Radiotherapy with volumetric modulated arc therapy for hepatocellular carcinoma patients ineligible for surgery or ablat
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g1 · W.-C. Hsu1, 2 · N.-N. Chung1 · F.-L. Chang1 · A. Fogliata3 · L. Cozzi3 1 Department of Radiation Oncology, Cheng-Ching General Hospital, Taichung 2 Department of Healthcare Administration, Asia University, Taichung 3 Oncology Institute of Southern Switzerland, Bellinzona
Radiotherapy with volumetric modulated arc therapy for hepatocellular carcinoma patients ineligible for surgery or ablative treatments Hepatocellular carcinoma (HCC), or primary liver cancer, is one of the most challenging oncological problems. HCC is the third cause of death due to cancer worldwide [1]. Surgery is not viable in a large fraction of patients because of advanced stage at diagnosis. These patients can be treated with different modalities including transcatheter chemotherapy (TACE), radiofrequency ablation (RFA), and percutaneous ethanol injection (PEI) [2, 3, 4, 5], but outcome is unsatisfactory. Radiotherapy was offered to HCC patients but most of the early studies demonstrated poor outcome and significant toxicity, including radiation-induced liver disease (RILD). Among the reasons for these problems, there is the low tolerance to doses as moderate as 30–50 Gy; the volume effect in the liver was investigated concluding that about 700 cm3 of the liver should be spared during irradiation and that the local control could have been increased escalating the total dose above 50 Gy [6, 7, 8, 9]. With intensity-modulated radiotherapy (IMRT), new hope emerged for radiotherapy in HCC [10, 11, 12]. Today, IMRT has evolved into a new form, the volumetric modulated arc therapy (VMAT) pioneered in its RapidArc mode by Otto [13]; technical details can be found elsewhere [14]. The role of RapidArc was assessed in a number of studies but its clinical application to the liver has been primarily limited to metastatic indications [15, 16]. A planning study by Kuo
et al. [17] demonstrated that RapidArc could also play a role in HCC. The present study reports the dosimetric and basic clinical results of a retrospective analysis for HCC patients treated with RapidArc. Endpoints of the study were tumor response and overall survival. More detailed clinical data will be published in a separate analysis.
Materials and methods Study population and treatment characteristics Between February 2009 and December 2010, 138 patients were treated for HCC with RapidArc at the home institute and were retrospectively analyzed to assess tumor response and overall survival. All patients presented Barcelona Clinic Liver Cancer (BCLC) stage A–C and were eligible for curative or palliative radiotherapy. All patient cohort demographics are reported in . Tab. 1. The gross tumor volume (GTV) was defined as the primary tumor plus abnormal portal areas revealed on CT images. IV contrast was used for all patients except for the patients with renal dysfunction. For those renal insufficient patients, MRI was added for target delineation precisely. The clinical target volume (CTV) was defined as the GTV plus a 1 cm margin for subclinical disease. The planning target volume (PTV)
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