Liver malignant tumors are one of the most common causes of cancer-related deaths in China. Selective internal yttrium-90 radioembolization therapy ((90)Y-SIRT) is a kind of promising local minimally invasive method, and its effectiveness and safety has been confirmed in clinical application over the past two decades. Moreover, it has been approved by the U.S. National Comprehensive Cancer Network and other international guidelines for the topical treatment of patients with liver malignancies. Taking into account the complexity of the (90)Y-SIRT and the need for multidisciplinary collaboration to improve the safety and success rate of treatment, the Nuclear Medicine Expert Committee of the Chinese society of Clinical Oncology, along with Beijing Nuclear Medicine Quality Control and Improvement Center invited experts from surgical oncology, interventional medicine, nuclear medicine, and other related fields to discuss and form a consensus on the clinical diagnosis, treatment and management, which mainly included definition, indications and contraindications, treatment procedures, postoperative follow-up, adverse reactions and complications, radiation safety management, etc. Herein, we provide the reference guidance to establish (90)Y-SIRT standardized management and treatment system various units for relevant practitioners.
Carcinoma, Hepatocellular/radiotherapy* ; China ; Consensus ; Humans ; Liver Neoplasms/radiotherapy* ; Microspheres ; Yttrium Radioisotopes

Stereotactic body radiotherapy (SBRT) is an advanced form of radiotherapy (RT) with a growing interest on its application in the treatment of hepatocellular carcinoma (HCC). It can deliver ablative radiation doses to tumors in a few fractions without excessive doses to normal tissues, with the help of advanced modern RT and imaging technologies. Currently, SBRT is recommended as an alternative to curative treatments, such as surgery and radiofrequency ablation. This review discusses the current status of SBRT to aid in the decision making on how it is incorporated into the HCC management.
Carcinoma, Hepatocellular ; Catheter Ablation ; Decision Making ; Radiosurgery ; Radiotherapy ; Radiotherapy, Image-Guided

PURPOSE: A mandibular metastasis is uncommon in patients with hepatocellular carcinoma (HCC). We report the clinical features of this rare lesion and evaluate the effectiveness of radiotherapy in affected patients.MATERIALS AND METHODS: We retrospectively reviewed our institutional medical records for HCC patients who received radiotherapy for bone metastasis, and included cases of mandible metastasis. The clinical features of these cases, and the characteristics and outcomes of the treatments were assessed.RESULTS: A total of 1,498 patients with a bone metastasis from HCC were treated with radiotherapy between July 1998 and April 2012 at our institution. We identified 9 patients (0.6%) in this cohort that received radiotherapy for a mandibular metastasis. The condyle was the most common location of mandibular metastasis. The median radiation dose was 40 Gy (range, 27.5 to 60 Gy), with a daily dose of 2–3 Gy. All of these 9 patients died during a median follow-up of 9 months (range, 1 to 19 months). Symptom relief was achieved in 7 of 8 patients who completed radiotherapy. Tumor size reduction was observed in 2 of 4 patients who underwent radiologic evaluation after radiotherapy.CONCLUSIONS: Metastasis to the mandible from HCC has a poor prognosis. Radiotherapy can be an effective local treatment option for symptomatic relief in these cases.
Carcinoma, Hepatocellular ; Cohort Studies ; Follow-Up Studies ; Humans ; Mandible ; Medical Records ; Neoplasm Metastasis ; Prognosis ; Radiotherapy ; Retrospective Studies

PURPOSE: To identify the prognostic factors that could influence survival and to compare prognoses of the patients with the number of the risk factors that might assist in the adequate management of hepatocellular carcinoma (HCC) patients with bone metastases that showed a heterogeneous range of survival. MATERIALS AND METHODS: A total of 41 patients, treated with radiotherapy (RT) for bone metastases from HCC from 2014 to 2017, were enrolled retrospectively. Survival was determined by the Kaplan–Meier method from the start of the RT for metastatic bone lesions. Pre-RT clinical features were evaluated and their influences on survival were analyzed. The significant factors were considered to compare survivals according to the number of prognostic factors. RESULTS: Median follow-up was 6.0 months (range, 0.5 to 47.0 months). The median overall survival was 6.5 months, and the 1-year and 2-year survival rates were 35.5% and 13.5%, respectively. Multivariate analysis revealed that the Child-Pugh class A group, alpha-fetoprotein increased more than 30 ng/mL, and HCC size of more than 5 cm were associated with worse overall survival. The median survivals in HCC with none, 1, 2, and 3 of the aforementioned risk factors were 19.5, 9.0, 2.5, and 1.0 months, respectively (p < 0.05). CONCLUSION: Our results show that the overall survivals were significantly different according to the number of the risk factors among HCC patients with bone metastases who showed various lengths of survival.
alpha-Fetoproteins ; Carcinoma, Hepatocellular ; Follow-Up Studies ; Humans ; Methods ; Multivariate Analysis ; Neoplasm Metastasis ; Prognosis ; Radiotherapy ; Retrospective Studies ; Risk Factors ; Survival Rate ; Triage

