The use of stereotactic body radiotherapy as a bridge to liver transplantation for hepatocellular carcinoma.

2016 ◽  
Vol 34 (4_suppl) ◽  
pp. 418-418 ◽  
Author(s):  
Aisling S Barry ◽  
Gonzalo Sapisochin ◽  
Moises Russo ◽  
Anthony M. Brade ◽  
James D. Brierley ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Liver Transplant ◽  
Stereotactic Body Radiotherapy ◽  
Liver Volume ◽  
Disease Free Survival ◽  
Patient Characteristics ◽  
Median Number ◽  
Wait List ◽  
Bridging Therapy ◽  
Actuarial Survival

418 Background: Approximately 30% of patients with hepatocellular carcinoma (HCC) on the wait list for liver transplant (LT) fall off the transplant list due to progressive HCC. Stereotactic Body Radiotherapy (SBRT) has been used as a “bridge” to LT in patients who are not amenable to RFA or TACE. Methods: Baseline patient characteristics, radiotherapy details and outcomes were reviewed in HCC patients who received SBRT as a bridge to LT. Results: Between July 2004 and Dec. 2014, 601 patients with HCC were listed for LT, of which 400 (66.5%) received bridging therapy. 38 patients, at high risk for HCC progression, were unsuitable for RFA or TACE, receiving SBRT as a bridging therapy. Median SBRT dose was 36Gy in 6 fractions (range 8.5-48Gy in 1 – 6 fractions), including 1 patient who was transplanted after receiving one fraction. 25 of 38 patients (67%) had all lesions treated (median number of lesions 2 {1-8}); 13 patients received SBRT only to the dominant lesion at highest risk of growing or rupturing. At the time of SBRT, 42% had HCC within Milan criteria, and median Child Pugh score was A6 (range A5-B8). 5 patients (13%) dropped off the transplant wait list due to development of metastatic disease (4) and macrovascular invasion with progressive disease (1). Median irradiated HCC volume was 60.5cc (range 7-216cc). Median liver volume (minus HCC) was 1491cc (737-2728cc). Median mean dose to the liver minus HCC was 11.2Gy (2.8-18.6Gy) and median effective liver volume irradiated was 28% (11-66%). 1 patient was admitted 2 months post SBRT with hepatic pain - possibly attributable to SBRT and another patient developed a rib fracture 8 months post SBRT (max rib dose 43Gy in 6 fractions). No other specific SBRT toxicity was noted. The 1-, 3- and 5-year disease free survival and actuarial survival of HCC patients treated with SBRT who went on to have transplant was 93%, 79% and 79%, and 89%, 76% and 76% respectively. Including patients who dropped off the transplant list, the intent-to-treat 1-, 3 - and 5-year survival was 89%, 65% and 65%. There was no reported increase in operative morbidity at the time of transplant in patients treated with SBRT. Conclusions: SBRT can be used safely and effectively in HCC patients as a bridge to liver transplant.

A 10-year retrospective analysis of risk factors, patterns of cancer recurrence, and survival after liver transplant for cirrhosis and hepatocellular carcinoma

2007 ◽  
Vol 25 (18_suppl) ◽  
pp. 4617-4617
Author(s):  
A. O. Kaseb ◽  
M. Bansal ◽  
I. Wollner ◽  
V. Shah ◽  
D. Moonka ◽  
...  
Keyword(s):  
Risk Factors ◽  
Hepatocellular Carcinoma ◽  
Liver Transplant ◽  
Disease Free Survival ◽  
Small Sample ◽  
Prognostic Indicators ◽  
Term Survival ◽  
Free Survival ◽  
Pathologic Features ◽  
Disease Free

4617 Introduction: Determining eligible patients who are likely to have better outcomes following orthotopic liver transplant (OLT) for cirrhosis and hepatocellular carcinoma (HCC) is an ongoing challenge. In addition, tumor recurrence represents a major limitation of long-term survival in this setting. Patients and Methods: The study analyzed 72 OLT recipients for cirrhosis and HCC, between 1996–2006. The endpoints were frequency, patterns, localization, and risk factors of recurrence. Survival from time of OLT to recurrence was compared with primary tumor and patient characteristics, and type of treatment received pre- and post-OLT using univariate and multivariate analyses. Survival was estimated using Kaplan-Meier plots. Results: 13 recurrences (18%) occurred after a median of 33.4 months follow up (6–123 months). 11/13 (84.6%) were distant metastases. Using cox regression analysis and log-rank p-value; bilobar involvement, a tumor number of =3, tumor grade 2 or 3, size >3 cm, vascular invasion, and elevated AFP at diagnosis were all positively associated with recurrence (either distant or any). Tumors that met Milan criteria were associated with a lower likelihood of recurrence. In addition, Pre and post-OLT treatments were not found to be associated with significantly improved disease-free survival. Conclusions: Our analyses confirmed that advanced pathologic features are independently associated with significantly shorter disease-free survival. Pre- and post-OLT treatment modalities were not observed to improve disease-free survival for patients with bad prognostic indicators. However, this is limited due to our small sample size and our univariate anaylsis. We conclude that careful patient selection based on prognostic indicators would maximize benefit from use of this expensive and limited resource. [Table: see text] No significant financial relationships to disclose.

