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Klein J, Korol R, Lo SS, Chu W, Lock M, Dorth JA, Ellis RJ, Mayr NA, Huang Z, Chung HT. Stereotactic body radiotherapy: an effective local treatment modality for hepatocellular carcinoma. Future Oncol 2015; 10:2227-41. [PMID: 25471036 DOI: 10.2217/fon.14.167] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Although liver-directed therapies such as surgery or ablation can cure hepatocellular carcinoma, few patients are eligible due to advanced disease or medical comorbidities. In advanced disease, systemic therapies have yielded only incremental survival benefits. Historically, radiotherapy for liver cancer was dismissed due to concerns over unacceptable toxicities from even moderate doses. Although implementation requires more resources than standard radiotherapy, stereotactic body radiotherapy can deliver reproducible, highly conformal ablative radiotherapy to tumors while minimizing doses to nearby critical structures. Trials of stereotactic body radiotherapy for hepatocellular carcinoma have demonstrated promising local control and survival results with low levels of toxicity in Child-Pugh class A patients. We review the published literature and make recommendations for the future of this emerging modality.
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Affiliation(s)
- Jonathan Klein
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, University of Toronto, Toronto, ON, M4N 3M5, Canada
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102
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Yeh MM, Yeung RS, Apisarnthanarax S, Bhattacharya R, Cuevas C, Harris WP, Hon TLK, Padia SA, Park JO, Riggle KM, Daoud SS. Multidisciplinary perspective of hepatocellular carcinoma: A Pacific Northwest experience. World J Hepatol 2015; 7:1460-83. [PMID: 26085907 PMCID: PMC4462686 DOI: 10.4254/wjh.v7.i11.1460] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 04/03/2015] [Accepted: 04/27/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most rapidly increasing type of cancer in the United States. HCC is a highly malignant cancer, accounting for at least 14000 deaths in the United States annually, and it ranks third as a cause of cancer mortality in men. One major difficulty is that most patients with HCC are diagnosed when the disease is already at an advanced stage, and the cancer cannot be surgically removed. Furthermore, because almost all patients have cirrhosis, neither chemotherapy nor major resections are well tolerated. Clearly there is need of a multidisciplinary approach for the management of HCC. For example, there is a need for better understanding of the fundamental etiologic mechanisms that are involved in hepatocarcinogenesis, which could lead to the development of successful preventive and therapeutic modalities. It is also essential to define the cellular and molecular bases for malignant transformation of hepatocytes. Such knowledge would: (1) greatly facilitate the identification of patients at risk; (2) prompt efforts to decrease risk factors; and (3) improve surveillance and early diagnosis through diagnostic imaging modalities. Possible benefits extend also to the clinical management of this disease. Because there are many factors involved in pathogenesis of HCC, this paper reviews a multidisciplinary perspective of recent advances in basic and clinical understanding of HCC that include: molecular hepatocarcinogenesis, non-invasive diagnostics modalities, diagnostic pathology, surgical modality, transplantation, local therapy and oncological/target therapeutics.
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Affiliation(s)
- Matthew M Yeh
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Raymond S Yeung
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Smith Apisarnthanarax
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Renuka Bhattacharya
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Carlos Cuevas
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - William P Harris
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Tony Lim Kiat Hon
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Siddharth A Padia
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - James O Park
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Kevin M Riggle
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
| | - Sayed S Daoud
- Matthew M Yeh, Raymond S Yeung, Department of Pathology, University of Washington School of Medicine, Seattle, WA 99210, United States
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103
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2014 KLCSG-NCC Korea Practice Guideline for the Management of Hepatocellular Carcinoma. Gut Liver 2015; 9:267-317. [PMID: 25918260 PMCID: PMC4413964 DOI: 10.5009/gnl14460] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/09/2015] [Indexed: 12/23/2022] Open
Abstract
The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.
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104
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2014 Korean Liver Cancer Study Group-National Cancer Center Korea practice guideline for the management of hepatocellular carcinoma. Korean J Radiol 2015; 16:465-522. [PMID: 25995680 PMCID: PMC4435981 DOI: 10.3348/kjr.2015.16.3.465] [Citation(s) in RCA: 143] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 04/02/2015] [Indexed: 02/07/2023] Open
Abstract
The guideline for the management of hepatocellular carcinoma (HCC) was first developed in 2003 and revised in 2009 by the Korean Liver Cancer Study Group and the National Cancer Center, Korea. Since then, many studies on HCC have been carried out in Korea and other countries. In particular, a substantial body of knowledge has been accumulated on diagnosis, staging, and treatment specific to Asian characteristics, especially Koreans, prompting the proposal of new strategies. Accordingly, the new guideline presented herein was developed on the basis of recent evidence and expert opinions. The primary targets of this guideline are patients with suspicious or newly diagnosed HCC. This guideline provides recommendations for the initial treatment of patients with newly diagnosed HCC.
