Article

Multidisciplinary Management of Hepatocellular Carcinoma

Department of Medicine, University of California San Francisco, San Francisco, California, USA.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association (Impact Factor: 6.53). 11/2011; 10(4):354-62. DOI: 10.1016/j.cgh.2011.11.008
Source: PubMed

ABSTRACT Hepatocellular carcinoma is a leading cause of death in patients with cirrhosis. Management algorithms continually are increasing in sophistication and involve application of single and multimodality treatments, including liver transplantation, hepatic resection, ablation, transarterial chemoembolization, radioembolization, and systemic chemotherapy. These treatments have been shown to increase survival times. As many as 75% of patients with limited-stage disease who are given curative therapies survive 5 years, whereas less than 20% of untreated patients survive 1 year. Treatment can be optimized based on the patient's tumor stage, hepatic reserve, and functional status. However, because of the heterogeneity in presentation among patients, a multidisciplinary approach is required to treat hepatocellular carcinoma, involving hepatologists, surgeons, interventional radiologists, and oncologists. We present each specialist's viewpoint on controversies and advances in the management of hepatocellular carcinoma.

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    • "Hepatocellular carcinoma (HCC) is the third cause of cancer death and one of the most challenging oncological problems [1]. Several treatment techniques, including surgery, transcatheter arterial chemoembolization, radiofrequency ablation, percutaneous ethanol injection, chemotherapy and targeted agents have been explored with complex decision trees and limited impact on outcome [2-6]. "
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    ABSTRACT: To report technical features, early outcome and toxicity of stereotactic body radiation therapy (SBRT) treatments with volumetric modulated arc therapy (RapidArc) for patients with hepatocellular carcinoma (HCC). Twenty patients (22 lesions) were prospectively enrolled in a feasibility study. Dose prescription was 50Gy in 10 fractions. Seven patients (35%) were classified as AJCC stage I-II while 13 (65%) were stages III-IV. Eighteen patients (90%) were Child-Pugh stage A, the remaining were stage B. All patients were treated with RapidArc technique with flattening filter free (FFF) photon beams of 10MV from a TrueBeam linear accelerator. Technical, dosimetric and early clinical assessment was performed to characterize treatment and its potential outcome. Median age was 68 years, median initial tumor volume was 124 cm3 (range: 6-848). Median follow-up time was 7.4 months (range: 3-13). All patients completed treatment without interruption. Mean actuarial overall survival was of 9.6 +/- 0.9 months (95%C.L. 7.8-11.4), median survival was not reached; complete response was observed in 8/22 (36.4%) lesions; partial response in 7/22 (31.8%), stable disease in 6/22 (27.3%), 1/22 (4.4%) showed progression. Toxicity was mild with only 1 case of grade 3 RILD and all other types were not greater than grade 2. Concerning dosimetric data, Paddick conformity index was 0.98 +/- 0.02; gradient index was 3.82 +/- 0.93; V95% to the clinical target volume was 93.6 +/- 7.7%. Mean dose to kidneys resulted lower than 3.0Gy; mean dose to stomach 4.5 +/- 3.0Gy; D1cm3 to spinal cord was 8.2 +/- 4.5Gy; D1% to the esophagus was 10.2 +/- 9.7Gy. Average beam on time resulted 0.7 +/- 0.2 minutes (range: 0.4-1.4) with the delivery of an average of 4.4 partial arcs (range: 3-6) of those 86% non-coplanar. Clinical results could suggest to introduce VMAT-RapidArc as an appropriate SBRT technique for patients with HCC in view of a prospective dose escalation trial.
    Radiation Oncology 01/2014; 9(1):18. DOI:10.1186/1748-717X-9-18 · 2.36 Impact Factor
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    • "Surgery, although providing survival rates up to 70% at 5 years [2], is viable in a small fraction of patients (less than 1/3) because of advanced stage at diagnosis. Patients also can be treated with transcatheter arterial chemoembolization (TACE), radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), chemotherapy and targeted agents [3-6] with complex decision trees and limited impact on outcome. Radiotherapy was offered to HCC patients but it was limited by severe radiation induced liver disease (RILD) when excessive fractions of the liver were involved in the radiation field [7] and the important relationship between the volume of irradiated normal liver and the toxicity profile [8-10]. "
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    ABSTRACT: Background To report early outcome and toxicity for inoperable patients with hepatocellular carcinoma (HCC) treated with volumetric modulated arc therapy (VMAT). Methods One hundred and thirty eight patients were retrospectively analysed. Dose prescription ranged from 45 to 66Gy with conventional fractionation regime. Based on AJCC staging, 88.4% presented stage III or IV. Two-thirds (69.6%) were Child-Pugh stage A, the remaining were stage B. According to Barcelona Clinic Liver Cancer staging, 72.5% of patients were classified as stage C. Results Median age was 66 years, median tumor volume was 516cm3 (28 to 3620cm3). The most patients (83%) were treated with 60Gy. Median follow-up time was 9 months. One-year overall survival rate was 45% (100% for AJCC stage I, 83% for stage II, 45% for stage III and 28% for stage IV), median survival was 10.3 months (95% C.I. 7.2-13.3). Local control was achieved in 94% (of 109 assessable patients), stable disease in 29%, partial response in 53%, complete response in 11%, and progression in 6%. Radiation-induced liver disease was observed in 34 patients (25%). Gastrointestinal grade 3 toxicity was modest with a total of 17 (12.3%) cases for all endpoints. Conclusions Clinical results could suggest to introduce VMAT as an appropriate technique for the patients with HCC.
    Radiation Oncology 12/2012; 7(1):207. DOI:10.1186/1748-717X-7-207 · 2.36 Impact Factor
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    ABSTRACT: The aim of the present study was to elucidate the effectiveness of transcatheter arterial infusion chemotherapy (TAI) of the whole liver using an epirubicin-mitomycin-lipiodol emulsion, prior to radiofrequency thermal ablation (RFA), in preventing intrahepatic distant recurrence (IDR) from single hepatocellular carcinoma (HCC). Of the 269 consecutive patients who underwent RFA in our institute for single HCC, a total of 182 patients were analyzed in the present study. The primary endpoint was comparison of the post-RFA IDR-free survival rates in patients treated using TAI with an epirubicin-mitomycin-lipiodol emulsion via the proper hepatic artery (TAI-EML) prior to RFA, and patients that received lipiodol infusion-alone prior to RFA. The secondary endpoints were local tumor progression (LTP) and overall survival (OS). Lipiodol infusion-alone prior to RFA was performed in 88 patients and TAI-EML prior to RFA in 94 patients. The mean tumor size was 2.06 cm (range, 0.9-3.2 cm) in the TAI group and 1.97 cm (range, 0.9-3.3 cm) in the lipiodol-alone group, respectively. The cumulative IDR-free survival rates at 1, 2 and 3 years were 74.0, 50.8 and 34.9%, respectively, in the lipiodol-alone group, and 90.8, 74.8 and 70.0%, respectively, in the TAI group (P<0.001). In terms of the OS, there was a significant difference between these two groups (P=0.048), although there was no significant difference in terms of the LTP (P=0.145). We concluded that TAI-EML prior to RFA appears to be useful in reducing post-RFA IDR and may contribute to improved survival rates.
    International Journal of Oncology 06/2012; 41(3):903-9. DOI:10.3892/ijo.2012.1512 · 3.03 Impact Factor
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