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Rim CH, Lee HY, Kim JS, Kim H. Radiofrequency ablation and stereotactic body radiotherapy for hepatocellular carcinoma: should they clash or reconcile? Int J Radiat Biol 2020; 97:111-119. [PMID: 33253598 DOI: 10.1080/09553002.2021.1857453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Until a few decades ago, surgical resection was the only valid option for treating hepatocellular carcinoma (HCC). However, various locoregional modalities including arterial-directed therapy, radiofrequency ablation (RFA), and radiotherapy have been recently shown to be effective. RFA is now established as a standard treatment for small localized HCCs, showing oncological results comparable to those of surgical resection in randomized studies. Stereotactic body radiotherapy (SBRT) is a modern radiotherapeutic modality that targets tumors with precision and delivers high radiation doses over a short period of time; it has particularly attracted clinical interest after its therapeutic efficacy was found to be similar to that of surgery in early-stage lung cancer. Given its potent disease control capability, SBRT has also been applied to early HCCs and demonstrated promising results in recent studies. It has also been noted for its suitability to treat tumors located in anatomical locations where RFA would be challenging. However, since its effectiveness has not been compared to that of RFA in randomized studies of patients eligible for RFA, the use of SBRT has been debated. This review was conducted to guide physicians from all fields involved in the treatment of early HCC. The therapeutic characteristics and indications of both SBRT and RFA are described, and recent comparative studies between the two modalities are discussed. In addition, we examined the factors that should be considered when selecting the appropriate treatments, and offer our recommendations.
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Affiliation(s)
- Chai Hong Rim
- Department of Radiation Oncology, Korea University Ansan Hospital, Gyeonggido, Korea
| | - Hye Yoon Lee
- Department of General Surgery, Korea University Ansan Hospital, Gyeonggido, Korea
| | - Jung Sun Kim
- Department of Medical Oncology, Korea University Ansan Hospital, Gyeonggido, Korea
| | - Hakyoung Kim
- Department of Radiation Oncology, Korea University Guro Hospital, Seoul, Korea
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Lee WH, Byun HK, Choi JS, Choi GH, Han DH, Joo DJ, Kim DY, Han KH, Seong J. Liver-directed combined radiotherapy as a bridge to curative surgery in locally advanced hepatocellular carcinoma beyond the Milan criteria. Radiother Oncol 2020; 152:1-7. [PMID: 32739317 DOI: 10.1016/j.radonc.2020.07.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Liver-directed combined radiotherapy (LDCRT) can provide substantial tumor control, which may be an effective bridge to curative surgery for selected patients. We aimed to investigate the outcomes of LDCRT for locally advanced hepatocellular carcinoma (LAHCC) beyond the Milan criteria. MATERIALS AND METHODS We identified 1078 patients diagnosed with LAHCC who received LDCRT and compared the outcomes based on no surgery, conversion to surgical resection, and liver transplantation (LT). Predictive factors for conversion to curative surgery were identified using logistic regression analysis. RESULTS The most frequently used LDCRT strategies were concurrent chemoradiation (CCRT) (497 patients, 46.1%) and transarterial chemoembolization (TACE) plus radiotherapy (251 patients 23.3%). After LDCRT, 96 (8.9%) and 42 patients (3.9%) received surgical resection and LT, respectively. After a median follow-up of 14.4 months, the 5-year overall survival (OS) rate was 16.5% for all patients. Conversion to curative surgery group had higher 5-year OS (surgical resection vs. LT vs. no surgery: 58.1% vs. 54.3% vs. 10.2%, p < 0.001). Patients aged < 60 years with a single tumor, no treatment history, pre-treatment Child class A, lower pre-treatment tumor marker levels, and radiologic complete or partial response (all p < 0.050) had a higher chance of conversion to surgery. CONCLUSION LDCRT could convert tumors to within the Milan criteria as a bridge to curative surgery, and improved long-term survival for the selected patients. Clinicians should consider LDCRT followed by curative surgery for young patients who are treatment-naïve and have good liver function with favorable tumor characteristics showing radiologic response to LDCRT.
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Affiliation(s)
- Won Hee Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dai Hoon Han
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Cho Y, Kim JW, Kim JK, Lee KS, Lee JI, Lee HW, Lee KH, Joo SM, Lim JH, Lee IJ. Phase I Radiation Dose-Escalation Study to Investigate the Dose-Limiting Toxicity of Concurrent Intra-Arterial Chemotherapy for Unresectable Hepatocellular Carcinoma. Cancers (Basel) 2020; 12:cancers12061612. [PMID: 32570869 PMCID: PMC7352219 DOI: 10.3390/cancers12061612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 02/08/2023] Open
Abstract
Concurrent intra-arterial chemotherapy and radiotherapy (iA-CCRT) can increase the response rate in hepatocellular carcinoma (HCC), but may cause a higher toxicity. We conducted this Phase I study to investigate the dose-limiting toxicity of iA-CCRT for HCC. In total, 52.5 Gy in 25 fractions was prescribed as planning target volume (PTV) 1 at dose level 1. The dose escalation was 0.2 Gy per fraction and up to 2.5 Gy, with 62.5 Gy at level 3. Concurrent intra-arterial 5-fluorouracil was administered during the first and fifth weeks of radiotherapy (RT). Toxicities were graded using the Common Toxicity Criteria for Adverse Events, version 4.0. Results: Seventeen patients with HCC were analyzed: four at dose level 1, 6 at level 2, and 7 at level 3. The mean irradiated dose administered to the uninvolved liver at each dose level was 21.3, 21.6, and 18.2 Gy, respectively. There was no grade ≥3 gastrointestinal toxicity; two patients experienced grade 3 hyperbilirubinemia. All patients had Child-Pugh class A disease, but 3 patients developed class B disease after iA-CCRT. During a median follow-up of 13 months, the median progression-free survival (PFS) and overall survival (OS) were 10 and 22 months, respectively. Patients treated at dose level 3 showed improved PFS and OS. Conclusions: Radiation dose escalation of iA-CCRT did not cause any significant toxicities in patients with advanced HCC. Further large-scale studies with long-term follow-up are needed to determine the efficacy and feasibility of higher doses of iA-CCRT.
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Affiliation(s)
- Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.C.); (J.W.K.)
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.C.); (J.W.K.)
| | - Ja Kyung Kim
- Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Korea;
| | - Kwan Sik Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (K.S.L.); (J.I.L.); (H.W.L.)
| | - Jung Il Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (K.S.L.); (J.I.L.); (H.W.L.)
| | - Hyun Woong Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (K.S.L.); (J.I.L.); (H.W.L.)
| | - Kwang-Hun Lee
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (K.-H.L.); (S.-M.J.)
| | - Seung-Moon Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (K.-H.L.); (S.-M.J.)
| | - Jin Hong Lim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea
- Correspondence: (J.H.L.); (I.J.L.); Tel.: +82-2-2019-3895 (J.H.L.); +82-2-2019-3152 (I.J.L)
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, Korea; (Y.C.); (J.W.K.)
- Correspondence: (J.H.L.); (I.J.L.); Tel.: +82-2-2019-3895 (J.H.L.); +82-2-2019-3152 (I.J.L)
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Li Z, Dong Y, Fan M, Yin Y, Zhu J, Li B, Huang W. Analysis of Hepatitis B Virus Reactivation After Radiotherapy in Patients With Hepatocellular Carcinoma Using the Lyman NTCP Model. Technol Cancer Res Treat 2020; 18:1533033819875136. [PMID: 31526114 PMCID: PMC6749789 DOI: 10.1177/1533033819875136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Purpose: To analyze the correlation of hepatitis B virus reactivation with patient-related and treatment-related dose–volume factors and to describe the feasibility of hepatitis B virus reactivation analyzed by a normal tissue complication probability model for patients with hepatocellular carcinoma treated with radiotherapy. Materials and Methods: Ninety patients with hepatitis B virus-related hepatocellular carcinoma treated with radiotherapy were enrolled in this retrospective study and were followed from June 2009 to December 2015. Of the 90 patients, 78 had received conventional fractionation radiotherapy to a mean dose of 39.6 to 50.4 Gy and 12 patients were scheduled to receive hypofractionation. The physical doses were converted into 2 Gy equivalents for analysis. The parameters, TD50 (1), n, and m, of the Lyman-Kutcher-Burman normal tissue complication probability model were derived using maximum likelihood estimation. Bootstrap and leave-one-out were employed to against model overfitting and improve the model stability. Results: Radiation-induced liver diseases were 17.8%, hepatitis B virus reactivation was 22.2%, and hepatitis B virus reactivation-induced hepatitis was 21.1%, respectively. In multivariate analysis, the V5Gy was associated with hepatitis B virus reactivation; TD50 (1), m, and n were 32.3, 0.55, and 0.71 Gy, respectively, for hepatitis B virus reactivation. Bootstrap and leave-one-out results showed that the hepatitis B virus parameter fits were extremely robust. Conclusion: A Lyman-Kutcher-Burman normal tissue complication probability model has been established to predict hepatitis B virus reactivation for patients with hepatocellular carcinoma who received radiotherapy.
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Affiliation(s)
- Zhenjiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yinping Dong
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Min Fan
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Yong Yin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Jian Zhu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Baosheng Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Wei Huang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
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Park S, Yoon WS, Rim CH. Indications of external radiotherapy for hepatocellular carcinoma from updated clinical guidelines: Diverse global viewpoints. World J Gastroenterol 2020; 26:393-403. [PMID: 32063688 PMCID: PMC7002906 DOI: 10.3748/wjg.v26.i4.393] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/06/2020] [Accepted: 01/11/2020] [Indexed: 02/06/2023] Open
Abstract
The etiology and disease patterns of hepatocellular carcinoma (HCC) significantly vary among regions. Modern standard treatments commonly require multidisciplinary approaches, including applications of up-to date medicine and advanced procedures, and necessitate the support of socioeconomic systems. For these reasons, a number of clinical guidelines for HCC from different associations and regions have been presented. External beam radiation therapy was contraindicated for HCC until a few decades ago, but with the development of new technologies, its application has rapidly increased as selective irradiation for tumorous lesions became possible. Most of the guidelines had been opposed or indifferent to radiotherapy in the past, but several guidelines have introduced indications and recommendations for radiotherapy in their updated versions. This review will discuss the characteristics of important guidelines and their contents regarding radiotherapy and will also provide guidance to physicians who are considering applications of locoregional modalities that include radiotherapy.
