A new clinical guideline from the American Society for Radiation Oncology (ASTRO) provides guidance on the use of external-beam radiation therapy (EBRT) to treat adults with primary liver cancers. The guideline, ASTRO’s first for primary liver cancers, is published in Practical Radiation Oncology.1
Common treatment options for primary hepatocellular carcinoma include liver transplantation, surgical removal of the tumor, thermal ablation, and catheter-based therapies for patients whose disease is confined to the liver, and systemic therapy for those whose disease is more advanced. For intrahepatic cholangiocarcinoma, standard treatment includes a combination of surgery and chemotherapy, with or without radiation. EBRT, which aims high doses of targeted radiation at tumor sites from outside the body with noninvasive techniques, has historically been used less frequently than other approaches.
“Patients diagnosed with liver cancer often have a number of treatment options available to them, and they should be presented with each of them before a treatment course is decided. The different disciplines—hepatology, surgical oncology, interventional radiology, and radiation oncology—should all be involved in multidisciplinary treatment discussions to determine what might be best for each patient,” said Smith Apisarnthanarax, MD, Vice Chair of the Guideline Task Force, Medical Director of the Seattle Cancer Care Alliance, and Professor of Radiation Oncology at the University of Washington, Seattle.
Smith Apisarnthanarax, MD
Recommendations in the guideline address patient selection, as well as planning and delivery techniques for EBRT in a range of clinical situations, including definitive/nontransplant, consolidative, salvage, preoperative (including bridge-to-transplant), postoperative, and palliative treatment settings. With an emphasis on multidisciplinary discussion and planning, key recommendations follow:
EBRT is strongly recommended as a potential first-line treatment for patients with hepatocellular carcinoma confined to the liver who are not candidates for curative therapy; consolidative therapy for patients with incomplete responses to other liver-directed treatments; and salvage therapy option for patients with local recurrences after other treatment. EBRT is conditionally recommended for patients with multifocal or unresectable hepatocellular carcinoma confined to the liver; and patients with macrovascular invasion, when sequenced with systemic or catheter-based therapies. The guideline includes treatment algorithms for the management of hepatocellular carcinoma that is confined to the liver and hepatocellular carcinoma with macrovascular invasion.
EBRT is conditionally recommended in the palliative setting for symptomatic primary hepatocellular carcinoma and/or hepatocellular carcinoma that has invaded a blood vessel. It also is conditionally recommended as a bridging therapy prior to liver transplantation or before surgery in carefully selected patients.
For patients with unresectable intrahepatic cholangiocarcinoma, EBRT with or without chemotherapy should be considered, typically after systemic therapy. For patients with resected intrahepatic cholangiocarcinoma and high-risk features, adjuvant EBRT is conditionally recommended. The guideline includes treatment algorithms for unresectable and resectable intrahepatic cholangiocarcinomas.
Finally, the guideline addresses optimal dosing, fractionation, treatment planning, and delivery techniques for EBRT, emphasizing that therapy should be based on individual factors including the extent and location of the cancer, underlying liver function, and available treatment technologies.
DISCLOSURE: Dr. Apisarnthanarax has served as a consultant to and received honoraria from Medtronic. For full disclosures of the other study authors, visit practicalradonc.org.
1. Apisarnthanarax S, Barry A, Cao M, et al: External beam radiation therapy for primary liver cancers. Pract Radiat Oncol 12:28-51, 2022.