Nov 1, 2012 - Hepatocellular Carcinoma as a Local Salvage Treatment After .... Treatment responses were defined as the best response ... cal software (version 13.0; SPSS, Inc., Chicago, Ill), and ..... Seo YS, Kim MS, Yoo SY, et al.
Original Article
Stereotactic Body Radiation Therapy for Inoperable Hepatocellular Carcinoma as a Local Salvage Treatment After Incomplete Transarterial Chemoembolization Jin-Kyu Kang, MD1; Mi-Sook Kim, MD, PhD1; Chul Koo Cho, MD, PhD1; Kwang Mo Yang, MD, PhD1; Hyung Jun Yoo, MD1; Jin Ho Kim, MD1; Sun Hyun Bae, MD1; Da Hoon Jung, MD1; Kum Bae Kim,1; Dong Han Lee, PhD2; Chul Ju Han, MD3; Jin Kim, MD3; Su Cheol Park, MD3; and Young Han Kim, MD4
BACKGROUND: The objective of this study was to evaluate the efficacy and safety of stereotactic body radiation therapy (SBRT) as a local salvage treatment after incomplete transarterial chemoembolization (TACE) for inoperable hepatocellular carcinoma (HCC). METHODS: The main eligibility criteria were a greatest tumor dimension (LD sum) 18 years; 2) an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1; 3) no previous abdominal radiation therapy (RT); 4) an initial diagnosis of primary HCC or recurrence; 5) an inoperable disease status or refusal to undergo surgery; 6) unsuitability for RFA or PEI; 7) leukocyte count 2000/lL, hemoglobin level 8.0 g/dL, platelets >50,000/lL, absolute neutrophil count 1500/lL, aspartate and alanine aminotransferase levels 30% of the initial tumor size. Stable disease (SD) was defined as a decrease in initial tumor volume 54 Gy was 100%, the rate in those who received 54 Gy was 81.7% (P ΒΌ .029 in univariate analysis). Thus, the current study demonstrates that a higher dose may be necessary for patients with inoperable HCC to achieve a better LC rate. In terms of hepatic complications, the dosages used in this study were generally well tolerated, and severe hepatic toxicity was acceptable. However, we did not apply a clear constraint to GI tissues in the current study. Consequently, 5 patients experienced severe GI complications (2 GDUs, 1 colonic ulcer, and 2 gastric perforations). It is noteworthy that, of the 4 patients who experienced severe gastroduodenal complications, 3 had pre-existing GDUs and cirrhosis. Furthermore, among patients with pre-existing cirrhosis, the prevalence of GDU is greater than in the general population, because portal hypertension probably impairs the mucosal defense mechanism.32 Moreover, it has been suggested that cirrhosis increases GI toxicities after chemoradiation.33 Our results suggest that a pre-existing GDU with cirrhosis is a significant risk factor in GI toxicity. Therefore, esophagogastroduodenoscopy before SBRT to determine the presence of pre-existing GDU may be warranted if a tumor is located near GI organs; and, when it is determined that a patient had a pre-existing GDU, more careful strategies to reduce GI toxicity, such as a lower SBRT dose with smaller fractions or prolongation of treatment time with a longer interval between fractions, should be considered. In conclusion, the current trial demonstrates that SBRT after incomplete TACE for inoperable HCC achieves promising response and LC rates. However, a longer follow-up will be required to confirm this finding. On the basis of the results from this study, we are planning a new multi-institutional phase 2 trial to reduce GI toxicities and achieve optimal outcomes. Cancer
November 1, 2012
A Single-Institution Phase 2 Trial/Kang et al
FUNDING SOURCES This work was supported by the National Nuclear R&D Program of the Ministry of Education, Science, and Technology, Republic of Korea.
CONFLICT OF INTEREST DISCLOSURES The authors made no disclosures.
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