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Proton Therapy in the Management of Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:cancers14122900. [PMID: 35740567 PMCID: PMC9220794 DOI: 10.3390/cancers14122900] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/29/2022] [Accepted: 06/07/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Radiation therapy is among the locoregional therapy modalities used to treat unresectable or medically inoperable hepatocellular carcinoma (HCC). Proton radiation therapy plays a major role in the treatment of HCC, especially when liver toxicity is a concern. The aim of this review is to provide a concise and comprehensive summary on the use of proton therapy in the management of HCC. Abstract Proton radiation therapy plays a central role in the treatment of hepatocellular carcinoma (HCC). Because of the near-zero exit dose and improved sparing of normal liver parenchyma, protons are being used even in challenging scenarios, including larger or multifocal liver tumors, and those associated with vascular tumor thrombus. There is a mounting level of evidence that suggests that protons are superior to photons in terms of survival and toxicity outcomes, specifically the progression to liver failure. A randomized controlled trial comparing protons to photons is currently underway to verify this hypothesis.
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Greco C, Catalano G, Di Grazia A, Orecchia R. Radiotherapy of Liver Malignancies. From Whole Liver Irradiation to Stereotactic Hypofractionated Radiotherapy. TUMORI JOURNAL 2018; 90:73-9. [PMID: 15143976 DOI: 10.1177/030089160409000116] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims and background Until recently radiotherapy of hepatic malignancies has played a limited role due to the well-known limited radiotolerance of the liver. The aim of this paper is to review the available data on the risk of radiation-induced liver disease (RILD) and to define the modern role of radiotherapy in the management of patients with metastatic or primary liver malignancies. Methods The advent of three-dimensional conformal treatment planning with dose-volume histogram analysis has made the study of partial liver irradiation possible. Limited portions of the liver may withstand high doses of radiation with minimal risk of RILD. Patients with solitary unresectable liver tumors may be treated with high-dose radiotherapy with curative intent. Recently, the feasibility of stereotactically guided treatment techniques with a single fraction or few treatment sessions has been explored in numerous institutions. Results The radiation tolerance of the whole liver found by several investigations is in the order of approximately 30 Gy, which seriously restricts its clinical application. The role of whole liver irradiation therefore appears of limited benefit in the palliation of patients with multiple liver metastases. The use of three-dimensional conformal techniques has made partial liver irradiation possible to doses in the 70–80 Gy range with conventional fractionation. At least two published series have reported improved local control and survival rates with dose escalation with three-dimensional conformal radiotherapy in patients with unresectable liver metastases. Similar outcomes have been recently reported with single dose (or hypofractionated) stereotactic radiotherapy both in metastatic and primary hepatic malignancies with minimal morbidity. Accurate target delineation and treatment reproducibility are the key to the success of this novel treatment approach, and specific treatment planning techniques and patient setup procedures must be developed to implement it. Conclusions Stereotactic high-dose radiotherapy is technically feasible for the treatment of inoperable liver malignancies, with the potential of high local control and low morbidity. Definitive evidence on the clinical advantages of this technique over other more established treatments can only be gathered from well-designed clinical studies.
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Affiliation(s)
- Carlo Greco
- Division of Radiation Oncology, European Institute of Oncology, Milan, Italy.