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105
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Kitajima T, Fujimoto Y, Hatano E, Nishida H, Ogawa K, Mori A, Okajima H, Kaido T, Nakamura A, Nagamatsu H, Uemoto S. Salvage living-donor liver transplantation for liver failure following definitive radiation therapy for recurrent hepatocellular carcinoma: a case report. Transplant Proc 2015; 47:804-8. [PMID: 25891735 DOI: 10.1016/j.transproceed.2015.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 02/11/2015] [Indexed: 02/08/2023]
Abstract
A 57-year-old man with a history of hepatitis B virus infection was referred to our hospital for living-donor liver transplantation (LDLT). Five years earlier, right lobectomy had been performed for solitary hepatocellular carcinoma (HCC) with bile duct tumor thrombus in segments 5 and 6 in the liver. Two years later, transarterial chemoembolization and radiofrequency ablation were performed for recurrent HCC. Two years after those local therapies, another recurrent HCC was treated with transhepatic arterial infusion chemotherapy with cisplatin and conventional radiation therapy (RT) with 60 Gy in 20 fractions, because the tumor was contiguous to the trunk of the portal vein. After the completion of RT, symptoms due to liver failure and severe infection caused by multiple liver abscesses developed despite the administration of antibiotics and percutaneous transhepatic cholangiodrainage. Therefore, LDLT was performed with the use of a right lobe graft donated by his wife. Vascular anastomosis was successfully performed with the use of normal procedures. The patient recovered uneventfully, and has since been doing well for 34 months, with no evidence of vascular complications. However, the degree of injury to the anastomotic vessels caused by definitive RT before LDLT remains unclear, whereas the safety and efficacy of some forms of RT as a bridge to deceased-donor LT have been reported. Salvage LDLT is effective for patients with liver failure after multidisciplinary treatment including radiation, while carefully taking radiation-induced vessel injury as a potential late complication into consideration, especially in LDLT cases.
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Affiliation(s)
- T Kitajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan.
| | - Y Fujimoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - E Hatano
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - H Nishida
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - K Ogawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - A Mori
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - H Okajima
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - T Kaido
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - A Nakamura
- Department of Radiation Oncology and Image-Applied Therapy, Graduate School of Medicine, Kyoto University, Japan
| | - H Nagamatsu
- Department of Medicine, Yame General Hospital, Japan
| | - S Uemoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
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106
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Yim HJ, Suh SJ, Um SH. Current management of hepatocellular carcinoma: an Eastern perspective. World J Gastroenterol 2015; 21:3826-42. [PMID: 25852267 PMCID: PMC4385529 DOI: 10.3748/wjg.v21.i13.3826] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/11/2014] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death, especially in Eastern areas. With advancements in diagnosis and treatment modalities for HCC, the survival and prognosis of HCC patients are improving. However, treatment patterns are not uniform between areas despite efforts to promote a common protocol. Although many hepatologists in Asian countries may adopt the principles of the Barcelona Clinic Liver Cancer staging system, they are also independently making an effort to expand the indications of each treatment and to combine therapies for better outcomes. Several expanded criteria for liver transplantation in HCC have been developed in Asian countries. Living donor liver transplantation is much more commonly performed in these countries than deceased donor liver transplantation, and it may be preceded by other treatments such as the down-staging of tumors. Local ablation therapies are often combined with transarterial chemoembolization (TACE) and the outcome is comparable to that of surgical resection. The indications of TACE are expanding, and there are new types of transarterial therapies. Although data on drug-eluting beads, TACE, and radioembolization in Asian countries are still relatively sparse compared with Western countries, these methods are gradually gaining popularity because of better tolerability and the possibility of improved response rates. Hepatic arterial infusion chemotherapy and radiotherapy are not included in Western guidelines, but are currently being used actively in several Asian countries. For more advanced HCCs, appropriate combinations of TACE, radiotherapy, and sorafenib can be considered, and emerging data indicate improved outcomes of combination therapies compared with single therapies. To include these paradigm shifts into newer treatment guidelines, more studies may be needed, but they are certainly in progress.
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107
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Keane FK, Tanguturi SK, Zhu AX, Dawson LA, Hong TS. Radiotherapy for liver tumors. Hepat Oncol 2015; 2:133-146. [PMID: 30190993 PMCID: PMC6095425 DOI: 10.2217/hep.15.7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Many patients with primary hepatic malignancies present with advanced disease that is not suitable for surgical resection, orthotopic liver transplantation, or radiofrequency ablation. Outcomes are particularly dismal in patients with large, unresectable tumors and/or tumor venous thrombosis. Liver-directed radiotherapy, including stereotactic body radiotherapy (SBRT), is able to treat a variety of tumor sizes and tumors with venous involvement and has demonstrated excellent safety and control outcomes. SBRT should be considered a standard option in patients with early-stage hepatocellular carcinoma who are not candidates for surgical resection, orthotopic liver transplantation or radiofrequency ablation. SBRT should be strongly considered in patients with larger tumors and/or tumors with tumor venous thrombosis who have adequate liver function. Radiotherapy should remain a focus of hepatocellular carcinoma research.
