Evaluation of combined therapy with chemoembolization and irradiation for large hepatocellular carcinoma

Impact of iodinated oil in proton therapy on relative stopping power of liver post-cTACE

Objective. Conventional transarterial chemoembolization (cTACE) is a common treatment for hepatocellular carcinoma (HCC), often with unsatisfactory local controls. Combining cTACE with radiotherapy shows a promise for unresectable large HCC, with proton therapy preserving healthy liver tissue. However, the proton therapy benefits are subject to the accuracy of tissue relative stopping power (RSP) prediction. The RSP values are typically derived from computed tomography (CT) images using stoichiometric calibration. Lipiodol deposition significantly increases CT numbers in liver regions of post-cTACE. Hence, it is necessary to evaluate the accuracy of RSP in liver regions of post-cTACE.Approach. Liver, water, and iodinated oil samples were prepared. Some liver samples contained iodinated oil. The water equivalent path length (WEPL) of sample was measured through the pullbacks of spread-out Bragg peak (SOBP) depth-dose profiles scanned in a water tank with and without sample in the beam path. Measured RSP values were compared to estimated RSP values derived from the CT number based on the stoichiometric calibration method.Main results. The measured RSP of water was 0.991, confirming measurement system calibration. After removing the RSP contribution from container walls, the pure iodinated oil and liver samples had RSP values of 1.12 and 1.06, while the liver samples mixed with varying oil volumes (5 ml, 10 ml, 15 ml) showed RSP values of 1.05, 1.05 and 1.06. Using the stoichiometric calibration method, pure iodinated oil and liver samples had RSP values of 2.79 and 1.06. Liver samples mixed with iodinated oil (5 ml, 10 ml, 15 ml) had calculated RSP values of 1.21, 1.34, and 1.46. The RSP discrepancy reached 149.1% for pure iodinated oil.Significance.Iodinated oil notably raises CT numbers in liver tissue. However, there is almost no effect on its RSP value. Proton treatment of post-cTACE HCC patients can therefore be overshooting if no proper measures are taken against this specific effect.

Efficacy and safety of external-beam radiation therapy for hepatocellular carcinoma: An overview of current evidence according to the different target population

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. During the recent years, external-beam radiation therapy (EBRT) has been safely and effectively employed for the management of HCC. We overviewed the current evidence regarding the efficacy and safety of EBRT for HCC according to the different target population. PubMed database was searched for identifying English-language full-text articles regarding EBRT for the treatment of HCC. Search items were "hepatocellular carcinoma AND radiation therapy". Until now, preliminary evidence has suggested the following role of EBRT for HCC. 1) EBRT, especially stereotactic body radiation therapy, is an emerging choice of therapy for small HCC. 2) EBRT combined with non-surgical treatment can achieve an excellent intrahepatic tumor control and a potential survival benefit for huge HCC. 3)Adjunctive EBRT may improve the efficacy of transarterial chemoembolization for HCC with portal vein tumor thrombosis. 4) EBRT can relieve the pain and improve the quality of life for patients with extrahepatic metastases. 5) EBRT may be a bridge to liver transplantation by minimizing the tumor progression. 6) Adjunctive EBRT may reduce the tumor recurrence and improve the survival after resection. In summary, EBRT is a promising choice of treatment of HCC. However, more high-quality evidence is needed to further establish the status of EBRT for the management of HCC.

Strategic application of radiotherapy for hepatocellular carcinoma

With increasing clinical use, radiotherapy (RT) has been considered reliable and effective method for hepatocellular carcinoma (HCC) treatment, depending on extent of disease and patient characteristics. RT for HCC can improve therapeutic outcomes through excellent local control, downstaging, conversion from unresectable to resectable status, and treatments of unresectable HCCs with vessel invasion or multiple intrahepatic metastases. In addition, further development of modern RT technologies, including image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy, has expanded the indication of RT. An essential feature of IGRT is that it allows image guidance therapy through in-room images obtained during radiation delivery. Compared with 3D-conformal RT, distinctions of IMRT are inverse treatment planning process and use of a large number of treatment fields or subfields, which provide high precision and exquisitely conformal dose distribution. These modern RT techniques allow more precise treatment by reducing inter- and intra-fractional errors resulting from daily changes and irradiated dose at surrounding normal tissues. More recently, particle therapy has been actively investigated to improve effectiveness of RT. This review discusses modern RT strategies for HCC, as well as optimal selection of RT in multimodal approach for HCC.

Particle Radiation Therapy for Gastrointestinal Cancers

Particle irradiation of cancerous disease has gained great traction in recent years. The ability for particle therapy centers to deliver radiation with a highly conformal dose distribution while maintaining minimal exit or excess dose delivered to normal tissue, coupled with various biological advantages particularly found with heavy-ion beams, enables treatment of diseases inapproachable with conventional radiotherapy. Here, we present a review of the current status of particle therapy with regard to cancers of the gastrointestinal tract, including esophagus, liver, pancreas, and recurrent rectal cancer.

Optimal Selection of Radiotherapy as Part of a Multimodal Approach for Hepatocellular Carcinoma

A multimodal approach to treatment is a basic oncologic principle with proven survival benefits for most cancer types. However, existing guidelines recommend single modalities for treating each stage of hepatocellular carcinoma (HCC). Nonetheless, multimodal approaches can be considered for HCC, depending on the characteristics of the disease in individual cases. Radiotherapy (RT), an effective local modality, is a critical element of most multimodal approaches. Improved RTtechnology and increased understanding of the tolerance of the liver to radiation have contributed to the popularity of RT for treating liver tumors in clinical practice. Consequently, numerous reports have described the effects of RT on liver cancer, despite a lack of stringent evidence for its benefits. RT can be delivered using various technologies and approaches, which may be the source of some confusion. For example, high-dose ablative RT can be curative on its own, or high-dose ablative or conventional RT can complement other treatments such as radiofrequency ablation and transarterial chemoembolization. Combinations of systemic agents and RT can also be applied. This review discusses the optimal selection of RT as part of a multimodal approach for HCC.

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.

Multimodality treatment with radiotherapy for huge hepatocellular carcinoma

BACKGROUND

For huge hepatocellular carcinoma (HCC), therapeutic decisions have varied from local therapy to systemic therapy, with radiotherapy (RT) playing only a palliative role. In this study, we investigated whether multimodality treatment involving RT could be effective in huge HCC.

RESULTS

This study was performed in 116 patients with HCC >10 cm. The number of patients in stage II, III and IV was 12, 54 and 50, respectively. RT was given as a combined modality in most patients. The median dose was 45 Gy, with 1.8 Gy per fraction. The median overall survival (OS) and progression-free survival (PFS) were 14.8 and 6.5 months, respectively. The median infield PFS was not reached. Infield failure, outfield intrahepatic and extrahepatic failure were observed in 8.6, 18.1, and 12.1% of patients, respectively. For OS and PFS, number of tumors, initial alpha-fetoprotein (AFP) level, treatment response, percent AFP decrement, and hepatic resection were significant prognostic factors. Tumor characteristics and treatment response were significantly different between long-term survivors and the other patients.

CONCLUSION

Although huge HCC presents an aggressive clinical course, multimodality approaches involving RT can offer an opportunity for prolonged survival.

Treatment outcomes of helical intensity-modulated radiotherapy for unresectable hepatocellular carcinoma

Background/Aims

This study reports treatment outcomes after helical intensity-modulated radiotherapy (IMRT) in unresectable hepatocellular carcinoma (HCC) patients for whom transarterial chemoembolization (TACE) was considered ineffective or unsuitable.

