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Cruz-Vallejo V, Ortíz-Muñiz R, Vallarino-Kelly T, Cervantes-Ríos E, Morales-Ramírez P. In vivo Characterization of the Radiosensitizing Effect of a Very Low Dose of BrdU in Murine Cells Exposed to Low-Dose Radiation. ENVIRONMENTAL AND MOLECULAR MUTAGENESIS 2019; 60:534-545. [PMID: 30851126 DOI: 10.1002/em.22284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/24/2019] [Accepted: 03/02/2019] [Indexed: 06/09/2023]
Abstract
The aim of the present study was to characterize the in vivo radiosensitizing effect of a very low dose of bromodeoxyuridine (BrdU) in mice exposed to low-dose radiation by establishing the following: (1) the radiosensitizing effect during DNA synthesis using single-cell gel electrophoresis (SCGE) in murine bone marrow cells, and (2) the number and timing of the mechanisms of genotoxicity and cytotoxicity, as well as the correlation of both end points, using flow cytometry analysis of the kinetics of micronucleus induction in reticulocytes. Groups of mice received intraperitoneal injections of 0.125 mg/g of BrdU 24 h prior to irradiation with 0.5 Gy of 60 Co gamma rays. DNA breaks measured using SCGE were determined at 30 min after exposure to radiation. The kinetics of micronucleated reticulocyte (MN-RET) induction was determined every 8 h after irradiation up to 72 h. The results from both experimental models indicated that low-level BrdU incorporation into DNA increased the sensitivity to 0.5 Gy of radiation, particularly in the S phase. The formation of micronuclei by gamma rays was produced at three different times using two main mechanisms. In the BrdU-substituted cells, the second mechanism was associated with a high cytotoxic effect that was absent in the irradiated BrdU-unsubstituted cells. The third mechanism, in which micronucleus formation was increased in irradiated substituted cells compared with the irradiated nonsubstituted control cells, was also related to an increase in cytotoxicity. Environ. Mol. Mutagen. 60:534-545, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Virginia Cruz-Vallejo
- Instituto Nacional de Investigaciones Nucleares, Carretera México-Toluca s/n, La Marquesa, Ocoyoacac, Estado de México C. P., 52750, Mexico
- Doctorado en Biología Experimental, Universidad Autónoma Metropolitana, Avenida San Rafael Atlixco 186 CP, 09340, Ciudad de México, Mexico
| | - Rocío Ortíz-Muñiz
- Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Avenida San Rafael Atlixco 186 CP, 09340, Ciudad de México, Mexico
| | - Teresita Vallarino-Kelly
- Instituto Nacional de Investigaciones Nucleares, Carretera México-Toluca s/n, La Marquesa, Ocoyoacac, Estado de México C. P., 52750, Mexico
| | - Elsa Cervantes-Ríos
- Departamento de Ciencias de la Salud, Universidad Autónoma Metropolitana-Iztapalapa, Avenida San Rafael Atlixco 186 CP, 09340, Ciudad de México, Mexico
| | - Pedro Morales-Ramírez
- Instituto Nacional de Investigaciones Nucleares, Carretera México-Toluca s/n, La Marquesa, Ocoyoacac, Estado de México C. P., 52750, Mexico
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Wada Y, Takami Y, Matsushima H, Tateishi M, Ryu T, Yoshitomi M, Matsumura T, Saitsu H. The Safety and Efficacy of Combination Therapy of Sorafenib and Radiotherapy for Advanced Hepatocellular Carcinoma: A Retrospective Study. Intern Med 2018; 57:1345-1353. [PMID: 29279513 PMCID: PMC5995712 DOI: 10.2169/internalmedicine.9826-17] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Objective Sorafenib is a standard therapy for advanced hepatocellular carcinoma (HCC), whereas radiotherapy is effective for local control of extrahepatic spread (EHS) or macrovascular invasion (MVI). This study investigated the safety and efficacy of this combined therapy to treat advanced HCC. Methods This retrospective study reviewed 62 patients with advanced-stage HCC with EHS or MVI who received sorafenib therapy, excluding the patients with only lung metastases. Results Of the 62 patients, 15 were treated using the combined therapy of sorafenib and radiotherapy (group RS), and 47 were treated with sorafenib monotherapy (group S). In group RS, patients were treated using three-dimensional conformal radiotherapy with a total irradiation dose of 30-60 Gy (median, 50 Gy). Irradiation was targeted at the bone, lymph nodes, adrenal gland, and MVI in 6, 5, 1, and 4 patients, respectively. The overall incidence of adverse events was 93.3% in group RS and 91.5% in group S (p=N.S.). Incidences of thrombocytopenia, leukopenia, and skin reaction were significantly higher in group RS (73.3%, 40.0%, and 66.7%, respectively) than in group S (36.2%, 10.6%, and 27.7%, respectively, p=0.02, 0.02, and <0.01, respectively). The incidence of severe adverse events, however, was comparable in the 2 groups: 20% in group RS and 19.2% in group S. The median progression-free survival (PFS) of EHS or MVI, PFS of whole lesions, and overall survival were longer in group RS (13.5, 10.6, and 31.2 months, respectively) than in group S (3.3, 3.5, and 12.1 months, respectively) (p<0.01 for all). Conclusion Sorafenib in combination with radiotherapy is a feasible and tolerable treatment option for advanced HCC.
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Affiliation(s)
- Yoshiyuki Wada
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Yuko Takami
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Hajime Matsushima
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Masaki Tateishi
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Tomoki Ryu
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Munehiro Yoshitomi
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
| | - Taisei Matsumura
- Department of Radiology, National Hospital Organization Kyushu Medical Center, Japan
| | - Hideki Saitsu
- Department of Hepato-Biliary-Pancreatic Surgery, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Japan
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Moore A, Cohen-Naftaly M, Tobar A, Kundel Y, Benjaminov O, Braun M, Issachar A, Mor E, Sarfaty M, Bragilovski D, Hur RB, Gordon N, Stemmer SM, Allen AM. Stereotactic body radiation therapy (SBRT) for definitive treatment and as a bridge to liver transplantation in early stage inoperable Hepatocellular carcinoma. Radiat Oncol 2017; 12:163. [PMID: 29052532 PMCID: PMC5649060 DOI: 10.1186/s13014-017-0899-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 10/06/2017] [Indexed: 12/30/2022] Open
Abstract
Background and Purpose Stereotactic body radiotherapy (SBRT) is an emerging modality for definitive treatment of Hepatocellular carcinoma (HCC). Materials and Methods This retrospective study included all early stage HCC patients who were not candidates for primary resection and/or local therapy, treated with SBRT between 11/2011 and 1/2016. Results Twenty-three patients were included. The median age was 62 years; 70% males; 30% females; 70% viral hepatitis carriers; 100% cirrhotic; 13 Child Pugh [CP]-A and 10 [CP]-B. The median tumor volume was 12.7cm3 (range, 2.2–53.6 cm3). Treatment was well tolerated. With the exception of one patient who developed RILD, no other patient had significant changes in 12 weeks of laboratory follow-up. SBRT was a bridge to transplantation in 16 patients and 11 were transplanted.. No surgical difficulties or complications were reported following SBRT, and none of the transplanted patients had local progression before transplantation. The median prescribed dose to the tumor was 54Gy (range, 30-54Gy), the median dose to the uninvolved liver was 6.0Gy(range, 1.6–12.6Gy). With a median follow-up time of 12 months, the median overall-survival for the 11 transplanted patients was not reached (range, 2.0–53.7+ months) and was 23 months for the 12 non-transplanted patients. The median progression-free survival for the transplanted patients was not reached (54+ months) and was 14.0 months for the non-transplanted patients. There was no SBRT-related mortality. Liver explant post SBRT revealed pathological complete response in 3(27.3%), pathological partial response in 6(54.5%), and pathological stable disease in 2(18.2%) tumors. Conclusions SBRT is safe and effective and can be used as a bridge to transplantation without comprising the surgical procedure.