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Affiliation(s)
- Florence K Keane
- Harvard Radiation Oncology Program, Harvard Medical School, 75 Francis Street, Brigham & Women's Hospital, ASB1 L2, Boston, MA 02215, USA
| | - Shyam K Tanguturi
- Harvard Radiation Oncology Program, Harvard Medical School, 75 Francis Street, Brigham & Women's Hospital, ASB1 L2, Boston, MA 02215, USA
| | - Andrew X Zhu
- Massachusetts General Hospital, Division of Hematology-Oncology, Department of Medicine; 32 Fruit St, Yawkey 7, Boston, MA 02114, USA
| | - Laura A Dawson
- Princess Margaret Cancer Centre, Department of Radiation Oncology, University of Toronto, 610 University Avenue, Toronto, ON M5G 2M9, USA
| | - Theodore S Hong
- Massachusetts General Hospital, Department of Radiation Oncology, 32 Fruit St, Yawkey 7, Boston, MA 02114, USA
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108
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Yie Y, Zhao S, Tang Q, Zheng F, Wu J, Yang L, Deng S, Hann SS. Ursolic acid inhibited growth of hepatocellular carcinoma HepG2 cells through AMPKα-mediated reduction of DNA methyltransferase 1. Mol Cell Biochem 2015; 402:63-74. [PMID: 25547067 DOI: 10.1007/s11010-014-2314-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/20/2014] [Indexed: 12/11/2022]
Abstract
Hepatocellular carcinoma (HCC), the major histological subtype of primary liver cancer, remains one of the most common malignancies worldwide. Due to the complicated pathogenesis of this malignancy, the outcome for comprehensive treatment is limited. Chinese herbal medicine (CHM) is emerging as a promising choice for its multi-targets and coordinated intervention effects against HCC. Ursolic acid (UA), a natural pentacyclic triterpenoid carboxylic acid found in CHM, exerts anti-tumor effects and is emerging as an effective compound for cancer prevention and therapy. However, the molecular mechanisms underlying the action of UA remain largely unknown. In this study, we showed that UA inhibited the growth of HCC cells and induced apoptosis in the dose- and time-dependent fashion. Furthermore, we found that UA induced phosphorylation of AMP-activated protein kinase alpha (AMPKα) and suppressed the protein expression of DNA methyltransferase 1 (DNMT1) in the dose-dependent manner. The inhibitor of AMPK, compound C blocked, while an activator of AMPK, metformin augmented the effect of UA on DNMT1 expression. In addition, UA suppressed the expression of transcription factor Sp1. Conversely, overexpression of Sp1 reversed the effect of UA on DNMT1 expression and cell growth. Collectively, our results show for the first time that UA inhibits growth of HCC through AMPKα-mediated inhibition of Sp1; this in turn results in inhibition of DNMT1. This study reveals a potential novel mechanism by which UA controls growth of HCC cells and suggests that DNMT1 could be novel target for HCC chemoprevention and treatment.
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Affiliation(s)
- Yinyi Yie
- Laboratory of Tumor Biology, Guangdong Provincial Hospital of Chinese Medicine, The Second Clinical Medical College, University of Guangzhou Traditional Chinese Medicine, Guangzhou, 510120, Guangdong, China
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109
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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] [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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110
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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: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [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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111
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Kondo Y, Kimura O, Shimosegawa T. Radiation therapy has been shown to be adaptable for various stages of hepatocellular carcinoma. World J Gastroenterol 2015; 21:94-101. [PMID: 25574082 PMCID: PMC4284364 DOI: 10.3748/wjg.v21.i1.94] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/12/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
In addition to surgical procedures, radiofrequency ablation is commonly used for the treatment of hepatocellular carcinomas (HCCs) of limited size and number. Transcatheter arterial chemoembolization (TACE), using iodized poppy seed oil, Lipiodol and anticancer drugs, has been actively performed for the treatment of unresectable HCC, particularly in Asian countries. Recently, Sorafenib become available for advanced HCCs when the liver is still sufficiently functional. Sorafenib is an oral multikinase inhibitor with antiproliferative and antiangiogenic effects. However, the effect of sorafenib seems to be inadequate to control the progression of HCC. Radiation therapy (RT) for HCC has a potential role across all stages of HCC. However, RT is generally not considered an option in HCC consensus documents or national guidelines, primarily because of insufficient supporting evidence. However, the method of RT has much improved because of advances in technology. Moreover, combined treatment of RT plus other treatments (TACE, sorafenib and chemotherapy etc.) has become one of the alternative therapies for HCC. Therefore, we should understand the various kinds of RT available for HCC. In this review, we focus on various kinds of external beam radiation therapy.
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112
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Qi WX, Fu S, Zhang Q, Guo XM. Charged particle therapy versus photon therapy for patients with hepatocellular carcinoma: a systematic review and meta-analysis. Radiother Oncol 2014; 114:289-95. [PMID: 25497556 DOI: 10.1016/j.radonc.2014.11.033] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 11/03/2014] [Accepted: 11/20/2014] [Indexed: 12/13/2022]
Abstract
PURPOSE To perform a systematic review and meta-analysis to compare the clinical outcomes and toxicity of hepatocellular carcinoma (HCC) patients treated with charged particle therapy (CPT) with those of individuals receiving photon therapy. METHODS We identified relevant clinical studies through searching databases. Primary outcomes of interest were overall survival (OS) at 1, 3, 5 years, progression-free survival (PFS), and locoregional control (LC) at longest follow-up. RESULTS 73 cohorts from 70 non-comparative observational studies were included. Pooled OS was significantly higher at 1, 3, 5 years for CPT than for conventional radiotherapy (CRT) [relative risk (RR) 1·68, 95% CI 1·22-2·31; p<0·001; RR 3.46, 95% CI: 1.72-3.51, p<0.001; RR 25.9, 95% CI: 1.64-408.5, p=0.02; respectively]. PFS and LC at longest follow-up was also significantly higher for CPT than for CRT (p=0·013 and p<0.001, respectively), while comparable efficacy was found between CPT and SBRT in terms of OS, PFS and LC at longest follow-up. Additionally, high-grade acute and late toxicity associated with CPT was lower than that of CRT and SBRT. CONCLUSION Survival rates for CPT are higher than those for CRT, but similar to SBRT in patients with HCC. Toxicity tends to be lower for CPT compared to photon radiotherapy.
