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Kirichenko A, Gayou O, Parda D, Kudithipudi V, Tom K, Khan A, Abrams P, Szramowski M, Oliva J, Monga D, Raj M, Thai N. Stereotactic body radiotherapy (SBRT) with or without surgery for primary and metastatic liver tumors. HPB (Oxford) 2016; 18:88-97. [PMID: 26776856 PMCID: PMC4750234 DOI: 10.1016/j.hpb.2015.07.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 07/14/2015] [Accepted: 07/28/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We report single center experience on the outcome and toxicity of SBRT alone or in combination with surgery for inoperable primary and metastatic liver tumors between 2007 and 2014. PATIENTS AND METHODS Patients with 1-4 hepatic lesions and tumor diameter ≤9 cm received SBRT at 46.8Gy ± 3.7 in 4-6 fractions. The primary end point was local control with at least 6 months of radiographic followup, and secondary end points were toxicity and survival. RESULTS Eighty-seven assessable patients (114 lesions) completed liver SBRT for hepatoma (39) or isolated metastases (48) with a median followup of 20.3 months (range 1.9-64.1). Fourteen patients underwent liver transplant with SBRT as a bridging treatment or for tumor downsizing. Eight patients completed hepatic resections in combination with planned SBRT for unresectable tumors. Two-year local control was 96% for hepatoma and 93.8% for metastases; it was 100% for lesions ≤4 cm. Two-year overall survival was 82.3% (hepatoma) and 64.3% (metastases). No incidence of grade >2 treatment toxicity was observed. CONCLUSION In this retrospective analysis we demonstrate that liver SBRT alone or in combination with surgery is safe and effective for the treatment of isolated inoperable hepatic malignancies and provides excellent local control rates.
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Affiliation(s)
- Alexander Kirichenko
- Department of Oncology, Division of Radiation Oncology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA,Correspondence Alexander V. Kirichenko, Division of Radiation Oncology, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212-4772, USA. Tel: +1 412 359 3408. Fax: +1 412 359 3171.
| | - Olivier Gayou
- Department of Oncology, Division of Radiation Oncology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - David Parda
- Department of Oncology, Division of Radiation Oncology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Vijay Kudithipudi
- Department of Oncology, Division of Radiation Oncology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Kusum Tom
- Department of General Surgery, Division of Abdominal Transplant, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Akhtar Khan
- Department of General Surgery, Division of Abdominal Transplant, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Peter Abrams
- Department of General Surgery, Division of Abdominal Transplant, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Molly Szramowski
- Department of General Surgery, Division of Abdominal Transplant, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Jose Oliva
- Division of Gastroenterology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Dulabh Monga
- Division of Medical Oncology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Moses Raj
- Division of Medical Oncology, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Ngoc Thai
- Department of General Surgery, Division of Abdominal Transplant, Allegheny General Hospital, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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Hong TS, Wo JY, Yeap BY, Ben-Josef E, McDonnell EI, Blaszkowsky LS, Kwak EL, Allen JN, Clark JW, Goyal L, Murphy JE, Javle MM, Wolfgang JA, Drapek LC, Arellano RS, Mamon HJ, Mullen JT, Yoon SS, Tanabe KK, Ferrone CR, Ryan DP, DeLaney TF, Crane CH, Zhu AX. Multi-Institutional Phase II Study of High-Dose Hypofractionated Proton Beam Therapy in Patients With Localized, Unresectable Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma. J Clin Oncol 2015; 34:460-8. [PMID: 26668346 DOI: 10.1200/jco.2015.64.2710] [Citation(s) in RCA: 310] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate the efficacy and safety of high-dose, hypofractionated proton beam therapy for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS In this single-arm, phase II, multi-institutional study, 92 patients with biopsy-confirmed HCC or ICC, determined to be unresectable by multidisciplinary review, with a Child-Turcotte-Pugh score (CTP) of A or B, ECOG performance status of 0 to 2, no extrahepatic disease, and no prior radiation received 15 fractions of proton therapy to a maximum total dose of 67.5 Gy equivalent. Sample size was calculated to demonstrate > 80% local control (LC) defined by Response Evaluation Criteria in Solid Tumors (RECIST) 1.0 criteria at 2 years for HCC patients, with the parallel goal of obtaining acceptable precision for estimating outcomes for ICC. RESULTS Eighty-three patients were evaluable: 44 with HCC, 37 with ICC, and two with mixed HCC/ICC. The CTP score was A for 79.5% of patients and B for 15.7%; 4.8% of patients had no cirrhosis. Prior treatment had been given to 31.8% of HCC patients and 61.5% of ICC patients. The median maximum dimension was 5.0 cm (range, 1.9 to 12.0 cm) for HCC patients and 6.0 cm (range, 2.2 to 10.9 cm) for ICC patients. Multiple tumors were present in 27.3% of HCC patients and in 12.8% of ICC patients. Tumor vascular thrombosis was present in 29.5% of HCC patients and in 28.2% of ICC patients. The median dose delivered to both HCC and ICC patients was 58.0 Gy. With a median follow-up among survivors of 19.5 months, the LC rate at 2 years was 94.8% for HCC and 94.1% for ICC. The overall survival rate at 2 years was 63.2% for HCC and 46.5% ICC. CONCLUSION High-dose hypofractionated proton therapy demonstrated high LC rates for HCC and ICC safely, supporting ongoing phase III trials of radiation in HCC and ICC.