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Affiliation(s)
- Assaf Moore
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Cohen-Naftaly
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Anna Tobar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Rabin Medical Center, Petah Tikva, Israel
| | - Yulia Kundel
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Benjaminov
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Imaging, Rabin Medical Center, Petah Tikva, Israel
| | - Marius Braun
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Assaf Issachar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Liver Institute, Rabin Medical Center, Petah Tikva, Israel
| | - Eytan Mor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Organ Transplantation, Rabin Medical Center, Petah Tikva, Israel
| | - Michal Sarfaty
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dimitri Bragilovski
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ran Ben Hur
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Noa Gordon
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Salomon M Stemmer
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Aaron M Allen
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Choudhary S, Mitra S, Sharma MK, Khullar P, Saxena U. Resurrection of whole liver radiotherapy-A case report. J Egypt Natl Canc Inst 2017; 29:105-108. [PMID: 28258915 DOI: 10.1016/j.jnci.2017.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 12/30/2016] [Accepted: 01/04/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This is a case report of a patient of lymphoma with liver metastasis who had persistent pain and jaundice despite multiple lines of chemotherapy. She underwent palliative liver irradiation. This is an uncommon modality due to fear of radiation induced hepatitis. We reviewed literature available on the use of liver irradiation for palliation and concluded that it can be safely used with good results. A 33-year-old female with Non-Hodgkin's Lymphoma (NHL) presented with obstructive jaundice. She underwent stenting followed by chemotherapy. She was lost to follow up to later present with a progressively increasing right hypochondrial mass, pain and icterus. Ultrasound abdomen revealed massive hepatomegaly with hypodense lesions in both liver lobes and centring the porta with dilatation of biliary radicals. Despite multiple lines of chemotherapy and use of opioids, there was no symptomatic relief in pain, size of mass or any decrease in biochemical parameters. Then she was offered palliative radiation in the form of partial liver irradiation to a dose of 21Gy/7 fractions. She had >50% pain relief after 2 fractions and was off opioids by last fraction. Liver span reduced from 6cm to 1cm below costal margin in mid clavicular line. Radiologically 60% reduction in size of liver lesions was observed. Also, a decreasing trend in biochemical parameters was observed. Use of whole or partial liver irradiation is rare in clinical practice due to fear of radiation induced hepatitis by conventional techniques. Newer techniques of delivering radiation can highly improvise accuracy and permit further dose escalation.
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Affiliation(s)
| | | | | | - Pooja Khullar
- DNB Radiation Oncology, Batra Hospital, New Delhi, India
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Herrmann E, Naehrig D, Sassowsky M, Bigler M, Buijsen J, Ciernik I, Zwahlen D, Pellanda AF, Meister A, Brauchli P, Berardi S, Kuettel E, Dufour JF, Aebersold DM. External beam radiotherapy for unresectable hepatocellular carcinoma, an international multicenter phase I trial, SAKK 77/07 and SASL 26. Radiat Oncol 2017; 12:12. [PMID: 28086942 PMCID: PMC5237353 DOI: 10.1186/s13014-016-0745-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 12/21/2016] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To assess feasibility and safety of conventionally fractionated radiotherapy (cfRT) in patients with hepatocellular carcinoma (HCC). METHODS Patients with histologically confirmed stage cT1-4, cN0-1 HCC and Child-Pugh Score (CPS) A or B disease were included in a phase I multicenter trial. Metastatic HCC were allowed if ≥90% of total tumor volume was located within the liver. Patients were enrolled onto five dose-escalation levels (54-70Gy in 2Gy fractions) based on a modified 3 + 3 design, with cohorts of five patients instead of three patients in dose levels 4 and 5. Primary trial endpoint was dose-limiting toxicity (DLT), as specifically defined for 17 clinical and nine laboratory parameters as grade ≥3 or ≥4 toxicity (CTCAE vs. 3). The threshold to declare a dose level as maximum tolerated dose (MTD) was defined as a DLT rate of ≤16.7% in dose levels 1-3, and ≤10% in dose levels 4-5. Best objective response of target liver lesions and adverse events (AE's) were assessed as secondary endpoints. RESULTS The trial was terminated early in DL 3 due to low accrual. Nineteen patients were recruited. Fifteen patients were evaluable for the primary and 18 for the secondary endpoints. Maximum tolerated dose was not reached. One patient in dose level 1, and one patient in dose level 2 experienced DLT (lipase > 5xULN, and neutrophils <500/μL respectively). However, dose level 3 (62Gy) was completed, with no DLTs in 3 patients. Overall, 56% of patients had a partial response and 28% showed stable disease according to RECIST. No signs of radiation induced liver disease (RILD). Two patients in dose level 3 experienced lymphocytopenia grade 4, with no clinical impact. CONCLUSION Conventionally fractionated radiotherapy of 58Gy to even large HCC was safe for patients with CPS A and B. 62Gy was delivered to three patients without any sign of clinically relevant increased toxicity. The maximum tolerated dose could not be determined. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00777894 , registered October 21st, 2008.
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Affiliation(s)
- Evelyn Herrmann
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Diana Naehrig
- Division of Radiation Oncology, Basel University Hospital, Basel, Switzerland
- Department of Radiation Oncology, Lifehouse at RPA, Sydney, NSW Australia
| | - Manfred Sassowsky
- Department of Radiation Oncology and Division of Medical Radiation Physics, Bern University Hospital, Bern, Switzerland
| | | | - Jeroen Buijsen
- Department of Radiation Oncology (MAASTRO Clinic), GROW – School for Oncology and Developmental Biolog, Maastricht, The Netherlands
| | - Ilja Ciernik
- Department of Radiation Oncology, University of Zurich, Zurich, Switzerland
- Department of Radiotherapy and Radiation Oncology, Dessau City Hospital, Dessau, Germany
| | - Daniel Zwahlen
- Department of Radiation Oncology, Hospital Graubuenden, Chur, Switzerland
| | - Alessandra Franzetti Pellanda
- Radiation Oncology Department, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Radiotherapy Service, Clinica Luganese SA, Lugano, Switzerland
| | - Andreas Meister
- Centre for Radiation Oncology, KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Simona Berardi
- Department of Radiation Oncology and Division of Medical Radiation Physics, Bern University Hospital, Bern, Switzerland
| | | | - Jean-François Dufour
- Department of Hepatology, University Clinic of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Daniel M. Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - for the Swiss Group for Clinical Cancer Research (SAKK)
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
- Division of Radiation Oncology, Basel University Hospital, Basel, Switzerland
- Department of Radiation Oncology, Lifehouse at RPA, Sydney, NSW Australia
- Department of Radiation Oncology and Division of Medical Radiation Physics, Bern University Hospital, Bern, Switzerland
- SAKK Coordinating Center, Bern, Switzerland
- Department of Radiation Oncology (MAASTRO Clinic), GROW – School for Oncology and Developmental Biolog, Maastricht, The Netherlands
- Department of Radiation Oncology, University of Zurich, Zurich, Switzerland
- Department of Radiotherapy and Radiation Oncology, Dessau City Hospital, Dessau, Germany
- Department of Radiation Oncology, Hospital Graubuenden, Chur, Switzerland
- Radiation Oncology Department, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
- Radiotherapy Service, Clinica Luganese SA, Lugano, Switzerland
- Centre for Radiation Oncology, KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
- Department of Hepatology, University Clinic of Visceral Surgery and Medicine, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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HWANG SANGYOUN, HEO KYU, KIM JOONSEOK, IM JUNGWOO, LEE SUNMI, CHO MONG, KANG DAEHWAN, HEO JEONG, LEE JUNWOO, CHOI CHEOLWON, YANG KWANGMO. Emodin attenuates radioresistance induced by hypoxia in HepG2 cells via the enhancement of PARP1 cleavage and inhibition of JMJD2B. Oncol Rep 2015; 33:1691-8. [DOI: 10.3892/or.2015.3744] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/08/2014] [Indexed: 11/06/2022] Open
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Cha J, Seong J, Lee IJ, Kim JW, Han KH. Feasibility of sorafenib combined with local radiotherapy in advanced hepatocellular carcinoma. Yonsei Med J 2013; 54:1178-85. [PMID: 23918567 PMCID: PMC3743177 DOI: 10.3349/ymj.2013.54.5.1178] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Sorafenib is an effective systemic agent for advanced hepatocellular carcinoma. To increase its efficacy, we evaluated the feasibility and benefit of sorafenib combined with radiotherapy. MATERIALS AND METHODS From July 2007 to July 2011, 31 patients were treated with a daily dose of 800 mg of sorafenib and radiotherapy. Among them, 13 patients who received radiotherapy on the bone metastasis were excluded. Thirteen patients received 30-54 Gy of radiotherapy on the primary tumor (primary group) and 5 patients received 30-58.4 Gy on the measurable metastatic lesions (measurable metastasis group). Tumor responses at 1 month after the completion of radiotherapy and overall survival were evaluated. RESULTS The in-field response rate was 100% in the primary group and 60% in the measurable metastasis group. A decrease of more than 80% in the tumor marker α-fetoprotein was observed in 7 patients in the primary group (54%). Toxicities of grades 3-4 were hand-foot syndrome in 3 (17%) patients, duodenal bleeding in 1 (6%) patient, thrombocytopenia in 3 (17%) patients and elevation of aspartate transaminase in 1 (6%) patient. The median overall survival was 7.8 months (95% confidence interval, 3.0-12.6). CONCLUSION The combined treatment of sorafenib and radiotherapy was feasible and induced substantial tumor responses in the target lesions. The results of this study emphasize the importance of individualized approach in the management of advanced hepatocellular carcinoma and encourage the initiation of a controlled clinical trial.