Prognosis of hepatic failure with the albumin-bilirubin model for hepatocellular carcinoma after stereotactic body radiotherapy with and without transplant.

2018 ◽  
Vol 36 (4_suppl) ◽  
pp. 384-384
Author(s):  
Shaakir Hasan ◽  
Alexander V. Kirichenko ◽  
Paul Renz ◽  
Vijay Kudithipudi ◽  
Molly Vincent ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Overall Survival ◽  
Hepatic Failure ◽  
Stereotactic Body Radiotherapy ◽  
Disease Free Survival ◽  
Median Dose ◽  
Free Survival ◽  
Prognostic Assessment ◽  
Disease Free

384 Background: The Albumin-Bilirubin (ALBI) model is a validated prognostic assessment of cirrhosis in hepatocellular carcinoma (HCC), stratifying patients to grades 1(ALBI-1), 2(ALBI-2), or 3(ALBI-3). We reported that ALBI distinguishes patients at higher risk for hepatic failure(HF) after stereotactic body radiotherapy (SBRT) within the Child Pugh(CP) A population. We now apply the ALBI model to both CP-A and CP-B patients after SBRT with or without orthotropic liver transplant (OLT), and assess its prognostic capability of overall survival (OS) and HF relative to the CP model. Methods: From 2009-2017, 68 patients with 81 HCC lesions and CP-A (45) or CP-B (23) cirrhosis completed SBRT in this IRB approved study. The median dose was 45 Gy (35 - 57 Gy) in 4-7 fractions. Initial ALBI and CP scores were measured against OS and progression of CP class, which was recorded every 3-4 months. Median follow-up = 18 months. Results: The median age = 62 and tumor size = 3.5 cm (1.1 Ð 11 cm). 26 patients were ALBI-1, 31 ALBI-2, and 11 ALBI-3 prior to SBRT. For all patients, 2-year local control was 96%. 1 and 2 year OS was 77% and 54%, disease free survival was 71% and 40%, and freedom from CP progression was 71% and 56%, respectively. OS was significantly different between ALBI-1, ALBI-2, and ALBI-3 patients (P = 0.01), as was progression of CP class (P<0.001). When stratified by initial CP class, there were no significant differences in survival or CP progression [Table 1]. In a subset of 37 CP-A and 15 CP-B without OLT, rates of progressive cirrhosis were better predicted by ALBI (P<0.001) than CP class (P=0.09). Conclusions: Compared to the CP model, the ALBI index more precisely predicted HF and OS in HCC patients for both early and intermediate cirrhosis. Its application may help better select candidates for OLT after SBRT, who may be at higher risk for HF than initially predicted. [Table: see text]

Stereotactic body radiotherapy (SBRT) in patients with hepatocellular carcinoma with Child-Pugh class B.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. e14683-e14683
Author(s):  
Higinia Rosa Cardenes ◽  
Foster D Lasley ◽  
Paul Kwo ◽  
Susan M. Perkins ◽  
Mary A. Maluccio
Keyword(s):  
Hepatocellular Carcinoma ◽  
Liver Cirrhosis ◽  
Phase I ◽  
Phase Ii ◽  
Local Control ◽  
Stereotactic Body Radiotherapy ◽  
Interim Analysis ◽  
Liver Volume ◽  
Upper Limit ◽  
Pugh Class

