External beam radiotherapy for unresectable hepatocellular carcinoma, an international multicenter phase I trial, SAKK 77/07 and SASL 26

CyberKnife Stereotactic Body Radiation Therapy as an Effective Treatment for Hepatocellular Carcinoma Patients With Decompensated Cirrhosis

Purpose: The aim of our study was to evaluate the curative effect and safety of CyberKnife stereotactic body radiation therapy in treating decompensated cirrhosis hepatocellular carcinoma (HCC) patients.

Methods: From March 2011 to December 2015, 32 HCC patients who refused or were ineligible for other treatments were treated with CyberKnife stereotactic body radiation therapy. Among these patients, 17 were Child-Pugh score 7 (53.13%), 7 were Child-Pugh score 8 (21.87%), 4 were Child-Pugh score 9 (12.50%), and 4 were Child-Pugh score 10 (12.50%). A total dose of 45–54 Gy in 5–10 fractions was given according to the location of lesions.

Results: The median follow-up period was 30 months (8–46 months). By July 2019, the tumors were recurrent or metastasized in 17 patients. The overall survival rates of 1, 2, and 3 years were 84.4, 61.8, and 46.0%, respectively. After 1, 2, and 3 years, the local control rates were 92.9%. The progression-free survival rates of the 1, 2, and 3-year treatments were 73.8, 44.6, and 33.4%, respectively.

Conclusions: CyberKnife stereotactic body radiation therapy was an effective option for HCC patients with decompensated cirrhosis. The liver injury occurrence rate was acceptable in our study.

Adjuvant radiotherapy in central hepatocellular carcinoma after narrow-margin hepatectomy: A 10-year real-world evidence

Objective

A prospective randomized control study investigated the feasibility and efficacy of adjuvant radiotherapy on patients with central hepatocellular carcinoma (HCC) after narrow-margin hepatectomy (<1 cm). This study presents an updated 10-year real-world evidence to further characterize the role of adjuvant radiotherapy.

Methods

Patients with central HCC after narrow-margin hepatectomy (<1 cm) were prospectively assigned to adjuvant radiotherapy group and control group. Patients' outcome, adverse events, long-term recurrence and survival rates were investigated.

Results

The 1-, 5-, and 10-year recurrence-free survival (RFS) rates were 81.0%, 43.9%, and 38.7%, respectively in adjuvant radiotherapy group and 71.7%, 35.8%, and 24.2%, respectively in control group (log-rank test, P=0.09). The 1-, 5-, and 10-year overall survival (OS) rates were 96.6%, 54.7%, and 42.8%, respectively in adjuvant radiotherapy group and 90.2%, 55.1%, and 30.0%, respectively in control group (log-rank test, P=0.20). The 1-, 5-, and 10-year RFS rates for patients with small HCC (≤5 cm) were 91.1%, 51.6%, and 48.4%, respectively in adjuvant radiotherapy group and 80.0%, 36.6%, and 26.6%, respectively in control group (log-rank test, P=0.03). Landmark analysis demonstrated that patients with small HCC in adjuvant radiotherapy group had a significantly improved OS in second five years after treatment in comparison to patients in control group (log-rank test, P=0.05).

Conclusions

Our updated results showed a sustained clinical benefit on reducing recurrence, improving long-term survival for small central HCC by adjuvant radiotherapy after narrow-margin hepatectomy. Long-term survival data also indicated that hepatectomy is an optimal treatment for selected patients with central HCC.

Impact of Proton Beam Irradiation of an Anatomic Subsegment of the Liver for Hepatocellular Carcinoma

PURPOSE

The objective of this research was to elucidate the impact on the prognosis, including the survival prognosis, resulting from proton beam irradiation of an anatomic subsegment of the liver (ASPT) for the treatment of hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

A total of 110 patients who received a diagnosis of HCC were analyzed in this retrospective study. Definitive proton beam therapy was delivered at a dose of 76 Gy (relative biological effectiveness) in 20 fractions between January 2008 and December 2015. When the HCC widely abutted blood vessels or when multiple HCC tumors occurred within the same liver subsegment, the clinical target volume was outlined as an anatomic subsegment of the liver, according to the portal territory, containing the tumor. In the remaining cases, the clinical target volume was delineated by adding a 5-mm margin around the gross tumor volume. The overall survival (OS), progression-free survival (PFS), and local control rates and adverse events were assessed. A review of the medical charts assessed adverse events that occurred during and after the treatment and were classified according to the Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

