Dutta Debnarayan, Tatineni Tushar, Yarlagadda Sreenija, Gupte Ajinkya, Reddy Sruthi K, Madhavan Ram, Nair Haridas, Sasidharan Ajay, Kannan Rajesh, Pottayil Shibu G, Holla Raghavendra, Sudhindran Surendran
Department of Radiation Oncology, Amrita Institute of Medical Science, Kochi, 682 041, India.
Department of Radiology, Amrita Institute of Medical Science, Kochi, 682 041, India.
Indian J Gastroenterol. 2021 Aug;40(4):389-401. doi: 10.1007/s12664-021-01172-w. Epub 2021 Oct 25.
This is a prospective study evaluating the role of stereotactic body radiotherapy (SBRT) with CyberKnife (CK) in Indian patients suffering from hepatocellular carcinoma with portal vein thrombosis (HCC-PVT).
Patients with inoperable HCC-PVT, good performance score (PS), and liver function are accrued for treatment on CK (version M6) and planned with Multiplan (iDMS V2.0). Triple-phase contrast computed tomography (CT) scan was done for contouring, and the gross tumor volume (GTV) included contrast-enhancing mass within main portal vein and adjacent parenchymal disease. Dose prescription was as per-risk stratification protocol (22-50 Gy in 5 fractions) while achieving the constraints of mean liver dose <15 Gy, 800 cc liver <8 Gy, and the duodenum max of ≤24 Gy).
Seventy-two HCC-PVT accrued till date (mean age 63 years [38-76 years], 96% male; Child-Pugh [CP] A 84%, B 9%; Barcelona-Clinic Liver Cancer [BCLC] C 96%; PS0-1: 80%, Karnofsky performance score [KPS]>70: 88%; co-morbidities 42%; infective 12%, alcohol intake 31%, adjuvant sorafenib 39%). CP scores 5, 6, 7, and 8 were in 35%, 32%, 8%, and 18%, respectively. Focal disease with portal vein thrombus (PVT) in 21%, liver involvement >50% and <50% in 46% and 32%. Liver cancer study group of Japan staging-based portal vein invasion VP2, VP3, and VP4 in 22%, 29%, and 40%. Cancer of the Liver Italian Programm (CLIP) scores 1, 2, 3, 4, and 5 were in 8%, 26%, 31%, 26%, and 7%, respectively. Mean follow-up was 7.3 months (median 6 months, standard deviation [SD] 6; range 3-30 months). Mean actuarial overall survival (OS) was 11.4 months (SE 1.587; 95% CI: 8-14.2 months). Six months and 12 months actuarial OS 55% and 38%, respectively. At last follow-up, 25/69 (36%) were alive and 44/69 (64%) were dead. Among 54 patients evaluated for response assessment, 23 (30%) had radiological confirmed PVT response, 1 (3%) had response of IVC thrombus, and 30 (42%) had no or minimal response to SBRT. Actuarial OS in responders and non-responders were 14.4 months (95% CI 9.4-19.2) and 7.4 months (95% CI 4.9-9.7), p-value: 0.022. Six and 12 months survival in responders and non-responders were 65.7% and 37% and 49% and 24.6%, respectively. Post-SBRT, 4 (12%) patients underwent transarterial chemoembolization (TACE) 3 patients (8%) and 1 patient (4%) transarterial radioembolization (TARE). Post-CK, (<4 weeks) 2 patients (4%) had decompensation.
PVT response or recanalization after SBRT is a statistically significant prognostic factor for survival function in HCC-PVT.
这是一项前瞻性研究，评估射波刀（CK）立体定向体部放疗（SBRT）在患有门静脉血栓形成的肝细胞癌（HCC-PVT）印度患者中的作用。
将无法手术的HCC-PVT、良好的体能状态评分（PS）和肝功能的患者纳入CK（M6版本）治疗，并使用Multiplan（iDMS V2.0）进行规划。进行三相对比计算机断层扫描（CT）扫描以进行轮廓勾画，大体肿瘤体积（GTV）包括门静脉主干内的强化肿块和相邻的实质病变。剂量处方按照风险分层方案（22 - 50 Gy，分5次），同时达到平均肝脏剂量<15 Gy、800 cc肝脏<8 Gy以及十二指肠最大剂量≤24 Gy的限制。
截至目前，共纳入72例HCC-PVT患者（平均年龄63岁[38 - 76岁]，96%为男性；Child-Pugh[CP]A 84%，B 9%；巴塞罗那临床肝癌[BCLC]C 96%；PS0 - 1：80%，卡诺夫斯基体能状态评分[KPS]>70：88%；合并症42%；感染性疾病12%，饮酒31%，辅助使用索拉非尼39%）。CP评分5、6、7和8分别占35%、32%、8%和18%。伴有门静脉血栓（PVT）的局灶性病变占21%，肝脏受累>50%和<50%分别占46%和32%。日本肝癌研究组基于门静脉侵犯的分期VP2、VP3和VP4分别占22%、29%和40%。意大利肝癌计划（CLIP）评分1、2、3、4和5分别占8%、26%、31%、26%和7%。平均随访时间为7.3个月（中位数6个月，标准差[SD]6；范围3 - 30个月）。平均精算总生存期（OS）为11.4个月（标准误1.587；95%置信区间：8 - 14.2个月）。6个月和12个月的精算OS分别为55%和38%。在最后一次随访时，69例中有25例（36%）存活，44例（64%）死亡。在54例接受疗效评估的患者中，23例（30%）经影像学证实PVT有反应，1例（3%）下腔静脉血栓有反应，30例（42%）对SBRT无反应或反应极小。有反应者和无反应者的精算OS分别为14.4个月（95%置信区间9.4 - 19.2）和7.4个月（95%置信区间4.9 - 9.7），p值：0.022。有反应者和无反应者6个月和12个月的生存率分别为65.7%和37%以及49%和24.6%。SBRT后，4例（12%）患者接受了经动脉化疗栓塞（TACE），3例（8%）和1例（4%）接受了经动脉放射性栓塞（TARE）。CK治疗后（<4周），2例（4%）患者出现失代偿。
SBRT后PVT反应或再通是HCC-PVT生存功能的一个具有统计学意义的预后因素。
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