Treatment of portal vein tumor thrombosis of hepatoma patients with either stereotactic radiotherapy or three-dimensional conformal radiotherapy

The treatment responses in cases of radiation therapy to portal vein thrombosis in advanced hepatocellular carcinoma

PURPOSE

To review the response to radiation therapy for hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT) and determine the factors favoring its efficacy.

METHODS AND MATERIALS

Patients with HCC and PVT referred for radiation therapy between 1997 and 2005 were retrospectively reviewed. Patients who had undergone treatment to primary HCC before radiation or had extrahepatic metastasis were excluded. A radiation dose of 60 Gy with 2 to 3Gy per fraction was prescribed. Clinical features before therapy were investigated, and the most significant imaging change after radiotherapy was regarded as the treatment response. Survival times were compared and the hazard ratios of independent variables were determined.

RESULTS

The treatment response rate of the 326 patients included in the study was 25.2% (n = 82). The median survival times were 13.3, 11.6, 9.0, 4.5, and 2.1 months for complete response, partial response, vascular transformation, no response, and the lost follow-up patients, respectively. Statistically significant differences in survival were not found among responder groups (p = 0.224-0.916) but were found between responders and nonresponders (p = 0.002). The most significant independent variables associated with survival (p < 0.001) were performance status and radiation dose. Minor independent factors were ascites, alfa-fetoprotein, albumin, and HBsAg (p = 0.009-0.038). In patients with favorable performance status, those with no more than one minor risk factor had a superior prognosis after radiation therapy (p = 0.013). This result was verified by a review of similar patients in 2006.

CONCLUSION

Radiation therapy is the treatment of choice for selected HCC patients with PVT.

Combination of sorafenib and intensity modulated radiotherapy for unresectable hepatocellular carcinoma

Unresectable hepatocellular carcinoma (HCC) has a poor therapeutic outcome. We report here on a 40-year-old male HCC patient who had undergone partial hepatectomy and was refractory to therapeutic embolization. In addition, the tumour expressed phosphorylated extracellular signal-regulated kinase and CD34. Sorafenib was administered as salvage treatment and resulted in a rapid decline in alpha-fetoprotein (AFP) levels. However, this was accompanied by a grade 3 skin reaction, which improved as sorafenib dosage was gradually reduced. Unfortunately, reducing the dose of sorafenib also resulted in a rebound in AFP levels and portal vein thrombosis was noted thereafter. Sorafenib 800 mg/day was resumed, but the tumour failed to respond. Intensity-modulated radiation therapy (IMRT) combined with sorafenib was administered, resulting in marked tumour shrinkage and causing recurrence of the systemic skin reaction and development of photosensitivity. The patient survived for 20 months after the start of sorafenib treatment. This case suggests that the combination of sorafenib and IMRT might provide clinical benefits in patients with HCC who express potential targets but fail to respond to sorafenib; however, skin reactions should be monitored.

Prognostic factors for patients with hepatocellular carcinoma with macroscopic portal vein or inferior vena cava tumor thrombi receiving external-beam radiation therapy

Prognostic factors in patients with hepatocellular carcinoma (HCC) with tumor thrombosis are not well established, especially for those given external-beam radiation therapy (EBRT). Patients (n = 136) with HCC who had portal vein (PV) or inferior vena cava (IVC) tumor thrombus received EBRT between January 1998 and October 2007. Demographic variables, laboratory values, tumor characteristics, and treatment modalities were determined at diagnosis and before EBRT. The total radiation dose ranged from 30 to 60 Gy (median, 50 Gy) and was focused on the tumor thrombi. Predictors of survival were identified using the univariate and multivariate analysis. Of the 136 patients, the tumor thrombus completely disappeared in 41 patients (30.1%), 36 patients (26.5%) had a partial response, 49 patients (36%) had stable disease, and 10 patients (7.4%) had progressive disease. On multivariate analysis, pretreatment unfavorable predictors were associated with lower albumin, higher gamma-glutamyltransferase and alpha-fetoprotein levels, poorer Child-Pugh classification, intrahepatic multifocality, lymph node metastases, poorer response to EBRT, and 2-dimension EBRT technique. Survival rates at 1, 2, and 3 years were 31.8%, 17.5%, and 8.8% for patients with PV tumor thrombi; 66.3%, 21.1%, and 15.8% for IVC tumor thrombi; and 25%, 8.3%, and 0% for PV plus IVC tumor thrombi, respectively. Overall median survival was 9.7 months. This study provides detailed information about the survival outcomes and prognostic factors of HCC with tumor thrombi in a relatively large cohort of patients treated with radiation, and the results will help in understanding the potential factors that influence survival for patients with HCC after EBRT.

