Speaker
Dr
Francesco Dionisi
(ATREP Agenzia provinciale per la Protonterapia, APSS Trento)
Description
Purpose: To investigate the “state of the art” of proton therapy in the management of hepatocellular carcinoma (HCC) in terms of 1) the worldwide adoption of this technique , 2) the proton delivery modality and 3) the treatment toxicity and the reported outcome.
Materials and Methods: A systematic review of published reports for the period 1985-2012 was performed according to the PRISMA guidelines with the following inclusion criteria: at least 5 patients, English language, at least 1 year follow up.
Results: Inclusion criteria were met by 7 studies (3 prospective, 4 retrospective) from the initial 657 citations retrieved. As of May 2012, six proton centers (2 in USA, 3 in Japan, 1 in China) published their results for the treatment of HCC for a total number of 878 patients. All the facilities adopted delivery techniques based on passively-scattered proton beams. Organ motion was managed by respiratory gating with the use of implanted fiducials in most cases; 4D CT was used in the latest series from USA. Gross tumor volume to clinical target volume (CTV) margins ranged from 0.5 to 1 cm; CTV to planning target volume margins were up to 2.1 cm even with the use of gated techniques. Various schedules of treatment were adopted, depending on tumor stage and location: the total dose delivered ranged from 52 to 84 Gy RBE in 4-38 fractions. Nine cases of radiation induced liver disease were reported; 29 non hematologic G3 toxicities occurred. Eight skin-subcutaneous tissue and 4 gastrointestinal G3 late toxicities were registered along with 3 rib fractures; 3 cases of bile duct stenosis were experienced in the earliest series from Japan. Local control was superior to 80% in all series, with a peak of 90.2% at 5 years in one series from Japan. Survival rates at 5 years were available for the Japanese series, ranging from 23.5% to 44.6%; a 55.9% survival rate at 5 years was registered in the report from Tsukuba for child-pugh A patients.
Conclusion: The encouraging results of the pioneeristic experiences from Japan enabled the slow but steady spread of the use of protons in the treatment of HCC in Western countries. Prospective data are needed; the increasing number of particle therapy centers with new treatment delivery techniques (i.e. active scanning) represents an opportunity to compare protons with the other, non surgical local therapies currently available for HCC treatment, such as x-ray radiotherapy, chemoembolisation and radiofrequency ablation.
Primary author
Dr
Francesco Dionisi
(ATREP Agenzia provinciale per la Protonterapia, APSS Trento)
Co-authors
Dr
Berardino De Bari
(Istituto del Radio, Spedali Civili, Brescia)
Dr
Eva Iannacone
(Radiotherapy Unit, Istituto Nazionali Tumori, Milano)
Dr
Fernando Barbera
(Istituto del Radio, Spedali Civili, Brescia)
Dr
Lamberto Widesott
(ATREP Agenzia provinciale per la Protonterapia, APSS Trento)
Dr
Marco Schwarz
(ATREP Agenzia provinciale per la Protonterapia, APSS Trento)
Dr
Maurizio Amichetti
(ATREP Agenzia provinciale per la Protonterapia (medical director), APSS Trento)
Dr
Paolo Borghetti
(Istituto del Radio, Spedali Civili, Brescia)
Dr
Stefano Lorentini
(ATREP Agenzia provinciale per la Protonterapia)
Prof.
Stefano Magrini
(Istituto del Radio, Spedali Civili, Brescia (Head))