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Affiliation(s)
- Sunmin Park
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan 15355, Gyeonggi-do, South Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan 15355, Gyeonggi-do, South Korea
| | - Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan 15355, Gyeonggi-do, South Korea
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Liu Y, Yan J, Wang F. Effects of TACE combined with precise RT on p53 gene expression and prognosis of HCC patients. Oncol Lett 2018; 16:5733-5738. [PMID: 30344728 PMCID: PMC6176346 DOI: 10.3892/ol.2018.9374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 07/30/2018] [Indexed: 12/27/2022] Open
Abstract
To investigate the effects of transcatheter arterial chemoembolization (TACE) combined with precise radiation therapy (RT) on p53 gene expression and prognosis of patients with hepatocellular carcinoma (HCC). A total of 80 patients with unresectable HCC treated in the First People's Hospital of Qinhuangdao from March 2009 to March 2015 were randomly divided into TACE group (n=40) and TACE + RT group (n=40). Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of p53 in both groups before and after treatment. The biochemical indexes of liver function [α-fetoprotein (AFP), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT)] were detected. Moreover, adverse reactions were compared between the two groups of patients, the short-term therapeutic effect was evaluated, and effects of two treatment methods on progression-free survival (PFS) and overall survival (OS) of patients were detected. There were no statistically significant differences in clinical data between the two groups of patients (P>0.05). The p53 protein levels were significantly downregulated in both treatment methods, and it was decreased more significantly in TACE + RT group than that in TACE group (P<0.05). Compared with those before treatment, AFP and GGT levels in both groups of patients after treatment were decreased, but the levels of ALT were increased (P<0.05), and TACE + RT group had a better curative effect than TACE group (P<0.05). Besides, the incidence rate of adverse reactions in TACE + RT group (37.5%) was obviously lower than that in TACE group (65%) (P<0.05). The number of patients with stable disease (SD) and progressive disease (PD) and disease control rate (DCR) in TACE + RT group were superior to those in TACE group (P<0.05). The 2-year survival rate and median PFS of patients in TACE + RT group were also significantly better than those in TACE group (P<0.05). In conclusion, TACE combined with RT has a better clinical effect than TACE alone in the treatment of HCC.
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Affiliation(s)
- Yupeng Liu
- Department of Emergency, The First People's Hospital of Qinhuangdao, The Affiliated Hospital of Hebei Medical University, Qinhuangdao, Hebei 066000, P.R. China
| | - Jingchen Yan
- Department of Intervention, Liaocheng Cancer Hospital, Liaocheng, Shandong 252000, P.R. China
| | - Feng Wang
- Department of Nuclear Medicine, The First Hospital of Shijiazhuang, Shijiazhuang, Hebei 050011, P.R. China
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Rim CH, Yoon WS. Leaflet manual of external beam radiation therapy for hepatocellular carcinoma: a review of the indications, evidences, and clinical trials. Onco Targets Ther 2018; 11:2865-2874. [PMID: 29844684 PMCID: PMC5962257 DOI: 10.2147/ott.s164651] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The use of external beam radiation therapy (EBRT) in the treatment of hepatocellular carcinoma (HCC), which was rarely performed due to liver toxicity with a previous technique, has increased. Palliation of portal vein thrombosis, supplementation for insufficient transarterial chemoembolization, and provision of new curative opportunities using stereotactic body radiotherapy are the potential indications for use of EBRT. The mechanism of EBRT treatment, with its radiobiological and physical perspectives, differs from those of conventional medical treatment or surgery. Therefore, understanding the effects of EBRT may be unfamiliar to physicians other than radiation oncologists, especially in the field of HCC, where EBRT has recently begun to be applied. The first objective of this review was to concisely explain the indications for use of EBRT for HCC for all physicians treating HCC. Therefore, this review focuses on the therapeutic outcomes rather than the detailed biological and physical background. We also reviewed recent clinical trials that may extend the indications for use of EBRT. Finally, we reviewed the current clinical practice guidelines for the treatment of HCC and discuss the current recommendations and future perspectives.
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Affiliation(s)
- Chai Hong Rim
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan, Republic of Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical College, Ansan, Republic of Korea
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Dong L, Zhang X, Xiang W, Ni J, Zhou W, Li H. Post-transcription mediated Snail stabilization is involved in radiation exposure induced invasion and migration of hepatocarcinoma cells. Biomed Pharmacother 2018; 103:767-772. [PMID: 29684855 DOI: 10.1016/j.biopha.2018.04.095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/23/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023] Open
Abstract
Increasing evidences suggested that radiotherapy can paradoxically promote tumor invasion and metastatic processes, while its detailed mechanism is not well illustrated. Our present study found that radiation can promote the migration and invasion of hepatocellular carcinoma (HCC) cells via induction of epithelial mesenchymal transition (EMT), which was evidenced by the results that radiation induced up regulation of vimentin while down regulation of E-Cadherin. As to the EMT-related transcription factors, radiation increased the expression of Snail, while not Slug, ZEB1 or TWIST. This was confirmed by the results that radiation increased the nuclear translocation of Snail in HCC cells. However, radiation had no effect on the expression or half-life of Snail mRNA. In HCC cells treated by cycloheximide (CHX, the translation inhibitor), radiation significantly increased the half-life of Snail protein, which suggested that radiation increased the expression of Snail via up regulation of its protein stability. Radiation increased the expression of COP9 signalosome 2 (CSN2), which has been reported to block the ubiquitination and degradation of Snail. Silence of CSN2/Snail can attenuate radiation induced cell migration and EMT of HCC cells. Collectively, our data suggested that radiation can promote HCC cell invasion and EMT by stabilization of Snail via CSN2 signals.
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Affiliation(s)
- Liyang Dong
- Departments of Invasive Technology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Xuebang Zhang
- Departments of Radiotherapy and Chemotherapy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Wei Xiang
- Departments of Invasive Technology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Junwei Ni
- Departments of Invasive Technology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Weizhong Zhou
- Departments of Invasive Technology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Haiyan Li
- Departments of Rehabilitation, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
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Song JH, Son SH, Kay CS, Jang HS. Reducing the probability of radiation-induced hepatic toxicity by changing the treatment modality from helical tomotherapy to fixed-beam intensity-modulated radiotherapy. Oncotarget. 2015;6:33952-33960. [PMID: 26376679 PMCID: PMC4741816 DOI: 10.18632/oncotarget.5581] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/22/2015] [Indexed: 12/12/2022] Open
Abstract
Purpose To estimate and compare the risk of radiation-induced hepatic toxicity (RIHT) in helical tomotherapy and fixed-beam intensity-modulated radiotherapy (IMRT) for the treatment of hepatocellular carcinoma (HCC). Materials and Methods Twenty patients with unresectable HCC treated with tomotherapy were selected. We performed tomotherapy re-planning to reduce the non-target normal liver volume receiving a dose of more than 15 Gy (NTNL-V15Gy), and we created a fixed-beam IMRT plan (FB-P). We compared the dosimetric results as well as the estimated probability of RIHT among the tomotherapy initial plan (T-IP), the tomotherapy re-plan (T-RP), and the FB-P. Results Comparing the T-RP and FB-P, the homogeneity index was 0.11 better with the T-RP. However, the mean NTNL-V15Gy was 6.3% lower with the FB-P. These differences result in a decline in the probability of RIHT from 0.216 in the T-RP to 0.115 in the FB-P. In patients whose NTNL-V15Gy was higher than 43.2% with the T-RP, the probability of RIHT markedly reduced from 0.533 to 0.274. Conclusions By changing the treatment modality from tomotherapy to fixed-beam IMRT, we could reduce the liver dose and the probability of RIHT without scarifying the target coverage, especially in patients whose liver dose is high.
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Song JH, Son SH, Kay CS, Jang HS. Identification of Biologically Effective Dose-Volumetric Parameters That Predict Radiation-Induced Hepatic Toxicity in Patients Treated With Helical Tomotherapy for Unresectable Locally Advanced Hepatocellular Carcinoma. Medicine (Baltimore) 2015; 94:e1904. [PMID: 26512611 PMCID: PMC4985424 DOI: 10.1097/md.0000000000001904] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The purpose of this study is to identify dose-volumetric parameters that predict radiation-induced hepatic toxicity (RIHT) by analyzing the relationship between the biologically effective dose (BED) delivered to the normal liver and RIHT.The clinical and dosimetric data from 123 patients with unresectable hepatocellular carcinoma (HCC) treated with helical tomotherapy were analyzed. The median radiation dose was a 50 Gy in 4.5 Gy fractions (range, 30-60 Gy in 1.8-5.0 Gy fractions) to 95% of the planning target volume. RIHT was defined as a Child-Pugh score increase of at least 2 points within 3 months of helical tomotherapy completion.RIHT developed in 60 patients (48.7%). Multivariate logistic regression analysis showed that VBED20 (percentage of nontarget normal liver volume that received more than a BED of 20 Gy) was a significant parameter (P < 0.001), and the cut-off value was 40.8% with a sensitivity and specificity of 0.833 and 0.698, respectively, according to the receiver operating characteristic curve (P < 0.001).Maintaining a VBED20 below 40.8% will reduce the risk of RIHT, and the proposed normal liver tolerance curve could be a useful guideline when treating unresectable HCC patients with various radiotherapy dose schedules.
