Magnetic Resonance Imaging Evaluation of Hepatocellular Carcinoma Treated With Stereotactic Body Radiation Therapy: Long Term Imaging Follow-Up

Mendiratta‐Lala, Mishal; Masch, William R.; Shankar, Prasad R.; Hartman, Holly; Davenport, Matthew S.; Schipper, Matthew J.; Maurino, C.; Cuneo, Kyle C.; Lawrence, Theodore S.; Owen, Dawn

doi:10.1016/j.ijrobp.2018.09.004

Cited by 54 publications

(43 citation statements)

References 41 publications

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“…All imaging-based post-treatment tumor response assessment algorithms (i.e., European Association for the Study of Liver Disease (EASL) [4], Modified Response Evaluation Criteria in Solid Tumors (mRECIST) [5], Liver Reporting and Data System (LI-RADS) treatment response algorithm (TRA) v.2018 [6]) utilize enhancement as a key imaging biomarker indicating viable disease. Unfortunately, residual enhancement does not predict response in HCCs treated with stereotactic body radiation therapy (SBRT) because the majority of successfully treated HCCs will exhibit residual arterial phase hyperenhancement (APHE) for 3 months or more [7][8][9][10][11][12][13][14][15][16] Thus, radiological criteria designed for assessing response to ablation or transarterial chemoembolization (TACE) (i.e., EASL [4] and mRECIST [5]) do not accurately determine local response to SBRT, particularly in the early post-treatment period.…”

Section: Introductionmentioning

confidence: 99%

Natural history of hepatocellular carcinoma after stereotactic body radiation therapy

et al. 2020

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Purpose To determine the long-term natural history of size change in SBRT-treated HCC to identify an imaging biomarker to help assess treatment response. Methods This was a retrospective cohort study of consecutive HCCs treated with SBRT from January 2008 to December 2016 with either 2 years post-treatment MRI follow-up or post-treatment resection histology. Size, major features for HCC, and mRECIST and LI-RADS v.2018 treatment response criteria were assessed at each post-treatment MRI. Local progression, distant progression, and survival were modeled with Kaplan Meier analyses. Results 56 HCCs met inclusion criteria. Mean baseline HCC diameter was 30 mm (range: 9-105 mm). At 3 months, 76% (N = 43) of treated HCCs decreased in size (mean reduction: 8 mm, range: 5-99 mm) and 0% (N = 0) increased in size. By 24 months, 11% (N = 5) had increased in size and were considered local progression. APHE remained in 77% (43/56) at 3 months, 38% (19/50) at 12 months, and 23% (11/47) at 24 months. mRECIST-defined viable disease was observed in 77% (43/56) at 3 months and 20% (9/47) at 24 months. LI-RADS v.2018 criteria identified viable or equivocal disease in 0% at 3 months and 10% (5/47) at 24 months. Conclusion Gradual loss of APHE and slow decrease in size are normal findings in HCCs treated with SBRT, and persistent APHE does not indicate viable disease. mRECIST is not accurate in the assessment of HCC after SBRT due to an overreliance on APHE to define viable disease. Increasing mass size or new nodular APHE at the treatment site may indicate local progression.

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Section: Introductionmentioning

confidence: 99%

Natural history of hepatocellular carcinoma after stereotactic body radiation therapy

et al. 2020

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“…Unlike the immediate post-treatment decreased-or non-enhancement following RFA and TACE, persistent arterial phase hyperenhancement for at least 12 months is common post SBRT and does not necessarily indicate viable neoplasm. [20] In addition to the mRECIST criteria, the AFP level as well as the apparent diffusion coe cient calculated from MRI sequences could improve the assessment of SBRT response and help to determine the LT candidates. [21,22] The role of radiation therapy in the management of HCC remains to be limited because of concerns about liver toxicity and RILD.…”

Section: Discussionmentioning

confidence: 99%

Clinical Outcome and Pathologic Correlation of Stereotactic Body Radiation Therapy as a Bridge to Transplantation for Advanced Hepatocellular Carcinoma

