High dose radiotherapy with image-guided hypo-IMRT for hepatocellular carcinoma with portal vein and/or inferior vena cava tumor thrombi is more feasible and efficacious than conventional 3D-CRT

Abstract

Objective: To compare the efficacies of conventional three-dimensional conformal radiotherapy and image-guided hypofractionated intensity-modulated radiotherapy treatments in advanced hepatocellular carcinoma patients with portal vein and/or inferior vena cava tumor thrombi. Methods: A total of 118 hepatocellular carcinoma patients with portal vein and/or inferior vena cava tumor thrombi who received external beam radiation therapy focused on tumor thrombi and intrahepatic tumors were retrospectively reviewed. During the three-dimensional conformal radiotherapy treatments, a median total dose of 54 Gy with a conventional fraction (1.8-2.0 Gy/fx) was delivered. During the image-guided hypofractionated intensity-modulated radiotherapy treatments, a median total dose of 60 Gy with fractions of 2.5−4.0 Gy/fx was delivered. Results: The median follow-up time was 11.8 months (range, 1.7-43.7 months). Higher radiation doses were delivered by image-guided hypofractionated intensity-modulated radiotherapy than by three-dimensional conformal radiotherapy (average dose 57.86 ± 7.03 versus 50.88 ± 6.60 Gy, P ≤ 0.001; average biological effective dose 72.35 ± 9.62 versus 61.45 ± 6.64 Gy, P < 0.001). A longer median survival was found with image-guided hypofractionated intensity-modulated radiotherapy than with three-dimensional conformal radiotherapy (15.47 versus 10.46 months, P = 0.005). Multivariate analysis showed that image-guided hypofractionated intensity-modulated radiotherapy is a significant prognostic factor for overall survival. Toxicity was mild for both image-guided hypofractionated intensity-modulated radiotherapy and three-dimensional conformal radiotherapy. Conclusions: High dose radiotherapy delivered by image-guided hypofractionated intensity-modulated radiotherapy appears to be an effective treatment that provides a survival benefit without increasing severe toxicity in hepatocellular carcinoma patients with portal vein and/or inferior vena cava tumor thrombi.

Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China (2017 Edition)

“…The use of 3D conformal radiotherapy (CRT), intensity-modulated radiation therapy (IMRT), image-guided radiation therapy, or stereotactic body radiation therapy is recommended. Image-guided IMRT is superior to 3D CRT [107]. The tomotherapy system is the radiation system designed for image-guided IMRT; it is suitable for patients with multiple lesions.…”

Critical appraisal of Chinese 2017 guideline on the management of hepatocellular carcinoma

“…Although only targeted therapy of sorafenib is indicated for stage IIIa patients with macrovascular invasion according to the BCLC recommendations, TACE is indicated for lesions with invasion at the second and the more peripheral portal branch in Japan, and even for lesions with portal vein tumor thrombus (PVTT) at the main trunk in China as long as collateral circulation is well-developed. While hepatic arterial infusion chemotherapy (HAIC) is commonly recommended for patients with portal invasion at the main portal trunk or at the first branch by the JSH guidelines, radiotherapies including transarterial radio embolization (TARE) and external radiation are more frequently used for this situation in China (54,55). For highly selective patients at stage IIb and IIIa, surgical resection is still indicated under the following situations: multiple lesions restrained in the same segment or the same lobe; lesions with PVTT in the same half liver which can be removed or resected.…”

Dose and Location of Irradiation Determine Survival for Patients with Hepatocellular Carcinoma with Macrovascular Invasion in External Beam Radiation Therapy

“…The RR for EBRT of PVTT/BDTT and HVTT in the present study was 51.2 and 88.6%, respectively. Hou et al[37] have also reported that patients with IVC thrombus treated with EBRT had a better RR and longer survival rate than those with PV thrombus. The reason for the superior efficacy of EBRT for HVTT compared to that for PVTT/BDTT is unclear.…”