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Affiliation(s)
- Jihye Cha
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
- Yonsei Liver Cancer Special Clinic, Yonsei University Health System, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Kwang-Hyub Han
- Yonsei Liver Cancer Special Clinic, Yonsei University Health System, Seoul, Korea
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Son SH, Kay CS, Song JH, Lee SW, Choi BO, Kang YN, Jang JW, Yoon SK, Jang HS. Dosimetric parameter predicting the deterioration of hepatic function after helical tomotherapy in patients with unresectable locally advanced hepatocellular carcinoma. Radiat Oncol 2013; 8:11. [PMID: 23298438 PMCID: PMC3552734 DOI: 10.1186/1748-717x-8-11] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 01/05/2013] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The purpose of this study was to identify parameters capable of predicting the deterioration of hepatic function after helical tomotherapy in patients with unresectable locally advanced hepatocellular carcinoma. METHODS Between March 2006 and February 2012, 72 patients were eligible for this study. All patients received hypofractionated radiotherapy using the TomoTherapy Hi-Art (TomoTherapy, Madison, WI, USA) at Seoul St. Mary's Hospital and Incheon St. Mary's Hospital, the Catholic University of Korea. The radiation dose was a median 50 Gy (range: 40-50 Gy) in 10 fractions to 95% of the planning target volume. Radiation-induced hepatic toxicity was defined as an increase of at least 2 points in the Child-Pugh (CP) score within 3 months after completion of helical tomotherapy. RESULTS An increase of at least 2 points in the CP score occurred in 32 of the 72 patients (44.4%). Multivariate logistic regression analysis revealed that pretreatment CP class and V15Gy were significant parameters associated with an increase in CP score (p = 0.009 and p < 0.001, respectively). The area under receiver operating characteristic curve was 0.863 for V15Gy (p < 0.001). For V15Gy, with a cutoff value of 43.2%, the accuracy was 0.806 (58/72) with a sensitivity of 0.938 and a specificity of 0.725. CONCLUSIONS An increase of at least 2 points in the CP score is a radiation dose-limiting factor, and the non-target normal liver receiving a dose more than 15 Gy (V15Gy) should be <43.2% to reduce the risk of the deterioration of hepatic function.
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Affiliation(s)
- Seok Hyun Son
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Jihye C, Jinsil S. Application of Radiotherapeutic Strategies in the BCLC-Defined Stages of Hepatocellular Carcinoma. Liver Cancer 2012; 1:216-25. [PMID: 24159586 PMCID: PMC3760456 DOI: 10.1159/000343836] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The Barcelona Clinic Liver Cancer (BCLC) staging system is the method currently used to stage hepatocellular carcinoma (HCC) and therefore plays an important role in deciding on an appropriate course of treatment. BCLC takes into consideration the extent of the disease as well as patient factors such as hepatic function and performance status. However, it does not propose solutions for all clinical situations. Although radiotherapy (RT) is not included in the BCLC guidelines, the potent local antitumor effect of RT should be considered seriously as a part of the treatment strategy. Novel RT technologies introduced during the last decade have made it possible to deliver higher doses of radiation to the tumor while avoiding damage to critical normal tissues adjacent to the tumor. Because of the growing interest in using RT for HCC patients unfit for or progressed beyond standard treatments, the role of RT for HCC patients needs to be specified within the BCLC staging system. Curative RT can be used for patients with either very early or early stage BCLC; focal high dose RTs, such as stereotactic body RT, are especially useful. Intermediate or advanced stage disease confined to the liver can be managed safely and effectively by localized RT in conjunction with other treatment modalities such as transarterial chemoembolization or concurrent or adjuvant chemotherapy. In this review, the efficacy of RT in each BCLC stage of HCC will be discussed.
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Affiliation(s)
| | - Seong Jinsil
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine Seoul, Republic of Korea
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Lee IJ, Seong J. The optimal selection of radiotherapy treatment for hepatocellular carcinoma. Gut Liver 2012; 6:139-48. [PMID: 22570744 PMCID: PMC3343153 DOI: 10.5009/gnl.2012.6.2.139] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Accepted: 07/18/2011] [Indexed: 12/20/2022] Open
Abstract
The majority of patients who present with hepatocellular carcinoma (HCC) are already at an advanced stage, and the tumors are unresectable. Radiotherapy (RT) technology can safely provide focused high-dose irradiation to these patients. A wide spectrum of RT technologiesis currently available, including internal RT consisting of Yttrium-90 ((90)Y), Iodine-131 ((131)I) anti-ferritin antibody and Homium-199 ((199)Ho) and external RT, such as three-dimensional conformal RT, intensity-modulated RT, helical tomotherapy, stereotactic body RT, and image-guided RT. However, it may be difficult for physicians to understand all of the available options and to select the optimal RT treatment. Physicians frequently query radiation oncologists on the practical indications of RT for managing patients with HCC. According to the Korean Liver Cancer Study Group practice guidelines, RT is considered appropriate for unresectable, locally advanced HCC without extrahepatic metastasis, a Child-Pugh class A or B, and tumors that occupy less than two-thirds of the liver with level II evidence. In this review, we discuss the application of various RT modalities based on disease status and the detailed indications for RT according to the Barcelona Clinic Liver Cancer staging system.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei Liver Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
| | - Jinsil Seong
- Department of Radiation Oncology, Yonsei Liver Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Hepatocellular carcinoma (HCC) is the fifth most common malignancy worldwide, and its incidence is on the rise. The primary therapy is resection or liver transplant, but only a minority of patients present with resectable disease. Historically, radiotherapy has not played a significant role in the treatment of liver malignancies because of the low tolerance of the whole liver to radiation. With improvements in 3-dimensional conformal radiotherapy and intensity-modulated radiotherapy, higher doses of radiation can be delivered to target lesions with low doses to the noninvolved liver; thus, experience in the use of radiation for the treatment of focal HCC has increased. At the same time, our understanding of the relationships between radiation dose and volume and the risk of classic radiation-induced liver disease and other toxicities more likely to occur in HCC patients has improved considerably. These developments have led to a body of evidence that now supports the careful use of radiotherapy for unresectable HCC. The rationale for studying radiotherapy in a randomized trial is strong.
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Affiliation(s)
- Mary Feng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.
