In oncologic practice, treatment guidelines provide appropriate treatment strategies based on evidence. Currently, many guidelines are used, including those of the European Association for the Study of the Liver and European Organization for Research and Treatment of Cancer (EASL-EORTC), National Comprehensive Cancer Network (NCCN), Asia-Pacific Primary Liver Cancer Expert (APPLE), and Korean Liver Cancer Study Group and National Cancer Centre (KLCSG-NCC). Although radiotherapy is commonly used in clinical practice, some guidelines do not accept it as a standard treatment modality. In this review, we will investigate the clinical practice guidelines currently used, and discuss the application of radiotherapy.
Carcinoma, Hepatocellular* ; Liver ; Liver Neoplasms ; Radiotherapy*

Carcinoma, Hepatocellular ; radiotherapy ; Catheter Ablation ; Humans ; Liver Neoplasms ; radiotherapy

With the accumulation of clinical experiences, the efficacy of radiotherapy has been recognized in management scheme for HCC. While hepatologists are beginning to show less reluctance for applying radiotherapy to the treatment of HCC, it is necessary that the hepatologists be informed of the rapid developments in technical strategy for radiation oncology. Recent advances in several technologies have opened a new era in radiation oncology. Modern imaging technologies can provide a 3-dimensional model of patient's anatomy, and this allows radiation oncologists to identify accurate tumor volumes as well as the tumors' relationship with the adjacent normal tissues. Moreover, the development of the computer-controlled multileaf collimator systems now enables physicians to perform precise beam shaping and to modulate the radiation dose distribution. A combination of these systems, 3-DCRT, is rapidly replacing the more conventional 2-D radiotherapy. 3-DCRT has evolved into a more sophisticated technology, intensity modulated radiotherapy (IMRT). In IMRT, with the powerful computer-aided optimization process, the radiation dose can be delivered to the target using highly complex isodose profiles. This new technology has been further developed into IGRT, which combines the CT-images scanning system and radiation equipments into one hardware package, and this system is currently ready for clinical application. In parallel with the radiation technologies described above, the strategy of stereotactic radiation has evolved from the conventional linear accelerator-based system to a gammaknife, and more recently, to a cyberknife. These systems are primarily based on the concept of radiosurgery. Currently, various radiation technologies have been adopted for the radiotherapy of HCC. In this article, each strategy will be discussed as well as the indications for radiotherapy and the radiation-related complications.
Carcinoma, Hepatocellular/*radiotherapy ; English Abstract ; Humans ; Liver Neoplasms/*radiotherapy ; Radiotherapy, Intensity-Modulated

Carcinoma, Hepatocellular ; radiotherapy ; therapy ; Combined Modality Therapy ; Humans ; Liver Neoplasms ; radiotherapy ; therapy ; Radiotherapy ; methods

Carcinoma, Hepatocellular ; pathology ; radiotherapy ; Humans ; Liver Neoplasms ; pathology ; radiotherapy ; Neoplasm Recurrence, Local ; radiotherapy

With increasing clinical use, radiotherapy (RT) has been considered reliable and effective method for hepatocellular carcinoma (HCC) treatment, depending on extent of disease and patient characteristics. RT for HCC can improve therapeutic outcomes through excellent local control, downstaging, conversion from unresectable to resectable status, and treatments of unresectable HCCs with vessel invasion or multiple intrahepatic metastases. In addition, further development of modern RT technologies, including image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and stereotactic body radiotherapy, has expanded the indication of RT. An essential feature of IGRT is that it allows image guidance therapy through in-room images obtained during radiation delivery. Compared with 3D-conformal RT, distinctions of IMRT are inverse treatment planning process and use of a large number of treatment fields or subfields, which provide high precision and exquisitely conformal dose distribution. These modern RT techniques allow more precise treatment by reducing inter- and intra-fractional errors resulting from daily changes and irradiated dose at surrounding normal tissues. More recently, particle therapy has been actively investigated to improve effectiveness of RT. This review discusses modern RT strategies for HCC, as well as optimal selection of RT in multimodal approach for HCC.
Carcinoma, Hepatocellular* ; Humans ; Methods ; Neoplasm Metastasis ; Radiosurgery ; Radiotherapy* ; Radiotherapy, Image-Guided ; Radiotherapy, Intensity-Modulated

