasibility as a biomarker for liver fibrosis. MATERIALS AND METHODS Twenty patients who underwent 4DCT and ultrasound-based transient elastography (UTE) were enrolled. All patients had chronic liver disease or cirrhosis. Liver elasticity measurements of the UTE were performed on the right lobe of the patient's liver in 20 patients. The serum biomarkers of the aspartate aminotransferase (AST)-to-platelet ratio index (APRI) and fibrosis-4 index (FIB-4) were available in 18 of the 20 total patients, which were measured within 1 week after undergoing 4DCT. The displacement between the 4DCT images obtained at the endpoints of exhalation and inspiration was determined using the actual (via deformable image registration) and simulated (via FEM) respiration-induced displacement. The elasticity of each element of the liver model was optimized by minimizing the error between the actual and simulated respiration-induced displacement. Then, each patient's estimated liver elasticity was defined as the mean Young's modulus of the liver's right lobe and that of the whole liver using the estimated elasticity map. The estimated liver elasticity was evaluated for correlations with the elasticity obtained via UTE and with two serum biomarkers (APRI and FIB-4). RESULTS The mean ± standard deviation (SD) of the errors between the actual and simulated respiration-induced displacement in the liver model was 0.54 ± 0.33 mm. The estimated liver's right lobe elasticity was statistically significantly correlated with the UTE (r = 0.87, P < 0.001). Furthermore, the estimated whole liver elasticity was statistically significantly correlated with the UTE (r = 0.84, P < 0.001), APRI score (r = 0.62, P = 0.005), and FIB-4 score (r = 0.54, P = 0.021). CONCLUSION In this study, liver elasticity was estimated through FEM-based simulation and actual respiratory-induced liver displacement obtained from 4DCT images. Furthermore, we assessed that the estimated elasticity of the liver's right lobe was strongly correlated with the UTE. Therefore, the estimated elasticity has the potential to be a feasible imaging biomarker for assessing liver fibrosis using only 4DCT images without additional inspection or equipment costs. Because our results were derived from a limited sample of 20 patients, it is necessary to evaluate the accuracy of elasticity estimation for each liver segment on larger groups of biopsied patients to utilize liver elasticity information for radiotherapy planning.
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Affiliation(s)
- Koya Fujimoto
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8535, Japan
| | - Takehiro Shiinoki
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8535, Japan
| | - Yuki Yuasa
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8535, Japan
| | - Hidekazu Tanaka
- Department of Radiation Oncology, Graduate School of Medicine, Yamaguchi University, 1-1-1 Minamikogushi, Ube, Yamaguchi, 755-8535, Japan
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Fiorentino A, Gregucci F, Desideri I, Fiore M, Marino L, Errico A, Di Rito A, Borghetti P, Franco P, Greto D, Donato V. Radiation treatment for adult rare cancers: Oldest and newest indication. Crit Rev Oncol Hematol 2021; 159:103228. [PMID: 33508447 DOI: 10.1016/j.critrevonc.2021.103228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 12/10/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022] Open
Abstract
AIM Aim of this analysis is to review the role of RT in the management of several rare tumors for adult patients. METHODS Collection data regarding RT and rare tumors was made by Pubmed. RESULTS For mucosal melanomas, RT is prescribed, being associated with lower local recurrence rate. For trachea tumors, RT was used as adjuvant or salvage treatment for unresectable disease. For pNET, RT can be a suitable option for post-surgical or unresectable/borderline. For bronchopulmonary neuroendocrine tumors the role of adjuvant treatments is uncertain. For hepatobiliary and ovarian malignancy, stereotactic body RT (SBRT) is a promising approach. For soft tissue sarcoma, perioperative treatments are indicated, and a growing role of SBRT in oligometastatic disease is recognized. For endocrine tumors, adjuvant RT has demonstrated benefits through reducing recurrence risk. CONCLUSION The radiotherapy is a frequent indication in adult rare cancers; thus the role of Radiation Oncologist must not be neglected.