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Affiliation(s)
- Jin Ho Song
- From the Department of Radiation Oncology, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju (JHS); Department of Radiation Oncology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea (SHS, CSK); and Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea (HSJ)
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Abstract
Hepatocellular carcinoma is the major complication of chronic liver diseases and particularly of cirrhosis whatever its etiology. Once encountered mainly in the endemic countries of hepatitis B and C, the incidence of hepatocellular carcinoma (6/100,000) is parallel to the global development of diabetes, overweight and alcohol consumption. Little progress has been made for this cancer, whose mortality is 100 % at 10 years. Liver transplantation is the only truly curative treatment (survival more than 50 % at 10 years) since it allows the eradication of hepatocellular carcinoma and its essential cause, cirrhotic liver. This is the only possible therapy when liver function is impaired. It has little impact since in the richest countries, less than 10 % of cases can be transplanted. Surgical resection and percutaneous destruction methods (uni- and multipolar radiofrequency, microwave, cryotherapy, electroporation) are the preferred treatments (survival less than 50 % at 5 years) but are only applicable for moderate tumour masses and in the absence of adjuvant therapy, are effective only in the medium term. Most patients received chemoembolization through hepatic artery, whose action is modest. Radiotherapy is widely used in Asia but almost non-existent in Western countries in this indication. Sorafenib is the only effective drug but its impact is modest. Therapies combining two modalities (embolization and radiotherapy; embolization and radiofrequency) seem promising and deserve wider testing. Screening and monitoring of cirrhosis is probably the major measure for potentially curative therapies.
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Affiliation(s)
- I Ruiz
- Service d'hépatologie, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France; Équipe 18, Inserm U955, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France
| | - C Féray
- Service d'hépatologie, hôpital Henri-Mondor, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France; Équipe 18, Inserm U955, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil, France.
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Wang C, Li S, Sun A, Chen L, Liang R, Li G, Han J. The comparison of outcomes between hypofractionated and conventional 3D-CRT regimens used in combination with TACE as first-line treatment of advanced hepatocellular carcinoma. Tumour Biol 2015; 36:4967-72. [PMID: 25773387 DOI: 10.1007/s13277-015-3144-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 12/05/2013] [Indexed: 10/23/2022] Open
Abstract
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.
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Kalogeridi MA, Zygogianni A, Kyrgias G, Kouvaris J, Chatziioannou S, Kelekis N, Kouloulias V. Role of radiotherapy in the management of hepatocellular carcinoma: A systematic review. World J Hepatol 2015; 7:101-112. [PMID: 25625001 PMCID: PMC4295187 DOI: 10.4254/wjh.v7.i1.101] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 10/26/2014] [Accepted: 11/19/2014] [Indexed: 02/06/2023] Open
Abstract
Many patients with hepatocellular carcinoma (HCC) present with advanced disease, not amenable to curative therapies such as surgery, transplantation or radiofrequency ablation. Treatment options for this group of patients include transarterial chemoembolization (TACE) and radiation therapy. Especially TACE, delivering a highly concentrated dose of chemotherapy to tumor cells while minimizing systemic toxicity of chemotherapy, has given favorable results on local control and survival. Radiotherapy, as a therapeutic modality of internal radiation therapy with radioisotopes, has also achieved efficacious tumor control in advanced disease. On the contrary, the role of external beam radiotherapy for HCC has been limited in the past, due to the low tolerance of surrounding normal liver parenchyma. However, technological innovations in the field of radiotherapy treatment planning and delivery, have provided the means of delivering radical doses to the tumor, while sparing normal tissues. Advanced and highly conformal radiotherapy approaches such as stereotactic body radiotherapy and proton therapy, evaluated for efficacy and safety for HCC, report encouraging results. In this review, we present the role of radiotherapy in hepatocellular carcinoma patients not suitable for radical treatment.
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HWANG SANGYOUN, HEO KYU, KIM JOONSEOK, IM JUNGWOO, LEE SUNMI, CHO MONG, KANG DAEHWAN, HEO JEONG, LEE JUNWOO, CHOI CHEOLWON, YANG KWANGMO. Emodin attenuates radioresistance induced by hypoxia in HepG2 cells via the enhancement of PARP1 cleavage and inhibition of JMJD2B. Oncol Rep 2015; 33:1691-8. [DOI: 10.3892/or.2015.3744] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/08/2014] [Indexed: 11/06/2022] Open
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Kondo Y, Kimura O, Kogure T, Ninomiya M, Umezawa R, Sugawara T, Matsushita H, Jingu K, Nakagome Y, Iwata T, Morosawa T, Fujisaka Y, Iwasaki T, Shimosegawa T. Radiation Therapy Is a Reasonable Option for Improving the Prognosis in Hepatocellular Carcinoma. TOHOKU J EXP MED 2015; 237:249-57. [DOI: 10.1620/tjem.237.249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yasuteru Kondo
- Division of Gastroenterology, Tohoku University Hospital
| | - Osamu Kimura
- Division of Gastroenterology, Tohoku University Hospital
| | | | | | - Rei Umezawa
- Division of Radiation Oncology, Tohoku University Hospital
| | | | | | - Keiichi Jingu
- Division of Radiation Oncology, Tohoku University Hospital
| | - Yu Nakagome
- Division of Gastroenterology, Tohoku University Hospital
| | - Tomoaki Iwata
- Division of Gastroenterology, Tohoku University Hospital
| | | | | | - Takao Iwasaki
- Division of Gastroenterology, Tohoku University Hospital
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Lee IJ, Kim JW, Han KH, Kim JK, Kim KS, Choi JS, Park YN, Seong J. Concurrent chemoradiotherapy shows long-term survival after conversion from locally advanced to resectable hepatocellular carcinoma. Yonsei Med J 2014; 55:1489-97. [PMID: 25323884 PMCID: PMC4205687 DOI: 10.3349/ymj.2014.55.6.1489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE For locally unresectable hepatocellular carcinoma (HCC) patients, concurrent chemoradiotherapy (CCRT) has been applied as a loco-regional treatment. After shrinkage of tumors in selected patients, surgical resection is performed. The aim of this study was to evaluate prognostic factors and long-term survivors in such patients. MATERIALS AND METHODS From January 2000 to January 2009, 264 patients with HCC were treated with CCRT (45 Gy with fractional dose of 1.8 Gy), and intra-arterial chemotherapy was administered during radiotherapy. Eighteen of these patients (6.8%) underwent hepatic resection after showing a response to CCRT. Cases were considered resectable when tumor-free margins and sufficient remnant volumes were obtained without extrahepatic metastasis. Prior to operation, there were six patients with complete remission, 11 with partial remission, and six with stable disease according to modified Response Evaluation Criteria in Solid Tumors. RESULTS In pathologic review, four patients (22.2%) showed total necrosis and seven patients (38.9%) showed 70-99% necrosis. A high level of necrosis (≥80%) was correlated with low risk for extrahepatic metastasis and long-term survival. In univariate analyses, vessel invasion and capsular infiltration were significantly correlated with disease free survival (DFS) (p=0.017 and 0.013, respectively), and vessel invasion was significantly correlated with overall survival (OS) (p=0.013). In multivariate analyses, capsule infiltration was a significant factor for DFS (p=0.016) and vessel invasion was significant for OS (p=0.015). CONCLUSION CCRT showed favorable responses and locally advanced HCC converted into resectable tumor after CCRT in selected patients. Long-term survivors showed the pathological features of near total necrosis, as well as negative capsule and vessel invasion.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang Hyub Han
- Department of Internal Medicine, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Ja Kyung Kim
- Department of Internal Medicine, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Young Nyun Park
- Department of Pathology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University College of Medicine, Seoul, Korea.
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Merle P, Rode A, Benlaredj R, Cuinet M, Said T, Bathaix F, Enachescu C, Mornex F. Efficacy and safety of transarterial chemoembolization combined to conformal radiotherapy for uninodular hepatocellular carcinoma. Int J Cancer Ther Oncol 2014. [DOI: 10.14319/ijcto.0204.10] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
This review summarizes the contents of a workshop on multimodality management for Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC) held on July 6, 2013, under the auspices of the 4th Asia-Pacific Primary Liver Cancer Expert Meeting Scientific Advisory Committee. BCLC stage C HCC represents a varied disease spectrum and, therefore, further stratification of BCLC stage C should be explored. Although sorafenib is currently the standard treatment for BCLC stage C HCC, the survival benefits are modest and new treatment strategies are still needed. Based on the opinions of Asian experts, there are numerous alternative options aside from sorafenib for the treatment of BCLC stage C HCC, including surgical resection, hepatic arterial infusion chemotherapy, transarterial chemoembolization, and external radiotherapy. Moreover, there are several studies on the multimodality management of BCLC stage C HCC, mainly in the form of retrospective studies and a few phase I and II trials. Multimodality management with combinations of various locoregional therapies or locoregional therapies with systemic targeted therapy using sorafenib needs to be actively investigated. The Asia-Pacific clinical practice guidelines on multimodality management for BCLC stage C HCC need recommendations based on the level of evidence, the strength of the data, and the strength of recommendations of previously reported systems.
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Affiliation(s)
- Chihwan Choi
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Japan
| | - Gi Hong Choi
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Japan
| | - Tae Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea, Japan
| | - Masatoshi Tanaka
- Division of Gastroenterology, Department of Medicine, Yokokura Hospital, Fukuoka, Japan
| | - Mao-Bin Meng
- Department of Radiation Oncology and CyberKnife Center, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Tianjin, China
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Japan,*Jinsil Seong, MD, PhD, Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752 (Republic of Korea), Tel. +82 2 2228 8111, E-mail
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Malarvizhi GL, Retnakumari AP, Nair S, Koyakutty M. Transferrin targeted core-shell nanomedicine for combinatorial delivery of doxorubicin and sorafenib against hepatocellular carcinoma. Nanomedicine. 2014;10:1649-1659. [PMID: 24905399 DOI: 10.1016/j.nano.2014.05.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 05/12/2014] [Accepted: 05/16/2014] [Indexed: 12/19/2022]
Abstract
UNLABELLED Combinatorial drug delivery is an attractive, but challenging requirement of next generation cancer nanomedicines. Here, we report a transferrin-targeted core-shell nanomedicine formed by encapsulating two clinically used single-agent drugs, doxorubicin and sorafenib against liver cancer. Doxorubicin was loaded in poly(vinyl alcohol) nano-core and sorafenib in albumin nano-shell, both formed by a sequential freeze-thaw/coacervation method. While sorafenib from the nano-shell inhibited aberrant oncogenic signaling involved in cell proliferation, doxorubicin from the nano-core evoked DNA intercalation thereby killing >75% of cancer cells. Upon targeting using transferrin ligands, the nanoparticles showed enhanced cellular uptake and synergistic cytotoxicity in ~92% of cells, particularly in iron-deficient microenvironment. Studies using 3D spheroids of liver tumor indicated efficient penetration of targeted core-shell nanoparticles throughout the tissue causing uniform cell killing. Thus, we show that rationally designed core-shell nanoparticles can effectively combine clinically relevant single-agent drugs for exerting synergistic activity against liver cancer. FROM THE CLINICAL EDITOR Transferrin-targeted core-shell nanomedicine encapsulating doxorubicin and sorafenib was studied as a drug delivery system against hepatocellular carcinoma, resulting in enhanced and synergistic therapeutic effects, paving the way towards potential future clinical applications of similar techniques.
