The response of thrombosis in the portal vein or hepatic vein in hepatocellular carcinoma to radiation therapy

Exploring the Evolving Landscape of Stereotactic Body Radiation Therapy in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) carries significant morbidity and mortality. Management of the HCC requires a multidisciplinary approach. Surgical resection and liver transplantation are the gold standard options for the appropriate settings. Stereotactic body radiation therapy (SBRT) has emerged as a promising treatment modality in managing HCC; its use is more studied and well-established in advanced HCC (aHCC). Current clinical guidelines universally endorse SBRT as a viable alternative to radiofrequency ablation (RFA), transarterial chemoembolisation (TACE), and transarterial radioembolisation (TARE), a recommendation substantiated by literature demonstrating comparable efficacy among these modalities. In early-stage HCC, SBRT primarily manages unresectable tumours unsuitable for ablative procedures such as microwave ablation and RFA. SBRT has been incorporated as a modality to downstage tumours or as a bridge to transplant. In the case of intermediate or advanced HCC, SBRT offers excellent results either as a single modality or adjunct to other locoregional modalities such as TACE/TARE. Recent data from late-stage HCC patients illustrate the effectiveness of SBRT in achieving local tumour control while minimising damage to surrounding healthy liver tissue. It has promising local control of approximately 80-90% in managing HCC. Additional prospective data comparing the efficacy of SBRT with the first-line recommended therapies such as RFA, TACE, and surgery are essential. The standard of care for patients with advanced/metastatic disease is systemic therapy (immunotherapy/tyrosine kinase inhibitors). SBRT, in combination with immune-checkpoint inhibitors, has an immune-modulatory effect that results in a synergistic effect. Recent findings indicate that the combination of immunotherapy and SBRT in HCC is well-tolerated and exhibits synergistic effects. Further exploration of diverse immunotherapy and radiotherapy strategies is essential to identify the appropriate time for combination treatments and to optimise dose and fraction regimens. Prospective, randomised studies are imperative to establish SBRT as the primary treatment for HCC.

Hepatocellular Carcinoma with Hepatic Vein and Inferior Vena Cava Invasion

Hepatocellular carcinoma (HCC) invades intrahepatic vessels causing tumor thrombosis. Infrequently, there is involvement of the hepatic vein (HV) and inferior vena cava (IVC). In this review, we summarize the epidemiology, classification, clinical features, and management of HCC with HV and IVC invasion. While the involvement of HV and IVC usually portends an overall poor survival, selected patients may be candidates for aggressive treatment and thus improving outcomes.

Comparison of External Beam Radiation Therapy Modalities for Hepatocellular Carcinoma With Macrovascular Invasion: A Meta-Analysis and Systematic Review

Purpose

We performed a systematic review and meta-analysis to compare external beam radiation therapy modalities for hepatocellular carcinoma (HCC) with macrovascular invasion (MVI).

Methods

Studies were selected from online databases from the date of inception to November 2021. The outcomes of interest were overall survival (OS), objective response rate (ORR), and local control rate (LCR).

Results

Forty-four studies (n = 3730) were selected from 1050 articles. The pooled 1-year OS were 60.9%, 45.3%, and 44.9 for particle radiotherapy (PRT) group, conventional radiotherapy (CRT), and stereotactic body radiotherapy (SBRT) group, respectively; p = 0.005 and 0.002 for PRT vs. CRT and SBRT, respectively. Both the PRT group and the SBRT group have the advantage over the CRT group in the pooled ORR. The PRT group showed significantly higher than the CRT group (p = 0.007) in LCR. For combination therapy, CRT plus transarterial chemoembolization can prolong survival than CRT alone (p = 0.006 for 1-year OS; p = 0.014 for 2-year OS). Among grade ≥ 3 complications, the most frequent type of toxicity in CRT, SBRT, PRT group was hematological toxicity, hepatotoxicity, dermatological toxicity, respectively.