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Affiliation(s)
- Alba Fiorentino
- Radiation Oncology Department, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Fabiana Gregucci
- Radiation Oncology Department, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti, Bari, Italy.
| | - Isacco Desideri
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Michele Fiore
- Radiation Oncology, Campus Bio-Medico University, Rome, Italy
| | - Lorenza Marino
- Radiation Oncology Department, Humanitas Istituto Clinico Catanese, Misterbianco, Catania, Italy
| | - Angelo Errico
- Radiotherapy Oncology Department, R. Dimiccoli Hospital, Barletta, Italy
| | - Alessia Di Rito
- Radiotherapy Oncology Department, IRCCS "Giovanni Paolo II", Bari, Italy
| | - Paolo Borghetti
- Radiation Oncology Department University and Spedali Civili, Brescia, Italy
| | | | - Daniela Greto
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Section of Radiation Oncology, University of Florence, Italy
| | - Vittorio Donato
- Radiation Oncology Department, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy
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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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MRI-guided stereotactic radiation therapy for hepatocellular carcinoma: a feasible and safe innovative treatment approach. J Cancer Res Clin Oncol 2021; 147:2057-2068. [PMID: 33398447 DOI: 10.1007/s00432-020-03480-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/22/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Hepatocellular carcinoma (HCC) in early stages benefits from local ablative treatments such as radiofrequency ablation (RFA) or transarterial chemoembolization (TACE). In this context, radiotherapy (RT) has shown promising results but has not been thoroughly evaluated. Magnetic resonance-guided RT (MRgRT) may represent a paradigm shifting improvement in stereotactic body radiotherapy (SBRT) for liver tumors. METHODS We retrospectively evaluated HCC patients treated on a hybrid low-tesla MRgRT unit. A total biologically effective dose (BED) > 100 Gy was delivered in 5 consecutive fractions, respecting the appropriate organs-at-risk constraints. Hybrid MR scans were used for treatment planning and cine MR was used for delivery gating. Patients were followed up for toxicity and treatment-response assessment. RESULTS Ten patients were enrolled, with a total of 12 lesions. All the lesions were irradiated with no interruptions. Six patients had already performed previous local therapies. Median follow-up after SBRT was 6.5 months (1-25). Two cases of acute toxicity were reported (G ≤ 2 according to CTCAE v4.0). At the time of the analysis, 90% of the population presented local control. Child-Pugh before and after treatment remained unchanged in all but one patient. CONCLUSION MRgRT is a feasible and safe option showing favorable toxicity profile for HCC treatment.
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Abstract
Introduction Globally, the incidence, as well as mortality, related to hepatocellular carcinoma (HCC) is on the rise, owing to relatively few curative options. Underlying cirrhosis is the most common etiology leading to HCC, but risk factors of cirrhosis show great regional variability. Over the years, there has been a steady development in the diagnostic and therapeutic modalities of HCC, including the availability of a wide range of systemic chemotherapeutic agents. We aim to review the recent advancements in the diagnostic and therapeutic strategies for HCC. Methodology The literature search was done using databases PubMed, Cochrane, and Science Direct, and the latest relevant articles were reviewed. Findings Screening of HCC is a pivotal step in the early diagnosis of the disease. Current guidelines recommend using ultrasound and alfa fetoprotein but various new biomarkers are under active research that might aid in diagnosing very small tumors, not picked up by the current screening methods. Treatment options are decided based upon the overall performance of the patient and the extent of the disease, as per the Barcelona classification. There are very few options that offer a cure for the disease, ranging from liver resection and transplantation to tumor ablation. Downstaging has proven to have a significant role in the course of the disease. An attempt to control the disease can be made via radiological interventions, such as transarterial chemoembolization, transarterial radioembolization, or radiation therapy. For advanced disease, sorafenib used to be the only option until a couple of years ago. Recently, many other systemic agents have received approval as first-line and second-line therapies for HCC. Genomics is an area of active clinical research as understanding the mutations and genomics involved in the evolution of HCC might lead to a breakthrough therapy. How to cite this article Raees A, Kamran M, Özkan H, et al. Updates on the Diagnosis and Management of Hepatocellular Carcinoma. Euroasian J Hepato-Gastroenterol 2021;11(1):32–40.
