Stereotactic Body Radiation Therapy (SBRT) for Hepatocellular Carcinoma: High Rates of Local Control with Low Toxicity

Abstract

Recent data show that overall survival after endoscopic mucosal resection (EMR) is similar to esophagectomy, however, limited data exists regarding the comparative efficacy of definitive radiotherapy (RT) for the treatment of T1N0 esophageal cancer. We sought to investigate the patterns of practice for the treatment of T1N0 esophageal cancer in the United States as well as to evaluate the comparative efficacy of esophagectomy vs EMR vs RT. Materials/Methods: Patients with clinical T1N0 esophageal carcinoma who underwent esophagectomy, EMR or RT (45 e 70 Gy) were identified from the National Cancer Database (NCDB) from 2004 to 2013. Univariate (UVA) and multivariable (MVA) effects of treatment type on survival were assessed using Cox proportional hazards regression. Overall survival (OS) was compared using Kaplan-Meier analysis and the log-rank test. Variables with p<0.001 were included in the MVA for OS. Results: 6,262 met criteria for inclusion in this study: 2,995 (48%) underwent esophagectomy, 2,130 (34%) underwent EMR and 1,137 (18%) underwent RT. Only 3 patients underwent esophageal brachytherapy. Median age was 68 years, and patients undergoing RT were older (72 y) compared to those undergoing esophagectomy (65 y) or EMR (70 y) (p<0.0001). In the esophagectomy, EMR and RT groups, 70%, 75% and 72% of patients had a Charlson score of 0, respectively. Median follow-up was 34 months. Median RT dose was 50.4 Gy and 78% underwent concurrent chemotherapy. 30 day mortality was 3.1% for esophagectomy and 0.6% for EMR. In recent years, EMR was more frequently utilized, rising from 23% to 43% whereas esophagectomy and RT were less frequently utilized in the same time period (p<0.0001). RT was more frequently utilized at non-academic centers than academic centers, 30.3% vs 9.3%, p<0.0001. Of the patients who underwent esophagectomy, 614 (21%) were upstaged. On MVA, patients with Charlson/Deyo score 1 (HR 1.2, pZ0.0003), older age (HR 1.03, p<0.001), Medicaid or no insurance (HR 1.5, pZ0.003), treatment at non-academic centers (HR 1.1, pZ0.009) and squamous histology (HR 1.3, p<0.001) were predictors of worse OS. There was no difference in OS between patients undergoing esophagectomy or EMR (pZ0.4) and this finding persisted when analysis was limited to T1a patients (pZ0.69). Patients requiring post-operative chemotherapy had a worse OS (HR 1.3, p<0.001). Patients who received definitive RT had a worse OS compared to patients who underwent esophagectomy or EMR (HR 1.8, p<0.001). Conclusion: EMR is increasingly utilized compared to esophagectomy and definitive RT for early esophageal cancer, whereas the utilization of esophageal brachytherapy was rare. Adoption of EMR in lieu of esophagectomy has not compromised survival. Patients undergoing esophagectomy and EMR had a superior OS compared to those who underwent definitive RT. Patients undergoing definitive RT appear to have unfavorable features likely affecting OS.

Narrow-Margin Hepatectomy Resulted in Higher Recurrence and Lower Overall Survival for R0 Resection Hepatocellular Carcinoma

“…Considering the pattern of marginal recurrence itself occurs frequently and it may, subsequently, induce the occurrence of intrahepatic multiple-nodule in patients with narrow margin resection, postoperative local radiotherapy may provide a favorable outcome through its role of local-regional control. To date, with the improvement of radiotherapy techniques, such as intensity modulated radiotherapy (IMRT) and SBRT, a significantly reduced radiation-induced toxicity and increased radiotolerance of normal tissue were obtained ( 39 , 40 ). A few prospective studies have been carried out to demonstrate the feasibility and advantages of adjuvant radiotherapy ( 32 , 41 , 42 ).…”

Multi‐institutional analysis of stereotactic body radiotherapy for sarcoma pulmonary metastases: High rates of local control with favorable toxicity

“…The CyberKnife SBRT technique was discussed in detail in our previous publication 16 . For VMAT linear accelerator‐based SBRT, patients were simulated supine and were immobilized in a custom body‐mold 19 . Respiratory motion was tracked using a 4‐D CT simulation for all patients.…”

Radiation Therapy in HCC: What Data Exist and What Data Do We Need to Incorporate into Guidelines?

“…with SBRT as salvage treatment demonstrate local control rates exceeding 90% [43][44][45] with favorable quality-of-life outcomes and toxicity profiles, which has supported continued interest in the development of SBRT options for patients with HCC.…”

“…Prospective and retrospective studies of SBRT in patients with BCLC Stage A HCC demonstrate excellent local control rates (►Table 1). 45,[48][49][50][51][52][53] In this population, SBRT is commonly performed as salvage treatment after RFA failure or for tumors ineligible for ablation due to size, location, or ultrasound visibility. An early prospective trial from the Netherlands treated eight HCC patients with single lesions up to 7 cm with CP Class A or no cirrhosis and found 1-year local control rates of 80%.…”