Palliative liver RT improves symptoms in half of HCC patients
A study of Hong Kong patients with unresectable hepatocellular carcinoma (HCC) found that half of the patients with hepatic pain and 55.6 percent of those with abdominal discomfort reported an improvement in their symptoms 1 month after receiving palliative radiotherapy (RT).
Among the 52 HCC patients (median age, 60 years; 84.6 percent male) who were unsuitable for or were refractory to transarterial chemoembolization (TACE) and stereotactic body radiotherapy (SBRT), 34 (65.4 percent) experienced pain, while 18 (34.6 percent) suffered from abdominal discomfort. [Sci Rep 2020;10:1254] All patients received palliative RT (8 Gy single fraction) on the basis of an earlier prospective phase II trial of 41 patients with HCC and liver metastases, where the same approach resulted in a clinically meaningful improvement in average index symptom intensity in 48 percent of patients. [J Clinl Onc 2013;31:3980-3986]
Overall, 51.9 percent of patients had clinical improvement of symptoms at 1 month; 50 percent of patients with pain and 55.6 percent of those with abdominal discomfort. However, “by means of the logistic regression model, no clinical or dosimetric factors could be identified in predicting symptom responders,” noted the researchers.
Twenty-one patients (40 percent) did not experience worsening of symptoms before death. Among those who did, the median time to symptom worsening was 89 days (range, 12–392 days).
“The treatment was well tolerated with no grade 4 or 5 toxicities,” wrote the researchers. “The most commonly seen grade 3 toxicity was elevation of aspartate transaminase (AST, n=3; 5.8 percent). Grade 3 fatigue, nausea and vomiting was observed in 1 patient (1.9 percent). No patient developed classic radiation-induced liver toxicity.”
“Of note, 73 percent of patients in the present study were hepatitis B virus [HBV] carriers,” wrote the researchers. “Entecavir was commenced in all HBV carriers 1 week before RT and no cases of viral re-activation were observed.”
Among 34 patients alive at 3 months post-RT, only three (8.8 percent) patients developed progression of Child-Pugh score ≥2. “This indicates that low-dose radiation is generally safe even in a population of patients with advanced disease and borderline hepatic function,” commented the researchers.
“Most patients (98 percent) in the present study had Barcelona Clinic Liver Cancer [BCLC] advanced disease, in which sorafenib is the current standard of care. However, sorafenib had no benefit in prolonging patients’ time to symptomatic progression and there is limited data concerning its efficacy on symptom improvement,” wrote the researchers. [N Engl J Med 2008;359:378-390; Lancet Oncol 2009;10:25-34]
“In our practice, low-dose RT was used to provide rapid palliation; sorafenib was started within 2 weeks after completion of RT. Among 23 patients thus treated, 52.6 percent had symptom improvement at 1 month and the median time to symptom worsening was 4 months, which compares favourably with the historical data of sorafenib,” reported the researchers. “Whether combining low-dose RT with sorafenib in advanced symptomatic HCC patients would confer quality of life benefit warrants further exploration.”
“Our preliminary results in an Asian population suggest that palliative low-dose liver RT may potentially be a safe, effective and convenient treatment in advanced HCC patients with pain or abdominal discomfort,” concluded the researchers. “A randomized controlled trial to compare palliative RT against best supportive care in terminal HCC patients is underway.”