Radiotherapy for Hepatocellular Carcinoma

Patients suffering from Hepatitis B and C  infection and, or, alcohol induced liver cirrhosis,  are more prone to develop hepatocellular carcinoma, i.e. liver cancer. Aflatoxin toxicity,   as well as fatty liver, may also make a person more prone to this aggressive cancer, considered among the top few causes of dying due to cancer.

Treatment of this cancer is linked to the general health status of the patient, the health of his liver, the number and size of the cancerous lesions, as well as the presence of the tumour in major vessels, nodes or other organs of the body.

Resection of a part of the liver, or removal of the entire liver, accompanied by transplanting the liver of a donor, has a high chance of resulting in cure. This treatment is, however, generally reserved for patients who  either have a  moderately sized single tumour, or  small tumours  less than 3 in number,  with good general health, and good functional capacity of the liver.

Patients with more extensive tumours, which are still confined to the liver, may undergo local treatments, with a view to controlling the tumour. This is done with the intent of making the  tumour amenable to  surgery  (downstaging), to buy time while the patient is on a waiting list for a donated liver, or, in some situations, as the sole therapy to prolong the life of a patient.

One of the therapies that is used is Trans Arterial Chemo Embolisation (TACE).  Performed by interventional radiologists, TACE involves  insertion of a catheter in the  blood vessel feeding the tumour, instillation of chemotherapy, locally into the tumours, and then closing off the blood supply to the tumour, thus allowing the drug to act locally.

Radiotherapy is the treatment of cancer using X rays. Various sophisticated techniques, that are an integration of advances in  computer software and in treatment machines called linear accelerators, enable safe radiotherapy. Tumours can be targeted better, notwithstanding their irregular shape, proximity to vital organs or movement with respiration or other bodily functions.

Radiotherapy was earlier considered ineffective for liver cancers; improvement in radiotherapy techniques has resulted in improvement in the therapeutic ratio, i.e. the chance of curing the tumour vis a vis the risk of damaging normal organs. With this improvement, high doses of radiotherapy can be administered, leading to  better chances of controlling tumours. Techniques used for this treatment are Intensity Modulated Radiotherapy ( IMRT) and  Volume Modulated Radiotherapy (VMAT), also called RapidArc. These treatments are delivered under image guidance, i.e. the patient is scanned, prior to each radiotherapy session, on the treatment couch itself, for accuracy. This is called Image Guided Radiotherapy ( IGRT). Since, with these mechanisms, the tumour is targeted accurately and the  bowel and normal liver spared well, very high doses of radiotherapy may be delivered in limited number of sessions; this is called Stereotactic Ablative Radiosurgery (SABR) or Stereotactic Body Radiotherapy  ( SBRT).

Stereotactic Ablative Radiosurgery dose colour wash for a lesion in the liver ( outlined in red).

Radiosurgery may be administered as the sole therapy for patients too unwell for surgery. It may also be used as bridge therapy for patients on a waitlist for liver transplant. This has the twin role of preventing progression during the waiting period as well as identifying patients with aggressive tumours that should not be treated with aggressive surgery, anyway.

Another application is as a treatment for patients with a portal vein tumour thrombus ( PVTT). Patient with any vascular involvement are thought to have a poor prognosis. Adding radiotherapy to the treatment protocol, alone , or along with TACE , is thought to improve the outcome for some patients suffering from HCC with PVTT. 

The treatment of HCC using  SABR/SBRT or the more protracted SHORT typically takes 2 - 3 weeks. In case surgery is planned following radiation, it may be performed anytime from 2 weeks to 6 months later.

In conclusion,  surgery is the ideal treatment for HCC. Non surgical options like TACE and SABR/SHORT help prepare patients for surgery as well as offer a possibility of controlling the disease for sometime, in case surgery is not possible.