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Affiliation(s)
- Aimun Raees
- The Aga Khan University Hospital, Karachi, Pakistan
| | | | - Hasan Özkan
- Department of Gastroenterology, Ankara University, School of Medicine, Ankara, Turkey
| | - Wasim Jafri
- The Aga Khan University Hospital, Karachi, Pakistan
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Rim CH, Lee HY, Kim JS, Kim H. Radiofrequency ablation and stereotactic body radiotherapy for hepatocellular carcinoma: should they clash or reconcile? Int J Radiat Biol 2020; 97:111-119. [PMID: 33253598 DOI: 10.1080/09553002.2021.1857453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Until a few decades ago, surgical resection was the only valid option for treating hepatocellular carcinoma (HCC). However, various locoregional modalities including arterial-directed therapy, radiofrequency ablation (RFA), and radiotherapy have been recently shown to be effective. RFA is now established as a standard treatment for small localized HCCs, showing oncological results comparable to those of surgical resection in randomized studies. Stereotactic body radiotherapy (SBRT) is a modern radiotherapeutic modality that targets tumors with precision and delivers high radiation doses over a short period of time; it has particularly attracted clinical interest after its therapeutic efficacy was found to be similar to that of surgery in early-stage lung cancer. Given its potent disease control capability, SBRT has also been applied to early HCCs and demonstrated promising results in recent studies. It has also been noted for its suitability to treat tumors located in anatomical locations where RFA would be challenging. However, since its effectiveness has not been compared to that of RFA in randomized studies of patients eligible for RFA, the use of SBRT has been debated. This review was conducted to guide physicians from all fields involved in the treatment of early HCC. The therapeutic characteristics and indications of both SBRT and RFA are described, and recent comparative studies between the two modalities are discussed. In addition, we examined the factors that should be considered when selecting the appropriate treatments, and offer our recommendations.
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Affiliation(s)
- Chai Hong Rim
- Department of Radiation Oncology, Korea University Ansan Hospital, Gyeonggido, Korea
| | - Hye Yoon Lee
- Department of General Surgery, Korea University Ansan Hospital, Gyeonggido, Korea
| | - Jung Sun Kim
- Department of Medical Oncology, Korea University Ansan Hospital, Gyeonggido, Korea
| | - Hakyoung Kim
- Department of Radiation Oncology, Korea University Guro Hospital, Seoul, Korea
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Cousins MM, Morris E, Maurino C, Devasia TP, Karnak D, Ray D, Parikh ND, Owen D, Ten Haken RK, Schipper MJ, Lawrence TS, Cuneo KC. TNFR1 and the TNFα axis as a targetable mediator of liver injury from stereotactic body radiation therapy. Transl Oncol 2020; 14:100950. [PMID: 33395747 PMCID: PMC7744766 DOI: 10.1016/j.tranon.2020.100950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 02/08/2023] Open
Abstract
Elevated soluble TNFR1 levels are predictive of liver toxicity among patients receiving radiation. Soluble TNFR1 levels do not independently predict liver toxicity when included in models with ALBI and mean liver dose. Data suggest that liver inflammation mediates toxicity after liver irradiation and that the TNFα axis is associated with this inflammation. Future studies of should evaluate approaches that target pre-treatment inflammation to reduce the risk of toxicity.
Introduction Radiation therapy for the management of intrahepatic malignancies can adversely affect liver function. Liver damage has been associated with increased levels of inflammatory cytokines, including tumor necrosis factor alpha (TNFα). We hypothesized that an inflammatory state, characterized by increased soluble TNFα receptor (sTNFR1), mediates sensitivity of the liver to radiation. Materials/Methods Plasma samples collected during 3 trials of liver radiation for liver malignancies were assayed for sTNFR1 level via enzyme-linked immunosorbent assay (ELISA). Univariate and multivariate logistic regression and longitudinal models were used to characterize associations between liver toxicity (defined as a ≥2-point increase in Child-Pugh [CP] score within 6 months of radiation treatment) and sTNFR1 levels, ALBI score, biocorrected mean liver dose (MLD), age, and baseline laboratory values. Results Samples from 78 patients given liver stereotactic body radiation therapy [SBRT] (92%) or hypofractionated radiation were examined. There was a significant association between liver toxicity and sTNFR1 levels, and higher values were associated with increased toxicity over a range of mean liver doses. When ALBI score and biocorrected dose were included in the model with sTNFR1, baseline ALBI score and change in ALBI (ΔALBI) were significantly associated with toxicity, but sTNFR1 was not. Baseline aminotransferase levels also predicted toxicity but not independently of ALBI score. Conclusions Elevated plasma sTNFR1 levels are associated with liver injury after liver radiation, suggesting that elevated inflammatory cytokine activity is a predictor of radiation-induced liver dysfunction. Future studies should determine whether administration of agents that decrease inflammation prior to treatment is warranted.