Methods

From January 2008 to December 2011, 22 unresectable HCC patients received helical IMRT. A daily dose of 1.8 to 4 Gy was delivered at five fractions per week to deliver a total dose of 30 to 60 Gy. The most-prescribed dose fractionation was a total dose of 50 to 57.5 Gy, with a daily dose of 2.3 to 2.5 Gy.

Results

In the entire group, the objective response rate of the primary tumor was 72.7%. In the eight patients with portal vein thrombosis (PVT), the objective response rate of PVT was 50.0%. Median disease progression-free survival was 11.8 months, and the 1-year disease progression-free survival rate was 40.2%. The median overall survival was 14.4 months, and the 1- and 2-year overall survival rates were 86.4% and 69.1%, respectively. PVT and Child-Pugh classifications were significant prognostic factors for overall survival in multivariate analyses.

Conclusions

Helical IMRT in patients with unresectable HCC resulted in high treatment response and survival rates. This study suggests helical IMRT is a practical treatment option for HCC patients in whom TACE is unsuitable or ineffective.

Multidisciplinary management of hepatocellular carcinoma

Treatment of HCC is complicated by its highly variable biologic behavior and the frequent coexistence of chronic liver disease and cirrhosis in affected patients. While surgery remains the most frequently employed treatment modality, curative resection is only possible for a minority of patients. More often, treatment goals are palliative and draw on the expertise of a range of medical specialists. This chapter aims to place current treatment strategies within the framework of a multidisciplinary approach with special emphasis on pretreatment evaluation, staging, and the selection of an appropriate treatment strategy.

The optimal selection of radiotherapy treatment for hepatocellular carcinoma

The majority of patients who present with hepatocellular carcinoma (HCC) are already at an advanced stage, and the tumors are unresectable. Radiotherapy (RT) technology can safely provide focused high-dose irradiation to these patients. A wide spectrum of RT technologiesis currently available, including internal RT consisting of Yttrium-90 ((90)Y), Iodine-131 ((131)I) anti-ferritin antibody and Homium-199 ((199)Ho) and external RT, such as three-dimensional conformal RT, intensity-modulated RT, helical tomotherapy, stereotactic body RT, and image-guided RT. However, it may be difficult for physicians to understand all of the available options and to select the optimal RT treatment. Physicians frequently query radiation oncologists on the practical indications of RT for managing patients with HCC. According to the Korean Liver Cancer Study Group practice guidelines, RT is considered appropriate for unresectable, locally advanced HCC without extrahepatic metastasis, a Child-Pugh class A or B, and tumors that occupy less than two-thirds of the liver with level II evidence. In this review, we discuss the application of various RT modalities based on disease status and the detailed indications for RT according to the Barcelona Clinic Liver Cancer staging system.

Radiotherapeutic strategies in the management of hepatocellular carcinoma

Although potentially curative therapies for hepatocellular carcinoma (HCC) are well established, they are offered only to a limited number of patients. For advanced HCC, sorafenib is now the treatment of choice. Radiotherapy technology has evolved remarkably during the past decade and can be precisely delivered, thereby permitting higher doses to the tumor and reduced doses to surrounding normal tissues. According to the Korean Liver Cancer Study Group (KLCSG) practice guidelines, radiation therapy is considered appropriate for unresectable, locally advanced HCC without extrahepatic metastasis, Child-Pugh class A or B, and tumors occupying less than two thirds of the liver with level II evidence. In this review, we discuss the radiotherapeutic strategies for each clinical setting in patients with HCC.

Usefulness of positron emission tomography with fluorine-18-fluorodeoxyglucose in predicting treatment response in unresectable hepatocellular carcinoma patients treated with external beam radiotherapy

PURPOSE

To assess the significance of the ratio between standardized uptake values (SUV) of tumor and normal liver tissue obtained from positron emission tomography with fluorine-18-fluorodeoxyglucose (FDG-PET) in predicting the response of hepatocellular carcinoma (HCC) patients treated with external beam radiotherapy (EBRT).

METHODS AND MATERIALS

We retrospectively analyzed 35 HCC patients who were treated with EBRT between January 2004 and June 2007. All patients underwent FDG-PET in which SUV values were obtained from tumor and normal liver tissues and were used to calculate the ratios (SUV(Tumor)/SUV(Liver)). After FDG-PET, patients received liver treatment including concurrent chemoradiation, transarterial chemoembolization plus RT, or intraarterial chemotherapy plus RT. Using three-dimensional conformal RT, median dose of 45 Gy was delivered in conventional fractions. Patients underwent abdominal/pelvic CT 1 month after RT, and treatment responses were evaluated according to the Response Evaluation Criteria in Solid Tumors criteria.

RESULTS

Patients were divided into high-SUV ratio group (n = 20) and low-SUV ratio group (n = 15) according to SUV ratio at a cutoff value of 2.5. Objective responses consisting of either complete response (CR) or partial response (PR) were observed in 16 and 6 patients (46% vs. 17%, p = 0.015), respectively; median survivals after RT were 8 months and 5 months (p = 0.41) for the high-SUV ratio group and the low-SUV ratio group, respectively. Rates of intrahepatic metastases (9% vs. 11%, p = 0.39) and distant metastases (32% vs. 32%, p = 0.27) showed no significant difference between two groups.

CONCLUSIONS

External beam RT for HCC patients with higher SUV ratios resulted in higher response rates than for patients with lower SUV ratios. Treatment of HCC with higher SUV ratios did not result in increased survival; high rates of intrahepatic and distant metastases in both SUV groups may have affected patient survival. SUV ratios from pre-RT FDG-PET may be beneficial for selecting patients who are likely to respond to EBRT for unresectable HCC.

[Transarterial chemoembolization and conformal radiotherapy for hepatocellular carcinoma]

Hepatocellular carcinoma is a poor prognosis tumour. The potential curative therapeutic options are orthotopic liver transplantation, surgical resection and radiofrequency ablation. Unfortunately, only a minority of patients (around 20%) are eligible for these techniques. Thus, patients can benefit from palliative options, such as transarterial chemoembolization (TACE) or sorafenib that bring only modest benefit on survival. Conformal radiotherapy allows delivering high dose radiation within a precise tumour volume while sparing the surrounding liver parenchyma. As employed in monotherapy, conformal radiotherapy is highly efficient for small size hepatocellular carcinoma (<5 cm). Above 5 cm, its efficacy is more limited but its association with TACE gives spectacular rates of complete responses. Controlled phase 2 or 3 trials are urgently warranted to define its indications in the therapeutic algorithm of hepatocellular carcinoma.

Early three-dimensional conformal radiotherapy for patients with unresectable hepatocellular carcinoma after incomplete transcatheter arterial chemoembolization: a prospective evaluation of efficacy and toxicity

PURPOSE

We prospectively evaluated the efficacy and toxicity of early 3-dimensional conformal radiotherapy (3D-CRT) for patients with unresectable hepatocellular carcinoma (HCC) after incomplete transcatheter arterial chemoembolization (TACE).

METHODS

Patients with unresectable HCC who failed 1 or 2 courses of TACE were eligible for this study. Three dimensional-CRT was added for HCC with incomplete uptake of iodized oil. Between January 2006 and February 2007, 40 patients (43 lesions) were enrolled. TACE was performed by using Lipiodol and adriamycin, followed by Gelfoam embolization. Two cycles of TACE were performed in 24 patients (60%), whereas 16 patients (40%) underwent one cycle. The median dose of 54 Gy (3 Gy daily) was delivered with 3D-CRT. Tumor response was evaluated by changes in tumor size on serial computed tomography scans and toxicity was evaluated by the Common Terminology Criteria for Adverse Events v3.0.

