International Journal of Radiation Oncology*Biology*Physics
Clinical InvestigationIndividualized Adaptive Radiation Therapy Allows for Safe Treatment of Hepatocellular Carcinoma in Patients With Child-Turcotte-Pugh B Liver Disease
Introduction
Hepatocellular carcinoma (HCC) most commonly arises in the setting of liver cirrhosis and associated underlying liver dysfunction and is a leading cause of death among patients with compensated cirrhosis.1 Although initially created to stratify patients with cirrhosis by risk of perioperative mortality, the Child-Turcotte-Pugh (CTP) score has been widely adopted as a means by which to convey liver function and overall prognosis in cirrhosis.2, 3, 4 CTP scores range from 5 to 15 based on bilirubin, albumin, prothrombin time, and the presence and degree of encephalopathy and ascites. Scores are classified as A (5-6), B (7-9), or C (10+), with class A patients having compensated cirrhosis, class B having some degree of liver function compromise, and class C having decompensated cirrhosis.
Stereotactic body radiation therapy (SBRT) has been shown to be a safe and effective treatment for HCC in patients with small tumors and CTP-A liver function.5,6 However, previous reports suggest unacceptably high rates of treatment-related toxicity in patients with CTP-B liver disease.7 Similarly, excess toxicity has been reported with other liver-directed therapies in patients with CTB-B liver disease, including ablative treatments and transarterial chemoembolization.8 As such, there are often limited available treatment options for patients with HCC and CTP-B liver disease.
Our approach to limiting SBRT-related toxicity in patients with cirrhosis has been to treat with an individualized adaptive approach based on baseline and midtreatment liver function.5 We sought to assess whether individualized adaptive liver SBRT tailored to liver function limited treatment-related toxicity in patients with CTP-B liver disease without compromising local control.
Section snippets
Patients
Institutional review board approval was obtained and informed consent waived for this Health Insurance Portability and Accountability Act–compliant retrospective cohort study. A retrospective review was performed of all patients with CTP-B liver disease and HCC treated on prospective clinical trials of individualized adaptive radiation therapy at our institution between 2006 and 2018 (NCT01519219, NCT01522937, and NCT02460835). There were no limitations on tumor size. All treated lesions had a
Patient, tumor, and treatment-related characteristics
Eighty patients with CTP-B HCC were treated with liver SBRT (see CONSORT diagram in Fig. E1). Seventy-six of these patients were alive 6 months after SBRT with an available CTP score, and form the cohort for analyses of treatment-related toxicity. Patient, tumor, and treatment-related characteristics can be found in Table 1. The median follow-up was 13.1 months (range, 1.3-67 months). Thirty-seven patients (46%) had CTP-B7 disease, 28 (35%) had CTP-B8 disease, and 15 (19%) had CTP-B9 disease.
Discussion
To our knowledge, this study represents the largest report of liver SBRT for HCC in patients with CTP-B liver disease. The natural history of cirrhosis, even in the absence of HCC, is one of progressive decline in liver function over time, with an approximate 5% to 7% rate of transition from compensated to uncompensated disease per year.4 The transition to a decompensated state is accompanied by a dramatic decrease in survival, with median survival frequently reported as <1 year in patients
Conclusions
The utilization of an individualized adaptive treatment approach allows for the safe and effective treatment of patients with CTP-B liver disease. Our rates of treatment-related toxicity in these high-risk patients is comparable with those of the reported series in patients with CTP-A liver dysfunction and substantially less than those reported to date in CTP-B patients. However, increasing the dose may increase both tumor control and toxicity; thus, further work is needed to optimize treatment
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2022, Journal of the National Cancer CenterCitation Excerpt :Jackson et al. reported 80 CP B patients with a median tumor size of 2.5 cm. Possibly due to the smaller tumor sizes among patients in this study, better outcomes (92% 1-year LC and 24% toxicity) were reported13. Hui Wang et al. enrolled 36 patients, all of whom had CP class B cirrhosis.
William C. Jackson and Ming Tang made equal contributions to this study.
Grant funding for this study was received from NIH P01 CA059827, University of Michigan Rogel Cancer Center.
Disclosures: Potential conflicts of interest do not exist.
Data sharing statement: Research data are stored in an institutional repository and will be shared upon request to the corresponding author.