PURPOSE: Recently radiotherapy is applied alone or in conjunction with transcatheter arterial chemoembolizaion (TACE) or percutaneous ethanol injection therapy (PEIT) for locally advanced hepatocellular carcinoma (HCC). The purpose of this study was to evaluate dose-response relationship of radiotherapy for local control and toxicity in inoperable HCC. MATERIALS AND METHODS: Twenty-eight patients who were not eligible for TACE and PEIT or had showed no response to these treatment were treated with a total dose of 40 Gy with 2 Gy per fraction or 30 Gy with 3 Gy per fraction (low dose group, 18 patients) or 45 Gy with 3 Gy per fraction (high dose group, 10 patients). RESULTS: The median survival duration was 8 months and 1-year survival rate was 37%. The treatment results were as follows; partial response in 11% and 70% (p=0.001), stable disease in 56% and 30%, and progressive disease in 33% and 0% in low dose group and high dose group, respectively. The incidence of gastrointestinal (G-I) toxicity by the criteria of Southwest Oncology Group was as follows; grade 1 in 22% and 40%, grade 2 in 17% and 10%, respectively (p=0.56). There was no patient with severe G-I toxicity above grade 3. The incidence of G-I toxicity by site was as follows; grade 1 in 24% and 29%, and grade 2 in 0% and 57% in patients with right lobe and left lobe lesion, respectively (p=0.001). CONCLUSION: This study indicates that there is clear dose-response relationship in local control. The G-I toxicity does not increase significantly with increment of radiation dose within the dose range tested in this study. And careful attention should be paid for G-I toxicity when the tumor is located in left lobe.
Carcinoma, Hepatocellular* ; Ethanol ; Humans ; Incidence ; Liver Neoplasms ; Radiotherapy* ; Survival Rate

PURPOSE: This treatment planning study was undertaken to evaluate the impact of beam angle configuration of intensity-modulated radiotherapy (IMRT) on the dose of the normal liver in hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The computed tomography datasets of 25 patients treated with IMRT for HCC were selected. Two IMRT plans using five beams were made in each patient; beams with equidistance of 72degrees (Plan I), and beams with a 30degrees angle of separation entering the body near the tumor (Plan II). Both plans were generated using the same constraints in each patient. Conformity index (CI), homogeneity index (HI), gamma index, mean dose of the normal liver (Dmean_NL), Dmean_NL difference between the two plans, and percentage normal liver volumes receiving at least 10, 20, and 30 Gy (V10, V20, and V30) were evaluated and compared. RESULTS: Dmean_NL, V10, and V20 were significantly better for Plan II. The Dmean_NL was significantly lower for peripheral (p = 0.001) and central tumors (p = 0.034). Dmean_NL differences between the two plans increased in proportion to gross tumor volume to normal liver volume ratios (p = 0.002). CI, HI, and gamma indices were not significantly different for the two plans. CONCLUSION: The IMRT plan based on beams with narrow separations reduced the irradiated dose of the normal liver, which would allow radiation dose escalation for HCC.
Carcinoma, Hepatocellular ; Humans ; Liver ; Radiotherapy, Intensity-Modulated ; Tumor Burden

PURPOSE: To compare volumetric modulated arc therapy of RapidArc with robotic stereotactic body radiation therapy (SBRT) of CyberKnife in the planning and delivery of SBRT for hepatocellular carcinoma (HCC) treatment by analyzing dosimetric parameters. MATERIALS AND METHODS: Two radiation treatment plans were generated for 29 HCC patients, one using Eclipse for the RapidArc plan and the other using Multiplan for the CyberKnife plan. The prescription dose was 60 Gy in 3 fractions. The dosimetric parameters of planning target volume (PTV) coverage and normal tissue sparing in the RapidArc and the CyberKnife plans were analyzed. RESULTS: The conformity index was 1.05 +/- 0.02 for the CyberKnife plan, and 1.13 +/- 0.10 for the RapidArc plan. The homogeneity index was 1.23 +/- 0.01 for the CyberKnife plan, and 1.10 +/- 0.03 for the RapidArc plan. For the normal liver, there were significant differences between the two plans in the low-dose regions of V1 and V3. The normalized volumes of V60 for the normal liver in the RapidArc plan were drastically increased when the mean dose of the PTVs in RapidArc plan is equivalent to the mean dose of the PTVs in the CyberKnife plan. CONCLUSION: CyberKnife plans show greater dose conformity, especially in small-sized tumors, while RapidArc plans show good dosimetric distribution of low dose sparing in the normal liver and body.
Carcinoma, Hepatocellular* ; Humans ; Liver ; Prescriptions ; Radiosurgery ; Radiotherapy, Intensity-Modulated*

PURPOSE: The goal of this study was to improve the accuracy of three-dimensional conformal radio therapy (3-D CRT) by measuring the treatment setup error and physiological movement of liver based on the analysis of images which were obtained by electronic portal imaging device (EPID). MATERIALS AND METHODS: For 10 patients with hepatocellular carcinoma, 4-7 portal images were obtained by using EPID during the radiotherapy from each patient daily. We analyzed the setup error and physiological movement of liver based on the verification data. We also determined the safety margin of the tumor in 3-D CRT through the analysis of physiological movement. RESULTS: The setup errors were measured as 3 mm with standard deviation 1.70 mm in x direction and 3.7 mm with standard deviation 1.88 mm in y direction respectively. Hence, deviation were smaller than 5 mm from the center of each axis. The measured range of liver movement due to the physiological motion was 8.63 mm on the average. Considering the motion of liver and setup error, the safety margin of tumor was at least 15 mm. CONCLUSION: EPID is a very useful device for the determination of the optimal margin of the tumor, and thus enhance the accuracy and stability of the 3-D CRT in patients with hepatocellular carcinoma.
Axis, Cervical Vertebra ; Carcinoma, Hepatocellular* ; Humans ; Liver* ; Radiotherapy