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Lee IJ, Seong J. Radiotherapeutic strategies in the management of hepatocellular carcinoma. Oncology 2011; 81 Suppl 1:123-33. [PMID: 22212946 DOI: 10.1159/000333275] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Although potentially curative therapies for hepatocellular carcinoma (HCC) are well established, they are offered only to a limited number of patients. For advanced HCC, sorafenib is now the treatment of choice. Radiotherapy technology has evolved remarkably during the past decade and can be precisely delivered, thereby permitting higher doses to the tumor and reduced doses to surrounding normal tissues. According to the Korean Liver Cancer Study Group (KLCSG) practice guidelines, radiation therapy is considered appropriate for unresectable, locally advanced HCC without extrahepatic metastasis, Child-Pugh class A or B, and tumors occupying less than two thirds of the liver with level II evidence. In this review, we discuss the radiotherapeutic strategies for each clinical setting in patients with HCC.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei Liver Cancer Clinic, Yonsei University College of Medicine, Seoul, Korea
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Price TR, Perkins SM, Sandrasegaran K, Henderson MA, Maluccio MA, Zook JE, Tector AJ, Vianna RM, Johnstone PAS, Cardenes HR. Evaluation of response after stereotactic body radiotherapy for hepatocellular carcinoma. Cancer 2011; 118:3191-8. [PMID: 22025126 DOI: 10.1002/cncr.26404] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/15/2011] [Accepted: 06/10/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is increasing in incidence due to hepatitis C. Stereotactic body radiotherapy (SBRT) is a noninvasive, effective therapy in the management of liver malignancies. The authors evaluated radiological response in 26 patients with HCC treated with SBRT at Indiana University. METHODS Between March 2005 and June 2008, 26 patients with HCC who were not surgical candidates were enrolled in a phase 1 to 2 trial. Eligibility criteria included solitary tumors ≤ 6 cm or up to 3 lesions with sum diameters ≤ 6 cm, and well-compensated cirrhosis. All patients had imaging before, at 1 to 3 months, and every 3 to 6 months after SBRT. RESULTS Patients received 3 to 5 fractions of SBRT. Median SBRT dose was 42 Gray (Gy) (range: 24-48 Gy). Median follow-up was 13 months. Per Response Evaluation Criteria in Solid Tumors (RECIST), 4 patients had a complete response (CR), 15 had a partial response (PR), and 7 achieved stable disease (SD) at 12 months. One patient with SD experienced progression marginal to the treated area. The overall best response rate (CR + PR) was 73%. In comparison, by European Association for the Study of the Liver (EASL) criteria, 18 of 26 patients had ≥ 50% nonenhancement at 12 months. Thirteen of 18 demonstrated 100% nonenhancement, being > 50% in 5 patients. Kaplan-Meier 1- and 2-year survival estimates were 77% and 60%, respectively. CONCLUSIONS SBRT is effective therapy for patients with HCC with an overall best response rate (CR + PR) of 73%. Nonenhancement on imaging, a surrogate for ablation, may be a more useful indicator than size reduction in evaluating HCC response to SBRT in the first 6 to 12 months, supporting EASL criteria.
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Affiliation(s)
- Tracy R Price
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Xu J, Qin X, Wang J, Zhang S, Zhong Y, Ren L, Wei Y, Zeng S, Wan D, Zheng S. Chinese guidelines for the diagnosis and comprehensive treatment of hepatic metastasis of colorectal cancer. J Cancer Res Clin Oncol 2011; 137:1379-96. [PMID: 21796415 DOI: 10.1007/s00432-011-0999-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 06/16/2011] [Indexed: 12/14/2022]
Affiliation(s)
- Jianmin Xu
- Zhongshan Hospital, Fudan University, Shanghai, China
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Ross HH, Rahman M, Levkoff LH, Millette S, Martin-Carreras T, Dunbar EM, Reynolds BA, Laywell ED. Ethynyldeoxyuridine (EdU) suppresses in vitro population expansion and in vivo tumor progression of human glioblastoma cells. J Neurooncol 2011; 105:485-98. [PMID: 21643840 DOI: 10.1007/s11060-011-0621-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 05/25/2011] [Indexed: 11/30/2022]
Abstract
Thymidine analogs (TAs) are synthetic nucleosides that incorporate into newly synthesized DNA. Halogenated pyrimidines (HPs), such as bromodeoxyuridine (BrdU), are a class of TAs that can be detected with antibodies and are commonly used for birthdating individual cells and for assessing the proliferative index of cell populations. It is well established that HPs can act as radiosensitizers when incorporated into DNA chains, but they are generally believed not to impair normal cell function in the absence of secondary stressors. However, we and others have shown that HP incorporation leads to a sustained suppression of cell cycle progression in mammalian cells, resulting in cellular senescence in somatic cells. In addition, we have shown that HP incorporation results in delayed tumor progression in a syngeneic rat model of glioma. Here we examine ethynyldeoxyuridine (EdU), a newly developed and alkylated TA, for its anti-cancer activity, both in vitro and in vivo. We show that EdU, like HPs, leads to a severe reduction in the proliferation rate of normal and transformed cells in vitro. Unlike HPs, however, EdU incorporation also causes DNA damage resulting in the death of a substantial subset of treated cells. When administered over an extended time as a monotherapy to mice bearing subcutaneous xenografts of human glioblastoma multiforme tumors, EdU significantly reduces tumor volume and increases survival without apparent significant toxicity. These results, combined with the fact that EdU readily crosses the blood-brain barrier, support the continued investigation of EdU as a potential therapy for malignant brain tumors.
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Affiliation(s)
- Heather H Ross
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA
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Lee IJ, Seong J, Koom WS, Kim YB, Jeon BC, Kim JH, Han KH. Selection of the Optimal Radiotherapy Technique for Locally Advanced Hepatocellular Carcinoma. Jpn J Clin Oncol 2011; 41:882-9. [DOI: 10.1093/jjco/hyr053] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Lee IJ, Seong J, Bae JI, You SH, Rhee Y, Lee JH. Effect of Oral Supplementation with Branched-chain Amino Acid (BCAA) during Radiotherapy in Patients with Hepatocellular Carcinoma: A Double-Blind Randomized Study. Cancer Res Treat 2011; 43:24-31. [PMID: 21509160 PMCID: PMC3072532 DOI: 10.4143/crt.2011.43.1.24] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 08/27/2010] [Indexed: 02/08/2023] Open
Abstract
Purpose The present study evaluated whether oral supplementation with a branched-chain amino acid (BCAA) improves the biochemical and amino acid profiles of liver tumor patients undergoing radiotherapy. Materials and Methods Patients were randomly assigned to one of 2 groups: a group given oral supplementation with BCAA granules (LIVACT granules; Samil Pharm Co., Korea, each granule containing L-isoleucine 952 mg, L-leucine 1,904 mg, and L-valine 1,144 mg) during radiotherapy, or a placebo group. Physical and biochemical examinations and measurements, including subjective symptoms, Child-Pugh class, body mass index, plasma albumin concentration, and plasma amino acid profiles were monitored. Results Fifty were enrolled between November 2005 and November 2006. We also analyzed data from 37 hepatocellular carcinoma (HCC) patients in order to evaluate a more homogenous group. The two groups of patients were comparable in terms of age, gender, Child-Pugh score, and underlying hepatitis virus type. Serum albumin, total protein, liver enzymes, and cholesterol showed a tendency to increase in the BCAA group. In this group, the percentage of cases that reverted to normal serum albumin levels between 3 and 10 weeks after administration of BCAA was significantly higher (41.18%) than in the placebo group (p=0.043). Conclusion Oral supplementation with a BCAA preparation seems to help HCC patients undergoing radiotherapy by increasing the BCAA concentration.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei University Health System, Seoul, Korea
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Lee IJ, Seong J, Bae JI, You SH, Rhee Y, Lee JH. Effect of Oral Supplementation with Branched-chain Amino Acid (BCAA) during Radiotherapy in Patients with Hepatocellular Carcinoma: A Double-Blind Randomized Study. Cancer Res Treat 2011. [PMID: 21509160 DOI: 10.4143/crt.2011.43.1.24.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE The present study evaluated whether oral supplementation with a branched-chain amino acid (BCAA) improves the biochemical and amino acid profiles of liver tumor patients undergoing radiotherapy. MATERIALS AND METHODS Patients were randomly assigned to one of 2 groups: a group given oral supplementation with BCAA granules (LIVACT granules; Samil Pharm Co., Korea, each granule containing L-isoleucine 952 mg, L-leucine 1,904 mg, and L-valine 1,144 mg) during radiotherapy, or a placebo group. Physical and biochemical examinations and measurements, including subjective symptoms, Child-Pugh class, body mass index, plasma albumin concentration, and plasma amino acid profiles were monitored. RESULTS Fifty were enrolled between November 2005 and November 2006. We also analyzed data from 37 hepatocellular carcinoma (HCC) patients in order to evaluate a more homogenous group. The two groups of patients were comparable in terms of age, gender, Child-Pugh score, and underlying hepatitis virus type. Serum albumin, total protein, liver enzymes, and cholesterol showed a tendency to increase in the BCAA group. In this group, the percentage of cases that reverted to normal serum albumin levels between 3 and 10 weeks after administration of BCAA was significantly higher (41.18%) than in the placebo group (p=0.043). CONCLUSION Oral supplementation with a BCAA preparation seems to help HCC patients undergoing radiotherapy by increasing the BCAA concentration.