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Affiliation(s)
- Theodore S Hong
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Jennifer Y Wo
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Beow Y Yeap
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Edgar Ben-Josef
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Erin I McDonnell
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lawrence S Blaszkowsky
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eunice L Kwak
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jill N Allen
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jeffrey W Clark
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lipika Goyal
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Janet E Murphy
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Milind M Javle
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - John A Wolfgang
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lorraine C Drapek
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ronald S Arellano
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Harvey J Mamon
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - John T Mullen
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sam S Yoon
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kenneth K Tanabe
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cristina R Ferrone
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - David P Ryan
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas F DeLaney
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher H Crane
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andrew X Zhu
- Theodore S. Hong, Jennifer Y. Wo, Beow Y. Yeap, Erin I. McDonnell, Lawrence S. Blaszkowsky, Eunice L. Kwak, Jill N. Allen, Jeffrey W. Clark, Lipika Goyal, Janet E. Murphy, John A. Wolfgang, Lorraine C. Drapek, Ronald S. Arellano, John T. Mullen, Sam S. Yoon, Kenneth K. Tanabe, Cristina R. Ferrone, David P. Ryan, Thomas F. DeLaney, and Andrew X. Zhu, Massachusetts General Hospital, Harvard Medical School; Harvey J. Mamon, Brigham and Women's Hospital/Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Edgar Ben-Josef, University of Pennsylvania Hospital, Philadelphia, PA; and Milind M. Javle and Christopher H. Crane, University of Texas MD Anderson Cancer Center, Houston, TX
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Dosimetric impact of different CT datasets for stereotactic treatment planning using 3D conformal radiotherapy or volumetric modulated arc therapy. Radiat Oncol 2015; 10:249. [PMID: 26626865 PMCID: PMC4666088 DOI: 10.1186/s13014-015-0557-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 11/24/2015] [Indexed: 12/25/2022] Open
Abstract
Background The purpose of this study was to assess the impact on dose to the planning target volume (PTV) and organs at risk (OAR) by using four differently generated CT datasets for dose calculation in stereotactic body radiotherapy (SBRT) of lung and liver tumors. Additionally, dose differences between 3D conformal radiotherapy and volumetric modulated arc therapy (VMAT) plans calculated on these CT datasets were determined. Methods Twenty SBRT patients, ten lung cases and ten liver cases, were retrospectively selected for this study. Treatment plans were optimized on average intensity projection (AIP) CTs using 3D conformal radiotherapy (3D-CRT) and volumetric modulated arc therapy (VMAT). Afterwards, the plans were copied to the planning CTs (PCT), maximum intensity projection (MIP) and mid-ventilation (MidV) CT datasets and dose was recalculated keeping all beam parameters and monitor units unchanged. Ipsilateral lung and liver volumes and dosimetric parameters for PTV (Dmean, D2, D98, D95), ipsilateral lung and liver (Dmean, V30, V20, V10) were determined and statistically analysed using Wilcoxon test. Results Significant but small mean differences were found for PTV dose between the CTs (lung SBRT: ≤2.5 %; liver SBRT: ≤1.6 %). MIPs achieved the smallest lung and the largest liver volumes. OAR mean doses in MIP plans were distinctly smaller than in the other CT datasets. Furthermore, overlapping of tumors with the diaphragm results in underestimated ipsilateral lung dose in MIP plans. Best agreement was found between AIP and MidV (lung SBRT). Overall, differences in liver SBRT were smaller than in lung SBRT and VMAT plans achieved slightly smaller differences than 3D-CRT plans. Conclusions Only small differences were found for PTV parameters between the four CT datasets. Larger differences occurred for the doses to organs at risk (ipsilateral lung, liver) especially for MIP plans. No relevant differences were observed between 3D-CRT or VMAT plans. MIP CTs are not appropriate for OAR dose assessment. PCT, AIP and MidV resulted in similar doses. If a 4DCT is acquired PCT can be omitted using AIP or MidV for treatment planning.
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Abstract
Radiation therapy plays an increasingly important role in the treatment of hepatic malignancies. There is convincing evidence of safety and efficacy employing brachytherapy (yttrium-90), three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic body radiotherapy (SBRT), and proton beam therapy (PBT) in all stages of primary and metastatic involvement in the liver. Technologic advances in tumor imaging, real-time tracking of moving targets during radiotherapy delivery, and superb radiation dose deposition control have enabled treatment of previously unapproachable lesions. Recently completed and ongoing clinical trials are refining optimal dose fractionation schedules for SBRT as monotherapy. Radioembolization as part of first-line therapy in metastatic colorectal tumors is being tested in large international trials combined with FOLFOX6 and bevacizumab, as well as in hepatocellular carcinoma with sorafenib. PBT is becoming more available as new facilities open in many countries providing particle beam therapy, which delivers unparalleled control of radiation dose close to critical structures. A major point of research is understanding how best to safely destroy tumors in the background of often fragile hepatic function from cirrhosis or heavily pretreated chemotherapy liver parenchyma. Fortunately, serious complications from radiotherapy are rare, acute toxicities are typically Common Terminology Criteria for Adverse Events v4.0 grade 1-2, with consistent response rates of 50% to 97% in the modern era.
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Affiliation(s)
- Andrew S Kennedy
- From Radiation Oncology, Sarah Cannon Research Institute, Nashville, TN
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105
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Abstract
Radiotherapy has a universal and predictable mode of action, that is, a physical mode of action consisting of the deposit of a dose of energy in tissues. Tumour cell damage is proportional to the energy dose. However, the main limitation of radiotherapy is the lack of spatial control of the deposition of energy, that is, it penetrates the healthy tissues, damages them and renders unfeasible delivery of an efficient energy dose when tumours are close to important anatomical structures. True nanosized radiation enhancers may represent a disruptive approach to broaden the therapeutic window of radiation therapy. They offer the possibility of entering tumour cells and depositing high amounts of energy in the tumour only when exposed to ionizing radiations (on/off activity). They may unlock the potential of radiation therapy by rendering the introduction of a greater energy dose, exactly within the tumour structure without passing through surrounding tissues feasible. Several nanosized radiation enhancers have been studied in in vitro and in vivo models with positive results. One agent has received the authorization to conduct clinical trials for human use. Opportunities to improve outcomes for patients receiving radiotherapy, to create new standards of care and to offer solutions to new patient populations are looked over here.
