RT for HCC, sunrising or sunset?

1,065 views

Published on

Department of Radiation Oncology, Zhongshan Hospital, Fudan University Zhao-Chong Zeng

Published in: Health & Medicine, Business
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,065
On SlideShare
0
From Embeds
0
Number of Embeds
572
Actions
Shares
0
Downloads
10
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

RT for HCC, sunrising or sunset?

  1. 1. RT for HCC, sunrising orRT for HCC, sunrising or sunset?sunset? Zeng.zhaochong@zs-hospital.sh.cnZeng.zhaochong@zs-hospital.sh.cn Department of Radiation Oncology, Zhongshan Hospital, Fudan University Zhao-Chong Zeng
  2. 2. Asia-Pacific regionAsia-Pacific region ChinaChina KoreaKorea SorafenibSorafenib PlaceboPlacebo RTRT RTRT IntrahepaticIntrahepatic++TACETACE 29.7 (29.7 (Ø≤Ø≤7cm)7cm) 1 >> 29.7 (29.7 (Ø≤Ø≤7cm)7cm) 1 25.8 3 32 ((ØØ 5-7cm)5-7cm) 4 Vascular InvasionVascular Invasion 5.65.6 2 4.14.1 2 9.79.7 5 11.611.6 6 Lung Mt.Lung Mt. 5.65.6 2 4.24.2 2 16.716.7 7 12.312.3 8 Lymph node Mt.Lymph node Mt. 5.65.6 2 3.23.2 2 7.97.9 9 1010 10 Comparison btw Sorafenib and RT for intermediate/advanced HCCComparison btw Sorafenib and RT for intermediate/advanced HCC References: 1 Eur J Cancer 2011;47:2117 2 Eur J Cancer 2012;48(10):1452-65. 3 IJRBP 2011;81(S2):352 4 Liver Int 2005;25:1189 55 Cancer SCI 2008;99:2510Cancer SCI 2008;99:2510 6.6. J Korean Med Sci 2011;26:1011J Korean Med Sci 2011;26:1011 7.7. Clin Exp MetastasesClin Exp Metastases 2012;29:197 8. IJRBP 2009;74:412 9. IJRBP 2005;63:1067 10.10. IJROBP 2010;78:729IJROBP 2010;78:729
  3. 3. Eur J CancerEur J Cancer 2012;48(10):1452-65
  4. 4. 281 HCC with PVT treated with conventional RT281 HCC with PVT treated with conventional RT Korean Academy Medical Sci 2011;26:1014Korean Academy Medical Sci 2011;26:1014
  5. 5. Comparison of cost-efficient btw. Sorafenib & RT Sorafenib EBRT Survival prolong 1.5 months 7.4 months Cost for survival benefit per-month 29, 866$ 2,297$ Level of EBM A C It is very important to do the RCT for HCC using EBRT Sorafenib: 8,000$/per monthSorafenib: 8,000$/per month××5.6 months=44,800$5.6 months=44,800$ 5.6-4.1=1.5 months prolong survival. 44,800$/1.5=29,866$/per mo.5.6-4.1=1.5 months prolong survival. 44,800$/1.5=29,866$/per mo. RT: 11.6-4.2 =7.4 months prolong survival. 17,000$/7.4=2,297$/per mo.RT: 11.6-4.2 =7.4 months prolong survival. 17,000$/7.4=2,297$/per mo.
  6. 6. Only 1 onging trialOnly 1 onging trial
  7. 7. Lancet Oncol. 2009 Jan;10(1):25-34.Lancet Oncol. 2009 Jan;10(1):25-34. N Engl J Med. 2008 Jul 24;359(4):378-90.N Engl J Med. 2008 Jul 24;359(4):378-90. 312 clinical trials312 clinical trials Siemens Varian Elekta Clinical Trial of RT for HCC: only 1 supported by Bayer. Sharp TrialSharp Trial Oriental TrialOriental Trial One boy is a boy, two boys half boy, three boys no boyOne boy is a boy, two boys half boy, three boys no boy
  8. 8. Clinical practice in RT for HCCClinical practice in RT for HCC 1.1. SBRT for Early stage HCCSBRT for Early stage HCC 2.2. Helical Tomotherapy (HT) for confined butHelical Tomotherapy (HT) for confined but unresectalbe HCCunresectalbe HCC 3.3. HT improves long-term survival via increasedHT improves long-term survival via increased dose without increase toxicity for HCC withdose without increase toxicity for HCC with macrovascular invasionmacrovascular invasion
  9. 9. A B C D
  10. 10. Liver SC G lK rK PTV
  11. 11. B C D A