Wang

Dai

Lin

et al. 2020

Preprint

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Background: Stereotactic body radiotherapy (SBRT) is an emerging modality for hepatocellular carcinoma (HCC). However, there is scant information about its safety and effectiveness in the neoadjuvant setting prior to liver transplantation (LT). We present the clinical outcome and pathologic assessment of SBRT followed by LT for patients with advanced HCC.Methods: This retrospective study included HCC patients treated with neoadjuvant SBRT prior to LT between 2009 and 2018. Radiographic response and adverse effects, including radiation-induced liver disease (RILD), were evaluated. Pathologic response was assessed by the percentage of tumor necrosis relative to the total tumor volume. Overall survival (OS) and recurrence-free survival (RFS) were calculated using the Kaplan–Meier method.Results: Fourteen patients underwent SBRT for a total of 25 HCC lesions, followed by LT. The median tumor size was 4.45 cm in diameter, and the median prescribed dose was 45 Gy in 5 fractions. SBRT provided significant AFP reduction, 100% infield control, and a 62.5% response rate. The maximum detected toxicity included grade 3 thrombocytopenia and two grade 3–4 hyperbilirubinemia. One patient developed non-classic RILD. Patients were bridged to LT with a median time of 8.4 months after SBRT, and 23.1% of them achieved a complete pathologic response. The median OS and RFS were 37.8 and 18.3 months from the time of LT, respectively.Conclusions: SBRT provides favorable tumor control and acceptable adverse effects for patients awaiting LT. Further prospective studies to test SBRT as a bridging therapy for LT are feasible.

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“…It is increasingly appreciated that it can take a long time to manifest an OR after SBRT. 33 mRECIST, which was primarily designed for embolic therapies, might not capture the true response of SBRT, which does not immediately affect arterial flow. It is also possible that nonresponsive lesions to segmental TARE might be selecting for radioresistant tumors, which might produce an impaired ORR.…”

Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Liver Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma After Segmental Transarterial Radioembolization

Hardy-Abeloos

Lazarev

et al. 2019

International Journal of Radiation Oncology*Biology*Physics

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Purpose: With increasing use of radiation for hepatocellular carcinoma (HCC) through transarterial radioembolization (TARE) and stereotactic body radiation therapy (SBRT), there is concern for increased radiation-related complications when using SBRT after TARE. This study compares safety of SBRT after segmental TARE versus transarterial chemoembolization (TACE). Methods and Materials: A retrospective review identified patients receiving SBRT after TACE or TARE for HCC from 2011 to 2017. TARE was delivered subselectively to individual segments using yttrium-90 with Theraspheres. Patients were assessed over time for Child-Turcott-Pugh (CTP)/albumin-bilirubin (ALBI) scores, and Common Terminology Criteria for Adverse Events version 4.0 grade !3 events. Linear mixed models were used to examine the trend of CTP and ALBI over time and compare groups. Secondary endpoints were objective response rate via modified Response Evaluation Criteria in Solid Tumors (RECIST), local control, and overall survival. Results: Ninety-nine patients met criteria with median follow-up of 9.8 months (range, 0.9-47): 31 had SBRT after segmental TARE and 68 patients post-TACE. The groups were well balanced with regard to etiology of HCC, baseline CTP and ALBI scores, and SBRT dose, but there were significant differences in baseline Eastern Cooperative Oncology Group performance status, Barcelona Clinic Liver Cancer staging, and median follow-up. There was a significant increase in post-SBRT CTP and ALBI scores (P < .0001) for both groups. However, there was no significant difference in rise in CTP (P Z .11) or ALBI score (P Z .82) over time between SBRT post-TACE versus postesegmental TARE. There was no significant increase in !grade 3 toxicity postsegmental TARE. There was also no significant difference in local controls (P Z 1.0) and overall survival (P Z .26) between cohorts, but objective response rate was worse post-TARE. Conclusions: SBRT after segmental TARE with Theraspheres appears to have acceptable tolerability and is effective compared with SBRT after TACE. Longer follow-up with larger numbers is needed to verify these data.

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Magnetic Resonance Imaging Evaluation of Hepatocellular Carcinoma Treated With Stereotactic Body Radiation Therapy: Long Term Imaging Follow-Up

Abstract: SBRT is an effective locoregional treatment option for HCC. Persistent APHE is common and does not necessarily indicate viable neoplasm; thus, standard response assessment such as mRECIST should be used with caution, particularly in the early phases post-SBRT therapy.

Cited by 54 publications

References 41 publications

Natural history of hepatocellular carcinoma after stereotactic body radiation therapy

Natural history of hepatocellular carcinoma after stereotactic body radiation therapy

Clinical Outcome and Pathologic Correlation of Stereotactic Body Radiation Therapy as a Bridge to Transplantation for Advanced Hepatocellular Carcinoma

Safety and Efficacy of Liver Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma After Segmental Transarterial Radioembolization

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