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Kim TH, Park JW, Kim YJ, Kim BH, Woo SM, Moon SH, Kim SS, Koh YH, Lee WJ, Park SJ, Kim JY, Kim DY, Kim CM. Phase I dose-escalation study of proton beam therapy for inoperable hepatocellular carcinoma. Cancer Res Treat 2014; 47:34-45. [PMID: 25381830 PMCID: PMC4296848 DOI: 10.4143/crt.2013.218] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/17/2013] [Indexed: 12/13/2022] Open
Abstract
Purpose The purpose of this study is to determine the optimal dose of proton beam therapy (PBT) in hepatocellular carcinoma (HCC) patients. Materials and Methods Inoperable HCC patients who had naïve, recurrent, or residual tumor to treatment were considered eligible for PBT. Patients received PBT with 60 GyE in 20 fractions (dose level 1; equivalent dose in 2 Gy fractions [EQD2], 65 GyE10); 66 GyE in 22 fractions (dose level 2; EQD2, 71.5 GyE10); or 72 GyE in 24 fractions (dose level 3; EQD2, 78 GyE10). Dose-limiting toxicity was determined by grade ≥ 3 acute toxicity. Results Twenty-seven patients were enrolled; eight, seven, and 12 patients were treated with dose levels 1, 2, and 3, respectively. Overall, treatment was well tolerated, with no dose-limiting toxicities. The complete response (CR) rates of primary tumors after PBT for dose levels 1, 2, and 3 were 62.5% (5/8), 57.1% (4/7), and 100% (12/12), respectively (p=0.039). The 3-and 5-year local progression-free survival (LPFS) rates among 26 patients, excluding one patient who underwent liver transplantation after PBT due to its probable significant effect on disease control, were 79.9% and 63.9%, respectively, and the 3-and 5-year overall survival rates were 56.4% and 42.3%, respectively. The 3-year LPFS rate was significantly higher in patients who achieved CR than in those who did not (90% vs. 40%, p=0.003). Conclusion PBT is safe and effective and an EQD2 ≥ 78 GyE10 should be delivered for achievement of local tumor control.
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Affiliation(s)
- Tae Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Joong-Won Park
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Yeon-Joo Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bo Hyun Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Myung Woo
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Ho Moon
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Soo Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Young-Hwan Koh
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Woo Jin Lee
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sang Jae Park
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Joo-Young Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang-Min Kim
- Center for Liver Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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Aiko S, Yoshizumi Y, Ishizuka T, Sakano T, Kumano I, Sugiura Y, Maehara T. Reduction rate of lymph node metastasis as a significant prognostic factor in esophageal cancer patients treated with neoadjuvant chemoradiation therapy. Dis Esophagus 2007; 20:94-101. [PMID: 17439591 DOI: 10.1111/j.1442-2050.2006.00624.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Tumor regression is used widely as a measure of tumor response following radiation therapy or chemoradiation therapy (CRT). In cases of esophageal cancer, a different pattern of tumor shrinkage is often observed between primary tumors and metastatic lymph nodes (MLNs). Regression of MLNs surrounded by normal tissue may be a more direct measure of the response to CRT than regression of a primary tumor as exfoliative mechanical clearance does not participate in shrinkage of MLNs. In this study we evaluated the significance of the reduction rate (RR) of MLNs as a prognostic factor in esophageal cancer patients treated with neoadjuvant CRT. Forty-two patients with marked MLNs were selected from 93 patients with esophageal carcinoma who had received neoadjuvant CRT. The RRs of the primary tumor and the MLNs were calculated from computed tomography scans. In 20 patients, surgical resection was carried out following CRT. Univariate analysis was used to determine which of the following variables were related to survival: size of the primary tumor and MLNs; RRs of both lesions; degree of lymph node (LN) metastasis; clinical stage; and surgical resection. Multivariate analysis was then performed to assess the prognostic relevance of each variable. The primary tumor was larger than the MLNs in 69% of patients before CRT and in 40% of patients after CRT. In 79% of the patients, the RR of the primary tumor was greater than the RR of the MLNs. The results of the univariate analyses showed that a high RR of the MLNs and surgical resection after CRT were associated with significantly improved survival. The multivariate analysis demonstrated that the RR of MLNs had the strongest influence on survival. The RR of LN metastasis should be evaluated as an important prognostic predictor in patients with marked LN metastasis of esophageal cancer treated with CRT.
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Affiliation(s)
- S Aiko
- National Defense Medical College, Surgery II, Saitama, Japan.