The median follow-up duration was 36.5 months (range, 1-90.6 months). The median age of the patients was 73 years (range, 48-90 years). ASPT was performed in 31 patients (28%). Three-year OS, PFS, and local control rates were 74.2%, 40.4%, and 91.7%, respectively. Multivariate analysis identified ASPT as a factor that significantly improved PFS (P = .049) but not OS (P = .79). No association was found between ASPT and the frequency of grade ≥3 acute/late adverse events.

CONCLUSIONS

ASPT was associated with a reduction in the rate of tumor progression and no significant toxicity but was not associated with OS.

A nomogram to predict prognosis of patients with unresected hepatocellular carcinoma undergoing radiotherapy: a population-based study

Background: Radiotherapy is a primary treatment strategy for patients with unresectable hepatocellular carcinoma (HCC); however, the prognostic factors among HCC patients who have received radiotherapy but not undergone surgery have not been systematically studied. Thus, the prognostic factors were investigated in this study based on the Surveillance, Epidemiology, and End Results (SEER) Medicare database.

Methods: A screening process was used for select cases from the SEER database. Survival was analyzed using the Kaplan-Meier method and log-rank test, the Cox proportional hazards regression model, and a competing risk model. A nomogram was established for predicting 1- and 3-year overall survival (OS) of patients.

Results: A total of 1305 HCC patients who received radiotherapy but had not undergone surgery were included in this study and divided into training (n = 1175) and validation cohorts (n = 130). Patients in the training cohort had a 1-year OS rate of 30.9±1.3%, a 3-year OS rate of 10.0±1.0%, and a median survival rate of 6.0 months (range, 5.4-6.6 months). Race (p = 0.025), T stage (p < 0.001), N stage (p < 0.001), M stage (p < 0.001), and chemotherapy (p < 0.001) were identified as independent risk factors by multivariate analyses in the training cohort, while sex, age, grade, marital status, and insurance status were not independent factors. Survival in patients who received radiotherapy was worse with respect to the following characteristics: black race; higher T, N, or M stage; and no chemotherapy. A nomogram was established based on the results of the multivariate analysis, which was internally validated by a concordance index (C-index) of 0.731±0.016 and a group of calibration plots. External validation was carried out and the C-index was 0.738±0.049, which demonstrated the effectiveness of the nomogram we constructed.

Conclusions: Race, T stage, N stage, M stage, and chemotherapy were independent risk factors for survival of HCC patients who received radiotherapy but had not undergone surgery. A validated nomogram was formulated to predict 1- and 3-year OS in these patients based on individual clinical characteristics.

Evaluation of the tumor movement and the reproducibility of two different immobilization setups for image-guided stereotactic body radiotherapy of liver tumors

Background

The purpose of this study is to evaluate the tumor movement and accuracy of patient immobilization in stereotactic body radiotherapy of liver tumors with low pressure foil or abdominal compression.

Methods

Fifty-four liver tumors treated with stereotactic body radiotherapy were included in this study. Forty patients were immobilized by a vacuum couch with low pressure foil, 14 patients by abdominal compression. We evaluated the ratio of gross tumor volume/internal target volume, the tumor movement in 4D-computed tomography scans and daily online adjustments after cone beam computed tomography scans.

Results

The ratio of gross tumor volume/internal target volume was smaller with low pressure foil. The tumor movement in 4D-computed tomography scans was smaller with abdominal compression, the cranial movement even significantly different (p = 0.02). The mean online adjustments and their mean absolute values in the vertical, lateral and longitudinal axis were smaller with abdominal compression. The online adjustments were significantly different (p < 0.013), their absolute values in case of the longitudinal axis (p = 0.043). There was no significant difference of the adjustments’ 3D vectors.

Conclusions

In comparison to low pressure foil, abdominal compression leads to a reduction of the tumor movement. Online adjustments decreased significantly, thus leading to higher accuracy in patient positioning.