Clinical and Dosimetric Results of Proton or Photon Radiation Therapy for Large (>5 cm) Hepatocellular Carcinoma: A Retrospective Analysis.

PURPOSE: Our purpose was to report the clinical and dosimetric attributes of patients with large unresectable hepatocellular carcinoma (HCC) undergoing proton or photon radiation therapy. METHODS AND MATERIALS: We retrospectively analyzed the outcomes and dosimetric indices of 159 patients with >5 cm nonmetastatic HCC who underwent definitive radiation therapy using either protons (N = 105) or photons (N = 54) between 2014 and 2018. Additional photon plans were performed in the 105 proton-treated patients using the same dose prescription criteria for intragroup dosimetric comparison. RESULTS: After a median follow-up of 47 months, patients with biologically effective dose (BED10) ≥ 75 Gy exhibited significantly better local control (LC; 2-year: 85.6% vs 20.5%; P < .001), progression-free survival (PFS; median, 7.4 vs 3.2 months; P < .001), and overall survival (OS; median, 18.1 vs 7.3 months; P < .001) compared with those with BED10 < 75 Gy. Notably, proton-treated patients had a significantly higher BED10 (96 vs 67 Gy; P < .001) and improved LC (2-year: 88.5% vs 33.8%; P < .001), PFS (median, 7.4 vs 3.3 months; P = .001), and OS (median, 18.9 vs 8.3 months; P < .001) than those undergoing photon radiation therapy. Furthermore, patients treated with protons had significantly lower V1 of the liver (P < .001), mean upper gastrointestinal tract dose (P < .001), and mean splenic dose (P < .001), with significantly decreased incidences of radiation-induced liver disease (P = .007), grade ≥3 upper gastrointestinal bleeding (P = .001), and grade ≥3 lymphopenia (P = .003). On multivariate analysis, proton radiation therapy consistently correlated with superior LC (P < .001), PFS (P < .001), and OS (P < .001). In intragroup dosimetric comparison, photon plans demonstrated significantly higher mean liver dose (P < .001) compared with actually delivered proton treatments, and 72 (69%) of them had mean liver dose exceeding 28 Gy, which necessitated target dose de-escalation. CONCLUSIONS: In the context of large HCC radiation therapy, a higher target BED10 was associated with improved outcomes. Notably, proton therapy has demonstrated the capability to deliver ablative doses while also being accompanied by fewer instances of severe toxicity.

A preliminary study of hepatocellular carcinoma post proton beam therapy using MRI as an early prediction of treatment effectiveness.

PURPOSE: To demonstrate the feasibility of magnetic resonance imaging (MRI) for early prediction of proton beam therapy (PBT) effectiveness in hepatocellular carcinoma (HCC). METHODS: Clinical data of the HCC patients without regional lymph node involvement or distant metastasis who received PBT at this institution between 2014 and 2017 were reviewed. A total of 43 patients were included. Tumor regression pattern after PBT were examined on the basis of follow-up duration. The variables were compared between patients with and without early tumor regression (ETR). RESULTS: The median follow-up duration was 40 months (range, 9-62 months). The cumulative overall survival rate at 6 months, 1 years and 5 years was 100%, 88.4%, 63.4%, respectively. Child-Pugh class A, local tumor control (LTC), complete response (CR), and ETR were significantly associated with overall survival (p < 0.05 each). Of 43 patients, 25 patients (58.1%) reached CR in the PBT-irradiated region. Twelve patients (27.9%) had a partial response and 3 patients (7.0%) had a stationary disease. Three patients (7.0%) developed in-field progression. The LTC rate at 5 years was 93.0%. Of the 25 patients who achieved a CR in the PBT-irradiated region, the median time to CR was 5 months (range, 1-19 months). Twenty-two patients (51.2%) showed ETR of the HCC, while 21 patients (48.8%) showed non-ETR. A significant association was observed between ETR and CR of the HCC after PBT (p < 0.001). CONCLUSION: The post-PBT MRI follow-up at 3 months is helpful for monitoring therapeutic response. ETR of the HCC predicted a higher rate of CR and was associated with overall survival, which provides more accurate clinical management.

Risk of nephrogenic systemic fibrosis in patients with impaired renal function undergoing fixed-dose gadoxetic acid-enhanced magnetic resonance imaging.

PURPOSE: To assess the risk of nephrogenic systemic fibrosis (NSF) in patients with renal impairment undergoing gadoxetic acid-enhanced magnetic resonance imaging. METHODS: This retrospective study included patients who had an estimated glomerular filtration rate (eGFR) below 60 mL/min per 1.73 m2 or had undergone dialysis around the time of gadoxetic acid exposure from January 2010 to November 2019. All patients received at least one intravenous injection of gadoxetic acid at a fixed dose of 2.5 mmol. The primary endpoint was the development of NSF after exposure to gadoxetic acid based on Girardi's clinicopathological scoring system. RESULTS: A total of 204 patients with renal impairment received 424 injections of gadoxetic acid, of which 131 and 54 had an eGFR of 30-59 and < 30 mL/min per 1.73 m2, respectively, and 19 had undergone hemodialysis. Eighty-two patients received multiple injections, with 23 receiving five or more injections. The dose of each exposure ranged from 0.02 to 0.07 mmol/kg and the cumulative doses ranged from 0.02 to 0.45 mmol/kg. Thirty-three patients had concomitant Child-Pugh class B or C cirrhosis. No NSF was detected during follow-up (median 20 months; range 6 days to 111 months). The upper bound of the 95% confidence interval for NSF risk was 2.2% and 1.1% per patient and examination, respectively. CONCLUSION: No NSF was detected in this study. However, it is premature to ascertain the risk of NSF using gadoxetic acid in patients with renal impairment and further studies are warranted.