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106
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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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Yu JI, Park HC, Lim DH, Paik SW. Do Biliary Complications after Hypofractionated Radiation Therapy in Hepatocellular Carcinoma Matter? Cancer Res Treat 2015; 48:574-82. [PMID: 26194367 PMCID: PMC4843719 DOI: 10.4143/crt.2015.076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 06/29/2015] [Indexed: 12/21/2022] Open
Abstract
Purpose The purpose of this study is to evaluate the efficacy of hypofractionated radiation therapy (RT) in the treatment of unresectable hepatocellular carcinoma (HCC) after failure of transarterial chemoembolization (TACE) or in cases of refractory HCC, and to investigate biliary complications after hypofractionated RT. Materials and Methods We retrospectively enrolled patients with unresectable, TACE-unresponsive, or refractory HCC treated with hypofractionated RT between July 2006 and December 2012. The perihilar region was defined as the 1-cm area surrounding the right, left, and the common hepatic duct, including the gallbladder and the cystic duct. Significant elevation of total bilirubin was defined as an increase of more than 3.0 mg/dL, and more than two times that of the previous level after completion of RT. Results Fifty patients received hypofractionated RT and 27 (54%) had a tumor located within the perihilar region. The median follow-up period was 24.7 months (range, 4.3 to 95.5 months). None of the patients developed classic radiation disease symptoms, but four patients (8%) showed significant elevation of total bilirubin within 1 year after RT. During follow-up, 12 patients (24%) developed radiologic biliary abnormalities, but only two patients had toxicities requiring intervention. Estimated local progression-free survival, progression-free survival, and overall survival of the patients at 3-year post-hypofractionated RT were 89.7%, 11.2%, and 57.4%, respectively. Conclusion Biliary complications associated with a higher dose exposure of hypofractionated RT were minimal, even in the perihilar region. Hypofractionated RT provided excellent local control and may be a valuable option for treatment of unresectable cases of TACE-unresponsive or refractory HCC.
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Affiliation(s)
- Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Chul Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Do Hoon Lim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Woon Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Long Z, Wang B, Tao D, Liu Y, Zhang J, Tan J, Luo J, Shi F, Tao Z. Clinical research on alternating hyperfraction radiotherapy for massive hepatocellular carcinoma. Oncol Lett 2015; 10:523-527. [PMID: 26171062 DOI: 10.3892/ol.2015.3185] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 04/13/2015] [Indexed: 02/06/2023] Open
Abstract
The delivery of high tumoricidal doses of radiation with low rates of toxicity is of particular significance for massive hepatocellular carcinoma (HCC) radiotherapy. In order to observe the efficacy and adverse reactions of alternating hyperfraction radiotherapy treatment of massive HCC, seventy-two cases of massive HCC were randomly divided into two groups, group A and group B. The liver lesions of group A were divided into sublesions and treated with alternating hyperfraction radiotherapy [intensity modulated radiotherapy (IMRT)]. The interval between radiotherapy to the sublesions was a minimum of six hours. The average radiotherapy dose to the sublesions was 2 Gy/fraction, once a day, five times per week, treating the gross tumor volume with a total dose of 40-50 Gy, and the clinical target volume with a total dose of 30-40 Gy. By contrast, the lesions of group B were not divided into sublesions for the IMRT treatment, but were treated with an otherwise identical protocol, by 2 Gy/fraction, once a day, five times per week, and with the same total dose. Patients were followed up with regular blood tests, liver function tests, measurements of serum α-fetoprotein levels and contrast-enhanced magnetic resonance imaging (MRI) of the liver. Treatment responses were assessed every 3 months by MRI. The results revealed that the overall response rates of the two groups were 82.9 and 81.3%, respectively (P=0.864). The alternating hyperfraction radiotherapy protocol resulted in enhanced survival (P=0.002). The median survival time of the two groups was 9.7 and 6.5 months, respectively. The overall 6-month, 1-year, 2-year and 3-year survival rates of the two groups were 62.9 and 59.4% (P=0.770), 48.6 and 21.9% (P=0.040), 17.1 and 0.0% (P=0.025) and 2.9 and 0.0% (P=1.000), respectively. The I-II degree of abnormal liver function and radiation-induced liver disease of group B was higher than that of group A (P=0.021 and 0.046, respectively). In addition, the incidence rate of radiation-induced liver injury of group A was lower than that of group B. Therefore, treatment of massive HCC with alternating hyperfraction radiotherapy improved the quality of life and prolonged the overall survival time, compared with conventional IMRT, suggesting that it was an effective radiation pattern.
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Affiliation(s)
- Zhixiong Long
- Department of Otolaryngology - Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Bin Wang
- Department of Otolaryngology - Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
| | - Dan Tao
- Department of Oncology, The Fifth Hospital of Wuhan, Wuhan, Hubei 430050, P.R. China
| | - Yanping Liu
- Department of Oncology, The Fifth Hospital of Wuhan, Wuhan, Hubei 430050, P.R. China
| | - Jiangzhou Zhang
- Department of Oncology, The Fifth Hospital of Wuhan, Wuhan, Hubei 430050, P.R. China
| | - Jiaan Tan
- Department of Oncology, Hubei Provincial Traditional Chinese Medical Hospital, Wuhan, Hubei 430061, P.R. China
| | - Jing Luo
- Department of Oncology, Hubei Provincial Traditional Chinese Medical Hospital, Wuhan, Hubei 430061, P.R. China
| | - Feifei Shi
- Department of Oncology, Hubei Provincial Traditional Chinese Medical Hospital, Wuhan, Hubei 430061, P.R. China
| | - Zezhang Tao
- Department of Otolaryngology - Head and Neck Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei 430060, P.R. China
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Hepatocellular carcinoma: Consensus, controversies and future directions. A report from the Canadian Association for the Study of the Liver Hepatocellular Carcinoma Meeting. Can J Gastroenterol Hepatol 2015; 29:178-84. [PMID: 25965437 PMCID: PMC4444026 DOI: 10.1155/2015/824263] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide and its incidence has rapidly increased in North America in recent years. Although there are many published guidelines to assist the clinician, there remain gaps in knowledge and areas of controversy surrounding the diagnosis and management of HCC. In February 2014, the Canadian Association for the Study of the Liver organized a one-day single-topic consensus conference on HCC. Herein, the authors present a summary of the topics covered and the result of voting on consensus statements presented at this meeting.