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Son SH, Jang HS, Jo IY, Choi BO, Jang JW, Yoon SK, Kay CS. Significance of an increase in the Child-Pugh score after radiotherapy in patients with unresectable hepatocellular carcinoma. Radiat Oncol 2014; 9:101. [PMID: 24779518 PMCID: PMC4016647 DOI: 10.1186/1748-717x-9-101] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Accepted: 04/21/2014] [Indexed: 12/15/2022] Open
Abstract
Background We attempted to analyze the effects of an increase in the Child-Pugh (CP) score on the overall survival of patients with unresectable hepatocellular carcinoma (HCC) after radiotherapy (RT). Methods From March 2006 to February 2012, 103 patients received RT using the TomoTherapy Hi-Art at Incheon St. Mary’s Hospital and Seoul St. Mary’s Hospital. The dose per fraction was 1.8–5 Gy, and the total dose was 40–60 Gy (median, 50 Gy). We considered an increase of at least 2 points in the CP score within 3 months after RT to be clinically important radiation-induced hepatic toxicity and analyzed the effects of an increased CP score on overall survival. Results The median follow-up duration was 11.6 months (range, 3.5–85.3 months). The median survival time was 11.6 months. In multivariate analysis, planning target volume and an increase in the CP score after RT were found to be a statistically significant factors (p = 0.010 and 0.015, respectively). In a comparison of cases with and without an increase in the CP score, there was an 11.0-month difference in the median survival time (6.9 vs. 17.9 months), and the relative risk of mortality was 1.8. Conclusion An increase of at least 2 points in the CP score within 3 months of RT completion is an important on-treatment factor that affects overall survival. To minimize such increases, careful patient selection and a more sophisticated radiation treatment plan are imperative.
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Affiliation(s)
| | | | | | | | | | | | - Chul Seung Kay
- Department of Radiation Oncology, Incheon St, Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea.
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Kim TH, Park JW, Kim YJ, Kim BH, Woo SM, Moon SH, Kim SS, Lee WJ, Kim DY, Kim CM. Simultaneous integrated boost-intensity modulated radiation therapy for inoperable hepatocellular carcinoma. Strahlenther Onkol 2014; 190:882-90. [PMID: 24638270 DOI: 10.1007/s00066-014-0643-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 02/12/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this work was to evaluate the clinical efficacy and safety of simultaneous integrated boost-intensity modulated radiation therapy (SIB-IMRT) in patients with inoperable hepatocellular carcinoma (HCC). METHODS AND MATERIALS A total of 53 patients with inoperable HCC underwent SIB-IMRT using two dose-fractionation schemes, depending on the proximity of gastrointestinal structures. The 41 patients in the low dose-fractionation (LD) group, with internal target volume (ITV) < 1 cm from gastrointestinal structures, received total doses of 55 and 44 Gy in 22 fractions to planning target volume 1 (PTV1) and 2 (PTV2), respectively. The 12 patients in the high dose-fractionation (HD) group, with ITV ≥ 1 cm from gastrointestinal structures, received total doses of 66 and 55 Gy in 22 fractions to the PTV1 and PTV2, respectively. RESULTS Overall, treatment was well tolerated, with no grade > 3 toxicity. The LD group had larger sized tumors (median: 6 vs. 3.4 cm) and greater frequencies of vascular invasion (80.6 vs. 16.7 %) than patients in the HD group (p < 0.05 each). The median overall survival (OS) was 25.1 mKonzept ist machbar und sicheronths and the actuarial 2-year local progression-free survival (LPFS), relapse-free survival (RFS), and OS rates were 67.3, 14.7, and 54.7 %, respectively. The HD group tended to show better tumor response (100 vs. 62.2 %, p = 0.039) and 2-year LPFS (85.7 vs. 59 %, p = 0.119), RFS (38.1 vs. 7.3 %, p = 0.063), and OS (83.3 vs. 44.3 %, p = 0.037) rates than the LD group. Multivariate analysis showed that tumor response was significantly associated with OS. CONCLUSION SIB-IMRT is feasible and safe for patients with inoperable HCC.
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Affiliation(s)
- Tae Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, 323 Ilsan-ro Ilsandong-gu, Goyang-si, 410-769, Gyeonggi-do, Republic of Korea
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Yoon HI, Seong J. Multimodality Treatment Involving Radiotherapy for Advanced Liver-Confined Hepatocellular Carcinoma. Oncology 2014; 87 Suppl 1:90-8. [DOI: 10.1159/000368151] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Miyaki D, Aikata H, Kan H, Fujino H, Urabe A, Masaki K, Fukuhara T, Kobayashi T, Naeshiro N, Nakahara T, Kawaoka T, Hiramatsu A, Takahashi S, Ishikawa M, Kakizawa H, Awai K, Chayama K. Clinical outcome of sorafenib treatment in patients with advanced hepatocellular carcinoma refractory to hepatic arterial infusion chemotherapy. J Gastroenterol Hepatol 2013; 28:1834-41. [PMID: 23808713 DOI: 10.1111/jgh.12311] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM It has been reported about poor prognosis in patients with advanced hepatocellular carcinoma (HCC) refractory to hepatic arterial infusion chemotherapy (HAIC). We assessed the survival benefits of sorafenib therapy for advanced HCC in HAIC refractory patients. METHODS The study subjects were 191 patients with advanced HCC who had been treated with HAIC. Sorafenib was used in 27 patients who finally failed to respond to HAIC (HAIC/sorafenib group). Clinical outcome was compared between HAIC/sorafenib and HAIC alone groups. RESULTS There were no significant differences in clinical characteristics and response rate of HAIC between the two groups (response rate: 25.9%, HAIC/sorafenib group; 30.4%, HAIC alone group). The median survival time (MST) for all patients was 11.0 months. The survival rate was significantly higher in the HAIC/sorafenib group than HAIC alone group (MST 22.2 vs 8.7 months, P = 0.017). From administration sorafenib, the disease control rate was 51.8% with MST of 10.4 months. Among HAIC non-responders, the survival rate was significantly higher in the HAIC/sorafenib group than HAIC alone group. Multivariate analysis identified additional therapy with sorafenib as significant and independent determinant of overall survival in all patients and HAIC non-responders. CONCLUSION Additional therapy with sorafenib could probably improve the prognosis of HAIC refractory patients.
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Affiliation(s)
- Daisuke Miyaki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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Cha H, Yoon HI, Lee IJ, Koom WS, Han KH, Seong J. Clinical factors related to recurrence after hepatic arterial concurrent chemoradiotherapy for advanced but liver-confined hepatocellular carcinoma. J Radiat Res 2013; 54:1069-1077. [PMID: 23633620 PMCID: PMC3823771 DOI: 10.1093/jrr/rrt034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 03/14/2013] [Accepted: 03/22/2013] [Indexed: 06/02/2023]
Abstract
Before the sorafenib era, advanced but liver-confined hepatocellular carcinoma (HCC) was treated by liver-directed therapy. Hepatic arterial concurrent chemoradiotherapy (CCRT) has been performed in our group, giving substantial local control but frequent failure. The aim of this study was to analyze patterns of failure and find out predictive clinical factors in HCC treated with a liver-directed therapy, CCRT. A retrospective analysis was done for 138 HCC patients treated with CCRT between May 2001 and November 2009. Protocol-based CCRT was performed with local radiotherapy (RT) and concurrent 5-fluorouracil (5-FU) hepatic arterial infusion chemotherapy (HAIC), followed by monthly HAIC (5-FU and cisplatin). Patterns of failure were categorized into three groups: infield, intrahepatic-outfield and extrahepatic failure. Treatment failure occurred in 34.0% of patients at 3 months after RT. Infield, intrahepatic-outfield and extrahepatic failure were observed in 12 (8.6%), 26 (18.7%) and 27 (19.6%) patients, respectively. Median progression-free survival for infield, outfield and extrahepatic failure was 22.4, 18 and 21.5 months, respectively. For infield failure, a history of pre-CCRT treatment was a significant factor (P = 0.020). Pre-CCRT levels of alpha-fetoprotein and prothrombin induced by vitamin K absence or antagonist-II were significant factors for extrahepatic failure (P = 0.029). Treatment failures after CCRT were frequent in HCC patients, and were more commonly intrahepatic-outfield and extrahepatic failures than infield failure. A history of pre-CCRT treatment and levels of pre-CCRT tumor markers were identified as risk factors that could predict treatment failure. More intensified treatment is required for patients presenting risk factors.
