International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationStereotactic Body Radiation Therapy in Recurrent Hepatocellular Carcinoma
Introduction
Patients with hepatocellular carcinoma (HCC) have a poor prognosis, with a high recurrence rate. Intrahepatic recurrence rate is exceedingly high in both early and advanced disease after curative treatment. Liver transplantation and repeated hepatectomies are theoretically the best therapies for recurrent HCC. However, multiple practical obstacles exist, including the extreme shortage of organs, extrahepatic spread, multicentric tumors, and inadequate normal liver reserve, making these ideal options available only to selected patients. Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are also treatment options for recurrent disease, and both may lead to significant but only small survival benefits 1, 2, 3, 4. In general, overall prognosis is still dismal. It is worthwhile to explore new therapeutic strategies for recurrent HCC.
HCC is a radiosensitive tumor (5). However, radiotherapy has a limited role in treating this disease because of the poor radiation tolerance of normal liver and the difficulty in tumor localization caused by organ motion. Recent technological developments in radiation therapy, such as stereotactic body radiation therapy (SBRT) and imaged-guided radiotherapy, make it possible to deliver a substantial dose of radiation to the tumor and avoid radiosensitive normal liver in the vicinity. Preliminary results of SBRT in HCC have shown its safety and efficacy in primary disease control 6, 7, 8, 9, 10. Nevertheless, its effect on survival is seldom reported, and no studies of SBRT that focus on recurrent HCC, to our knowledge, have been published.
In this study, we analyzed the outcomes of 36 patients with recurrent HCC after SBRT using Cyberknife (Accuray Inc., Sunnyvale, CA) image-guided radiosurgery system. We examined its safety and efficacy for recurrent HCC patients and compared survival rate with that of a historical control group.
Section snippets
Patients
From January 2008 to December 2009, 36 patients with 42 lesions were enrolled in this study. The eligibility criteria were (1) patients who were previously diagnosed with HCC by cytohistology (19 patients) or noninvasive criteria (17 patients); that is, based on [a] a nodule of >2 cm together with the classic enhancement on one imaging technique or an alpha fetoprotein (AFP) of >200 ng/ml, or [b] a 1- to 2-cm nodule with typical features on two imaging studies [11]); (2) patients undergoing
Tumor response and local control
Follow-up CT scan or MRI was available for 35 patients (41 lesions). One patient developed brain metastasis 2 months after SBRT. He died before the first follow-up CT scan or MRI. Of the 41 evaluable lesions, the complete response (CR), partial response (PR), stable disease (SD), and PD rates were 22.0%, 36.6%, 39.0%, and 2.4%, respectively. Treatment responses of recurrent HCC and newly developed HCC after prior treatment to SBRT were not statistically different. Out-field intrahepatic
Discussion
Standard treatment of recurrent HCC has not yet been established. In this study, our preliminary results support the fact that SBRT could be a treatment option for patients who are unsuitable for surgery. There are some advantages for SBRT in treating recurrent HCC. First, in addition to high in-field local control, the survival rates in this study appear comparable to those seen with other treatment modalities. Our study resulted in 2-year OS of 64%, which is comparable to that of RFA 2, 12
Conclusions
In conclusion, our study supports that SBRT is feasible in treating recurrent unresectable HCC, resulting in 59% tumor response rate (CR + PR), 98% in-field disease control rate (CR + PR + SD), and an encouraging survival rate. The acute toxicities are usually mild and tolerable. However, out-field recurrence is still the main course of failure and further studies of combination of SBRT and systemic therapies may be reasonable.
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2022, Translational OncologyCitation Excerpt :According to the clinical guideline, SBRT is now widely applied as treatment in patients with HCC that are not suitable for surgery, TACE, or other loco-regional treatment [10,11]. The treatment failure pattern is mainly caused by intra-hepatic recurrence [12]. Theoretically, prophylactic normal liver irradiation could affect the risk of recurrence by eliminating the micro-metastasis.
Conflict of interest: none.