PURPOSE: There is limited data on radiotherapy (RT) for hepatocellular carcinoma (HCC) in patients with Child-Pugh classification B (CP-B). This study aimed to evaluate the treatment outcomes of fractionated conformal RT in HCC patients with CP-B. MATERIALS AND METHODS: We retrospectively reviewed the data of HCC patients with CP-B treated with RT between 2009 and 2014 at 13 institutions in Korea. HCC was diagnosed by the Korea guideline of 2009, and modern RT techniques were applied. Fraction size was ≤ 5 Gy and the biologically effective dose (BED) ≥ 40 Gy₁₀ (α/β = 10 Gy). A total of 184 patients were included in this study. RESULTS: Initial CP score was seven in 62.0% of patients, eight in 31.0%, and nine in 7.0%. Portal vein tumor thrombosis was present in 66.3% of patients. The BED ranged from 40.4 to 89.6 Gy₁₀ (median, 56.0 Gy₁₀). After RT completion, 48.4% of patients underwent additional treatment. The median overall survival (OS) was 9.4 months. The local progression-free survival and OS rates at 1 year were 58.9% and 39.8%, respectively. In the multivariate analysis, non-classic radiation-induced liver disease (RILD) (p < 0.001) and additional treatment (p < 0.001) were the most significant prognostic factors of OS. Among 132 evaluable patients without progressive disease, 19.7% experienced non-classic RILD. Normal liver volume was the most predictive dosimetric parameter of non-classic RILD. CONCLUSION: Fractionated conformal RT showed favorable OS with a moderate risk non-classic RILD. The individual radiotherapy for CP-B could be cautiously applied weighing the survival benefits and the RILD risks.
Carcinoma, Hepatocellular ; Classification ; Disease-Free Survival ; Humans ; Korea ; Liver ; Liver Diseases ; Multivariate Analysis ; Portal Vein ; Radiotherapy ; Radiotherapy, Conformal ; Retrospective Studies ; Thrombosis ; Treatment Outcome

The treatment options available for patients with hepatocellular carcinoma (HCC) with portal vein invasion (PVI) include sorafenib, transarterial radioembolization (TARE), radiation therapy (RT), transarterial chemoembolization with RT, and proton beam irradiation. Herein, we present a case of HCC with segmental PVI that was managed via TARE. The patient had a 4 cm HCC that invaded the segment VIII portal vein branch without extrahepatic spread. Liver function was Child-Pugh grade A, and performance status was good. TARE was performed without any adverse events, and a radiological complete response (CR) was achieved. Thereafter, the patient was followed-up every 3–6 months without any further treatment, and the CR was maintained for >3 years. Therefore, TARE may be a useful alternative therapeutic option for patients with HCC exhibiting segmental PVI.
Carcinoma, Hepatocellular ; Embolization, Therapeutic ; Humans ; Liver ; Portal Vein ; Protons ; Radiotherapy ; Venous Thrombosis

Hepatocellular carcinoma (HCC) involving the inferior vena cava (IVC) and/or right atrium (RA) is a rare and intractable disease. A standard treatment has not been established yet, owing to the rarity of disease and difficulties in the therapeutic treatment. Herein, we report the case of a patient who had recurrent HCC (after a prior lobectomy) involving both IVC and RA and underwent multimodality treatments including external beam radiotherapy and transarterial chemotherapy, followed by sorafenib treatment. The disease was well controlled with local treatments and sustained for 7 years until last follow-up after the systemic treatments. Our case shows a possibility of long-term survival for patients affected by HCC involving IVC and/or RA, after a rigorous multimodality treatment strategy.
Carcinoma, Hepatocellular ; Disease-Free Survival ; Drug Therapy ; Follow-Up Studies ; Heart Atria ; Humans ; Liver Neoplasms ; Radiotherapy ; Vena Cava, Inferior

Proton beam therapy (PBT) is one of the advances in radiotherapy techniques, which enables dose escalation with lower probability of radiation-induced liver or gastrointestinal injuries. However, the chest wall proximal to the tumor can be affected by high dose irradiation. Here, we report on a 58-year-old male patient who presented with huge hepatocellular carcinoma, received treatment with transarterial chemoembolization and PBT, and developed severe chest wall pain due to radiation-induced myositis. The patient's symptoms were controlled by oral steroids.
Carcinoma, Hepatocellular ; Humans ; Liver ; Male ; Middle Aged ; Myositis ; Proton Therapy ; Protons ; Radiotherapy ; Steroids ; Thoracic Wall

Stereotactic body radiotherapy (SBRT) is a form of radiotherapy that delivers high doses of irradiation with high precision in a small number of fractions. However, it has not frequently been performed for the liver due to the risk of radiation-induced liver toxicity. Furthermore, liver SBRT is cumbersome because it requires accurate patient repositioning, target localization, control of breathing-related motion, and confers a toxicity risk to the small bowel. Recently, with the advancement of modern technologies including intensity-modulated RT and image-guided RT, SBRT has been shown to significantly improve local control and survival outcomes for hepatocellular carcinoma (HCC), specifically those unfit for other local therapies. While it can be used as a stand-alone treatment for those patients, it can also be applied either as an alternative or as an adjunct to other HCC therapies (e.g., transarterial chemoembolization, and radiofrequency ablation). SBRT might be an effective and safe bridging therapy for patients awaiting liver transplantation. Furthermore, in recent studies, SBRT has been shown to have a potential role as an immunostimulator, supporting the novel combination strategy of immunoradiotherapy for HCC. In this review, the role of SBRT with some technical issues is discussed. In addition, future implications of SBRT as an immunostimulator are considered.
Carcinoma, Hepatocellular* ; Humans ; Immunotherapy ; Liver ; Liver Transplantation ; Moving and Lifting Patients ; Radioimmunotherapy ; Radiosurgery* ; Radiotherapy ; Radiotherapy, Intensity-Modulated

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