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Abstract
The nearly ubiquitous association of hepatocellular cancer (HCC) with underlying liver dysfunction portends a dismal prognosis. At the time of presentation with HCC, many patients have advanced cirrhosis that precludes effective therapy. Important prognostic factors include characteristics of the tumor (size, location, involvement of major blood vessels) and the functional state of the liver (quantified by synthetic function and portal hypertension). Localized tumors in a noncirrhotic liver may be treated successfully with surgical resection. In the setting of mild to moderate cirrhosis, localized therapy such as radiofrequency ablation, percutaneous ethanol ablation, chemoembolization, or Yttrium 90 microsphere infusion may be options, depending on the liver reserve and resources available. In the setting of advanced cirrhosis, treatment of the tumor may exacerbate liver decompensation, resulting in a shortened survival. In all of these instances, regardless of the therapy pursued, the underlying field defect with malignant potential remains in place. Liver transplantation has been employed to resolve both life-threatening problems, but it is fraught with many barriers. Appropriate patient selection and the use of adjuvant therapies are being pursued to improve the outcome of transplantation for HCC. Patients may have limited therapy options if they have poor performance status, are not surgical candidates, have a tumor that extends into the main portal vein, or have metastases to distant lymph nodes or organs. Chemotherapy is of marginal efficacy. Emerging therapies exploiting molecular targets are being explored with some promise.
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Affiliation(s)
- Mary F Mulcahy
- Department of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL 60611, USA.
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Kawashima M, Furuse J, Nishio T, Konishi M, Ishii H, Kinoshita T, Nagase M, Nihei K, Ogino T. Phase II study of radiotherapy employing proton beam for hepatocellular carcinoma. J Clin Oncol 2005; 23:1839-46. [PMID: 15774777 DOI: 10.1200/jco.2005.00.620] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of proton beam radiotherapy (PRT) for hepatocellular carcinoma. PATIENTS AND METHODS Eligibility criteria for this study were: solitary hepatocellular carcinoma (HCC); no indication for surgery or local ablation therapy; no ascites; age >/= 20 years; Zubrod performance status of 0 to 2; no serious comorbidities other than liver cirrhosis; written informed consent. PRT was administered in doses of 76 cobalt gray equivalent in 20 fractions for 5 weeks. No patients received transarterial chemoembolization or local ablation in combination with PRT. RESULTS Thirty patients were enrolled between May 1999 and February 2003. There were 20 male and 10 female patients, with a median age of 70 years. Maximum tumor diameter ranged from 25 to 82 mm (median, 45 mm). All patients had liver cirrhosis, the degree of which was Child-Pugh class A in 20, and class B in 10 patients. Acute reactions of PRT were well tolerated, and PRT was completed as planned in all patients. Four patients died of hepatic insufficiency without tumor recurrence at 6 to 9 months. Three of these four patients had pretreatment indocyanine green retention rate at 15 minutes of more than 50%. After a median follow-up period of 31 months (16 to 54 months), only one patient experienced recurrence of the primary tumor, and 2-year actuarial local progression-free rate was 96% (95% CI, 88% to 100%). Actuarial overall survival rate at 2 years was 66% (48% to 84%). CONCLUSION PRT showed excellent control of the primary tumor, with minimal acute toxicity. Further study is warranted to scrutinize adequate patient selection in order to maximize survival benefit of this promising modality.
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Affiliation(s)
- Mitsuhiko Kawashima
- Division of Radiation Oncology, Hepatobiliary, and Pancreatic Medical Oncology, and Hepatobiliary Surgery, National Cancer Center Hospital East, Chiba, Japan.
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Abstract
Radiotherapy has historically played a minor role in the treatment of patients with unresectable liver metastases from colorectal cancer and other malignancies. This can be attributed chiefly to the low tolerance of the whole liver to radiation. High-precision radiotherapy planning techniques have allowed much higher doses of radiation to be delivered safely to focal liver metastases, while sparing most of the normal liver. When combined with hepatic arterial fluorodeoxyuridine, high-dose focal liver radiotherapy is associated with excellent response rates, local control, and survival in patients with unresectable liver metastases from colorectal cancer. Radiotherapy, with and without concurrent systemic chemotherapy, has also been used with encouraging outcomes for patients with liver metastases from colorectal cancer and other cancers. There appears to be a radiation dose response for liver metastases; tumors treated with doses of 70 Gy or greater are likelier to have durable local control. Advancements in tumor imaging, in radiotherapy techniques that will allow the safe delivery of higher doses of radiation, and in novel tumor radiation sensitizers and normal tissue radioprotectors should substantially improve the outcome of patients with unresectable liver metastases treated with radiotherapy.
