Two-week schedule of hypofractionated radiotherapy as a local salvage treatment for small hepatocellular carcinoma

Stereotactic ablative radiotherapy for pulmonary oligometastases from primary hepatocellular carcinoma: a multicenter and retrospective analysis (KROG 17-08)

OBJECTIVE

Hypofractionated radiotherapy has recently been applied to treat pulmonary metastases of hepatocellular carcinoma. However, there is no definite evidence on its safety and efficacy. We evaluate the clinical outcomes of hypofractionated radiotherapy for oligo pulmonary metastases of hepatocellular carcinoma in the multicenter and retrospective study.

METHODS

From March 2011 to February 2018, 58 patients with fewer than five pulmonary metastases of hepatocellular carcinoma who underwent hypofractionated radiotherapy in nine tertiary university hospitals were analyzed retrospectively. The primary endpoint was the local control rate. The secondary endpoints were overall survival, progression-free survival, prognostic factors affecting the treatment outcomes and treatment-related side effects.

RESULTS

The local tumor response rate including complete and partial response was 77.6% at 3 months after hypofractionated radiotherapy. The median survival and progression-free survival times were 20.9 and 5.3 months, respectively. The 1-year overall survival and progression-free survival rates were 65.5 and 22.4%, respectively. The good treatment response after hypofractionated radiotherapy (P = 0.001), the absence of intrahepatic tumor (P = 0.004) and Child-Pugh class A (P = 0.010) were revealed as significant prognostic factors for overall survival in the multivariate analysis. A progression-free interval of <6 months (P = 0.009) was a negative prognostic factor for overall survival in the multivariate analysis. Of 58 patients, five (8.6%) had grade 2 or higher radiation pneumonitis after hypofractionated radiotherapy.

CONCLUSIONS

The favorable local control rate and acceptable toxicity indicate the clinical usefulness of hypofractionated radiotherapy for hepatocellular carcinoma patients who have less than five pulmonary metastases.

Stereotactic ablative radiotherapy for hepatocellular carcinoma: A systematic review and meta-analysis of local control, survival and toxicity outcomes

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.

Stereotactic body radiation therapy for early-stage hepatocellular carcinoma - a systematic review on outcome

Background: Hepatocellular carcinoma (HCC) incidence is rising worldwide, especially due to increased detection of early-stage or small-sized tumors. Nevertheless, most of the patients are still not qualified for surgical resection at diagnosis due to the localization of the tumor, underlying liver disease or comorbidities. Stereotactic body radiation therapy (SBRT) is a radiotherapy modality which can deliver a high dose of radiation to the target tissue with a high degree of precision. It shows promise in terms of efficacy and morbidity.Material and methods: The aim of this systematic review is to summarize current knowledge on patient-specific outcomes of SBRT for small HCC including overall survival, local control, the effect of dose escalation and the toxicity of the treatment. The systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After a comprehensive database search, 16 studies (973 patients with 1034 lesions) were included in qualitative and quantitative analyses; 14 of them were retrospective.Results: Average tumor diameter was 23 mm and 95% of patients were in good general condition. Median BED10 (biologically equivalent dose calculated for α/β ratio of 10 Gy) was 100 Gy (range 59.5-180 Gy). Mean weighted local control across studies was 94%, 92% and 93% at 1, 2, and 3 years, respectively. Mean weighted overall survival across studies was 90.9%, 67.5% and 73.4% at 1, 2, and 3 years, respectively. There were 171 grade 1-2 toxicities (17.5%) and 53 ≥ grade 3 toxicities (5.3%). There was no treatment-associated mortality.Conclusion: SBRT offers high local control with overall survival that is comparable with radiofrequency ablation and surgery. Quality of findings, especially on toxicities, is decreased by incomplete reporting and retrospective designs of published studies. Therefore, there is a need for better reporting and prospective studies to univocally recommend SBRT as a definitive treatment option in the guidelines for small HCCs.

Long-term outcomes of the 2-week schedule of hypofractionated radiotherapy for recurrent hepatocellular carcinoma

Background

The 2-week schedule of hypofractionated radiotherapy as a salvage treatment for hepatocellular carcinoma (HCC) has previously exhibited promising results; this study aimed to assess its long-term clinical outcomes in patients with recurrent HCC ineligible for curative treatments.

Methods

We retrospectively enrolled 77 patients (84 lesions) with HCC who were treated with hypofractionated radiotherapy between December 2008 and July 2013. Primary inclusion criteria were HCC unsuitable for curative treatments and HCC located within 2 cm of a critical normal organ. We administered 3.5–5 Gy/fraction for 2 weeks, resulting in a total dose of 35–50 Gy.

