Three-dimensional conformal radiation therapy for unresectable hepatocellular carcinoma patients who had failed with or were unsuited for transcatheter arterial chemoembolization

Background: The purpose of our study was to evaluate the outcome of unresectable hepatocellular carcinoma (HCC) patients, who had either failed with or were unsuited for transcatheter arterial chemoembolization (TACE), treated with three-dimensional conformal radiation therapy (3DCRT) and to determine the prognostic outcome factors. Methods: From September 1999 to March 2003, 44 patients with unresectable HCC underwent 3DCRT Thirty-seven patients were male and seven female. Mean age was 62 years, ranging from 34 to 88. Eastern Cooperative Oncology Group (ECOG) performance status was 0 in 10 patients, 1 in 19 patients, and 2 in 15 patients. According to Child-Pugh classification for cirrhosis of the liver, 32 patients were in class A and 12 patients in class B. There were 14 patients with main portal vein thrombosis. Twenty patients had alpha-fetoprotein (AFP) level >400 ng/ml. Tumor size was <5 cm in 16 patients, 5-10 cm in 16 patients, and >10 cm in 12 patients. Thirty-two patients had tumors of confluent type, the remaining patients presented a single hepatic tumor. Serum hepatitis antigen markers were positive for type B in 35 patients and type C in nine patients. Twenty-one patients had Okuda Stage I, 22 patients Stage II, and one patient Stage III. According to the AJCC staging system (5th edition), eight patients were in Stage II (T2N0M0), 19 in Stage IIIA(T3NOMO)and 17 in Stage IVA (T4N0M0). Results: An objective response was observed in 27 of 44 patients, giving a response rate of 61.4%.The survival rates at 1, 2 and 3 years were 60.5%, 40.3% and 32.0%, respectively. In the analysis of prognostic factors, Okuda stage, AJCC stage, portal vein thrombosis, pretreatment AFP level, and total dose of radiotherapy all had significant impact on survival. Conclusions: 3DCRT induced a substantial tumor response rate of 61.4% with survival rates at 1, 2 and 3 years of 60.5%,40.3% and 32.0%, respectively, and a median survival time of 15.2 months in patients with unresectable HCC who had either failed with or were unsuited for TACE. The complications are acceptable and can be managed with conservative treatment. Although we do not know whether there is a survival benefit through the use of this treatment, 3DCRT seems to be a practical method of salvage for this subset of patients. Further study is warranted to evaluate the survival of such patients with and without this treatment.