Conclusions

Among patients with HCC with MVI, the 1-year OS and the 2-year OS were both higher in the PRT group than in the CRT, SBRT groups. The ORR was similar between the PRT and SBRT groups. The combination therapy based on radiotherapy is expectable. PRT is associated with less complications than photon radiotherapy.

Predictive factors for survival following stereotactic body radiotherapy for hepatocellular carcinoma with portal vein tumour thrombosis and construction of a nomogram

Background

We evaluated the treatment response and predictive factors for overall survival (OS) in patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis (PVTT), who underwent stereotactic body radiotherapy (SBRT). Additionally, we developed and validated a personalised prediction model for patient survival.

Methods

Clinical information was retrospectively collected for 80 patients with HCC and PVTT, who were treated with SBRT at the Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital) between December 2015 and June 2019. A multivariate Cox proportional hazard regression model was used to identify the independent predictive factors for survival. Clinical factors were subsequently presented in a nomogram. The area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA) were used to evaluate the accuracy of the model and the net clinical benefit.

Results

All patients completed the planned radiotherapy treatment, and the median follow-up duration was 10 months (range, 1–35.3 months). The median survival duration was 11.5 months, with 3-, 6-, and 12-month survival rates of 92.5, 74.5, and 47.5%, respectively. The multivariable Cox regression model indicated that the following were significant independent predictors of OS: clinical T stage (p = 0.001, hazard ratio [HR] = 3.085, 95% confidence interval [CI]: 1.514–6.286), cirrhosis (p = 0.014, HR = 2.988, 95% CI: 1.246–7.168), age (p = 0.005, HR = 1.043, 95% CI: 1.013–1.075), alpha-fetoprotein level (p = 0.022, HR = 1.000, 95% CI: 1.000–1.000), and haemoglobin level (p = 0.008, HR = 0.979, 95% CI: 0.963–0.994). A nomogram based on five independent risk factors and DCA demonstrated a favourable predictive accuracy of patient survival (AUC = 0.74, 95% CI: 0.63–0.85) and the clinical usefulness of the model.

Conclusions

SBRT is an effective treatment for patients with HCC with PVTT. Notably, clinical T stage, presence of cirrhosis, age, alpha-fetoprotein levels, and haemoglobin levels are independent prognostic factors for survival. The presented nomogram can be used to predict the survival of patients with HCC and PVTT, who underwent SBRT.

Nomogram for Predicting the Prognosis of Patients with Hepatocellular Carcinoma Presenting with Pulmonary Metastasis

Background

Only a few studies have investigated the clinical features and outcomes of patients with pulmonary metastasis from hepatocellular carcinoma (HCC) at the initial diagnosis. This study aimed to evaluate the prevalence, risk factors and prognostic factors related to pulmonary metastasis and then construct a nomogram to predict the outcomes of patients with HCC presenting with pulmonary metastasis.

Methods

The Surveillance, Epidemiology, and End Results (SEER) database was used to select patients. A total of 25,236 eligible patients diagnosed with HCC from 2010 to 2015 were selected. Then, 897 patients with HCC presenting with pulmonary metastasis at the initial diagnosis were included in the primary set (n=598) and validation set (n=299). Logistic and Cox regression analyses were used to determine the risk factors and prognostic factors for pulmonary metastasis. A nomogram predicting the prognosis of patients with HCC presenting with pulmonary metastasis was constructed based on independent prognostic factors identified in Cox regression analyses. Both internal and external validations of the nomogram were performed using discrimination and calibration plots.

Results

The prevalence of pulmonary metastasis was 3.6% (897/25,236) in the entire cohort diagnosed with HCC as the initial diagnosis. Age, race, Edmonson-Steiner classification grade I/III, higher T stage, N stage, alpha fetoprotein(AFP) levels, brain metastasis, bone metastasis and intrahepatic metastasis were positively correlated with the development of HCC with pulmonary metastasis at the initial diagnosis. Prognostic factors incorporated in the nomogram were sex, T stage, bone metastasis, AFP levels, treatment, radiation and chemotherapy. The concordance index (C-index) of the nomogram in the primary set was 0.661 (95% CI: 0.633-0.688), indicating considerable predictive accuracy. The calibration curves showed consistency between the nomogram and the actual observations. When the nomogram was applied to the validation set, the results also remained reconcilable, and the C-index of the nomogram was 0.657 (95% CI: 0.626-0.698).

