Abstract
Purpose
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.
Results
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.
Conclusion
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.
Zusammenfassung
Ziel
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.
Ergebnisse
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).
Schlussfolgerung
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.
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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.
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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). https://doi.org/10.1007/s00066-012-0298-6
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DOI: https://doi.org/10.1007/s00066-012-0298-6