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Affiliation(s)
- Hyejung Cha
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Hong In Yoon
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Kwang-Hyub Han
- Yonsei Liver Cancer Special Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Republic of Korea
- Yonsei Liver Cancer Special Clinic, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Soliman H, Ringash J, Jiang H, Singh K, Kim J, Dinniwell R, Brade A, Wong R, Brierley J, Cummings B, Zimmermann C, Dawson LA. Phase II trial of palliative radiotherapy for hepatocellular carcinoma and liver metastases. J Clin Oncol 2013; 31:3980-6. [PMID: 24062394 DOI: 10.1200/jco.2013.49.9202] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate the feasibility and response of liver radiotherapy (RT) in improving symptoms and quality of life in patients with hepatocellular carcinoma (HCC) or liver metastases (LM). PATIENTS AND METHODS Eligible patients had HCC or LM, unsuitable for or refractory to standard therapies, with an index symptom of pain, abdominal discomfort, nausea, or fatigue. The Brief Pain Inventory (BPI), Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep), and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) were completed by patients at baseline and each follow-up. The primary outcome was the percentage of patients with a clinically significant change at 1 month in the BPI subscale of symptom on average in the past 24 hours. Secondary outcomes were improvement in other BPI subscales and at other time points, FACT-Hep and EORTC QLQ-C30 at each follow-up, and toxicity at 1 week. RESULTS Forty-one patients (30 men and 11 women) with HCC (n = 21) or LM (n = 20) were accrued. At 1 month, 48% had an improvement in symptom on average in the past 24 hours. Fifty-two percent of patients had improvement in symptom at its worst, 37% at its least, and 33% now. Improvements in the FACT-G and hepatobiliary subscale were seen in 23% and 29% of patients, respectively, at 1 month. There were also improvements in EORTC QLQ-C30 functional (range, 11% to 21%) and symptom (range, 11% to 50%) domains. One patient developed grade 3 nausea at 1 week. CONCLUSION Improvements in symptoms were observed at 1 month in a substantial proportion of patients. A phase III study of palliative liver RT is planned. [Corrected]
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Affiliation(s)
- Hany Soliman
- Hany Soliman, Odette Sunnybrook Cancer Centre, University of Toronto; Jolie Ringash, Haiyan Jiang, John Kim, Robert Dinniwell, Anthony Brade, Rebecca Wong, James Brierley, Bernard Cummings, Camilla Zimmermann, and Laura A. Dawson, Princess Margaret Cancer Centre, University of Toronto; and Jolie Ringash and Kawalpreet Singh, University of Toronto, Toronto, Ontario, Canada
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Kong M, Hong SE, Choi WS, Choi J, Kim Y. Treatment outcomes of helical intensity-modulated radiotherapy for unresectable hepatocellular carcinoma. Gut Liver 2013; 7:343-51. [PMID: 23710317 PMCID: PMC3661968 DOI: 10.5009/gnl.2013.7.3.343] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 08/29/2012] [Accepted: 09/07/2012] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Moonkyoo Kong
- Department of Radiation Oncology, Kyung Hee University School of Medicine, Seoul, Korea
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Son SH, Jang HS, Lee H, Choi BO, Kang YN, Jang JW, Yoon SK, Kay CS. Determination of the α/β ratio for the normal liver on the basis of radiation-induced hepatic toxicities in patients with hepatocellular carcinoma. Radiat Oncol 2013; 8:61. [PMID: 23497395 PMCID: PMC3641977 DOI: 10.1186/1748-717x-8-61] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 03/08/2013] [Indexed: 12/30/2022] Open
Abstract
Background The purpose of this study was to determine the α/β ratio for normal liver with hepatitis by analyzing the toxicity data from patients with unresectable hepatocellular carcinoma treated with helical tomotherapy. Methods Between March 2006 and February 2012, 98 patients were eligible for this study. 66 patients received 45–50 Gy in 4.5-5 Gy fractions (Group A) and 32 patients received 36–60 Gy in 2.5-3 Gy fractions (Group B). Radiation-induced hepatic toxicity was defined as an increase of at least 2 points in the Child-Pugh score within 4 months of completing helical tomotherapy. We attempted to find the statistically significant parameters in the 2 groups using α/β ratios of 2, 4, 6, 8, or 10, and compared the estimated probability curves of each significant parameter. We hypothesized that the α/β ratio associated with the best matches for the curves between the 2 groups would be equivalent to the α/β ratio for the normal liver. Results When using an α/β ratio of 2 or 4, different parameters were found to be statistically significant in a multivariate analysis (Group A: VBED30 for α/β ratio = 2 and VBED25 for α/β ratio = 4, Group B: VBED25 for α/β ratio = 2 and VBED20 for α/β ratio = 4). When using an α/β ratio of 6, 8, or 10, VBED20 was found to be a statistically significant parameter in both groups. Comparison of the estimated probability curve of each significant parameter between the groups revealed that an α/β ratio of 8 resulted in the best matches. Conclusions We suggest that the α/β ratio of the normal liver with hepatitis is 8. We hope that previously reported parameters and their values can be effectively used in different fractionation schemes by calculating the biologically effective dose using an α/β ratio of 8.
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Affiliation(s)
- Seok Hyun Son
- Department of Radiation Oncology, Incheon St, Mary's Hospital, College of Medicine, the Catholic University of Korea, Incheon, Korea
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Son SH, Kay CS, Song JH, Lee SW, Choi BO, Kang YN, Jang JW, Yoon SK, Jang HS. Dosimetric parameter predicting the deterioration of hepatic function after helical tomotherapy in patients with unresectable locally advanced hepatocellular carcinoma. Radiat Oncol 2013; 8:11. [PMID: 23298438 PMCID: PMC3552734 DOI: 10.1186/1748-717x-8-11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 01/05/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify parameters capable of predicting the deterioration of hepatic function after helical tomotherapy in patients with unresectable locally advanced hepatocellular carcinoma. METHODS Between March 2006 and February 2012, 72 patients were eligible for this study. All patients received hypofractionated radiotherapy using the TomoTherapy Hi-Art (TomoTherapy, Madison, WI, USA) at Seoul St. Mary's Hospital and Incheon St. Mary's Hospital, the Catholic University of Korea. The radiation dose was a median 50 Gy (range: 40-50 Gy) in 10 fractions to 95% of the planning target volume. Radiation-induced hepatic toxicity was defined as an increase of at least 2 points in the Child-Pugh (CP) score within 3 months after completion of helical tomotherapy. RESULTS An increase of at least 2 points in the CP score occurred in 32 of the 72 patients (44.4%). Multivariate logistic regression analysis revealed that pretreatment CP class and V15Gy were significant parameters associated with an increase in CP score (p = 0.009 and p < 0.001, respectively). The area under receiver operating characteristic curve was 0.863 for V15Gy (p < 0.001). For V15Gy, with a cutoff value of 43.2%, the accuracy was 0.806 (58/72) with a sensitivity of 0.938 and a specificity of 0.725. CONCLUSIONS An increase of at least 2 points in the CP score is a radiation dose-limiting factor, and the non-target normal liver receiving a dose more than 15 Gy (V15Gy) should be <43.2% to reduce the risk of the deterioration of hepatic function.
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Affiliation(s)
- Seok Hyun Son
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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29
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Abstract
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.
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Miyaki D, Aikata H, Honda Y, Naeshiro N, Nakahara T, Tanaka M, Nagaoki Y, Kawaoka T, Takaki S, Waki K, Hiramatsu A, Takahashi S, Ishikawa M, Kakizawa H, Awai K, Chayama K. Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma according to Child-Pugh classification. J Gastroenterol Hepatol 2012; 27:1850-7. [PMID: 23020312 DOI: 10.1111/j.1440-1746.2012.07276.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM We compared the treatment response, survival, and safety to hepatic arterial infusion chemotherapy (HAIC) in patients with advanced hepatocellular carcinoma (HCC) according to Child-Pugh (CP) score. METHODS The study subjects were 249 patients with advanced HCC and CP class A and B who had been treated with HAIC. Patients were grouped according to CP score (5/6, 7 and 8/9) and their tumor response, tolerance, and survival were assessed. RESULTS The median survival time (MST) was 8.2, 9.7, 6.3, and 3.9 months for the whole group, patients with CP 5/6, 7 and 8/9, respectively (P < 0.0001). Complete response (CR) and partial response (PR) were seen in 11 and 57 patients, respectively, with an overall response rate of 27.3%. The response rate was higher in patients with CP score 5/6 and 7, than CP 8/9 (30.5%, 28.2%, 13.8%). The dropout rate was significantly higher in patients with CP score 8/9 than the other two (8.0%, 12.8%, 33.3%, respectively). The survival rate was significantly better in patients who achieved CR/PR than the others with CP score 5/6, 7. CP score 8/9 was an independent negative factor for response and survival. CONCLUSION Advanced HCC patients with CP score of 5/6 and 7 showed a better response to HAIC and better prognosis than those with CP score 8/9.
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Affiliation(s)
- Daisuke Miyaki
- Department of Medicine and Molecular Science, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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31
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Abstract
The Barcelona Clinic Liver Cancer (BCLC) staging system is the method currently used to stage hepatocellular carcinoma (HCC) and therefore plays an important role in deciding on an appropriate course of treatment. BCLC takes into consideration the extent of the disease as well as patient factors such as hepatic function and performance status. However, it does not propose solutions for all clinical situations. Although radiotherapy (RT) is not included in the BCLC guidelines, the potent local antitumor effect of RT should be considered seriously as a part of the treatment strategy. Novel RT technologies introduced during the last decade have made it possible to deliver higher doses of radiation to the tumor while avoiding damage to critical normal tissues adjacent to the tumor. Because of the growing interest in using RT for HCC patients unfit for or progressed beyond standard treatments, the role of RT for HCC patients needs to be specified within the BCLC staging system. Curative RT can be used for patients with either very early or early stage BCLC; focal high dose RTs, such as stereotactic body RT, are especially useful. Intermediate or advanced stage disease confined to the liver can be managed safely and effectively by localized RT in conjunction with other treatment modalities such as transarterial chemoembolization or concurrent or adjuvant chemotherapy. In this review, the efficacy of RT in each BCLC stage of HCC will be discussed.
