Skip to main content
Log in

Radiotherapy with volumetric modulated arc therapy for hepatocellular carcinoma patients ineligible for surgery or ablative treatments

Radiotherapie mit volumetrisch modulierter Bogentherapie für chirurgische oder ablativ nicht behandelbare hepatozelluläre Karzinompatienten

  • Original article
  • Published:
Strahlentherapie und Onkologie Aims and scope Submit manuscript



The aim of this article is to report the dosimetric and clinical findings in the treatment of primary hepatocellular carcinoma (HCC) with volumetric modulated arc therapy (VMAT, RapidArc).

Methods and materials

A total of 138 patients were investigated. Dose prescription ranged from 45–66 Gy. Most patients (88.4 %) presented AJCC stage III or IV and 83 % were N0–M0. All were classified as Barcelona Clinic Liver Cancer (BCLC) stage A–C. All patients were treated using 10 MV photons with single or multiple, coplanar or non-coplanar arcs, and cone-down technique in case of early response of tumors.


The patients’ median age was 66 years (range 27–87 years), 83 % were treated with 60 Gy (12 % at 45 Gy, 6 % at 66 Gy), 62 % with cone-down, 98 % with multiple arcs. The mean initial planning target volume (PTV) was 777 ± 632 cm3; the mean final PTV (after the cone-down) was 583 ± 548 cm3. High target coverage was achieved. The final PTV was V98% > 98 %. Kidneys received on average 5 and 8 Gy (left and right), while the maximum dose to the spinal cord was 22 Gy; mean doses to esophagus and stomach were 23 Gy and 15 Gy, respectively. The average volume of healthy liver receiving more than 30 Gy was 294 ± 145 cm3. Overall survival at 12 months was 45 %; median survival was 10.3 months (95 % confidence interval 7.2–13.3 months). Actuarial local control at 6 months was 95 % and 93.7 % at 12 months. The median follow-up was 9 months and a maximum of 28 months.


This study showed from the dosimetric point of view the feasibility and technical appropriateness of RapidArc for the treatment of HCC. Clinical results were positive and might suggest, with appropriate care, to consider RapidArc as an additional therapeutic opportunity for these patients.



Bericht über den dosimetrischen und klinischen Befund bei der Bestrahlung vom primären heptozellulärem Karzinom (HCC) mit der volumetrisch modulierten Bogentherapie (VMAT, RapidArc).

Methoden und Material

Insgesamt wurden 138 Patienten untersucht. Die Dosisverschreibung reichte von 45 bis 66 Gy. Die meisten Patienten (88,4 %) zeigten AJCC Stage III oder IV und 83 % waren N0-M0. Alle wurden als „Barcelona Clinic Liver Cancer“ (BCLC) Stage A bis C klassifiziert. Die Patienten wurden mit 10 MV Photonen behandelt, entweder mit einem oder mehreren, koplanaren oder nichtkoplanaren Bögen. Bei einem frühen Ansprechen des Tumors wurde die „Cone-down“-Technik (PTV-Reduktion) angewendet.


Das mittlere Alter der Patienten lag bei 66 Jahren (Spanne 27–87 Jahre), 83 % wurden mit 60 Gy (12 % mit 45 Gy und 6 % mit 66 Gy) behandelt. Bei 65 % wurde die „Cone-down“-Technik, bei 98 % mehrere Bögen angewendet. Das mittlere Volumen der initialen PTVs betrug 777± 632 cm3 und für die finalen PTVs (nach der „Cone-down“-Technik) 583 ± 548 cm3. Eine hohe Zielabdeckung wurde erreicht, das finale PTV hatte V98% > 98 %. Die Nieren erhielten im Mittel 5 und 8 Gy (links und rechts), die maximale Dosis im Rückenmark betrug 22 Gy sowie die mittlere Dosis in der Speiseröhre und im Magen 23 und 15 Gy. Das durchschnittliche Volumen der gesunden Leber, welche mehr als 30 Gy erhielt, war 294 ± 145 cm3. Das Gesamtüberleben nach 12 Monaten betrug 45 %, das mediane Überleben 10,3 Monate (95 %-KI 7,2–13,3 Monate). In den auswertbaren Patienten wurde nach 6 Monaten bei 94 % und nach 12 Monaten bei 93,7%eine lokale Kontrolle erreicht (medianer Follow-up von 9 Monaten, mit einem maximalen von 28).