RESULTS

An objective response was achieved in 27 of 43 lesions (62.8%), with a complete response in 9 lesions (20.9%) and partial response in 18 lesions (41.9%). The overall survival rate was 72.0% at 1 year and 45.6% at 2 years. There was no grade 3 or greater acute toxicity. Nine patients (22.5%) showed progression of the disease within the irradiated field during the follow-up and intrahepatic metastases developed in 16 patients (40.0%).

CONCLUSION

Early 3D-CRT for HCC unresponsive to 1 or 2 cycles of TACE resulted in a 62.8% tumor response rate and relatively high complete response rates (20.9%) with acceptable toxicity. This study shows that the application of 3D-CRT could be considered for patients with incomplete TACE.

[Nonsurgical management of hepatocellular carcinoma]

Most of patients with hepatocellular carcinoma (HCC) cannot benefit from surgical therapies. Among nonsurgical options, only radiofrequency can challenge surgery for small size tumours. Conformal radiotherapy is likely highly efficient on solitary tumours, but controlled studies are warranted to conclude. Other options are purely palliative. Transarterial hepatic chemoembolization is the goal-standard for multifocal hepatocellular carcinoma and sorafenib for hepatocellular carcinoma with portal vein invasion, leading to modest but significant benefit on survival rates. Yttrium-90 radioembolization is under evaluation through controlled studies, and could be of major interest for multifocal hepatocellular carcinoma with or without portal venous invasion.

Nonoperative therapies for combined modality treatment of hepatocellular cancer: expert consensus statement

Although surgical resection and liver transplantation are the only treatment modalities that enable prolonged survival in patients with hepatocellular carcinoma (HCC), the majority of HCC patients presents with advanced disease and do not undergo resective or ablative therapy. Transarterial chemoembolization (TACE) is indicated in intermediate/advanced stage unresectable HCC even in the setting of portal vein involvement (excluding main portal vein). Sorafenib has been shown to improve survival of patients with advanced HCC in two controlled randomized trials. Yttrium 90 is a safe microembolization treatment that can be used as an alternative to TACE in patients with advanced liver only disease or in case of portal vein thrombosis. External beam radiation can be helpful to provide local control in selected unresectable HCC. These different treatment modalities may be combined in the treatment strategy of HCC and also used as a bridge to resection or liver transplantation. Patients should undergo formal multidisciplinary evaluation prior to initiating any such treatment in order to individualize the best available options.

Approach to radiation therapy in hepatocellular carcinoma

Hepatocellular carcinoma (HCC), the 5th most common cancer and the third most common cause of cancer-related death in the world with an estimated incidence of approximately 1 million new cases annually, has becoming a major global health problem in the world. A variety of treatment modalities, including resection, liver transplantation, transarterial chemoembolization (TACE), local ablative therapy and radiation therapy (RT) have been reported. Although partial hepatectomy and liver transplantation may offer the best chance of cure, only 15% of the patients have the chance to be treated by surgery when diagnosed. The effectiveness of systemic chemotherapy for HCC has been minimal, and local ablative therapy may offer comparable survival in patients with small HCC and preserve liver function. Recently, with developments in radiotherapy techniques, radiotherapy has been shown to play potential roles in a wide spectrum of HCC and to become more important so that it is necessary to evaluate the effect of radiotherapy in treatment of HCC. This paper is aiming mainly at the current radiation therapy strategies and their current advances, the optimal radiation therapy strategies will complement the current treatments and improve the treatment efficiency.

Is local radiotherapy still valuable for patients with multiple intrahepatic hepatocellular carcinomas?

PURPOSE

To investigate whether local radiotherapy (RT) is valuable for patients with multiple hepatocellular carcinomas (HCCs).

METHODS AND MATERIALS

From July 1992 to August 2006, 107 patients with unresectable HCC were treated with local RT after incomplete transcatheter arterial chemoembolization (TACE). The RT field included a main tumor with or without other tumor nodules, depending on the effectiveness of TACE. The median RT dose was 50.4 Gy in conventional fractionation. Patients were categorized into four groups: Group 1, single tumor (39 patients); Group 2, multiple tumors within the RT field (25 patients); Group 3, controlled tumors out of the RT field (19 patients); and Group 4, tumors that remained viable out of the RT field (24 patients).

RESULTS

Group 1 showed the best survival rate (MST, 35 months; 2-year OS, 60%) and Group 4 the worst (MST, 5 months; 2-year OS, 16%). Group 2 and Group 3 showed similar survival (MST, 13 vs. 19 months; 2-year OS, 35% vs. 46%; p = 0.698). Significantly worse intrahepatic control in Group 4 was observed. The survival in Groups 2 and 3 (MST, 16 months) was significantly different from that in Group 4 (p = 0.004), and was marginally significant compared with that in Group 1 (p = 0.051).

CONCLUSIONS

Local RT to the main tumor could be applicable in well-controlled intrahepatic tumors out of the RT field. Patients with viable intrahepatic tumors out of the RT field showed worse survival. In future clinical trials, these patients need to be excluded.

Challenge and hope in radiotherapy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most critical global health issues. With frequent association of viral liver disease, HCC is highly complex, harboring both cancer and chronic liver disease. The tumor stage and underlying liver function are both major determinants of the treatment selection as well as prognosis in HCC patients, thus allowing no more than a 20% chance for potentially curative therapies. Radiotherapy technology has been evolved remarkably during the past decade, and radiation can be precisely delivered, thereby permitting higher doses to the tumour and reduced doses to surrounding normal tissues. There has been increasing interest in the merits of radiotherapy in HCC over the past few years, as indicated by a Pub Med search. Radiotherapy has been used as the definitive therapy with curative intent in early stage tumours. It has been used also in combination with TACE for intermediate stage tumours. In locally advanced tumours, radiotherapy has been combined with systemic agents. Despite its efficacy, radiotherapy has not yet been incorporated into the standard management guidelines of HCC. The lack of high evidence level data, especially randomized controlled trials, has posed an obstacle in including radiotherapy into the routine treatment schema of HCC. Therefore, well-designed prospective studies are strongly recommended using developing technology for radiotherapy alone or combination therapies. Also, many issues such as the optimal dose-fractionation, intra- or extrahepatic metastasis after radiotherapy, and radiation-induced hepatic dysfunction remain to be solved. In this review, current status of radiotherapy for HCC will be discussed with regard to technical consideration and combination strategy. The limitation and future perspectives will also be discussed.

Innovative therapy for hepatocellular carcinoma: three-dimensional high-dose photon radiotherapy

The development of three-dimensional conformal radiotherapy (3DCRT) has enabled high dose radiation to be directed to tumour with a frank sparing of the non-tumour surrounding liver parenchyma without restriction due to tumour topography and size, presence of peritumourous satellite nodules or associated segmental portal vein thrombosis. 3DCRT can be safely delivered alone or concomitantly with transarterial chemoembolization (TACE), giving very encouraging results. Efficacy is strongly related to a smaller tumor size and higher dose of radiation while toxicity closely correlates to the pre-radiotherapy liver functions and the dose delivered to the uninvolved liver. These data has led to integrate 3DCRT in the multimodal treatment of HCC as a possible curative-intent option as well as surgical resection or percutaneous procedures although phase-III controlled studies are warranted to clarify this point. This may represent a promising approach in patients who are inoperable or for whom other ablation therapies are not feasible. The next steps will be the optimization of delivery modes of this type of photon therapy, taking account that other radiation modalities such as proton beam therapy for instance might be shown as of great interest within the next few years.

Estimate of radiobiologic parameters from clinical data for biologically based treatment planning for liver irradiation

PURPOSE

The Radiation Therapy Oncology Group (RTOG) is initiating a few new hypofractionation regimens (RTOG 0438) to treat liver cancer patients. To evaluate the radiobiologic equivalence between different regimens requires reliable radiobiologic parameters. The purpose of this work is to estimate a plausible set of such parameters for liver tumors and to design new optimized dose fractionation schemes to increase patient survival.