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Wang PM, Chung NN, Hsu WC, Chang FL, Jang CJ, Scorsetti M. Stereotactic body radiation therapy in hepatocellular carcinoma: Optimal treatment strategies based on liver segmentation and functional hepatic reserve. Rep Pract Oncol Radiother 2015; 20:417-24. [PMID: 26696781 DOI: 10.1016/j.rpor.2015.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 01/08/2015] [Accepted: 03/22/2015] [Indexed: 01/01/2023] Open
Abstract
AIM To discuss current dosage for stereotactic body radiation therapy (SBRT) in hepatocellular carcinoma (HCC) patients and suggest alternative treatment strategies according to liver segmentation as defined by the Couinaud classification. BACKGROUND SBRT is a safe and effective alternative treatment for HCC patients who are unable to undergo liver ablation/resection. However, the SBRT fractionation schemes and treatment planning strategies are not well established. MATERIALS AND METHODS In this article, the latest developments and key findings from research studies exploring the efficacy of SBRT fractionation schemes for treatment of HCC are reviewed. Patients' characteristics, fractionation schemes, treatment outcomes and toxicities were compiled. Special attention was focused on SBRT fractionation approaches that take into consideration liver segmentation according to the Couinaud classification and functional hepatic reserve based on Child-Pugh (CP) liver cirrhosis classification. RESULTS The most common SBRT fractionation schemes for HCC were 3 × 10-20 Gy, 4-6 × 8-10 Gy, and 10 × 5-5.5 Gy. Based on previous SBRT studies, and in consideration of tumor size and CP classification, we proposed 3 × 15-25 Gy for patients with tumor size <3 cm and adequate liver reserve (CP-A score 5), 5 × 10-12 Gy for patients with tumor sizes between 3 and 5 cm or inadequate liver reserve (CP-A score 6), and 10 × 5-5.5 Gy for patients with tumor size >5 cm or CP-B score. CONCLUSIONS Treatment schemes in SBRT for HCC vary according to liver segmentation and functional hepatic reserve. Further prospective studies may be necessary to identify the optimal dose of SBRT for HCC.
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Affiliation(s)
- Po-Ming Wang
- Department of Radiation Oncology, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan
| | - Na-Na Chung
- Department of Radiation Oncology, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan
| | - Wei-Chung Hsu
- Department of Radiation Oncology, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan ; Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Feng-Ling Chang
- Department of Radiation Oncology, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan
| | - Chin-Jyh Jang
- Department of Radiation Oncology, Chung-Kang Branch, Cheng-Ching General Hospital, Taichung, Taiwan
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Cancer Center, Istituto Clinico Humanitas, Rozzano, Milano, Italy
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Bowen SR, Saini J, Chapman TR, Miyaoka RS, Kinahan PE, Sandison GA, Wong T, Vesselle HJ, Nyflot MJ, Apisarnthanarax S. Differential hepatic avoidance radiation therapy: Proof of concept in hepatocellular carcinoma patients. Radiother Oncol 2015; 115:203-10. [PMID: 25934165 DOI: 10.1016/j.radonc.2015.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 03/16/2015] [Accepted: 04/03/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE To evaluate the feasibility of a novel planning concept that differentially redistributes RT dose away from functional liver regions as defined by (99m)Tc-sulphur colloid (SC) uptake on patient SPECT/CT images. MATERIALS AND METHODS Ten HCC patients with different Child-Turcotte-Pugh scores (A5-B9) underwent SC SPECT/CT scans in treatment position prior to RT that were registered to planning CT scans. Proton pencil beam scanning (PBS) therapy plans were optimized to deliver 37.5-60.0Gy (RBE) over 5-15 fractions using single field uniform dose technique robust to range and setup uncertainty. Photon volumetrically modulated arc therapy (VMAT) plans were optimized to the same prescribed dose and minimum target coverage. For both treatment modalities, differential hepatic avoidance RT (DHART) plans were generated to decrease dose to functional liver volumes (FLV) defined by a range of thresholds relative to maximum SC uptake (43-90%) in the tumor-subtracted liver. Radiation dose was redistributed away from regions of increased SC uptake in each FLV by linearly scaling mean dose objectives during PBS or VMAT optimization. DHART planning feasibility was assessed by a significantly negative Spearman's rank correlation (RS) between dose difference and SC uptake. Patient, tumor, and treatment planning characteristics were tested for association to DHART planning feasibility using non-parametric Kruskal-Wallis ANOVA. RESULTS Compared to conventional plans, DHART plans achieved a 3% FLV dose reduction for every 10% SC uptake increase. DHART planning was feasible in the majority of patients with 60% of patients having RS<-0.5 (p<0.01, range -1.0 to 0.2) and was particularly effective in 30% of patients (RS<-0.9). Mean dose to FLV was reduced by up to 20% in these patients. Only fractionation regimen was associated with DHART planning feasibility: 15 fraction courses were more feasible than 5-6 fraction courses (RS<-0.93 vs. RS>-0.60, p<0.02). CONCLUSION Differential avoidance of functional liver regions defined on sulphur colloid SPECT/CT is achievable with either photon VMAT or proton PBS therapy. Further investigation with phantom studies and in a larger cohort of patients may validate the utility of DHART planning for HCC radiotherapy.
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Affiliation(s)
- Stephen R Bowen
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA; University of Washington School of Medicine, Department of Radiology, Seattle, USA.
