Proton therapy for hepatocellular carcinoma: Current knowledges and future perspectives

Abstract

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death, as few patients can be treated with currently available curative local modalities. In patients with HCC where curative modalities are not feasible, radiation therapy (RT) has emerged as an alternative or combination therapy. With the development of various technologies, RT has been increasingly used for the management of HCC. Among these advances, proton beam therapy (PBT) has several unique physical properties that give it a finite range in a distal direction, and thus no exit dose along the beam path. Therefore, PBT has dosimetric advantages compared with X-ray therapy for the treatment of HCC. Indeed, various reports in the literature have described the favorable clinical outcomes and improved safety of PBT for HCC patients compared with X-ray therapy. However, there are some technical issues regarding the use of PBT in HCC, including uncertainty of organ motion and inaccuracy during calculation of tissue density and beam range, all of which may reduce the robustness of a PBT treatment plan. In this review, we discuss the physical properties, current clinical data, technical issues, and future perspectives on PBT for the treatment of HCC.

Keywords: Hepatocellular carcinoma; Proton beam therapy; Radiation therapy; X-ray therapy.

Figure 1

Radiation dose distribution according to technique of radiation therapy. Axial views of A: 3-dimentional conformal radiation therapy (3D-CRT); B: Volumetric arc therapy (VMAT); C: Passive scattering proton beam therapy (PBT); D: Pencil beam scanning PBT; sagittal views of E: 3D-CRT; F: VMAT; G: PBT with wobbling technique; H: PBT with pencil beam scanning technique. There are low dose distributions in 3D-CRT (A, E) and VMAT (B, F) due to the exit dose.