  12. 12. Clinical practice in RT for HCCClinical practice in RT for HCC 1.1. SBRT for Early stage HCCSBRT for Early stage HCC 2.2. Helical Tomotherapy (HT) for confined butHelical Tomotherapy (HT) for confined but unresectable HCCunresectable HCC 3.3. HT improves long-term survival via increasedHT improves long-term survival via increased dose without increase toxicity for HCC withdose without increase toxicity for HCC with macrovascular invasionmacrovascular invasion
  13. 13. A B C D Followup CT after TACE, poorer Lipidol deposit in the larger tumor. Better deposit in the smaller satellite lesion.
  14. 14. LKidneyLKidney R KidneyR Kidney GastricGastric SCSC LiverLiver PTVPTV GastricGastric GTV/GTV/CTVCTV LiverLiver KidneyKidney SCSC 三 3DCRT , GTV 60Gy conventional dose , gastric 53Gy , liver V35 40% 。 Palliative RT HT , GTV 59.5 Gy/17Fx ,≈ 76Gy Conventional dose , gastric 23Gy , liver V35 18% 。 Curable RT
  15. 15. 11-6-3 11-8-24AFP=205 AFP=50 AFP=8.0 11-12-2211-10-25 From palliative to cure——a great leapFrom palliative to cure——a great leap !!
  16. 16. A B C D E F G Case 2. large and multiple HCC in the Right Lobe.
  17. 17. A B C 2011-3-8 2011-3-8 2011-4-19 2011-6-1D E Case 2
  18. 18. A B C D E F G Followup CT after TACE on 2011-7-19
  19. 19. Followup CT after HT on 2011-11-17 (3 M later)
  20. 20. Followup MRI on 2012-4-10
  21. 21. 2011-3-4 2011-7-19 2011-10-19 2011-11-17 2012-4-10 Proliferation of left Lob during therapies
  22. 22. Clinical practice in RT for HCC 1. SBRT for Early stage HCC 2. Helical Tomotherapy (HT) for confined but unresectalbe HCC 3. HT improves long-term survival via increased dose without increase toxicity for HCC with macrovascular invasion
  23. 23. 2012-2-7 Case 1. A huge tumor located in the left lobe and adhered with stomach.Case 1. A huge tumor located in the left lobe and adhered with stomach. 2012-2-7
  24. 24. TPS in TomoTPS in Tomo 2.8Gy/20Fx2.8Gy/20Fx
  25. 25. PTVPTV PTVPTV stomach SmallbowelLiver Min. Max. Mean PTV 3DCR T 48.3 66.9 58.0 Tomo 43.2 59.0 57.1 Liver- PTV 3DCR T 0.45 66.9 17.3 Tomo 1.7 58.0 13.6 Stomac h 3DCR T 5.2 59.1 42.3 Tomo 8.2 57.3 34.3 stomach 3DCRT TOMO V50 28% 4.9% V55 10.4% 0.45% Comparison in DVHComparison in DVH bwt 3DCRT & Tomobwt 3DCRT & Tomo PTVPTV stomachstomach SmallbowelSmallbowel LiverLiver Spinal cordSpinal cord Left kidneyLeft kidney Right kidneyRight kidney
  26. 26. 2012-4-10 2012-2-7 Intrahepatic tumorIntrahepatic tumor response toresponse to TomotherapyTomotherapy A huge tumor located inA huge tumor located in the left lobe and adheredthe left lobe and adhered with stomach. Afterwith stomach. After treated with HT, tumortreated with HT, tumor responded to RT well inresponded to RT well in the following CT or MRIthe following CT or MRI at the completion afterat the completion after 1.5, 3 and 5 months.1.5, 3 and 5 months. 2012-5-22 2013-3-4
  27. 27. 2012-2-7 2012-4-10 2012-5-22 PVT response toPVT response to Tomotherapy inTomotherapy in following imagingsfollowing imagings 2013-3-4
  28. 28. www.nordridesign.com Case 2Case 2 :: IVC tumorIVC tumor thrombi + Intrahepaticthrombi + Intrahepatic T.T. From Palliative to CureFrom Palliative to Cure
  29. 29. www.nordridesign.com
  30. 30. www.nordridesign.com 11-10-14 11-6-28 AFP declined from 309 to 8μg/L
  31. 31. www.nordridesign.com PTV PTV liverSpinal cord heart liverheartSpinal cord Min. Ma x. Mea n PTV 3DC RT 50.9 59. 2 54.8 Tom o 48.8 58. 0 55.6 Liver- PTV 3DC RT 0 58. 4 21.1 Tom o 0.47 57. 2 17.6 Spina l Cord 3DC RT 0.6 48. 7 18.5 Tom o 1.35 28. 4 15.1 Heart 3DC RT 0.9 58. 3 18.4 Tom o 2.14 57. 2 20.2 TomoTomo 3DCRT3DCRT