| | | | - Tobias R Chapman
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
| | - Robert S Miyaoka
- University of Washington School of Medicine, Department of Radiology, Seattle, USA
| | - Paul E Kinahan
- University of Washington School of Medicine, Department of Radiology, Seattle, USA
| | - George A Sandison
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
| | - Tony Wong
- Seattle Cancer Care Alliance Proton Therapy Center, USA
| | - Hubert J Vesselle
- University of Washington School of Medicine, Department of Radiology, Seattle, USA
| | - Matthew J Nyflot
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
| | - Smith Apisarnthanarax
- University of Washington School of Medicine, Department of Radiation Oncology, Seattle, USA
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Akasaka H, Sasaki R, Miyawaki D, Mukumoto N, Sulaiman NSB, Nagata M, Yamada S, Murakami M, Demizu Y, Fukumoto T. Preclinical evaluation of bioabsorbable polyglycolic acid spacer for particle therapy. Int J Radiat Oncol Biol Phys 2015; 90:1177-85. [PMID: 25539373 DOI: 10.1016/j.ijrobp.2014.07.048] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 06/25/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of a polyglycolic acid (PGA) spacer through physical and animal experiments. METHODS AND MATERIALS The spacer was produced with surgical suture material made of PGA, forming a 3-dimensional nonwoven fabric. For evaluation or physical experiments, 150-MeV proton or 320-MeV carbon-ion beams were used to generate 60-mm width of spread-out Bragg peak. For animal experiments, the abdomens of C57BL/6 mice, with or without the inserted PGA spacers, were irradiated with 20 Gy of carbon-ion beam (290 MeV) using the spread-out Bragg peak. Body weight changes over time were scored, and radiation damage to the intestine was investigated using hematoxylin and eosin stain. Blood samples were also evaluated 24 days after the irradiation. Long-term thickness retention and safety were evaluated using crab-eating macaques. RESULTS No chemical or structural changes after 100 Gy of proton or carbon-ion irradiation were observed in the PGA spacer. Water equivalency of the PGA spacer was equal to the water thickness under wet condition. During 24 days' observation after 20 Gy of carbon-ion irradiation, the body weights of mice with the PGA spacer were relatively unchanged, whereas significant weight loss was observed in those mice without the PGA spacer (P<.05). In mice with the PGA spacer, villus and crypt structure were preserved after irradiation. No inflammatory reactions or liver or renal dysfunctions due to placement of the PGA spacer were observed. In the abdomen of crab-eating macaques, thickness of the PGA spacer was maintained 8 weeks after placement. CONCLUSIONS The absorbable PGA spacer had water-equivalent, bio-compatible, and thickness-retaining properties. Although further evaluation is warranted in a clinical setting, the PGA spacer may be effective to stop proton or carbon-ion beams and to separate normal tissues from the radiation field.
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Affiliation(s)
- Hiroaki Akasaka
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Hyogo Japan
| | - Ryohei Sasaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Hyogo Japan.
| | - Daisuke Miyawaki
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Hyogo Japan
| | - Naritoshi Mukumoto
- Division of Radiation Oncology, Kobe University Graduate School of Medicine, Hyogo Japan
| | | | - Masaaki Nagata
- Division of Gastroenterology, Kobe University Graduate School of Medicine, Hyogo Japan
| | - Shigeru Yamada
- Research Center Hospital, Research Center for Charged Particle Therapy, National Institute of Radiological Sciences, Chiba, Japan
| | - Masao Murakami
- Radiation Oncology Center, Dokkyo Medical University, Tochigi, Japan
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, Hyogo, Japan
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Hyogo Japan
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113
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Aitken KL, Hawkins MA. Stereotactic body radiotherapy for liver metastases. Clin Oncol (R Coll Radiol) 2015; 27:307-15. [PMID: 25682933 DOI: 10.1016/j.clon.2015.01.032] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 01/08/2015] [Accepted: 01/12/2015] [Indexed: 01/12/2023]
Abstract
The role for local ablative therapies in the management paradigm of oligometastatic liver disease is increasing. The evidence base supporting the use of stereotactic body radiotherapy for liver metastases has expanded rapidly over the past decade, showing high rates of local control with low associated toxicity. This review summarises the evidence base to date, discussing optimal patient selection, challenges involved with treatment delivery and optimal dose and fractionation. The reported toxicity associated with liver stereotactic body radiotherapy is presented, together with possible pitfalls in interpreting the response to treatment using standard imaging modalities. Finally, potential avenues for future research in this area are highlighted.
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Affiliation(s)
- K L Aitken
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust, London, UK
| | - M A Hawkins
- CRUK MRC Oxford Institute for Radiation Oncology, Gray Laboratories, University of Oxford, Oxford, UK.
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114
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Scorsetti M, Comito T, Cozzi L, Clerici E, Tozzi A, Franzese C, Navarria P, Fogliata A, Tomatis S, D'Agostino G, Iftode C, Mancosu P, Ceriani R, Torzilli G. The challenge of inoperable hepatocellular carcinoma (HCC): results of a single-institutional experience on stereotactic body radiation therapy (SBRT). J Cancer Res Clin Oncol 2015; 141:1301-9. [PMID: 25644863 DOI: 10.1007/s00432-015-1929-y] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/26/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the feasibility and efficacy of stereotactic body radiation therapy (SBRT) in the treatment of hepatocellular carcinoma (HCC) unsuitable for standard loco-regional therapies. MATERIALS AND METHODS Patients with 1-3 inoperable HCC lesions with diameter ≤6 cm were treated by SBRT. According to lesions size and liver function, two prescription regimens were adopted: 48-75 Gy in three fractions or 36-60 Gy in six fractions. SBRT was delivered using the volumetric modulated arc therapy technique with flattening filter-free photon beams. The primary end points of this study were in-field local control (LC) and toxicity. Secondary end points were overall survival (OS) and progression-free survival (PFS). RESULTS Forty-three patients with 63 HCC lesions were irradiated. All patients had Child-Turcotte-Pugh class A or B disease. Thirty lesions (48%) were treated with 48-75 Gy in three consecutive fractions, and 33 (52%) received 36-60 Gy in six fractions. Median follow-up was 8 months (range 3-43 months). Actuarial LC at 6, 12 and 24 months was 94.2 ± 3.3, 85.8 ± 5.5 and 64.4 ± 11.5%, respectively. A biological equivalent dose (BED) >100 Gy and GTV size were significant prognostic factors for LC in univariate analysis (p < 0.001 and p < 0.02). Median OS was 18.0 ± 5.8 months. Actuarial OS at 6, 12 and 24 months was 91.1 ± 4.9, 77.9 ± 8.2 and 45.3 ± 14.0%, respectively. Univariate analysis showed that OS is correlated with LC (p < 0.04), BED >100 (p < 0.05) and cumulative gross tumor volume GTV <5 cm (p < 0.04). Median PFS was 8 months, with a 1-year PFS rate of 41%. A significant (≥ grade 3) toxicity was observed in seven patients (16%) 2-6 months after the completion of the treatment. No classic radiation-induced liver disease was observed. CONCLUSION Stereotactic body radiation therapy is a safe and effective therapeutic option for HCC lesions unsuitable to standard loco-regional therapies, with acceptable local control rates and low treatment-related toxicity. The significant correlation between LC and higher doses and between LC and OS supports the clinical value of SBRT in these patients.
