Hepatobiliary and Pancreatic: 3‐Dimensional conformal radiotherapy for hepatocellular carcinoma

Abstract

Hepatocellular carcinoma is the sixth most common cancer worldwide and is responsible for approximately 600,000 deaths per year. Despite improvements in diagnosis and therapy, survival is still poor with an overall survival rate at 5 years of only 5%. In patients who are unsuitable for ‘curative’ resections, therapeutic options include radiofrequency ablation, transcatheter arterial chemoembolization, hepatic artery infusion chemotherapy and treatment with sorafenib. However, treatment options are limited in some patients because of tumors that are too large for local therapies and contraindications to procedures such as transcatheter arterial chemoembolization. Furthermore, hepatic artery infusion chemotherapy is not widely practiced outside of Japan. Thus far, the use of radiotherapy for advanced cancers has not been widely adopted because of poor tolerance of the liver to radiation-induced injury, particularly in the setting of cirrhosis. Recently, however, interest in the use of radiotherapy has been rekindled by advances in tumor imaging and the use of more precise radiation beams. This appeared to be helpful in the patient illustrated below. A 61-year-old lady with chronic hepatitis B without cirrhosis was investigated because of the development of abdominal pain.A triple phase computed tomography (CT) scan revealed a 10.4 cm hepatocellular cancer in the right lobe of the liver with prominent arterial phase enhancement (Figure 1) and early washout in the venous phase. The tumor was too large for radiofrequency ablation and treatment with transarterial chemoembolization was contraindicated because of the presence of portal vein thrombosis. Her alpha-fetoprotein level was 9920 mg/l and she was assessed as having a Cancer of the Liver Italian Program (CLIP) score (a prognostic scoring system) of 4 with a predicted median survival of 3.2 months. She was treated with 3-dimensional conformal radiotherapy to a total dose of 21 Gy in 7 fractions at a specialized cancer center. After radiotherapy, her abdominal pain improved and her alpha-fetoprotein level fell to 267 mg/l. A repeat triple phase CT performed 3 months after radiotherapy revealed a lesion that was stable in size but had become diffusely low-attenuating and now lacked arterial enhancement (Figure 2).At 9 months after radiotherapy, abdominal pain recurred, her alpha-fetoprotein level rose to 450 mg/l and a new 2 cm lesion was shown on a repeat CT scan. She was intolerant of treatment with sorafenib and died 11 months after treatment with radiotherapy.