Results

The median follow-up period was 33.6 (range, 4.8–78.3) months. The 3- and 5-year overall survival rates were 52.3% and 40.9%, respectively, and local control rates were 79.5% and 72.6% in all treated lesions, respectively. The 5-year local control rate was better in the higher radiation dose group than in the lower radiation dose group (50 Gy: 79.7% vs. < 50 Gy: 66.1%); however, the difference was not statistically significant (P = 0.493). We observed grade ≥ 3 hepatic toxicity in 2 (2.6%) patients and grade 3 gastrointestinal bleeding in 1 (1.3%) patient. However, grade ≥ 4 toxicity was not observed after hypofractionated radiotherapy.

Conclusions

The 2-week schedule of hypofractionated radiotherapy for recurrent HCC exhibited good local control and acceptable treatment-related toxicity during the long-term follow-up period. Thus, this fractionation schedule can be a potential salvage treatment option for recurrent HCC, particularly for tumors located close to a radiosensitive gastrointestinal organ.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4953-x) contains supplementary material, which is available to authorized users.

Proton therapy for hepatocellular carcinoma: Current knowledges and future perspectives

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death, as few patients can be treated with currently available curative local modalities. In patients with HCC where curative modalities are not feasible, radiation therapy (RT) has emerged as an alternative or combination therapy. With the development of various technologies, RT has been increasingly used for the management of HCC. Among these advances, proton beam therapy (PBT) has several unique physical properties that give it a finite range in a distal direction, and thus no exit dose along the beam path. Therefore, PBT has dosimetric advantages compared with X-ray therapy for the treatment of HCC. Indeed, various reports in the literature have described the favorable clinical outcomes and improved safety of PBT for HCC patients compared with X-ray therapy. However, there are some technical issues regarding the use of PBT in HCC, including uncertainty of organ motion and inaccuracy during calculation of tissue density and beam range, all of which may reduce the robustness of a PBT treatment plan. In this review, we discuss the physical properties, current clinical data, technical issues, and future perspectives on PBT for the treatment of HCC.

Consensus on Stereotactic Body Radiation Therapy for Small-Sized Hepatocellular Carcinoma at the 7th Asia-Pacific Primary Liver Cancer Expert Meeting

BACKGROUND

Stereotactic body radiation therapy (SBRT) is an advanced technique of external beam radiation therapy that delivers large ablative doses of radiation. In the past decade, many cancer centers have adopted SBRT as one mode of radically treating small-sized hepatocellular carcinoma (HCC), based on encouraging clinical outcomes. SBRT thus seems reasonable as first-line treatment of inoperable HCC confined to the liver. However, most of the clinical studies to date have been retrospective in nature, with key issues still under investigation.

SUMMARY

The above-mentioned publications were subjected to scrutiny, fueling discussions at the 7th Asia-Pacific Primary Liver Cancer Expert (APPLE 2016) Meeting on various clinical variables, such as indications for SBRT, therapeutic outcomes, treatment-related toxicities, doses prescribed, and specific techniques. The consensus reached should be of interest to all professionals active in the treatment of HCC, especially radiation oncologists.

KEY MESSAGES

SBRT is a safe and effective therapeutic option for patients with small-sized HCC, offering substantial local control, improved overall survival, and low toxicity.

Prognostic value of tumor volume and radiation dose in moderate-sized hepatocellular carcinoma: A multicenter analysis in Korea (KROG 14-17)

The purpose of this study is to investigate the prognostic value of tumor volume and radiation dose for predicting treatment outcomes in moderate-sized hepatocellular carcinoma (HCC).A total of 72 patients with unresectable HCC ranging in size from 5 to 10 cm were treated with high-dose radiotherapy including hypofractionated radiotherapy (HRT) and stereotactic body radiotherapy (SBRT), in 3 institutions from 2003 to 2013. The HRT doses ranged from 33 to 60 Gy in 3 to 10 fractions. The primary endpoint was local progression-free survival (PFS); the secondary endpoints were overall PFS, overall survival (OS), and treatment toxicity.The median follow-up period after radiotherapy was 12.8 months. The local PFS rates at 1 and 2 years were 57.0% and 39.0%, respectively, with a median of 13.6 months. The OS rates at 1 and 2 years were 70.1% and 45.2%, respectively, with a median of 21.1 months. A gross tumor volume (GTV) of 214 cm and a total dose of 105 Gy10 were identified as the optimal cutoff values of radiotherapeutic factors for local PFS. Patients with GTV ≤ 214 cm and total dose >105 Gy10 had significant higher 2-year local PFS and OS than patients with GTV >214 cm and total dose ≤ 105 Gy10 (P = .020 for local PFS, P = .009 for OS).The optimal cutoff values of GTV ≤ 214 cm and total dose >105 Gy10 may be useful for predicting survival outcomes when treating moderate-sized HCC with high-dose radiotherapy.