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Affiliation(s)
| | - Seong Jinsil
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine Seoul, Republic of Korea
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Park MS, Kim SU, Park JY, Kim DY, Ahn SH, Han KH, Chon CY, Seong J. Combination treatment of localized concurrent chemoradiation therapy and transarterial chemoembolization in locally advanced hepatocellular carcinoma with intrahepatic metastasis. Cancer Chemother Pharmacol 2012; 71:165-73. [PMID: 23079897 DOI: 10.1007/s00280-012-1993-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 09/26/2012] [Indexed: 12/14/2022]
Abstract
PURPOSE Although sorafenib has been approved for treating advanced hepatocellular carcinoma (HCC), its high cost, frequent adverse events, and unsatisfactory efficacy remain unresolved. We evaluated the efficacy and safety of the combination treatment of localized concurrent chemoradiation therapy (CCRT) for locally advanced HCC with portal vein thrombosis (PVT) and transarterial chemoembolization (TACE) for intrahepatic metastasis. METHODS Between January 2006 and June 2011, 30 patients with HCC with portal vein invasion and intrahepatic metastasis were enrolled. After TACE for intrahepatic metastasis, localized CCRT (45 Gy over 5 weeks with conventional fractionation and hepatic artery infusional chemotherapy using 5-fluorouracil as a radiosensitizer, administered during the first and fifth weeks of radiotherapy) was used to treat main HCC with PVT. The modified response evaluation criteria in solid tumors (mRECIST) were used to evaluate tumor response. RESULTS The median age of the patients (26 men, 4 women) was 51 years. Objective response rates were 30.0% (9/30) and 32.1% (9/28) in the intention-to-treat and per protocol analyses, respectively. The median progression-free survival (PFS) and overall survival (OS) were 4.5 and 9.8 months, respectively. Baseline α-fetoprotein (AFP) correlated significantly with PFS (P = 0.008), whereas baseline AFP, completion of the protocol, and overall radiological response influenced OS significantly (all P < 0.05). All adverse events were predictable and manageable with conservative care. CONCLUSIONS Combination treatment of localized CCRT and TACE was effective and tolerable in patients with locally advanced HCC with PVT and intrahepatic metastasis. This protocol may be an alternative option when sorafenib cannot be prescribed.
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Affiliation(s)
- Mi Sung Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Carmi L, Georgiades C. Combination percutaneous and intraarterial therapy for the treatment of hepatocellular carcinoma: a review. Semin Intervent Radiol 2012; 27:296-301. [PMID: 22550369 DOI: 10.1055/s-0030-1261788] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Transcatheter arterial chemoembolization (TACE) and percutaneous ablation therapies have been shown to provide effective therapy and afford survival prolongation for patients with unresectable hepatocellular carcinoma (HCC). Both treatments, however, have inherent limitations that restrict their benefit; TACE is not a curative therapy and ablation efficacy is significantly limited by lesion size. Current treatment strategies aim to combine intraarterial and percutaneous liver-directed therapies synergistically to improve tumor response, and by extension improve patient survival. This article reviews the current literature on combination treatments, and examines the circumstances in which therapeutic combinations would improve tumor response and patient survival.
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Affiliation(s)
- Lemore Carmi
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
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Yoon HI, Koom WS, Lee IJ, Jeong K, Chung Y, Kim JK, Lee KS, Han KH, Seong J. The significance of ICG-R15 in predicting hepatic toxicity in patients receiving radiotherapy for hepatocellular carcinoma. Liver Int 2012; 32:1165-71. [PMID: 22435801 DOI: 10.1111/j.1478-3231.2012.02784.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 02/14/2012] [Indexed: 12/13/2022]
Abstract
AIM To evaluate whether the retention rate of indocyanine green 15 min after administration (ICG-R15) could predict radiation hepatotoxicity in patients treated with radiotherapy (RT) for hepatocellular carcinoma (HCC). METHODS We retrospectively reviewed data of 146 HCC patients treated with RT between February 1994 and December 2008. The ICG-R15 was measured within 1 month prior to the start of RT. Radiation hepatotoxicity was evaluated by incidence of radiation-induced liver disease (RILD) between 2 weeks and 3 months after completion of RT. We analysed the correlation between the incidence rate of RILD and the ICG-R15 before RT (pre-RT ICG-R15). RESULTS The classic and non-classic RILD occurred in 15 patients (10.3%): classic type in five patients (3.4%) and non-classic RILD in 10 patients (6.9%). A positive correlation was shown between the probability of RILD and increase in pre-RT ICG-R15 (P < 0.0001). Univariate analysis indicated that cut-off value of pre-RT ICG-R15 could predict RILD significantly. The incidence of RILD for the patients with 22% or higher pre-RT ICG-R15 levels was 40.7% as compared to 3.4% for those with levels lower than 22% (P < 0.0001). There was no clinical factor that significantly affected RILD in univariate analysis. Multivariate analysis indicated that the pre-RT ICG-R15 value was the only significant factor affecting RILD (P < 0.0001). CONCLUSION These results suggest that pre-RT ICG-R15 could be a useful factor in predicting radiation hepatotoxicity in HCC patients treated with RT.
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Affiliation(s)
- Hong In Yoon
- Department of Radiation Oncology, Yonsei University Health System, Seoul, Korea
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35
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Murakami E, Aikata H, Miyaki D, Nagaoki Y, Katamura Y, Kawaoka T, Takaki S, Hiramatsu A, Waki K, Takahashi S, Kimura T, Kenjo M, Nagata Y, Ishikawa M, Kakizawa H, Awai K, Chayama K. Hepatic arterial infusion chemotherapy using 5-fluorouracil and systemic interferon-α for advanced hepatocellular carcinoma in combination with or without three-dimensional conformal radiotherapy to venous tumor thrombosis in hepatic vein or inferior vena cava. Hepatol Res 2012; 42:442-53. [PMID: 22176468 DOI: 10.1111/j.1872-034x.2011.00943.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM We investigated the efficacy of hepatic arterial infusion chemotherapy (HAIC) using 5-fluorouracil (5-FU) and systemic interferon (IFN)-α (HAIC-5-FU/IFN) for advanced hepatocellular carcinoma (HCC) with venous tumor thrombosis (VTT) in the hepatic vein trunk (Vv2) or inferior vena cava (Vv3). METHODS Thirty-three patients with HCC/Vv2/3 underwent HAIC with 5-FU (500 mg/body weight/day, into hepatic artery on days 1-5 on the first and second weeks) and IFN-α (recombinant IFN-α-2b 3 000 000 U or natural IFN-α 5 000 000 U, intramuscularly on days 1, 3 and 5 of each week). Three-dimensional conformal radiotherapy (3D-CRT) was used in combination with HAIC-5-FU/IFN in 14 of 33 patients to reduce VTT. RESULT The median survival time (MST) was 7.9 months, and 1- and 2-year survival rates were 30% and 20%, respectively. Evaluation of intrahepatic response after two cycles of HAIC-5-FU/IFN showed complete response (CR) in three (9%) and partial response (PR) in seven (21%), with an objective response rate of 30%. Multivariate analysis identified reduction of VTT (P = 0.0006), size of largest tumor (P = 0.013) and intrahepatic response CR/PR (P = 0.030) as determinants of survival. CR/PR correlated significantly with tumor liver occupying rate (P = 0.016) and hepatitis C virus Ab (P = 0.010). Reduction of VTT correlated significantly with radiotherapy (P = 0.021) and platelet count (P = 0.015). Radiotherapy-related reduction in VTT significantly improved survival of 16 patients with Vv3 and non-CR/PR response of HAIC-5-FU/IFN (P = 0.028). CONCLUSION As for advanced HCC with VTT of Vv2/3, HAIC-5-FU/IFN responsive patients could obtain favorable survival. Despite ineffective HAIC-5-FU/IFN, the combination with effective radiotherapy to VTT might improve patients' prognosis.
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Affiliation(s)
- Eisuke Murakami
- Departments of Medicine and Molecular Science, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Science Radiation Oncology, Division of Genome Radiobiology and Medical Science Diagnostic Radiology, Division of Medical Intelligence and Informatics, Hiroshima University, Hiroshima, Japan
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Abstract
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.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei Liver Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Liver Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
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Eun HS, Kim MJ, Kim HJ, Ko KH, Moon HS, Lee ES, Kim SH, Lee HY, Lee BS. The retrospective cohort study for survival rate in patients with advanced hepatocellular carcinoma receiving radiotherapy or palliative care. Korean J Hepatol 2012; 17:189-98. [PMID: 22102385 PMCID: PMC3304653 DOI: 10.3350/kjhep.2011.17.3.189] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background/Aims This study was conducted to investigate the assessment of treatment efficacy of radiotherapy (RT) and other therapeutic modalities compared with palliative care only for treatment with advanced hepatocellular carcinoma (HCC). Methods From 2002 to 2010, based on the case of 47 patients with advanced HCC, we have investigated each patients' Child-Pugh's class, ECOG performance, serum level of alpha fetoprotein and other baseline characteristics that is considered to be predictive variables and values for prognosis of HCC. Out of overall patients, the 29 patients who had received RT were selected for one group and the 18 patients who had received only palliative care were classified for the other. The analysis in survival between the two groups was done to investigate the efficacy of RT. Results Under the analysis in survival, the mean survival time of total patients group was revealed between 30.1 months and 45.9 months in RT group, while it was 4.8 months in palliative care group, respectively. In the univariate analysis for overall patients, there were significant factors which affected survival rate like as follows: ECOG performance, Child-Pugh's class, the tumor size, the type of tumor, alpha fetoprotein, transarterial chemoembolization, and RT. The regressive analysis in multivariate Cox for total patients. No treatment under radiotherapy and high level of Child-Pugh's class grade were independent predictors of worse overall survival rate in patients. In contrast, for the subset analysis of the twenty-nine patients treated with radiotherapy, the higher serum level of alpha fetoprotein was an independent predictors of worse overall survival rate in patients. Conclusions We found that the survival of patients with advanced HCC was better with radiotherapy than with palliative care. Therefore, radiotherapy could be a good option for in patients with advanced HCC.
