Abstract
Given the growing interest in using proton beam therapy (PBT) for hepatocellular carcinoma (HCC), it is possible that transarterial chemoembolization (TACE) could be used for selected patients who have previously undergone PBT. However, these cases can be technically challenging to treat and require appropriate preparation. Thus, we aimed to identify angiographic findings in this setting. We retrospectively identified 31 patients (28 men and 3 women, mean age: 69 years, range: 43–84 years) who underwent hepatic angiography plus TACE or transarterial infusion chemotherapy (TAI) for HCC that recurred after PBT (July 2007 to June 2018). We discovered four angiographic findings, which we speculate were related to the previous PBT. 18 patients experienced recurrence in the irradiated field, and 13 patients experienced recurrence outside the irradiated field. 29 patients underwent TACE and only 2 patients underwent TAI. The mean number of previous PBT treatments was 1.3 ± 0.6 (range: 1–4). The median interval from the earliest PBT treatment to hepatic angiography was 559 days (range: 34–5,383 days), and the median interval from the latest PBT treatment to hepatic angiography was 464 days (range: 34–5,383 days). Abnormal staining of the irradiated liver parenchyma was observed in 22 patients, which obscured the angiographic tumor staining in 4 patients. Development of a tortuous tumor feeder vessel was observed in 13 patients. Development of an extrahepatic collateral pathway was observed in 7 patients. Development of an arterioportal or arteriovenous shunt was observed in 4 patients. Based on these findings, we conclude that PBT was associated with various angiographic findings during subsequent transarterial chemotherapy for recurrent HCC, and familiarity with these findings will be important in developing appropriate treatment plans.
Highlights
Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver [1]
We identified patients who underwent transarterial chemotherapy for HCC that recurred after proton beam therapy (PBT) between July 2007 and June 2018. 37 patients fulfilled the inclusion criteria: (1) diagnosis of HCC was confirmed pathologically or clinically according to the accepted guidelines [9], (2) PBT was performed for HCC before the transarterial chemotherapy, and (3) transarterial chemoembolization (TACE) or transarterial infusion chemotherapy (TAI) was performed
In the PBT irradiation fields, we identified four angiographic findings: (1) abnormal staining of the irradiated liver parenchyma, (2) development of a tortuous tumor feeder vessel, (3) development of an extrahepatic collateral pathway, and (4) development of AP or AV shunts
Summary
Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver [1]. According to the NCCN guidelines, there are numerous strategies for treating HCC, including resection, transplantation, radiofrequency ablation, transarterial chemoembolization (TACE), radiotherapy (RT), and systemic therapy using sorafenib or lenvatinib [2]. All patients with HCC should be evaluated for potential curative therapies, including resection and transplantation [2]. Locoregional therapy, including ablation, TACE, and RT, is indicated for patients who are not candidates for curative therapy or indicated as a bridge therapy for patients who are candidates for transplantation [2]. Recent reports have described favorable clinical outcomes after proton beam therapy (PBT) for HCC, based on a 5year overall survival rate of 24–48% [3, 4] and a 5-year local control rate of approximately 80% [3, 5].
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