Response Findings after Treatment and Outcomes on CT after Endovascular Repair of Mycotic Aortic Aneurysm.

PURPOSE: To demonstrate post-treatment computed tomography (CT) findings and outcomes of endovascular aortic repair (EVAR) for mycotic aortic aneurysm (MAA). MATERIALS AND METHODS: Clinical data of patients with MAA who underwent EVAR from June 2010 to December 2017 were retrospectively reviewed. A total of 22 patients were included (19 men and 3 women). The periaortic features of the MAA regression after EVAR were graded and evaluated by follow-up CT. RESULTS: The median follow-up was 36.5 months (range, 0.5-97 months.). The cumulative survival rate at 1 month, 6 months, 1 year, and 5 years was 95.5%, 86.4%, 81.6%, and 73.4%, respectively. The early and late infection-related complication (IRC) rate was 18.2% and 13.6%, respectively. One patient died within 1 month from severe acidosis and shock. Of the other patients, the median time to stable response of the MAA was 6 months (range, 3-36 months). Fourteen patients (66.7%) showed early response of the MAA, while 7 patients (33.3%) showed delayed response. A significant association was observed between delayed response and late IRCs (P = .026). CONCLUSIONS: The post-EVAR periaortic features on follow-up CT aid in monitoring the treatment response of the MAA. Early response of the MAA was associated with a low rate of late IRCs and might aid in adjusting the antibiotic duration after the patient has achieved complete or nearly complete regression of the MAA.

Predictive Factors for Additional ProGlide Deployment in Percutaneous Endovascular Aortic Repair.

PURPOSE: To evaluate outcomes and predictive factors for additional ProGlide device deployment in percutaneous endovascular aortic repair (PEVAR) with the preclose technique. MATERIALS AND METHODS: Clinical data of patients who underwent PEVAR with the preclose technique from February 2012 to January 2015 were retrospectively reviewed. A total of 268 patients (229 men, 39 women) who underwent PEVAR (thoracic endovascular aortic repair [TEVAR], n = 113; endovascular abdominal aortic repair [EVAR], n = 152; simultaneous TEVAR and EVAR, n = 3) with 418 femoral access sites were enrolled. The mean age of the patients was 69 years ± 14. Univariate and multivariate analyses were performed to identify predictive factors associated with additional ProGlide device deployment. RESULTS: Primary technical success with adequate hemostasis and two ProGlide devices was 87.6%, and 48 femoral arterial access sites (11.5%) required additional ProGlide device deployment. The secondary technical success rate was 99.0%. Four femoral access sites (1.0%) needed surgical repair. Anterior wall calcification near the arteriotomy increased the risk of additional ProGlide device deployment (adjusted odds ratio, 6.19; 95% confidence interval, 2.81-13.64; P < .001), whereas larger sheath size, common femoral artery (CFA) diameter, and depth from the skin to the arteriotomy did not. CONCLUSIONS: Additional ProGlide device deployment reduces the rate of surgical repair after primary hemostasis failure in PEVAR. Anterior CFA wall calcification is a significant predictor for additional ProGlide device deployment.

Impact of spontaneous tumor rupture on prognosis of patients with T4 hepatocellular carcinoma.

BACKGROUND AND OBJECTIVES: Compare the outcomes of three groups of patients with T4 hepatocellular carcinoma (HCC): tumor rupture with shock (RS group), tumor rupture without shock (R group), and no tumor rupture (NR group). MATERIALS AND METHODS: We retrospectively reviewed 221 patients with T4 HCC from 2010 to 2012. The clinical background and prognosis were analyzed. RESULTS: Overall in-hospital mortality rate was 18.1%; overall median survival time was 4 months. The NR group were more likely to have multiple and infiltrative tumors (P < 0.001). Relative to the NR group, the R + RS group had better survival rates at 6 months (49.2% vs. 32.2%), 1 year (35.3% vs. 21.0%), 3 years (22.5% vs. 11.0%), and 5 years (17.7% vs. 5.5%) (P = 0.010). Patients in the RS group had a higher in-hospital mortality rate, but significantly better long-term survival than the NR and R group (P < 0.001). Multivariate analysis indicated that Child-Pugh class B or C, presence of portal venous thrombosis, and absence of shock were significantly associated with poor survival. CONCLUSION: Patients with tumor rupture and shock had worse in-hospital survival. However, patients without decompensated liver cirrhosis and portal venous thrombosis, and eligible for curative treatment had favorable long-term outcome. J. Surg. Oncol. 2016;113:789-795. © 2016 The Authors. Journal of Surgical Oncology Published by Wiley Periodicals, Inc.