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Affiliation(s)
- Wei-Xiang Qi
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, China
| | - Shen Fu
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, China; Department of Radiation Oncology, Fudan University Shanghai Cancer Center, China.
| | - Qing Zhang
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, China
| | - Xiao-Mao Guo
- Department of Radiation Oncology, Shanghai Proton and Heavy Ion Center, China; Department of Radiation Oncology, Fudan University Shanghai Cancer Center, China
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113
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Aiolfi R, Sitia G. Emerging role of dual antiplatelet therapy in the prevention of hepatitis B virus-associated hepatocellular carcinoma. J Hepatocell Carcinoma 2014; 1:183-6. [PMID: 27508186 PMCID: PMC4918276 DOI: 10.2147/jhc.s48763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Platelets, the chief effectors of vascular homeostasis, have been identified as important players in the pathogenesis of both acute and chronic liver disease in preclinical models of hepatitis B viral infection. Platelets are thought to promote the accumulation of virus-specific T-cells into the liver parenchyma. Importantly, the inhibition of platelet activation by clinically relevant doses of aspirin and clopidogrel was able to reduce immune-mediated necroinflammatory liver disease, extracellular matrix deposition, and hepatocellular carcinoma development; the same treatment was able to improve overall survival. These results strongly support the design of clinical trials aiming to define the potential of antiplatelet therapy in the prevention of hepatitis B virus-associated hepatocellular carcinoma.
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Affiliation(s)
- Roberto Aiolfi
- Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Sitia
- Division of Immunology, Transplantation and Infectious Diseases, San Raffaele Scientific Institute, Milan, Italy
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114
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115
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116
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Abstract
The most common non-surgical approaches for the treatment of localized hepatocellular carcinoma remain hepatic artery-delivered particles laden with chemotherapy (TACE), or radioactive microparticles (TARE). External beam radiotherapy has been an effective option in many parts of the world for selected HCC patients, but now has an expanded role with stereotactic and proton beam technologies. This review focuses on existing evidence and current guidance for utilizing these modalities for localized, but unresectable, non-transplantable HCC patients.x.
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Affiliation(s)
- Andrew S Kennedy
- Radiation Oncology Research, Sarah Cannon Research Institute, 3322 West End Avenue, Suite 800, Nashville, TN, 37203, USA,
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117
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The Role of Radiotherapy and Chemoradiation in the Management of Primary Liver Tumours. Clin Oncol (R Coll Radiol) 2014; 26:569-80. [DOI: 10.1016/j.clon.2014.05.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 02/18/2014] [Accepted: 05/28/2014] [Indexed: 12/11/2022]
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118
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Hong TS, Bosch WR, Krishnan S, Kim TK, Mamon HJ, Shyn P, Ben-Josef E, Seong J, Haddock MG, Cheng JC, Feng MU, Stephans KL, Roberge D, Crane C, Dawson LA. Interobserver variability in target definition for hepatocellular carcinoma with and without portal vein thrombus: radiation therapy oncology group consensus guidelines. Int J Radiat Oncol Biol Phys 2014; 89:804-13. [PMID: 24969794 DOI: 10.1016/j.ijrobp.2014.03.041] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/24/2014] [Accepted: 03/25/2014] [Indexed: 01/14/2023]
Abstract
PURPOSE Defining hepatocellular carcinoma (HCC) gross tumor volume (GTV) requires multimodal imaging, acquired in different perfusion phases. The purposes of this study were to evaluate the variability in contouring and to establish guidelines and educational recommendations for reproducible HCC contouring for treatment planning. METHODS AND MATERIALS Anonymous, multiphasic planning computed tomography scans obtained from 3 patients with HCC were identified and distributed to a panel of 11 gastrointestinal radiation oncologists. Panelists were asked the number of HCC cases they treated in the past year. Case 1 had no vascular involvement, case 2 had extensive portal vein involvement, and case 3 had minor branched portal vein involvement. The agreement between the contoured total GTVs (primary + vascular GTV) was assessed using the generalized kappa statistic. Agreement interpretation was evaluated using Landis and Koch's interpretation of strength of agreement. The S95 contour, defined using the simultaneous truth and performance level estimation (STAPLE) algorithm consensus at the 95% confidence level, was created for each case. RESULTS Of the 11 panelists, 3 had treated >25 cases in the past year, 2 had treated 10 to 25 cases, 2 had treated 5 to 10 cases, 2 had treated 1 to 5 cases, 1 had treated 0 cases, and 1 did not respond. Near perfect agreement was seen for case 1, and substantial agreement was seen for cases 2 and 3. For case 2, there was significant heterogeneity in the volume identified as tumor thrombus (range 0.58-40.45 cc). For case 3, 2 panelists did not include the branched portal vein thrombus, and 7 panelists contoured thrombus separately from the primary tumor, also showing significant heterogeneity in volume of tumor thrombus (range 4.52-34.27 cc). CONCLUSIONS In a group of experts, excellent agreement was seen in contouring total GTV. Heterogeneity exists in the definition of portal vein thrombus that may impact treatment planning, especially if differential dosing is contemplated. Guidelines for HCC GTV contouring are recommended.
