Hong Kong Consensus Statements for the Management of Unresectable Hepatocellular Carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is highly prevalent in Hong Kong due to the high prevalence of chronic hepatitis B infection. Liver cancer is the fourth most common cancer and the third most common cause of cancer death. Due to the high case load, there is a high level of local expertise in treating HCC, and the full spectrum of treatment modalities is available. This document summarizes how these modalities should be used based on the latest evidence. SUMMARY: In 2 meetings held in early 2017, a multidisciplinary group of Hong Kong clinicians, including liver surgeons, interventional radiologists, clinical oncologists, and medical oncologists, met to update local consensus statements for management of HCC. These statements are based on the latest evidence and give detailed guidance on how to deploy these modalities, in particular for cases of HCC which are not suited to surgical resection. KEY MESSAGES: These statements give detailed information on how to decide if a patient is a candidate for resection, methods to improve candidacy for resection, and guidance for use of various nonsurgical interventions to manage patients ineligible for resection.

Limitation of radiological T3 subclassification of rectal cancer due to paucity of mesorectal fat in Chinese patients.

OBJECTIVES: To describe the thickness of mesorectal fat in local Chinese population and its impact on rectal cancer staging. DESIGN: Case series. SETTING: Two local regional hospitals in Hong Kong. PATIENTS: Consecutive patients referred for multidisciplinary board meetings from January to October 2012 were selected. MAIN OUTCOME MEASURES: Reports of cases that had undergone staging magnetic resonance imaging for histologically proven rectal cancer were retrospectively retrieved and reviewed by two radiologists. All magnetic resonance imaging examinations were acquired with 1.5T magnetic resonance imaging. Measurements were made by agreement between the two radiologists. The distance in mm was obtained in the axial plane at levels of 5 cm, 7.5 cm, and 10 cm from the anal verge. Four readings were obtained at each level, namely, anterior, left lateral, posterior, and right lateral positions. RESULTS: A total of 25 patients (16 males, 9 females) with a median age of 69 (range, 38-84) years were included in the study. Mean thickness of the mesorectal fat at 5 cm, 7.5 cm, and 10 cm from the anal verge was 3.1 mm (standard deviation, 3.0 mm), 9.8 mm (5.3 mm), and 11.8 mm (4.2 mm), respectively. The proportions of patients with mean mesorectal fat thickness of <15 mm were 100%, 84%, and 75% at 5 cm, 7.5 cm, and 10 cm from the anal verge, respectively. The thickness of mesorectal fat was the least anteriorly, and <15 mm at all three arbitrary levels (P<0.001). CONCLUSION: The thickness of mesorectal fat was <15 mm in the majority of patients and in most positions. Tumours invading 10 mm beyond the serosa on magnetic resonance imaging may paradoxically threaten the circumferential resection margin in Chinese patients. Use of T3 subclassification of rectal cancer in Chinese patients may be limited.

Treatment of primary liver cancer using highly-conformal radiotherapy with kV-image guidance and respiratory control.

PURPOSE: To implement a reliable, practical and reproducible treatment procedure, based on in-room kV-image guidance and respiratory control, for liver cancer patients treated with high dose conformal radiotherapy using a commercially available treatment system. MATERIALS AND METHODS: CT stimulation was conducted under voluntary breath hold or gating using the Varian Real-time Position Management™ (RPM) System. Treatments were delivered daily under kV image guidance to verify the diaphragmatic or lipiodol-defined tumor position. RESULTS: Thirty-three patients with liver confined hepatocellular carcinoma were treated between May 2006 and Dec 2009. After a median follow-up period of 16.5 months (range: 3.5-40.7), all but 2 patients demonstrated radiological tumor regression. Eight patients (24%) achieved complete remission. The median tumor shrinkage was 42% (27-100%). Subsequent in-field tumor progression was observed in only three patients (10%). For the 23 patients with abnormal alpha fetoprotein level, 22 of them showed biochemical response with a median AFP level drop of 78%. The treatment was well tolerated: Grade 3 toxicities occurred in 5 patients (1 leucopenia, 1 elevated liver enzyme and 3 elevated bilirubin level) but there was no grade 4 toxicity or treatment related death. The 1 year overall survival rate is 71.7% and median survival time is 17.2 months (3.5-40.7 months). CONCLUSIONS: Excellent treatment results with minimal toxicities could be achieved in a clinical environment with a commercially available highly sophisticated radiotherapy system.

