This study evaluated the incidence of hepatic toxicity after stereotactic ablative radiotherapy (SABR) using 3 fractions to the liver, and identified the predictors for hepatic toxicity. We retrospectively reviewed 78 patients with primary and metastatic liver cancers, who underwent SABR using 3 fractions between 2003 and 2011. To examine the incidence of hepatic toxicity, we defined newly developed hepatic toxicity> or =grade 2 according to the National Cancer Institute Common Terminology Criteria for Adverse Events v4.0 within 3 months after the end of SABR as a significant adverse event. To identify the predictors for hepatic toxicity, we analyzed several clinical and dosimetric parameters (rV(5Gy)-rV(35Gy): normal liver volume receiving or =grade 2 occurred in 10 patients (13%): grade 2 in 9 patients and grade 3 in 1 patient. On univariate analysis, baseline Child-Pugh (CP) score (5 vs. 6-8), normal liver volume, and planning target volume were the significant clinical predictors. All dosimetric parameters were significant: rV(20Gy) was the most significant predictor. On multivariate analysis, baseline CP score (hazard ratio, 0.026; P=0.001) was the only significant predictor. In conclusion, SABR using 3 fractions in primary and metastatic liver cancers produces low hepatic toxicity, especially in patients with a baseline CP score of 5. However, further studies are needed to minimize hepatic toxicity in patients with baseline CP scores> or =6.
Aged ; *Dose Fractionation ; Female ; Hepatitis/*etiology/pathology/prevention & control ; Humans ; Liver Neoplasms/complications/pathology/*surgery ; Male ; Middle Aged ; Neoplasm Metastasis ; Radiation Injuries/*etiology/pathology/prevention & control ; Radiosurgery/*adverse effects/*methods ; Radiotherapy Dosage ; Treatment Outcome

BACKGROUND: Craniofacial resection (CFR) has been regarded as a standard treatment for various tumors involving the anterior skull base. The purpose of this study was to evaluate the results of CFR for the patients with anterior skull base malignancies in our hospital. METHODS: We retrospectively analyzed 17 patients with anterior skull base malignancies treated with CFR between 2001 and 2012. Mean follow-up duration was 41 months (range, 2-103 months). RESULTS: Intracranial involvement was found in 11 patients (65%) and orbital extension in 6 patients (35%). Classical bifrontal craniotomy was combined with endoscopic endonasal approach in 14 patients and external approach in 3 patients. Vascularized flap was used for reconstruction of the anterior fossa floor in 16 patients (94%). The most common pathological type was squamous cell carcinoma (6 patients). Gross total resection was achieved in all cases. Postoperative complications developed in 4 patients (24%) and included local wound problem and brain abscess. One patient with liver cirrhosis died from unexpected varix bleeding after the operation. Although postoperative treatment, such as radiotherapy or chemotherapy, was performed in 14 patients, local recurrence was seen in 6 patients. The mean overall survival time after the operation was 69.0 months (95% confidence interval: 47.5-90.5 months) with a 1-, 2-, and 5-year survival rate of 82.3%, 76.5%, and 64.7%, respectively. Postoperative radiotherapy was found to be the powerful prognostic factor for favorable survival. CONCLUSION: Considering the higher local control rate and acceptable complication or mortality rate, CFR with adjuvant radiotherapy is a gold standard treatment option for malignant tumors involving anterior skull base, especially with extensive intracranial involvement.
Brain Abscess ; Carcinoma, Squamous Cell ; Cranial Fossa, Anterior ; Craniotomy ; Drug Therapy ; Follow-Up Studies ; Hemorrhage ; Humans ; Intraoperative Complications ; Liver Cirrhosis ; Mortality ; Orbit ; Paranasal Sinus Neoplasms ; Postoperative Complications ; Radiotherapy ; Radiotherapy, Adjuvant ; Recurrence ; Retrospective Studies ; Skull Base* ; Skull* ; Survival Rate ; Treatment Outcome ; Varicose Veins ; Wounds and Injuries

