J Liver Cancer.  2021 Sep;21(2):113-123. 10.17998/jlc.2021.05.26.

Differences in radiotherapy application according to regional disease characteristics of hepatocellular carcinoma

• Rim CH

• KMID: 2520898
• DOI: http://doi.org/10.17998/jlc.2021.05.26

Abstract

There are differences in opinion regarding the application of external beam radiotherapy in the treatment of hepatocellular carcinoma. Some major guidelines state that external beam radiotherapy is yet to attain a sufficient level of evidence. However, caution should be exercised when attempting to understand the clinical need for external beam radiotherapy solely based on the level of evidence. Previously, external beam radiotherapy had low applicability in the treatment of hepatocellular carcinoma before computed tomography-based planning was popularized. Modern external beam radiotherapy can selectively target tumor cells while sparing normal liver tissues. Recent technologies such as stereotactic body radiotherapy have enabled more precise treatment. The characteristics of hepatocellular carcinoma differ significantly according to the regional etiology. The main cause of hepatocellular carcinoma is the hepatitis B virus. It is commonly diagnosed as a locally advanced tumor but with relatively preserved hepatic function. The majority of these hepatocellular carcinoma cases are found in the East Asian population. Hepatocellular carcinoma caused by hepatitis C virus or other benign hepatitis tends to be diagnosed as a less locally aggressive tumor but with deteriorated liver function. The Western world and Japan tend to have patients with such causes. External beam radiotherapy has been more commonly performed for the former, although the use of external beam radiotherapy in the latter might have more concerns with regard to hepatic toxicity. This review discusses the above subjects along with perspectives regarding external beam radiotherapy in recent guidelines.

Keyword

Hepatocellular carcinoma; External beam radiation therapy; Radiotherapy; Liver neoplasm; Guidelines

Figure

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  Figure 1 Two-dimensional radiotherapy portal image of almost the entire liver. Adopted from J Egypt Natl Canc Inst 2017;29:105–108.13

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  Figure 2 Computerized tomography-based radiotherapy planning and a case of locally advanced hepatocellular carcinoma (HCC) with portal vein thrombosis (PVT). (A) A color wash of distribution of radiation dose (upper left, lower left, and lower right) and dose-volume histogram (upper right). We planned to save at least 70% of normal liver (left lobe) to be irradiated under 30 Gy. (B) Pre-radiotherapy images: multiple HCCs dominantly located in the right lobe involving right PVT. Child Pugh-score was A6. (C) One year after 53 Gy/20 F external radiotherapy and 3 times of transarterial chemoembolization. The tumors were controlled without evidence of viable tumors, with a necrotic change of the main tumor and hypertrophy of the left lobe. The Child-Pugh score was A6. The patient was further followed up for another year and died due to gastrointestinal bleeding. GTV, gross tumor volume; CTV, clinical target volume.

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  Figure 3 Key summary of selected clinical guidelines for hepatocellular carcinoma (HCC). AASLD, American Association for the Study of Liver Disease; RO, radiation oncology; AJCC, American Joint Committee on Cancer; HCC, hepatocellular carcinoma; EASL, European Association for the Study of the Liver; BCLC, Barcelona Clinic of Liver Cancer; pRO, practical radiation oncology; CPS, Child-Pugh Score; MV, major vessel; LT, liver transplantation; KLCSG, Korea Liver Cancer Study Group; mUICC, modified Union for International Cancer Control; TACE, transarterial chemoembolization; PVT, portal vein thrombosis; NCCN, national cancer comprehensive network; UNOS, United Network for Organ Sharing; SBRT, stereotactic body radiotherapy; ESLC, Egyptian Study of Liver Cancer; CLIP, Cancer of Liver Italian Program; INASL, Indian National Association for the Study of the Liver; APASL, Asia-Pacific Association for the Study of the Liver; HKLC, Hong Kong Liver Cancer study group; NCCS, National Cancer Center Singapore; RFA, radiofrequency ablation; TLCA, Taiwan Liver Cancer Association; PEI, percutaneous alcohol injection; ASR, age-standardized incidence rate. Recommendation levels are according to *NCCN system, †Oxford system, otherwise GRADE system.

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