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BCLC 2022 Update: Still a Long Way to Prove the Efficacy of External Beam Radiation Therapy
CC BY 4.0 · Indian J Med Paediatr Oncol 2023; 44(04): 440-441
DOI: DOI: 10.1055/s-0042-1758523
ecently, the Barcelona Clinic Liver Cancer (BCLC) group has updated its recommendation for the management of hepatocellular carcinoma (HCC) to emphasize personalized treatment.[1]
One major change in the BCLC 22 update is the incorporation of “treatment stage migration (TSM)” defined as upstaging of patient profile leading to shifting of recommendation to the option that would be considered for more advanced stage. It is surprising that in the present update, external beam radiation therapy (EBRT) has not been included in the treatment algorithm.
Various studies have been published that have demonstrated the safety and efficacy of EBRT such as stereotactic body radiation therapy (SBRT) and proton therapy in BCLC A-B HCC.[2] Mathew et al have demonstrated 1-, 3- and 5-year overall survival (OS) of 77·3%, 39·0%, and 24·1%, respectively, in 297 patients (pts) with 436 HCCs. BCLC-C group includes both pts with macrovascular invasion and those with extrahepatic metastasis. Studies have shown improved survival with SBRT in pts with macrovascular invasion who are not fit for other modalities of local treatment.[3]
The study by Collen et al in patients with synchronous oligometastatic—non small cell lung cancer (NSCLC) patients treated with SBRT had demonstrated a median overall survival (mOS) of 23 months.[4] Similarly, SBRT can be considered to be the primary lesion along with oligometastatic sites in HCC resulting in improved quality of life and extending survival.[5] Choi et al has reported mOS of 13.3 months in pts with Hep B-related BCLC-C group of patients.[6]
Evolving evidence has also suggested that concurrent use of immunotherapy with SBRT (SBRT-IO) has resulted in more powerful immune activation effects. In a study by Chiang et al, the overall response rate (ORR) was 87.5% (CR: 50%, PR: 37.5%) in the SBRT-IO arm as compared with 17% (CR: 2.4%, PR: 14.3%) in the TACE alone group. Similarly, the 12 months OS was 93.8% versus 80.4%, respectively.[7]
EBRT has been included as one of the treatment options in a selected group of population with HCC by the National Comprehensive Cancer Network (NCCN), American Association for the Study of Liver Diseases (AASLD).[8] [9] Recently the American Society for Radiation Oncology (ASTRO) has also recommended the use of EBRT in HCC. As per guidelines, radiation therapy can be used as a first-line option in patients with early disease not amenable to other local therapies. Further ASTRO has also recommended RT to consolidate other local therapies after incomplete response or recurrence. In the BCLC-C group of the population, it can be used with palliative intent.[10]
In conclusion, evidence is available for the use of EBRT in all stages of BCLC, especially in patients with progressive or metastatic disease but more randomized prospective trials results are required. We do hope that in future updates of BCLC guidelines, incorporation of EBRT will be considered as a treatment option for patients with HCC.
Authors' Contributions
DS, RK, and DT contributed to the concept and design, and writing of the article.
Publication History
Article published online:
01 December 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
Recently, the Barcelona Clinic Liver Cancer (BCLC) group has updated its recommendation for the management of hepatocellular carcinoma (HCC) to emphasize personalized treatment.[1]
One major change in the BCLC 22 update is the incorporation of “treatment stage migration (TSM)” defined as upstaging of patient profile leading to shifting of recommendation to the option that would be considered for more advanced stage. It is surprising that in the present update, external beam radiation therapy (EBRT) has not been included in the treatment algorithm.
Various studies have been published that have demonstrated the safety and efficacy of EBRT such as stereotactic body radiation therapy (SBRT) and proton therapy in BCLC A-B HCC.[2] Mathew et al have demonstrated 1-, 3- and 5-year overall survival (OS) of 77·3%, 39·0%, and 24·1%, respectively, in 297 patients (pts) with 436 HCCs. BCLC-C group includes both pts with macrovascular invasion and those with extrahepatic metastasis. Studies have shown improved survival with SBRT in pts with macrovascular invasion who are not fit for other modalities of local treatment.[3]
The study by Collen et al in patients with synchronous oligometastatic—non small cell lung cancer (NSCLC) patients treated with SBRT had demonstrated a median overall survival (mOS) of 23 months.[4] Similarly, SBRT can be considered to be the primary lesion along with oligometastatic sites in HCC resulting in improved quality of life and extending survival.[5] Choi et al has reported mOS of 13.3 months in pts with Hep B-related BCLC-C group of patients.[6]
Evolving evidence has also suggested that concurrent use of immunotherapy with SBRT (SBRT-IO) has resulted in more powerful immune activation effects. In a study by Chiang et al, the overall response rate (ORR) was 87.5% (CR: 50%, PR: 37.5%) in the SBRT-IO arm as compared with 17% (CR: 2.4%, PR: 14.3%) in the TACE alone group. Similarly, the 12 months OS was 93.8% versus 80.4%, respectively.[7]
EBRT has been included as one of the treatment options in a selected group of population with HCC by the National Comprehensive Cancer Network (NCCN), American Association for the Study of Liver Diseases (AASLD).[8] [9] Recently the American Society for Radiation Oncology (ASTRO) has also recommended the use of EBRT in HCC. As per guidelines, radiation therapy can be used as a first-line option in patients with early disease not amenable to other local therapies. Further ASTRO has also recommended RT to consolidate other local therapies after incomplete response or recurrence. In the BCLC-C group of the population, it can be used with palliative intent.[10]
In conclusion, evidence is available for the use of EBRT in all stages of BCLC, especially in patients with progressive or metastatic disease but more randomized prospective trials results are required. We do hope that in future updates of BCLC guidelines, incorporation of EBRT will be considered as a treatment option for patients with HCC.