BACKGROUND: Metastatic pathological fractures of the spine are a major problem for cancer patients; however, there is no consensus on treatment strategy. The purpose of this study was to evaluate various treatment options by analyzing their patterns for metastatic pathological fractures of the spine. METHODS: In this study, 54 patients (male:female = 36:18) who were diagnosed with metastatic pathological fractures of spine were recruited. Demographic data, origin of cancer, type of treatment, and results were obtained from electronic medical records. Treatment options were divided into radiotherapy (RT), vertebroplasty (VP) or kyphoplasty (KP), operation (OP), and other treatments. Treatment results were defined as aggravation, no response, fair response, good response, and unknown. The survival time after detection of pathologic fractures was analyzed with the Kaplan-Meier method. RESULTS: The mean age of the patients was 62.3 years. Hepatocellular carcinoma was the most common cancer of primary origin (n = 9), followed by multiple myeloma (n = 8). RT was the most common primary choice of treatment (n = 29, 53.7%), followed by OP (n = 13, 24.1%), and VP or KP (n = 10, 18.5%). Only 13 of 29 RT cases and 7 of 13 OP cases demonstrated a fair or good response. The mean survival time following detection of pathological spinal fractures was 11.1 months for 29 patients, who died during the study period. CONCLUSIONS: RT was the most common primary choice of treatment for metastatic pathological fractures of the spine. However, the response rate was suboptimal. Although OP should be considered for the relief of mechanical back pain or neurologic symptoms, care should be taken in determining the surgical indication. VP or KP could be considered for short-term control of localized pain, although the number of cases was too small to confirm the conclusion. It is difficult to determine the superiority of the treatment modalities, hence, a common guideline for the diagnosis and treatment of metastatic pathological fractures of the spine is required.
Carcinoma, Hepatocellular/mortality/pathology ; Female ; Humans ; Liver Neoplasms/mortality/pathology ; Male ; Middle Aged ; Multiple Myeloma/mortality/pathology ; Retrospective Studies ; Spinal Fractures/etiology/mortality/*radiotherapy/*surgery ; Spinal Neoplasms/*complications/secondary ; Spine ; Treatment Outcome

Hepatitis C virus (HCV) is one of the main viral causes of hepatocellular carcinoma (HCC) and is associated with lymphoproliferative disorder such as non-Hodgkin's lymphoma (NHL). However, there are only few case reports on concomitantly induced NHL and HCC by HCV. Herein, we report a case of synchronous NHL and HCC in a patient with chronic hepatitis C which was unexpectedly diagnosed during liver transplantation surgery. This case suggests that although intrahepatic lymph node enlargements are often considered as reactive or metastatic lymphadenopathy in chronic hepatitis C patients with HCC, NHL should also be considered as a differential diagnosis.
Antineoplastic Agents/therapeutic use ; Carcinoma, Hepatocellular/complications/*diagnosis/radiotherapy ; Drug Therapy, Combination ; Embolization, Therapeutic ; Fluorodeoxyglucose F18 ; Gadolinium DTPA ; Genotype ; Hepatitis B virus/genetics ; Hepatitis C, Chronic/complications/*diagnosis/*virology ; Humans ; Liver Neoplasms/complications/*diagnosis/radiotherapy ; Lymph Nodes/pathology ; Lymphoma, Non-Hodgkin/complications/*diagnosis/drug therapy ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Positron-Emission Tomography ; Tomography, X-Ray Computed

Because of its safety and treatment effectiveness, the popularity of radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC) has gradually increased. However, some serious complications of RFA such as hepatic infarction, bowel perforation, and tumor seeding have been reported. Recently, we experienced a case of diaphragmatic hernia after RFA for HCC. A 61-year-old man with alcoholic cirrhosis was diagnosed with a 1.0 cm sized HCC in segment (S) 5 and a 1.3 cm sized HCC in S 8 of the liver. He was treated by transarterial chemoembolization and RFA. After RFA, an abdominal CT revealed a diaphragmatic defect with herniating mesentery. Twenty-two months after the RFA, the chest CT showed the diaphragmatic defect with herniating colon and mesentery. Because he had no symptoms, and surgical repair for the diaphragmatic hernia would be a high risk operation for him, we decided to treat the patient conservatively. For its great rarity, we report this case with a review of the literature.
Carcinoma, Hepatocellular/*diagnosis/*radiotherapy/therapy ; Catheter Ablation/*adverse effects ; Chemoembolization, Therapeutic ; Hernia, Diaphragmatic/*etiology/surgery ; Humans ; Liver Cirrhosis, Alcoholic/complications/*diagnosis ; Liver Neoplasms/*diagnosis/*radiotherapy/therapy ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Tomography, X-Ray Computed