e14683 Background: Stereotactic body radiotherapy (SBRT) is a promising therapeutic modality in hepatocelular carcinoma (HCC). A Phase I trial was conducted at Indiana University (IU) in patients with Child Pugh Class (CPC) A and B. Based on our results, patients with CPC-B patients with score <=7 continued enrollment in the phase II. We now present an interim analysis for this patient population. Methods: 14 patients with HCC with liver cirrhosis, CPC-B, were treated with SBRT in a Phase I-II trial at IU. All patients were scheduled to receive five fractions, 800 cGy per fraction (total dose 4000 cGy), 1-2 fractions per week. Dose was prescribed to the 80-90% isodose line covering the planning target volume (PTV). A modified RECIST criterion was used to determine local failure. Demographics, clinical variables, treatment –related toxicities within 90 days of end of treatment, and local control (LC) at 6 and 12 months were tabulated. Progression Free Survival (PFS), Time to Progression (TTP), and Overall Survival (OS) estimates were calculated using Kaplan-Meier methodology. This was an unplanned interim analysis. A formal interim analysis will take place later. Results: There were 13 males and 1 female; median age of 56.5 years (range 49-69). All patients had 1 treated lesion. Median (range) for gross tumor volume (GTV) (cc) was 40.1 (8.0-74.6); PTV volume (cc) was 120.1 (34.7-210.0); and uninvolved liver volume (cc) was 2137.9 (973.0-2796.0). There were 3 grade 4 toxicities, 1 each of hyperbilirubinemia, hypokalemia, and thrombycytopenia. Four patients underwent orthotopic liver transplant. Local control at 6 and 12 months were 90% [95% C.I. (55.5%, 99.8%)] and 87.5% [95% C.I. (47.4%, 99.7%)], respectively. Median PFS is 11.0 months (95% CI: 3.9 months, 17.4 months). Ten patients died or progressed including 4 patients who died without progressing. Median TTP is 17.4 months (95% CI: 5.3 months, upper limit not estimable). Median OS is 19.8 months (95% CI: 4.0 months, upper limit not estimable). Conclusions: in carefully selected patients with hepatocellular carcinoma in the context of CPC B liver cirrhosis, score less or equal than 7, SBRT is an effective therapy with a good toxicity profile. Phase II is ongoing.

Multiple utilities of portal vein embolization for patients with hepatocellular carcinoma.

2012 ◽  
Vol 30 (4_suppl) ◽  
pp. 319-319
Author(s):  
Toru Beppu ◽  
Hirohisa Okabe ◽  
Kazutoshi Okabe ◽  
Toshiro Masuda ◽  
Kosuke Mima ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Overall Survival ◽  
Portal Vein ◽  
Portal Vein Embolization ◽  
Liver Volume ◽  
Disease Free Survival ◽  
Remnant Liver ◽  
Right Hepatectomy ◽  
Tace Group ◽  
Disease Free

319 Background: Portal vein embolization (PVE) is a multi-potential treatment for hepatocellular carcinoma (HCC). The aim of this study is to identify the efficacies of PVE for resectable and unresectable HCC patients. Methods: Until 2011, 668 HCC patients underwent hepatic resection and 102 HCC patients treated with PVE. PVE was performed with percutaneous and ipsilateral approach using ethanolamine oleate iopamidol. Preoperative future remnant liver volume (%LV) and functional liver volume (%FLV ) were assessed with our developed combined 99mTc- galactosyl human serum albumin (GSA) scintigraphy (SPECT)/CT system. In unresectable cases chemoembolization (TACE) was repeated after PVE. Results: 1. Comparison of %LV and %FLV after right-PVE (n=40). %FLV before PVE was significantly lower in PVE group (38%) compared to non-PVE group (58%), but increased remarkably after PVE (from 38% to 55%, P < 0.0001). Right hepatectomy was successfully completed in 10 patients based on %FLV, instead of conventional %LV. 2. Long-term prognosis after right-hepatectomy with /without PVE (n=60). The 3- and 5-year disease-free survival (DFS) rates in the PVE group were significantly greater than those in the non-PVE group (78% and 78% versus 20% and 0%, P = 0.01). The 3- and 5-year overall survival (OS) rates in the PVE group were also higher than those in the non-PVE group (72% and 72% versus 57% and 12%, P <0.05). By multivariate analysis, independent prognostic factors for DFS were application of PVE (HR3.59), Multiple tumor (HR3.57), Fibrosis stage F3–4 (HR2.81), and protein induced by vitamin K absence or antagonists-II (PIVKA-II) ≥678AU/ml (HR2.69). 3. Prevention of intrahepatic metastases in unresectable HCCs in hemi-liver (n=40). The 3-year intrahepatic recurrence rates in the non-portal-embolized area was 58.8% and 81.8%, and the 5-year OS was 38.2% and 8.5%, in the PVE/TACE group and TACE group, respectively. The former rates were sinificantly higher (P<0.05). Conclusions: PVE can improve resectability, and might improve disease-free and overall survival for patients with both resectable and unresectable HCC.