Conclusion

A list of risk factors associated with pulmonary metastasis occurrence in patients with HCC was selected, and the nomogram accurately predicted the prognosis of patients with HCC presenting with pulmonary metastasis at the initial diagnosis.

Intensity-modulated radiotherapy for hepatocellular carcinoma: dosimetric and clinical results

Since the introduction of 3-dimensional conformal radiotherapy (3DCRT), new radiotherapy techniques have expanded the indication of radiotherapy for the treatment of hepatocellular carcinoma (HCC), from the hitherto palliative to a now curative-intent purpose. Intensity-modulated radiotherapy (IMRT), currently the most advanced radiotherapy technique, is considered an attractive option for the treatment of HCC, and is more widely applied because it can deliver a higher dose to the tumor than 3DCRT while sparing surrounding normal organs. However, the advantages and potential disadvantages of IMRT for treating HCC have not been fully established. This article deals with three different IMRT techniques, including static IMRT and volumetric modulated arc therapy using conventional multileaf collimator (MLC) mounted linear accelerators, and helical IMRT using binary MLC mounted helical tomotherapy machine. We review dosimetric and clinical studies for these IMRT techniques for the treatment of HCC.

New Evidence and Perspectives on the Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Portal vein tumor thrombosis (PVTT) is an intractable condition but common phenomenon in hepatocellular carcinoma (HCC). HCC patients with PVTT may have worse liver function, a higher chance of comorbidity related to portal hypertension, lower tolerance to treatment and poorer prognoses. In Western guidelines, patients are offered palliative treatment with sorafenib or other systemic agents because HCC with PVTT is grouped together with metastatic HCC during the planning of its management. In recent years, various treatment options have become available for patients with HCC and PVTT. Therapy has also shifted toward evidence-based treatment. However, policies for the management of HCC with PVTT have not been established. This comprehensive literature review aims to present current and available management options for patients with HCC and PVTT. Evidence is mainly based on studies published after 2010.

Definitive radiation therapy for hepatocellular carcinoma with portal vein tumor thrombus

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Prognosis for patients with HCC and PVTT is historically poor.

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Definitive RT may improve OS by prolonging the time to hepatic failure.

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Our data suggest dose escalation may further improve OS.

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Patients who received a BED >75 Gy had significantly better OS.

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RT was well tolerated with no confirmed cases of radiation-induced liver disease.

Background

The purpose of this study is to review the results of radiation therapy (RT) for hepatocellular carcinoma (HCC) with portal venous tumor thrombus (PVTT) in a Western patient population.

Methods

Thirty-four patients with HCC PVTT treated from 2007 to 2014 with RT were identified. Biologically effective dose (BED) was calculated for each patient, and greater than the median dose delivered (75 Gray (Gy)) was evaluated as a potential prognostic factor. Survival was compared and independent prognostic variables were evaluated by a Cox proportional hazards regression model.

Results

Twenty-six patients (76.5%) exhibited a radiographic response to RT, and 10 patients (29.4%) ultimately developed local failure. Local control, liver control, distant control and OS at one year were 57.1%, 36.4%, 55.2% and 57.4%, respectively. Patients who received a BED >75 Gy had a significantly better local control at 1 year (93.3% vs 45.6%; Log Rank p = 0.0184). Patients who received a BED >75 Gy also had significantly better median survival (24.7mo vs 6.1mo) and 1-year overall survival (76.5% vs 30.0%) when compared with BED ≤75 Gy (Log-Rank p = 0.002).

Conclusion

Our data suggest that RT should be considered for well-selected patients with HCC and PVTT for the purpose of improving local control and potentially prolonging the time to worsening venous obstruction and liver failure. When feasible, dose-escalation should be considered with a target BED of >75 Gy if normal organ dose constraints can be safely met.