Transcatheter arterial chemoembolization in combination with radiotherapy for unresectable hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

To evaluate the efficacy and safety of transcatheter arterial chemoembolization (TACE) plus radiotherapy (RT) for unresectable hepatocellular carcinoma (UHCC) using meta-analysis of data from the literature involving available randomized controlled trials of TACE in combination with RT compared with that of TACE alone (Therapy I versus II) in treating UHCC.

MATERIAL AND METHODS

We searched the Cochrane Library, MEDLINE, CENTRAL, EMBASE, CBMdisc, and CNKI as well as employing manual searches. Meta-analysis was performed on the results of homogeneous studies. Analyses subdivided by study design were also performed.

RESULTS

We found 17 trials involving 1476 patients. 5 of total were Randomized Controlled Trials (RCTs) and 12 were Non-randomized Controlled Clinical Trials (CCTs). In terms of quality, 5 RCTs were graded B, and 12 CCTs were graded C. Our results showed that Therapy I, compared with Therapy II, significantly improved the survival and the tumor response of patients, and was thus more therapeutically beneficial. Serious adverse events were not increased exception for total bilirubin (TB) level.

CONCLUSIONS

Therapy I was more therapeutically beneficial. However, considering the strength of the evidence, additional randomized controlled trials are needed before Therapy I can be recommended routinely.

Three-dimensional conformal radiotherapy for hepatocellular carcinoma with inferior vena cava invasion

BACKGROUND

Hepatocellular carcinoma with inferior vena cava invasion is a rare but fatal condition of disease progression. The aim of this study was to analyze the results of treatment for hepatocellular carcinoma with inferior vena cava invasion by three-dimensional conformal radiation therapy.

METHODS

From 1990 to 2006, 18 histopathologically confirmed hepatocellular carcinoma patients with inferior vena cava invasion who were unsuitable for surgery were treated by three-dimensional conformal radiation therapy at our hospital with two to four static or dynamic conformal arc fields.

RESULTS

A median total tumor dose of 50 Gy (range 30-60 Gy) was delivered. The progression-free rate was 91.6% among the patients in whom follow-up computed tomography was obtained. Actuarial survival at 1 year was 33.3%, and the median survival period was 5.6 months.

CONCLUSIONS

Three-dimensional conformal radiation therapy might offer a chance of long survival for a part of the hepatocellular carcinoma patients with inferior vena cava invasion, since a third of such patients survived more than a year. Additional treatments should be considered to prevent distant metastases and hepatic functional deterioration after three-dimensional conformal radiation therapy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Conformal radiotherapy for hepatocellular carcinoma

Technical advancements in radiation therapy (RT) have facilitated the safe delivery of conformal, dose-escalated radiation to a wide spectrum of hepatocellular carcinoma (HCC) patients. A variety of doses and RT fractionation schemes have been used, and RT has been used in combination with transarterial chemoembolization (TACE). Compared to untreated historical controls or those treated with TACE alone, outcomes following RT alone or TACE and RT are better. Despite advances in RT delivery, liver toxicity following RT remains a dose-limiting factor, and investigations to better understand the pathophysiology of RT-induced liver toxicity are warranted. For most tumors, RT can provide sustained local control. However, HCC tends to recur within the liver away from the irradiated volume, providing rationale for combining RT with systemic or regional therapies. There is a particular interest in combining RT with anti-VEGF-targeted agents for their independent activity in HCC as well as their radiation sensitization properties. Randomized trials of RT are warranted.

