J Liver Cancer.  2020 Mar;20(1):90-97. 10.17998/jlc.20.1.90.

Combined Transarterial Chemoembolization and External Beam Radiotherapy in a Patient with Recurrent Huge Hepatocellular Carcinoma after Hepatic Resection

• Yu J
• Jung J
• Yoon SM

• KMID: 2505848
• DOI: http://doi.org/10.17998/jlc.20.1.90

Abstract

The optimal treatment strategy for unresectable huge hepatocellular carcinoma (HCC) is yet to be established. Non-surgical monotherapy demonstrated insufficient oncologic outcomes in previously reported studies. To improve the clinical outcomes of unresectable huge HCC, combined locoregional treatments can be considered in selected cases. Here, we report a case of 58-year-old male patient who was treated with combined transarterial chemoembolization (TACE) and external beam radiotherapy for recurrent HCC after a previous hepatic resection. After combined TACE and radiotherapy for the intrahepatic lesion, two metastases were diagnosed in the pelvic bones and lung; each lesion was successfully treated with salvage radiotherapy. During the long-term follow-up period (around 8 years 7 months after combined TACE and radiotherapy for the recurrent huge HCC), no definite viable tumors were observed in any of the treated liver, bone, and lung lesions.

Keyword

Huge; Hepatocellular carcinoma; Therapeutic chemoembolization; Radiotherapy

Figure

• 

  Figure 1. Serial liver dynamic computed tomography (CT) images from the time of recurrence to the last follow-up at 8.6 years. (A) a recurrent hepatocellular carcinoma (HCC) measuring 11 cm (yellow arrowheads) in segment 3 was observed on the arterial phase. (B) Partial iodized oil uptake in recurrent HCC was observed on the follow-up CT scan 1 month after the first TACE. (C) Iso-dose lines of radiotherapy for the recurrent HCC on the planning CT. Total dose (30 Gy in 12 fractions) was prescribed with 97% iso-dose line. (D) After TACE (a total of 5 times) and radiotherapy, no definitive viable HCC was observed. Follow-up CT images at 1 year (E), 2 years (F), 3 years (G), 5 years (H), and 8.4 years (I) after radiotherapy.

• 

  Figure 2. (A, B) Positron emission tomography-computed tomography scan showing a huge osteolytic lesion with maximum standardized uptake value of 11.2 in the right iliac bone. (C) Iso-dose lines of 3-dimensional conformal radiotherapy for the right iliac bone mass on the planning CT. Total dose (60 Gy in 24 fractions) was prescribed with 97% iso-dose line. (D) Follow-up CT at 3 months after radiotherapy showed a marked decreasing in the enhancing mass. (E) Additional shrinkage of the tumor was observed at 1-year follow-up CT. (F) Two years after radiotherapy, pathologic fractures at the site of bone destruction by the metastatic tumor in the right iliac bone (yellow arrows) were observed. No recurrence was observed on right iliac bone at 3 years (G), 5 years (H), or 6.8 years (I) after radiotherapy.

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  Figure 3. Chest computed tomography (CT) (A) and positron emission tomography-CT (B) scans showing a hypermetabolic metastatic nodule with a maximum standardized uptake value of 11.8 (yellow arrowheads) in the right middle lobe. (C) Iso-dose lines of stereotactic body radiotherapy for lung metastasis on the planning CT. Total dose (60 Gy in 4 fractions) was prescribed with 97% iso-dose line. (D) After 3 months of stereotactic body radiotherapy, a focal radiation pneumonitis (yellow arrows) without a viable tumor was found. Radiation induced fibrotic changes without recurrence were observed at 1 year (E), 2 years (F), 3 years (G), 4 years (H), and 5 years (I) after radiotherapy.

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  Figure 4. Summary of treatments with the trends of alpha-fetoprotein levels from the initial diagnosis to the last follow-up. TACE, transarterial chemoembolization; RT, radiotherapy; HCC, hepatocellular carcinoma; SBRT, stereotactic body radiotherapy.

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