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Affiliation(s)
- Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Walter R Bosch
- Department of Radiation Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Sunil Krishnan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tae K Kim
- Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harvey J Mamon
- Department of Radiation Oncology, Dana-Farber Cancer Institute/Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul Shyn
- Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Edgar Ben-Josef
- Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei University Medical College, Seoul, Korea
| | | | - Jason C Cheng
- Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mary U Feng
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan
| | - Kevin L Stephans
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, Ohio
| | - David Roberge
- Department of Radiation Oncology, Montreal General Hospital/McGill University Health Centre, Montreal, Quebec, Canada
| | - Christopher Crane
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Cancer Centre/University of Toronto, Toronto, Ontario, Canada
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Sharma H. Role of external beam radiation therapy in management of hepatocellular carcinoma. J Clin Exp Hepatol 2014; 4:S122-5. [PMID: 25755603 PMCID: PMC4284217 DOI: 10.1016/j.jceh.2014.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/08/2014] [Indexed: 12/12/2022] Open
Abstract
Diagnosis at advanced disease stage and early vascular invasion are the bane of majority of patients with hepatocellular carcinoma (HCC) in India. The currently standardized curative and palliative treatment modalities [surgery, ablative techniques, trans-catheter chemotherapy, systemic chemotherapy] are suboptimal for a significant proportion of disease stages. Interest in radiotherapy for hepatocellular carcinoma has seen a resurgence with revolutionary improvements in targeting radiation doses safely. Encouraging results have been reported with a host of radiation techniques from conformal radiotherapy, stereotactic whole body radiation therapy to charged particle based therapies. The dissemination of this knowledge has been slow across other specialties involved in care of patients with HCC. However the increasing availability of radiotherapy services predicts a hopeful future for wider evaluation of radiotherapy in HCC.
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Affiliation(s)
- Hanish Sharma
- Address for correspondence: Hanish Sharma, Senior Research Associate, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India.
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120
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Tanguturi SK, Wo JY, Zhu AX, Dawson LA, Hong TS. Radiation therapy for liver tumors: ready for inclusion in guidelines? Oncologist 2014; 19:868-79. [PMID: 25001265 DOI: 10.1634/theoncologist.2014-0097] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Despite the historically limited role of radiotherapy in the management of primary hepatic malignancies, modern advances in treatment design and delivery have renewed enthusiasm for radiation as a potentially curative treatment modality. Surgical resection and/or liver transplantation are traditionally regarded as the most effective forms of therapy, although the majority of patients with hepatocellular carcinoma and intrahepatic cholangiocarcinoma present with locally advanced or unresectable disease on the basis of local vascular invasion or inadequate baseline hepatobiliary function. In this context, many efforts have focused on nonoperative treatment approaches including novel systemic therapies, transarterial chemoembolization, ethanol ablation, radiofrequency ablation, and stereotactic body radiation therapy (SBRT). This review aims to summarize modern advances in radiotherapy, particularly SBRT, in the treatment of primary hepatic malignancies.
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Affiliation(s)
- Shyam K Tanguturi
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Y Wo
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrew X Zhu
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Laura A Dawson
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Theodore S Hong
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts, USA; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Radiation Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
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121
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Dionisi F, Widesott L, Lorentini S, Amichetti M. Is there a role for proton therapy in the treatment of hepatocellular carcinoma? A systematic review. Radiother Oncol 2014; 111:1-10. [DOI: 10.1016/j.radonc.2014.02.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 01/28/2014] [Accepted: 02/02/2014] [Indexed: 02/06/2023]
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122
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Fukumitsu N, Okumura T, Ishikawa H, Ohnishi K, Mizumoto M, Numajiri H, Tsuboi K, Sakurai H. [Liver cancer: progress in diagnosis and treatments. Topics: VI. Progress in treatments of liver cancer; 7. Radiotherapy of liver cancer]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2014; 103:116-122. [PMID: 24605499 DOI: 10.2169/naika.103.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
| | | | | | - Kayoko Ohnishi
- Proton Medical Risearch Center, University of Tsukuba, Japan
| | | | - Haruko Numajiri
- Proton Medical Risearch Center, University of Tsukuba, Japan
| | - Koji Tsuboi
- Proton Medical Risearch Center, University of Tsukuba, Japan
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123
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Wo JY, Dawson LA, Zhu AX, Hong TS. An emerging role for radiation therapy in the treatment of hepatocellular carcinoma and intrahepatic cholangiocarcinoma. Surg Oncol Clin N Am 2013; 23:353-68. [PMID: 24560114 DOI: 10.1016/j.soc.2013.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Radiation therapy is emerging as a potentially effective treatment of locally advanced, unresectable hepatocellular carcinoma (HCC). Outcomes from early prospective studies seem promising, with improved survival compared with historical controls. Cure of early stage and unresectable HCC may be possible with high-quality radiation therapy. Many questions remain, including determination of the ideal radiation dose and fractionation schema, optimal patient selection criteria based on tumor size, tumor location, extent of vascular invasion, and baseline liver function, and the role of radiation therapy compared with other localized standard treatments including radiofrequency ablation or transarterial chemoembolization.
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Affiliation(s)
- Jennifer Y Wo
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom Street, Cox 3, Boston, MA 02114, USA.
| | - Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2M9, Canada
| | - Andrew X Zhu
- Department of Medical Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Theodore S Hong
- Department of Radiation Oncology, Massachusetts General Hospital, 100 Blossom Street, Cox 3, Boston, MA 02114, USA
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125
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Abei M, Okumura T, Fukuda K, Hashimoto T, Araki M, Ishige K, Hyodo I, Kanemoto A, Numajiri H, Mizumoto M, Sakae T, Sakurai H, Zenkoh J, Ariungerel G, Sogo Y, Ito A, Ohno T, Tsuboi K. A phase I study on combined therapy with proton-beam radiotherapy and in situ tumor vaccination for locally advanced recurrent hepatocellular carcinoma. Radiat Oncol 2013; 8:239. [PMID: 24131485 PMCID: PMC3854490 DOI: 10.1186/1748-717x-8-239] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 10/05/2013] [Indexed: 02/08/2023] Open
Abstract
Background Proton-beam radiotherapy (PBT) has been shown to be effective to hepatocellular carcinoma (HCC) as a nonsurgical local treatment option. However, HCC still remains as one of the most difficult cancers to be cured because of frequent recurrences. Thus, methods to inhibit the recurrence need to be explored. To prevent the HCC recurrence, we here report on a prospective phase I study of ‘in situ’ tumor vaccination using CalTUMP, a newly developed immunoadjuvant consisting of BCG extract bound to hydroxyapatite and microparticulated tuberculin, following local PBT for HCC. Methods Patients with locally advanced recurrent HCC, which had been heavily pretreated with various treatments, were enrolled. PBT was performed with the conventional method to the target HCC. Subsequently, CalTUMP was injected into the same irradiated-tumor three times at one-week intervals. Three dose-levels of CalTUMP (1/10, 1/3, and 1/1) were administered to 3 patients each. Vital signs, blood samples, ultrasound, and computed tomographic scans were monitored to evaluate the safety. Results Three intratumoral injections of CalTUMP following PBT (median dose: 72.6 GyE) were accomplished in 9 patients. Transient low-grade fever and minor laboratory changes were observed in 7 patients after CalTUMP injections. No other treatment-related adverse events were observed. Median progression-free survival was 6.0 months (range: 2.1-14.2) and 4 patients were progression-free for more than 1 year. Conclusions Intratumoral injection of CalTUMP following PBT was feasible and safe in patients with heavily pre-treated HCC. Further clinical studies to evaluate the efficacy of this in situ tumor vaccination are warranted.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Koji Tsuboi
- Proton Medical Research Center, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennohdai, Tsukuba, Ibaraki 305-8575, Japan.
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Wigg A, Hon K, Mosel L, Sladden N, Palumbo K. Down-staging of hepatocellular carcinoma via external-beam radiotherapy with subsequent liver transplantation: a case report. Liver Transpl 2013; 19:1119-24. [PMID: 23894122 DOI: 10.1002/lt.23714] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/08/2013] [Indexed: 01/12/2023]
Abstract
Despite the widespread use of locoregional therapies [radiofrequency ablation and transarterial chemoembolization (TACE)], there is currently a lack of high-quality evidence supporting their use for hepatocellular carcinoma (HCC) in patients on the liver transplantation (LT) waiting list or requiring down-staging. Radiotherapy has rarely been used in this setting and has usually been in the form of more complex and less accessible techniques such as proton-beam and stereotactic body radiation therapy. Only 1 report describes the use of conventional 3-dimensional conformal external-beam radiotherapy (cEBRT) techniques as neoadjuvant or down-staging therapy for patients who are LT candidates. This report describes the use of cEBRT in a 52-year-old hepatitis C-positive man with cirrhosis. A 40-mm right lobe HCC was treated initially with TACE while he was on the waiting list. The lesion progressed beyond transplant criteria (76 mm). Conventional external-beam radiotherapy (EBRT) was used (54 Gy in 27 fractions) to down-stage the lesion. EBRT was well tolerated and resulted in a complete radiological response with no arterial enhancement of the lesion for a total of 16 months. Subsequent LT and a review of the explant demonstrated complete histological necrosis of the lesion. This report provides the first description of complete histological necrosis of HCC through the use of cEBRT techniques as down-staging/neoadjuvant therapy before LT. Because of its potential efficacy, accessibility, tolerability, noninvasive and outpatient nature, and ability to treat lesions adjacent to vessels and biliary structures, further trials examining the efficacy of cEBRT versus other neoadjuvant techniques are urgently required.
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Affiliation(s)
- Alan Wigg
- Hepatology and Liver Transplant Medicine Unit, Flinders Medical Centre, Bedford Park, Australia; South Australian Liver Transplant Unit, Flinders Medical Centre, Bedford Park, Australia
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Kanemoto A, Mizumoto M, Okumura T, Takahashi H, Hashimoto T, Oshiro Y, Fukumitsu N, Moritake T, Tsuboi K, Sakae T, Sakurai H. Dose-volume histogram analysis for risk factors of radiation-induced rib fracture after hypofractionated proton beam therapy for hepatocellular carcinoma. Acta Oncol 2013; 52:538-44. [PMID: 22950386 DOI: 10.3109/0284186x.2012.718094] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Radiation-induced rib fracture has been reported as a late complication after external radiotherapy to the chest. The purpose of this study was to clarify the characteristics and risk factors of rib fracture after hypofractionated proton beam therapy (PBT). MATERIAL AND METHODS The retrospective study comprised 67 patients with hepatocellular carcinoma who were treated using PBT of 66 Cobalt-Gray-equivalents [Gy (RBE)] in 10 fractions. We analyzed the patients' characteristics and determined dose-volume histograms (DVHs) for the irradiated ribs, and then estimated relationships between risk of fracture and several dose-volume parameters. An irradiated rib was defined to be any rib included in the area irradiated by PBT as determined by treatment-planning computed tomography. RESULTS Among the 67 patients, a total of 310 ribs were identified as irradiated ribs. Twenty-seven (8.7%) of the irradiated ribs developed fractures in 11 patients (16.4%). No significant relationships were seen between incidence of fracture and characteristics of patients, including sex, age, tumor size, tumor site, and follow-up period (p ≥ 0.05). The results of receiver operating characteristic curve analysis using DVH parameters demonstrated that the largest area under the curve (AUC) was observed for the volume of rib receiving a biologically effective dose of more than 60 Gy(3 )(RBE) (V60) [The equivalent dose in 2 Gy fractions (EQD2); 36 Gy(3)] and the AUCs of V30 to V120 (EQD2; 18-72 Gy(3)) and Dmax to D(10 cm)(3) were similar to that of V60. No significant relationships were seen for DVH parameters and intervals from PBT to incidence of fracture. CONCLUSION DVH parameters are useful in predicting late adverse events of rib irradiation. This study identified that V60 was a most statistically significant parameter, and V30 to V120 and Dmax to D(10 cm)(3) were also significant and clinically useful for estimating the risk of rib fracture after hypofractionated PBT.