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Affiliation(s)
- Marta Scorsetti
- Radiotherapy and Radiosurgery, Oncology, Liver Surgery, Hepatology Departments, Humanitas Clinical and Research Center, Rozzano, MI, Italy
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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] [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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116
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Kim KM. Nonsurgical multidisciplinary approach for recurrent hepatocellular carcinoma after surgical resection. Hepat Oncol 2015; 2:29-38. [PMID: 30190985 DOI: 10.2217/hep.14.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative resection and local ablation, and this represents a major challenge for HCC treatment. Although several treatment guidelines have been reported, they detail initial treatment choices and there are no established guidelines for recurrent HCC. The current treatment options for recurrent HCC do not differ from the primary treatments, but the unique characteristics of HCC recurrence should be considered when choosing treatments and each treatment should be individualized to different clinical situations. Furthermore, combinations of various treatments have been recently attempted. This review summarizes the current evidence for nonsurgical treatments of recurrent HCC after resection and suggests a multidisciplinary approach to improving the prognosis of recurrent HCC.
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117
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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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118
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Allison RR, Patel RM, McLawhorn RA. Radiation oncology: physics advances that minimize morbidity. Future Oncol 2014; 10:2329-44. [DOI: 10.2217/fon.14.176] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT Radiation therapy has become an ever more successful treatment for many cancer patients. This is due in large part from advances in physics including the expanded use of imaging protocols combined with ever more precise therapy devices such as linear and particle beam accelerators, all contributing to treatments with far fewer side effects. This paper will review current state-of-the-art physics maneuvers that minimize morbidity, such as intensity-modulated radiation therapy, volummetric arc therapy, image-guided radiation, radiosurgery and particle beam treatment. We will also highlight future physics enhancements on the horizon such as MRI during treatment and intensity-modulated hadron therapy, all with the continued goal of improved clinical outcomes.
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Affiliation(s)
- Ron R Allison
- 21st Century Oncology, Inc., 801 WH Smith Blvd, Greenville, NC 27858, USA
| | - Rajen M Patel
- 21st Century Oncology, Inc., 801 WH Smith Blvd, Greenville, NC 27858, USA
| | - Robert A McLawhorn
- 21st Century Oncology, Inc., 801 WH Smith Blvd, Greenville, NC 27858, USA
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Choi C, Koom WS, Kim TH, Yoon SM, Kim JH, Lee HS, Nam TK, Seong J. A prospective phase 2 multicenter study for the efficacy of radiation therapy following incomplete transarterial chemoembolization in unresectable hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2014; 90:1051-60. [PMID: 25303890 DOI: 10.1016/j.ijrobp.2014.08.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 08/07/2014] [Accepted: 08/11/2014] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to investigate the efficacy and toxicity of radiation therapy (RT) following incomplete transarterial chemoembolization (TACE) in unresectable hepatocellular carcinoma (HCC). METHODS AND MATERIALS The study was designed as a prospective phase 2 multicenter trial. Patients with unresectable HCC, who had viable tumor after TACE of no more than 3 courses, were eligible. Three-dimensional conformal RT (3D-CRT) was added for HCC treatment with incomplete uptake of iodized oil, and the interval from TACE to RT was 4 to 6 weeks. The primary endpoint of this study was the tumor response after RT following incomplete TACE in unresectable HCC. Secondary endpoints were patterns of failure, progression-free survival (PFS), time to tumor progression (TTP), overall survival (OS) rates at 2 years, and treatment-associated toxicity. Survival was calculated from the start of RT. RESULTS Between August 2008 and December 2010, 31 patients were enrolled. RT was delivered at a median dose of 54 Gy (range, 46-59.4 Gy) at 1.8 to 2 Gy per fraction. A best objective in-field response rate was achieved in 83.9% of patients, with complete response (CR) in 22.6% of patients and partial response in 61.3% of patients within 12 weeks post-RT. A best objective overall response rate was achieved in 64.5% of patients with CR in 19.4% of patients and PR in 45.1% of patients. The 2-year in-field PFS, PFS, TTP, and OS rates were 45.2%, 29.0%, 36.6%, and 61.3%, respectively. The Barcelona Clinic liver cancer stage was a significant independent prognostic factor for PFS (P=.023). Classic radiation-induced liver disease was not observed. There were no treatment-related deaths or hepatic failure. CONCLUSIONS Early 3D-CRT following incomplete TACE is a safe and practical treatment option for patients with unresectable HCC.
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Affiliation(s)
- Chihwan Choi
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang-si, Republic of Korea
| | - Sang Min Yoon
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyung-Sik Lee
- Department of Radiation Oncology, Dong-A University Hospital, Dong-A University School of Medicine, Busan, Republic of Korea
| | - Taek-Keun Nam
- Department of Radiation Oncology, Chonnam National University Hospital, Gwang-Ju, Republic of Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Choi C, Choi GH, Kim TH, Tanaka M, Meng MB, Seong J. Multimodality Management for Barcelona Clinic Liver Cancer Stage C Hepatocellular Carcinoma. Liver Cancer 2014; 3:405-16. [PMID: 26280002 PMCID: PMC4531424 DOI: 10.1159/000343861] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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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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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Jacob J, Nguyen F, Deutsch E, Mornex F. [Stereotactic body radiation therapy in the management of liver tumours]. Cancer Radiother 2014; 18:486-94. [PMID: 25195113 DOI: 10.1016/j.canrad.2014.07.145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 12/22/2022]
Abstract
Stereotactic radiotherapy is a high-precision technique based on the administration of high doses to a limited target volume. This treatment constitutes a therapeutic progress in the management of many tumours, especially hepatic ones. If surgery remains the standard local therapy, stereotactic radiotherapy is first dedicated to inoperable patients or unresectable tumours. Patients with moderately altered general status, preserved liver function and tumour lesions limited in number as in size are eligible to this technique. Results in terms of local control are satisfying, regarding primary tumours (notably hepatocellular carcinomas) as metastases stemming from various origins. If treatment protocols and follow-up modalities are not standardized to this day, iconographic acquisition using four-dimensional computed tomography, target volumes delineation based on morphological and/or metabolic data, and image-guided radiotherapy contribute to an oncologic efficacy and an improved sparing of the functional liver. The purpose of this literature review is to report the results of the main works having assessed stereotactic radiotherapy in the management of primary and secondary liver tumours. Technical particularities of this radiation modality will also be described.