Strategies to tackle the challenges of external beam radiotherapy for liver tumors

Primary and metastatic liver cancer is an increasingly common and difficult to control disease entity. Radiation offers a non-invasive treatment alternative for these patients who often have few options and a poor prognosis. However, the anatomy and aggressiveness of liver cancer poses significant challenges such as accurate localization at simulation and treatment, management of motion and appropriate selection of dose regimen. This article aims to review the options available and provide information for the practical implementation and/or improvement of liver cancer radiation programs within the context of stereotactic body radiotherapy and image-guided radiotherapy guidelines. Specific patient inclusion and exclusion criteria are presented given the significant toxicity found in certain sub-populations treated with radiation. Indeed, certain sub-populations, such as those with tumor thrombosis or those with larger lesions treated with transarterial chemoembolization, have been shown to have significant improvements in outcome with the addition of radiation and merit special consideration. Implementing a liver radiation program requires three primary challenges to be addressed: (1) immobilization and motion management; (2) localization; and (3) dose regimen and constraint selection. Strategies to deal with motion include simple internal target volume (ITV) expansions, non-gated ITV reduction strategies, breath hold methods, and surrogate marker methods to enable gating or tracking. Localization of the tumor and organs-at-risk are addressed using contrast infusion techniques to take advantage of different normal liver and cancer vascular anatomy, imaging modalities, and margin management. Finally, a dose response has been demonstrated and dose regimens appear to be converging. A more uniform approach to treatment in terms of technique, dose selection and patient selection will allow us to study liver radiation in larger and, hopefully, multicenter randomized studies.

Risk-adapted simultaneous integrated boost-proton beam therapy (SIB-PBT) for advanced hepatocellular carcinoma with tumour vascular thrombosis

PURPOSE

To evaluate clinical effectiveness and safety of simultaneous integrated boost-proton beam therapy (SIB-PBT) in hepatocellular carcinoma (HCC) patients with tumour vascular thrombosis (TVT).

MATERIAL AND METHODS

Forty-one HCC patients with TVT underwent SIB-PBT using three dose-fractionation schemes: if gross tumour volume <1cm (n=27), 1-1.9cm (n=7), and ⩾2cm (n=7) from gastrointestinal structures, 50GyE (EQD2, 62.5GyE₁₀), 60Gy (EQD2, 80GyE₁₀), 66Gy (EQD2, 91.3GyE₁₀), respectively, in 10 fractions was prescribed to planning target volume 1 (PTV1), and 30GyE (EQD2, 32.5GyE₁₀) in 10 fractions was prescribed to PTV2.

RESULTS

Overall, treatment was well tolerated, with no grade toxicity ⩾3. Median overall survival (OS) was 34.4months and 2-year local progression-free survival (LPFS), relapse free survival (RFS), and OS rates were 88.1%, 25%, and 51.1%, respectively. Patients treated with EQD2 of ⩾80GyE₁₀ tended to show better TVT response (92.8% vs. 55.5%, p=0.002) 2-year LPFS (92.9% vs. 82.5%, p=0.463), RFS (28.8% vs. 19%, p=0.545), and OS (58.4% vs. 46.8%, p=0.428) rates than those with EQD2 of <80GyE₁₀. Multivariate analysis showed that TVT response and Child Pugh classification were independent prognostic factors for OS.

CONCLUSIONS

SIB-PBT is feasible and promising for HCC patients with TVT.

Stereotactic body radiation therapy for primary and metastatic liver tumors: From technological evolution to improved patient care

Technical developments allowed stereotactic body radiation therapy (SBRT) to deliver effective doses of irradiation with high precision in a small number of fractions. This paper reviews the role of SBRT for liver metastases, hepatocellular carcinoma and cholangiocarcinoma, paying special attention to patient eligibility and treatment outcomes regarding local control, toxicity and quality of life. As well as discussing specific issues of these different tumors, such as the presence of underlying liver cirrhosis and the impact on toxicity, it outlines the limitations of SBRT and future areas of development and research.