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Affiliation(s)
- Matthew M Cousins
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Emily Morris
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Christopher Maurino
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Theresa P Devasia
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - David Karnak
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Dipankar Ray
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, 3110 Taubman Center, SPC 5368, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5368, USA
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Randall K Ten Haken
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Theodore S Lawrence
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA
| | - Kyle C Cuneo
- Department of Radiation Oncology, University of Michigan, UH B2C490, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5010, USA.
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Cozzi L, Comito T, Loi M, Fogliata A, Franzese C, Franceschini D, Clerici E, Reggiori G, Tomatis S, Scorsetti M. The Potential Role of Intensity-Modulated Proton Therapy in Hepatic Carcinoma in Mitigating the Risk of Dose De-Escalation. Technol Cancer Res Treat 2020; 19:1533033820980412. [PMID: 33287650 PMCID: PMC7727039 DOI: 10.1177/1533033820980412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To investigate the role of intensity-modulated proton therapy (IMPT) for hepatocellular carcinoma (HCC) patients to be treated with stereotactic body radiation therapy (SBRT) in a risk-adapted dose prescription regimen. METHODS A cohort of 30 patients was retrospectively selected as "at-risk" of dose de-escalation due to the proximity of the target volumes to dose-limiting healthy structures. IMPT plans were compared to volumetric modulated arc therapy (VMAT) RapidArc (RA) plans. The maximum dose prescription foreseen was 75 Gy in 3 fractions. The dosimetric analysis was performed on several quantitative metrics on the target volumes and organs at risk to identify the relative improvement of IMPT over VMAT and to determine if IMPT could mitigate the need of dose reduction and quantify the consequent potential patient accrual rate for protons. RESULTS IMPT and VMAT plans resulted in equivalent target dose distributions: both could ensure the required coverage for CTV and PTV. Systematic and significant improvements were observed with IMPT for all organs at risk and metrics. An average gain of 9.0 ± 11.6, 8.5 ± 7.7, 5.9 ± 7.1, 4.2 ± 6.4, 8.9 ± 7.1, 6.7 ± 7.5 Gy was found in the near-to-maximum doses for the ribs, chest wall, heart, duodenum, stomach and bowel bag respectively. Twenty patients violated one or more binding constraints with RA, while only 2 with IMPT. For all these patients, some dose de-intensification would have been required to respect the constraints. For photons, the maximum allowed dose ranged from 15.0 to 20.63 Gy per fraction while for the 2 proton cases it would have been 18.75 or 20.63 Gy. CONCLUSION The results of this in-silico planning study suggests that IMPT might result in advantages compared to photon-based VMAT for HCC patients to be treated with ablative SBRT. In particular, the dosimetric characteristics of protons may avoid the need for dose de-escalation in a risk-adapted prescription regimen for those patients with lesions located in proximity of dose-limiting healthy structures. Depending on the selection thresholds, the number of patients eligible for treatment at the full dose can be significantly increased with protons.
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Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Tiziana Comito
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Mauro Loi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Ciro Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Elena Clerici
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Giacomo Reggiori
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, IRCSS, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
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Chui AMN, Yau TCC, Cheung TT. An overview in management of hepatocellular carcinoma in Hong Kong using the Hong Kong Liver Cancer (HKLC) staging system. Glob Health Med 2020; 2:312-318. [PMID: 33330826 DOI: 10.35772/ghm.2020.01062] [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] [Received: 07/10/2020] [Revised: 09/16/2020] [Accepted: 09/23/2020] [Indexed: 12/13/2022]
Abstract
In Hong Kong, liver cancer is the fifth most common cancer and the third most common cause of cancer deaths. The prevalence of hepatitis B is high in Hong Kong because of the high rate of hepatitis B virus infection, and chronic hepatitis B has remained the leading cause of hepatocellular carcinoma in the city, accounting for 80% of all cases in the period from 1992 to 2016. In view of the different etiologies of hepatocellular carcinoma around the world, a group of liver experts in Hong Kong developed the Hong Kong Liver Cancer staging system in order to provide more aggressive treatment guidance (predominantly a wider use of surgical resection) for Asian patients of hepatocellular carcinoma. In this article focussing on the Hong Kong Liver Cancer staging system, we briefly reviewed the screening criteria adopted in Hong Kong for liver resection, local ablation, transcatheter arterial chemoembolization, transcatheter arterial radioembolization, stereotactic body radiation therapy, and systemic therapy.
