Moderated by : Professor Jinsil Seong

1. 1
Research Discussion
Moderated by : Professor Jinsil Seong

2. 22
What has been published?

3. 3
CyberKnife for Liver Cancer
Inoperable primary hepatocellular carcinoma
Combined with transarterial chemoembolization (TACE)1
As sole treatment when other local therapies not indicated2
For recurrences3
Cholangiocarcinoma in combination with chemotherapy4
As a bridge to transplant7
Liver metastases
From various primary tumors5
In patients treated multiple times6
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1Choi et al. BMC Cancer 2008;8:351.
2Louis et al. Technol Cancer Res Treat 2010;9:479-487.
3Huang et al. International journal of radiation oncology, biology, physics 2012;84:355-361.
4Park et al. Gut Liver 2010;4:103-105.
5Ambrosino et al. Anticancer Res 2009;29:3381-3384.
6Lanciano et al. Front Oncol 2012;2:23.
7O’Connor et al. Liver Transplant, 2012 Aug;18(8):949-54.

4. 4
CyberKnife for Liver Cancer
 Korea institute of Radiological and Medical Science
SBRT for inoperable HCC as a salvage after incomplete TACE
 Retrospective
 2008-2011, 50 patients (C-P A/B, tumor <10cm, 1-5 TACE before RT)
 Median prescribed dose: 57 Gy in 3 fractions (range, 42-60 Gy)
 Response rate at 6 mo: 76.6% (CR in 38.3%, PR in 38.3%)
 2 Y LC: 94.6%, 2 Y OS: 68.7%
Korea
Kang et al. Cancer. 2012;118:5424-31.
Kwon et al. BMC Cancer. 2010 Sep 3;10:475
 The Catholic Univ. of Korea
Long term effect of SBRT for HCC ineligible for local treatment
 Retrospective
 2004-2007, 42 patients (C-P A/B, tumor <100 cc, without PVTT)
 Median prescribed dose: 33 Gy in 3 fractions (range, 30-39 Gy)
 In-field response rate at 1 mo: 85.8% (CR in 59.6%, PR in 26.2%)
 1Y OS: 92.9%, 3Y OS: 58.6%

5. 5
CyberKnife for Liver Cancer
 National Defense Medical Center
SBRT for inoperable recurrent HCC
 Retrospective
 2008-2009, 36 patients (recurrent tumor after curative treatment)
 Median prescribed dose: 37 Gy in 4-5 fractions (range, 25-48 Gy)
 Response rate: 58.6% (CR in 22%, PR in 36.6%)
 2Y OS: 64%
 Matched-pair analysis with 138 patients given other or no treatment
- 2Y OS: 72.6% in SBRT group, 42.1% in control group (p=0.013)
 National Defense Medical Center
SBRT or 3DRT for PVTT in HCC patients
 Prospective
 2002-2004, 43 patients (22 in SBRT group, 21 in 3DRT group)
 Median prescribed dose- SBRT: 45 Gy in 15 fractions/ 3DRT: 45 Gy in 25 fractions
 Response rate: 79% (CR in 7%, PR in 71%)
 1Y OS: 100% in CR, 56% in PR
Taiwan
Huang et al. IJROBP 2012 Oct 1;84(2):355-61
Lin CS et al. JJCO 2006 Apr;36(4):212-7

6. 6
CyberKnife for Liver Cancer
 Tianjin Cancer Hospital
Radiosurgery for primary HCC
 Retrospective
 2006-2008, 17 patients (stage I-III, 12 patients received local treatment)
 Median prescribed dose: 45 Gy in 3-8 fractions (range, 39-52 Gy)
 Response rate: 100%
China
Liu et al. Zhonghua Zhong Liu Za Zhi. 2010 Mar;32(3):229-33.

7. 7
CyberKnife for Liver Cancer
 University Hospital Domaine Universitaire Sart Tilman, Belgium
SBRT for inoperable HCC
 Retrospective
 25 patients (CP-A/B, single tumor)
 Median prescribed dose: 45 Gy in 3 fractions
 2Y local control: 95%
 1Y OS: 79%, 2Y OS: 52%
 Baylor Univ. Medical center Dallas, USA
Long-Term Outcomes of SBRT in HCC as a Bridge to Transplantation
 Retrospective
 2005-2010, 10 patients
 Median prescribed dose: 51 Gy in 3 fractions (range, 33-54 Gy)
 CR in 27%, 5Y OS & DFS: 100%
Europe / US
Louis et al. TCRT.Volume 9, Number 5, October 2010
Oconnor et al. Liver Transl 2012 Aug;18:949-954

8. 8
CyberKnife for Liver Cancer
 Indiana Univ. School of Medicine, USA
Phase I feasibility trial of SBRT for HCC
 Prospective, Dose escalation
 21 patients (CP-A/B, tumor ≤ 6 cm)
 Protocol scheme:
36 Gy in 3 fractions > planned escalation until reaching MTD
 2Y local control: 100%, 1Y OS: 75%, 2Y OS: 60%
Europe / US
Price et al. Cancer. 2012 Jun 15;118(12):3191-8
Cardenes et al. Clin Transl Oncol. 2010 Mar;12(3):218-25
 Indiana Univ. School of Medicine, USA
Radiosurgery for primary HCC
 Retrospective
 2006-2008, 17 patients (stage I-III, 12 patients received local treatment)
 Median prescribed dose: 45 Gy in 3-8 fractions (range, 39-52 Gy)
 Response rate: 100%

9. 9
CyberKnife for Liver Cancer
 Centre Oscar Lambret, Lille, France
IG-IMRT for unresectable liver metastasis
 Retrospective
 2007-2009, 42 patients
 Median prescribed dose: 40 Gy in 4 fractions/45 Gy in 3 fractions
 1Y LC: 90%, 2Y LC: 86%
 1Y OS: 94%, 2Y OS: 48%
Europe / US
Vautraver et al. IJROBP 2011 Nov 1;81:39-47

10. 10
TomoTherapy for Liver Cancer
• Locally advanced
• Large lesions
• Multiple lesions
• Liver metastases
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11. 11
TomoTherapy for Liver Cancer
 The Catholic Univ. of Korea
Simultaneous multi-target RT for HCC with multiple extrahepatic mets
 Retrospective
 42 patients (152 intra and extrahepatic metastases)
 Median prescribed dose: 33 Gy in 3 fractions (range, 30-39 Gy)
 In-field response rate at 1 mo: 85.8% (CR in 59.6%, PR in 26.2%)
 1Y OS: 92.9%, 3Y OS: 58.6%
 Yonsei Univ. of Korea
Optimal RT technique for locally advanced HCC
 2006-2007, 12 patients, 60 Gy in 30 fractions
 Comparison of plans(3D-CRT, linac-based IMRT and helical tomotherapy)
 Lower irradiated liver volume at 40, 50 and 60 Gy
 Superior tumor coverage
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Korea
Jang et al. IJROBP 2009 Nov 1;81:39-47
Lee et al. JJCO. 2011 Jul;41(7):882-9

12. 12
TomoTherapy for Liver Cancer
 Shin-Kong Memorial Hospital, National Yang-Ming University
Angiogenic blockade and RT in HCC
 Retrospective
 2007-2008, 23 patients, RT + sunitinib
 Median prescribed dose: 52.5 Gy in 15 fractions
 Response rate: 74%
 1Y OS: 70%
 Vrije Univ. Brussel, Belgium
Phase II study in the multidisciplinary Tx of oligometastatic CRC
 24 patients(≤ 5 metastases, in lung, liver, LN)
 Median prescribed dose: 50 Gy in 5 fractions
 Response rate in metastatic lesion: 55%
 1Y LC: 54%, 1Y PFS: 14%, 1Y OS: 78%
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Chi et al. IJROBP. 2010 Sep 1;78(1):188-93
Engels B et al. Radiation Oncology. 2012 Mar 16;7:34

13. 1313
Current Research Interests?

14. 14
HCC studies and protocols
 Korea CK
 led by Kim of Korea Cancer Center Hospital, multi-institution studies
 Incomplete response after TACE? Sample size?
 60Gy in 3?
 2-year local control, OS?
 Taiwan CK
 led by Ren of Tri-Service General Hospital, Taiwan, multi-institution studies
 TACE ineffective or unsuitable, sample size 150
 Randomized, arm A – SABR and/or Thalidomide/Sorafenib, 4.5-6.5 per faction, 1F
per day, 10 fractions, total 45-60Gy; arm B – TACE and/or Thalidomide/Sorafenib or
observation
 Safety profile, local control and PFS, OS in two years
 China CK
 led by Song of Tianjin Cancer Hospital, multi-institution studies
 Naïve patients, sample size 100
 45Gy in 3
 OS at 1 and 2-year; local control, PFS and acute and late toxicities
 Korea TT
 led by Seong of Yonsei University Medical College
 9-13Gy x 4f

15. 1515
Future Research Direction?

16. 16
Standardizing protocol?
Criteria in selecting the patients?
Impact of target delineation strategies?
Dose and fractionation scheme?
The treatment margins for CK or TT?
Ways of image guidance and motion management?
How can we connect the guidelines to medical
associations in different countries?
SBRT (CyberKnife) and IG-IMRT (TomoTherapy)
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17. 17
Future Research and Regional Synergy
Future research areas/direction?
Possible regional collaboration ?
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