We performed a retrospective review of 281 hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) treated with radiation therapy (RT) between 1998 and 2008 to develop a prognostic model for those patients. Of the 281 patients, PVTT and intrahepatic main masses completely disappeared in 10 patients (3.6%), and shown a partial response in 141 patients (50.2%). The median survival was 11.6 months. Patients who had more than PR have shown significantly longer survival than the others (22.0 months vs 5.0 months, P < 0.001). On the multivariate analysis, pre-treatment poor prognosticators for overall survival were ECOG performance status, Child-Pugh class, multiple tumors, main PVTT, complete portal vein occlusion, lymph node metastasis, and primary tumor size. Prognostic index of RT for PVTT of HCC (PITH) scores were defined as the number of pre-treatment poor prognostic factors. PITH scores correlated well with overall survival. In the analysis of 1 and 2 yr overall survival rate, patients who had PITH scores of 3 or greater showed a significantly lower rate of overall survival than the others (33.0%, 17.3% vs 70.1%, 40.8%, respectively, P < 0.001). The PITH scoring model, proposed in the current study in HCC patients with PVTT, reliably predict overall survival.
Adult ; Aged ; Aged, 80 and over ; Carcinoma, Hepatocellular/complications/mortality/*radiotherapy ; Humans ; Kaplan-Meier Estimate ; Liver Neoplasms/complications/mortality/*radiotherapy ; Male ; Middle Aged ; Neoplasm Staging ; *Portal Vein ; Prognosis ; Retrospective Studies ; Severity of Illness Index ; Tomography, X-Ray Computed ; Venous Thrombosis/complications/mortality/*radiotherapy

OBJECTIVETo study the clinical efficiency of metallic stent implantation in combination with three-dimensional conformal radiation therapy in the treatment of hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus.

METHODS22 cases of HCC patients with portal vein tumor thrombus were devided into 2 groups: 10 patients (group A) recieved stent implantation in combination with conformal radiation therapy, 12 patients (group B) recieved stent implantation and transcatheter arterial chemoembolization. The adverse reactions, and liver function before and after treatment were compared between the two groups. The stent patency rate at 4, 6 and 12 months and the survival rate at 3, 6 and 12 months were followed up. Comparison of liver function was analyzed by Wilcoxon signed rank test. Comparison of stent patency rate curves and survival curves was analyzed by Log rank test.

RESULTSThe portal vein catheterization was successful in all the patients. The stents were successfully implanted by transhepatic portal vein approach, and portal vein stenosis was re-opened. There was no abdominal hemorrhage in all the patients, but there were symptoms of abdominalgia, fever, nausea, vomiting and flatulence of varying degrees after interventional operation, and these symptoms were relieved by symptomatic treatment in one week. All patients in group A completed the treatment. I-II degree gastrointestinal tract reactions occurred in 3 cases, I-II degree myelosuppression occurred in 2 cases, and they were all completely relieved after treatment. The stent patency rate at 4, 6 and 12 months was 90%, 70%, 30% in group A; and 50%, 25% , 16.7% in group B (P < 0.05). The survival rate at 3, 6 and 12 months was 100%, 80% , 30% in group A and 91.7%, 41.7%, 16.7% in group B (P < 0.05).

CONCLUSIONStent implantation combined with three-dimensional conformal radiation therapy is a good treatment for hepatocellular carcinoma with portal vein tumor thrombus and causes less damage to liver.

Adult ; Aged ; Carcinoma, Hepatocellular ; complications ; diagnostic imaging ; therapy ; Combined Modality Therapy ; Female ; Follow-Up Studies ; Humans ; Liver Neoplasms ; complications ; diagnostic imaging ; therapy ; Male ; Metals ; Middle Aged ; Neoplasm Invasiveness ; Portal Vein ; pathology ; Radiography ; Radiotherapy, Conformal ; Radiotherapy, Intensity-Modulated ; Retrospective Studies ; Stents ; Survival Rate ; Treatment Outcome ; Venous Thrombosis ; diagnostic imaging ; etiology ; therapy

BACKGROUNDThis study evaluated the clinical application of CT guided 125iodine implantation in patients with portal vein tumor thrombus in primary hepatocellular carcinoma.

METHODSThe ten patients (9 males and 1 female, aged from 36 to 72 years) with portal vein tumor thrombus accompanying hepatocellular carcinoma had been treated with comprehensive therapy including surgery, transcatheter arterial chemoembolization, radiotherapy ablation, microwave ablation or percutaneous ethanol injection. The average diameter of each tumor thrombus was 21.5 mm x 30.5 mm. Seeds of 30 MBq 125I were implanted 5 mm apart within the portal vein tumor thrombus. The follow-up after 4 months included enhanced spiral CT.

RESULTSCT screening of the tumours indicated that 4 out of 10 patients showed complete response to the therapy, 5 partial response and 1 stable disease. Adverse effects included aggravated abdominal dropsy and temporarily increased transaminase, which were controlled by medical management. Severe complications such as haemorrhage, biliary fistula, hepatic abscess, pancreatic fistula and hepatic function failure were not observed. Implanted seeds migrated to lung and left hepatic lobe in 1 case.