Treatment of hepatocellular carcinoma with portal vein tumor thrombus: advances and challenges

Portal vein tumor thrombus is a frequent, challenging complication in hepatocellular carcinoma. Hepatocellular carcinoma patients with portal vein tumor thrombus may show worse liver function, less treatment tolerance and worse prognosis than patients without portal vein tumor thrombus, and they may be at higher risk of comorbidity related to portal hypertension. Western and some Asian guidelines stratify hepatocellular carcinoma with portal vein tumor thrombus together with metastatic hepatocellular carcinoma and therefore recommend only palliative treatment with sorafenib or other systemic agents. In recent years, more treatment options have become available for hepatocellular carcinoma patients with portal vein tumor thrombus, and an evidence-based approach to optimizing disease management and treatment has become more widespread. Nevertheless, consensus policies for managing hepatocellular carcinoma with portal vein tumor thrombus have not been established. This comprehensive literature review, drawing primarily on studies published after 2010, examines currently available management options for patients with hepatocellular carcinoma and portal vein tumor thrombus.

The Clinical Utilization of Radiation Therapy in Korea between 2011 and 2015

Purpose

The purpose of this study was to estimate the clinical utilization of radiation therapy (RT) in Korea between 2011 and 2015.

Materials and Methods

We analyzed the claims data from the Health Insurance Review and Assessment Service to estimate the clinical utilization of RT. The source population consisted of all patients who had any of the International Classification of Diseases 10th revision cancer diagnoses (C00-C97) and those with diagnostic codes D00-D48, who were also associated with at least one of the procedure codes related to RT.

Results

The total number of patients who received RT in 2011, 2012, 2013, 2014, and 2015 were 54,810, 59,435, 61,839, 64,062, and 66,183, respectively. Among them, the total numbers of male and female patients were 24,946/29,864 in 2011, 27,211/32,224 in 2012, 28,111/33,728 in 2013, 29,312/34,750 in 2014, and 30,266/35,917 in 2015. The utilization rate of RT in cancer patients has also increased steadily over the same period from 25% to 30%. The five cancers that were most frequently treated with RT between 2011 and 2012 were breast, lung, colorectal, liver, and uterine cervical cancers. However, the fifth most common cancer treated with RT that replaced uterine cervical cancer in 2013 was prostate cancer. More than half of cancer patients (64%) were treated with RT in the capital area (Seoul, Gyeonggi, and Incheon).

Conclusion

The total number of patients who underwent RT increased steadily from 2011 to 2015 in Korea. The utilization rate of RT in cancer patients is also increasing.

Combination treatment with transarterial chemoembolization, radiotherapy, and hyperthermia (CERT) for hepatocellular carcinoma with portal vein tumor thrombosis: Final results of a prospective phase II trial

Background & Aims

This study was designed to evaluate the efficacy and safety of combination transarterial chemoembolization (TACE) followed by radiotherapy (RT) and hyperthermia (CERT) in hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT).

Methods

This single-institution, single-arm, prospective phase II study was performed from October 2013 to February 2016. The objective response rate (ORR) was evaluated at 3 months after CERT completion, and overall ORR was the primary end point.

Results

During the study period, 69 of 77 patients who consented to participate underwent at least one session of hyperthermia and RT. More than half of the patients (39, 56.5%) complained of severe hyperthermia-related pain. The overall ORR was 43.5% (30/69), and the ORR of the RT target area was 69.6% (48/69). Liver function status was not significantly affected by CERT. Overall survival, local progression-free survival, and progression-free survival of all enrolled patients at 2 years was 62.9%, 47.6%, and 14.3%, respectively.

Conclusions

An overall ORR of 43.5% was observed after CERT, but a promising ORR of 69.6% was achieved in the RT target area. Toxicities related to CERT were manageable, and pain intolerance to hyperthermia was the main obstacle to treatment maintenance.