  32. 32. VariablesVariables 3D-CRT(n=50)3D-CRT(n=50) HT(n=34)HT(n=34) P-valuesP-values Age(yr) Average 53.56 ± 11.88 53.79 ± 12.36 0.931 Gender Female 2 3 0.359 Male 48 31 HBsAg Negative 7 2 0.238 Positive 43 32 KPS 70 1 2 0.268 0.268 80 28 13 90 20 19 100 1 0 AFP status (µg/L) ≤20 17 9 0.518 >20 33 24 Child-Pugh classification A 48 33 0.797 B 2 1 Max. diameter of intrahepatic tumors Average (cm) 8.89 ± 5.36 7.78 ± 3.34 0.298 Intrahepatic tumor number Solitary 30 15 0.152 Multiple 20 19 Thrombus location PV trunk 21 15 0.929 PV branch 18 12 IVC 8 6 IVC + PV 3 1 Volume of normal liver Average (mm3 ) 1079.48 ± 397.48 1028.36 ± 258.76 0.511 Baseline characteristics in 84 HCC patients with tumor thrombi who received 3D-CRT or HTBaseline characteristics in 84 HCC patients with tumor thrombi who received 3D-CRT or HT
  33. 33. Variables 3D-CRT (n=50) HT (n=34) P-values Radiation Dose (Gy) Total 50.54 ± 7. 93 57.79 ±6.51 <0.01 BED* 59.44 ±7.76 71.83 ± 9.88 0.011 Dose of normal liver Mean (Gy) 20.77 ± 4.44 22.41 ± 4.31 0.098 V5 (%) 69.28 ± 15.57 83.21 ± 14.45 <0.01 V10(%) 60.98 ± 15.59 66.53 ± 15.80 0.118 V15(%) 51.17 ± 14.29 55.21 ± 13.75 0.204 V20(%) 43.98 ± 12.85 44.64 ± 11.00 0.810 V30(%) 31.88 ± 10.91 31.35 ± 10.04 0.823 Intrahepatic tumor control after EBRT controlled 36(72.0%) 31(91.2%) 0.032 uncontrolled 14(28.0%) 3 (8.8%) Tumor thrombus control after EBRT Response or stable 41(82.0%) 33(97.1%) 0.036 progressive 9(18.0%) 1(2.9%) Toxicity 0 11(22%) 16(47.1%) 0.016I-II 39(78%) 18(52.9%) III-IV 0 0 Overall radiation fractions Average 25.48±3.80 19.44±4.09 <0.010 Overall survival Median 10.5 13.4 Effect and toxicity of EBRT in 84 HCC patients with macrovascular invasionEffect and toxicity of EBRT in 84 HCC patients with macrovascular invasion * BED=nd(1+d/* BED=nd(1+d/αα//ββ)) ;; αα//ββ=12 for HCC=12 for HCC
  34. 34. HT Median OS:13.4mHT Median OS:13.4m 3DCRT Median OS:10.5m3DCRT Median OS:10.5m
  35. 35. Conclusion In comparison to 3D-CRT, HT improves the therapy response and survival for HCC with macrovascular invasion, which could deliver higher dose in shorter therapy period with acceptable toxicity.
  36. 36. Survival & Causes of death for HCC with extrahepatic metastases Metastatic sites Overall Survival(mo) Cause of Liver Failure RT Non-RT Lymph node 8.9 1 3 1 61.5%61.5% 22 Lung 17 3 8 4 67.5%67.5% 44 Bone 7.4 5 88.5%88.5% 55 Adrenal 13.6 6 83.3%83.3% 661.1. IJROBP 2005;63:1067-76IJROBP 2005;63:1067-76 2.2. Clin Transl Oncol 2013;Feb.Clin Transl Oncol 2013;Feb. 3.3. Clin Exp Metastasis 2012;29:197-205Clin Exp Metastasis 2012;29:197-205 4.4.Hepatol Int 2008;2:237-43Hepatol Int 2008;2:237-43 5.5.Cancer 2009;115:2710-20Cancer 2009;115:2710-20 6.6.JJR under reviewJJR under review
  37. 37. Hereafter Clinical trials: Focus on Intrahepatic tumors control SBRT for early stage HCC RT for confined intrahepatic HCC RT for PV branches tumor thrombi
  38. 38. HCC PS 0~2 PS 3~4 Child-Pugh A/B Child-Pugh C PS Liver function Extrahepatic M - + Vascular inv. Intrahep. T Tumor Size - + ≤3cm > 3cm ≥4 nodules2~3 nodules Stage I IIa IIb IIIa IIIb IVbIVa •Support care •Support care •LT (UCSF) •TACE •RT •+Sorafenib •TACE •resection •+RF •resection •TACE •LT (UCSF) •resection •RF≤3cm •LT (UCSF) Treatment Choice •TACE •resection •RT •+sorafenib Solitary Do you believe it? >65 % pt. Need RT
  39. 39. Now, no evident to supportNow, no evident to support this’s sunrising. We do notthis’s sunrising. We do not care this, please enjoycare this, please enjoy beautiful sun scene in thisbeautiful sun scene in this moment.moment. Zeng.zhaochong@zs-hospital.sh.cnZeng.zhaochong@zs-hospital.sh.cn

×