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Affiliation(s)
- Ayae Kanemoto
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Masashi Mizumoto
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Toshiyuki Okumura
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Hideto Takahashi
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Takayuki Hashimoto
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Yoshiko Oshiro
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Nobuyoshi Fukumitsu
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Takashi Moritake
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Koji Tsuboi
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Takeji Sakae
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
| | - Hideyuki Sakurai
- Proton Medical Research Center and Department of Radiation Oncology, University of Tsukuba,
Tsukuba, Ibaraki, Japan
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128
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Ling TC, Kang JI, Bush DA, Slater JD, Yang GY. Proton therapy for hepatocellular carcinoma. Chin J Cancer Res 2013. [DOI: 10.1007/s11670-012-0276-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Habermehl D, Debus J, Ganten T, Ganten MK, Bauer J, Brecht IC, Brons S, Haberer T, Haertig M, Jäkel O, Parodi K, Welzel T, Combs SE. Hypofractionated carbon ion therapy delivered with scanned ion beams for patients with hepatocellular carcinoma - feasibility and clinical response. Radiat Oncol 2013; 8:59. [PMID: 23497349 PMCID: PMC3663740 DOI: 10.1186/1748-717x-8-59] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/28/2013] [Indexed: 01/28/2023] Open
Abstract
Purpose Photon-based radiation therapy does currently not play a major role as local ablative treatment for hepatocellular carcinoma (HCC). Carbon ions offer distinct physical and biological advantages. Due to their inverted dose profile and the high local dose deposition within the Bragg peak, precise dose application and sparing of normal tissue is possible. Furthermore, carbon ions have an increased relative biological effectiveness (RBE) compared to photons. Methods and materials A total of six patients with one or more HCC-lesions were treated with carbon ions delivered by the raster-scanning technique according to our clinical trial protocol. Diagnosis of HCC was confirmed by histology or two different imaging modalities (CT and MRI) according to the AASLD-guidelines. Applied fractionation scheme was 4 × 10 Gy(RBE). Correct dose application was controlled by in-vivo PET measurement of β + −activity in the irradiated tissue shortly after treatment. Results Patients were observed for a median time period of 11.0 months (range, 3.4 – 12.7 months). Imaging studies showed a partial response in 4/7 lesions and a stable disease in 3/7 lesions in follow-up CT- and MRI scans. Local control was 100%. One patient with multifocal intrahepatic disease underwent liver transplantation 3 months after carbon ion therapy. During radiotherapy and the follow-up period no severe adverse events have occurred. Conclusions We report the first clinical results of patients with HCC undergoing carbon ion therapy using the rasterscanning technique at our institution. All patients are locally controlled and experienced no higher toxicities in a short follow-up period. Further patients will be included in our prospective Phase-I clinical trial PROMETHEUS-01 (NCT01167374).
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Affiliation(s)
- Daniel Habermehl
- Department of Radiation Oncology, University Hospital of Heidelberg, INF 400, Heidelberg 69120, Germany.
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130
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Toramatsu C, Katoh N, Shimizu S, Nihongi H, Matsuura T, Takao S, Miyamoto N, Suzuki R, Sutherland K, Kinoshita R, Onimaru R, Ishikawa M, Umegaki K, Shirato H. What is the appropriate size criterion for proton radiotherapy for hepatocellular carcinoma? A dosimetric comparison of spot-scanning proton therapy versus intensity-modulated radiation therapy. Radiat Oncol 2013; 8:48. [PMID: 23497543 PMCID: PMC3606425 DOI: 10.1186/1748-717x-8-48] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 02/24/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We performed a dosimetric comparison of spot-scanning proton therapy (SSPT) and intensity-modulated radiation therapy (IMRT) for hepatocellular carcinoma (HCC) to investigate the impact of tumor size on the risk of radiation induced liver disease (RILD). METHODS A number of alternative plans were generated for 10 patients with HCC. The gross tumor volumes (GTV) varied from 20.1 to 2194.5 cm3. Assuming all GTVs were spherical, the nominal diameter was calculated and ranged from 3.4 to 16.1 cm. The prescription dose was 60 Gy for IMRT or 60 cobalt Gy-equivalents for SSPT with 95% planning target volume (PTV) coverage. Using IMRT and SSPT techniques, extensive comparative planning was conducted. All plans were evaluated by the risk of RILD estimated using the Lyman-normal-tissue complication probability model. RESULTS For IMRT the risk of RILD increased drastically between 6.3-7.8 cm nominal diameter of GTV. When the nominal diameter of GTV was more than 6.3 cm, the average risk of RILD was 94.5% for IMRT and 6.2% for SSPT. CONCLUSIONS Regarding the risk of RILD, HCC can be more safely treated with SSPT, especially if its nominal diameter is more than 6.3 cm.