METHODS AND MATERIALS

A model was developed to fit clinical survival data from irradiation of a series of primary liver patients. The model consists of six parameters including radiosensitivity parameters alpha and alpha/beta, potential doubling time T(d). Using this model together with the Lyman model for calculations of the normal tissue complication probability, we designed a series of hypofractionated treatment strategies for liver irradiation.

RESULTS

The radiobiologic parameters for liver tumors were estimated to be: alpha/beta = 15.0 +/- 2.0 Gy, alpha = 0.010 +/- 0.001 Gy (-1), T(d) = 128 +/- 12 day. By calculating the biologically effective dose using the obtained parameters, it is found that for liver patients with an effective liver volume of approximately 45% the dose fractionation regimens suggested in RTOG 0438 can be escalated to higher dose for improved patient survival ( approximately 80% at 1 year) while keeping the normal tissue complication probability to less than 10%.

CONCLUSIONS

A plausible set of radiobiologic parameters has been obtained based on clinical data. These parameters may be used for radiation treatment planning of liver tumors, in particular, for the design of new treatment regimens aimed at dose escalation.

Potential prognostic benefits of radiotherapy as an initial treatment for patients with unresectable advanced hepatocellular carcinoma with invasion to intrahepatic large vessels

OBJECTIVES

To examine the efficacy and prognostic benefits of radiotherapy (RT) in patients who have unresectable advanced hepatocellular carcinoma (HCC) with invasion to intrahepatic large vessels (IHLVs).

METHODS

Sixty-eight patients who had advanced HCC with invasion to IHLVs were studied. Thirty-two consecutive patients initially received 3-dimensional conformal RT for HCC invasion to IHLVs. Tumor response, prognostic factors, and survival were studied in the patients given RT. Prognostic factors and survival were assessed in the study group as a whole. Data were analyzed using the Kaplan-Meier method, univariate analysis, and a Cox model.

RESULTS

The rate of objective response to RT was 48%. Predictors of survival in the patients who received RT were a hepatic function of Child-Pugh class A (p = 0.0263) and a response to RT (p = 0.0121). In the study group as a whole, independent predictors of survival in a Cox model were multinodular HCC (p = 0.007), inferior vena caval invasion (p = 0.001), a serum alpha-fetoprotein level of >1,000 ng/ml (p = 0.032), and the performance of RT (p < 0.001). Notably, the median survival of the nonresponders to RT (n = 15) was significantly longer than that of the patients who received no treatment for HCC (n = 21; 7.0 vs. 3.4 months, p = 0.0014).

CONCLUSION

RT is considered an effective initial treatment for HCC invasion to IHLVs, and may offer survival benefits, even in nonresponders, because of the induction of stable disease.

[Efficacy of transarterial chemolipiodolization with or without 3-dimensional conformal radiotherapy for huge HCC with portal vein tumor thrombosis]

BACKGROUND/AIMS

The treatment efficacy for advanced hepatocellular carcinoma is poor. This study examined the efficacy and toxicity of 3-dimensional conformal radiotherapy (3D-CRT) in combination with transarterial chemolipiodolization (TACL) for a huge hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT).

METHODS

From March 2001 to November 2004, 49 patients with advanced HCC with PVTT (size>8 cm, modified UICC stage IVa) were enrolled in this retrospective study. Twenty two patients underwent more than 2 cycles of TACL (adriamycin 50 mg/m(2), cisplatin 60 mg/m(2), 5-fluorouracil 200 mg/m(2) every 4-6 weeks) without 3D-CRT, while 27 patients underwent consecutive TACL with 3D-CRT (40-45 Gy for 4-5 weeks) that was started one week after the 1st TACL. The response was assessed by a computed tomography (CT) and the serum alpha-fetoprotein (AFP) level at 1-2 month intervals.

RESULTS

The objective response rates in the TACL group and TACL with 3D-CRT group were 18% and 48% at 3 months (P=0.051), and 10.5% and 42% at 6 months (P=0.024) respectively. The median survival time was 13 months and 13.5 months in TACL and TACL with 3D-CRT groups, respectively (P=0.502). The treatment response was better in the TACL with 3D-CRT group but there was no significant difference in survival between the two groups. Most toxicities in the two groups were mild, not exceeding grade 1 according to the WHO criteria.

CONCLUSIONS

For patients with a huge HCC with PVTT, TACL with 3D-CRT achieved some meaningful clinical benefit. Prospective controlled trials will be needed to confirm the real benefit of TACL combined with 3D-CRT.

Liver Embolizations in Oncology. A Review. Part II. Arterial Radioembolizations, Portal Venous Embolizations, Experimental Arterial Embolization Procedures

Arterial embolization of the liver may temporarily retard the growth of its primary and secondary tumors which are both mainly nourished arterially. Addition of radioisotopes, mostly (131)I or (90)Y, results in radioembolizations which predominantly act by radiation and less by ischemia. They may therefore be utilized in the absence of portal venous flow when conventional embolization is hazardous. (131)I-oily radioembolization seems to prolong short-term survival in such patients with unresectable hepatocellular cancers, and to improve the prognosis after resection of hepatocellular cancer. The procedure does however not palliate better than "cold" chemoembolization in patients with preserved portal flow, except for having milder side effects. Embolization with (90)Y-coupled microspheres may shrink primary and secondary liver tumors but has so far unproven effects on survival. Embolization of portal venous branches gives compensatory hypertrophy of the non-embolized liver and can increase the volume of the future remnant liver before resection. This diminishes the risk for postoperative liver failure after extensive resection and/or in the presence of chronic liver disease, and permits wider surgical indications. Tumor growth may however be accelerated, and the hypertrophy is inhibited by severe liver parenchymal disease in which situation the method would be most needed. Experimental use of liver arterial embolizations includes combined arterial and portal embolizations, i.e. "chemical hepatectomy," arterial embolizations before external radiotherapy, administration of boron for neutron capture therapy, immunoembolizations, and future gene therapy.

Three-dimensional conformal radiotherapy of unresectable hepatocellular carcinoma patients for whom transcatheter arterial chemoembolization was ineffective or unsuitable

OBJECTIVES

To evaluate 3-dimensional conformal radiotherapy (3D-CRT) of unresectable hepatocellular carcinoma (HCC) patients for whom transcatheter arterial chemoembolization (TACE) was ineffective or unsuitable, and to determine whether tumor response and portal vein thrombosis (PVT) response to treatment were prognostic factors for overall survival.

METHODS

From July 2001 to June 2005, 70 unresectable HCC patients were treated with 3D-CRT; PVT was present in 41 patients. A daily radiation dose ranging from 2 to 3 Gy was administered using 6 or 15 MV x-rays to deliver a total dose between 44 and 54 Gy.

RESULTS

Of 70 patients, follow-up computed tomography showed that primary tumor responses were complete response (CR) in 4 (5.7%) patients, partial response (PR) in 34 (48.6%), no response (NR) in 28 (37.1%), and progressive disease (PD) in 4 (8.6%). Of 41 patients with PVT, PVT responses were CR in 4 (9.7%) patients, PR in 12 (29.3%), NR in 20 (48.8%), and PD in 5 (12.2%). The median survival times were 18.0 and 20.1 month in the primary tumor and the PVT responders (CR + PR), respectively, which were longer than the 6.8 and 7.2 months in the primary tumor and the PVT nonresponders (NR + PD), respectively.

CONCLUSIONS

3D-CRT was associated with a 54.3% objective response rate for primary tumors and a 39.0% objective response rate for PVT. Both primary tumor and PVT responses were found to be prognostic factors for overall survival. The present results suggest 3D-CRT is a practical treatment option in HCC patients for whom TACE is ineffective or unsuitable.