ABLATION OF HEPATOCELLULAR CARCINOMA AS A BRIDGE TO LIVER TRANSPLANT PROLONGS WAIT LIST ELIGIBILITY

2008 ◽  
Vol 86 (Supplement) ◽  
pp. 215-216
Author(s):  
L Lilly ◽  
D Dubay ◽  
J Kachura ◽  
G Therapondos ◽  
D Grant ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Liver Transplant ◽  
Wait List

Phase I Study of Individualized Stereotactic Body Radiotherapy for Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

2008 ◽  
Vol 26 (4) ◽  
pp. 657-664 ◽  
Author(s):  
Regina V. Tse ◽  
Maria Hawkins ◽  
Gina Lockwood ◽  
John J. Kim ◽  
Bernard Cummings ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Phase I ◽  
Intrahepatic Cholangiocarcinoma ◽  
Stereotactic Body Radiotherapy ◽  
Phase I Study ◽  
Liver Enzymes ◽  
Liver Toxicity ◽  
Liver Volume ◽  
Estimated Risk ◽  
Grade 3

Purpose To report outcomes of a phase I study of individualized stereotactic body radiotherapy treatment (SBRT) for unresectable hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC). Patients and Methods Patients with unresectable HCC or IHC, and who are not suitable for standard therapies, were eligible for six-fraction SBRT during 2 weeks. Radiation dose was dependent on the volume of liver irradiated and the estimated risk of liver toxicity based on a normal tissue complication model. Toxicity risk was escalated from 5% to 10% and 20%, within three liver volume–irradiated strata, provided at least three patients were without toxicity at 3 months after SBRT. Results Forty-one patients with unresectable Child-Pugh A HCC (n = 31) or IHC (n = 10) completed six-fraction SBRT. Five patients (12%) had grade 3 liver enzymes at baseline. The median tumor size was 173 mL (9 to 1,913 mL). The median dose was 36.0 Gy (24.0 to 54.0 Gy). No radiation-induced liver disease or treatment-related grade 4/5 toxicity was seen within 3 months after SBRT. Grade 3 liver enzymes were seen in five patients (12%). Two patients (5%) with IHC developed transient biliary obstruction after the first few fractions. Seven patients (five HCC, two IHC) had decline in liver function from Child-Pugh class A to B within 3 months after SBRT. Median survival of HCC and IHC patients was 11.7 months (95% CI, 9.2 to 21.6 months) and 15.0 months (95% CI, 6.5 to 29.0 months), respectively. Conclusion Individualized six-fraction SBRT is a safe treatment for unresectable HCC and IHC.

Hepatic Arterial Therapy as a Bridge to Ablation or Transplant in the Treatment of Hepatocellular Carcinoma

2011 ◽  
Vol 77 (7) ◽  
pp. 868-873 ◽  
Author(s):  
Russell Ware Farmer ◽  
Ivan Kralj ◽  
Alessandr Valdata ◽  
Jose Urbano ◽  
Daniel P. Enguix ◽  
...  
Keyword(s):  
Hepatocellular Carcinoma ◽  
Multimodal Treatment ◽  
Median Number ◽  
Left Lobe ◽  
Open Label ◽  
Bridging Therapy ◽  
Treatment Type ◽  
Drug Eluting Beads ◽  
Drug Eluting ◽  
Segmental Arteries

Hepatocellular carcinoma (HCC) is a challenging malignancy as a result of the advanced course at presentation. Recent interventional advances have improved treatment of lesions unamenable to resection using drug-eluting microbeads delivered into the hepatic circulation. We hypothesize that the use of hepatic arterial therapy (HAT) will safely identify appropriate patients who can proceed to ablation and/or transplantation. We evaluated our open-label, multicenter, multinational, single-arm study including 240 patients with intermediate-staged HCC who received drug-eluting beads and were not initial candidates for transplantation or resection. We reviewed the resulting clinical data to determine factors leading to possible ablation or transplant. Of 240 patients undergoing HAT, 14 (5.8%) received ablation or transplant. We compared those receiving ablation or transplant with those receiving only HAT. Groups were similar regarding sex, age, median number of tumors (one; range, 1 to 25), Child's score, tobacco and alcohol abuse, and treatment type. Patients who were downstaged were more likely to have: hepatitis-related tumors (76 to 66%, P = 0.02), distinct lesions on imaging (92 to 76%, P = 0.004), and less than 25 per cent parenchymal involvement (84 to 59%, P = 0.0001). These patients typically had one tumor frequently in the left lobe (58.8 vs 30.9%, P = 0.0001), accessible through segmental arteries (47 vs 17%, P = 0.001), with increased segmental branch occlusion (57 vs 39%, P = 0.02). HAT should be considered a potential bridging therapy to eventual ablation or transplant in the multimodal treatment of HCC.

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