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Affiliation(s)
- Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario, Canada.
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Suzuki M, Sakurai Y, Masunaga S, Kinashi Y, Nagata K, Ono K. Dosimetric study of boron neutron capture therapy with borocaptate sodium (BSH)/lipiodol emulsion (BSH/lipiodol-BNCT) for treatment of multiple liver tumors. Int J Radiat Oncol Biol Phys 2004; 58:892-6. [PMID: 14967447 DOI: 10.1016/j.ijrobp.2003.09.084] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2003] [Revised: 09/17/2003] [Accepted: 09/22/2003] [Indexed: 12/21/2022]
Abstract
PURPOSE We performed a computational study to investigate the feasibility of borocaptate sodium (BSH)/lipiodol-boron neutron capture therapy (BSH/lipiodol-BNCT) for multiple liver tumors using Simulation Environment for Radiotherapy Applications (SERA), a currently available BNCT treatment planning system. METHODS AND MATERIALS Three treatment plans for BSH/lipiodol-BNCT using two or three epithermal neutron beams in one fraction were generated for 4 patients with multiple liver tumors using the SERA system. The (10)B concentrations in the tumor and the liver assumed in the study were 197.3 and 15.3 ppm, respectively; and were obtained from experimental studies in animals. The therapeutic gain factors for the liver tumors, defined as the minimum dose to the tumor/maximum dose to the liver, and the inhomogeneity index of the thermal neutron fluence for the whole of the liver, defined as the maximum neutron fluence - minimum neutron fluence/mean neutron fluence, were evaluated in each plan. RESULTS Three epithermal neutron beams incident on the anterior, posterior, and right side of the patient can deliver the most homogeneous distribution of thermal neutron fluence to the whole of the liver and provide the greatest therapeutic gain factors for tumors in the right lobe and approximately equal therapeutic gain factors for tumors in the left lobe, compared with the two opposed (anterior-posterior) and two orthogonal (anterior-right) beams. CONCLUSIONS From a dosimetric viewpoint, the BSH/lipiodol-BNCT treatment plan using three epithermal neutron beams is the most suitable for the treatment of multiple liver tumors.
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Affiliation(s)
- Minoru Suzuki
- Radiation Oncology Research Laboratory, Research Reactor Institute, Kyoto University, Osaka, Japan.
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Dawson LA, McGinn CJ, Lawrence TS. Conformal chemoradiation for primary and metastatic liver malignancies. ACTA ACUST UNITED AC 2003; 21:249-55. [PMID: 14648782 DOI: 10.1002/ssu.10043] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Historically, radiation therapy has played a minor role in the management of patients with unresectable primary hepatobiliary malignancies and liver metastases from colorectal cancer. This can be attributed chiefly to the low tolerance of the whole liver to radiation. Three-dimensional radiation planning techniques have allowed much higher doses of radiation to be delivered to focal liver tumors, while sparing the majority of the normal liver. When combined with fluorodeoxyuridine (FUdR), high-dose focal liver radiation is associated with excellent response rates, local control, and survival in patients with large unresectable tumors. There appears to be a radiation dose response for intrahepatic malignancies. Advancements in tumor imaging, radiation techniques that can safely deliver higher doses of radiation, novel tumor radiation sensitizers, and normal-tissue radioprotectors should substantially improve the outcome of patients with unresectable intrahepatic malignancies treated with chemoradiation.
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Affiliation(s)
- Laura A Dawson
- Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, Toronto, Ontario.
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Abstract
The use of three-dimensional radiotherapy (RT) and the prospective follow-up of patients for radiation-induced liver disease (RILD) have led to a more quantitative understanding of the partial organ tolerance of the liver compared with previous estimates based on clinical judgment alone. Parameters of both the Lyman normal tissue complication probability (NTCP) model and a local damage-organ injury (D-I) NTCP model have been fit to clinical data from patients who have received hepatic radiation. Based on analyses of over 180 patients, the liver exhibits a large volume effect and a low threshold volume for RILD. Mean liver dose is associated with RILD, and no cases of RILD have been reported in patients with a mean liver dose of less than 31 Gy. Most recent estimates of the partial liver tolerance to RT suggest that if less than 25% of the normal liver is treated with RT, then there may be no upper limit on dose associated with RILD. Estimates of the liver doses associated with a 5% risk of RILD for uniform irradiation of one third, two thirds, and the whole liver are 90 Gy, 47 Gy, and 31 Gy, respectively.