The evolving role of radiation therapy in hepatocellular carcinoma

Technical advancements in imaging, in radiation therapy (RT) planning and RT delivery, have facilitated the safe delivery of conformal radiation therapy to patients with unresectable hepatocellular carcinoma (HCC). Although experience in liver cancer RT is limited, the RT technologies and tools to deliver RT safely are being disseminated rapidly. A variety of doses and RT fractionations have been used to treat HCC, and RT has been used in combination with other therapies including transarterial hepatic chemoembolization (TACE). Outcomes following RT alone or RT and TACE appear better than outcomes following similar historical controls of TACE alone, however, randomized trials of RT are needed. The first site of recurrence following RT is most often within the liver, away from the high dose volume, providing rationale for combining RT with regional or systemic therapies. Given the vascular properties of HCC, the combination of RT with anti-VEGF targeted agents may improve outcomes further.

Liver transplantation as curative approach for advanced hepatocellular carcinoma: is it justified?

BACKGROUND

Liver transplantation is considered as one of therapeutic approaches to hepatocellular carcinoma (HCC). The present study aims to evaluate the efficacy of various therapeutic options for HCC.

MATERIALS AND METHODS

One hundred twenty patients with known HCC in various tumour stages were evaluated in the present study. Patients were treated either with primary tumour resection, transarterial chemoembolisation (TACE) or liver transplantation (LTx) by an interdisciplinary team.

RESULTS

The overall 1-year and 5-year survivals of patients in LTx group were 95 and 57%, respectively, which were significantly higher than those in primary tumour resection group (65 and 33%, P < 0.01) and those in TACE group (44 and 4%, P < 0.01). In parallel, 1-year and 5-year tumour-free survivals of patients in LTx group (75 and 62%) were significantly higher than those in primary tumour resection group (50 and 11%, P < 0.01). There were no significant differences in 1- and 5-year survivals of patients with early tumour stage received LTx or primary tumour resection, whereas patients in advanced tumour stage based on pathological findings of explanted liver significantly benefited from LTx as compared to primary resection.

CONCLUSIONS

LTx can be a curative approach for patients with advanced HCC without extrahepatic metastasis. However, organ shortage is a major limiting factor in the selection of HCC patients for LTx.

Efficacy of preoperative radiotherapy to portal vein tumor thrombus in the main trunk or first branch in patients with hepatocellular carcinoma

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) in the main trunk or the first branch is very poor.

METHODS

Radiotherapy (RT) to PVTT was followed by hepatectomy within 2 weeks. The dose used was 30-36 Gy, in 10-12 fractions, for 15-20 days. The efficacy of preoperative RT to PVTT in the main trunk or first branch was evaluated by comparing results in patients who underwent hepatectomy (group R; n = 15) with preoperative RT and those without preoperative RT (group N; n = 28).

RESULTS

The 1-, 3-, and 5-year survival rates in group R were 86.2%, 43.5%, and 34.8%, respectively, while these values in group N were 39.0%, 13.1%, and 13.1%, respectively. The survival curve of group R was significantly better than that of group N (P = 0.0359). In group R, five (83.3%) of six patients whose tumor thrombus was completely necrosed (based on pathological examination) and whose follow-up period was over 2 years survived for more than 2 years. Female sex (P = 0.0066), multiple tumors (P = 0.0369), and absence of preoperative RT (P = 0.0359) were ranked as significant factors for a poor prognosis by univariate analysis. Multivariate analysis revealed absence of preoperative RT and female sex to be significant factors for a poor prognosis.

CONCLUSION

Preoperative RT to PVTT in the main trunk or first branch improved the prognosis of patients with HCC with PVTT, and could be a promising new modality in the treatment of these patients.

Conformal radiation therapy for portal vein tumor thrombosis of hepatocellular carcinoma

BACKGROUND AND PURPOSE

The prognosis of patients with portal vein tumor thrombosis (PVTT) from hepatocellular carcinoma (HCC) is poor; without treatment, their survival is less than 3months. We retrospectively evaluated the treatment outcomes of conformal radiation therapy (CRT) in patients with HCC-PVTT.