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Affiliation(s)
- Chie Toramatsu
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Norio Katoh
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita-15Nhisi-7, , Kita-ku, Sapporo 060-8638, Japan
| | - Shinichi Shimizu
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita-15Nhisi-7, , Kita-ku, Sapporo 060-8638, Japan
| | - Hideaki Nihongi
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Taeko Matsuura
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Seishin Takao
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Naoki Miyamoto
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Ryusuke Suzuki
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Kenneth Sutherland
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Rumiko Kinoshita
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita-15Nhisi-7, , Kita-ku, Sapporo 060-8638, Japan
| | - Rikiya Onimaru
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita-15Nhisi-7, , Kita-ku, Sapporo 060-8638, Japan
| | - Masayori Ishikawa
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Kikuo Umegaki
- Department of Medical Physics, Hokkaido University Graduate School of Medicine, Sapporo Japan
| | - Hiroki Shirato
- Department of Radiation Medicine, Hokkaido University Graduate School of Medicine, Kita-15Nhisi-7, , Kita-ku, Sapporo 060-8638, Japan
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Klein J, Dawson LA. Hepatocellular carcinoma radiation therapy: review of evidence and future opportunities. Int J Radiat Oncol Biol Phys 2012; 87:22-32. [PMID: 23219567 DOI: 10.1016/j.ijrobp.2012.08.043] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 08/29/2012] [Accepted: 08/29/2012] [Indexed: 02/06/2023]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of global cancer death. Curative therapy is not an option for most patients, often because of underlying liver disease. Experience in radiation therapy (RT) for HCC is rapidly increasing. Conformal RT can deliver tumoricidal doses to focal HCC with low rates of toxicity and sustained local control in HCC unsuitable for other locoregional treatments. Stereotactic body RT and particle therapy have been used with long-term control in early HCC or as a bridge to liver transplant. RT has also been effective in treating HCC with portal venous thrombosis. Patients with impaired liver function and extensive disease are at increased risk of toxicity and recurrence. More research on how to combine RT with other standard and novel therapies is warranted. Randomized trials are also needed before RT will be generally accepted as a treatment option for HCC. This review discusses the current state of the literature and opportunities for future research.
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Affiliation(s)
- Jonathan Klein
- Department of Radiation Oncology, Princess Margaret Hospital/University of Toronto, Toronto, Ontario, Canada
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132
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Ling TC, Kang JI, Bush DA, Slater JD, Yang GY. Proton therapy for hepatocellular carcinoma. Chin J Cancer Res 2012; 24:361-7. [PMID: 23359779 PMCID: PMC3551328 DOI: 10.3978/j.issn.1000-9604.2012.10.09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 10/24/2012] [Indexed: 12/26/2022] Open
Abstract
Proton radiotherapy has seen an increasing role in the treatment of hepatocellular carcinoma (HCC). Historically, external beam radiotherapy has played a very limited role in HCC due to a high incidence of toxicity to surrounding normal structures. The ability to deliver a high dose of radiation to the tumor is a key factor in improving outcomes in HCC. Advances in photon radiotherapy have improved dose conformity and allowed dose escalation to the tumor. However, despite these advances there is still a large volume of normal liver that receives a considerable radiation dose during treatment. Proton beams do not have an exit dose along the beam path once they enter the body. The inherent physical attributes of proton radiotherapy offer a way to maximize tumor control via dose escalation while avoiding excessive radiation to the remaining liver, thus increasing biological effectiveness. In this review we discuss the physical attributes and rationale for proton radiotherapy in HCC. We also review recent literature regarding clinical outcomes of using proton radiotherapy for the treatment of HCC.
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Affiliation(s)
- Ted C Ling
- Department of Radiation Medicine, Loma Linda University Medical Center, CA 92354, USA
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133
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Lee AY, Wu T, Vannier MW, Testa G, Liauw SL. Unresectable Hepatocellular Carcinoma Due to Portal Venous Thrombosis: Focal Stereotactic Body Radiation Therapy Can Promote Resectability. J Gastrointest Cancer 2012; 43 Suppl 1:S202-7. [PMID: 22492210 DOI: 10.1007/s12029-012-9387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Andrew Y Lee
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, 5758 S Maryland Ave MC 9006, Chicago, IL, 60637, USA
| | - Tianming Wu
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, 5758 S Maryland Ave MC 9006, Chicago, IL, 60637, USA
| | - Michael W Vannier
- Department of Radiology, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Giuliano Testa
- Department of Transplant Surgery, Baylor University Medical Center at Dallas, Dallas, TX, USA
| | - Stanley L Liauw
- Department of Radiation and Cellular Oncology, University of Chicago Pritzker School of Medicine, 5758 S Maryland Ave MC 9006, Chicago, IL, 60637, USA.
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Abstract
Proton beam therapy (PBT) makes it possible to deliver a high concentration of radiation to a tumor using its Bragg peak, and it is simple to utilize as its radiobiological characteristics are identical to those of photon beams. PBT has now been used for half a century, and more than 60,000 patients worldwide are reported to have been treated with proton beams. The most significant change to PBT occurred in the 1990s, when the Loma Linda University Medical Center became the first hospital in the world to operate a medically dedicated proton therapy facility. Following its success, similar medically dedicated facilities have been constructed. Internationally, results have demonstrated the therapeutic superiority of PBT over alternative treatment options for several disease sites. Further advances in PBT are expected from both clinical and technological perspectives.
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