501 - Hepatocellular carcinoma responding to sequential radioembolization and external radiotherapy: A successful salvage?

Case Summary

Radioembolization and external radiotherapy are treatment modalities in HCC. Whether there is a role for sequential use of radioembolization and external radiotherapy is presently unknown. Here we report a patient with unresectable HCC treated with radioembolization followed by external radiotherapy. Clinical Presentation 59-year-old male Pakistani patient with hepatitis C treated in 2009 with clearance of virus, presented in 9.2016 with right upper quadrant pain (ECOG 1). He was found to have bifocal liver lesions in the right lobe (V/VI overall 7cm) fulfilling the radiologic criteria for HCC. The tumor marker AFP was 45306 IU/ml (N 0-5) Child-Pugh score was A6. Radioembolization was administered on the 1.12.2016 which was well tolerated, and AFP level decreased to 9393 IU/ml on 1.3.2017. Follow-up imaging with MRI Liver and PET-CT in 3.2017 showed decrease in size of the right liver lesion; However residual enhancing and FDG-avid uptake in the lesion impressive of residual active disease and new FDG-avid retroperitoneal lymph nodes were described. External beam radiotherapy was administered from 26.3.2017 till 27.4.2017 to the primary liver tumor, involved lymph nodes and to high risk nodal to a total of 55 Gy / 50 Gy in 2.2 Gy/ 2.0 Gy per fraction respectively using Volumetric modulated arc therapy (Rapid Arc) with simultaneous integrated boost, no significant toxicity was observed. On the 28.5.2017 AFP was 5.0 IU/ml and imaging in 6.2017 showed regression of the hepatic lesions and complete response of the involved lymph nodes. The patient continued to have remission with complete response radiologically in hepatic lesions and lymph nodes for more than 14 months till present time and AFP remains < 2 IU/ml on 21.5.2018. Patient maintained good performance (ECOG 0) with Child Pugh A5. Conclusions External beam radiotherapy is effective and well tolerated in a patient with rapidly progressing HCC post-radioembolization. The results described here support further studies on sequential radioembolization-external radiotherapy and related response biomarkers.

Editorial acknowledgement

Clinical trial identification