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Case report
peer-reviewed
2 Place Winner

Intensity Modulated Proton Therapy with Advanced Planning Techniques in a Challenging Hepatocellular Carcinoma Patient



Abstract

The use of radiation therapy has been increasing over recent years for the treatment of hepatocellular carcinoma (HCC). Proton beam therapy (PBT) has emerged as a promising treatment option for HCC patients due to its dosimetric advantages of sparing more normal liver tissue from radiation at low to moderate doses compared to photon-based treatments while still delivering high doses of radiation to tumors. The PBT therapy may be particularly beneficial in high-risk HCC cirrhotic patients with large, bulky tumors and/or vascular invasion complicated by surrounding perfusion abnormalities. We present a case of a 62-year-old male with an unresectable 13 cm diffusely infiltrative HCC tumor with main portal vein invasion and elevated alpha-feta protein (AFP) of 37,200 that was intolerant of standard sorafenib treatment. He was treated with hypofractionated PBT to 67.5 GyE in 15 fractions using a novel combination of simultaneously integrated boost intensity modulated proton therapy (SIB-IMPT), breath hold technique, and functional liver imaging with technetium-99m [99mTc] sulfur colloid single-photon emission computed tomography (SPECT/CT) to assist in the differentiation of tumor and normal liver. He had a complete radiographic and biochemical response by AFP normalization by seven months post-treatment without evidence of radiation hepatotoxicity.



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Case report
peer-reviewed

Intensity Modulated Proton Therapy with Advanced Planning Techniques in a Challenging Hepatocellular Carcinoma Patient


Author Information

Smith Apisarnthanarax Corresponding Author

Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center

Jatinder Saini

Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center

Physics, Seattle Proton Therapy Center

Radiation Oncology, Seattle Proton Therapy Center

Avril O'Ryan-Blair

Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

Radiation Oncology, Seattle Proton Therapy Center

Medical Dosimetry, Seattle Proton Therapy Center

Jackie Castro

Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

Radiation Oncology, Seattle Proton Therapy Center

Medical Dosimetry, Seattle Proton Therapy Center

Stephen R. Bowen

Radiation Oncology, University of Washington School of Medicine


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. This case report was conducted under an approved institutional review board study at the University of Washington. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.


Case report
peer-reviewed

Intensity Modulated Proton Therapy with Advanced Planning Techniques in a Challenging Hepatocellular Carcinoma Patient


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Case report
peer-reviewed
2 Place Winner

Proton Therapy: Advanced Applications for the Most Challenging Cases

Intensity Modulated Proton Therapy with Advanced Planning Techniques in a Challenging Hepatocellular Carcinoma Patient

Smith Apisarnthanarax">Smith Apisarnthanarax , Jatinder Saini">Jatinder Saini, Avril O'Ryan-Blair">Avril O'Ryan-Blair, Jackie Castro">Jackie Castro, Stephen R. Bowen">Stephen R. Bowen

  • Author Information
    Smith Apisarnthanarax Corresponding Author

    Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center

    Jatinder Saini

    Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center

    Physics, Seattle Proton Therapy Center

    Radiation Oncology, Seattle Proton Therapy Center

    Avril O'Ryan-Blair

    Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

    Radiation Oncology, Seattle Proton Therapy Center

    Medical Dosimetry, Seattle Proton Therapy Center

    Jackie Castro

    Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

    Radiation Oncology, Seattle Proton Therapy Center

    Medical Dosimetry, Seattle Proton Therapy Center

    Stephen R. Bowen

    Radiation Oncology, University of Washington School of Medicine


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. This case report was conducted under an approved institutional review board study at the University of Washington. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

    Acknowledgements


    Article Information

    Published: September 10, 2017

    DOI

    10.7759/cureus.1674

    Cite this article as:

    Apisarnthanarax S, Saini J, O'ryan-blair A, et al. (September 10, 2017) Intensity Modulated Proton Therapy with Advanced Planning Techniques in a Challenging Hepatocellular Carcinoma Patient. Cureus 9(9): e1674. doi:10.7759/cureus.1674

    Publication history

    Received by Cureus: August 08, 2017
    Peer review began: August 17, 2017
    Peer review concluded: September 02, 2017
    Published: September 10, 2017

    Copyright

    © Copyright 2017
    Apisarnthanarax et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

The use of radiation therapy has been increasing over recent years for the treatment of hepatocellular carcinoma (HCC). Proton beam therapy (PBT) has emerged as a promising treatment option for HCC patients due to its dosimetric advantages of sparing more normal liver tissue from radiation at low to moderate doses compared to photon-based treatments while still delivering high doses of radiation to tumors. The PBT therapy may be particularly beneficial in high-risk HCC cirrhotic patients with large, bulky tumors and/or vascular invasion complicated by surrounding perfusion abnormalities. We present a case of a 62-year-old male with an unresectable 13 cm diffusely infiltrative HCC tumor with main portal vein invasion and elevated alpha-feta protein (AFP) of 37,200 that was intolerant of standard sorafenib treatment. He was treated with hypofractionated PBT to 67.5 GyE in 15 fractions using a novel combination of simultaneously integrated boost intensity modulated proton therapy (SIB-IMPT), breath hold technique, and functional liver imaging with technetium-99m [99mTc] sulfur colloid single-photon emission computed tomography (SPECT/CT) to assist in the differentiation of tumor and normal liver. He had a complete radiographic and biochemical response by AFP normalization by seven months post-treatment without evidence of radiation hepatotoxicity.



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Smith Apisarnthanarax

Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center

For correspondence:
apisarn@uw.edu

Jatinder Saini

Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center

Avril O'Ryan-Blair

Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

Jackie Castro

Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

Stephen R. Bowen, Ph.D.

Radiation Oncology, University of Washington School of Medicine

Smith Apisarnthanarax

Radiation Oncology, University of Washington/Seattle Cancer Care Alliance Proton Therapy Center

For correspondence:
apisarn@uw.edu

Jatinder Saini

Radiation Oncology, Seattle Cancer Care Alliance Proton Therapy Center

Avril O'Ryan-Blair

Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

Jackie Castro

Medical Dosimetry, Seattle Cancer Care Alliance Proton Therapy Center

Stephen R. Bowen, Ph.D.

Radiation Oncology, University of Washington School of Medicine