Conflict of Interest
None declared.
Authors' Contributions
DS, RK, and DT contributed to the concept and design, and writing of the article.
References
- Reig M, Forner A, Rimola J. et al. BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update. J Hepatol 2022; 76 (03) 681-693
- Mathew AS, Atenafu EG, Owen D. et al. Long term outcomes of stereotactic body radiation therapy for hepatocellular carcinoma without macrovascular invasion. Eur J Cancer 2020; 134: 41-51 DOI: 10.1016/j.ejca.2020.04.024.
- Que J, Wu HC, Lin CH, Huang CI, Li LC, Ho CH. Comparison of stereotactic body radiation therapy with and without sorafenib as treatment for hepatocellular carcinoma with portal vein tumor thrombosis. Medicine (Baltimore) 2020; 99 (13) e19660 DOI: 10.1097/MD.0000000000019660.
- Collen C, Christian N, Schallier D. et al. Phase II study of stereotactic body radiotherapy to primary tumor and metastatic locations in oligometastatic nonsmall-cell lung cancer patients. Ann Oncol 2014; 25 (10) 1954-1959 DOI: 10.1093/annonc/mdu370.
- Hawkins MA, Dawson LA. Radiation therapy for hepatocellular carcinoma: from palliation to cure. Cancer 2006; 106 (08) 1653-1663
- Choi CKK, Ho CHM, Wong MYP. et al. Long-term results of palliative stereotactic radiotherapy of Barcelona Clinic Liver Cancer Stage C Hepatitis B–related hepatocellular carcinoma. Hong Kong J Radiol. 2021; 24: 81-86
- Chiang CL, Chiu KWH, Lee FAS, Kong FS, Chan ACY. Combined stereotactic body radiotherapy and immunotherapy versus transarterial chemoembolization in locally advanced hepatocellular carcinoma: a propensity score matching analysis. Front Oncol 2021; 11: 798832 DOI: 10.3389/fonc.2021.798832.
- Benson AB, D'Angelica MI, Abbott DE. et al. Hepatobiliary cancers, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19 (05) 541-565 DOI: 10.6004/jnccn.2021.0022.
- Marrero JA, Kulik LM, Sirlin CB. et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2018; 68 (02) 723-750 DOI: 10.1002/hep.29913.
- Apisarnthanarax S, Barry A, Cao M. et al. External beam radiation therapy for primary liver cancers: an ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12 (01) 28-51 DOI: 10.1016/j.prro.2021.09.004.
Address for correspondence
Publication History
Article published online:
01 December 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India
References
- Reig M, Forner A, Rimola J. et al. BCLC strategy for prognosis prediction and treatment recommendation: the 2022 update. J Hepatol 2022; 76 (03) 681-693
- Mathew AS, Atenafu EG, Owen D. et al. Long term outcomes of stereotactic body radiation therapy for hepatocellular carcinoma without macrovascular invasion. Eur J Cancer 2020; 134: 41-51 DOI: 10.1016/j.ejca.2020.04.024.
- Que J, Wu HC, Lin CH, Huang CI, Li LC, Ho CH. Comparison of stereotactic body radiation therapy with and without sorafenib as treatment for hepatocellular carcinoma with portal vein tumor thrombosis. Medicine (Baltimore) 2020; 99 (13) e19660 DOI: 10.1097/MD.0000000000019660.
- Collen C, Christian N, Schallier D. et al. Phase II study of stereotactic body radiotherapy to primary tumor and metastatic locations in oligometastatic nonsmall-cell lung cancer patients. Ann Oncol 2014; 25 (10) 1954-1959 DOI: 10.1093/annonc/mdu370.
- Hawkins MA, Dawson LA. Radiation therapy for hepatocellular carcinoma: from palliation to cure. Cancer 2006; 106 (08) 1653-1663
- Choi CKK, Ho CHM, Wong MYP. et al. Long-term results of palliative stereotactic radiotherapy of Barcelona Clinic Liver Cancer Stage C Hepatitis B–related hepatocellular carcinoma. Hong Kong J Radiol. 2021; 24: 81-86
- Chiang CL, Chiu KWH, Lee FAS, Kong FS, Chan ACY. Combined stereotactic body radiotherapy and immunotherapy versus transarterial chemoembolization in locally advanced hepatocellular carcinoma: a propensity score matching analysis. Front Oncol 2021; 11: 798832 DOI: 10.3389/fonc.2021.798832.
- Benson AB, D'Angelica MI, Abbott DE. et al. Hepatobiliary cancers, version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 19 (05) 541-565 DOI: 10.6004/jnccn.2021.0022.
- Marrero JA, Kulik LM, Sirlin CB. et al. Diagnosis, staging, and management of hepatocellular carcinoma: 2018 practice guidance by the American Association for the Study of Liver Diseases. Hepatology 2018; 68 (02) 723-750 DOI: 10.1002/hep.29913.
- Apisarnthanarax S, Barry A, Cao M. et al. External beam radiation therapy for primary liver cancers: an ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2022; 12 (01) 28-51 DOI: 10.1016/j.prro.2021.09.004.