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Affiliation(s)
- Ik Jae Lee
- Department of Radiation Oncology, Yonsei University Health System, Seoul, Korea
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Radiotherapy and chemotherapy as therapeutic strategies in extrahepatic biliary duct carcinoma. Strahlenther Onkol 2010; 186:672-80. [PMID: 21136029 DOI: 10.1007/s00066-010-2161-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Accepted: 09/16/2010] [Indexed: 12/11/2022]
Abstract
PURPOSE this report aims to provide an overview on radiotherapy and chemotherapy in extrahepatic biliary duct carcinoma (BDC). PATIENTS AND METHODS a PubMed research identified clinical trials in BDC through April 1, 2010 including randomised controlled trials, SEER analyses and retrospective trials. Additionally, publications on the technical progress of radiotherapy in or close to the liver were analysed. RESULTS most patients with cholangiocarcinoma present with unresectable disease (80-90%), and more than half of the resected patients relapse within 1 year. Adjuvant and palliative treatment options need to be chosen carefully since 50% of the patients are older than 70 years at diagnosis. Adjuvant radiotherapy or chemotherapy after complete resection (R0) has not convincingly shown a prolongation of survival but radiotherapy did after R1 resection. However, data suggest that liver transplantation could offer long-term survival in selected patients when combined with neoadjuvant chemoradiotherapy in patients with marginally resectable disease. For patients with unresectable biliary tract carcinoma (BTC), palliative stenting was previously the treatment of choice. But recent SEER analyses show that radiotherapy prolongs survival, relieves symptoms and contributes to biliary decompression and should be regarded as the new standard. Novel technical advances in radiotherapy may allow for dose-escalation and could significantly improve outcome for patients with cholangiocarcinoma. CONCLUSION both the literature and recent technical progress corroborate the role of radiotherapy in BDC offering chances for novel clinical trials. Progress is less pronounced in chemotherapy.
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Son SH, Choi BO, Ryu MR, Kang YN, Jang JS, Bae SH, Yoon SK, Choi IB, Kang KM, Jang HS. Stereotactic body radiotherapy for patients with unresectable primary hepatocellular carcinoma: dose-volumetric parameters predicting the hepatic complication. Int J Radiat Oncol Biol Phys 2010; 78:1073-80. [PMID: 20207492 DOI: 10.1016/j.ijrobp.2009.09.009] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Revised: 09/04/2009] [Accepted: 09/04/2009] [Indexed: 02/06/2023]
Abstract
PURPOSE To identify the parameters that predict hepatic toxicity and deterioration of hepatic function. MATERIALS AND METHODS A total of 47 patients with small unresectable primary hepatocellular carcinoma received hypofractionated stereotactic body radiotherapy (SBRT) using the CyberKnife. Of those, 36 patients received no other local treatments that could influence hepatic toxicity at least for 3 months after the completion of SBRT. The gross tumor volume (GTV) was 18.3 ± 15.9 cm(3) (range, 3.0-81.3 cm(3)), and the total dose administered was 30-39 Gy (median, 36 Gy). To assess the deterioration of hepatic function, we evaluated the presence or absence of the progression of Child-Pugh class (CP class). To identify the parameters of predicting the radiation-induced hepatic toxicity and deterioration of the hepatic function, several clinical and dose-volumetric parameters were evaluated. RESULTS Of 36 patients, 12 (33%) developed Grade 2 or higher hepatic toxicity and 4 (11%) developed progression of CP class. The multivariate analysis showed that the only significant parameter associated with the progression of CP class was the total liver volume receiving a dose less than 18 Gy (<18 Gy). CONCLUSIONS The progression of CP class after SBRT limits other additional local treatments and also reflects the deterioration of hepatic function. Therefore, it would be important to note that the presence or absence of the progression of CP class is a dose-limiting factor. The total liver volume receiving <18 Gy should be greater than 800 cm(3) to reduce the risk of the deterioration of hepatic function.
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Affiliation(s)
- Seok Hyun Son
- Department of Radiation Oncology, College of Medicine, Catholic University of Korea, Seoul, Korea
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Lee IJ, Seong J, Shim SJ, Han KH. Radiotherapeutic Parameters Predictive of Liver Complications Induced by Liver Tumor Radiotherapy. Int J Radiat Oncol Biol Phys 2009; 73:154-8. [DOI: 10.1016/j.ijrobp.2008.04.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2007] [Revised: 04/10/2008] [Accepted: 04/10/2008] [Indexed: 12/22/2022]
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Abstract
The thymidine analog bromodeoxyuridine (BrdU) is incorporated into newly synthesized DNA and has been shown to increase the susceptibility of incorporating cells to ionizing radiation. However, in the absence of secondary stressors, BrdU is thought to substitute relatively benignly for thymidine and is commonly used to "birth-date" proliferative cells. We report a novel antiproliferative effect of BrdU on cancer cells, which is independent of its role in radiosensitization. A single, brief in vitro exposure to BrdU induces a profound and sustained reduction in the proliferation rate of all cancer cells examined. Cells do not die but variably up-regulate some senescence-associated proteins as they accumulate in the G1 phase of the cell cycle. Bromodeoxyuridine also impairs the proliferative capacity of primary tumor-initiating human glioma cells and may therefore represent a means of targeting cancer stem cells. Finally, conservative in vivo BrdU regimens--in the absence of any other treatment--significantly suppress the progression of gliomas in the highly aggressive, syngeneic RG2 model. These results suggest that BrdU may have an important role as an adjunctive therapeutic for a wide variety of cancers based on new insights into its effect as a negative regulator of cell cycle progression.
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Mornex F, Girard N, Beziat C, Kubas A, Khodri M, Trepo C, Merle P. Feasibility and efficacy of high-dose three-dimensional-conformal radiotherapy in cirrhotic patients with small-size hepatocellular carcinoma non-eligible for curative therapies--mature results of the French Phase II RTF-1 trial. Int J Radiat Oncol Biol Phys 2007; 66:1152-8. [PMID: 17145534 DOI: 10.1016/j.ijrobp.2006.06.015] [Citation(s) in RCA: 183] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Revised: 06/07/2006] [Accepted: 06/07/2006] [Indexed: 02/07/2023]
Abstract
PURPOSE Hepatocellular carcinoma (HCC) is a poor prognosis tumor, and only 20% of patients will benefit from curative therapies (surgery, liver transplantation, percutaneous ablation). Although conventional radiotherapy has been traditionally regarded as inefficient and toxic for cirrhotic patients, three-dimensional conformal radiotherapy (3DCRT) has provided promising preliminary data for the treatment of HCC. METHODS AND MATERIALS Prospective phase II trial including Child-Pugh A/B cirrhotic patients with small-size HCC (1 nodule < or =5 cm, or 2 nodules < or =3 cm) nonsuitable for curative treatments, to assess tolerance and efficacy of high-dose (66 Gy, 2 Gy/fraction) 3DCRT. RESULTS Twenty-seven patients were enrolled. Among the 25 assessable patients, tumor response was observed for 23 patients (92%), with complete response for 20 patients (80%), and partial response for 3 patients (12%). Stable disease was observed in 2 patients (8%). Grade 4 toxicities occurred in 2 of 11 (22%) Child-Pugh B patients only. Child-Pugh A patients tolerated treatment well, and 3/16 (19%) developed asymptomatic Grade 3 toxicities. CONCLUSION High-dose 3DCRT is a noninvasive, well-tolerated modality that is highly suitable for the treatment of small HCCs in cirrhotic patients, with promising results. However, additional trials are needed to optimize this technique and formally compare it with the usual curative approaches.
