CyberKnife Radiosurgery - Value as an Adjunct to Surgical Treatment of HCC?

Abstract

Introduction: CyberKnife radiosurgery (CK) is an effective tool for the treatment of malignancies. Its greatest potential is in high-dose radiosurgery delivered to targets in organs that move with respiration, e.g., liver tumors. For hepatocellular carcinoma (HCC), however, surgical treatment (resection, transplantation) is most likely to produce long-term survival; for non-resectable tumors, therapies other than radiosurgery are typically recommended. This study evaluated the long-lasting anti-tumor effects of CK combined with surgery in patients with HCC. MATERIALS AND METHODS : Eighteen patients (three women, 15 men) were included in this prospective observational study. They received 21 single-fraction CK treatments (26 Gy). Patient characteristics, treatment effects, tumor response (according to the Response Evaluation Criteria In Solid Tumors (RECIST) grading) and survival were measured for a median period of 29 months.

Results: Local tumor control was achieved in 15 patients, with complete and partial remission observed in 10 and five patients, respectively. One patient was treated for two separate lesions in one session, and one received three treatments each separated by two-year intervals; both patients are tumor-free. Two patients showed minimal response, and in one patient local tumor viability could not be excluded by MRI. Nine patients had HCC recurrence, all distant to the treated site. Nine patients died during follow-up, including two with clear relation to tumor progress. Tumor-free survival was 79.4% after one year and 29.8% after three years, and the corresponding overall survival was 84.8% and 66%. CONCLUSION : This study shows the high effectiveness of single-session frameless CyberKnife radiosurgery for treatment of hepatocellular carcinoma and reconfirms previous results of fractioned radiotherapy of HCC. It also demonstrates the potential of radiosurgery to be combined with surgical concepts.

Keywords: cyberknife; hcc; liver cancer; radiosurgery.

Figure 1. Treatment and follow-up algorithm as approved by the ethics committee.

Figure 2. Intrahepatic distribution of the treated hepatocellular carcinoma lesions.

Figure 3. Treatment of a centrally located hepatocellular carcinoma in segment 7 in a patient with Child A cirrhosis. Imaging before and after CK radiosurgery (above) and prescription planning (below).

Figure 4. Disease-free survival after single-session CK radiosurgery (note that the two patients with repeat treatment are listed as separate events).

Figure 5. Overall survival after single-session CK radiosurgery.