The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel’s discussion and updated recommendations regarding systemic therapy for first-line and subsequent-line treatment of patients with hepatocellular carcinoma.

Radiation necrosis in the brain commonly occurs in three distinct clinical scenarios, namely, radiation therapy for head and neck malignancy or intracranial extraaxial tumor, stereotactic radiation therapy (including radiosurgery) for brain metastasis, and radiation therapy for primary brain tumors. Knowledge of the radiation treatment plan, amount of brain tissue included in the radiation port, type of radiation, location of the primary malignancy, and amount of time elapsed since radiation therapy is extremely important in determining whether the imaging abnormality represents radiation necrosis or recurrent tumor. Conventional magnetic resonance (MR) imaging findings of these two entities overlap considerably, and even at histopathologic analysis, tumor mixed with radiation necrosis is a common finding. Advanced imaging modalities such as diffusion tensor imaging and perfusion MR imaging (with calculation of certain specific parameters such as apparent diffusion coefficient ratios, relative peak height, and percentage of signal recovery), MR spectroscopy, and positron emission tomography can be useful in differentiating between recurrent tumor and radiation necrosis. In everyday practice, the visual assessment of diffusion-weighted and perfusion images may also be helpful by favoring one diagnosis over the other, with restricted diffusion and an elevated relative cerebral blood volume being seen much more frequently in recurrent tumor than in radiation necrosis.

This retrospective study suggests that in patients with HCC tumours of ≥ 3 cm, treatment with TACE + SBRT provides a survival advantage over treatment with only TACE. Confirmation of this observation requires that the concept be tested in a prospective, randomized clinical trial.

Stereotactic body radiation therapy (SBRT) employs precision target tracking and image‐guidance techniques to deliver ablative doses of radiation to localized malignancies; however, treatment with conventional photon beams requires lengthy treatment and immobilization times. The use of flattening filter‐free (FFF) beams operating at higher dose rates can shorten beam‐on time, and we hypothesize that it will shorten overall treatment delivery time. A total of 111 lung and liver SBRT cases treated at our institution from July 2008 to July 2011 were reviewed and 99 cases with complete data were identified. Treatment delivery times for cases treated with a FFF linac versus a conventional dose rate linac were compared. The frequency and type of intrafraction image guidance was also collected and compared between groups. Three hundred and ninety‐one individual SBRT fractions from 99 treatment plans were examined; 36 plans were treated with a FFF linac. In the FFF cohort, the mean (± standard deviation) treatment time (time elapsed from beam‐on until treatment end) and patient's immobilization time (time from first alignment image until treatment end) was 11.44 false(± 6.3false) and 21.08 false(± 6.8false) minutes compared to 32.94 false(± 14.8false) and 47.05 false(± 17.6false) minutes for the conventional cohort (p<0.01 for all values). Intrafraction‐computed tomography (CT) was used more often in the conventional cohort (84% vs. 25%; p<0.05), but use of orthogonal X‐ray imaging remained the same (16% vs. 19%). For lung and liver SBRT, a FFF linac reduces treatment and immobilization time by more than 50% compared to a conventional linac. In addition, treatment with a FFF linac is associated with less physician‐ordered image guidance, which contributes to further improvement in treatment delivery efficiency.PACS number: 87.55.‐x

Biomarkers play an essential role in the management of patients with invasive cancers. Pancreatic ductal adenocarcinoma (PDC) associated with poor prognosis due to advanced presentation and limited therapeutic options. This is further complicated by absence of validated screening and predictive biomarkers for early diagnosis and precision treatments respectively. There is emerging data on biomarkers in pancreatic cancer in past two decades. So far, the CA 19-9 remains the only approved biomarker for diagnosis and response assessment but limited by low sensitivity and specificity. In this article, we aim to review current and future biomarkers that has potential serve as critical tools for early diagnostic, predictive and prognostic indications in pancreatic cancer.

While endoscopic ultrasound (EUS)-guided fiducial placement is technically feasible, its role in the delivery of image-guided radiation therapy (IGRT) is unclear. In this study, we evaluated the feasibility and safety of using EUS-guided fiducial markers for delivering IGRT in patients with pancreatic cancer. Following computed tomography (CT) simulation, a radiation therapy treatment plan was prepared for each patient. A kilovoltage (kv) image obtained before each treatment session was aligned with images generated during treatment planning, based on the position of fiducials. Radiation therapy was then delivered. Image analysis was also performed by alignment of bony landmarks (current standard of care). Daily shifts of fiducials between the two sets of images represented movement of the pancreas relative to the bony landmarks. EUS-guided fiducial placement was technically successful in all nine patients and no complications were encountered. The fiducials were easily identified for image fusion and IGRT was delivered successfully to all patients. The movement of the pancreas relative to bones was 0.2 cm (0.1-0.5 cm), 0.5 cm (0.2-1.5 cm), and 0.4 cm (0.2-0.9 cm) in the anterior-posterior, superior-inferior, and left-right axes, respectively. This technique may have significant clinical implications in terms of radiation dosimetry.

No abstract