Local radiotherapy with or without transcatheter arterial chemoemboliziation for patients with unresectable hepatocellular carcinoma

Purpose: To evaluate the treatment outcome, patterns of failure, and progno stic factors for patients with unresectable hepatocellular carcinoma (HCC) treated with local radiotherapy alone or as an adjunct to transcatheter art erial chemoembolization (TACE). Methods and Materials: From March 1994 to December 1997, 25 patients with u nresectable HCC underwent local radiotherapy to a portion of the liver. Twe nty-three patients were classified as having cirrhosis in Child-Pugh class A and 2 in class B. Mean diameter of the treated hepatic tumor was 10.3 cm. Mean dose of radiation was 46.9 +/- 5.9 Gy in a daily fraction of 1.8-2 Gy . Sixteen patients were also treated with Lipiodol and chemotherapeutic age nts mixed with Ivalon or Gelfoam particles for chemoembolization, either be fore and/or after radiotherapy. Percutaneous ethanol injection therapy (PEI T) was given to one patient. All patients were monitored for treatment-rela ted toxicity and for survival and patterns of failure. Results: In a median follow-up period of 23 months, 11 patients were alive and 14 dead. The median survival duration from treatment was 19.2 months wi th a 2-year survival of 41%. Only 3 of 25 patients had local progression of the treated hepatic tumor. The recurrences were seen within the liver or e xtrahepatic. The 2-year local, regional, and extrahepatic progression-free survival rates were 78%, 46%, and 39%, respectively. The local control rank ed the highest. Patients with Okuda Stage I disease had significantly longe r survival than those with Stage II and III (p = 0.02). Patients with T4 di sease (p = 0.02) or treated with radiotherapy alone (p = 0.003) had signifi cantly shorter survival. T4 disease (p = 0.03) and pretreatment alpha-fetop rotein level of more than 200 ng/ml (p = 0.03) were associated with signifi cantly worse regional progression-free survival. A significant difference w as observed in both regional progression-free survival (p = 0.0001) and ext rahepatic progression-free survival (p = 0.005) between patients with and w ithout portal vein thrombosis before treatment. The presence of satellite n odules had a significantly worse impact on regional progression-free surviv al (p = 0.04) and extrahepatic progression-free survival (p = 0.03). Patien ts with hepatic tumor more than 6 cm in diameter or portal vein thrombosis tended to have shorter survival. Radiation-induced liver disease (RILD) and gastrointestinal bleeding were the most common treatment-related toxicitie s. Conclusion: Radiotherapy is effective in the treatment of patients with unr esectable HCC. Its effect appeared to be more prominent within the site to which radiation was given. The combination of TACE and radiation was associ ated with better control of HCC than radiation given alone, probably due to the selection of patients with favorable prognosis for the combined treatm ent. A dose-volume model should be established in the next phase of researc h in the treatment of unresectable HCC. (C) 2000 Elsevier Science Inc.