If a patient with hepatocellular carcinoma has Child-Pugh grade A or B liver function, consider the possible benefits of external radiation therapy, regardless of where the tumor is located.
Stereotactic radiotherapy for early-stage hepatocellular carcinoma
Stereotactic body radiation therapy (SBRT) can be delivered in a single (in this case also known as stereotactic radiosurgery) or limited number of high-dose divided radiation doses to a small, precisely located target, with the irradiation dose precisely converging on the target lesion, minimizing the exposure of nearby normal tissue to radiation exposure.
SBRT is a radical local treatment for hepatocellular carcinoma with greatly enhanced biological effects compared to conventional dose-split external radiotherapy, improving the effectiveness of radiotherapy for hepatocellular carcinoma.
In China, SBRT was reported to have local control rates of 90.9% and 84.1% at 1 and 2 years, respectively; and overall survival rates of 94.1%, 81.9%, 73.5%, and 64.3% at 1, 2, 3, and 5 years, respectively, similar to those of surgical resection, liver transplantation, or radiofrequency ablation.
SBRT is appropriate for patients with hepatocellular carcinoma who have:
- Patients who are not candidates for or unwilling to undergo tumor resection, liver transplantation, or radiofrequency ablation, or who are limited in their ability to receive these treatments in a timely manner, may undergo SBRT. For patients awaiting liver transplantation, SBRT may also be used as a bridging treatment.
- SBRT may be considered in patients with residual or recurrent tumor after surgical resection, liver transplantation, or radiofrequency ablation.
SBRT may also be considered in patients with poor iodine oil deposition and residual disease after transcatheter hepatic arterial chemoembolization (TACE) treatment.
In addition to this, SBRT for hepatocellular carcinoma requires the following conditions:
- The distance between the tumor and the cavernous organs (e.g., esophagus, stomach, intestine, etc.) is greater than 5 mm.
- SBRT can be used for larger or more extensive lesions beyond early small hepatocellular carcinoma if the normal liver is of sufficient size to tolerate irradiation.
- Barcelona Clinic Liver Cancer (BCLC) staging is A/B, without major vascular invasion or thrombosis and without extrahepatic metastases. If beyond these stages but necessary and eligible for SBRT, aggressive combination therapy is required to effectively control or eliminate small extrahepatic metastatic lesions before SBRT can be performed.
- Normal liver volume of no less than 700 mm and a Child-Pugh grade of A for liver function; patients with Child-Pugh grade B may also undergo SBRT, but the dose of radiation therapy needs to be given with caution.
- Eastern Cooperative Oncology Group (ECOG) physical status score of 0 to 2.
External radiation radiotherapy may complement interventional therapy
For non-surgical resectable hepatocellular carcinoma confined to the liver, external radiation therapy can complement interventional therapy, consolidate the effects of interventional therapy, and prolong patient survival.
Particularly in patients with masses less than 5 cm, interventional embolization chemotherapy is difficult to achieve complete ischemic necrosis of the tumor, and residual tumor cells become a source of later recurrence or metastasis.
External radiation radiotherapy should be considered in patients with portal/inferior vena cava thrombosis
.
For hepatocellular carcinoma with portal/inferior vena cava thrombosis, radiotherapy may prolong patient survival. Therefore, external radiation radiotherapy should be considered for hepatocellular carcinoma with portal/inferior vena cava thrombosis.
External radiation therapy can be used for multidisciplinary comprehensive treatment of metastases
.
Extrahepatic metastases from hepatocellular carcinoma include lymph node metastases, lung metastases, bone metastases, adrenal metastases, brain metastases, peritoneal and pleural endometrium metastases, etc.
Many metastases require comprehensive multidisciplinary treatment, including radiotherapy, and external radiation therapy has become a superior treatment for multidisciplinary comprehensive treatment of metastases.
Authoritative guidelines at home and abroad agree that for symptoms (such as pain, jaundice, cough, etc.) caused by infiltration and compression of metastases from lymph nodes, bone, adrenal gland, lung, and brain in hepatocellular carcinoma, external radiation therapy can effectively relieve symptoms such as pain, obstruction or bleeding, stop complications, improve survival quality, and also slow down tumor development, thus prolonging survival.
Which patients with intrahepatic cholangiocarcinoma are suitable for radiotherapy?
- Small intrahepatic cholangiocellular carcinoma that is not amenable to surgical resection may be considered for SBRT. The NCCN guidelines suggest that large-split radiotherapy or SBRT (1 to 5 sessions) may be an option for the treatment of intrahepatic lesions in intrahepatic cholangiocellular carcinoma.
- The NCCN guidelines recommend external radiation therapy for symptom control and prolonged survival in inoperable intrahepatic cholangiocarcinoma.
- Postoperative adjuvant radiotherapy for R1 or R2 resected intrahepatic cholangiocarcinoma may prolong patient survival.