Hypofractionated Stereotactic Radiotherapy after Transarterial Chemoembolisation Failure in an Unresectable Hepatocellular Carcinoma: A Case Presentation
Introduction. Transarterial chemoembolization is the first-line treatment in unresectable hepatocellular carcinoma. There is no standard treatment after transarterial chemoembolization failure. We report the case of a patient with advanced hepatocellular carcinoma who showed a complete response and a long cancer control with hypofractionated stereotactic radiotherapy after transarterial chemoembolization failure. Case Presentation. A 70-year-old Caucasian woman was treated with transarterial chemoembolization for advanced hepatocellular, but no cancer control was obtained. A hypofractionated stereotactic radiotherapy was planned delivering 40？Gy in 5 fractions. A dramatic reduction in alpha-fetoprotein was observed. Contrast-enhanced ultrasonography at 1 and 2 months showed large necrotic areas. Computerised tomography scan showed a 90% objective tumour response, then a complete remission at 3 and 6 months after treatment, respectively. Status of patient remained unchanged for 2 years. Conclusions. Hypofractionated stereotactic radiotherapy can improve survival and prognosis of unresectable hepatocellular carcinoma patient. 1. Introduction Hepatocellular carcinoma (HCC) is a very heterogeneous disease, and the management of therapeutic approach may be variable and strongly related to patient’s liver dysfunction as well as tumour stage [1]. A patient affected by intermediate or advanced stage HCC is only candidate for a palliative treatment. Transarterial chemoembolization (TACE) is standard treatment of unresectable HCC [2]; however, prognosis of these patients remains dismal, especially when TACE fails. Hypofractionated stereotactic radiotherapy (HSRT) can lead to a significant benefit for patients affected by intermediate or advanced HCC, alone or combined with TACE [3]. We report the case of a patient with advanced HCC who showed a complete response and a long cancer control with HSRT after TACE failure. 2. Case Presentation A 70-year-old woman, with a history of alcoholic cirrhosis was admitted to our hospital because a liver mass had been discovered by ultrasonography scan. Her Eastern Cooperative Oncology Group (ECOG) performance score was 1. Physical examination showed no palpable mass, abdominal distension, or weight loss. Laboratory details showed white blood cell 5,980/μL; red blood cell 4,24 × 106/μL; haemoglobin 10,8？g/dL; hematocrit 35%; platelet 137,000/μL; INR 1,11; urea nitrogen 26？mg/dL; creatinine 0,73？mg/dL; total protein 7,8？g/dL; albumin 3,5？g/dL; aspartate aminotransferase (AST) 55？U/L; alanine aminotransferase (ALT) 42？U/L;
References
[1]
J. M. Llovet, C. Brú, and J. Bruix, “Prognosis of hepatocellular carcinoma: the BCLC staging classification,” Seminars in Liver Disease, vol. 19, no. 3, pp. 329–337, 1999.
[2]
C. Cammà, F. Schepis, A. Orlando et al., “Transarterial chemoembolization for unresectable hepatocellular carcinoma: meta-analysis of randomized controlled trials,” Radiology, vol. 224, no. 1, pp. 47–54, 2002.
[3]
S. Ursino, C. Greco, F. Cartei, et al., “Radiotherapy and hepatocellular carcinoma: update and review of the literature,” European Review for Medical and Pharmacological Sciences, vol. 16, no. 11, pp. 1599–1604, 2012.
[4]
J. W. Zhang, X. Y. Feng, H. Q. Liu et al., “CT volume measurement for prognostic evaluation of unresectable hepatocellular carcinoma after TACE,” World Journal of Gastroenterology, vol. 16, no. 16, pp. 2038–2045, 2010.
[5]
J. M. Llovet, M. I. Real, X. Monta？a et al., “Arterial embolisation or chemoembolisation versus symptomatic treatment in patients with unresectable hepatocellular carcinoma: a randomised controlled trial,” The Lancet, vol. 359, no. 9319, pp. 1734–1739, 2002.
[6]
R. Lencioni, X. P. Chen, L. Dagher, and A. P. Venook, “Treatment of intermediate/advanced hepatocellular carcinoma in the clinic: how can outcomes be improved?” The Oncologist, vol. 15, supplement 4, pp. 42–52, 2010.
[7]
K. Ahrar and S. Gupta, “Hepatic artery embolization for hepatocellular carcinoma: technique, patient selection, and outcomes,” Surgical Oncology Clinics of North America, vol. 12, no. 1, pp. 105–126, 2003.
[8]
K. Nishimine, H. Uchida, N. Matsuo et al., “Segmental transarterial chemoembolization with Lipiodol mixed with anticancer drugs for nonresectable hepatocellular carcinoma: follow-up CT and therapeutic results,” Cancer Chemotherapy and Pharmacology, Supplement, vol. 33, no. 1, supplement, pp. S60–S68, 1994.
[9]
R. A. Abrams, T. F. Pajak, T. L. Haulk, M. Flam, and S. O. Asbell, “Survival results among patients with α-fetoprotein-positive, unresectable hepatocellular carcinoma: analysis of three sequential treatments of the RTOG and Johns Hopkins Oncology Center,” Cancer Journal from Scientific American, vol. 4, no. 3, pp. 178–184, 1998.
[10]
A. Takeda, M. Takahashi, E. Kunieda et al., “Hypofractionated stereotactic radiotherapy with and without transarterial chemoembolization for small hepatocellular carcinoma not eligible for other ablation therapies: preliminary results for efficacy and toxicity,” Hepatology Research, vol. 38, no. 1, pp. 60–69, 2008.
[11]
J. H. Kwon, S. H. Bae, J. Y. Kim et al., “Long-term effect of stereotactic body radiation therapy for primary hepatocellular carcinoma ineligible for local ablation therapy or surgical resection. Stereotactic radiotherapy for liver cancer,” BMC Cancer, vol. 10, article 475, 2010.
[12]
J. K. Kang, M. S. Kim, C. K. Cho, et al., “Stereotactic body radiation therapy for inoperable hepatocellular carcinoma as a local salvage treatment after incomplete transarterial chemoembolization,” Cancer, vol. 118, no. 21, pp. 5424–5431, 2012.
[13]
Y. Honda, T. Kimura, H. Aikata, et al., “Stereotactic body radiation therapy combined with transcatheter arterial chemoembolization for small hepatocellular carcinoma,” Journal of Gastroenterology and Hepatology, 2012.