Sublethal irradiation induces vascular endothelial growth factor and promotes growth of hepatoma cells: implications for radiotherapy of hepatocellular carcinoma

PURPOSE

To investigate the clinical benefit of additional radiotherapy to patients with unresectable hepatocellular carcinoma treated with transcatheter arterial chemoembolization (TACE) and the molecular effects of radiation on gene expression in hepatoma cells.

EXPERIMENTAL DESIGN

Between August 1996 and August 2003, 276 and 64 patients with American Joint Committee on Cancer stage T3N0M0 hepatocellular carcinoma receiving TACE alone and TACE followed by three-dimensional conformal radiotherapy, respectively, at our institution were studied. Clinical outcome and pattern of failure were analyzed for the association of survival benefit with radiotherapy. The molecular effects of radiotherapy were studied in vitro and in vivo using human hepatoma cells with different p53 mutation and hepatitis B virus infection status.

RESULTS

Median follow-up and survival time in the TACE alone and TACE + radiotherapy groups were 39 and 19 months, and 51 and 17 months, respectively. Additional radiotherapy to TACE did not improve overall survival (P = 0.65). However, different failure patterns were noted after TACE and after radiotherapy. Although all irradiated tumors regressed substantially, radiotherapy rapidly enhanced both intrahepatic and extrahepatic tumor progression outside the radiotherapy treatment field in a significant portion of patients, which offset the benefit of radiotherapy on overall survival. In molecular analysis of the radiation effects on human hepatoma cells, radiotherapy rapidly induced p53-independent transcriptional up-regulation of vascular endothelial growth factor (VEGF), increased VEGF secretion in a dose-, time-, and cell type-dependent manner, and promoted hepatoma cell growth in vivo with enhanced intratumor angiogenesis, which correlated well with elevated levels of serum VEGF.

CONCLUSIONS

Radiotherapy to eradicate a primary hepatocellular carcinoma might result in the outgrowth of previously dormant microtumors not included in the radiotherapy treatment field. Radiotherapy-induced VEGF could be a paracrine proliferative stimulus. Therapeutic implications of the study justify the combination of three-dimensional conformal radiotherapy with anti-VEGF angiogenic modalities for the treatment of unresectable hepatocellular carcinoma to reduce relapses.

Radiation therapy for hepatocellular carcinoma: from palliation to cure

Technologic advances have provided the means to deliver tumoricidal doses of radiation therapy (RT) to patients with unresectable hepatocellular carcinoma (HCC) while avoiding critical normal tissues, providing the opportunity to use RT for curative intent treatment of HCC. For the current report, the expanded role of external beam RT in the setting of HCC from palliation to cure was reviewed. A systematic literature search was undertaken using the MEDLINE data base and secondary references to identify peer-reviewed, English-language articles that reported clinical outcomes after external beam RT alone or in combination with other treatments for HCC. Abstracts from the 2005 American Society of Clinical Oncology, American Society for Therapeutic Radiology and Oncology, American Gastrointestinal Association, and Society of Surgical Oncology Gastrointestinal Cancer Symposium also were included in the search. More than 60 articles reporting on clinical outcomes among patients who received RT for HCC have been published since 1990, including 20 articles that described unique sets of at least 15 patients. RT was used for palliation, to improve local control, and with curative intent in a wide spectrum of patients who most often were unsuitable for surgery and other treatments. Pain reduction following RT was noted in approximately 75% of patients with bone metastases from HCC who received RT. For patients with liver-confined disease treated with conformal RT, proton beam RT, and/or image guided RT with or without transarterial chemoembolization (TACE), local control response rates ranged from 40% to 90%, and the median survival ranges from 10 months to 25 months. For patients with HCC who had portal vein thrombus, the median survival after RT to treat the thrombus and/or the hepatic tumor with or without TACE ranged from 5.3 months to 9.7 months. Although outcomes after high-dose conformal RT for liver-confined HCC were excellent, the potential survival benefit of RT should be tested in randomized controlled trials that require international collaboration.

Local radiotherapy as a complement to incomplete transcatheter arterial chemoembolization in locally advanced hepatocellular carcinoma

PURPOSE

In order to determine the effect of additional radiotherapy (RT) after an incomplete transcatheter arterial chemoembolization (TACE) in an unresectable hepatocellular carcinoma (HCC), the treatment results of patients receiving TACE plus RT were analyzed and compared with those treated with TACE alone.

MATERIALS AND METHODS

One hundred and five patients with an unresectable HCC were treated with TACE from January 1992 to December 2002. In 73 of these patients, the TACE was incomplete. Among them, TACE was repeatedly performed in 35 patients (TACE group), and the remaining 38 patients were also treated with local RT (TACERT group). The patients were either in stage III or IVa, Eastern Cooperative Oncology Group 2 or less, and Child-Pugh class A or B. The average frequency of TACE prior to RT was 2 and the RT was started within 7-10 days after the TACE.

RESULTS

The 2-year survival rate was significantly higher in the TACERT than in the TACE group (36.8 % vs. 14.3%, P=0.001). According to the tumor size, the 2-year survival rates in the TACERT and TACE groups were 63% vs. 42% in 5-7 cm (P=0.22), 50% vs. 0% in 8-10 cm (P=0.03), and 17% vs. 0% in larger than 10 cm (P=0.0002) respectively.

CONCLUSION

There was a significantly improved survival rate in the TACERT group of unresectable HCC patients than in the TACE group, particularly in case of tumors > or =8 cm in diameter. Therefore, RT in addition to TACE is strongly recommended for patients with an unresectable HCC.

Adverse hepatic events caused by radiotherapy for advanced hepatocellular carcinoma

BACKGROUND

Radiotherapy is often used to treat patients with unresectable advanced hepatocellular carcinoma (HCC). The present study examines the nature and frequency of adverse events with respect to liver function in such patients after radiotherapy.

METHODS

Forty-six patients with HCC who underwent radiotherapy were retrospectively examined. Radiotherapy was applied using coplanar 2-3-beam arrangements to a target dose of 50 Gy/5 weeks. The adverse hepatic events were evaluated according to the National Cancer Institute Common Toxicity Criteria and the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Scheme during the acute phase and the late phase by following the patients for up to 1 year. The influence on survival by adverse hepatic events and other factors was analyzed.

RESULTS

The full irradiation dose of 50 Gy was given to 40 patients (87.0%). Grade 3 or 4 toxicity was observed in 18 (39.1%) within 3 months after radiotherapy and in 11 (33.3%) of 33 thereafter, respectively. The most frequent and serious adverse events were hyperbilirubinemia, hypoalbuminemia, and ascites. The independent adverse prognostic factors for survival were portal vein tumor thrombus (P = 0.0012), tumor response (P = 0.011), acute adverse hepatic event (P = 0.012), and late adverse hepatic event (P = 0.015).

CONCLUSIONS

Hypoalbuminemia, hyperbilirubinemia, and ascites were important hepatic adverse events that developed after applying radiotherapy to treat advanced HCC. These adverse events seriously affected survival.

Three-dimensional conformal radiotherapy for portal vein thrombosis of hepatocellular carcinoma

BACKGROUND

Portal vein thrombosis (PVT) is a common complication in patients with advanced-stage hepatocellular carcinoma (HCC). The authors evaluated the impact of radiotherapy (RT) for PVT of HCC and analyzed the dose-response relation between RT and PVT.