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Affiliation(s)
- Hyuk Soo Eun
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon, Korea
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Abstract
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.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei Liver Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
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39
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Kang MK, Kim MS, Kim SK, Ye GW, Lee HJ, Kim TN, Eun JR. High-Dose Radiotherapy with Intensity-Modulated Radiation Therapy for Advanced Hepatocellular Carcinoma. Tumori 2011; 97:724-731. [DOI: 10.1177/030089161109700608] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Aims and Background We report the results of intensity-modulated radiotherapy for patients with advanced hepatocellular carcinoma who were not candidate for local ablative therapies, transarterial chemoembolization or hepatic arterial infusion chemotherapy. Methods and Study Design Between 2003 and 2008, 27 patients were treated with high-dose radiotherapy (median dose, 50.4 Gy). The equivalent sphere size of tumors was 11.4 ± 2.6 cm. Nineteen and 8 patients were Child-Pugh class A and B, respectively. Eighteen patients had thromboses in large veins. Six patients were treated with radiotherapy as the initial treatment modality, and 21 patients received other treatments before radiotherapy. Results The overall response rate was 44.4% (1 pathologic complete response and 11 partial responses). The primary failure pattern was intrahepatic disease progression. Until the last follow-up, the primary liver masses and vein thromboses did not progress in 63.6% and 60.0% of the patients, respectively. The median progression-free survival and overall survival after radiotherapy rate were 3 and 5 months, respectively. Based on univariate analyses, response, Child-Pugh classification, and vein thrombosis were significant factors for overall survival, and tumor response, tumor size, vein thrombosis, and multiplicity were significant factors for progression-free survival. Tumor response was the only significant prognostic factor for overall survival and progression-free survival based on multivariate analyses. Conclusions Radiotherapy with intensity-modulated radiotherapy achieved a good response rate in patients with advanced hepatocellular carcinoma, and patients who had a good response lived longer than patients who did not have a good response.
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Affiliation(s)
- Min Kyu Kang
- Departments of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Myung Se Kim
- Departments of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Sung Kyu Kim
- Departments of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Gi Won Ye
- Departments of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Heon Ju Lee
- Departments of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Tae Nyeun Kim
- Departments of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jong Ryul Eun
- Departments of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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Kim JS, You CR, Jang JW, Bae SH, Choi JY, Yoon SK, Kay CS. Application of helical tomotherapy for two cases of advanced hepatocellular carcinoma. Korean J Intern Med 2011; 26:201-6. [PMID: 21716911 PMCID: PMC3110853 DOI: 10.3904/kjim.2011.26.2.201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Revised: 01/29/2008] [Accepted: 05/13/2008] [Indexed: 01/10/2023] Open
Abstract
The role of radiotherapy in the treatment of hepatocellular carcinoma (HCC) has been limited to date, because the liver has a low tolerance to radiation. However, reconstructing tumors and surrounding organs via a three-dimensional conformal planning system can avoid excess radiotherapy exposure to the rest of the liver and adjacent organs. Recently, the concept of "adaptive radiotherapy," such as with helical tomotherapy, has been introduced for treating HCC. Helical tomotherapy obtains an image from the computed tomography component, which allows targeted regions to be visualized prior to, during, and immediately after each treatment and delivers intensity-modulated radiation therapy. We report two patients with advanced HCC who underwent tomotherapy treatment. One was a patient afflicted with advanced HCC and a portal vein tumor thrombus, which was treated with tomotherapy combined with transarterial chemolipiodolization. The other was a patient afflicted with multiple pulmonary metastases treated with tomotherapy followed by systemic chemotherapy.
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MESH Headings
- Adult
- Carcinoma, Hepatocellular/diagnostic imaging
- Carcinoma, Hepatocellular/radiotherapy
- Carcinoma, Hepatocellular/secondary
- Chemotherapy, Adjuvant
- Dose Fractionation, Radiation
- Female
- Humans
- Imaging, Three-Dimensional
- Liver Neoplasms/diagnostic imaging
- Liver Neoplasms/pathology
- Liver Neoplasms/radiotherapy
- Male
- Neoplasm Invasiveness
- Radiographic Image Interpretation, Computer-Assisted
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Conformal
- Tomography, Spiral Computed
- Treatment Outcome
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Affiliation(s)
- Joon Sung Kim
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Chan Ran You
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Jeong Won Jang
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Si-Hyun Bae
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Jong Yong Choi
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Seung Kew Yoon
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Chul Seung Kay
- Department of Radiation Oncology, The Catholic University of Korea School of Medicine, Seoul, Korea
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Yoon SM, Lim YS, Won HJ, Kim JH, Kim KM, Lee HC, Chung YH, Lee YS, Lee SG, Park JH, Suh DJ. Radiotherapy plus transarterial chemoembolization for hepatocellular carcinoma invading the portal vein: long-term patient outcomes. Int J Radiat Oncol Biol Phys 2011; 82:2004-11. [PMID: 21621346 DOI: 10.1016/j.ijrobp.2011.03.019] [Citation(s) in RCA: 172] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 03/09/2011] [Accepted: 03/21/2011] [Indexed: 01/10/2023]
Abstract
PURPOSE We have evaluated the clinical outcomes of patients after transarterial chemoembolization (TACE) and 3-dimensional conformal radiotherapy for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). METHODS AND MATERIALS A registry database of 412 patients treated with TACE and three-dimensional conformal radiotherapy for HCC with PVTT between August 2002 and August 2008 were analyzed retrospectively. The radiotherapy volume included the PVTT, with a 2- to 3-cm margin to cover adjacent HCC. Intrahepatic primary HCC was managed by TACE before or after radiotherapy. RESULTS Median patient age was 52 years old, and 88.1% of patients were male. Main or bilateral PVTT was observed in 200 (48.5%) patients. Median radiation dose was 40 Gy (range, 21-60 Gy) delivered in 2- to 5-Gy fractions. We found that 3.6% of patients achieved a complete response and that 24.3% of patients achieved a partial response. The response and progression-free rates of PVTT were 39.6% and 85.6%, respectively. Median patient survival was 10.6 months, and the 1- and 2-year survival rates were 42.5% and 22.8%, respectively. Significant independent variables associated with overall survival included advanced tumor stage, alpha-fetoprotein level, degree of PVTT, and response to radiotherapy. Forty-one patients (10.0%) showed grade 3-4 hepatic toxicity during or 3 months after completion of radiotherapy. Grades 2-3 gastroduodenal complications were observed in 15 patients (3.6%). CONCLUSIONS Radiotherapy is a safe and effective treatment for PVTT in patients with HCC. These results suggested that the combination of TACE and radiotherapy is a treatment option for relieving and/or stabilizing PVTT in patients with advanced HCC.
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Affiliation(s)
- Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Lee IJ, Seong J, Koom WS, Kim YB, Jeon BC, Kim JH, Han KH. Selection of the Optimal Radiotherapy Technique for Locally Advanced Hepatocellular Carcinoma. Jpn J Clin Oncol 2011; 41:882-9. [DOI: 10.1093/jjco/hyr053] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Lee IJ, Seong J, Bae JI, You SH, Rhee Y, Lee JH. Effect of Oral Supplementation with Branched-chain Amino Acid (BCAA) during Radiotherapy in Patients with Hepatocellular Carcinoma: A Double-Blind Randomized Study. Cancer Res Treat 2011; 43:24-31. [PMID: 21509160 PMCID: PMC3072532 DOI: 10.4143/crt.2011.43.1.24] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 08/27/2010] [Indexed: 02/08/2023] Open
Abstract
Purpose The present study evaluated whether oral supplementation with a branched-chain amino acid (BCAA) improves the biochemical and amino acid profiles of liver tumor patients undergoing radiotherapy. Materials and Methods Patients were randomly assigned to one of 2 groups: a group given oral supplementation with BCAA granules (LIVACT granules; Samil Pharm Co., Korea, each granule containing L-isoleucine 952 mg, L-leucine 1,904 mg, and L-valine 1,144 mg) during radiotherapy, or a placebo group. Physical and biochemical examinations and measurements, including subjective symptoms, Child-Pugh class, body mass index, plasma albumin concentration, and plasma amino acid profiles were monitored. Results Fifty were enrolled between November 2005 and November 2006. We also analyzed data from 37 hepatocellular carcinoma (HCC) patients in order to evaluate a more homogenous group. The two groups of patients were comparable in terms of age, gender, Child-Pugh score, and underlying hepatitis virus type. Serum albumin, total protein, liver enzymes, and cholesterol showed a tendency to increase in the BCAA group. In this group, the percentage of cases that reverted to normal serum albumin levels between 3 and 10 weeks after administration of BCAA was significantly higher (41.18%) than in the placebo group (p=0.043). Conclusion Oral supplementation with a BCAA preparation seems to help HCC patients undergoing radiotherapy by increasing the BCAA concentration.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei University Health System, Seoul, Korea
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Lee IJ, Seong J, Bae JI, You SH, Rhee Y, Lee JH. Effect of Oral Supplementation with Branched-chain Amino Acid (BCAA) during Radiotherapy in Patients with Hepatocellular Carcinoma: A Double-Blind Randomized Study. Cancer Res Treat 2011. [PMID: 21509160 DOI: 10.4143/crt.2011.43.1.24.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The present study evaluated whether oral supplementation with a branched-chain amino acid (BCAA) improves the biochemical and amino acid profiles of liver tumor patients undergoing radiotherapy. MATERIALS AND METHODS Patients were randomly assigned to one of 2 groups: a group given oral supplementation with BCAA granules (LIVACT granules; Samil Pharm Co., Korea, each granule containing L-isoleucine 952 mg, L-leucine 1,904 mg, and L-valine 1,144 mg) during radiotherapy, or a placebo group. Physical and biochemical examinations and measurements, including subjective symptoms, Child-Pugh class, body mass index, plasma albumin concentration, and plasma amino acid profiles were monitored. RESULTS Fifty were enrolled between November 2005 and November 2006. We also analyzed data from 37 hepatocellular carcinoma (HCC) patients in order to evaluate a more homogenous group. The two groups of patients were comparable in terms of age, gender, Child-Pugh score, and underlying hepatitis virus type. Serum albumin, total protein, liver enzymes, and cholesterol showed a tendency to increase in the BCAA group. In this group, the percentage of cases that reverted to normal serum albumin levels between 3 and 10 weeks after administration of BCAA was significantly higher (41.18%) than in the placebo group (p=0.043). CONCLUSION Oral supplementation with a BCAA preparation seems to help HCC patients undergoing radiotherapy by increasing the BCAA concentration.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei University Health System, Seoul, Korea
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Park CK, Bae SH, Yang HJ, Chun HJ, Choi IB, Choi JY, Yoon SK. Successful treatment of stereotactic body radiation therapy combined with transarterial chemolipiodolization for hepatocellular carcinoma with biliary obstruction. Korean J Intern Med 2011; 26:94-8. [PMID: 21437169 PMCID: PMC3056263 DOI: 10.3904/kjim.2011.26.1.94] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 09/03/2007] [Accepted: 06/10/2008] [Indexed: 01/10/2023] Open
Abstract
Conventional radiation therapy (RT) is a widely recognized treatment for hepatocellular carcinoma (HCC). However, conventional RT plays only a limited role in HCC treatment because of its low efficacy and the low tolerance of the liver for this modality. Stereotactic body radiation therapy (SBRT) was recently developed and represents the most advanced radiation therapy technique currently available. It can deliver a high dose in a short time to well-defined hepatic tumors, with rapid dose fall-off gradients. We believe that SBRT with transarterial chemolipiodolization (TACL) may prove promising as a combined treatment modality for HCC due to its precision and relative safety. Here we present a case of successful treatment of advanced HCC with obstructive jaundice using this combined modality.