Adjuvant chemoradiation for resected gastric cancer: a 10-year experience.

BACKGROUND: The Intergroup 0116 study demonstrated that concurrent chemoradiation improved overall survival (OS) in resected gastric cancer. However, there are few reports focusing on late toxicity and factors governing prognosis. This study aimed to determine these two important aspects for employing this regimen. METHODS: Patients with resected gastric cancer stage IB to IV (M0) disease, treated between July 1998 and December 2007, were analyzed. The majority of the patients were treated using 5 cycles of 5-fluorouracil (5FU)/leucovorin chemotherapy with 45 Gy/25 fractions radiotherapy concurrent with cycles 2 and 3, as per the Intergroup 0116 study. RESULTS: We treated 120 patients (107 standard protocol, 13 with concurrent 5FU alone), and 14% had a close or positive margin. Median age was 59 years (35-79 years). Acute toxicity ≥ grade 3 was seen in 66% of all patients (hematological 61%, stomatitis 3%, diarrhea 6%, vomiting 2%). Median follow-up was 33 months (range 6-125 months). Five-year OS and relapse-free survival were 51 and 54%, respectively. On multivariate analysis, surgical margin status, stage of the disease, and radiotherapy with computed tomography (CT) planning were important prognostic factors. Anemia and gastritis were the two most frequently occurring late complications, though they were usually mild and asymptomatic. Clinically significant renal impairment was uncommon. Other rare complications included intestinal obstruction, malabsorption, hypertension, and secondary malignancy. CONCLUSIONS: Postoperative chemoradiation is safe and late toxicity is usually mild in extent. Results were comparable to the Intergroup 0116 study. R0 resection is of utmost importance and radiotherapy should best be delivered by conformal techniques.

Screening for family members of patients with nasopharyngeal carcinoma.

Nasopharyngeal carcinoma (NPC) is well known for its peculiarly skewed distribution with highest incidence in Southern Chinese population. Familial aggregation is evident, hence screening for early detection is offered by oncology centers in Hong Kong to first-degree relatives of patients with NPC. During the period 1994-2001, 929 family members were screened in our center. The screenees were advised to attend an annual examination that includes serological test against Epstein Barr Virus (EBV), physical examination to exclude cervical lymphadenopathy and cranial nerve palsy, and endoscopic examination of the nasopharyngeal region. Two different methods were used for the serology test: indirect immuno-fluorescent (IF) test for IgA against viral capsid antigen; and starting in 1997 enzyme-linked immunosorbent assay (ELIZA) against nuclear antigen and viral capsid antigen. Twelve cases of nasopharyngeal carcinoma were diagnosed, giving a detection rate of 5/1,155 (433/100,000) person-year for male and 7/1,404 (499/100,000) person-year for female participants observed. The corresponding average annual incidence in Hong Kong during this period was 24.1 and 9.6 per 100,000, respectively. Forty-one percent of these detected cases had Stage I disease, whereas only 2% of patients referred to the department for primary treatment presented with such early disease. Six cases were detected at first visit, and all were EBV-positive. Another 78 screenees with positive serology at first visit were followed up for 204 person years, and thus far NPC was detected in 3 after an interval of 6-32 months. Of the 845 initially EBV-negative screenees followed up for 2,337 person-years, NPC was detected in 3 after an interval of 12-45 months. One showed sero-conversion at the time of diagnosis. We conclude that family members of known patients do show a substantially higher risk of developing NPC, and regular screening by current method improves the chance of early detection.