METHODS

Between March 1995 and December 2003, 59 patients diagnosed as HCC with PVT were included. The inclusion criteria were unresectable tumor with thrombosis in the main or first branch of the portal vein, liver function of Child-Pugh Class A or B, and an Eastern Cooperative Oncology Group performance status score of 0-2. The median age of the patients was 57 years (range, 36-78 years). A daily dose ranging from 2 to 3 gray (Gy) was administered using 6 or 10-megavolt (MV) X-rays, at 5 fractions a week, to deliver a total dose range of 30-54 Gy, which was a biologic effective dose of 39-70.2 Gy(10) with an alpha/beta ratio of 10.

RESULTS

Follow-up computed tomography scans showed a complete response (CR) in 4 of 59 patients (6.8%), a partial response (PR) in 23 patients (39.0%), no response (NR) in 28 patients (47.5%), and progressive disease (PD) in 4 patients (6.8%). The mean RT doses in the responders (CR and PR) and nonresponders (NR and PD) were 59.6 +/- 5.6 Gy(10) and 54.9 +/- 8.5 Gy(10), respectively (P = 0.036). The response rates in patients receiving < 58 Gy(10) and > or = 58 Gy(10) were 20% and 54.6%, respectively (P = 0.034). The median survival duration and the 1-year and 2-year survival rates in the responders were 10.7 months, 40.7%, and 20.7%, respectively, and were 5.3 months, 25.0%, and 4.7%, respectively, in the nonresponders (P = 0.050).

CONCLUSIONS

RT induced a 45.8% objective response rate for PVT in patients with HCC. A dose-response relation was found to exist between the RT dose and PVT response. These results suggested that RT may be a treatment option for PVT in patients with HCC and that an RT dose > or = 58 Gy(10) should be recommended.

5-Fluorouracil concentration in blood, liver and tumor tissues and apoptosis of tumor cells after preoperative oral 5’-deoxy-5-fluorouridine in patients with hepatocellular carcinoma

AIM: To study the levels of 5-fluorouracail (5-FU) in plasma, liver and tumor in patients with hepatocellular carcinoma after oral administration of 5’-deoxy-5-fluorouridine (5’-DFUR).

METHODS: Thirty-nine patients with hepatocellular carcinoma were treated with oral 5’-DFUR for more than 4 d before operation. The contents of 5-FU in plasma, liver and tumor were measured by high performance liquid chromatography (HPLC) and apoptosis of tumor cells was evaluated by in-situ TUNEL after resection of tumor.

RESULTS: The concentrations of 5-FU were 1.1 μg/mL, 5.6, 5.9, and 10.5 μg/g in plasma, the liver tissue, the center of tumor and the periphery of tumor, respectively. 5-FU concentration was significantly higher in the periphery of tumor than that in the liver tissue and the center of tumor (10.5 ± 1.6 μg/g vs 5.6 ± 0.8 μg/g, t = 21.38, P < 0.05; 10.5 ± 1.6 μg/g vs 5.9 ± 0.9 μg/g, t = 20.07, P < 0.05). 5-FU level was significantly lower in plasma than that in the liver and the tumor (1.1 ± 0.3 μg/mL vs 5.6 ± 0.8 μg/g, t = 19.63, P < 0.05; 1.1 ± 0.3 μg/mL vs 10.5 ± 1.6 μg/g, t = 41.01, P < 0.05). Apoptosis of tumor cells was significantly increased after oral 5’-DFUR compared to the control group without 5’-DFUR treatment.

CONCLUSION: There is a higher concentration of 5-FU distributed in the tumor compared with liver tissue and apoptosis of tumor cells is increased following oral 5’-DFUR compared with the control group. The results indicate that 5’-DFUR is hopeful as neo-adjuvant chemotherapy to prevent recurrence after resection of hepatocellular carcinoma.

Docetaxel shows radiosensitization in human hepatocellular carcinoma cells

AIM: To determine the radiosensitizing potential of docetaxel in human hepatocellular carcinoma SMMC-7721 cells and its mechanisms.

METHODS: SMMC-7721 cells were incubated with docetaxel at 0.125, 0.25, and 0.5 nmoL/L for 24 h and at 0.125 and 0.25 nmol/L for 48 h before irradiation. Radiation doses were given from 0 to 10 Gy. Cell survival was measured by a standard clonogenic assay after a 9-d incubation. The reactive oxygen species (ROS) and glutathione (GSH) are detected after being given the same dose of docetaxel for the same time.

RESULTS: The sensitization enhancement ratios (SER) for SMMC-7721 cells determined at the 50% survival level were 1.15, 1.21 and 1.49 at 0.125, 0.25, and 0.5 nmol/L for pre-incubation of 24 h, respectively; the SER were 1.42, 1.67 at 0.125 and 0.25 nmol/L, for pre-incubation of 48 h, respectively. The ROS of SMMC-7721 cells increased and GSH decreased after pretreatment with the same doses of docetaxel for 24 or 48 h.

CONCLUSION: A radiosensitizing effect of docetaxel could be demonstrated unambiguously in this cell line used. In addition, our data showed that the mechanism of radiopotentiation by docetaxel probably does not involve a G2/M block in SMMC-7721 cells, and ROS generation and GSH deletion may play a key role in the radiosensitizing effect of docetaxel.

External beam radiation therapy for hepatocellular carcinoma: potential of intensity-modulated and image-guided radiation therapy

External beam radiotherapy has historically played a minor role in the primary treatment of hepatocellular carcinoma. Although there is evidence for tumor response to external beam radiotherapy and despite the fact that a radiation dose-response relationship has been established, the limited radiation tolerance of the adjacent normal liver has prohibited wider use of radiation therapy in this disease. Recent technological and conceptual developments in the field of radiation therapy-such as intensity-modulated radiation therapy, image-guided radiation therapy, and stereotactic body radiation therapy-have the potential to improve radiation treatments by conforming the delivered radiation dose distribution tightly to the tumor or target volume outline while sparing normal liver tissue from high-dose radiation. Image guidance allows for a reduction of added (normal tissue) safety margins designed to account for interfraction patient and target setup variability, and stereotactic targeting will further reduce residual target setup uncertainty. Combining improvements in tumor targeting with normal tissue sparing, radiation dose delivery will enable clinically effective and safe radiation delivery for liver tumors such as hepatocellular carcinoma. This article reviews the role of radiotherapy for hepatocellular carcinoma; presents modern radiation therapy modalities and concepts such as intensity-modulated, image-guided, and stereotactic body radiation therapy; and hypothesizes about their future effect on primary treatment alternatives.

Results of the first prospective study of carbon ion radiotherapy for hepatocellular carcinoma with liver cirrhosis

PURPOSE

To evaluate the toxicity and antitumor effect of carbon ion radiotherapy for hepatocellular carcinoma within a Phase I-II trial.

METHODS AND MATERIALS

Between June 1995 and February 1997, 24 patients with histopathologically proven hepatocellular carcinoma were treated to 15 fractions within 5 weeks in a step-wise dose-escalation study. The disease stage was Stage II in 10, IIIA in 6, and IVA in 8 patients. The Common Toxicity Criteria, Radiation Therapy Oncology Group/European Organization for the Research and Treatment of Cancer criteria, and Child-Pugh score were used to evaluate toxicity. The antitumor effect was evaluated by the tumor response, cumulative local control, and survival rates.

RESULTS

During a median follow-up of 71 months (range, 63-83 months), no severe adverse effects and no treatment-related deaths occurred. The Child-Pugh score did not increase by >2 points after the start of therapy. In 78% and 75% of all patients, the score did not increase by >1 point in the early and late phase, respectively. The overall tumor response rate was 71%. The local control and overall survival rate was 92% and 92%, 81% and 50%, and 81% and 25% at 1, 3, and 5 years, respectively.

CONCLUSION

Carbon ion radiotherapy appears safe and effective for patients with hepatocellular carcinoma. Additional clinical studies using a larger subject group are required to confirm the therapeutic efficacy.