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Affiliation(s)
- Françoise Mornex
- Department of Radiation Oncology, Centre Hospitalier Lyon-Sud, Lyon, France.
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Ben-David MA, Griffith KA, Abu-Isa E, Lawrence TS, Knol J, Zalupski M, Ben-Josef E. External-beam radiotherapy for localized extrahepatic cholangiocarcinoma. Int J Radiat Oncol Biol Phys 2006; 66:772-9. [PMID: 17011452 DOI: 10.1016/j.ijrobp.2006.05.061] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 05/09/2006] [Accepted: 05/24/2006] [Indexed: 02/02/2023]
Abstract
PURPOSE The role of radiation therapy (RT) in extrahepatic cholangiocarcinoma (EHCC) is not clear and only limited reports exist on the use of this modality. We have reviewed our institutional experience to determine the pattern of failure in patients after potentially curative resection and the expected outcomes after adjuvant RT and in unresectable patients. METHODS AND MATERIALS After institutional review board approval, 81 patients diagnosed with EHCC (gallbladder 28, distal bile duct 24, hilar 29) between June 1986 and December 2004 were identified and their records reviewed. Twenty-eight patients (35%) underwent potentially curative resection with R0/R1 margins. Fifty-two patients (64%) were unresectable or underwent resection with macroscopic residual disease (R2). All patients received three-dimensional planned megavoltage RT. The dose for each patient was converted to the equivalent total dose in a 2 Gy/fraction, using the linear-quadratic formalism and alpha/beta ratio of 10. The median dose delivered was 58.4 Gy (range, 23-88.2 Gy). 54% received concomitant chemotherapy. RESULTS With a median follow-up time of 1.2 years (range, 0.1-9.8 years) 75 patients (93%) have died. Median overall survival (OS) and progression-free survival (PFS) were 14.7 (95% CI, 13.1-16.3) and 11 (95% CI, 7.6-13.2) months, respectively. There was no difference among the three disease sites in OS (p = 0.70) or PFS (p = 0.80). Complete resection (R0) was the only predictive factor significantly associated with increase in both OS and PFS (p = 0.002), and there was no difference in outcomes between R1 and R2 resections. The first site of failure was predominantly locoregional (68.8% of all failures). CONCLUSION Local failure is a major problem in EHCC, suggesting the need for more intense radiation schedules and better radiosensitizing strategies. Because R1 resection appears to convey no benefit, it appears that surgery should be contemplated only when an R0 resection is likely. Borderline-resectable patients might be better served by neoadjuvant therapy.
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Affiliation(s)
- Merav A Ben-David
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109-0010, USA
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Fuller CD, Thomas CR, Wong A, Cavanaugh SX, Salter BJ, Herman TS, Fuss M. Image-guided intensity-modulated radiation therapy for gallbladder carcinoma. Radiother Oncol 2006; 81:65-72. [PMID: 16971012 DOI: 10.1016/j.radonc.2006.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Revised: 07/26/2006] [Accepted: 08/11/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE Clinical and technical parameter analysis of patients treated with ultrasound-based image-guided tomotherapeutic IMRT for gallbladder cancer. METHODS AND MATERIALS Between 8/2001 and 5/2005, 10 patients with primary tumors of the gallbladder were treated by image-guided IMRT to median doses of 59 Gy. To analyze normal tissue radiation exposure reduction using this novel approach, a virtual plan comparison between actually delivered IMRT plans and re-computed plans with identical inverse planning parameters but more conventional PTV safety margins was conducted. RESULTS Average CTV was 379 cm(3), with a mean initial PTV of 834 cm(3). In 9/10 patients, a boost was delivered to a mean CTV(boost) of 171 cm(3) and average PTV(boost) of 241 cm(3). One patient reported RTOG grade 3 acute toxicity. All other patients exhibited Grade 2 or lower acute toxicity. Preliminary median overall survival was 16.7 months (range 3.2-34.9 months), with 5/10 patients alive at analysis. Virtual plan comparison revealed significant organ-at-risk sparing by the enabled PTV margin reduction. CONCLUSION Ultrasound-based image-guided IMRT is a feasible mechanism of delivering conformal radiation doses to tumors of the gallbladder with acceptable toxicity. Early outcome data with this novel radiation planning and delivery technique are encouraging and comparable to previously reported literature.
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Affiliation(s)
- Clifton D Fuller
- Department of Radiation Oncology, The University of Texas Health Science Center at San Antonio, TX, USA
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Mornex F, Girard N, Merle P, Béziat C, Kubas A, Wautot V, Khodri M, Trepo C. Tolérance et efficacité de la radiothérapie de conformation en cas de carcinome hépatocellulaire chez le patient cirrhotique. Résultats de l'essai de phase II RTF1. Cancer Radiother 2005; 9:470-6. [PMID: 16219480 DOI: 10.1016/j.canrad.2005.09.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE While some patients presenting with hepatocellular carcinoma (HCC) benefit from curative therapies (transplantation, surgery, percutaneous ablation), others are only candidates for palliative options such as chemoembolization or symptomatic care. Although conventional external-beam radiotherapy of the liver is regarded as little efficient and potentially toxic in cirrhotic patients, 3-dimensional conformal radiotherapy (CRT), by decreasing the amount of normal liver included in the radiation portal, allows dose escalation to occur without increasing the risk of radiation-induced hepatitis. This trial was designed to assess the efficacy and tolerance of CRT for small-size HCC in cirrhotic patients. PATIENTS AND METHODS Prospective phase II trial including stage A/B cirrhotic patients with small-size HCC not suitable for curative treatments; CRT consisted in a standard fractionation radiation, with a total dose of 66 Gy. RESULTS Twenty-seven patients were included, 15 of whom had previously been treated for HCC; mean age was 68. Among the 23 assessable patients, 18 (78%) presented with complete response, 3 (13%) with partial response, and 2 with no response. Acute complications occurred in 24 patients, and were mainly acceptable (grade 1/2: 22 patients, grade 3/4: 11 patients, 4 (15%) of whom had clinical and/or hematological toxicities). Only 2 (9%) grade 3/4 clinical and/or hematological late toxicities are reported. CONCLUSION CRT is a non-invasive curative technique highly suitable for small-size HCC in cirrhotic patients; further investigations are needed to compare it to the other available treatments, and to integrate it into the curative therapeutic algorithm of HCC.
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Affiliation(s)
- F Mornex
- Département de radiothérapie-oncologie, centre hospitalier Lyon-Sud, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France.
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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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Seong J, Han KH, Park YN, Nam SH, Kim SH, Keum WS, Kim KS. Lethal hepatic injury by combined treatment of radiation plus chemotherapy in rats with thioacetamide-induced liver cirrhosis. Int J Radiat Oncol Biol Phys 2003; 57:282-8. [PMID: 12909244 DOI: 10.1016/s0360-3016(03)00540-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess lethal hepatic injury by combined treatment of radiation (RT) plus chemotherapy in a rat model with thioacetamide (TAA)-induced liver cirrhosis. METHODS AND MATERIALS Male Wistar rats were treated with 0.3 g/L TAA in drinking water. The development of liver cirrhosis was histologically confirmed, and the degree of liver function impairment was assessed by indocyanine green retention test (ICG R15). The established cirrhotic rats were given one of the following treatments: partial liver radiotherapy (25 Gy on about one-third of the whole liver), 5-fluorouracil (5-FU) chemotherapy (50 mg/kg), and combined treatment of partial RT plus 5-FU. The treated rats were closely followed until either death or 30 weeks after the treatment, and the postmortem liver sampling was examined for lethal hepatic injury by the treatments. RESULTS The rats developed overt liver cirrhosis after 30 weeks of TAA treatment. At that time, the mean ICG R15 level in the TAA-treated rats (TAA-rats) was 14.1% +/- 0.7% compared to 4.6% +/- 0.7% in the control (p < 0.05). The 30-week survival rates in the control and TAA-rats were 100% (5/5) and 75% (6/8), respectively, after partial liver RT (p = 0.72). In the 5-FU chemotherapy group, the survival in TAA-rats was only one-half of that in the controls (100% vs. 50%, p = 0.06). Poor survival in TAA-rats was shown also in the combined group of partial RT plus 5-FU (87.5% vs. 16.7%, p = 0.06). The rats that died before the last observation time showed advanced cirrhosis with areas of lobular collapse, in contrast to the moderate cirrhotic features in those that survived. CONCLUSION In a rat cirrhosis model with mildly impaired liver function, combined treatment of partial RT plus 5-FU resulted in significantly high incidence of lethal liver injury. The results in this study show that a combined treatment of RT plus chemotherapy in cirrhotic patients should be applied with extreme caution.