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Affiliation(s)
- Arnold Man Nok Chui
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | | | - Tan To Cheung
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.,Department of Surgery, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Thermal Ablation Versus Stereotactic Body Radiotherapy After Transarterial Chemoembolization for Inoperable Hepatocellular Carcinoma: A Propensity Score-Weighted Analysis. AJR Am J Roentgenol 2020; 217:691-698. [PMID: 32997517 DOI: 10.2214/ajr.20.24117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND. Transarterial chemoembolization (TACE) has synergistic properties when combined with ablative therapies for hepatocellular carcinoma (HCC). OBJECTIVE. The purpose of our study was to compare outcomes for inoperable HCC between TACE with percutaneous thermal ablation (TACE-TA) and TACE with stereotactic body radiotherapy (TACE-SBRT) using propensity score-weighted cohorts. METHODS. This retrospective study included 190 patients with a single inoperable HCC treated from 2007 to 2018 by either TACE-SBRT (n = 90) or TACE-TA (n = 100). The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS) and hepatotoxicity (defined as Child-Pugh score elevation of ≥ 2 within 2-6 months after treatment). Fine-Gray competing risk models with propensity score weighting and transplant as the competing risk factor were used to model OS and PFS. RESULTS. The median follow-up time was 48.2 months. Both OS and PFS were significantly higher for TACE-TA (77% and 76%, respectively, at 2 years) than TACE-SBRT (49% and 50%, respectively, at 2 years) in the propensity score-weighted multivariate model (OS: subdistribution hazard ratio [sHR] = 2.70, p < .001; PFS: sHR = 1.71, p = .02). Treatment-related hepatotoxicity occurred in 9% of patients who underwent TACE-TA versus 27% of those who underwent TACE-SBRT (p = .01). For the subset of patients with Barcelona Clinic Liver Cancer A HCC and Child-Pugh A cirrhosis (TACE-SBRT, n = 36 patients; TACE-TA, n = 55 patients), OS (p = .11) and PFS (p = .19) were not significantly different between the two treatment modalities. CONCLUSION. Compared with TACE-SBRT, TACE-TA showed superior OS and PFS, possibly from its lesser hepatotoxicity. The two strategies did not differ in OS and PFS for patients with the earliest-stage HCC and preserved liver function. CLINICAL IMPACT. Across all patients, TACE-TA may be superior to TACE-SBRT for inoperable HCC.
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Bennett S, Søreide K, Gholami S, Pessaux P, Teh C, Segelov E, Kennecke H, Prenen H, Myrehaug S, Callegaro D, Hallet J. Strategies for the delay of surgery in the management of resectable hepatobiliary malignancies during the COVID-19 pandemic. Curr Oncol 2020; 27:e501-e511. [PMID: 33173390 PMCID: PMC7606047 DOI: 10.3747/co.27.6785] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic. Background Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible. Methods An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma. Results Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed. Conclusions There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.
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Affiliation(s)
- S Bennett
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
| | - K Søreide
- Norway: Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, and Department of Clinical Medicine, University of Bergen, Bergen
| | - S Gholami
- United States: Division of Surgical Oncology, Department of Surgery, University of California, Davis, CA (Gholami); Virginia Mason Cancer Institute, Seattle, WA (Kennecke)
| | - P Pessaux
- France: Department of Surgery, Institut Hospitalo-Universitaire de Strasbourg, Strasbourg
| | - C Teh
- Philippines: Institute of Surgery, St. Luke's Medical Center, Quezon City; Department of Surgery, Makati Medical Center, Makati; and Department of General Surgery, National Kidney and Transplant Institute, Quezon City
| | - E Segelov
- Australia: Monash University and Monash Health, Melbourne
| | - H Kennecke
- United States: Division of Surgical Oncology, Department of Surgery, University of California, Davis, CA (Gholami); Virginia Mason Cancer Institute, Seattle, WA (Kennecke)
| | - H Prenen
- Belgium: Department of Oncology, University Hospital Antwerp, Antwerp
| | - S Myrehaug
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
| | - D Callegaro
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
- Italy: Department of Surgery, Fondazione irccs Istituto Nazionale Tumori, Milan
| | - J Hallet
- Canada: Department of Surgery, University of Toronto, Toronto, ON (Bennett, Callegaro, Hallet); Department of Radiation Oncology, University of Toronto, Toronto, ON (Myrehaug); Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON (Hallet)
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