Baumann Brian C, Wei Jenny, Plastaras John P, Lukens John N, Damjanov Nevena, Hoteit Maarouf, Hsu Christine, Levine Matthew, Mondschein Jeffrey, Nadolski Gregory, Olthoff Kim, Reiss Kim A, Rosen Mark, Siegelman Evan, Metz James M, Ben-Josef Edgar
Departments of *Radiation Oncology ∥Medical Oncology #Transplant Surgery **Interventional Radiology ††Radiology †Leonard Davis Institute of Health Economics §Perelman School of Medicine ¶Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA ‡Department of Radiation Oncology, Siteman Cancer Center, Washington University in Saint Louis, Saint Louis, MO.
Am J Clin Oncol. 2018 Nov;41(11):1118-1124. doi: 10.1097/COC.0000000000000435.
Stereotactic body radiotherapy (SBRT) is potentially curative treatment for small hepatocellular carcinomas (HCC), but data are limited on its efficacy and toxicity. We hypothesized that SBRT can achieve excellent local control (LC) with acceptable toxicity treating HCC lesions, even in advanced cirrhosis.
Thirty-seven nonmetastatic HCC patients received SBRT to 43 lesions between October 2012 and April 2016. Median dose was 50 Gy/5 fractions. All Child-Pugh (CP) ≥B patients underwent a planned 1-month break after the first 3 fractions to assess hepatic toxicity. Patients were treated without separately placed fiducial markers using Linac-based SBRT with breath-hold (67%) or 4D-computed tomography with compression belt (33%) to reduce motion. Patients underwent magnetic resonance imaging q3 months post-SBRT.
Median age was 65 (range, 44 to 88). Pre-SBRT mean CP was 6.4 (range, A5 to C11). Nine (24%) had CP≥B8. Thirty-one of 33 patients (93%) had prior liver-directed therapy (median 2). Seventeen (40%) had solitary lesions. Median lesion diameter was 2.7 cm (range, 1.1 to 5.6). Median follow-up was 14 months (range, 2 to 45). There was 1 local failure (multifocal HCC with 3 prior transarterial chemoembolization). LC, freedom from liver progression, and overall survival at 12 months was 95%, 66%, 87% in the full cohort, and 100%, 76%, 93% for patients with solitary lesions. Four had grade 3 toxicity (ascites [n=2]/gastrointestinal bleed [n=1]/capsular pain [n=1]). Eight of 9 CP≥B8 patients had no grade ≥3 hepatic toxicity.
SBRT for HCC is well-tolerated even in patients with advanced cirrhosis and prior liver-directed treatment and provides excellent LC even for larger lesions that cannot be controlled with radiofrequency ablation. LC with SBRT compares favorably to other liver-directed therapies. Prospective studies comparing SBRT with other liver-directed therapies are warranted.
立体定向体部放疗（SBRT）可能是小肝细胞癌（HCC）的根治性治疗方法，但关于其疗效和毒性的数据有限。我们推测，即使在晚期肝硬化患者中，SBRT治疗HCC病灶也能在可接受的毒性范围内实现良好的局部控制（LC）。
2012年10月至2016年4月期间，37例非转移性HCC患者接受了针对43个病灶的SBRT治疗。中位剂量为50 Gy/5次分割。所有Child-Pugh（CP）≥B级的患者在完成前3次分割后计划休息1个月，以评估肝脏毒性。患者在治疗时未单独放置基准标记物，采用基于直线加速器的SBRT并配合屏气（67%）或使用压迫带的4D计算机断层扫描（33%）来减少运动。SBRT治疗后每3个月对患者进行一次磁共振成像检查。
中位年龄为65岁（范围44至88岁）。SBRT治疗前平均CP评分为6.4（范围A5至C11）。9例（24%）患者CP≥B8。33例患者中有31例（93%）曾接受过肝脏定向治疗（中位次数为2次）。17例（40%）患者有孤立性病灶。病灶中位直径为2.7 cm（范围1.1至5.6 cm）。中位随访时间为14个月（范围2至45个月）。有1例局部复发（多灶性HCC，曾接受3次经动脉化疗栓塞）。整个队列在12个月时的局部控制率、无肝进展生存率和总生存率分别为95%、66%、87%，孤立性病灶患者分别为100%、76%、93%。4例患者出现3级毒性反应（腹水[2例]/胃肠道出血[1例]/包膜疼痛[1例]）。9例CP≥B8的患者中有8例未出现≥3级肝脏毒性反应。
即使是晚期肝硬化且曾接受过肝脏定向治疗的患者，SBRT治疗HCC的耐受性也良好，对于无法用射频消融控制的较大病灶也能提供良好的局部控制。SBRT的局部控制效果优于其他肝脏定向治疗。有必要开展前瞻性研究，比较SBRT与其他肝脏定向治疗的效果。