Treatment outcome of hepatic re-irradiation in patients with hepatocellular carcinoma

PURPOSE

We evaluated the efficacy and toxicity of repeated high dose 3-dimensional conformal radiation therapy (3D-CRT) for patients with unresectable hepatocellular carcinoma.

MATERIALS AND METHODS

Between 1998 and 2011, 45 patients received hepatic re-irradiation with high dose 3D-CRT in Samsung Medical Center. After excluding two ineligible patients, 43 patients were retrospectively reviewed. RT was delivered with palliative or salvage intent, and equivalent dose of 2 Gy fractions for α/β = 10 Gy ranged from 31.25 Gy10 to 93.75 Gy10 (median, 44 Gy10). Tumor response and toxicity were evaluated based on the modified Response Evaluation Criteria in Solid Tumors criteria and the Common Terminology Criteria for Adverse Events (CTCAE) ver. 4.0.

RESULTS

The median follow-up duration was 11.2 months (range, 4.1 to 58.3 months). An objective tumor response rate was 62.8%. The tumor response rates were 81.0% and 45.5% in patients receiving ≥45 Gy10 and <45 Gy10, respectively (p = 0.016). The median overall survival (OS) of all patients was 11.2 months. The OS was significantly affected by the Child-Pugh class as 14.2 months vs. 6.1 months (Child-Pugh A vs. B, p < 0.001), and modified Union for International Cancer Control (UICC) T stage as 15.6 months vs. 8.3 months (T1-3 vs. T4, p = 0.004), respectively. Grade III toxicities were developed in two patients, both of whom received ≥50 Gy10.

CONCLUSION

Hepatic re-irradiation may be an effective and tolerable treatment for patients who are not eligible for further local treatment modalities, especially in patients with Child-Pugh A and T1-3.

Stereotactic body radiotherapy: an effective local treatment modality for hepatocellular carcinoma

Although liver-directed therapies such as surgery or ablation can cure hepatocellular carcinoma, few patients are eligible due to advanced disease or medical comorbidities. In advanced disease, systemic therapies have yielded only incremental survival benefits. Historically, radiotherapy for liver cancer was dismissed due to concerns over unacceptable toxicities from even moderate doses. Although implementation requires more resources than standard radiotherapy, stereotactic body radiotherapy can deliver reproducible, highly conformal ablative radiotherapy to tumors while minimizing doses to nearby critical structures. Trials of stereotactic body radiotherapy for hepatocellular carcinoma have demonstrated promising local control and survival results with low levels of toxicity in Child-Pugh class A patients. We review the published literature and make recommendations for the future of this emerging modality.

The challenge of inoperable hepatocellular carcinoma (HCC): results of a single-institutional experience on stereotactic body radiation therapy (SBRT)

OBJECTIVES

To evaluate the feasibility and efficacy of stereotactic body radiation therapy (SBRT) in the treatment of hepatocellular carcinoma (HCC) unsuitable for standard loco-regional therapies.

MATERIALS AND METHODS

Patients with 1-3 inoperable HCC lesions with diameter ≤6 cm were treated by SBRT. According to lesions size and liver function, two prescription regimens were adopted: 48-75 Gy in three fractions or 36-60 Gy in six fractions. SBRT was delivered using the volumetric modulated arc therapy technique with flattening filter-free photon beams. The primary end points of this study were in-field local control (LC) and toxicity. Secondary end points were overall survival (OS) and progression-free survival (PFS).

RESULTS

Forty-three patients with 63 HCC lesions were irradiated. All patients had Child-Turcotte-Pugh class A or B disease. Thirty lesions (48%) were treated with 48-75 Gy in three consecutive fractions, and 33 (52%) received 36-60 Gy in six fractions. Median follow-up was 8 months (range 3-43 months). Actuarial LC at 6, 12 and 24 months was 94.2 ± 3.3, 85.8 ± 5.5 and 64.4 ± 11.5%, respectively. A biological equivalent dose (BED) >100 Gy and GTV size were significant prognostic factors for LC in univariate analysis (p < 0.001 and p < 0.02). Median OS was 18.0 ± 5.8 months. Actuarial OS at 6, 12 and 24 months was 91.1 ± 4.9, 77.9 ± 8.2 and 45.3 ± 14.0%, respectively. Univariate analysis showed that OS is correlated with LC (p < 0.04), BED >100 (p < 0.05) and cumulative gross tumor volume GTV <5 cm (p < 0.04). Median PFS was 8 months, with a 1-year PFS rate of 41%. A significant (≥ grade 3) toxicity was observed in seven patients (16%) 2-6 months after the completion of the treatment. No classic radiation-induced liver disease was observed.