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Affiliation(s)
- J Jacob
- Service d'oncologie-radiothérapie, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard de Port-Royal, 75230 Paris cedex 05, France.
| | - F Nguyen
- Département de radiothérapie, institut de cancérologie Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - E Deutsch
- Département de radiothérapie, institut de cancérologie Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| | - F Mornex
- Service de radiothérapie-oncologie, centre hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; EMR 3738, université Claude-Bernard Lyon 1, 69373 Lyon cedex 08, France
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123
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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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Kavanagh BD. Stereotactic body radiation therapy as a derivative of stereotactic radiosurgery: clinically independent but with enduring common themes. J Clin Oncol 2014; 32:2827-31. [PMID: 25113758 DOI: 10.1200/jco.2014.56.7362] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Brian D Kavanagh
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
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125
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Stereotactic body radiotherapy for liver tumors. Strahlenther Onkol 2014; 190:872-81. [DOI: 10.1007/s00066-014-0714-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 06/28/2014] [Indexed: 12/14/2022]
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Kim KH, Kim MS, Chang JS, Han KH, Kim DY, Seong J. Therapeutic benefit of radiotherapy in huge (≥10 cm) unresectable hepatocellular carcinoma. Liver Int 2014; 34:784-94. [PMID: 24330457 DOI: 10.1111/liv.12436] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 12/07/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Huge (≥10 cm) hepatocellular carcinomas (HCCs) show dismal prognosis and only a limited number of cases are eligible for curative resection. We studied the therapeutic benefit of radiotherapy (RT) in patients with huge unresectable HCCs. METHODS Data from 283 patients with huge HCCs and preserved liver function who underwent non-surgical treatment from July 2001 to March 2012 were retrospectively reviewed. Patients were divided into 4 groups according to the initial treatment: Group A (N= 49), transarterial chemoembolization (TACE); Group B (N = 35), TACE + RT; Group C (N = 50), hepatic arterial infusion chemotherapy; and Group D (n = 149), concurrent chemoradiotherapy (CCRT). RESULTS AND CONCLUSIONS The median follow-up period was 27.8 months (range, 12.9-121.9 months). The median overall survival (OS) was longer in Groups B (15.3 months) and D (12.8 months) than in Groups A (7.5 months) and C (8.2 months; Group B vs. A, Bonferroni corrected P [P(c)] = 0.04; Group B vs. C, P(c) = 0.02; Group D vs. A, P(c) = 0.01; Group D vs. C, Pc = 0.006). Groups B and D also showed superior progression-free survival (PFS) and intrahepatic control than Groups A and C. In multivariate analysis, tumour multiplicity, serum alpha-foetoprotein level (≥200 ng/ml) and initial treatment were independent prognostic factors for OS and PFS. Patients with huge unresectable HCCs treated with RT, either as CCRT or in combination with TACE, showed excellent intrahepatic control and prolonged survival. RT could be considered a promising treatment modality in these patients.
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Affiliation(s)
- Kyung Hwan Kim
- Departments of Radiation Oncology, Yonsei Liver Cancer Special Clinic, Yonsei University Health System, Seoul, Korea
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Marrero J, Maluccio MA, McCurdy H, Abou-Alfa GK. Expert perspectives on evidence-based treatment planning for patients with hepatocellular carcinoma. Cancer Control 2014; 21:5-16. [PMID: 24681845 DOI: 10.1177/1073274814021002s02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Jorge Marrero
- University of Texas Southwestern Medical Center, Dallas, TX 75390.
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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] [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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Klein J, Dawson L. Hepatocellular carcinoma radiation therapy: Review of evidence and future opportunities. Int J Radiat Oncol Biol Phys 2013;87:22-32. Int J Radiat Oncol Biol Phys 2014. [DOI: 10.1016/j.ijrobp.2013.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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130
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Wang PM, Hsu WC, Chung NN, Chang FL, Jang CJ, Fogliata A, Scorsetti M, Cozzi L. Feasibility of stereotactic body radiation therapy with volumetric modulated arc therapy and high intensity photon beams for hepatocellular carcinoma patients. Radiat Oncol 2014; 9:18. [PMID: 24410988 PMCID: PMC3940026 DOI: 10.1186/1748-717x-9-18] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 12/21/2013] [Indexed: 02/07/2023] Open
Abstract
Background To report technical features, early outcome and toxicity of stereotactic body radiation therapy (SBRT) treatments with volumetric modulated arc therapy (RapidArc) for patients with hepatocellular carcinoma (HCC). Methods Twenty patients (22 lesions) were prospectively enrolled in a feasibility study. Dose prescription was 50Gy in 10 fractions. Seven patients (35%) were classified as AJCC stage I-II while 13 (65%) were stages III-IV. Eighteen patients (90%) were Child-Pugh stage A, the remaining were stage B. All patients were treated with RapidArc technique with flattening filter free (FFF) photon beams of 10MV from a TrueBeam linear accelerator. Technical, dosimetric and early clinical assessment was performed to characterize treatment and its potential outcome. Results Median age was 68 years, median initial tumor volume was 124 cm3 (range: 6–848). Median follow-up time was 7.4 months (range: 3–13). All patients completed treatment without interruption. Mean actuarial overall survival was of 9.6 ± 0.9 months (95%C.L. 7.8-11.4), median survival was not reached; complete response was observed in 8/22 (36.4%) lesions; partial response in 7/22 (31.8%), stable disease in 6/22 (27.3%), 1/22 (4.4%) showed progression. Toxicity was mild with only 1 case of grade 3 RILD and all other types were not greater than grade 2. Concerning dosimetric data, Paddick conformity index was 0.98 ± 0.02; gradient index was 3.82 ± 0.93; V95% to the clinical target volume was 93.6 ± 7.7%. Mean dose to kidneys resulted lower than 3.0Gy; mean dose to stomach 4.5 ± 3.0Gy; D1cm3 to spinal cord was 8.2 ± 4.5Gy; D1% to the esophagus was 10.2 ± 9.7Gy. Average beam on time resulted 0.7 ± 0.2 minutes (range: 0.4-1.4) with the delivery of an average of 4.4 partial arcs (range: 3–6) of those 86% non-coplanar. Conclusions Clinical results could suggest to introduce VMAT-RapidArc as an appropriate SBRT technique for patients with HCC in view of a prospective dose escalation trial.