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Affiliation(s)
- Jinsil Seong
- Department of Radiation Oncology, Brain Korea 21 Project for Medicine, Yonsei University Medical College, Seoul, South Korea.
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Guo WJ, Yu EX, Liu LM, Li J, Chen Z, Lin JH, Meng ZQ, Feng Y. Comparison between chemoembolization combined with radiotherapy and chemoembolization alone for large hepatocellular carcinoma. World J Gastroenterol 2003; 9:1697-701. [PMID: 12918103 PMCID: PMC4611526 DOI: 10.3748/wjg.v9.i8.1697] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the efficacy of transcatheter arterial chemoembolization (TACE) combined with radiotherapy for unresectable large hepatocellular carcinoma (HCC).
METHODS: From June 1994 to June 1999, a total of 76 patients with large unresectable HCC were treated with TACE followed by external-beam irradiation. 89 patients with large HCC, who underwent TACE alone during the same period, served as the control group. Clinical features, therapeutic modalities, acute effects and survival rates were analyzed and compared between TACE plus irradiation group and TACE alone group. A multivariate analysis of nine clinical variables and one treatment variable (irradiation) was performed by the Cox proportional hazards model.
RESULTS: The clinical features and therapeutic modalities except irradiation between the two groups were comparable (P > 0.05). The objective response rate (RR) in TACE plus irradiation group was higher than that in TACE alone group (47.4% vs 28.1%, P < 0.05). The overall survival rates in TACE plus irradiation group (64.0%, 28.6%, and 19.3% at 1, 3, 5 years, respectively) were significantly higher than those in TACE alone group (39.9%, 9.5%, and 7.2%, respectively, P = 0.0001). Cox proportional hazards model analysis showed that tumor extension and Child grade were significant and were independent negative predictors of survival, while irradiation was an independent positive predictor of survival.
CONCLUSION: TACE combined with radiotherapy is more effective than TACE alone, and is a promising treatment for unresectable large HCC.
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Affiliation(s)
- Wei-Jian Guo
- Department of Oncology, Xinhua Hospital of Shanghai Second Medical University, 1665 Kongjiang Road, Shanghai 200092, China.
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Park HC, Seong J, Han KH, Chon CY, Moon YM, Suh CO. Dose-response relationship in local radiotherapy for hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2002; 54:150-5. [PMID: 12182985 DOI: 10.1016/s0360-3016(02)02864-x] [Citation(s) in RCA: 225] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Dose escalation using three-dimensional conformal radiotherapy (3D-CRT) is based on the hypothesis that increasing the dose can enhance tumor control. This study aimed to determine whether a dose-response relationship exists in local radiotherapy for primary hepatocellular carcinoma (HCC). METHODS AND MATERIALS One hundred fifty-eight patients were enrolled in the present study between January 1992 and March 2000. The exclusion criteria included the presence of an extrahepatic metastasis, liver cirrhosis of Child class C, tumors occupying more than two-thirds of the entire liver, and a performance status on the Eastern Cooperative Oncology Group scale of more than 3. Radiotherapy was given to the field, including the tumor, with generous margin using 6- or 10-MV X-rays. The mean radiation dose was 48.2 +/- 7.9 Gy in daily 1.8-Gy fractions. The tumor response was assessed based on diagnostic radiologic examinations, including a computed tomography scan, magnetic resonance imaging, and hepatic artery angiography 4-8 weeks after the completion of treatment. Liver toxicity and gastrointestinal complications were evaluated. RESULTS An objective response was observed in 106 of 158 (67.1%) patients. Statistical analysis revealed that the total dose was the most significant factor associated with the tumor response. The response rates in patients treated with doses <40 Gy, 40-50 Gy, and >50 Gy were 29.2%, 68.6%, and 77.1%, respectively. Survivals at 1 and 2 years after radiotherapy were 41.8% and 19.9%, respectively, with a median survival time of 10 months. The rate of liver toxicity according to the doses <40 Gy, 40-50 Gy, and >50 Gy was 4.2%, 5.9%, and 8.4%, respectively, and the rate of gastrointestinal complications was 4.2%, 9.9%, and 13.2%, respectively. CONCLUSIONS The present study showed the existence of a dose-response relationship in local radiotherapy for primary HCC. Only the radiation dose was a significant factor for predicting an objective response. The results of this study showed that 3D-CRT can theoretically be used for treating primary HCC.
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Affiliation(s)
- Hee Chul Park
- Department of Radiation Oncology, Brain Korea 21 Project for Medical Science, Seoul, South Korea
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Poggi MM, Coleman CN, Mitchell JB. Sensitizers and protectors of radiation and chemotherapy. Curr Probl Cancer 2001; 25:334-411. [PMID: 11740469 DOI: 10.1067/mcn.2001.120122] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- M M Poggi
- Radiation Oncology Sciences Program, National Cancer Institute, Bethesda, Maryland, USA
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Seong J, Kim SH, Suh CO. Enhancement of tumor radioresponse by combined chemotherapy in murine hepatocarcinoma. J Gastroenterol Hepatol 2001; 16:883-9. [PMID: 11555102 DOI: 10.1046/j.1440-1746.2001.02533.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Recent studies have shown that local radiotherapy can be an effective component of the treatment for hepatocellular carcinoma. To further improve therapeutic efficacy, use of drugs that can beneficially interact with radiation has been suggested. The purpose of this study was to identify drugs that can enhance radioresponse of murine hepatocarcinoma. METHODS C3H/HeJ mice bearing 8 mm tumors of murine hepatocarcinoma, HCa-I, were treated with 25 Gy radiation and one of the following drugs: 5-Fu, 150 mg/kg; adriamycin, 8 mg/kg; cisplatin, 6 mg/kg; paclitaxel, 40 mg/kg; and gemcitabine, 50 mg/kg. Tumor response to the treatment was determined by the use of a tumor growth delay assay and by an enhancement factor. The apoptotic level was assessed in tissue sections. The expression of regulating molecules was analyzed by using western blotting for p53, Bcl-2, Bax, Bcl-XL, Bcl-XS, and p21(WAF1/CIP1). RESULTS Among the drugs tested, only gemcitabine enhanced the antitumor effect of radiation, with an enhancement factor of 1.6. The induction of apoptosis by a combination of gemcitabine and radiation was shown as only an additive level. In the analysis of radiation-induced expression of regulating molecules, the most significant change by combining gemcitabine with radiation was the activation of p21(WAF1/CIP1). CONCLUSION Gemcitabine is the first to show an enhancement of radioresponse of murine hepatocarcinoma when combined with radiation. The key element of enhancement is thought to be p21(WAF1/CIP1).
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Affiliation(s)
- J Seong
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University Medical College, Seoul, Korea.