CONCLUSION

Stereotactic body radiation therapy is a safe and effective therapeutic option for HCC lesions unsuitable to standard loco-regional therapies, with acceptable local control rates and low treatment-related toxicity. The significant correlation between LC and higher doses and between LC and OS supports the clinical value of SBRT in these patients.

The comparison of outcomes between hypofractionated and conventional 3D-CRT regimens used in combination with TACE as first-line treatment of advanced hepatocellular carcinoma

Treatment of primary hepatocellular carcinoma (HCC) with transcatheter hepatic arterial chemoembolization (TACE) and three-dimensional conformal radiotherapy (3D-CRT) achieves good short-term but poor long-term survival. We retrospectively assessed whether outcomes differ between hypofractionated and conventional 3D-CRT regimens. Patients were treated in our institution between June 2005 and October 2009. All patients received two cycles of TACE followed by either hypofractionated 3D-CRT (6-8 Gy fractions for 3-4 weeks to 48-64 Gy) or conventional 3D-CRT (2 Gy fractions for 6-7 weeks to 60-70 Gy) 4 weeks later. We assessed data from 110 patients (55 in each 3D-CRT group). Overall response rates were similar in the two groups. Acute adverse event rates were not significantly higher in the hypofractionated 3D-CRT group than in the conventional 3D-CRT group; two patients and one patient, respectively, died of late radiation-induced liver failure. Overall survival at 1 year was 83.6 % in the hypofractionated 3D-CRT group versus 68.8 % in the conventional 3D-CRT group (P = 0.019), and at 3 years, it was 31.7 versus 13.9 % (P = 0.004). Median survival was 27.97 versus 16.13 months (P = 0.002). Hypofractionated 3D-CRT seemed to provide better overall survival than conventional 3D-CRT regimens combined with TACE as a first-line treatment for advanced HCC.

Nonsurgical multidisciplinary approach for recurrent hepatocellular carcinoma after surgical resection

Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative resection and local ablation, and this represents a major challenge for HCC treatment. Although several treatment guidelines have been reported, they detail initial treatment choices and there are no established guidelines for recurrent HCC. The current treatment options for recurrent HCC do not differ from the primary treatments, but the unique characteristics of HCC recurrence should be considered when choosing treatments and each treatment should be individualized to different clinical situations. Furthermore, combinations of various treatments have been recently attempted. This review summarizes the current evidence for nonsurgical treatments of recurrent HCC after resection and suggests a multidisciplinary approach to improving the prognosis of recurrent HCC.

A sorafenib derivative and novel SHP-1 agonist, SC-59, acts synergistically with radiotherapy in hepatocellular carcinoma cells through inhibition of STAT3

Radiotherapy shows limited benefit as treatment for hepatocellular carcinoma (HCC). In this study, we aimed to overcome the radioresistance of HCC by using a novel sorafenib derivative, SC-59 that targets SHP-1-related signaling. HCC cell lines (SK-Hep1, Hep3B, and Huh7) were treated with sorafenib, SC-59, radiation, sorafenib plus radiation, or SC-59 plus radiation, and then apoptosis, colony formation, signal transduction and the phosphatase activity were analyzed. The synergistic effect of radiotherapy and SC-59 was analyzed using a combination index (CI) approach. In vivo efficacy was determined in a Huh7-bearing subcutaneous model. Mice were treated with radiation (5 Gy, one fraction per day) for 4 days, SC-59 (10mg/kg/day) for 24 days, or a combination. Tumor samples were further analyzed for p-STAT3 and SHP-1 activity. SC-59 displayed a better synergistic effect when used in combination with radiotherapy than sorafenib in HCC cell lines. SC-59 downregulated p-STAT3 and its downstream targets and increased SHP-1 phosphatase activity. Both ectopic STAT3 and inhibition of SHP-1 abolished SC-59-induced radiosensitization. Moreover, SC-59 significantly synergized radiotherapy in a Huh7 xenograft model by targeting SHP-1/STAT3 signaling. The novel sorafenib derivative, SC-59, acting as a SHP-1 agonist, displays a better synergistic effect when used in combination with radiotherapy than sorafenib for the treatment of HCC. Further clinical investigation is warranted.