Therapeutic effects and prognostic factors in three-dimensional conformal radiotherapy combined with transcatheter arterial chemoembolization for hepatocellular carcinoma

AIM

To evaluate the therapeutic efficacy of three-dimensional conformal radiotherapy (3D-CRT) combined with transcatheter arterial chemoembolization (TACE) on the patients with hepatocellular carcinoma (HCC).

METHODS

Between 1998 and 2001, 94 patients with HCC received 3D-CRT combined with TACE. A total 63 patients had a Okuda stage I lesion and 31 patients had stage II. The median tumor size was 10.7 cm (range 3.0-18 cm), and liver cirrhosis was present in all the patients. There were 43 cases of class A and 51 class B. TACE was performed using lipiodol, 5-fluorouracil, cisplatin, doxorubicin hydrochloride and mitomycin, followed by gelatin sponge cubes. Fifty-nine patients received TACE only one time, while the others 2 to 3 times. 3D-CRT was started 3-4 wk after TACE. All patients were irradiated with a stereotactic body frame and received 4-8 Gy single high-dose radiation for 8-12 times at the isocenter during a period of 17-26 d (median 22 d).

RESULTS

The median follow-up was 37 mo (range 10-48 mo) after diagnosis. The response rate was 90.5%. The overall survival rate at 1-, 2-, and 3- year was 93.6%, 53.8% and 26.0% respectively, with the median survival of 25 mo. On univariate analysis, age (P=0.026), Child-Pugh classification for cirrhosis of liver (P=0.010), Okuda stage (P=0.026), tumor size (P=0.000), tumor type (P=0.029), albuminemia (P=0.035), and radiation dose (P=0.000) proved to be significant factors for survival. On multivariate analysis, age (P=0.024), radiation dose (P=0.001), and tumor size (P=0.000) were the significant factors.

CONCLUSION

3D-CRT combined with TACE is an effective and feasible approach for HCC. Age, radiation dose and tumor size were found to be significant prognostic factors for survival of patients with HCC treated by 3D-CRT combined with TACE. Further study for HCC is needed to improve the treatment efficacy.

Radioresponse of hepatocellular carcinoma-treatment of lymph node metastasis

PURPOSE

To analyze the radioresponse of hepatocellular carcinomas (HCC), using accurate measurements of the tumor size in extrahepatic lymph node metastasis, and to obtain information for the future treatment of primary intrahepatic lesions.

MATERIALS AND METHODS

Fifty-one extrahepatic lymph node metastases from primary HCCs, which could be treated by external radiotherapy alone, were included in this study. The radiation dose ranged from 30 to 51 Gy with fraction sizes of 2.0 approximately 3.0 Gy. Responses were determined by measuring the areas on CT scans 0, 1 and 3 months after the completion of radiotherapy. The median follow-up period of the surviving patients was 10 months.

RESULTS

The overall response rate was 76%, and the important factors were; total dose of radiation, time dose fractionation (TDF) value and the biologically effective dose (BED). A dose of 45 Gy or higher showed an objective response rate of 93%, and if the TDF value was higher than 90, a similar result was observed. In about half (47%) of the patients the maximum response was observed at 3 months or later. The response duration was observable in 14 patients surviving 12 months or longer. Regrowth of irradiated lesions were observed in 4 (66.7%) patients among those who received less than 45 Gy, and in 4 (50%) among those who were treated with 45 Gy or more. There was a statistically significant difference in the survivals between the responders and non-responders (p=0.008). Gastrointestinal bleeding or ulceration was observed in 8 patients, including 3 with NCI common toxicity criteria grade III or higher.

CONCLUSION

Radiotherapy was an effective palliative modality for extrahepatic metastasis in HCCs. A radiation dose of 45 Gy or higher (or a TDF value >or=90), was required for a major response.

Combined interventional therapies of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies in the world, responsible for an estimated one million deaths annually. It has a poor prognosis due to its rapid infiltrating growth and complicating liver cirrhosis. Surgical resection, liver transplantation and cryosurgery are considered the best curative options, achieving a high rate of complete response, especially in patients with small HCC and good residual liver function. In nonsurgery, regional interventional therapies have led to a major breakthrough in the management of unresectable HCC, which include transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), microwave coagulation therapy (MCT), laser-induced thermotherapy (LITT), etc. As a result of the technical development of locoregional approaches for HCC during the recent decades, the range of combined interventional therapies has been continuously extended. Most combined multimodal interventional therapies reveal their enormous advantages as compared with any single therapeutic regimen alone, and play more important roles in treating unresectable HCC.

Prospective trial of combined transcatheter arterial chemoembolization and three-dimensional conformal radiotherapy for portal vein tumor thrombus in patients with unresectable hepatocellular carcinoma

PURPOSE

We conducted a prospective trial of combined transarterial chemoembolization (TACE) and three-dimensional conformal radiotherapy (3D-CRT) for portal vein tumor thrombus (PVTT) in unresectable hepatocellular carcinoma (HCC). The aim of the present study was to investigate the efficacy and toxicity of this trial regime.

METHODS AND MATERIALS

Patients with unresectable HCC complicated with tumor thrombus in the first branch of portal vein were selected as eligible for this study. TACE was performed using Lipiodol, epirubicin hydrochloride, and mitomycin, followed by gelatin sponge cubes. The 3D-CRT was performed targeting the clinical target volume (CTV) defined as PVTT only to a total dose of 60 Gy using 10-MV accelerator.

RESULTS

A total of 19 patients were enrolled in this study. Survival rates at 1 and 2 years were 40.6% and 10.2%, respectively. The median survival time was 7.0 months. An objective response was observed in 11 of 19 cases (57.9%). Recanalization of the first portal branches was not observed; however, the protrusion of PVTT into the main portal trunk decreased in all cases. Growth of intrahepatic metastasis outside the 3D-CRT field was observed in 12 cases (63%). Deterioration of the Child-Pugh Score was observed in 5 of 6 cases with the percent volume of the total liver receiving a dose exceeding 30 Gy (V(30)) > or =40%, vs. 2 of 13 cases with a V(30) <40% (p < 0.01).

CONCLUSION

This combined therapy was feasible. Our results indicate that V(30) was a predictive test for deterioration of liver function. Further investigation of treatment modalities is needed to prevent the growth of intrahepatic metastasis.

Comparison between chemoembolization combined with radiotherapy and chemoembolization alone for large hepatocellular carcinoma

AIM: To investigate the efficacy of transcatheter arterial chemoembolization (TACE) combined with radiotherapy for unresectable large hepatocellular carcinoma (HCC).

METHODS: From June 1994 to June 1999, a total of 76 patients with large unresectable HCC were treated with TACE followed by external-beam irradiation. 89 patients with large HCC, who underwent TACE alone during the same period, served as the control group. Clinical features, therapeutic modalities, acute effects and survival rates were analyzed and compared between TACE plus irradiation group and TACE alone group. A multivariate analysis of nine clinical variables and one treatment variable (irradiation) was performed by the Cox proportional hazards model.

RESULTS: The clinical features and therapeutic modalities except irradiation between the two groups were comparable (P > 0.05). The objective response rate (RR) in TACE plus irradiation group was higher than that in TACE alone group (47.4% vs 28.1%, P < 0.05). The overall survival rates in TACE plus irradiation group (64.0%, 28.6%, and 19.3% at 1, 3, 5 years, respectively) were significantly higher than those in TACE alone group (39.9%, 9.5%, and 7.2%, respectively, P = 0.0001). Cox proportional hazards model analysis showed that tumor extension and Child grade were significant and were independent negative predictors of survival, while irradiation was an independent positive predictor of survival.