Diese Studie zeigt aus einer dosimetrischen Sicht die Machtbarkeit und technische Eignung von RapidArc bei HCC. Die klinischen Resultate waren positiv und können darauf hindeuten, RapidArc, mit der nötigen Sorgfalt, als zusätzliche therapeutische Behandlungsmöglichkeit für diese Patienten zu berücksichtigen.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2


  1. Altekruse SF, McGlynn KA, Reichman ME (2009) Hepatocellular carcinoma incidence, mortality, and survival trends in the United States from 1975 to 2005. J Clin Oncol 27:1485–1491

    Article  PubMed  Google Scholar 

  2. Bujold A, Dawson LA (2011) Stereotactic radiation therapy and selective internal radiation therapy for hepatocellular carcinoma. Cancer Radiother 15:54–63

    Article  PubMed  CAS  Google Scholar 

  3. Dawson LA (2011) Overview: where does radiation therapy fit in the spectrum of liver cancer local-regional therapies? Semin Radiat Oncol 21:241–246

    Article  PubMed  Google Scholar 

  4. Feng M, Ben-Josef E (2011) Radiation therapy for hepatocellular carcinoma. Semin Radiat Oncol 21:271–277

    Article  PubMed  Google Scholar 

  5. Guy J, Kelley RK, Roberts J et al (2012) Multidisciplinary management of hepatocellular carcinoma. Clin Gastroenterol Hepatol 10:354–363

    Article  PubMed  Google Scholar 

  6. Dawson LA, Ten Haken RK (2005) Partial volume tolerance of the liver to radiation. Semin Radiat Oncol 15:279–283

    Article  PubMed  Google Scholar 

  7. Pan CC, Kavanagh BD, Dawson LA et al (2010) Radiation-associated liver injury. Int J Radiat Oncol Biol Phys 76:S94–S100

    Article  PubMed  Google Scholar 

  8. Park HC, Seong J, Han KH et al (2002) Dose-response relationship in local radiotherapy for hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 54:150–155

    Article  PubMed  Google Scholar 

  9. Ben-Josef E, Normolle D, Ensminger WD et al (2005) Phase II trial of high-dose conformal radiation therapy with concurrent hepatic artery floxuridine for unresectable intrahepatic malignancies. J Clin Oncol 23:8739–8747

    Article  PubMed  Google Scholar 

  10. Cheng JC, Wu JK, Huang CM et al (2003) Dosimetric analysis and comparison of three-dimensional conformal radiotherapy and intensity-modulated radiation therapy for patients with hepatocellular carcinoma and radiation-induced liver disease. Int J Radiat Oncol Biol Phys 56:229–234

    Article  PubMed  Google Scholar 

  11. Eccles CL, Bissonnette JP, Craig T et al (2008) Treatment planning study to determine potential benefit of intensity-modulated radiotherapy versus conformal radiotherapy for unresectable hepatic malignancies. Int J Radiat Oncol Biol Phys 72:582–588

    Article  PubMed  Google Scholar 

  12. Lee MT, Purdie TG, Eccles CL et al (2010) Comparison of simple and complex liver intensity modulated radiotherapy. Radiat Oncol 5:115

    Article  PubMed  Google Scholar 

  13. Otto K (2008) Volumetric modulated arc therapy: IMRT in a single gantry arc. Med Phys 35:310–317

    Article  PubMed  Google Scholar 

  14. Fogliata A, Clivio A, Nicolini G et al (2008) Intensity modulation with photons for benign intracranial tumours: a planning comparison of volumetric single arc, helical arc and fixed gantry techniques. Radiother Oncol 89:254–262

