Consensus for Radiotherapy in Hepatocellular Carcinoma from The 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014): Current Practice and Future Clinical Trials

Abstract

A consensus meeting to develop practice guidelines and to recommend future clinical trials for radiation therapy (RT), including external beam RT (EBRT), and selective internal RT (SIRT) in hepatocellular carcinoma (HCC) was held at the 5th annual meeting of the Asia-Pacific Primary Liver Cancer Expert consortium. Although there is no randomized phase III trial evidence, the efficacy and safety of RT in HCC has been shown by prospective and retrospective studies using modern RT techniques. Based on these results, the committee came to a consensus on the utility and efficacy of RT in the management of HCC according to each disease stage as follows: in early and intermediate stage HCC, if standard treatment is not compatible, RT, including EBRT and SIRT can be considered. In locally advanced stage HCC, combined EBRT with transarterial chemoembolization or hepatic arterial infusion chemotherapy, and SIRT can be considered. In terminal stage HCC, EBRT can be considered for palliation of symptoms and reduction of morbidity caused by the primary tumor or its metastases. Despite the currently reported benefits of RT in HCC, the committee agreed that there is a compelling need for large prospective studies, including randomized phase III trial evidence evaluating the role of RT. Specifically studies evaluating the efficacy and safety of sequential combination of EBRT and SIRT are strongly recommended.

Real world clinical practice in treating advanced hepatocellular carcinoma: When East meets West

“…In the west, although EBRT is being increasingly used in patients with MVI, it is not recommended by the EASL guideline [17]. In contrast, EBRT is recommended for patients with HCC and MVI in the Asia-Pacific and Taiwan guidelines [19,26]. Meanwhile, HAIC is widely used for patients with HCC and PVTT in Japanese hospitals [27].…”

Commentary on the article entitled “hepatocellular carcinoma with macrovascular invasion treated with yttrium-90 radioembolization prior to transplantation”

“…P a t i e n t s w i t h H C C w i t h p o r t a l v e i n t u m o u r thrombosis (PVTT) are in BCLC-stage C. The BCLC recommendation is sorafenib and the median survival of these patients is 11 months (2,6,7). Yttrium-90 microspheres have been recommended in guidelines and in expert consensus statements to be used in HCC with PVTT as numerous reports have shown their effectiveness in these patients (2,7,8). The article written by Levi Sandri et al entitled "hepatocellular carcinoma with macrovascular invasion treated with yttrium-90 radioembolization prior to transplantation" which is published in this issue of the Journal (9) is interesting.…”

“…Limitations due to size, number and location of tumours, as well as quantity and quality of liver remnant, prohibit partial hepatectomy. Percutaneous radiofrequency ablation can produce good long-term survival in patients with a solitary or a few small HCC nodules (2). Liver transplantation removes not only the tumour, but replaces the underlying cirrhotic liver with a normal liver.…”

“…Liver transplantation removes not only the tumour, but replaces the underlying cirrhotic liver with a normal liver. It is not surprising that liver transplantation offers the best overall and tumour-free survival in selected patients (1,2).…”

"A Case of Complete Response with Biliary Stenosis after Hepatic Arterial Injection and Stereotactic Body Radiotherapy to Hepatoecllular Carcinoma with Portal Vein Thrombosis"

“…3 The Asia-Pacific Primary Liver Cancer consensus recommends combined radiotherapy in patients with BCLC stage C tumors. 4 Transarterial chemoembolization (TACE) and hepatic arterial injection chemotherapy (HAIC) can be used combined with EBRT for HCC with portal vein invasion. 5,6 Stereotactic body radiotherapy (SBRT) is a novel technique that delivers a high radiation dose to lesions over a short period of time, usually 1-2 weeks.…”