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Affiliation(s)
| | | | | | | | | | | | | | - Luca Cozzi
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
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131
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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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Vivarelli M, Montalti R, Risaliti A. Multimodal treatment of hepatocellular carcinoma on cirrhosis: An update. World J Gastroenterol 2013; 19:7316-7326. [PMID: 24259963 PMCID: PMC3831214 DOI: 10.3748/wjg.v19.i42.7316] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 08/08/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the most frequent primary liver tumor, and overall, it is one of the most frequent cancers. The association of HCC with chronic liver disease, and cirrhosis in particular, is well known, making treatment complex and challenging. The treatment of HCC must take into account the presence and stage of chronic liver disease, with the aim of preserving hepatic function that is often already impaired, the stage of HCC and the clinical condition of the patient. The different treatment options include surgical resection, transplantation, local ablation, chemoembolization, radioembolization and molecular targeted therapies; these treatments can be combined in various ways to achieve different goals. Ideally, liver transplantation is best treatment for early stage HCC on cirrhosis because it removes both the tumor and the chronic disease that produced it; however, the application of this powerful tool is limited by the scarcity of donors. Downstaging and bridging are different strategies for the management of HCC patients who will undergo liver transplantation. Several professionals, including gastroenterologists, radiologists and surgeons, are involved in the choice of the most appropriate treatment for a single case, and a multidisciplinary approach is necessary to optimize the outcome. The purpose of this review is to provide a comprehensive description of the current treatment options for patients with HCC by analyzing the advantages, disadvantages and rationale for their use.
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133
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Bibault JE, Dewas S, Vautravers-Dewas C, Hollebecque A, Jarraya H, Lacornerie T, Lartigau E, Mirabel X. Stereotactic body radiation therapy for hepatocellular carcinoma: prognostic factors of local control, overall survival, and toxicity. PLoS One 2013; 8:e77472. [PMID: 24147002 PMCID: PMC3795696 DOI: 10.1371/journal.pone.0077472] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/02/2013] [Indexed: 12/20/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) has been evaluated in several recent studies. The CyberKnife® is an SBRT system that allows for real-time tracking of the tumor. The purpose of this study was to evaluate the prognostic factors for local control and overall survival following this treatment. Patients and Methods 75 patients with 96 liver-confined HCC were treated with SBRT at the Oscar Lambret Comprehensive Cancer Center. Fiducials were implanted in the liver before treatment and were used as markers to track the lesion’s movement. Treatment response was scored according to RECIST v1.1. Local control and overall survival were calculated using the Kaplan and Meier method. A stepwise multivariate analysis (Cox regression) of prognostic factors was performed for local control and overall survival. Results There were 67 patients with Child-Turcotte-Pugh (CTP) Class A and eight patients with CTP Class B. Treatment was administered in three sessions. A total dose of 40–45 Gy to the 80% isodose line was delivered. The median follow-up was 10 months (range, 3–49 months). The local control rate was 89.8% at 1 and 2 years. Overall survival was 78.5% and 50.4% at 1 and 2 years, respectively. Toxicity mainly consisted of grade 1 and grade 2 events. Higher alpha-fetoprotein (aFP) levels were associated with less favorable local control (HR=1.001; 95% CI [1.000, 1.002]; p=0.0063). A higher dose was associated with better local control (HR=0.866; 95% CI [0.753, 0.996]; p=0.0441). A Child-Pugh score higher than 5 was associated with worse overall survival (HR= 3.413; 95% CI [1.235, 9.435]; p=0.018). Conclusion SBRT affords good local tumor control and higher overall survival rates than other historical controls (best supportive care or sorafenib). High aFP levels were associated with lesser local control, but a higher treatment dose improved local control.
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Affiliation(s)
- Jean-Emmanuel Bibault
- Academic Radiation Oncology Department & University Lille II, CLCC Oscar Lambret, Lille, France
| | - Sylvain Dewas
- Academic Radiation Oncology Department & University Lille II, CLCC Oscar Lambret, Lille, France
| | - Claire Vautravers-Dewas
- Academic Radiation Oncology Department & University Lille II, CLCC Oscar Lambret, Lille, France
| | - Antoine Hollebecque
- Department of Medicine, Institut Gustave Roussy, University Paris , Villejuif, France
| | - Hajer Jarraya
- Department of Radiology, CLCC Oscar Lambret, Lille, France
| | - Thomas Lacornerie
- Academic Radiation Oncology Department & University Lille II, CLCC Oscar Lambret, Lille, France
| | - Eric Lartigau
- Academic Radiation Oncology Department & University Lille II, CLCC Oscar Lambret, Lille, France
| | - Xavier Mirabel
- Academic Radiation Oncology Department & University Lille II, CLCC Oscar Lambret, Lille, France
- * E-mail:
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Chen XH, Li ZQ, Peng H, Jin SM, Fu HQ, Zhu TC, Weng XG. Type 1 insulin-like growth factor receptor monoclonal antibody (HX-1162) treatment for liver cancer. Onco Targets Ther 2013; 6:527-30. [PMID: 23700371 PMCID: PMC3660154 DOI: 10.2147/ott.s44162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
One of the most important molecules mediating the proliferation, growth, and metastasis of cancer cells is insulin-like growth factor (IGF), with its receptor IGF-1R. Here, we describe the potential of an IGF-1R monoclonal antibody, HX-1162, on liver cancer apoptosis in vitro and in vivo. We found that HX-1162 could induce the apoptosis of cultured liver cancer cells. Additionally, HX-1162 treatment inhibited the tumor growth after cancer cell grafting and enhanced the cell apoptosis inside the tumor tissue. We conclude that IGF-1R targeting therapy provides a new avenue toward treating liver cancer.
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Affiliation(s)
- Xue-Hui Chen
- The First Affiliated Hospital of Xinxiang Medical University, Weihui, People's Republic of China
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