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Affiliation(s)
- Chan-Kwon Park
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Si-Hyun Bae
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Hong-Jun Yang
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Ho-Jong Chun
- Department of Radiation Oncology, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Il-Bong Choi
- Department of Radiation Oncology, The Catholic University of Korea School of Medicine, Seoul, Korea
| | - Jong-Young Choi
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
| | - Seung-Kew Yoon
- Department of Internal Medicine, The Catholic University of Korea School of Medicine, Seoul, Korea
- WHO Collaborating Center for Reference and Research on Viral Hepatitis, Seoul, Korea
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Merle P, Mornex F. [Transarterial chemoembolization and conformal radiotherapy for hepatocellular carcinoma]. Cancer Radiother 2011; 15:69-71. [PMID: 21237690 DOI: 10.1016/j.canrad.2010.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 07/21/2010] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- P Merle
- Service d'hépatogastroentérologie, hôpital de l'Hôtel-dieu, 1 place de l'Hôpital, Lyon, France.
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Liang SX, Huang XB, Zhu XD, Zhang WD, Cai L, Huang HZ, Li YF, Chen L, Liu MZ. Dosimetric predictor identification for radiation-induced liver disease after hypofractionated conformal radiotherapy for primary liver carcinoma patients with Child-Pugh Grade A cirrhosis. Radiother Oncol. 2011;98:265-269. [PMID: 21056489 DOI: 10.1016/j.radonc.2010.10.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 10/13/2010] [Accepted: 10/14/2010] [Indexed: 01/12/2023]
Abstract
PURPOSE Radiation-induced liver disease (RILD) is the most severe complication in liver cancer treatment. The aim of this study was to identify dosimetric predictors for RILD in primary liver carcinoma (PLC) patients with Child-Pugh Grade A cirrhosis after hypofractionated conformal radiotherapy (CRT). METHODS AND MATERIALS A total of 114 eligible patients (mean age 45 years old) were enrolled and treated. The mean gross tumor volume (GTV) was (378.3±308.1) cm(3). A median dose of 53 Gy was delivered to the PLC by hypofractionated CRT (three fractions/week) with a median fraction size of 4.6 Gy (range: 4-6 Gy). RESULTS Patients were followed up for 1-79 months (median 19 months) after the completion of irradiation. RILD was diagnosed in nine (7.9%) patients. Univariate analyses revealed that GTV and the percentage of normal liver volume receiving more than 5-40 Gy irradiations (V(5-40)) were related to the risk of developing RILD. Multivariate analyses demonstrated that only GTV and V(20) were independent predictors. Using V(20) as the predictor for RILD, the accuracy, sensitivity, and specificity was 76.3%, 88.9%, and 75.2%, respectively. CONCLUSIONS Our data suggest that V(20) is the unique significant dosimetric predictor for RILD risks in PLC patients with Child-Pugh Grade A cirrhosis after hypofractionated CRT.
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Chon YE, Seong J, Kim BK, Cha J, Kim SU, Park JY, Ahn SH, Han KH, Chon CY, Shin SK, Kim DY. Gastroduodenal complications after concurrent chemoradiation therapy in patients with hepatocellular carcinoma: endoscopic findings and risk factors. Int J Radiat Oncol Biol Phys 2010; 81:1343-51. [PMID: 20934268 DOI: 10.1016/j.ijrobp.2010.07.1986] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/17/2010] [Accepted: 07/16/2010] [Indexed: 01/03/2023]
Abstract
PURPOSE Concurrent chemoradiation therapy (CCRT) is useful in advanced hepatocellular carcinoma (HCC), but little is known about radiation-induced gastroduodenal complications following therapy. To determine risk factors, we investigated the prevalence and patterns of gastroduodenal complications following CCRT using endoscopy. METHODS AND MATERIALS Enrolled in the study were 123 patients treated with CCRT for unresectable HCC between January 1998 and December 2005. Radiation-induced gastroduodenal complications were defined as radiation gastritis/duodenitis, radiation gastric/duodenal ulcer, or other gastroduodenal toxicity associated with radiation, based on Common Terminology Criteria for Adverse Events (CTCAE 3.0). Serious gastroduodenal complications were defined as events occurring within 12 months from completion of CCRT, those requiring prompt therapeutic intervention, or symptoms equivalent to Grade 3 or 4 radiation-related gastroduodenal toxicity, including nausea or vomiting, based on CTCAE 3.0. RESULTS A month after completion of CCRT, 65 (52.8%) patients displayed endoscopic evidence of radiation-induced gastroduodenal complications. Radiation gastric and duodenal ulcers were found in 32 (26.0%) and 20 (16.3%) patients, respectively; radiation gastritis and duodenitis were found in 50 (40.7%) and 42 (34.1%) patients, respectively. Radiation-related bleeding was observed in 13 patients (10.6%). Serious gastroduodenal complications occurred in 18 patients (14.6%) and were significantly more frequent in patients with liver cirrhosis than in those without cirrhosis (p=0.043). There were no radiation-related deaths. CONCLUSIONS Endoscopically detectable radiation-induced gastroduodenal complications were common in HCC following CCRT. Although serious complications were uncommon, the frequency was higher in patients with liver cirrhosis; thus, these patients should be closely monitored when receiving CCRT.
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Affiliation(s)
- Young Eun Chon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Seo YS, Kim MS, Yoo SY, Cho CK, Choi CW, Kim JH, Han CJ, Park SC, Lee BH, Kim YH, Lee DH. Preliminary result of stereotactic body radiotherapy as a local salvage treatment for inoperable hepatocellular carcinoma. J Surg Oncol 2010; 102:209-14. [PMID: 20740576 DOI: 10.1002/jso.21593] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the toxicity and efficacy of stereotactic body radiotherapy (SBRT) for the treatment of localized hepatocellular carcinoma (HCC) in the absence of another standard treatment option. METHODS The authors reviewed the details of 38 patients with inoperable HCC (diameter <10 cm) treated by SBRT in a prospectively registered database at their institution. All patients had been treated by transcatheter arterial chemoembolization before SBRT, which had been finally deemed ineffective. SBRT dosages (33-57 Gy in three or four fractions) were administered according to tumor volumes, which ranged from 11 to 464 ml (median, 40.5 ml). RESULTS Two-year overall survival and local progression-free survival rates were 61.4% and 66.4%, respectively. The local response rate was 63% at 3 months after SBRT. A high radiation dose was found to be independently related to survival. A decline in liver function was observed in six patients (16%) and Grade 3 musculoskeletal toxicity in one patient (2.7%). CONCLUSIONS This study showed that SBRT can be safely administered to select HCC patients, and these results suggest that this technique should be considered a salvage treatment. A further well-controlled large-scale study and longer follow-up are needed to determine optimal dose-fraction schedules and characterize late complications.
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Affiliation(s)
- Young Seok Seo
- Department of Radiation Oncology, Korea Cancer Center Hospital, Korea Institute of Radiological & Medical Sciences, Nowon-gu, Seoul, Korea
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Kwon JH, Bae SH, Kim JY, Choi BO, Jang HS, Jang JW, Choi JY, Yoon SK, Chung KW. Long-term effect of stereotactic body radiation therapy for primary hepatocellular carcinoma ineligible for local ablation therapy or surgical resection. Stereotactic radiotherapy for liver cancer. BMC Cancer 2010; 10:475. [PMID: 20813065 PMCID: PMC2940809 DOI: 10.1186/1471-2407-10-475] [Citation(s) in RCA: 200] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Accepted: 09/03/2010] [Indexed: 12/25/2022] Open
Abstract
Background We evaluated the long-term effect of stereotactic body radiation therapy (SBRT) for primary small hepatocellular carcinoma (HCC) ineligible for local therapy or surgery. Methods Forty-two HCC patients with tumors ≤ 100 cc and ineligible for local ablation therapy or surgical resection were treated with SBRT: 30-39 Gy with a prescription isodose range of 70-85% (median 80%) was delivered daily in three fractions. Median tumor volume was 15.4 cc (3.0-81.8) and median follow-up duration 28.7 months (8.4-49.1). Results Complete response (CR) for the in-field lesion was initially achieved in 59.6% and partial response (PR) in 26.2% of patients. Hepatic out-of-field progression occurred in 18 patients (42.9%) and distant metastasis developed in 12 (28.6%) patients. Overall in-field CR and overall CR were achieved in 59.6% and 33.3%, respectively. Overall 1-year and 3-year survival rates were 92.9% and 58.6%, respectively. In-field progression-free survival at 1 and 3 years was 72.0% and 67.5%, respectively. Patients with smaller tumor had better in-field progression-free survival and overall survival rates (<32 cc vs. ≥32 cc, P < 0.05). No major toxicity was encountered but one patient died with extrahepatic metastasis and radiation-induced hepatic failure. Conclusions SBRT is a promising noninvasive-treatment for small HCC that is ineligible for local treatment or surgical resection.
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Affiliation(s)
- Jung Hyun Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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