CONCLUSIONCT guided implantation of 125iodine seeds, can effectively treat portal vein tumor thrombus accompanying hepatocellular carcinoma with minimal damage and few complications.

Adult ; Aged ; Carcinoma, Hepatocellular ; complications ; radiotherapy ; Female ; Follow-Up Studies ; Humans ; Iodine Radioisotopes ; therapeutic use ; Liver Neoplasms ; complications ; radiotherapy ; Male ; Middle Aged ; Portal Vein ; Radiotherapy ; methods ; Tomography, X-Ray Computed ; methods ; Treatment Outcome ; Venous Thrombosis ; etiology ; radiotherapy

BACKGROUND/AIMS: The treatment efficacy for advanced hepatocellular carcinoma is poor. This study examined the efficacy and toxicity of 3-dimensional conformal radiotherapy (3D-CRT) in combination with transarterial chemolipiodolization (TACL) for a huge hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). METHODS: From March 2001 to November 2004, 49 patients with advanced HCC with PVTT (size>8 cm, modified UICC stage IVa) were enrolled in this retrospective study. Twenty two patients underwent more than 2 cycles of TACL (adriamycin 50 mg/m2, cisplatin 60 mg/m2, 5-fluorouracil 200 mg/m2 every 4-6 weeks) without 3D-CRT, while 27 patients underwent consecutive TACL with 3D-CRT (40-45 Gy for 4-5 weeks) that was started one week after the 1st TACL. The response was assessed by a computed tomography (CT) and the serum alpha-fetoprotein (AFP) level at 1-2 month intervals. RESULTS: The objective response rates in the TACL group and TACL with 3D-CRT group were 18% and 48% at 3 months (P=0.051), and 10.5% and 42% at 6 months (P=0.024) respectively. The median survival time was 13 months and 13.5 months in TACL and TACL with 3D-CRT groups, respectively (P=0.502). The treatment response was better in the TACL with 3D-CRT group but there was no significant difference in survival between the two groups. Most toxicities in the two groups were mild, not exceeding grade 1 according to the WHO criteria. CONCLUSIONS: For patients with a huge HCC with PVTT, TACL with 3D-CRT achieved some meaningful clinical benefit. Prospective controlled trials will be needed to confirm the real benefit of TACL combined with 3D-CRT.
Adult ; Aged ; Aged, 80 and over ; Carcinoma, Hepatocellular/complications/radiotherapy/*therapy ; Chemoembolization, Therapeutic/*methods ; Combined Modality Therapy ; Data Interpretation, Statistical ; Female ; Humans ; Liver Neoplasms/complications/radiotherapy/*therapy ; Male ; Middle Aged ; *Portal Vein ; Radiotherapy, Conformal/adverse effects/*methods ; Severity of Illness Index ; Survival Analysis ; Venous Thrombosis/etiology/radiotherapy/*therapy

BACKGROUND/AIMS: Determination of the optimal radiotherapeutic parameters for radiotherapy of hepatocellular carcinoma (HCC) is still under investigation. The purpose of this study is to identify the risk factors associated with radiation-related morbidity. METHODS: We evaluated one hundred fifty-eight patients, who were given radiotherapy for HCC between January 1992 and March 2000. Radiation-induced liver disease (RILD) was defined as the development of nonmalignant ascites without disease progression and an anicteric elevation of the alkaline phosphatase level by at least twofold. Gastrointestinal toxicity was assessed by using the RTOG-EORTC scale. RESULTS: Six patients (3.8%) displayed RILD. In these patients, three patients had not responded to other previous treatments. Two patients with portal vein thrombosis or huge sized mass, above 10 cm, showed liver toxicity and two other patients presented with Child-Pugh class B liver cirrhosis. Eight patients (5%) had gastro-duodenal ulcers. In one of these 8 patients, the left lobe close to the stomach was involved and two patients had been treated for gastro-duodenal ulcer. In two more patients, the radiation field, with using anterior/posterior radiation ports, covered a significant volume of the gastrointestinal tract. One of eight patients had been irradiated with a large fraction size (250 cGy). CONCLUSIONS: The efforts should be made to reduce the radiation-related complications for hepatocellular carcinoma by considering the volume and the function of remaining liver, the location of tumor, the tumor size and the severity of liver cirrhosis.
Adult ; Aged ; Carcinoma, Hepatocellular/complications/*radiotherapy ; Female ; Humans ; Liver Cirrhosis/diagnosis/*etiology ; Liver Neoplasms/complications/*radiotherapy ; Male ; Middle Aged ; Peptic Ulcer/etiology ; Radiotherapy Dosage ; Risk Factors