    Article  PubMed  Google Scholar 

  15. Scorsetti M, Alongi F, Castiglioni S et al (2011) Feasibility and early clinical assessment of flattening filter free (FFF) based stereotactic body radiotherapy (SBRT) treatments. Radiat Oncol 6:113

    Article  PubMed  Google Scholar 

  16. Scorsetti M, Bignardi M, Alongi F et al (2011) Stereotactic body radiation therapy for abdominal targets using volumetric intensity modulated arc therapy with RapidArc: feasibility and clinical preliminary results. Acta Oncol 50:528–538

    Article  PubMed  Google Scholar 

  17. Kuo YC, Chiu YM, Shih WP et al (2011) Volumetric intensity-modulated Arc (RapidArc) therapy for primary hepatocellular carcinoma: comparison with intensity-modulated radiotherapy and 3-D conformal radiotherapy. Radiat Oncol 6:76

    Article  PubMed  Google Scholar 

  18. Ulmer W, Pyyry J, Kaissl W (2005) A 3D photon superposition/convolution algorithm and its foundation on results of Monte Carlo calculations. Phys Med Biol 50:1767–1790

    Article  PubMed  CAS  Google Scholar 

  19. ICRU report 83 (2010) Prescribing, recording and reporting Intensity Modulated Photon Beam Therapy (IMRT) (ICRU report 83). Washington

  20. Therasse P, Arbuck SG, Eisenhauer EA et al (2000) New guidelines to evaluate the response to treatment in solid tumors. European Organization for research and treatment of Cancer, National Cancer Institute of the United States, National Cancer Institute of Canada. J Natl Cancer Inst 92:205–216

    Article  PubMed  CAS  Google Scholar 

  21. Bignardi M, Cozzi L, Fogliata A et al (2009) Critical appraisal of volumetric modulated arc therapy in stereotactic body radiation therapy for metastases to abdominal lymph nodes. Int J Radiat Oncol Biol Phys 75:1570–1577

    Article  PubMed  Google Scholar 

  22. Price TR, Perkins SM, Sandrasegaran K et al (2012) Evaluation of response after stereotactic body radiotherapy for hepatocellular carcinoma. Cancer 118:3191–3198

    Article  PubMed  Google Scholar 

  23. Seo YS, Kim MS, Yoo SY et al (2010) Preliminary result of stereotactic body radiotherapy as a local salvage treatment for inoperable hepatocellular carcinoma. J Surg Oncol 102:209–214

    Article  PubMed  Google Scholar 

  24. Kwon JH, Bae SH, Kim JY et al (2010) 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 10:475

    Article  PubMed  Google Scholar 

  25. Kubas A, Mornex F, Merle P et al (2008) Irradiation of hepatocellular carcinoma: impact of breathing on motions and variations of volume of the tumor, liver and upper abdominal organs. Cancer Radiother 12:768–774

    Article  PubMed  CAS  Google Scholar 

  26. Bundschuh RA, Andratschke N, Dinges J et al (2012) Respiratory gated 18F-FDG PET/CT for target volume delineation in stereotactic radiation treatment of liver metastases. Strahlenther Onkol 188:592–598

    Article  PubMed  CAS  Google Scholar 

  27. Gong GZ, Yin Y, Xing L, Guo YJ et al (2012) RapidArc combined with the active breathing coordinator provides an effective and accurate approach for the radiotherapy of hepatocellular carcinoma. Strahlenther Onkol 188:262–268

    Article  PubMed  CAS  Google Scholar 

Download references

Conflict of interest

On behalf of all authors, the corresponding author states the following: Dr. L. Cozzi is Head of Research at Oncology Institute of Southern Switzerland and acts as a scientific advisor to Varian Medical Systems. The other authors have no conflicts of interest.

Author information

Authors and Affiliations


Corresponding author

Correspondence to A. Fogliata MSc.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Wang, PM., Hsu, WC., Chung, NN. et al. Radiotherapy with volumetric modulated arc therapy for hepatocellular carcinoma patients ineligible for surgery or ablative treatments. Strahlenther Onkol 189, 301–307 (2013).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: