External Beam Radiation Therapy for Primary Liver Cancers

Patient Guideline Summary

Publication Date: October 20, 2021

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American Society for Radiation Oncology (ASTRO) for External Beam Radiation Therapy for Primary Liver Cancers. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Two types of liver cancer are addressed in this guideline: hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC).

We will use the above abbreviations throughout this summary to refer to those two entities and EBRT to refer to External Beam Radiation Therapy.

Risk factors for HCC are hepatitis B and C virus infection and nonalcoholic fatty liver disease.

Risk factors for IHC include smoking, diabetes, and previous liver or biliary damage.

At some point, liver cancer has been treated with every known method.
- For cure, there is a transplantation, surgery, and thermal ablation.
- For local and regional control, catheter-based methods are used.
- For cancer extent that is unlikely to be cured, immunotherapy and targeted agents are currently the standard of care.

EBRT has recently been reconsidered due to an improved understanding of the mechanisms involved.

This patient summary focuses on radiotherapy for these two cancer types.

Treatment

HCC

EBRT is recommended for liver-confined HCC cancer
- as “potential first-line” treatment if not judged to be curable
- alone or with catheter-based methods for unresectable HCC
- after an incomplete response to other treatments
- for local recurrence after other treatments
- alone or with other treatments for macrovascular invasion or palliation of symptoms.

Prior to surgery, EBRT is recommended
- in preparation for transplant
- for patients with potentially removable portal vein blood clotting.

EBRT Technique for HHC
- Dose escalation and hypofractionation (hypofractionated radiotherapy is the delivery of fewer, larger doses of radiotherapy made possible by more precise targeting of the cancer) are to be considered depending on cancer characteristics.
- Moderate hypofractionation is recommended for macrovascular invasion.
- Intensity-modulated radiation therapy (IMRT) or proton therapy and respiratory motion management and daily image guidance are recommended for patients receiving dose escalation and hypofractionation.
- The radiation dose must be calculated to minimize radiation damage to the liver.

IHC

EBRT is recommended after chemotherapy in unresectable IHC.
EBRT is recommended after curative-intent surgery, alone or with concurrent chemotherapy, in high-risk patients.

EBRT Technique for IHC
- Dose escalation and hypofractionation are to be considered depending on cancer characteristics.
- After surgery, standard fractionation is recommended.
- Intensity-modulated radiation therapy (IMRT) or proton therapy and respiratory motion management and daily image guidance are recommended for patients receiving dose escalation and hypofractionation.
- The radiation dose must be calculated to minimize radiation damage to the liver.

Abbreviations

ASTRO: American Society For Radiation Oncology
EBRT: External Beam Radiotherapy
HCC: Hepatocellular Carcinoma
IHC: Intrahepatic Cholangiocarcinoma
IMRT: Intensity-modulated Radiation Therapy

Source Citation

Apisarnthanarax S, Barry A, Cao M, Czito B, DeMatteo R, Drinane M, Hallemeier CL, Koay EJ, Lasley F, Meyer J, Owen D, Pursley J, Schaub SK, Smith G, Venepalli NK, Zibari G, Cardenes H. External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol. 2021 Oct 21:S1879-8500(21)00233-2. doi: 10.1016/j.prro.2021.09.004. Epub ahead of print. PMID: 34688956.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.