External Beam Radiation Therapy for Hepatocellular Carcinoma: Potential of Intensity-Modulated and Image-Guided Radiation Therapy

Department of Radiation Oncology, UTHSC at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78229, USA.
Gastroenterology (Impact Factor: 16.72). 12/2004; 127(5 Suppl 1):S206-17. DOI: 10.1053/j.gastro.2004.09.035
Source: PubMed


External beam radiotherapy has historically played a minor role in the primary treatment of hepatocellular carcinoma. Although there is evidence for tumor response to external beam radiotherapy and despite the fact that a radiation dose-response relationship has been established, the limited radiation tolerance of the adjacent normal liver has prohibited wider use of radiation therapy in this disease. Recent technological and conceptual developments in the field of radiation therapy-such as intensity-modulated radiation therapy, image-guided radiation therapy, and stereotactic body radiation therapy-have the potential to improve radiation treatments by conforming the delivered radiation dose distribution tightly to the tumor or target volume outline while sparing normal liver tissue from high-dose radiation. Image guidance allows for a reduction of added (normal tissue) safety margins designed to account for interfraction patient and target setup variability, and stereotactic targeting will further reduce residual target setup uncertainty. Combining improvements in tumor targeting with normal tissue sparing, radiation dose delivery will enable clinically effective and safe radiation delivery for liver tumors such as hepatocellular carcinoma. This article reviews the role of radiotherapy for hepatocellular carcinoma; presents modern radiation therapy modalities and concepts such as intensity-modulated, image-guided, and stereotactic body radiation therapy; and hypothesizes about their future effect on primary treatment alternatives.

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Available from: Bill J Salter, Oct 04, 2015
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    • "p = 0.009) compared with 3DCRT [14]. Fuss et al. reported that IMRT allowed a dose escalation to 60 Gy, in which range 3DCRT had to reduce the total dose to decrease the probability of RILD to acceptable levels [15]. "
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    ABSTRACT: To compare the RapidArc plan for primary hepatocellular carcinoma (HCC) with 3-D conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT) plans using dosimetric analysis. Nine patients with unresectable HCC were enrolled in this study. Dosimetric values for RapidArc, IMRT, and 3DCRT were calculated for total doses of 45~50.4 Gy using 1.8 Gy/day. The parameters included the conformal index (CI), homogeneity index (HI), and hot spot (V₁₀₇%) for the planned target volume (PTV) as well as the monitor units (MUs) for plan efficiency, the mean dose (Dmean) for the organs at risk (OAR) and the maximal dose at 1% volume (D1%) for the spinal cord. The percentage of the normal liver volume receiving ≥ 40, > 30, > 20, and > 10 Gy (V₄₀ Gy, V₃₀ Gy, V₂₀ Gy, and V₁₀ Gy) and the normal tissue complication probability (NTCP) were also evaluated to determine liver toxicity. All three methods achieved comparable homogeneity for the PTV. RapidArc achieved significantly better CI and V107% values than IMRT or 3DCRT (p < 0.05). The MUs were significantly lower for RapidArc (323.8 ± 60.7) and 3DCRT (322.3 ± 28.6) than for IMRT (1165.4 ± 170.7) (p < 0.001). IMRT achieved a significantly lower Dmean of the normal liver than did 3DCRT or RapidArc (p = 0.001). 3DCRT had higher V₄₀Gy and V₃₀ Gy values for the normal liver than did RapidArc or IMRT. Although the V10 Gy to the normal liver was higher with RapidArc (75.8 ± 13.1%) than with 3DCRT or IMRT (60.5 ± 10.2% and 57.2 ± 10.0%, respectively; p < 0.01), the NTCP did not differ significantly between RapidArc (4.38 ± 2.69) and IMRT (3.98 ± 3.00) and both were better than 3DCRT (7.57 ± 4.36) (p = 0.02). RapidArc provided favorable tumor coverage compared with IMRT or 3DCRT, but RapidArc is not superior to IMRT in terms of liver protection. Further studies are needed to establish treatment outcome differences between the three approaches.
    Radiation Oncology 06/2011; 6(1):76. DOI:10.1186/1748-717X-6-76 · 2.55 Impact Factor
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    • "Clinical investigations suggested that one-third, twothirds , and the whole liver can be safely irradiated with 90, 47, and 31 Gy, respectively, and that a partial volume of the liver can be irradiated with a tumor-control dose [11]. Furthermore, advanced irradiation techniques such as 3D-conformal RT (CRT) and image-guided RT (IGRT) made it possible to deliver a higher dose to the tumor without damage to the normal liver [12]. Although clinical results of RT for HCC-PVTT have been reported [13] [14] [15] [16] [17] [18], the optimal RT dose remains to be established . "
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    ABSTRACT: The prognosis of patients with portal vein tumor thrombosis (PVTT) from hepatocellular carcinoma (HCC) is poor; without treatment, their survival is less than 3months. We retrospectively evaluated the treatment outcomes of conformal radiation therapy (CRT) in patients with HCC-PVTT. Thirty-eight HCC patients with PVTT in whom other treatment modalities were not indicated underwent CRT. The total dose was translated into a biologic effective dose (BED) of 23.4-59.5Gy(10) (median 50.7Gy(10)) as the alpha/beta ratio=10. Predictive factors including the age, performance status, Child-Pugh classification, PVTT size, and BED were evaluated for tumor response and survival. Complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD) were observed in 6 (15.8%), 11 (28.9%), 17 (44.7%), and 4 (10.5%) patients, respectively. The response rate (CR+PR) was 44.7%. The PVTT size (<30 vs. 30mm) and BED (<58 vs. 58Gy(10)) were significant factors for tumor response. The median survival and 1-year survival rate were 9.6months and 39.4%. The Child-Pugh classification (A vs. B) and BED were significant factors for survival. CRT is effective not only for tumor response but also for survival in HCC-PVTT patients in whom other treatment modalities are not indicated.
    Radiotherapy and Oncology 09/2007; 84(3):266-71. DOI:10.1016/j.radonc.2007.07.005 · 4.36 Impact Factor
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    ABSTRACT: Objective The curative result or long -term survival of hepatocellula r carcinoma (HCC) has been pursued ever since its discovery even most of the cases are evaluated as absolute -non-cure before their management. A number of treatment approaches have been applied and option for a certain case is absolutely necessary. The objective of this article is to evaluate today's treatment methods and find some information for the option. Methods The characteristics of most of these approaches are studied and compared for their role in the curative management. The key points, advantages and disadvantages of these approaches are discussed. Results Current treatments fall into categories of surgical, percutaneous, chemical and physical as well as biomedical ones. Different modes of regional cancer therapy for HCC have been tried, but the relative efficacy remains unclear. Anti-angiogenic agents, gene therapy and tumor vaccine will probably play a role, particularly in the prevention of tumor recurrence. Some issues remain to be solved. Conclusion For the recent future, the ideal strategy for curative results might be the establishment of a comprehensive way of combined approaches.
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