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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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Herfarth KK, Debus J, Lohr F, Bahner ML, Rhein B, Fritz P, Höss A, Schlegel W, Wannenmacher MF. Stereotactic single-dose radiation therapy of liver tumors: results of a phase I/II trial. J Clin Oncol 2001; 19:164-70. [PMID: 11134209 DOI: 10.1200/jco.2001.19.1.164] [Citation(s) in RCA: 345] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To investigate the feasibility and the clinical response of a stereotactic single-dose radiation treatment for liver tumors. PATIENTS AND METHODS Between April 1997 and September 1999, a stereotactic single-dose radiation treatment of 60 liver tumors (four primary tumors, 56 metastases) in 37 patients was performed. Patients were positioned in an individually shaped vacuum pillow. The applied dose was escalated from 14 to 26 Gy (reference point), with the 80% isodose surrounding the planning target volume. Median tumor size was 10 cm(3) (range, 1 to 132 cm(3)). The morbidity, clinical outcome, laboratory findings, and response as seen on computed tomography (CT) scan were evaluated. RESULTS Follow-up data could be obtained from 55 treated tumors (35 patients). The median follow-up period was 5.7 months (range, 1.0 to 26.1 months; mean, 9.5 months). The treatment was well tolerated by all patients. There were no major side effects. Fifty-four (98%) of 55 tumors were locally controlled after 6 weeks at the initial follow-up based on the CT findings (22 cases of stable disease, 28 partial responses, and four complete responses). After a dose-escalating and learning phase, the actuarial local tumor control rate was 81% at 18 months after therapy. A total of 12 local failures were observed during follow-up. So far, the longest local tumor control is 26.1 months. CONCLUSION Stereotactic single-dose radiation therapy is a feasible method for the treatment of singular inoperable liver metastases with the potential of a high local tumor control rate and low morbidity.
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Affiliation(s)
- K K Herfarth
- Division of Radiation Oncology, German Cancer Research Center, Heidelberg, Germany.
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Seong J, Park HC, Han KH, Lee DY, Lee JT, Chon CY, Moon YM, Suh CO. Local radiotherapy for unresectable hepatocellular carcinoma patients who failed with transcatheter arterial chemoembolization. Int J Radiat Oncol Biol Phys 2000; 47:1331-5. [PMID: 10889387 DOI: 10.1016/s0360-3016(00)00519-8] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of this study was to investigate the efficacy of local radiotherapy (RT) as a salvage treatment for unresectable hepatocellular carcinoma (HCC) patients who failed with transcatheter arterial chemoembolization (TACE). METHODS AND MATERIALS Patients with unresectable HCC who had been treated with and eventually failed with TACE were eligible. The judgment of TACE failure was based on incomplete tumor filling of lipiodol-adriamycin mixture on either angiography or computed tomography (CT) scan. From January 1993 to December 1997, 27 patients were entered into this study. They had UICC Stage III (17) or IVA (10) disease, with a mean tumor size of 7.2 +/- 2.9 cm. Local RT was done, with a mean tumor dose of 51.8 +/- 7.9 Gy, in daily 1.8-Gy fractions using a 10- or 6-MV linear accelerator. Survival was calculated from both the diagnosis and the start of RT using the Kaplan-Meier method. RESULTS An objective response was observed in 16 of 24 patients (66.7%) including 1 CR. Intrahepatic metastasis was noted outside the RT field in 10 patients (37.0%). Extrahepatic distant metastasis occurred in 4 patients. Survival rates at 1, 2, and 3 years were 85. 2%, 58.1%, and 33.2%, respectively, from the diagnosis and 55.9%, 35. 7%, and 21.4%, respectively, from the start of RT. The median survivals were 26 months from the diagnosis and 14 months from the start of RT. Acute toxicity involved alteration in liver function test (13 patients) and thrombocytopenia (2 patients). Subacute and chronic toxicity involved gastroduodenal ulcer (3 patients) and duodenitis (2 patients). There was no treatment-related death. CONCLUSION In unresectable HCC patients who failed with TACE, local RT induced a substantial tumor response of 66.7%, with a 3-year survival rate of 21.4% and a median survival time of 14 months. Toxicity was significant but manageable. Although we do not know if there is survival benefit through this treatment, local RT in these patients seems to be valuable as a salvage for TACE-failed HCC.
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Affiliation(s)
- J Seong
- Department of Radiation Oncology, Yonsei University Medical College, Seoul, South Korea.
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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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Herfarth KK, Debus J, Lohr F, Bahner ML, Fritz P, Höss A, Schlegel W, Wannenmacher MF. Extracranial stereotactic radiation therapy: set-up accuracy of patients treated for liver metastases. Int J Radiat Oncol Biol Phys 2000; 46:329-35. [PMID: 10661339 DOI: 10.1016/s0360-3016(99)00413-7] [Citation(s) in RCA: 158] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Patients with liver metastases might benefit from high-dose conformal radiation therapy. A high accuracy of repositioning and a reduction of target movement are necessary for such an approach. The set-up accuracy of patients with liver metastases treated with stereotactic single dose radiation was evaluated. METHODS AND MATERIALS Twenty-four patients with liver metastases were treated with single dose radiation therapy on 26 occasions using a self-developed stereotactic frame. Liver movement was reduced by abdominal pressure. The effectiveness was evaluated under fluoroscopy. CT scans were performed on the planning day and directly before treatment. Representative reference marks were chosen and the coordinates were calculated. In addition, the target displacement was quantitatively evaluated after treatment. RESULTS Diaphragmal movement was reduced to median 7 mm (range: 3-13 mm). The final set-up accuracy of the body was limited to all of median 1.8 mm in latero-lateral direction (range: 0.3-5.0 mm) and 2.0 mm in anterior-posterior direction (0.8-3.8 mm). Deviations of the body in cranio-caudal direction were always less than the thickness of one CT slice (<5 mm). However, a repositioning was necessary in 16 occasions. The final target shift was median 1.6 mm (0.2-7.0 mm) in latero-lateral and 2.3 mm in anterior-posterior direction (0.0-6.3 mm). The median shift in cranio-caudal direction was 4.4 mm (0.0-10.0 mm). CONCLUSIONS In patients with liver metastases, a high set-up accuracy of the body and the target can be achieved. This allows a high-dose focal radiotherapy of these lesions. However, a control CT scan should be performed directly before therapy to confirm set-up accuracy and possibly prompt necessary corrections.
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Affiliation(s)
- K K Herfarth
- German Cancer Research Center, Department of Radiation Oncology, University of Heidelberg.
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Seong J, Keum KC, Han KH, Lee DY, Lee JT, Chon CY, Moon YM, Suh CO, Kim GE. Combined transcatheter arterial chemoembolization and local radiotherapy of unresectable hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 1999; 43:393-7. [PMID: 10030267 DOI: 10.1016/s0360-3016(98)00415-5] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The best prognosis in hepatocellular carcinoma (HCC) can be achieved with surgical resection; however, the number of resected cases are limited due to advanced lesions or associated liver disease. The purpose of this study was to investigate the efficacy and toxicity of a prospective trial of combined transcatheter arterial chemoembolization (TACE) and local radiotherapy (RT) in unresectable HCC. METHODS AND MATERIALS Patients with histologically proven unresectable HCC due to either advanced lesions or associated cirrhosis were eligible. From March 1992 to August 1994, 30 patients were entered into this study. TACE was performed with Lipiodol (5 ml) and doxorubicin (Adriamycin ; 50 mg), followed by gelatin sponge particle (Gelfoam) embolization. Local RT was started within 7-10 days following TACE. Mean tumor dose was 44.0+/-9.3 Gy in daily 1.8 Gy fractions. Response was assessed by computerized tomography (CT) scan 4-6 weeks following completion of the treatment and then at 1-3-month intervals. Survival was calculated from the start of TACE using the Kaplan-Meier method. RESULTS An objective response was observed in 19 patients, giving a response rate of 63.3%. Distant metastasis occurred in 10 patients, with 8 in the lung only and 2 in both lung and bone. Survival rates at 1, 2, and 3 years were 67%, 33.3%, and 22.2%, respectively. Median survival was 17 months. There were 6 patients surviving more than 3 years. Toxicity included transient elevation of liver function tests in all patients, fever in 20, thrombocytopenia in 4, and nausea and vomiting in 1. There was no treatment-related death. CONCLUSION Combined TACE and local RT is feasible and tolerable. It gives a 63.3% response rate with median survival of 17 months. We feel that this regimen would be a new promising modality in unresectable HCC. Further study is required to compare the therapeutic efficacy of this regimen to TACE alone.
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Affiliation(s)
- J Seong
- Department of Radiation Oncology, Yonsei University Medical College, Seoul, Korea
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Affiliation(s)
- G Read
- Royal Preston Hospital, UK
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