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Affiliation(s)
- L A Dawson
- Department of Radiation Oncology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI 48109-0010, USA.
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Dawson LA, McGinn CJ, Normolle D, Ten Haken RK, Walker S, Ensminger W, Lawrence TS. Escalated focal liver radiation and concurrent hepatic artery fluorodeoxyuridine for unresectable intrahepatic malignancies. J Clin Oncol 2000; 18:2210-8. [PMID: 10829040 DOI: 10.1200/jco.2000.18.11.2210] [Citation(s) in RCA: 320] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE To evaluate the response, time to progression, survival, and impact of radiation (RT) dose on survival in patients with intrahepatic malignancies treated on a phase I trial of escalated focal liver RT. PATIENTS AND METHODS From April 1996 to January 1998, 43 patients with unresectable intrahepatic hepatobiliary cancer (HB; 27 patients) and colorectal liver metastases (LM; 16 patients) were treated with high-dose conformal RT. The median tumor size was 10 x 10 x 8 cm. The median RT dose was 58.5 Gy (range, 28.5 to 90 Gy), 1.5 Gy twice daily, with concurrent continuous-infusion hepatic arterial fluorodeoxyuridine (0.2 mg/kg/d) during the first 4 weeks of RT. RESULTS The response rate in 25 assessable patients was 68% (16 partial and one complete response). With a median potential follow-up period of 26.5 months, the median times to progression for all tumors, LM, and HB were 6, 8, and 3 months, respectively. The median survival times of all patients, patients with LM, and patients with HB were 16, 18, and 11 months, respectively. On multivariate analyses, escalated RT dose was independently associated with improved progression-free and overall survival. The median survival of patients treated with 70 Gy or more has not yet been reached (16.4+ months), compared with 11.6 months in patients treated with lower RT doses (P =.0003). CONCLUSION The excellent response rate, prolonged intrahepatic control, and improved survival in patients treated with RT doses of 70 Gy or more motivate continuation of dose-escalation studies for patients with intrahepatic malignancies.
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Affiliation(s)
- L A Dawson
- Departments of Radiation Oncology, Internal Medicine, and Pharmacology, University of Michigan, Ann Arbor 48109-0010, USA.
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Ohara K, Tatsuzaki H, Fuji H, Sugahara S, Okumura T, Akaogi E, Onizuka M, Ishikawa S, Mitsui K, Itai Y. Radioresponse of thymomas verified with histologic response. Acta Oncol 1998; 37:471-4. [PMID: 9831376 DOI: 10.1080/028418698430421] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Patterns of radiologic response of 10 thymomas treated by preoperative radiotherapy (RT) (18-20 Gy/2 weeks) were determined in conjunction with histologic response. Changes in tumor volume were evaluated with CT scans obtained 5 to 36 days before and 14 to 24 days after the initiation of RT and before surgery. The extent of tumor volume reduction (TR) varied widely (40-78%), while the mean daily volume decrement expressed as a percentage of the pre-RT tumor volume correlated significantly with the pre-RT tumor volume. Histologically, the tumors, all of which were resected 17 to 33 days after RT initiation, generally consisted of predominant fibrous tissues, rare necrotic foci, and few epithelial cells. The TR did not correlate with pre-RT tumor volume, observation period, histologic subtype, or quantity of remaining epithelial cells. The TR of thymomas does not predict RT impact on tumor cells but does reflect the quantity of inherent tumor stroma.
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Affiliation(s)
- K Ohara
- Department of Radiology, Tsukuba University Hospital, the Institute of Clinical Medicine, University of Tsukuba, Tsukuba City, Japan.
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