CONCLUSION: TACE combined with radiotherapy is more effective than TACE alone, and is a promising treatment for unresectable large HCC.

Concurrent hyperglycemia does not influence the long-term prognosis of unresectable hepatocellular carcinomas

AIM: The association has been established between the disorder of carbohydrate metabolism and liver cancer. However, little is known regarding the impact of concurrent hyperglycemia on prognosis of hepatocellular carcinoma (HCC). The present study aimed at solving this problem.

METHODS: A total of 225 patients included in this study, were admitted from January 1998 to December 2001 for an unresectable HCC proven by histological and imaging examinations. Most of the patients received interventional treatment, radiation and biotherapy. Response was evaluated by computerized tomography (CT) scan conducted 4-6 weeks following completion of the treatment, and then every 3 months. Survival was calculated from the beginning of treatment using the Kaplan-Meier method. Pretreatment, treatment and follow-up variables with possible prognostic significance were analyzed. A stepwise multivariate analysis was performed using the Cox regression model, and a prognostic index was obtained.

RESULTS: No differences were observed in survival parameters between the patients with and without hyperglycemia, median survival times of the patients were being 26 ± 3.46 months and 29.5 ± 2.04 months, respectively, and the 3-year survival rate was 8.36% and 9.62%, respectively. The univariate analysis indicated that there were several survival-associated variables including serum AFP level, clinical stage, Child-Pugh grade, method of treatment, size and number of tumor nodule (s). However, only the clinical stage, Child-Pugh grade and the treatment procedure were proved to be independent prognostic factors in the multivariate analysis.

CONCLUSION: This study indicates that hyperglycemia does not influence the long-term prognosis of HCC, and concurrent hyperglycemia should not be considered as an unfavorable prognostic factor during the treatment of patients with HCC.

Study of local three-dimensional conformal radiotherapy combined with transcatheter arterial chemoembolization for patients with stage III hepatocellular carcinoma

The purpose of this study was to evaluate treatment-related toxicity, outcome, patterns of failure, and prognostic factors for patients with stage III unresectable hepatocellular carcinoma (HCC) treated with a combination of local 3-dimensional conformal radiotherapy (3D-CRT) and transcatheter arterial chemoembolization (TACE) under the support of G-CSF. From October 1997 to August 2001, 45 patients with stage III unresectable hepatocellular carcinoma underwent transcatheter arterial chemoembolization with local 3D-CRT. Twenty-seven patients were classified as having stage IIIA disease according to the American Joint Committee on Cancer (AJCC) staging system and 18 were classified as stage IIIB. The mean diameter of the treated hepatic tumor was 8.5 cm. Before 3D-CRT, 2 cycles of transcatheter arterial chemoembolization were prescribed. Forty-eight hours later, the G-CSF was prescribed for 5 days after the completion of every TACE. With the interval of 10 to 14 days after the second cycle of TACE, 3D-CRT was prescribed to all patients with a total dose of 50.4 Gy at 1.8 Gy per fraction 5 days per week. After the completion of 3D-CRT, the additional 2 cycles of TACE were given. All patients were monitored for treatment-related toxicity, outcome, patterns of failure, causes of death, and prognostic factors. Forty-two of 45 patients were treated smoothly with the primary schedule. In a median follow-up period of 27 months, 22 patients were alive and 23 were dead. Progressive disease occurred in 28 patients, including local recurrence alone (4 patients), distant metastases with local recurrence (8 patients), and distant metastases alone (16 patients). Nine patients developed radiation-induced liver disease (RILD). Three patients had treatment-related gastrointestinal bleeding. There were 2 treatment-related deaths, including 1 from RILD and 1 from gastrointestinal bleeding. Complete regression (CR) was observed in 6 patients, partial regression (PR) in 35 patients, and stable disease (SD) in 4 patients. The median overall survival duration from treatment was 23.5 months with a 1-year overall survival rate of 68.5%, a 2-year survival rate of 48.3%, and a 3-year survival rate of 22.6%. The median freedom from progressive disease survival duration from treatment was 25 months with 1-year, 2-year, and 3-year progression-free survival rates of 76.2%, 56.8%, and 42.4%, respectively. The stage of HCC, regional lymph node status, portal vein thrombosis, pretreatment alpha-fetoprotein level (AFP), and tumor size affected the treatment outcomes significantly. Therefore, for patients with stage III unresectable hepatocellular carcinoma, combined local 3D conformal radiotherapy with transcatheter arterial chemoembolization under the support of G-CSF is an effective treatment protocol. Further research is required to decrease distant metastases and to determine the safe irradiation dose-volume.

Expression of mutant P53 and VEGF in experimental gastric cancer in rats and the effect of decoction Weikang-ning

AIM

To study the expression of P⁵³ gene mutation and VEGF in rats with experimental gastric cancer and the preventing effects of decoction Weikang-ning(WKN).

METHODS

Male Wistar rats aged 2-3month (weight 120-140 g) were fed with MNNG to induce gastric adenocarcinoma. Rats were divided into control group, WKN group 1 and 2. The morphology of gastric mucous were observed by light microscope and electric microscope. Expression of mutant P53and VEGF were studied with immunohistochemistry.

RESULTS

The malignancy phenotype of stomach epithelial cell such as heteromorphism, heteropyknosis and increased nucleus plasma ratio in rats of WKN group were slightly less severe than that in control group, also the expressed mutant P⁵³ protein (3.4905±1.5225) and VEGF (3.519±2.204) in WKN group were decreased (P<0.01) significantly.

CONCLUSION

The development of experimental gastric cancer by WKN in rats is associated with high expression of P⁵³ and VEGF. The decoction WKN suppresses the expression P⁵³ and VEGF and thus has the preventive and therapeutic effects on gastric cancer.

Respiratory gating for liver tumors: use in dose escalation

PURPOSE

To determine the clinical impact of the Varian Real-Time Position Monitor (RPM) respiratory gating system for treatment of liver tumors.

METHODS AND MATERIALS

Ten patients with liver tumors were selected for evaluation of this passive system, which tracks motion of reflective markers mounted on the abdomen with an infrared-sensitive camera. At simulation, a fluoroscopic movie, breathing trace, and CT scans synchronized at end-expiration (E-E) and end-inspiration were acquired in treatment position using the RPM system. Organs and gross tumor volume were contoured on each CT. Each organ's positional change between two scan sets was quantified by calculation of the center of volume shift and an "index coefficient," defined as the volume common to the two versions of the organ to the volume included in at least one (intersection/union). Treatment dose was determined by use of normal tissue complication probability calculations and dose-volume histograms. Gated portal images were obtained to monitor gating reproducibility with treatment.

RESULTS

Eight patients received 177 treatments with RPM gating. Average superior-to-inferior (SI) diaphragm motion on initial fluoroscopy was reduced from 22.7 mm without gating to 5.1 mm with gating. Comparing end-inspiration to E-E CT scans, average SI movement of the right diaphragm was 11.5 mm vs. 2.2 mm for two E-E CT scans. For all organs, average E-I SI organ motion was 12.8 mm vs. 2.0 mm for E-E studies. Index coefficients were closer to 1.0 for E-E than end-inspiration scans, indicating gating reproducibility. The average SI displacement of diaphragm apex on gated portal images compared with DRR was 2.3 mm. Treatment was prolonged less than 10 minutes with gating. The reproducible decrease in organ motion with gating enabled reduction in gross tumor volume-to-planning target volume margin from 2 to 1 cm. This allowed for calculated dose increases of 7%-27% (median: 21.3%) in 6 patients and enabled treatment in 2.

CONCLUSION

Gating of radiotherapy for liver tumors enables safe margin reduction on tumor volume, which, in turn, may allow for dose escalation.