MATERIALS AND METHODS

Thirty-eight HCC patients with PVTT in whom other treatment modalities were not indicated underwent CRT. The total dose was translated into a biologic effective dose (BED) of 23.4-59.5Gy(10) (median 50.7Gy(10)) as the alpha/beta ratio=10. Predictive factors including the age, performance status, Child-Pugh classification, PVTT size, and BED were evaluated for tumor response and survival.

RESULTS

Complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) were observed in 6 (15.8%), 11 (28.9%), 17 (44.7%), and 4 (10.5%) patients, respectively. The response rate (CR+PR) was 44.7%. The PVTT size (<30 vs. 30mm) and BED (<58 vs. 58Gy(10)) were significant factors for tumor response. The median survival and 1-year survival rate were 9.6months and 39.4%. The Child-Pugh classification (A vs. B) and BED were significant factors for survival.

CONCLUSIONS

CRT is effective not only for tumor response but also for survival in HCC-PVTT patients in whom other treatment modalities are not indicated.

Hepatocellular carcinoma (HCC): an update

In the absence of large randomized trials, the current treatment strategy for hepatocellular carcinoma (HCC) remains a matter of choice depending mostly on retrospective studies, experience of centers, and the technical therapeutic possibilities. In fact, treatment decisions must be based on HCC extension and liver function, which is dependent on underlying liver disease. Cirrhosis limits therapeutic choices, life expectancy, and tolerance to therapy. Surgical resection and/or local destruction are the most common curative treatments. Orthotopic liver transplantation is probably the best treatment for small HCC developed in cirrhosis because it treats tumor, cirrhosis, and preneoplastic lesions at the same time. However, this treatment method is feasible in fewer than 5% of cases. Adjuvant treatments include transarterial chemoembolization, chemotherapy, polyprenoic acid, interferon, adoptive immunotherapy, and intra-arterial radioactive lipiodol. Results from trials warrant confirmation in larger randomized trials to show a clear survival benefit on recurrence rate, secondary prevention, and overall survival. Chemoembolization is the only palliative treatment that has been proven to be active, unlike systemic chemotherapy, immunotherapy, and hormone therapy, whose activity is largely questionable and must all be restricted to clinical trials. Possible future therapeutic strategies include epidermal growth factor receptor inhibitors, antivascular endothelial growth factor therapies, cyclin D inhibitors, and HMG-CoA reductase inhibitors.

Treatment of hepatocellular carcinoma accompanied by portal vein tumor thrombus

The prognosis of patients with hepatocellular carcinoma (HCC) accompanied by portal vein tumor thrombus (PVTT) is generally poor if left untreated: a median survival time of 2.7-4.0 mo has been reported. Furthermore, while transcatheter arterial chemoembolization (TACE) has been shown to be safe in selected patients, the median survival time with this treatment is still only 3.8-9.5 mo. Systemic single-agent chemotherapy for HCC with PVTT has failed to improve the prognosis, and the response rates have been less than 20%. While regional chemotherapy with low-dose cisplatin and 5-fluorouracil or interferon and 5-fluorouracil via hepatic arterial infusion has increased the response rate, the median survival time has not exceeded 12 (range 4.5-11.8) mo. Combined treatment consisting of radiation for PVTT and TACE for liver tumor has achieved a high response rate, but the median survival rates have still been only 3.8-10.7 mo. With hepatic resection as monotherapy, the 5-year survival rate and median survival time were reportedly 4%-28.5% and 6-14 mo. The most promising results were reported for combined treatments consisting of hepatectomy and TACE, chemotherapy, or internal radiation. The reported 5-year survival rates and median survival times were 42% and 31 mo for TACE followed by hepatectomy; 36.3% and 22.1 mo for hepatectomy followed by hepatic arterial infusion chemotherapy; and 56% for chemotherapy or internal radiation followed by hepatectomy.